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Role of echo Doppler techniques in the evaluation and treatment of heart failure patients
Stefano Ghio
Divisione di Cardiologia, IRCCS Policlinico S Matteo, Piazza Golgi 1, 27100 Pavia, Italy
Corresponding author. Tel: +39 0382 503718; fax: +39 0382 501884. E-mail address: s.ghio{at}smatteo.pv.it
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Abstract
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The guidelines on diagnosis and treatment of chronic heart failure
(HF) published in 2005 by the European and American Association
recognize the great importance of two-dimensional and Doppler
echocardiography in the evaluation of patients with HF. However,
the focus of both documents is on the capability of echo to
identify the structural abnormalities of myocardium, heart valves,
or pericardium responsible for the development of HF, whereas
few suggestions are given on how echo information should be
used to best treat HF patients. To reach this goal, two basic
conditions have to be fulfilled. The first one is that echocardiographists
know which are the main clinical needs that the echo examination
can help to address: (i) assessing the aetiology of HF, (ii)
characterizing the haemodynamic profile, and (iii) estimating
the short–medium-term risk of HF patients. The second
is that clinicians/HF specialists who have the responsibility
of the management of HF patients become familiar with the interpretation
of the echo examination, which is not so easy given the large
use by the echo community of new techniques and the increasing
number of new echo parameters proposed in the literature.
Key Words: Echography • Heart failure • Guidelines
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Introduction
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The European and the American guidelines on diagnosis and treatment
of chronic heart failure (HF) recognize the importance of two-dimensional
and Doppler echocardiography in the evaluation of patients with
HF.
1,2 However, the focus of both documents is on the capability
of echo to identify the structural abnormalities of myocardium,
heart valves, or pericardium responsible for the development
of HF, whereas few suggestions are given on how echo information
should be used to best treat HF patients. Clearly, despite a
large number of echo publications, more work has to be done
to reach an expert consensus on how the ultrasound evaluation
can really improve the management of HF patients.
To reach this goal, two basic conditions have to be fulfilled. The first one is that echocardiographists must know which echo information are relevant for the clinicians who treat HF patients. In general, echo can help to address three main clinical needs: (i) assessing the aetiology of HF, (ii) characterizing the haemodynamic profile, and (iii) estimating the short–medium-term risk of HF patients. In addition, it is necessary that clinicians/HF specialists who have the responsibility of the management of HF patients become familiar with the interpretation of the echo examination. This point may not be taken for granted, given the large use by the echo community of new techniques and the increasing number of new echo parameters proposed in the literature. Therefore, it is of paramount importance that the final echo report includes all relevant echo parameters in an easy to interpret pathophysiological order.
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Echo contribution to the assessment of aetiology
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In the initial evaluation of patients with HF, a complete two-dimensional
and Doppler study at rest is the single most useful diagnostic
test to assess the aetiology of HF and, consequently, to decide
on treatments and to plan the follow-up. Valve disease can be
easily quantified with echo Doppler; difficulties may arise
when a mild gradient through the aortic valve is associated
with severe left ventricular dysfunction (in this situation,
a stress echo is necessary to assess the severity of aortic
stenosis).
3 Hypertrophic cardiomyopathy, restrictive/infiltrative
cardiomyopathy, and constrictive pericarditis can also be diagnosed
or suspected at echo as responsible for HF.
4,5 In the presence
of left ventricular dilatation and reduced ejection fraction,
the differential diagnosis should include primary dilated cardiomyopathy
and ischaemic heart disease. The evaluation of regional left
ventricular function can be of help to distinguish these two
conditions, but its predictive accuracy is poor: in fact, it
is frequent that in patients with ischaemic heart disease, the
left ventricle is uniformly hypokinetic and, conversely, that
in patients with primary dilated cardiomyopathy, segmental wall
motion abnormalities are observed at echo.
6 Echocardiography
cannot substitute coronary arteriography in the diagnostic algorithm
of HF patients. A substantial number of patients with symptoms
and/or signs of HF, especially in the elderly population, may
have normal or mildly reduced left ventricular ejection fraction;
in fact, diastolic HF has emerged over the last years as a separate
clinical entity. The diagnosis of diastolic HF does not necessitate
echo confirmation of diastolic dysfunction.
7–10 Not only
echo parameters are inadequate to describe the diastolic function
(i.e. left ventricular relaxation and compliance), but also
the evaluation of diastolic function is unnecessary in this
condition.
10 The diagnosis, prognosis, and treatment of diastolic
HF remain controversial issues.
11
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Non-invasive haemodynamic evaluation
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Right heart catheterization is the only technique that allows
to obtain precise evaluation of haemodynamic data which are
of utmost relevance in patients with HF, such as intracardiac
pressures, cardiac output, and vascular resistance. However,
right heart catheterization is not exempt from risks.
12 This
represents an obvious limitation to a widespread use of the
technique if we consider that many HF patients may experience
stability and instability phases in a rapid succession, implying
that the necessity of a haemodynamic evaluation to optimize
therapy may occur several times in a year. Echocardiography
allows a non-invasive estimate of all the most important haemodynamic
parameters, although the accuracy of the estimate is different
for different parameters. In some cases, echo gives the possibility
to obtain not only a semi-quantitative estimate of the haemodynamic
datum, but also a precise quantitative measure: semi-quantitative
estimates are obtained using echo parameters which are easy
to be measured and easy to be interpreted, whereas a quantitative
approach usually requires several echo data to be analysed in
multivariable equations. Therefore, the greater precision in
measurements is obtainable at the expense of an increase in
the complexity of the procedure and in the possibility of errors.
An example is the echo estimate of pulmonary capillary wedge
pressure (PCWP). The categorization of the transmitral flow
velocity curve at pulsed Doppler into a restrictive or non-restrictive
pattern is associated with the levels of PCWP in patients with
systolic HF: a restrictive pattern, characterized by a deceleration
time of <120 ms, is highly predictive of a PCWP
20 mmHg,
whereas a DT>153 ms is highly predictive of a PCWP
12 mmHg.
13 The pathophysiological background of such a categorization is
simple and, at the same time, very strong: transmitral velocities
depend on the diastolic pressure gradients through the valve,
determined by atrial and ventricular pressure and by left ventricular
compliance.
14 When left atrial pressure is normal, the early
diastolic velocity has a low amplitude and a prolonged deceleration
time and much of the left ventricular filling occurs during
atrial contraction. When left atrial pressure is high, the transmitral
flow is characterized by high early diastolic wave, short deceleration
time, and small atrial contribution. Noticeably, the feasibility
of this evaluation is very good because a pulsed Doppler flow
curve through the mitral valve can be obtained in all patients
in sinus rhythm (with the only exception of those in whom either
tachycardia or an atrioventricular block determines a summation
profile) and its differentiation in restrictive vs. non-restrictive
is immediate. Most importantly, the evaluation of the transmitral
flow pattern portends important prognostic information and its
value can be further improved using simple loading manipulations
or by assessing its changes after optimization of therapy.
15–19 A quantitative estimate of PCWP can be obtained including multiple
echo data in multivariable equations, which are obtained both
by the transmitral Doppler curve and by other techniques (having
a lower feasibility than transmitral Doppler).
20,21 Whether
a quantitative measure of PCWP may increase the prognostic value
of the transmitral Doppler flow has never been demonstrated.
Right atrial pressure is another haemodynamic parameter which
can be estimated using quantitative methods or using a simple
categorization based on dimensions and collapsibility of the
inferior vena cava.
22,23 Pulmonary vascular resistance can be
estimated only using multivariable equations.
24 The use of such
equations poses theoretical problems, as all parameters included
in the analysis are obtained by pulmonary Doppler flow velocity
curve (pre-ejection time, acceleration time, and ejection time)
and correlate with right ventricular afterload; however, right
ventricular afterload is not always correlated with pulmonary
vascular resistance. In fact, if mean pulmonary artery pressure
is high and PCWP is also elevated, right ventricular afterload
is high, but vascular resistance is low. In addition, there
are practical considerations to be done. The calculation of
pulmonary vascular resistance is mandatory when clinicians have
to decide if the patient can be listed for transplantation (or
can remain in the transplant list): high pulmonary vascular
resistance is a clear contraindication unless reversibility
with vasodilators is demonstrated. However, no data in the literature
suggest that echo measurements can be used for such an evaluation
of patients with HF.
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Prognostic stratification
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Many clinical, functional, haemodynamic, and biochemical parameters
have been proposed in the literature to assess the short- or
medium-term risk of patients with HF; however, none of these
parameters is able to predict mortality with good sensitivity
and specificity. As a matter of fact, the decision of listing
a patient for heart transplantation still depends more on his
clinical conditions and refractoriness to therapy, rather than
on specific haemodynamic or functional values. To make things
more complicated, predictors of mortality due to refractory
HF do not work as well with sudden death. So, what is the role
of echo in this complex scenario? First of all, echo information
on cardiac geometry and function and on right heart haemodynamics
integrate the clinical data to build up a risk profile of the
patient with HF as accurate as possible. Second and most important,
the non-invasiveness of echo allows to monitor the haemodynamic
and functional characteristics of the patient over time: in
fact, it is well known that changes after optimization of therapy
better correlate with prognosis than with ‘baseline’
data.
25
Which are the threshold values suggested in the literature for a judgement of high risk HF patients? Concerning left ventricular ejection fraction, a first threshold is at normality values: in the V-HeFT trial, annual mortality rate was 8% in patients with normal when compared with 19% in patients with reduced ejection fraction.26 More recent results from the CHARM programme confirm that ejection fraction is inversely related to mortality; nevertheless, at values above 45%, this index does not further contribute to the assessment of cardiovascular risk in HF patients.27 Another threshold for ejection fraction is usually positioned at values of 30 and 35%, as such values indicate advanced left ventricular dysfunction; in the most recent guidelines on chronic HF, these thresholds are recommended to select patients to be implanted with defibrillators and biventricular pacemakers.1,2 Changes in left ventricular dimensions and function over time are also relevant in terms of prognostic stratification: a reverse remodelling at 1 year portends poorer prognosis, whereas a >5% increase in ejection fraction at 6 or 12 months is an indicator or favourable outcome.28,29 A restrictive pattern of the transmitral pulsed Doppler flow velocity curve is an important negative prognostic indicator; the rationale is that it reflects an elevated PCWP. As already specified, the changes in this pattern with simple loading manipulations or after optimization of pharmacological therapy increase its prognostic value.19–22,30 Finally, if left ventricular dysfunction is advanced and the transmitral flow pattern is restrictive, it is mandatory to assess the right ventricular function: the association of pulmonary hypertension with reduced right ventricular function indicates patients with end-stage disease.31 A simple echocardiographic indicator of the right ventricular function is the measure of the tricuspid annular plane systolic excursion (TAPSE): a TAPSE<14 mm is an independent predictor of poor prognosis in patients with advanced left ventricular dysfunction.32
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A correct echo recording and final report
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To facilitate the clinical interpretation of echo data, the
results should be finally reported according to a precise pathophysiological
order (which, in the opinion of the author, corresponds exactly
to the order the echo examination should be performed by the
echocardiographist); in HF patients with primary dilated cardiomyopathy
or ischaemic heart disease, the order could, therefore, be the
one reported below. Describing the structure and function of
the left ventricle is the first step of the examination; quantitative
measurements of dimensions, volumes, and ejection fraction are
obviously mandatory, although the algorithms used to make the
calculations are not so stringent. Assessing the presence and
degree of mitral regurgitation is then necessary to characterize
the pump function of the heart; in addition, the aetiology of
mitral regurgitation should be clarified, as this could be relevant
to the selection of candidates to cardiac resynchronization
(‘functional’ mitral regurgitation responds rapidly
to this therapy). The impact of left ventricular dysfunction
of the pulmonary circulation is the second step: PCWP may be
estimated using several methods, whereas pulmonary artery pressure
may be easily assessed in the presence of regurgitant jets through
the tricuspid and pulmonary valves. The third step, mandatory
in the presence of high pulmonary wedge or artery pressure,
is the evaluation of right ventricular function and the estimation
of right atrial pressure. Finally, in selected patients with
bundle branch block and NYHA class III or IV, assessment of
left ventricular dyssynchrony should become part of the routine
echo examination. In fact, although cardiac resynchronization
therapy has proved to reduce morbidity and mortality in such
patients, the selection of responders could improve cost-effectiveness
of such therapy.
33
Conflict of interest: none declared.
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Abstract
Introduction