Echocardiographic Algorithms for Detecting Elevated Diastolic Pressures∗

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 69, NO. 15, 2017

ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER

http://dx.doi.org/10.1016/j.jacc.2017.02.022

EDITORIAL COMMENT

Echocardiographic Algorithms for Detecting Elevated Diastolic Pressures* Reasonable, Not Perfect Frank A. Flachskampf, MD, PHD,a,b Tomasz Baron, MD, PHDa,b

D

iastolic function is an imprecise term for

measurement of pulmonary capillary wedge pressure

a set of

physiological

(PCWP; or left ventricular diastolic pre-A pressure,

parameters best characterized by diastolic

which is close to PCWP) at rest, the study by Andersen

pressure-volume relationships at rest and under

et al. (8) in this issue of the Journal provides the best

changing load conditions. To identify these relation-

evaluation yet of the accuracy of the current guide-

ships without precise pressure or volume data seems

lines. Of course, measuring PCWP is not the same as

truly an impossible mission. Nevertheless, such

measuring the relaxation constant tau or the ven-

assessment is now part of routine echocardiography.

tricular stiffness constant k, which must be extracted

Lacking direct access to left ventricular pressure,

from

the assessment focuses on several indirect indicators

pressure-volume data. These parameters would pro-

left ventricular

curve-fitting

high-resolution

pressure

or

of pressure: filling patterns of the left ventricle and

vide better information about diastolic function than

the left atrium; the size of the left atrium; the longitu-

the isolated measurement of a single diastolic pres-

dinal lengthening velocity of the basal myocardium

sure, which could lie on a multitude of different

(e 0 ); right ventricular systolic pressure, which, in

pressure-volume curves. Nevertheless, the PCWP in

contrast to left ventricular diastolic pressures, can at

our understanding is crucial for explaining patients’

least be roughly estimated; and others. By interpret-

decreased exercise tolerance and dyspnea, which are

ing these elements, answers to 2 related, but different

the typical symptoms raising the clinical suspicion of

diagnostic questions are sought: 1) whether left

possible diastolic dysfunction.

ventricular diastolic pressures are elevated; and 2) whether diastolic dysfunction is present. To this

SEE PAGE 1937

end, the American Society of Echocardiography and

This multicenter study included, partly retrospec-

the European Association of Cardiovascular Imaging

tively and in larger part prospectively, patients with

formulated guidelines in 2009 and 2016 that offered

clinical indications for right-sided or left-sided heart

algorithms (1,2) to answer these 2 questions. These

catheterization. Clinical data, including biomarkers,

algorithms

were gleaned from chart review and were interpreted

criticized

in

their

2009

version

for

being

awkward,

were

widely

ambiguous,

and

by investigators blinded to echocardiographic and

frequently wrong (3–7), thus spurring a new effort in

invasive data to test how good a purely “clinical”

2016 to make them more user friendly.

approach to the diagnosis of diastolic dysfunction

With 450 included patients having simultaneous or

would be. Patients’ characteristics included atrial

nearly simultaneous echocardiographic and invasive

fibrillation in 4%, pacing or left bundle branch block in 9%, and moderate or severe aortic or mitral valve disease in 6%. In 7% of all patients, not all echocar-

*Editorials published in the Journal of the American College of Cardiology

diographic key parameters could be obtained, and

reflect the views of the author and do not necessarily represent the views

these patients were excluded from analysis.

of JACC or the American College of Cardiology. From the aDepartment of Medical Sciences, Uppsala University, Uppsala, Sweden; and the bUppsala Clinical Research Center, Uppsala University,

Approximately 60% of all patients had elevated PCWP (>12 mm Hg). Accuracy of echocardiography for

Uppsala, Sweden. Both authors have reported that they have no re-

the diagnosis of elevated PCWP was 87%, with a

lationships relevant to the contents of this paper to disclose.

positive predictive value of 91% (likelihood that

1950

Flachskampf and Baron

JACC VOL. 69, NO. 15, 2017 APRIL 18, 2017:1949–51

Echocardiographic Algorithms for Diastolic Function Assessment

PCWP was in fact elevated if echocardiography pre-

pathological, but pre-A pressures may be normal, and

dicted so) and a negative predictive value of 87%

E velocities and E/e 0 ratios may be relatively low (10).

(likelihood that PCWP was in fact normal if echocar-

The diastolic stress test with acquisition of E/e 0 and

diography predicted so). The accuracy was slightly

tricuspid regurgitation velocity during or immediately

higher for patients with reduced ejection fraction

after moderate physical exercise is therefore an option

than for those with preserved ejection fraction. These

recommended in the current guidelines in unclear

are impressive numbers, all considerably better than

cases. The paper by Andersen et al. (8), however,

seen with a diagnosis made purely on clinical

focuses on the detection of elevated diastolic pres-

grounds,

and

“good”

accuracy

(only

receiver-

sures at rest and only briefly deals with the different

operating characteristic curve statistics are given) is

grades of diastolic function (a graded increase in filling

also reported for following the specific guideline

pressure was seen from grade 1 to 3); whether the

recommendations in patients not in sinus rhythm or

currently recommended grades of diastolic dysfunc-

with substantial valvular heart disease.

tion are robust and meaningful awaits further study.

How can these findings be reconciled with the vocal

Looking at individual parameters, it is worth

published criticism of the guideline approach? An

noting that the best correlation of an echocardio-

early comparative echocardiographic catheterization

graphic parameter with filling pressures was with the

study in patients with acute severe heart failure found

estimate of systolic pulmonary pressure, followed, in

disappointing diagnostic utility of tissue Doppler pa-

descending order, by the ratio of peak systolic and

rameters, in particular E/e 0 (3). This finding was most

diastolic pulmonary venous flow velocities, the E/A

likely the result of rapidly changing hemodynamics

ratio, and the E/e 0 ratio, all with modest correlation

and a high proportion of resynchronization pacing

coefficients (r) of 0.5 to 0.6. The relationship of the

therapy in these patients (9), but it underlined the

left atrial volume index with filling pressures, some-

importance of not relying on a single echocardio-

times glorified as the “glycated hemoglobin of dia-

graphic parameter, an observation re-emphasized in

stolic pressure,” was particularly weak (r ¼ 0.23).

the present study. A large echocardiographic cathe-

These findings re-emphasize the need for a multi-

terization study found weak relationships between

parametric approach and the futility of estimating

diastolic dysfunction grades and established physio-

pressures from 1 or 2 echocardiographic variables

logical parameters such as the relaxation constant tau

only.

or end-diastolic left ventricular pressures (4). Other

The reluctance to embrace the guidelines approach

investigators have criticized a lack of age correction in

is in part caused by the perception that its reliance on

the cutoffs for echocardiographic parameters, thus

a multitude of indirect parameters represents a rather

leading to erroneous classification not supported

awkward, unsatisfactory solution. More analytic ap-

by actual outcomes (5). Further, guideline algorithms

proaches have been explored, for example, recon-

have been interpreted in different ways, leading to

struction of intracavitary pressure gradients from

different estimates of the prevalence of diastolic

color Doppler data of left ventricular inflow (11),

dysfunction (6). Considerable interobserver variability

measurements of early diastolic left ventricular strain

with regard to the assignment of diastolic dysfunction

rate (12), and left ventricular torsion (13). Unfortu-

grades has been found (7). It is important, however, to

nately, none of these has been developed and

understand the distinction between detection of

validated sufficiently to recommend it for routine

elevated diastolic pressures and detection of diastolic

application in the diagnosis of diastolic dysfunction.

dysfunction as defined and graded in the guidelines.

This study also corrects some widely held expecta-

Although elevated pressures are typically manifesta-

tions about conditions with increased diastolic

tions of diastolic dysfunction, this feature may be

pressures:

“masked” at rest (i.e., there may be dormant

reduced ejection fraction, only 60% had elevated dia-

dysfunction or reduced “diastolic reserve,” which may

stolic pressures; and in moderate or severe mitral

be unmasked by provocation, e.g., exercise or volume

regurgitation, only 74% (5 of 19) patients had elevated

load). The guideline definition of grade 1 diastolic

pressures.

in

patients

with

heart

failure

with

dysfunction includes patients with normal PCWP at

Limitations of the study include its partly retro-

rest that increases with exercise or other provocation.

spective nature and the selection of patients with

This distinction between diastolic (dys-)function and

clinical indications for right-sided or left-sided heart

actual filling pressure level may be perceived as

catheterization, which led to a high incidence (60%)

specious, but it provides for situations such as hyper-

of increased diastolic pressures and thus may

trophic cardiomyopathy, in which diastolic function,

augment

in

approach over the value to be expected in a less

particular

myocardial

relaxation,

is

clearly

specificity

of

the

echocardiographic

Flachskampf and Baron

JACC VOL. 69, NO. 15, 2017 APRIL 18, 2017:1949–51

Echocardiographic Algorithms for Diastolic Function Assessment

selected population. The inclusion of relatively small

on the contrary be commended for testing their

numbers of patients with moderate or severe valvular

concepts.

heart disease and with nonsinus rhythms is prob-

Hence this large, well-conducted study confirms

lematic because it may affect overall diagnostic

reasonable utility, but not perfect accuracy, of the

accuracies and is also not enough for validation of

recommended, multiparametric algorithms to assess

algorithms in these small subgroups. In particular,

left ventricular diastolic pressures at rest as a proxy of

the effect of mitral regurgitation on left atrial pres-

left ventricular diastolic function.

sure and volume, transmitral flow profile, and pulmonary pressure may well be impossible to separate

ADDRESS FOR CORRESPONDENCE: Dr. Frank A.

from diastolic dysfunction effects. Further, several

Flachskampf, Department of Medical Sciences, Uppsala

study investigators were members of the writing

University, Cardiology/Clinical Physiology, Akademiska

group of the current guidelines, but it would be unfair

sjukhuset, Ingång 40, plan 5, 751 85 Uppsala, Sweden.

to count that as a limitation, and those authors should

E-mail: frank.fl[email protected].

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KEY WORDS catheterization, diastole, Doppler, heart failure, net reclassification improvement

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