© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12600
Echocardiography
Ia Diastolic Dysfunction: An Echocardiographic Grade Anil Pandit, M.D.,* Farouk Mookadam, M.D.,* Fayaz A. Hakim, M.D.,* Eoin Mulroy, M.D.,* Rayya Saadiq, M.D.,* Mairead Doherty, M.D.,* Stephen Cha, M.Sc.,† James Seward, M.D.,‡ and Susan Wilansky, M.D.* *Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona; †Division of Biostatistics, Mayo Clinic, Rochester, Minnesota; and ‡Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Objective: To demonstrate that a distinct group of patients with Grade Ia diastolic dysfunction who do not conform to present ASE/ESE diastolic grading exists. Method and Results: Echocardiographic and demographic data of the Grade Ia diastolic dysfunction were extracted and compared with that of Grades I and II in 515 patients. The mean of age of the cohort was 75 9 years and body mass index did not differ significantly between the 3 groups (P = 0.45). Measurements of left atrial volume index (28.58 7 mL/m2 in I, 33 10 mL/m2 in Ia, and 39 12 mL/m2 in II P < 0.001), isovolumic relaxation time (IVRT) (100 17 msec in I, 103 21 msec in Ia, and 79 15 msec in II P < 0.001), deceleration time (248 52 msec in I, 263 58 msec in Ia, and 217 57 msec in II P < 0.001), medial E/e0 (10 3 in I, 18 5.00 in Ia, and 22 8 in II), and lateral E/e0 (8 3 in I, 15 6 in Ia, and 18 9 in II P < 0.001) were significantly different in grade Ia compared with I and II. These findings remained significant even after adjusting for age, gender, diabetes, and smoking. Conclusion: Patients with echocardiographic characteristics of relaxation abnormality (E/A ratio of 0.75–1.5, lateral E/e0 ≥ 12, medial E/e0 ≥ 15, and average ≥ 13). However, in clinical practice, patients have been noted to have a Grade I mitral inflow pattern (E/ A < 0.8) and a Grade II tissue Doppler (TDI) mitral annular pattern (lateral E/e0 ≥ 12, medial E/e0 ≥ 15, and average ≥ 13). The aim of the present study was to demonstrate that this distinct group of patients designated as “Grade Ia” diastolic dysfunction exists and do not conform to the current schema of left ventricular diastolic dysfunction grading systems from the ASE7 or ESE.6 Methods: Study Design: A single-center retrospective review of adult patients who underwent noninvasive hemodynam-
Ia Diastolic Dysfunction
ic assessment by transthoracic echocardiography from December 2011 to March 2012. Patient Population: Patients between ages 18 and 90 years who underwent transthoracic echocardiography for noninvasive hemodynamic assessment at Mayo Clinic Arizona from December 2011 to March 2012 were included in the study. Patients with normal diastolic function, Grade III/IIIb diastolic dysfunction, severe valvular abnormalities (≥ moderate mitral regurgitation), severe mitral annular calcification, mitral stenosis, prosthetic mitral valve, mitral annuloplasty ring, heart transplant recipients, constrictive pericarditis, hypertrophic cardiomyopathy, and those with regional wall-motion abnormalities affecting basal septum and/or lateral walls were excluded from the study. Of 620 patients, we identified 515 who were reported to have Grade I and grade II diastolic dysfunction. These patients were further divided into 3 grades based on their echocardiographic diastolic parameters including E/A ratio (normal: >1), E/e0 ratio (normal: E/e0 lateral < 12, medial < 15, and average < 13), are as follows: I: E/A ratio < 0.8 and normal filling pressures (E/e0 lateral < 12, medial < 15, and average < 13) Ia: E/A ratio < 0.8 and elevated filling pressures (E/e0 lateral ≥ 12, medial ≥ 15, and average ≥ 13) II: E/A ratio = 0.8–1.5 and elevated filling pressures (E/e0 lateral ≥12, medial ≥15, and average ≥13). Echocardiography: Subjects included in this study underwent detailed transthoracic two-dimensional and Doppler echocardiography (GE Healthcare, Milwaukee, WI, USA) based on standardized ASE guidelines and recommendations.6,9 The Valsalva maneuver was performed to assess “normal versus pseudonormal” filling patterns.6 All patients were instructed in the performance of the Valsalva maneuver and allowed to practice to proficiency and the best tracings were recorded. Echocardiographic images were uploaded digitally to an online system (ProSolv CardioVascular, Indianapolis, IN, USA) for measurement and data analysis. Board-certified echocardiographers with more than 20 years of experience interpreted the echocardiographic studies. Quantitative echocardiographic measurements were performed according to the American Society of Echocardiography guidelines9 and included: LAVI (using the area length method indexed to body surface area), ejection fraction
(EF) (using volumetric biplane Simpson’s method), and diastolic parameters (E velocity, A velocity, IVRT, DT, E/A ratio, and E/e0 ). Demographic, clinical, and echocardiographic parameters were compared between all three groups and (I vs. Ia and Ia vs. I). Statistical Analysis: The data were summarized as means and standard deviation for normally distributed data. The means were compared using Student’s t test. Categorical variables were analyzed by chi-square analysis. Any 2-tailed P-value of less than 0.05 was considered statistically significant for demographic data. However, for echocardiographic data, which were divided into the 3 groups; Grades I, Ia, and II and compared as follows: I versus Ia (I as a control) and Ia versus II (II as a control), a 2-tailed t-statistic was used with a P-value of 0.025 considered significant. One-way analysis of variance (ANOVA) was used to assess difference among the groups. A multiple regression model was used to assess if the findings remained significant when adjusted for age, gender, diabetes mellitus, and smoking. Results: Demographic Data: The demographic data of study subjects are summarized in Table I. There were more males than females in the study cohort (55% vs. 45%). The mean age of the cohort was 75 9 years and did not differ significantly among the 3 groups (P = 0.45). The mean body mass index (BMI) of the cohort was 27.9 5.6 (P = 0.68) and did not differ significantly among the study groups. Likewise, the presence of hypertension and coronary artery disease were comparable across all three groups. There were more smokers in patients with Grade II diastolic dysfunction (35% in Ia, 8% in I, and 46% in II, P < 0.001) and a significantly lower incidence of diabetics in those with grade I diastolic dysfunction. (12% in I, 21% in Ia, and 22% in II, P < 0.04). Echocardiographic Data: The echocardiographic characteristics are summarized in Tables II and III. Except for the EF, all the diastolic parameters differed among the 3 groups as shown in Table II. To demonstrate that Grade Ia has different diastolic characteristics on echo Doppler measurements, we compared echocardiographic diastology parameters of Grade Ia to Grade II and Grade I separately as shown in Table II. First, we compared the echocardiographic features of Grade Ia with Grade I as a control. We found that 57
Pandit, et al.
TABLE I Demographic Characteristics among Grade I, Ia, and II Diastolic Dysfunction Variable
Total (n)
Age Body mass index, kg/m2 Gender Male, n (%) Female, n (%) Hypertension, n (%) Smoking, n (%) Diabetes, n (%) Coronary artery disease, n (%)
515 515 515
512 507 507 514
Overall (n = 515)
I (n = 173)
Ia (n = 249)
II (n = 93)
P-Value
75.17 9.36 27.96 5.66
75.08 8.98 28.18 5.44
75.61 9.65 27.74 5.90
74.17 9.27 28.16 5.45
0.45 0.68
Echocardiography
Ia Diastolic Dysfunction: An Echocardiographic Grade Anil Pandit, M.D.,* Farouk Mookadam, M.D.,* Fayaz A. Hakim, M.D.,* Eoin Mulroy, M.D.,* Rayya Saadiq, M.D.,* Mairead Doherty, M.D.,* Stephen Cha, M.Sc.,† James Seward, M.D.,‡ and Susan Wilansky, M.D.* *Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona; †Division of Biostatistics, Mayo Clinic, Rochester, Minnesota; and ‡Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Objective: To demonstrate that a distinct group of patients with Grade Ia diastolic dysfunction who do not conform to present ASE/ESE diastolic grading exists. Method and Results: Echocardiographic and demographic data of the Grade Ia diastolic dysfunction were extracted and compared with that of Grades I and II in 515 patients. The mean of age of the cohort was 75 9 years and body mass index did not differ significantly between the 3 groups (P = 0.45). Measurements of left atrial volume index (28.58 7 mL/m2 in I, 33 10 mL/m2 in Ia, and 39 12 mL/m2 in II P < 0.001), isovolumic relaxation time (IVRT) (100 17 msec in I, 103 21 msec in Ia, and 79 15 msec in II P < 0.001), deceleration time (248 52 msec in I, 263 58 msec in Ia, and 217 57 msec in II P < 0.001), medial E/e0 (10 3 in I, 18 5.00 in Ia, and 22 8 in II), and lateral E/e0 (8 3 in I, 15 6 in Ia, and 18 9 in II P < 0.001) were significantly different in grade Ia compared with I and II. These findings remained significant even after adjusting for age, gender, diabetes, and smoking. Conclusion: Patients with echocardiographic characteristics of relaxation abnormality (E/A ratio of 0.75–1.5, lateral E/e0 ≥ 12, medial E/e0 ≥ 15, and average ≥ 13). However, in clinical practice, patients have been noted to have a Grade I mitral inflow pattern (E/ A < 0.8) and a Grade II tissue Doppler (TDI) mitral annular pattern (lateral E/e0 ≥ 12, medial E/e0 ≥ 15, and average ≥ 13). The aim of the present study was to demonstrate that this distinct group of patients designated as “Grade Ia” diastolic dysfunction exists and do not conform to the current schema of left ventricular diastolic dysfunction grading systems from the ASE7 or ESE.6 Methods: Study Design: A single-center retrospective review of adult patients who underwent noninvasive hemodynam-
Ia Diastolic Dysfunction
ic assessment by transthoracic echocardiography from December 2011 to March 2012. Patient Population: Patients between ages 18 and 90 years who underwent transthoracic echocardiography for noninvasive hemodynamic assessment at Mayo Clinic Arizona from December 2011 to March 2012 were included in the study. Patients with normal diastolic function, Grade III/IIIb diastolic dysfunction, severe valvular abnormalities (≥ moderate mitral regurgitation), severe mitral annular calcification, mitral stenosis, prosthetic mitral valve, mitral annuloplasty ring, heart transplant recipients, constrictive pericarditis, hypertrophic cardiomyopathy, and those with regional wall-motion abnormalities affecting basal septum and/or lateral walls were excluded from the study. Of 620 patients, we identified 515 who were reported to have Grade I and grade II diastolic dysfunction. These patients were further divided into 3 grades based on their echocardiographic diastolic parameters including E/A ratio (normal: >1), E/e0 ratio (normal: E/e0 lateral < 12, medial < 15, and average < 13), are as follows: I: E/A ratio < 0.8 and normal filling pressures (E/e0 lateral < 12, medial < 15, and average < 13) Ia: E/A ratio < 0.8 and elevated filling pressures (E/e0 lateral ≥ 12, medial ≥ 15, and average ≥ 13) II: E/A ratio = 0.8–1.5 and elevated filling pressures (E/e0 lateral ≥12, medial ≥15, and average ≥13). Echocardiography: Subjects included in this study underwent detailed transthoracic two-dimensional and Doppler echocardiography (GE Healthcare, Milwaukee, WI, USA) based on standardized ASE guidelines and recommendations.6,9 The Valsalva maneuver was performed to assess “normal versus pseudonormal” filling patterns.6 All patients were instructed in the performance of the Valsalva maneuver and allowed to practice to proficiency and the best tracings were recorded. Echocardiographic images were uploaded digitally to an online system (ProSolv CardioVascular, Indianapolis, IN, USA) for measurement and data analysis. Board-certified echocardiographers with more than 20 years of experience interpreted the echocardiographic studies. Quantitative echocardiographic measurements were performed according to the American Society of Echocardiography guidelines9 and included: LAVI (using the area length method indexed to body surface area), ejection fraction
(EF) (using volumetric biplane Simpson’s method), and diastolic parameters (E velocity, A velocity, IVRT, DT, E/A ratio, and E/e0 ). Demographic, clinical, and echocardiographic parameters were compared between all three groups and (I vs. Ia and Ia vs. I). Statistical Analysis: The data were summarized as means and standard deviation for normally distributed data. The means were compared using Student’s t test. Categorical variables were analyzed by chi-square analysis. Any 2-tailed P-value of less than 0.05 was considered statistically significant for demographic data. However, for echocardiographic data, which were divided into the 3 groups; Grades I, Ia, and II and compared as follows: I versus Ia (I as a control) and Ia versus II (II as a control), a 2-tailed t-statistic was used with a P-value of 0.025 considered significant. One-way analysis of variance (ANOVA) was used to assess difference among the groups. A multiple regression model was used to assess if the findings remained significant when adjusted for age, gender, diabetes mellitus, and smoking. Results: Demographic Data: The demographic data of study subjects are summarized in Table I. There were more males than females in the study cohort (55% vs. 45%). The mean age of the cohort was 75 9 years and did not differ significantly among the 3 groups (P = 0.45). The mean body mass index (BMI) of the cohort was 27.9 5.6 (P = 0.68) and did not differ significantly among the study groups. Likewise, the presence of hypertension and coronary artery disease were comparable across all three groups. There were more smokers in patients with Grade II diastolic dysfunction (35% in Ia, 8% in I, and 46% in II, P < 0.001) and a significantly lower incidence of diabetics in those with grade I diastolic dysfunction. (12% in I, 21% in Ia, and 22% in II, P < 0.04). Echocardiographic Data: The echocardiographic characteristics are summarized in Tables II and III. Except for the EF, all the diastolic parameters differed among the 3 groups as shown in Table II. To demonstrate that Grade Ia has different diastolic characteristics on echo Doppler measurements, we compared echocardiographic diastology parameters of Grade Ia to Grade II and Grade I separately as shown in Table II. First, we compared the echocardiographic features of Grade Ia with Grade I as a control. We found that 57
Pandit, et al.
TABLE I Demographic Characteristics among Grade I, Ia, and II Diastolic Dysfunction Variable
Total (n)
Age Body mass index, kg/m2 Gender Male, n (%) Female, n (%) Hypertension, n (%) Smoking, n (%) Diabetes, n (%) Coronary artery disease, n (%)
515 515 515
512 507 507 514
Overall (n = 515)
I (n = 173)
Ia (n = 249)
II (n = 93)
P-Value
75.17 9.36 27.96 5.66
75.08 8.98 28.18 5.44
75.61 9.65 27.74 5.90
74.17 9.27 28.16 5.45
0.45 0.68
