The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion

Yu Ting Tan; Frauke Wenzelburger; Eveline Lee; Grant Heatlie; Francisco Leyva; Kiran Patel; Michael Frenneaux; John E. Sanderson

doi:10.1016/j.jacc.2009.03.037

The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion

Yu Ting Tan, Frauke Wenzelburger, Eveline Lee, Grant Heatlie, Francisco Leyva, Kiran Patel, Michael Frenneaux, John E. Sanderson

Applied Medicine

Research output: Contribution to journal › Article › peer-review

385 Citations (Scopus)

Abstract

Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.

Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.

Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.

Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.

Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation

Original language	English
Pages (from-to)	36-46
Number of pages	11
Journal	Journal of the American College of Cardiology
Volume	54
Issue number	1
DOIs	https://doi.org/10.1016/j.jacc.2009.03.037
Publication status	Published - 30 Jun 2009

Keywords

diastolic
heart failure
rotation
strain
untwist
speckle tracking echocardiography
incremental prognostic value
mitral annulus velocity
long axis function
myocardial-infarction
natriuretic peptide
chamber stiffness
index
dysfunction
hypertrophy

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Tan, Y. T., Wenzelburger, F., Lee, E., Heatlie, G., Leyva, F., Patel, K., Frenneaux, M., & Sanderson, J. E. (2009). The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. Journal of the American College of Cardiology, 54(1), 36-46. https://doi.org/10.1016/j.jacc.2009.03.037

The pathophysiology of heart failure with normal ejection fraction : exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. / Tan, Yu Ting; Wenzelburger, Frauke; Lee, Eveline et al.

In: Journal of the American College of Cardiology, Vol. 54, No. 1, 30.06.2009, p. 36-46.

Research output: Contribution to journal › Article › peer-review

Tan, YT, Wenzelburger, F, Lee, E, Heatlie, G, Leyva, F, Patel, K, Frenneaux, M & Sanderson, JE 2009, 'The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion', Journal of the American College of Cardiology, vol. 54, no. 1, pp. 36-46. https://doi.org/10.1016/j.jacc.2009.03.037

Tan YT, Wenzelburger F, Lee E, Heatlie G, Leyva F, Patel K et al. The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. Journal of the American College of Cardiology. 2009 Jun 30;54(1):36-46. doi: 10.1016/j.jacc.2009.03.037

Tan, Yu Ting ; Wenzelburger, Frauke ; Lee, Eveline et al. / The pathophysiology of heart failure with normal ejection fraction : exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. In: Journal of the American College of Cardiology. 2009 ; Vol. 54, No. 1. pp. 36-46.

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title = "The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion",

abstract = "Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation",

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T1 - The pathophysiology of heart failure with normal ejection fraction

T2 - exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion

AU - Tan, Yu Ting

AU - Wenzelburger, Frauke

AU - Lee, Eveline

AU - Heatlie, Grant

AU - Leyva, Francisco

AU - Patel, Kiran

AU - Frenneaux, Michael

AU - Sanderson, John E.

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N2 - Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation

AB - Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation

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KW - myocardial-infarction

KW - natriuretic peptide

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KW - hypertrophy

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