Left Ventricular Filling Pressure by Doppler Echocardiography in Patients With End-Stage Renal Disease Angela Y-M Wang, Mei Wang, Christopher W-K Lam, Iris H-S Chan, Yan Zhang, John E. Sanderson Hypertension 2008 ; July : R2 손주웅

Background  Cardiovascular disease  leading cause of death in ESRD patients  accelerated atherosclerosis and LVH  Starting long-term dialysis therapy  LVH was already present in three quarters  LV dilatation and systolic dysfunction.  important predictors of outcome

Background  LV filling pressure  noninvasively using echocardiography  important value for prognostication  The ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (EM) : E/Em ratio  using tissue doppler imaging  more accurate than other methods for estimating LV filling pressure

Background  The objective of this study  The estimation of the E/Em ratio using tissue doppler imaging adds significant long-term prognostic value  Standard clinical, biochemical, dialysis, echocardiographic parameters

Methods  Study design and subjects  4-year prospective study  220 stable patients with ESRD on CAPD  Continuous PD for > 3 months  Exclusion criteria  Severe valvular disease  Hypertrophic cardiomyopathy  Underlying malignancy  Chronic liver disease  SLE  Chronic rheumatic heart disease  CHF

Methods  Clinical and Demographic Data  Atherosclerotic vascular disease  Presence of coronary artery disease  History of angina, previous MI  CVA  peripheral vascular disease  Systolic and diastolic blood pressures  Measured on every follow-up

Methods  Echocardiography and Tissue Doppler Imaging  LV ejection fraction  Midwall fractional shortening  LV mass  Mitral inflow velocities  Myocardial velocities

Methods  Outcome Measures  Death from all causes  Cardiovascular death  Definite myocardial ischemic event  Heart failure  Cerebrovascular event  Arrhythmia  Peripheral vascular accident

Results

 During the 48 month follow-up  84 patients had died  53 deaths(63%) were of cardiovascular causes  31 deaths(37%) were of noncardiovascular causes  E/Em ratio was highest among patients who died from cardiovascular causes.

Results

Discussion  In this study  >60% of our patients with ESRD had elevated LV filling pressure  E/Em  independent and additional prognostic value for long-term mortality and cardiovascular death  single best Doppler predictor of elevated LV filling pressure  powerful independent predictor of all-cause mortality

Discussion  E/Em ratio of > 15  predicting LV end-diastolic pressure >15 mmHg  sensitivity : 82%  specificity : 88%  reliable marker of increased LV filling pressure

Discussion  E/Em ratio  more significant predictor of long-term mortality and cardiovascular death compare with mwFS  Higher E/Em ratio  indicating a higher LV diastolic filling pressure  associated with greater LV hypertrophy and dilatation and more systolic dysfunction

Discussion  E/Em ratio > 15  greater prevalence of diabetes, atherosclerotic vascular disease and heart failure, higher systolic blood pressure, greater inflammation, more anemia and hypoalbuminemia and lower residual renal function  LV hypertrophy, reduced aortic distensibility, diabetes, and coronary artery disease  all contribute to an increased LV filling pressure in ESRD  Higher E/Em ratio was associated with a worse echocardiographic profile  E/Em ratio  as surrogate marker of LV filling pressure

Discussion  Limitation  only prevalent dialysis patients were included,which may introduce survival bias  all of the parameters were measured at a single time point and did not reflect changes over time  invasive measurement of LV filling pressure was not performed  volume status was not directly assessed

Conclusion  the incremental value of measuring E/Em ratio  an estimate of LV filling pressure  standard clinical, biochemical, and dialysis risk factors and conventional echocardiographic and Doppler-derived measures  LV filling pressure should be estimated during echocardiographic examination for additional prognostication in patients with ESRD.