Application of the newest European Association of Cardiovascular Imaging Recommendation regarding the long-term prognostic relevance of left ventricular diastolic function in heart failure with preserved ejection fraction
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The long-term predictive value of the new proposed algorithm in the updated 2016 guidelines of the European Association of Cardiovascular Imaging to assess diastolic dysfunction (DD) in patients with heart failure with preserved ejection fraction (HFpEF) has not been validated.
The analysis included 451 patients who were diagnosed with HFpEF as confirmed via echocardiography. The endpoints were mortality and hospitalization for HF. The Kaplan–Meier curves and Cox regression models were generated to determine the risk of all-cause mortality based on the 2016 and 2009 DD grading algorithm, respectively. We evaluated the net reclassification index of outcomes on the basis of 2009 DD grade after abiding by the 2016 recommendations.
After a follow-up of 2976 days, 119 patients (26.4%) died. According to the 2016 DD grading, grade III DD was associated with a significantly higher risk of mortality (hazard ratio [HR], 2.209; 95% CI 1.144–4.266) and HF hospitalization (HR, 2.047; 95% CI 1.348–3.870), as compared with grade I DD. Grade II DD was also associated with a higher risk of mortality (HR, 1.538; 95% CI 1.313–1.924). However, only grade III DD was independently associated with worse mortality based on 2009 DD grading. The net reclassification index for mortality increased significantly after grading by 2016 algorithm (10.6%, p < 0.001).
The 2016 DD grading algorithm showed improved prognostic value of long-term mortality in patients with HFpEF. Based on the findings of the study, the appropriate grading of DD is important in the prognostication of patients with HFpEF.
• The application of the 2016 European Association of Cardiovascular Imaging recommendations diastolic dysfunction (DD) grading algorithm improves the predictive value for mortality.
• Our analysis suggests DD grades II and III based on 2016 guidelines is associated with poor outcomes as compared with grade I. The echocardiographic indices of the new algorithm should be obtained and applied to effectively evaluate DD.
KeywordsLeft-sided heart failure Transthoracic echocardiography Mortality
Angiotensin-converting enzyme inhibitors
Angiotensin II receptor blockers
American Society of Echocardiography
Calcium channel blockers
European Association of Cardiovascular Imaging
Heart failure with preserved ejection fraction
Irbesartan in Heart Failure With Preserved Ejection Fraction
Left atrial pressure
Left atrium volume index
Left ventricular diastolic dysfunction
Major cardiovascular events
New York Heart Association
Pulmonary capillary wedge pressure
Receiver operating characteristic
Systolic heart failure
Taiwan Diastolic Heart Failure Registry
Tricuspid regurgitation pressure gradient
This work was supported, in part, by the IBMS CRC Research Program of Institute of Biomedical Science, Academia Sinica (IBMS-CRC99-P02), and grants (NSC 99-2314-B-002-131-MY3, NSC 100-2341-B-002-160-) from the National Science Council of R.O.C.
Compliance with ethical standards
The scientific guarantor of this publication is Dr. Cho-Kai Wu.
Conflict of interest
The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.
Statistics and biometry
No complex statistical methods were necessary for this paper.
Written informed consent was obtained from all subjects (patients) in this study.
Institutional Review Board approval was obtained.
• Performed at one institution
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