Acute pulmonary edema in patients with reduced left ventricular ejection fraction is associated with concentric left ventricular geometry

  • Junichi Imanishi
  • Kenji Kaihotsu
  • Sachiko Yoshikawa
  • Makoto Nishimori
  • Naohiko Sone
  • Tomoyuki Honjo
  • Masanori Iwahashi
Original Paper


Although acute pulmonary edema (APE) is common in patients with heart failure (HF) with preserved ejection fraction (EF), its pathogenesis in patients with HF with reduced EF (HFrEF) is not completely understood. The purpose of our study was to explore the contributions of left ventricular (LV) geometry to understand the difference between HFrEF patients with or without APE. We studied 122 consecutive acute decompensated HF patients with HFrEF (≤40%). APE was defined as acute-onset dyspnea and radiographic alveolar edema requiring immediate airway intervention. LV geometry was determined from a combination of the LV mass index and relative wall thickness (RWT). Long-term unfavorable outcome events were tracked during a follow-up of a median of 21 months (interquartile range, 10–28 months), during which APE was observed in 29 patients (24%). Compared to those without APE, hospitalized patients with APE had a higher systolic blood pressure, RWT, and LVEF and lower end-diastolic dimension. Among echocardiographic variables, a multivariate logistic regression analysis identified RWT as the only independent determinant of APE (hazard ratio: 2.46, p < 0.001). Those with concentric geometry (n = 25; RWT > 0.42) had a higher incidence of APE relative to those with non-concentric geometry. Furthermore, among patients with APE, mortality was significantly higher among those with concentric geometry (log-rank, p = 0.008). Compared with non-concentric geometry, concentric geometry (increased RWT, not LV mass) was strongly associated with APE onset and a poorer outcome among APE patients. An easily obtained echocardiographic RWT index may facilitate the risk stratification of patients.


Echocardiography Acute pulmonary edema Left ventricular geometry Relative wall thickness 



The authors would like to thank Kensuke Matsumoto, MD, Ph.D for editorial assistance.

Compliance with ethical standards

Conflict of interest

The authors have no conflict of interest to disclose.


  1. 1.
    Felker GM, Adams KF Jr, Konstam MA, O’Connor CM, Gheorghiade M (2003) The problem of decompensated heart failure: nomenclature, classification, and risk stratification. Am Heart J 145(2 Suppl):S18–S25. doi: 10.1067/mhj.2003.150 CrossRefPubMedGoogle Scholar
  2. 2.
    Girou E, Brun-Buisson C, Taille S, Lemaire F, Brochard L (2003) Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA 290(22):2985–2991. doi: 10.1001/jama.290.22.2985 CrossRefPubMedGoogle Scholar
  3. 3.
    Gheorghiade M, Abraham WT, Albert NM, Greenberg BH, O’Connor CM, She L, Stough WG, Yancy CW, Young JB, Fonarow GC, Investigators O-H, Coordinators (2006) Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA 296(18):2217–2226. doi: 10.1001/jama.296.18.2217 CrossRefPubMedGoogle Scholar
  4. 4.
    Kawaguchi M, Hay I, Fetics B, Kass DA (2003) Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations. Circulation 107(5):714–720CrossRefPubMedGoogle Scholar
  5. 5.
    McEniery CM, Qasem A, Schmitt M, Avolio AP, Cockcroft JR, Wilkinson IB (2003) Endothelin-1 regulates arterial pulse wave velocity in vivo. J Am Coll Cardiol 42(11):1975–1981CrossRefPubMedGoogle Scholar
  6. 6.
    Vrints CJ, Bult H, Bosmans J, Herman AG, Snoeck JP (1992) Paradoxical vasoconstriction as result of acetylcholine and serotonin in diseased human coronary arteries. Eur Heart J 13(6):824–831CrossRefPubMedGoogle Scholar
  7. 7.
    Lenders JW, Eisenhofer G, Mannelli M, Pacak K (2005) Phaeochromocytoma. The Lancet 366(9486):665–675. doi: 10.1016/S0140-6736(05)67139-5 CrossRefGoogle Scholar
  8. 8.
    Yamanaka O, Yasumasa F, Nakamura T, Ohno A, Endo Y, Yoshimi K, Miura K, Yamaguchi H (1994) “Myocardial stunning"-like phenomenon during a crisis of pheochromocytoma. Jpn Circ J 58(9):737–742CrossRefPubMedGoogle Scholar
  9. 9.
    Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF, Aranda JM Jr, Abraham WT, Smart FW, Stevenson LW, Kueffer FJ, Bourge RC (2008) Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation 118(14):1433–1441. doi: 10.1161/CIRCULATIONAHA.108.783910 CrossRefPubMedGoogle Scholar
  10. 10.
    Ganau A, Devereux RB, Roman MJ, de Simone G, Pickering TG, Saba PS, Vargiu P, Simongini I, Laragh JH (1992) Patterns of left ventricular hypertrophy and geometric remodeling in essential hypertension. J Am Coll Cardiol 19(7):1550–1558CrossRefPubMedGoogle Scholar
  11. 11.
    de Simone G, Devereux RB, Roman MJ, Alderman MH, Laragh JH (1994) Relation of obesity and gender to left ventricular hypertrophy in normotensive and hypertensive adults. Hypertension 23(5):600–606CrossRefPubMedGoogle Scholar
  12. 12.
    Muiesan ML, Salvetti M, Monteduro C, Bonzi B, Paini A, Viola S, Poisa P, Rizzoni D, Castellano M, Agabiti-Rosei E (2004) Left ventricular concentric geometry during treatment adversely affects cardiovascular prognosis in hypertensive patients. Hypertension 43(4):731–738. doi: 10.1161/ CrossRefPubMedGoogle Scholar
  13. 13.
    Milani RV, Lavie CJ, Mehra MR, Ventura HO, Kurtz JD, Messerli FH (2006) Left ventricular geometry and survival in patients with normal left ventricular ejection fraction. Am J Cardiol 97(7):959–963. doi: 10.1016/j.amjcard.2005.10.030 CrossRefPubMedGoogle Scholar
  14. 14.
    Koren MJ, Devereux RB, Casale PN, Savage DD, Laragh JH (1991) Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med 114(5):345–352CrossRefPubMedGoogle Scholar
  15. 15.
    Cohn JN (1995) Structural basis for heart failure. Ventricular remodeling and its pharmacological inhibition. Circulation 91(10):2504–2507CrossRefPubMedGoogle Scholar
  16. 16.
    Cohn JN, Francis GS (1995) Cardiac failure: a revised paradigm. J Card Fail 1(4):261–266CrossRefPubMedGoogle Scholar
  17. 17.
    Verma A, Meris A, Skali H, Ghali JK, Arnold JM, Bourgoun M, Velazquez EJ, McMurray JJ, Kober L, Pfeffer MA, Califf RM, Solomon SD (2008) Prognostic implications of left ventricular mass and geometry following myocardial infarction: the VALIANT (VALsartan In Acute myocardial iNfarcTion) Echocardiographic Study. JACC Cardiovasc Imaging 1(5):582–591. doi: 10.1016/j.jcmg.2008.05.012 CrossRefPubMedGoogle Scholar
  18. 18.
    McKee PA, Castelli WP, McNamara PM, Kannel WB (1971) The natural history of congestive heart failure: the Framingham study. N Engl J Med 285(26):1441–1446. doi: 10.1056/NEJM197112232852601 CrossRefPubMedGoogle Scholar
  19. 19.
    Kramer K, Kirkman P, Kitzman D, Little WC (2000) Flash pulmonary edema: association with hypertension and reoccurrence despite coronary revascularization. Am Heart J 140(3):451–455. doi: 10.1067/mhj.2000.108828 CrossRefPubMedGoogle Scholar
  20. 20.
    Gheorghiade M, Zannad F, Sopko G, Klein L, Pina IL, Konstam MA, Massie BM, Roland E, Targum S, Collins SP, Filippatos G, Tavazzi L, International Working Group on Acute Heart Failure S (2005) Acute heart failure syndromes: current state and framework for future research. Circulation 112(25):3958–3968. doi: 10.1161/CIRCULATIONAHA.105.590091 CrossRefPubMedGoogle Scholar
  21. 21.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ, Chamber Quantification Writing G, American Society of Echocardiography’s G, Standards C, European Association of E (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18 (12):1440–1463. doi: 10.1016/j.echo.2005.10.005 CrossRefPubMedGoogle Scholar
  22. 22.
    Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, Reichek N (1986) Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol 57(6):450–458CrossRefPubMedGoogle Scholar
  23. 23.
    Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelisa A (2009) Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 10(2):165–193. doi: 10.1093/ejechocard/jep007 CrossRefPubMedGoogle Scholar
  24. 24.
    Shigematsu Y, Hamada M, Mukai M, Matsuoka H, Sumimoto T, Hiwada K (1995) Clinical evidence for an association between left ventricular geometric adaptation and extracardiac target organ damage in essential hypertension. J Hypertens 13(1):155–160CrossRefPubMedGoogle Scholar
  25. 25.
    Reichek N, Devereux RB (1982) Reliable estimation of peak left ventricular systolic pressure by M-mode echographic-determined end-diastolic relative wall thickness: identification of severe valvular aortic stenosis in adult patients. Am Heart J 103(2):202–203CrossRefPubMedGoogle Scholar
  26. 26.
    Eaton LW, Weiss JL, Bulkley BH, Garrison JB, Weisfeldt ML (1979) Regional cardiac dilatation after acute myocardial infarction: recognition by two-dimensional echocardiography. N Engl J Med 300(2):57–62. doi: 10.1056/NEJM197901113000202 CrossRefPubMedGoogle Scholar
  27. 27.
    Erlebacher JA, Weiss JL, Eaton LW, Kallman C, Weisfeldt ML, Bulkley BH (1982) Late effects of acute infarct dilation on heart size: a two dimensional echocardiographic study. Am J Cardiol 49(5):1120–1126CrossRefPubMedGoogle Scholar
  28. 28.
    McKay RG, Pfeffer MA, Pasternak RC, Markis JE, Come PC, Nakao S, Alderman JD, Ferguson JJ, Safian RD, Grossman W (1986) Left ventricular remodeling after myocardial infarction: a corollary to infarct expansion. Circulation 74(4):693–702CrossRefPubMedGoogle Scholar
  29. 29.
    Zile MR, Baicu CF, Gaasch WH (2004) Diastolic heart failure–abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med 350(19):1953–1959. doi: 10.1056/NEJMoa032566 CrossRefPubMedGoogle Scholar
  30. 30.
    Li L, Shigematsu Y, Hamada M, Hiwada K (2001) Relative wall thickness is an independent predictor of left ventricular systolic and diastolic dysfunctions in essential hypertension. Hypertens Res 24(5):493–499CrossRefPubMedGoogle Scholar
  31. 31.
    Quinones MA, Gaasch WH, Cole JS, Alexander JK (1975) Echocardiographic determination of left ventricular stress-velocity relations. Circulation 51(4):689–700CrossRefPubMedGoogle Scholar
  32. 32.
    Matsukubo H, Matsuura T, Endo N, Asayama J, Watanabe T (1977) Echocardiographic measurement of right ventricular wall thickness. A new application of subxiphoid echocardiography. Circulation 56(2):278–284CrossRefPubMedGoogle Scholar
  33. 33.
    Roman MJ, Ganau A, Saba PS, Pini R, Pickering TG, Devereux RB (2000) Impact of arterial stiffening on left ventricular structure. Hypertension 36(4):489–494CrossRefPubMedGoogle Scholar
  34. 34.
    Figueras J, Baneras J, Pena-Gil C, Barrabes JA, Rodriguez Palomares J, Garcia Dorado D (2016) Hospital and 4-Year Mortality Predictors in Patients With Acute Pulmonary Edema With and Without Coronary Artery Disease. J Am Heart Assoc. doi: 10.1161/JAHA.115.002581 PubMedGoogle Scholar
  35. 35.
    Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Battistelli M, Bartoccini C, Santucci A, Santucci C, Reboldi G, Porcellati C (1995) Adverse prognostic significance of concentric remodeling of the left ventricle in hypertensive patients with normal left ventricular mass. J Am Coll Cardiol 25(4):871–878. doi: 10.1016/0735-1097(94)00424-O CrossRefPubMedGoogle Scholar
  36. 36.
    Gheorghiade M, Pang PS (2009) Acute heart failure syndromes. J Am Coll Cardiol 53(7):557–573. doi: 10.1016/j.jacc.2008.10.041 CrossRefPubMedGoogle Scholar
  37. 37.
    Devereux RB, Pini R, Aurigemma GP, Roman MJ (1997) Measurement of left ventricular mass: methodology and expertise. J Hypertens 15(8):801–809CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2017

Authors and Affiliations

  • Junichi Imanishi
    • 1
  • Kenji Kaihotsu
    • 1
  • Sachiko Yoshikawa
    • 1
  • Makoto Nishimori
    • 1
  • Naohiko Sone
    • 1
  • Tomoyuki Honjo
    • 1
  • Masanori Iwahashi
    • 1
  1. 1.Division of Cardiovascular Medicine, Department of Internal MedicineShinko HospitalKobeJapan

Personalised recommendations