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1 MINISTRY OF EDUCATION AND MINISTRY OF TRAINING DEFENCE MILITARY MEDICINE ACADEMY ====== LÊ THỊ BÍCH VÂN STUDY THE CHARACTERISTICS OF SEVERAL PARAMETERS USED TO ESTIMATE THE LEFT VENTRICULAR FILLING PRESSURE ON DOPPLER ECHOCARDIOGRAPHY IN NYHA III – IV HEART FAILURE PATIENT Specialized: Internal medicine Code: 9720107 SUMMARY OF MEDICAL DOCTORAL THESIS HA NOI - 2019 THE RESEARCH WORK ACCOMPLISHED AT MILITARY MEDICAL UNIVERSITY Scientific supervisors: Phạm Nguyễn Vinh MD, PhD Critic 1: Phạm Hữu Văn, MD, PhD Critic 2: Phạm Nguyên Sơn, MD, PhD Critic 3: Hồng Đình Anh, MD, PhD The Thesis will be defended against the Jury of Military Medical University on: … hour, month, date This Thesis can be referred at: National Library of Viet Nam Library of Military Medical University INTRODUCTION Heart failure (HF), the terminal stage of almost every known cardiac disorders, is one of the most frequently encountered medical conditions in the clinics and its prevalence has been shown to increase recently In Vietnam, the incidence of heart failure also has an escalating tendency and a major problem that cardiologists usually face is that serious HF has a high mortality rate Advanced HF patients having reduced left ventricular systolic function usually have significant concomitant systolic and diastolic function disorders leading to an increase in left ventricular filling pressure (LVFP) In the clinical context, the LVFP has important diagnostic, prognostic values which help cardiologists choose the right management timely LVFP is considered to be: end-diastolic ventricular pressure, mean pulmonary capillary wedge pressure In addition to cardiac catheterization which allows accurate measurement of the end-diastolic ventricular pressure, the pulmonary capillary wedge pressure, etc., Doppler ultrasound has long been recognized as a reliable imaging modality that can be used to evaluate increased LVFP clinically In our country, several studies on evaluating diastolic function using Doppler ultrasound were conducted on a variety of patient populations Some studies strived to find a relationship between Doppler ultrasound parameters and LVFP, and however they were done in a discrete way and therefore has a limited specificity and sensitivity In 2016, according to the ASE’s guidelines, LVFP measurements in HF patients with reduced EF need an integration of Doppler parameters and tissue Doppler has become very valuable and beneficial in the clinical context On the other hand, the invasiveness of cardiac catheterization is considered to be more difficult, expensive and riskier than Doppler echocardiography and is rarely used in real-life HF patients; in addition, measuring LVFP based on symptoms such as dyspnea, neck vein distension, chest films, etc has certain limitations and highly depends on clinical examination skills LVFP is considered as elevated when enddiastolic left ventricular pressure > 16 mmHg or PCWP > 12 mmHg, which is in accordance with the changes in Doppler parameters, including: peak E-wave velocity, E/A ratio, E/e’ ratio, tricuspid regurgitation peak velocity (TRV), left atrial volume index (LAVi) that were published in LVFP measurements guidelines of ASE 2016 and there are not yet study in Vietnam Therefore, we decide to conduct this this thesis: “ Study the characteristics of several parameters used to estimate the left ventricular filling pressure on Doppler echocardiography in NYHA III – IV heart failure patient” This study with the following objectives in mind: a Evaluating the characteristics of several parameters used to estimate the LVFP on Doppler echocardiography and tissue Doppler including: peak E-wave velocity, E/A ratio, E/e’ ratio, peak TRV, atrial volume index in NYHA III-IV HF patients with EF equal to 40% or less b Identifying the relationship between several parameters used to measure LVFP and various clinical, sub-clinical characteristics in NYHA III-IV HF patients with EF equal to 40% or less Scientific significance, practice and make new contributions to the topic This study has scientific significance, practice and make new contributions to Cardiology, especially Echocardiology, such as : • The study found that the difference of the characteristics of several parameters used to estimate the LVFP on Doppler echocardiography and tissue Doppler including between patients with advanced heart failure and control group • The integration of these parameters used to estimate LVFP according to ASE 2016 in our study demonstrates that there is no statistical significance in incidence of elevated LVFP between the EF< 30% group and 30 < EF ≤ 40%, between NYHA III and NYHA IV patients, between the Ischemic heart disase and BCTTG, between Male-Female and age group • There are 83 patients (82,2%) identified to have elevated LVFP, the rest identified to have normal LVFP • The E/e’ ratio > 14 when used alone to estimate elevated LVFP (41.6%) will miss half of the time where there is an elevated LVFP compared to the case where parameters were integrated and used (82,2%) • Based on peak E-wave ratio and E/A ratio from the transmitral flow, it is confirmed that 8.91% of the cases don’t have elevated LVFP and 44,55% have elevated LVFP without the need to investigate other parameters, however, almost half of the cases need more parameters to confirm the existence of elevated LVFP • The study shown that some relationships between several parameters used to measure LVFP and various clinical, subclinical characteristics in NYHA III-IV HF patients with EF equal to 40% or less The layout of thesis + The thesis has 143 pages include sections: questioning (2 pages), Chapter 1: Overview (page 43), Chapter 2: Objects and methods of research (21 pages), Chapter 3: The results research (46 pages), chapter 4: Discussion (30 pages) Conclusion (2 pages) Recommendations (1 page) + The thesis has 48 tables, 17 charts, 13 pictures, 01 diagrams The thesis uses 125 reference documents (17 Vietnamese, 56 English) CHAPTER OVERVIEW OF DOCUMENTS 1.1 General and epidemiological chronic heart failure with reduced ejection fraction There are many changes in the definition of HF In 1950s, HF is a condition in which the dysfunction of myocardial contraction causes heart to lose its ability to supply blood to the body appropriately This condition first occurs when the patient exerts, and then it happens even when the patient rests.In 2016 - 2017, the definition based on ASC and ESC : HF is a clinical syndrome characterized by typical symptoms (e.g breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/ or elevated intracardiac pressures at rest or during stress From 2016 up to now, ESC offers some of new definitions : The main terminology used to describe HF is historical and is based on measurement of the LVEF - HF with normal LVEF (HFpEF) : LVEF ≥ 50%, accompanied with signs and/or symptoms, elevated natriuretic peptide level or at least abnormal structure of heart (left ventricular thickness and/or dilated left atrium) or left ventricular diastolic dysfunction - HF with mild reduced EF (HFmrEF)] : LVEF in the range of 40 – 49%, accompanied with signs and/or symptoms, elevated natriuretic peptide level or at least abnormal structure of heart (left ventricular thickness and/or dilated left atrium) or left ventricular diastolic dysfunction - HF with reduced EF (HFpEF)] : LVEF typically considered equal or less than 40% accompanied with signs and/or symptoms Epidemiology It is estimated that 38 million people worldwide have heart failure (HF), with most published studies reporting a prevalence of between 1% and 2% of the adult population Data from Europe and North America suggest that 1%–2% of all hospital admissions are related to HF, amounting to more than million admissions annually, with 80– 90% being due to decompensation of chronic HF The syndrome still carries a poor prognosis: 5% to 10% of patients die during hospitalization, with a further 15% dying by months, and over half of patients die within years of their first HF hospitalization Rates of rehospi- talization are also high The financial burden of HF, principally due to the cost of hospitalization, is expected to increase substantially in the coming decades due to the aging of the population worldwide 1.2 Left ventricular filling pressure The term LV filling pressures can refer to mean pulmonary capillary wedge pressure (PCWP) (which is an indirect estimate of LV diastolic pressures), mean left atrial pressure (LAP), LV pre-A wave pressure, mean LV diastolic pressure, and LV end-diastolic pressure (LVEDP) The optimal performance of the left ventricle depends on its ability to cycle between two states: (1) a compliant chamber in diastole that allows the left ventricle to fill from low LA pressure and (2) a stiff chamber (rapidly rising pressure) in systole that ejects the stroke volume at arterial pressures The ventricle has two alternating functions: systolic ejection and diastolic filling Furthermore, the stroke volume must increase in 10 response to demand, such as exercise, without much increase in LA pressure The theoretically optimal LV pressure curve is rectangular, with an instantaneous rise to peak and an instantaneous fall to low diastolic pressures, which allows for the maximum time for LV filling This theoretically optimal situation is approached by the cyclic interaction of myofilaments and assumes competent mitral and aortic valves Diastole starts at aortic valve closure and includes LV pressure fall, rapid filling, diastasis (at slower heart rates), and atrial contraction Elevated filling pressures are the main physiologic consequence of diastolic dysfunction Filling pressures are considered elevated when the mean pulmonary capillary wedge pressure (PCWP) is > 12 mm Hg or when the LVEDP is > 16mm Hg 1.2.4 Estimation of the left ventricular filling pressure by Doppler echocardiography Chart 2.1 shows the estimation of the left ventricular filling pressure by Doppler echocardiography in HF patients who has reduced LVEF (classified by ASE 2016) 10 19 CHAPTER RESEARCH RESULTS 3.1 General Characteristics of the study population Age : the average age of our study population is 62 ± 15 age, the age of severe HF patients is ranged from 60 to 79 age Sex : male is 1.88 times higher than female Sex ratios of disease group and control group are equal The average age of disease group is 1.8 times higher than one of control group Because of the significant difference of age between two group, we only use the parameters of the control group for reference Table 3.2 The subgroup in our study Subgroup Patient, n (%) Group with 30% < EF ≤ 38 (37,62) 40% Group with EF ≤ 30% 63 (62,38) Group with NYHA III 43 (42,57) Group with NYHA IV 58 (57,43) Group with dilated 36 (35,64) myocardiopathy Group with ischemia heart 65 (64,36) disease Group aged 20 – 39 (7.92) Group aged 40 – 59 32 (31,68) Group aged ≥ 60 61 (60,40) Group with QRS ≥ 120 ms 30 (29,70) Group with QRS < 120 ms 71 (70,30) Disease group : 101 inpatients with NYHA classes III-IV and LVEF ≤ 40%, after analysing, we divided this group to subgroup listed (table 3.2) 19 20 3.2 Characteristics of Doppler echocardiographic parameters 3.2.1 Characteristics of several Doppler echocardiographic parameters of study population : Table 3.13 Study population’s characteristics of the spectral Doppler through mitral valve and tissue Doppler Characteristics Disease group n =101 Control group n =66 P E (cm/s) ( ±SD) 86,68± 27,19 85,19± 13,53 >0,05 E/A ( ±SD) 1,99± 1,18 1,63± 0,41 0,006 EDT (ms) ( ±SD) 142,68±71,51 208,57±46,35