title: Prediction of heart failure and adverse cardiovascular events in outpatients with coronary artery disease using mitral E/A ratio in conjunction with e-wave deceleration time: the heart and soul study.
abstract: BACKGROUND
  Deceleration time (DT) of early mitral inflow (E) is a marker of diastolic left ventricular (LV) chamber stiffness that is routinely measured during the quantitation of LV diastolic function with Doppler echocardiography. Shortened DT after myocardial infarction predicts worse cardiovascular outcome. Recent studies have shown that indexing DT to peak E-wave velocity (pE) augments its prognostic power in a population with a high prevalence of coronary risk factors and in patients with hypertension during antihypertensive treatment. However, in ambulatory subjects with stable coronary artery disease (CAD), it is not known whether DT predicts cardiovascular events and whether DT/pE improves its prognostic power.
  
  
  METHODS
  The ability of DT and DT/pE to predict heart failure (HF) hospitalizations and other major adverse cardiovascular events (MACEs) was studied prospectively in 926 ambulatory patients with stable CAD enrolled in the Heart and Soul Study. Unadjusted and multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for HF and other MACEs.
  
  
  RESULTS
  During a mean of 6.3 ± 2.0 years, there were 124 hospitalizations for HF and 198 other MACEs. Relative to participants with mitral E/A ratios in the normal range (0.75 < E/A < 1.5; n = 604), those with E/A ratios ≥ 1.5 (n = 107) had an increased risk for HF (HR, 2.54; 95% CI, 1.52-4.25, P < .001) but not for other MACEs (HR, 1.00; 95% CI, 0.60-1.68; P = 1.00), while those with E/A ratios ≤ 0.75 (n = 215) were not at increased risk for either outcome. Among patients with normal E/A ratios, lower DT/pE predicted HF (HR, 0.47; 95% CI, 0.23-0.97, P = .04 per point increase in ln{msec/[cm/sec]}), while DT alone did not. However, in this group with normal E/A ratios, neither DT/pE nor DT alone was predictive of other MACEs. In patients with E/A ratios ≤ 0.75 (n = 215) and those with E/A ratios ≥ 1.5 (n = 107), neither DT nor DT/pE predicted either end point.
  
  
  CONCLUSIONS
  In ambulatory patients with stable CAD, restrictive filling (E/A ratio ≥ 1.5) is a powerful predictor of HF. Among those with normal mitral E/A ratios (0.75-1.5), only DT/pE predicts HF, while neither DT nor DT/pE predicts other MACEs. This suggests that mitral E/A ratio has significant prognostic value in patients with CAD, and in those with normal mitral E/A ratios, the normalization of DT to pE augments its prognostic power.
authors.affiliation: Department of Medicine, Veterans Affairs Medical Center, San Francisco, California; Department of Medicine, University of California, San Francisco, San Francisco, California.
authors.forename: Rakesh K
authors.initials: RK
authors.lastname: Mishra
authors.forename: Richard B
authors.initials: RB
authors.lastname: Devereux
authors.forename: Beth E
authors.initials: BE
authors.lastname: Cohen
authors.forename: Mary A
authors.initials: MA
authors.lastname: Whooley
authors.forename: Nelson B
authors.initials: NB
authors.lastname: Schiller
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D002140:California / Q000453:epidemiology; D003324:Coronary Artery Disease / Q000150:complications* / Q000453:epidemiology / Q000503:physiopathology; D003654:Deceleration; D003971:Diastole; D015150:Echocardiography, Doppler / Q000379:methods*; D005080:Exercise Test / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D010045:Outpatients; D011237:Predictive Value of Tests; D015995:Prevalence; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D016277:Ventricular Function, Left / Q000502:physiology*