title: Pre-load stress echocardiography for predicting the prognosis in mild heart failure.
abstract: OBJECTIVE
  This study sought to introduce and confirm the efficacy of pre-load stress echocardiography with leg-positive pressure (LPP) for improving risk stratification of patients with mild stable heart failure.
  
  
  BACKGROUND
  Heart failure patients with mild symptoms and a poor prognosis should be identified and treated aggressively to improve clinical outcome.
  
  
  METHODS
  We performed transthoracic echocardiography with LPP in 202 patients with chronic cardiac disease. Twenty-two of these patients also underwent cardiac catheterization, and left ventricular pressure was measured during LPP along with simultaneous Doppler recordings. Patients were classified into 3 groups on the basis of their left ventricular (LV) diastolic dysfunction as assessed by transmitral flow velocity: restrictive or pseudonormal (PN) at rest, impaired relaxation (IR) at rest and during LPP (stable IR), and IR at rest and PN during LPP (unstable IR). Clinical outcome was compared among these groups.
  
  
  RESULTS
  The LPP increased LV end-diastolic pressure from 15.8 ± 4.7 mm Hg to 20.5 ± 5.0 mm Hg in the unstable IR group and from 10.5 ± 2.6 mm Hg to 14.7 ± 3.8 mm Hg in the stable IR group (both p < 0.001). During an average follow-up of 548 ± 407 days, 5 patients had cardiac death, 37 had acute heart failure, 4 had an acute myocardial infarction, and 7 had a stroke. The all-cause cardiac event rate in unstable IR was higher than in stable IR (p < 0.001), and was similar in the PN group (p = 0.81). Event-free survival was significantly lower in unstable IR than in stable IR (p = 0.003). In a Cox proportional hazards model, unstable IR was an independent predictor of all-cause cardiac events (hazard ratio: 8.0; p < 0.001).
  
  
  CONCLUSIONS
  The left LV end-diastolic pressure-volume relationship can be estimated by changes in transmitral flow velocity during LPP. Thus, pre-load stress echocardiography using LPP provides additional prognostic information in mild heart failure beyond that provided by conventional Doppler echocardiography at rest.
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan. Electronic address: yamadah@tokushima-u.ac.jp.
authors: Hirotsugu
authors: H
authors: Yamada
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Kenya
authors: K
authors: Kusunose
authors: Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan.
authors: Susumu
authors: S
authors: Nishio
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Mika
authors: M
authors: Bando
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Junko
authors: J
authors: Hotchi
authors: Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan.
authors: Shuji
authors: S
authors: Hayashi
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Takayuki
authors: T
authors: Ise
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Shusuke
authors: S
authors: Yagi
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Koji
authors: K
authors: Yamaguchi
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Takashi
authors: T
authors: Iwase
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Takeshi
authors: T
authors: Soeki
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Tetsuzo
authors: T
authors: Wakatsuki
authors: Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
authors: Masataka
authors: M
authors: Sata
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D006328:Cardiac Catheterization; D002908:Chronic Disease; D025401:Echocardiography, Stress; D005260:Female; D006333:Heart Failure / Q000175:diagnosis*; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis
keywords: Doppler echocardiography; heart failure; leg-positive pressure; stress echocardiography; survival