title: Exercise Tolerance and the Post Exercise Diastolic Filling Pattern in Patients With the Resting Impaired Relaxation.
abstract: BACKGROUND
  In patients with normal LV systolic function, cardiac output increases with exercise mediated by increased stroke volume early in exercise and an increase in heart rate later in exercise. Despite normal LV systolic function, patients who display an impaired relaxation pattern may have a reduced exercise tolerance. We hypothesized that the resting impaired relaxation pattern that persists during exercise results in reduced LV filling volume and reduced exercise tolerance.
  
  
  METHODS
  We evaluated consecutive exercise echocardiograms performed at Harper Hospital from 1998-2000 for patients with sinus rhythm, normal resting wall motion and ejection fraction (> 55%), evidence of resting impaired relaxation, and a negative exercise echocardiogram. There were 49 patients fitting the above criteria who were compared with a group of age and sex matched patients (43 patients) with a normal rest and exercise echocardiogram with normal resting transmitral Doppler. Rest and post exercise echocardiography and Doppler parameters were obtained.
  
  
  RESULTS
  Patients in the impaired relaxation group demonstrated shorter exercise times as compared to the normal control group (8.8 ± 1.6 versus 9.7 ± 2.0 minutes, P < 0.001). In patients with normal resting transmitral diastolic filling, there was an increased the extent of atrial contribution to LV filling volume post exercise associated with shortening of isovolumic relaxation. Two patterns were seen in the impaired relaxation group post exercise. In 1 subgroup in which E/A ratio decreased post exercise, exercise duration was reduced (7.4 ± 1.3 minutes, P < 0.001) as compared to the subgroup with E/A increase (9.6 ± 1.2 minutes) post exercise which was similar to normal controls. Forward stepwise regression indicated that exercise time was primarily related to E/A change post exercise for all patient groups (r = 0.625, P = 0.0008). Specifically, this was true for patients with E/A reversal at rest (r = 0.584, P = 0.0028). However, for patients with normal diastolic filling at rest, the diastolic velocity integral was the major predictor (r = 0.695, P < 0.0084).
  
  
  CONCLUSIONS
  We conclude that the transmitral Doppler pattern post exercise provides insight into the mechanism of reduced exercise tolerance in some patients with the resting impaired relaxation pattern. Preservation of this pattern post exercise is associated with reduced exercise tolerance.
authors.affiliation: Wayne State University, Detroit, MI and University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Lavine
authors.affiliation: Wayne State University, Detroit, MI and University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Walsh
keywords: Diastolic filling; Exercise; Impaired relaxation; Transmitral filling patterns