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5 MID Study

5 MID Study. 5 Year Mortality in Patients with Left Ventricular Diastolic Dysfunction and Preserved Ejection Fraction. Catholic Health System, Buffalo, NY Salim H Memon M.B.B.S. Yuji Saito M.D., Ph.D., F.A.C.C. Background. Epidemiological Importance Olmsted County, Minnesota

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5 MID Study

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  1. 5 MID Study 5 Year Mortality in Patients with Left Ventricular Diastolic Dysfunction and Preserved Ejection Fraction Catholic Health System, Buffalo, NY Salim H Memon M.B.B.S. Yuji Saito M.D., Ph.D., F.A.C.C.

  2. Background Epidemiological Importance Olmsted County, Minnesota 2042 randomly selected residents (mean age 63) 5.6% had moderate or severe diastolic dysfunction with normal EF Cleveland Clinic study 36,261 adults (mean age 58) with LVEF ≥55% 65.2 % had diastolic dysfunction

  3. Background Clinical Importance Asymptomatic Risk factor for DHF / HFpEF Heart failure Prevalence of more than 5 million 50% have DHF / HFpEF

  4. Background Prognostic Importance Limited Studies available Increased Mortality with DD (3 significant studies) No increased Mortality with Mild/Grade 1 DD No mortality reducing drugs up to date

  5. Background Types of LV Dysfunction • Systolic - Impaired cardiac contractility • Diastolic - Abnormal cardiac relaxation, stiffness or filling Distinct disorders Not a continuous spectrum of disorders Can co-exist

  6. Background Terminology • Diastolic Dysfunction • Diastolic Heart Failure • Heart Failure with Preserved Ejection Fraction (HFpEF) Characteristics: • Normal LVEF • Normal LV end-diastolic volume • Abnormal diastolic function

  7. Normal Diastolic Function Video from:

  8. Abnormal Diastolic Function Video from:

  9. Diagnosis and Grading Requires Comprehensive assessment using Echocardiography • Transmitral Doppler inflow velocity patterns • Pulmonary venous Doppler flow patterns • Tissue Doppler velocities • Color M-mode flow propagation velocity

  10. Trans Mitral Doppler Inflow pattern

  11. Trans Mitral Doppler Inflow pattern

  12. Tissue Doppler (Septal) a΄ e΄

  13. Measuring IVRT from CW Doppler

  14. Grading Diastolic Dysfunction

  15. 5 MID Study • Study Design • Study Flow Diagram • Outcome Measures • Methods • Statistical Analyses used • Results • Conclusions • Strengths and Limitations • Future Considerations • References • Acknowledgements

  16. Study Design • Case Control Retrospective Analysis • Comparison of patients with normal and abnormal diastolic function in terms of all cause mortality over 60 months from the date of 2-Dimensional Echocardiogram • Institutional Review Board Approval • Sisters of Charity Hospital

  17. Study Design Inclusion Criteria: • Age ≥ 18 • 2-D Echocardiogram between Dec’07 – Dec’08 • Preserved Ejection Fraction (≥50%)

  18. Study Design Exclusion Criteria: • LV Ejection Fraction < 50% • Atrial Fibrillation • Unable to assess Diastolic function • Unavailable Mortality Data • Severe Mitral Valve Disease • History of Mitral Valve Surgery • Two 2D-Echocardiograms (2nd Echo excluded)

  19. Study Flow Diagram 3018 Patients who has 2-Dimensional Echocardiograms from Dec’07 to Dec’08 were assessed for eligibility for the study 2107 Patients were excluded LV Ejection Fraction < 50% Atrial Fibrillation Unable to assess Diastolic function Unavailable Mortality Data Severe Mitral Valve Disease History of Mitral Valve Surgery 911 Patients included 661 Had diastolic dysfunction (abnormal diastolic dysfunction) 250 Had normal diastolic function Followed for 60 months for all cause mortality

  20. Grading of Diastolic Dysfunction

  21. Outcome Measure All Cause Mortality

  22. Statistical Analyses • IBM Statistical Package for Social Sciences (SPSS) software V.20 • Continuous data expressed as Mean with 1 SD • Categorical – Number (%) • Analyze Group Differences: • Continuous Variables: ANOVA • Categorical Variables: χ²tests • Kaplin – Meier Curves – Unadjusted Survival • Cox Regression Survival Analyses for adjusted survival

  23. Baseline Demographic and Clinical Characteristics

  24. Baseline Demographic and Clinical Characteristics

  25. Echocardiograhic Characteristics

  26. Outcome:Normal Function vs DD

  27. Outcome:Normal Function vs DD

  28. Outcome:Normal Function vs DD Diastolic Dysfunction as Risk for all cause mortality: Hazard Ratio = 1.325 (1.005 – 1.748) p-value = 0.046

  29. Outcome:Normal Function vs different grades of DD

  30. Outcome:Normal Function vs different grades of DD

  31. Outcome:Normal Function vs different grades of DD

  32. Outcome:Normal Function vs different grades of DD

  33. Outcome:Normal Function vs different grades of DD

  34. Conclusions • Moderate and severe Left Ventricular DD with preserved ejection fraction was associated with worsened 5-year all-cause mortality. • Mortality was worse when DD was more severe. • Mild DD had no significant impact on survival.

  35. Strengths and Limitations Strengths: • Long follow up • One of the very few mortality studies based on grades of Left Ventricular Diastolic Dysfunction • Good number of subjects in the cohort Limitations: • Retrospective nature • Single Geographical Location • Unequal representation of both genders

  36. Future Considerations Can Diastolic Dysfunction be defined a significant precursor for development of DHF? As Impaired Fasting Glucose or Impaired Glucose Tolerance is for Diabetes Mellitus As Prehypertension is for Hypertension Can aggressive control of DD risk factors prevent progression to DHF?

  37. References • Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic; Redfield MM et al; JAMA. 2003;289(2):194. • Mortality rate in patients with diastolic dysfunction and normal systolic function; Halley CM et al; Arch Intern Med. 2011;171(12):1082. • Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM.  Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251-9. [PMID: 16855265] • Lam CS, Donal E, Kraigher-Krainer E, Vasan RS.  Epidemiology and clinical course of heart failure with preserved ejection fraction. Eur J Heart Fail. 2011;13:18-28. [PMID: 20685685] • Mitral ratio of peak early to late diastolic filling velocity as a predictor of mortality in middle-aged and elderly adults: the Strong Heart Study; Bella JN et al; Circulation. 2002;105(16):1928 • www.biodigital.com • http://www.learntheheart.com/GADD-echoClassification.html

  38. Acknowledgements Continuous support and mentoring • Dr. Khalid Qazi • Dr. Henri Woodman • Dr. AzharSupariwala Institutional Review Board • Dr. SateeshSatchidanand • Danielle Casucci • Catholic Health System – IRB Echo Lab Staff at Sisters of Charity Hospital

  39. Methods

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