Prediction of mortality by a 2-steps systolic and diastolic exercise echocardigraphy protocol in patients with normal left ventricular systolic function

Funding Acknowledgements Type of funding sources: None. Background Exercise echocardiography (ExE) may evaluate left ventricular (LV) systolic and diastolic function. We sought to assess the combined prognostic value of systolic and diastolic function by a 2-steps protocol in patients referred for a clinically indicated ExE. Methods LV systolic and DF according to ASE/EACVI guidelines, and mitral regurgitation (MR) were evaluated at rest in 772 patients (age 67±12 years) with preserved LV ejection fraction (≥50). Afterwards, we assessed regional/global LV systolic function at peak exercise on a treadmill (step 1), and MR and E/e’ in the immediate post-exercise period (step 2). Abnormal ExE was defined as ischemia or fixed wall motion abnormalities, and raised E/e´values as >15 at rest and at exercise (e´ at the septal level). The patients were followed for a median of 1.7 years (25th–75th percentiles 1.07–2.59) for the occurrence of overall mortality. Results Ischemia was reported in 161 patients (21%) and abnormal ExE in 192 (25%). DF at rest was abnormal in 221 patients (29%) and indeterminate in 77 (10%). E/e´ >15 was found in 148 patients at rest (19%) and in 125 at exercise (16%). Mean achieved metabolic equivalents were 8.4±3.0 and 78% of the tests were maximal. There were 36 deaths (4.7%). Independent predictors were: age (HR= 1.07, 95% CI=1.03–1.11; p = 0.002), male gender (HR= 4.09, 95% CI=1.83–9.14; p = 0.001), peak double product (HR= 0.91, 95% CI=0.85–0.97; p = 0.002), peak wall motion score index (HR= 7.99, 95% CI=2.98–21.48; p<0.001) and post-exercise E/e´ value (HR= 1.08, 95% CI=1.02–1.15; p = 0.013). Neither resting E/e´ values nor resting abnormal DF resulted independent predictors. Annualized mortality-rates were 10.9 % in patients with (+) ExE plus (+) exercise E/e´, 3.7% in (-) ExE and (+) exercise E/e, 3.6% in those with (+) ExE and (-) exercise E/e´, and 1.2% with both variables normal. Conclusions A two-steps protocol for systolic and diastolic ExE assessment is able to predict mortality in patients with normal resting LV function. Mortality was 10-times higher when the 2 assessments were abnormal in comparison with both normal.