Elsevier

Journal of Cardiac Failure

Volume 27, Issue 11, November 2021, Pages 1222-1230
Journal of Cardiac Failure

Clinical Utility of Overlap Time for Incomplete Relaxation to Predict Cardiac Events in Heart Failure

https://doi.org/10.1016/j.cardfail.2021.05.018Get rights and content

Highlights

  • Cases with transmitral E-A overlap are occasionally found in the clinical setting, and its clinical meaning is not well determined.

  • E-A overlap time was related to heart rate and left ventricular function.

  • Patients with E-A overlap as a marker of incomplete relaxation had a significantly high event rate.

ABSTRACT

Background

The overlap time of transmitral flow can be a novel marker of subclinical left ventricular dysfunction for predicting adverse events in heart failure (HF). We aimed to (1) investigate the role of overlap time of the E-A wave in association with clinical parameters and (2) evaluate whether the overlap time could add prognostic information with respect to other conventional clinical prognosticators in HF.

Methods

We prospectively evaluated 153 patients hospitalized with HF (mean age 68 ± 15 years; 63% male). The primary endpoint was readmission following HF or cardiac death.

Results

During a median period of 25 months, 43 patients were readmitted or died. Overlap time appeared to be associated with worse outcomes. After adjustment for readmission scores and ratios of diastolic filling period and cardiac cycle length in a Cox proportional-hazards model, overlap time was associated with event-free survival, independent of elevated left atrial pressure based on guidelines. When overlap time was added to the model based on clinical variables and elevated left atrial pressure, the C-statistic significantly improved from 0.70 (95% CI: 0.63–0.77) to 0.77 (95% CI: 0.69–0.83, compared) (P = 0.035).

Conclusion

This preliminary study suggested that prolonged overlap time may have potential for predicting readmission and cardiac mortality risk assessment in patients with HF.

Section snippets

Study Population

We designed a single-center prospective study (Fig. 1). A total of 272 patients first hospitalized with HF who underwent echocardiographic studies after HF stabilization were enrolled initially. The study covered the period between January 2013 and December 2017. Exclusion criteria were as follows: post valve replacement (n = 22), severe valvular disease (n = 4), pacemaker implantation (n = 6), active cancer (n = 4), or severe chronic obstructive pulmonary disease (n = 4). We also removed

Clinical Backgrounds

Table 1 shows patients’ baseline characteristics at discharge. A total of 153 hospitalized patients with HF (mean age 68 ± 15 years; 63% male) were enrolled. Patients had been treated with angiotensin converting enzymes and angiotensin converting enzyme inhibitors (67%), beta-blockers (79%) and diuretics (73%). Table 2 shows the comparison of characteristics and echocardiographic variables between 2 groups, with or without overlap of the E-A wave. In this analysis, heart rate (P = 0.01),

Discussion

Our study sought to assess the clinical meaning of E-A overlap as an association between overlap time and CV events in HF. Our study brings several insights into the interpretation of E-A overlap: (1) overlap time was related to heart rate, DFL/CCL and LV systolic and diastolic function; (2) patients with overlap of the E-A wave had a significantly higher event rate compared to patients without overlap of the E-A wave; and (3) the association between the overlap time and the primary outcome

Limitations

The present study has several limitations. First, this was a single-center study with a small sample size. Therefore, the subgroup analysis was limited (eg, HFpEF and HFrEF). On the other hand, we thought that the advantage of a single-center study outweighed the limitation of small sample size in the hypothesis-generating study because of the least number of biases, such as differences in treatment quality or diversity of causes. The sample size was small, and there were relatively few events,

Conclusions

This preliminary study suggests that overlap time may have some potential for predicting readmission and cardiac mortality risk as a marker of incomplete relaxation in HF.

Funding

This work was supported by the Takeda Science Foundation and Public Trust Cardiovascular Research Fund (to KK). The funding source had no role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, the preparation, review or approval of the manuscript, or the decision to submit the manuscript for publication.

Contributions

KK and MA designed the work; RZ, YH, SN, TI, KY, DF, SY, HY, TS, and TW conducted the work and acquired data; KK and MA analyzed and interpreted the data; KK, MA and MS drafted the work; all authors reviewed the work, provided input and gave final approval of the manuscript.

Conflicts of Interest

None.

References (23)

The first 2 authors contributed equally to this work (KK, MA).

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