Key result
Adjusting echocardiographic thresholds for diastolic dysfunction in patients with severe aortic stenosis increased the specificity for detecting elevated NT-proBNP levels from 25% to over 85%.
Why the study?
Current 2016 ASE/EACVI guidelines for evaluating LV diastolic dysfunction do not adjust assessment of high filling pressures for patients with aortic stenosis, despite disease-specific diastolic features.
Does adjusting echocardiographic thresholds improve the detection of elevated filling pressures (NT-proBNP ≥500 ng/L) in elderly patients with severe symptomatic aortic stenosis?
Cohort (n=169)
No
Does adjusting echocardiographic thresholds improve the detection of elevated filling pressures (NT-proBNP ≥500 ng/L) in elderly patients with severe symptomatic aortic stenosis?
Adjusting standard echocardiographic thresholds for diastolic dysfunction significantly improves the specificity for detecting elevated filling pressures in elderly patients with severe aortic stenosis.
BACKGROUND: The 2016 guidelines of the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) for evaluation of left ventricular (LV) diastolic dysfunction by Doppler flow and tissue Doppler- echocardiography do not adjust assessment of high filling pressures for patients with aortic stenosis (AS). However, most of the studies on this patient group indicate age independent specific diastolic features in AS. The aim of this study is to identify disease-specific range and distribution of diastolic functional parameters and their ability to identify high N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels as a marker for high filling pressures. METHODS: In this study, 169 patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Resting echocardiography was performed including Doppler of the mitral inflow, pulmonary venous flow, tricuspid regurgitant flow and tissue Doppler in the mitral ring and indexed volume-estimates of the left atrium (LAVI). Echocardiography, and NT-proBNP levels were assessed before TAVR/SAVR and at two postoperative visits at 6 and 12 months. The scoring recommended by ASE/EACVI detected elevated NT pro-BNP with a specificity of 25%. Adjusting thresholds towards PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E deceleration time < 220 ms, and E/septal e' ≥ 20 or septal e' < 5.0 cm/s increased prediction of NT-proBNP levels ≥500 ng/L with substantially improved specificity (> 85%). CONCLUSION: Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and NT-proBNP indicate elevated filling pressures in most of the patients, improving only modestly 6-12 months after TAVR and SAVR. Applying the 2016 ASE/EACVI recommendations for detection of elevated filling pressures to patients with AS, elevated NT pro-BNP levels could not be reliably detected. However, adjusting thresholds of the echocardiographic parameters increased specificities to useful diagnostic levels. TRIAL REGISTRATION: The study was prospectively approved by the regional ethical committee, REK North with the registration number: REK 2010/397-10 .
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Caglayan et al. (2021) conducted a cohort in Severe symptomatic aortic stenosis (n=169). Adjusted echocardiographic thresholds vs. 2016 ASE/EACVI recommendations was evaluated on Specificity for detecting NT-proBNP ≥500 ng/L. Adjusting echocardiographic thresholds for diastolic dysfunction in patients with severe aortic stenosis increased the specificity for detecting elevated NT-proBNP levels from 25% to over 85%.
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