The Strengths and Limitations of E/E' in Heart Failure with Preserved Ejection Fraction
Why the study?
Does the echocardiographic E/e' ratio accurately correlate with invasive left ventricular filling pressures and predict outcomes in patients with HFpEF?
Population
Patients with heart failure with preserved ejection fraction, defined by signs and symptoms of heart failure…
Comparison
Echocardiographic evaluation, specifically the… vs Invasively-measured left ventricular filling…
Design
Editorial
Authors
Discussion
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Implication
While E/e' is the most robust echocardiographic index for estimating filling pressures in HFpEF, its correlation with invasive hemodynamics is modest and its sensitivity is poor, highlighting limitations in current non-invasive diagnostic algorithms.
Key Points
- To review the correlation between guideline-recommended echocardiographic parameters—chiefly the E/e' ratio—and invasively measured left ventricular filling pressures, as well as their prognostic relevance in heart failure with preserved ejection fraction.
- Evaluated systematic review and meta-analysis data from 9 studies assessing echocardiographic indices against invasive pulmonary capillary wedge pressure or left ventricular end-diastolic pressure in patients with signs and symptoms of heart failure and ejection fraction >45%.
- Assessed prognostic outcomes across 18 studies examining mortality and composite clinical endpoints.
- Analyzed diagnostic sensitivity and specificity across pooled multi-index guideline validation cohorts (n = 1,233) and resting versus exercise hemodynamic evaluations.
- The E/e' ratio showed a modest pooled correlation with invasive filling pressures (r = 0.56; range 0.19–0.84), which remained modest when restricted to simultaneous studies or ejection fraction ≥50% (r = 0.59–0.62).
- E/e' was significantly associated with adverse outcomes across most cohorts, with a combined hazard ratio of 1.05 (95% CI: 1.03–1.06) per one-unit increase.
- The ASE/EACVI diagnostic algorithm demonstrated high pooled specificity (86%) but a low pooled sensitivity of only 61% (n = 1,233) for identifying elevated filling pressures, with single-index E/e' resting sensitivities dropping as low as 2.4% to 19%.
Structured PICO
Does the echocardiographic E/e' ratio accurately correlate with invasive left ventricular filling pressures and predict outcomes in patients with HFpEF?
P
Population
Patients with heart failure with preserved ejection fraction (HFpEF), defined by signs and symptoms of heart failure and normal or mildly reduced ejection fraction (EF >45%).
I
Intervention
Echocardiographic evaluation, specifically the E/e' ratio (quotient of early diastolic mitral inflow velocity and mitral annular tissue velocity).
C
Comparator
Invasively-measured left ventricular filling pressures (pulmonary capillary wedge pressure or LV end-diastolic pressure).
O
Outcome
Correlation between E/e' ratio and invasively-measured filling pressures, and association with mortality and/or composite endpoint.surrogate
While E/e' is the most robust echocardiographic index for estimating filling pressures in HFpEF, its correlation with invasive hemodynamics is modest and its sensitivity is poor, highlighting limitations in current non-invasive diagnostic algorithms.
Limitations
- Age dependency of E and e' velocities
- Limited accuracy of e' velocity in subjects with regional dysfunction
- Effects of arrhythmias including atrial fibrillation
- Low sensitivity for identifying high LV filling pressures
- Potential publication bias in the HFpEF evidence base
Cite This Study
Obokata et al. (2018) studied this question.