Clinical utility of tissue Doppler imaging in patients with acute myocardial infarction complicated by cardiogenic shock
© Hameed et al; licensee BioMed Central Ltd. 2008
Received: 16 February 2008
Accepted: 20 March 2008
Published: 20 March 2008
Echocardiography is widely used in the management of patients with cardiogenic shock (CS). Left ventricular ejection fraction (EF) has been shown to be an independent predictor of survival in CS. Tissue Doppler Imaging (TDI) is a sensitive echocardiographic technique that allows for the early quantitative assessment of regional left ventricular dysfunction. TDI derived indices, including systolic velocity (S'), early (E') and late (A') diastolic velocities of the lateral mitral annulus, are reduced in heart failure patients (EF < 30%) and portend a poor prognosis. In CS patients, the application of TDI prior to revascularization remains unknown.
To characterize TDI derived indices in CS patients as compared to patients with chronic CHF.
Between 2006 and 2007, 100 patients were retrospectively evaluated who underwent echocardiography for assessment of LV systolic function. This population included: Group I) 50 patients (30 males, 57 ± 13 years) with chronic CHF as controls; and Group II) 50 patients (29 males, 58 ± 10 years) with CS. Spectral Doppler indices including peak early (E) and late (A) transmitral velocities, E/A ratio, and E-wave deceleration time were determined. Tissue Doppler indices including S', E' and A' velocities of the lateral annulus were measured.
Of the entire cohort, the mean LVEF was 25 ± 5%. Cardiogenic shock patients demonstrated significantly lower lateral S', E' and a higher E/E' ratio (p < 0.01), as compared to CHF patients. The in-hospital mortality in the CHF cohort was 5% as compared to the CS group with an in hospital mortality of 40%. In the subset of CS patients (n = 30) who survived, the mean S' at presentation was higher as compared to those patients who died in hospital (3.5 ± 0.5 vs. 1.8 ± 0.5 cm/s).
Despite similar reduction in LV systolic function, CS patients have reduced myocardial velocities and higher filling pressures using TDI, as compared to CHF patients. Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery following revascularization is yet to be determined.
Cardiogenic shock (CS) is a state of inadequate tissue perfusion due to cardiac dysfunction. It is a potentially lethal complication that occurs in 10% of all cases of acute myocardial infarction (MI) . Between 1995 and 2004, the National Registry of Myocardial Infarction database recorded 300 000 ST elevation MI's of which 8.6% presented with CS . In patients hospitalized for either myocardial infarction, decompensated heart failure or following cardiac surgery, CS was the leading cause of death resulting in mortality rates of up to 80% . Although rapid stabilization and treatment of reversible causes via early revascularization is a priority, the mortality rate due to CS in the current era remains high [3, 4].
Prognostic echocardiographic factors for determination of early recovery after CS are limited. Short and long term mortality appears to be associated with initial depressed LV systolic function and mitral regurgitation (MR) as assessed by echocardiography . In patients with LV ejection fraction (EF) less than 30%, survival at one year was 24% versus 56% for those with preserved systolic function .
Tissue Doppler imaging (TDI) is a sensitive, noninvasive echocardiographic method that records velocity of tissue motion within the myocardium. TDI has been evaluated in both in vitro and in vivo studies, allowing for the quantitative assessment of both global and regional function of the myocardium . Indices derived from TDI, including systolic velocity (S'), early (E') and late (A') diastolic velocities of the lateral mitral annulus, are reduced in heart failure patients (EF < 30%) and portend a poor prognosis. Transmitral to early diastolic velocity ratio (E/E') obtained via TDI correlates strongly with LV filling pressures . An E/E' ratio > 10 identified a pulmonary capillary wedge pressure (PCWP) > 15 mm Hg with a sensitivity of 92% and a specificity of 80% . In addition to chronic CHF, a higher E/E' has also been shown to correlate with a worse prognosis in acute myocardial ischemia and hypertension [9–12]. The application of TDI prior to revascularization in patients presenting with CS remains unknown.
The objective of this study was to describe TDI derived indices in patients presenting with cardiogenic shock after acute myocardial infarction, prior to percutaneous revascularization.
Between 2006 and 2007, 100 consecutive patients were retrospectively evaluated who underwent echocardiography for assessment of LV systolic function. This population included: Group I) 50 patients with chronic CHF as age and sex matched controls; and Group II) 50 patients with CS. The CHF group was defined as LVEF < 40%, NYHA class III or IV status, with documented severe three vessel coronary artery disease on cardiac catheterization, requiring hospitalization for decompensated heart failure.
All patients in the cardiogenic shock (CS) group presented with an acute myocardial infarction defined as a rise and/or fall of cardiac biomarkers with at least one value above the 99th percentile of the upper reference limit. Additionally, all patients had to either have symptoms of ischemia, ECG changes of new ischemia (new ST-T changes or new left bundle branch block), or the development of pathological Q waves on EKG . Cardiogenic shock was diagnosed if the patient satisfied all of the following clinical and hemodynamic criteria: i) hypotension (a systolic blood pressure < 90 mmHg for at least 30 minutes or the need for supportive measures to maintain a systolic blood pressure ≥ 90 mmHg); ii) a cardiac index ≤ 2.2 l/min per m2; iii) and a pulmonary capillary wedge pressure ≥ 15 mmHg in the setting of an acute ischemic insult. All CS patients met the above criteria. The medical records of all 100 patients were extensively reviewed for baseline demographic and hemodynamic data. The retrospective study was approved by the local institutional review board.
Parasternal and apical views were obtained using the GE Vivid 7 (GE Medical Systems, Milwaukee, WI) standard echocardiographic system and multifrequency transducer with tissue Doppler capability. Standard two dimensional images, M-mode, spectral and color Doppler, and TDI were performed. All echoes were performed within 6 hours of the patient's initial admission to hospital. For the patients in CS, all echo parameters were obtained prior to revascularization.
Left ventricular (LV) inter-ventricular septal thickness (IVS), posterior wall thickness (PWT), and LV ejection fraction (EF) were determined from 2-dimensional images according to established criteria [14, 15].
Left ventricular diastolic function was assessed using both conventional and novel diastolic parameters. Transmitral LV filling velocities at the tips of the mitral valve leaflets were obtained from the apical 4-chamber view using pulsed wave Doppler echocardiography. The transmitral LV filling signal was traced manually and the following variables were obtained: peak early (E) and late (A) transmitral velocities, and E/A ratio.
Tissue-Doppler derived indices were recorded at the lateral mitral annulus. A sample volume of 6 × 6 mm was positioned along the basal lateral wall of the apical 4 chamber view. These indices included systolic velocities (S'), early diastolic (E') velocities and late diastolic (A') velocities. Finally, the dimensionless index of E/E' was calculated. The estimated left atrial pressure was subsequently calculated as E/E' × 1.25 + 1.9 .
The data are summarized as mean ± SD or number (percentage). Chi-square or Fisher exact tests were applied to compare categorical variables. A Student t-testing was used to compare parameters between both groups. A p value < 0.05 was considered significant. The Statistical Analysis System 8.01 (SAS Insitute, Cary, NC) was used to perform the analysis.
Clinical and 2-D echocardiographic findings in all patients (n = 100)
CHF (n = 50)
CS (n = 50)
57 ± 13
58 ± 10
Male Gender (%)
Diabetes mellitus (%)
Smoking history (%)
Beta blockers (%)
ACE inhibitors (%)
Inotropic support (%)
Left Heart Dimensions
10 ± 2
11 ± 2
11 ± 2
11 ± 1
60 ± 2
59 ± 3
25 ± 6
23 ± 7
Hemodynamic data and Doppler echocardiographic findings in all patients (n = 100)
CHF (n = 50)
CS (n = 50)
81 ± 11
84 ± 7
SBP (mm Hg)
87 ± 7
86 ± 10
DBP (mm Hg)
50 ± 4
48 ± 8
Mitral E velocity (cm/s)
71 ± 10
72 ± 8
Mitral A velocity (cm/s)
64 ± 13
66 ± 12
1.03 ± 0.3
1.04 ± 0.4
Doppler tissue imaging
6.2 ± 1.3
3.0 ± 0.9
5.1 ± 1.1
3.2 ± 1.2
3.8 ± 1.0
3.2 ± 1.1
13 ± 3
22 ± 3
LAP (mm Hg)
19 ± 4
31 ± 4
Diastolic Echocardiographic Parameters
Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction with an in-hospital mortality rate greater than 50% . A variety of structural and functional abnormalities are identifiable on echocardiography in patients presenting with acute CS . Although Picard et al demonstrated reduced LV systolic function and mitral regurgitation as predictors of survival and response to early revascularization in CS , our study is the first to characterize a reduction in TDI derived indices in CS patients. Despite similar reductions in LV systolic function, our study demonstrated CS patients have reduced myocardial velocities and higher filling pressures using TDI as compared to CHF patients.
Mitral annular systolic velocity (S') reflects the long axis motion of the ventricle which is an important component of LV systolic function . Peak myocardial systolic velocity averaged from six sites around the mitral annulus correlates well with LV ejection fraction. A S' value greater than 7.5 cm/s had a sensitivity of 79% and a specificity of 88% in predicting normal global LV function . Sub-endocardial fibers make a substantial contribution to long axis function, and are susceptible to a variety of cardiac pathologies. Hypertension, coronary artery disease and CHF have been shown to negatively affect these fibers and reduce S'. A reduction in S' correlates with increased morbidity and mortality in each of these disease states [11, 18, 19].
In our study, CS patients had a significantly lower S' compared to CHF patients. Shock has severe metabolic consequences, involving mainly energy metabolism, substrate utilization, and acid-base regulation. As longitudinally arranged subendocardial fibers are most vulnerable to ischemia and metabolic abnormalities, it is not an unexpected finding that LV base-apex contraction was abnormal in our CS population. Given the prognostic value in other cardiac disease states, a reduction of S' in CS may be of similar clinical importance in this patient population. In our study, albeit small numbers, the subset of patients in CS who survived demonstrated increased S' values on initial presentation, prior to revasculariation, as compared to those who died in-hospital.
Similar to systolic annular velocity (S'), early diastolic mitral annular (E') appears to be a strong independent predictor for the short and long-term prognosis of patients with cardiovascular disease. E' has been proposed as a useful index for the non-invasive evaluation of LV relaxation, that is relatively preload independent . Recent studies have shown that a reduced E' predicts increased cardiovascular morbidity and mortality [11, 14, 19]. Wang et al demonstrated that an E' less than 3 cm/s was the best prognostic marker for long-term follow up in a population of patients with chronic hypertension .
In the current study, E' was significantly reduced in the CS population as compared to chronic CHF patients. The potential mechanism for this abnormality may relate to the acute increase in LV wall stress due to the ischemic insult in the CS state. The reduced E' may be a sensitive marker of regional relaxation abnormality reflected in the long axis dimension that could potentially be evident earlier than clinical manifestations of global left ventricular relaxation abnormality.
Since E' is reduced and diastolic mitral annular increases with higher filling pressures, the E/E' ratio correlates well with invasive pulmonary capillary wedge pressure (PCWP) measurements [8, 20, 21]. Elevated PCWP is associated with a higher mortality rate after acute MI and has been shown to carry independent prognostic information in CHF patients [22–24]. In our study, CS patients had an elevated E/E' ratio and LAP confirming raised LV filling pressures. The spectrum of diastolic abnormalities which may account for the elevated ratios include increased myocardial stiffness, reduced LV compliance, and elevated LV end-diastolic parameters. A restricted filling pattern tends to correlate with higher mortality at 30 days and 1 year in CS , and is known to be associated with a poor prognosis in CHF patients . Hillis et al. previously established that in the setting of acute MI, an E/E' ratio greater than 15 can identify patients at an increased risk of mortality with a sensitivity of 70% and a specificity of 91% [24, 25]. In addition, the prognostic value of E/E' was incremental to clinical factors and conventional echocardiographic parameters of LV systolic and diastolic function [24, 25]. An elevated E/E' ratio in CS patients may be of comparable value in distinguishing this select population at higher risk for poor cardiovascular outcomes .
Similar to other studies using TDI, this methodology is affected by the quality of 2D images and cardiac translation, rotation, or both. Only lateral annular velocities were analyzed as septal annular velocities may be subjected to the influence of the right ventricle. Only the lateral wall of the left ventricle was routinely sampled with TDI as per routine in our echocardiography laboratory. However, lateral velocities may be affected by both translational effects and beam angle [20, 27]. The reduced LV systolic function in the CS population may have represented myocardial stunning, and thus the true LVEF may have been underestimated in this subgroup. Tissue Doppler imaging parameters was not obtained immediately following revascularization nor at 6 month followup in the patient population. Lastly, this study is limited by the relatively small sample size and retrospective design. A larger, prospective study is needed in order to make more substantive conclusions regarding the clinical utility of tissue Doppler indices prior to percutaneous revascularization in patients with cardiogenic shock.
Despite similar reduction in LV systolic function, CS patients have reduced myocardial velocities and higher filling pressures compared to chronic CHF patients. Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery following revascularization is yet to be determined.
- Babaey A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS, NRMI Investigators: Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA. 294 (4): 448-54. 2005 Jul 27,View ArticleGoogle Scholar
- Hochman JS, Boland J, Sleeper LA, Porway M, Brinker J, Col J, Jacobs A, Slater J, Miller D, Wasserman H, Menegus M, Talley D: Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. Circulation. 1995, 91 (3): 873-81.View ArticlePubMedGoogle Scholar
- Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, Buller CE, Jacobs AK, Slater JN, McKinlay SM, Picard MH, Menegus MA, Boland J, Dzavik V, Thompson CR, Wong SC, Steingart R, Forman R, Aylward P, Godfrey E, Nickens PD: Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Engl J Med. 1999, 341: 625-34.View ArticlePubMedGoogle Scholar
- Hochman JS, Sleeper LA, White HD, Dzavik W, Wong SC, Menon V, Webb J, Steingart R, Picard M, Menegus M, Boland J, Sanborn T, Buller C, Modur S, Forman R, Nickens PD, Jacobs AK, Slater J, LeJemtel T: One-year survival following early revascularization for cardiogenic shock. JAMA. 2001, 285: 190-2.View ArticlePubMedGoogle Scholar
- Picard MH, Davindoff R, Sleeper LA, Mendes LA, Thompson CR, Dzavik V, Steingart R, Gin K, White HD, Hochman JS: Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. Circulation. 2003, 107: 279-84.View ArticlePubMedGoogle Scholar
- Miyatake K, Yamagishi M, Tanaka N, Uematsu M, Yamazaki N, Mine Y, Sano A, Hirama M: New method for evolution of left ventricular wall motion by color-coded tissue Doppler imaging. In vitro and in vivo studies. J Am Coll Cardio. 1995, 25: 717-24. 10.1016/0735-1097(94)00421-L.View ArticleGoogle Scholar
- Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA: Doppler tissue imaging: a non-invasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol. 1997, 30: 1527-33.View ArticlePubMedGoogle Scholar
- Gulati VK, Katz WE, Follansbee WP, Gorcsan J: Mitral annular descent velocity by tissue Doppler echocardiography as an Index of global left ventricular function. Am J Cardiol. 1996, 77: 979-84.View ArticlePubMedGoogle Scholar
- Dokainish H, Zoghbi WA, Lakkis NM, Ambriz E, Patel R, Quinones MA, Nagueh SF: Incremental predictive power of B-type natriuretic peptide and tissue Doppler echocardiography in prognosis of patient with congestive heart failure. J Am Coll Cardiol. 2005, 45: 1223-6.View ArticlePubMedGoogle Scholar
- Yu C, Sanderson JE, Marwick TH, Oh JK: Tissue Doppler imaging: a new prognosticator in cardiovascular diseases. J Am Coll Cardiol. 2007, 49: 1903-14.View ArticlePubMedGoogle Scholar
- Wang m, Yip GW, Wang AY, Zhang Y, Ho PY, Ise MK, Yu CM, Sanderson JE: Tissue Doppler imaging provides incremental prognostic value in patients with systemic hypertension and left ventricular hypertrophy. J Hypertens. 2005, 23: 183-91.View ArticlePubMedGoogle Scholar
- Arques S, Roux E, Luccioni R: Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function. Cardiovasc Ultrasound. 5: 16-2007 Mar 26,
- Thygesen K, Alpert JS, White HD, : Task force for the Redefinition of Myocardial Infarction. Circulation. 2007, 116: 2634-2653.View ArticlePubMedGoogle Scholar
- Lang RB, Bierig M, Devereaux RB, et al.: Chamber quantification writing group: American Society of Echocardiography's Guidelines and Standards Committee, European Association of Echocardiography. Recommendations for chamber quantification: A report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005, 18: 1440-1463.View ArticlePubMedGoogle Scholar
- Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, Reichek N: Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986, 57: 450-8.View ArticlePubMedGoogle Scholar
- Henein MY, Gibson DG: Long axis function in disease. Heart. 1999, 81 (3): 229-31.View ArticlePubMedPubMed CentralGoogle Scholar
- Alam M, Wardell J, Andersson E, Samad BA, Nordlander R: Effects of first myocardial infarction on left ventricular systolic and diastolic function with the use of mitral annular velocity determined by pulsed wave Doppler tissue Imaging. J Am Soc Echocardiogr. 2000, 13: 343-52.View ArticlePubMedGoogle Scholar
- Marwick TH, Case C, Leano R, Short L, Baglin T, Cain P, Garrahy P: Use of tissue Doppler imaging to facilitate the prediction of events in patients with abnormal left ventricular function by dobutamine echocardiography. Am J Cardiol. 2004, 93: 142-6.View ArticlePubMedGoogle Scholar
- Nikitin NP, Loh PH, Silva R, Ghosh J, Khaleva OY, Goode K, Rigby AS, Alamgir F, Clark AL, Cleland JG: Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction. Heart. 2006, 92: 775-9.View ArticlePubMedGoogle Scholar
- Sohn DW, Chai IH, Lee DJ, Kim HC, Kim HS, Oh BH, Lee MM, Park YB, Choi YS, Seo JD, Lee YW: Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol. 1997, 30: 474-80.View ArticlePubMedGoogle Scholar
- Nagueh SF, Sun H, Kopelen HA, Middleton KJ, Khoury DS: Hemodynamic determinants of mitral annulus diastolic velocities by tissue Doppler. J Am Coll Cardiol. 2001, 37: 278-85.View ArticlePubMedGoogle Scholar
- Reynolds HR, Anand SK, Fox JM, Harkness S, Dzavik V, White HD, Webb JG, Gin K, Hochman JS, Picard MH: Restrictive physiology in cardiogenic shock: Observations from echocardiography. Am Heart J. 2006, 151 (4): 890.e9-890.e15.View ArticleGoogle Scholar
- Xie GY, Berk MR, Smith MD, Gurley JC, DeMaria AN: Prognostic value of Doppler transmitral flow patterns in patients with congestive heart failure. Jam Coll Cardiol. 1994, 24 (1): 132-9.View ArticleGoogle Scholar
- Hillis GS, Moller JE, Pellikka PA, Gersh BJ, Wright RS, Ommen SR, Reeder GS, Oh JK: Non-invasive estimation of left ventricular filling pressure by E/E' is a powerful predictor of survival after acute myocardial infarction. J Am Coll Cardiol. 2004, 43: 360-7.View ArticlePubMedGoogle Scholar
- Hillis GS, Ujino K, Mulvagh SL, Hagen ME, Oh JK: Echocardiographic indices of increased left ventricular filling pressure and dilation after acute myocardial infarction. J Am Soc Echocardiogr. 2006, 19: 450-6.View ArticlePubMedGoogle Scholar
- Vermes E, Houël R, Simon M, Le Besnerais P, Loisance D: Tissue Doppler imaging to predict myocardial recovery during mechanical circulatory support. Ann Thorac Surg. 2000, 70 (6): 149-51.Google Scholar
- Dokainish H, Zoghbi WA, Lakkis NM, Ambriz E, Patel R, Quinones MA, Nagueh SF: Incremental predictive power of B-type natriuretic peptide and tissue Doppler echocardiography in the prognosis of patients with congestive heart failure. J Am Coll Cardiol. 2005, 45: 1223-6.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.