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Echocardiographic Tissue Doppler Imaging Is a Powerful Independent
    Prognosticator of Overall Mortality in the General Population
 Results From the Fourth Copenhagen City Heart Study (2002-2007)


Disclosure information
The following relationships exist related to this presentation:

   Rasmus Mogelvang – No disclosures
   Peter Sogaard      – Consulting fees    GE Healthcare    Modest level
   Sune A. Pedersen   – No disclosures
   Niels T. Olsen     – No disclosures
   Peter Schnohr      – No disclosures
   Jan S. Jensen       – No disclosures
Echocardiographic Tissue Doppler Imaging Is a
Powerful Independent Prognosticator of Overall
     Mortality in the General Population
Results From the Fourth Copenhagen City Heart Study (2002-2007)


                                   Survival
                                                     Normal
 Rasmus Mogelvang
 The Copenhagen City Heart Study
 & Department of Cardiology,
 Gentofte University Hospital
 Denmark
                                                    Abnormal

                                                       Time
                The Failing Heart




Heart Failure        High morbidity and mortality

                     Increasing incidence




                        3
                 The Failing Heart


                            High morbidity and mortality

Heart Failure               Increasing incidence


                            Constant advances in treatment
     Early identification                     Echocardiography


                                            Conventional
  Tissue Doppler Imaging           versus



                               4
                     Methods
   1,100 persons from the
Copenhagen City Heart Study


                                         Copenhagen

Conventional Echocardiography
             &
  Tissue Doppler Imaging
                                 http://www.lib.utexas.edu/maps



 Mean Follow-up: 5.1 years



                             5
    Characteristics of the Study Population
                                              Survivors Non-survivors
                                               (n=946)     (n=90)       P-value
Age - years                                      58          74         P<0.001
Male gender – %                                  41          44         P=0.58
Body Mass Index – kg/m2                          25.6        25.7       P=0.91
Heart rate – beats per minute                    69          71         P=0.10
Hypertension – %                                 42          72         P<0.001
Diabetes - %                                       7         13         P<0.04
Ischemic heart disease - %                         8         21         P<0.001
Severe diastolic dysfunction – %                   0.7        1.2        P=0.47
Left ventricular ejection fraction <50% - %        0.9        3.5       P<0.05
Left ventricular dilatation - %                    5.7        5.5        P=1.00
Left ventricular hypertrophy - %                  15         37         P<0.001




                                       6
Tissue Doppler Imaging

           s’




         Systole        Diastole

                                   a’


                   e’




           7
 Tissue Doppler Imaging
s’                  s’



          a’
     e’
                  Systole            Diastole

                                         a’
                        Survivors Non-survivors

      s’ – cm/s             6.1            5.3
                                e’
      e’ – cm/s             7.2            5.4
      a’ – cm/s             6.7            6.3




                    8
Kaplan-Meier Survival Plots
 Survival - %              s’
    100

      95                                 High values
                                         Medium values
      90

      85                                 Low values
                1       2   3    4   5   6
                    Follow-up in years

 Survival - %              a’
     100

      95                                 High values

      90                                 Medium values

      85                                 Low values

                1      2    3   4    5   6


                            9
Kaplan-Meier Survival Plots
   Multivariate Analysis
 Survival - %             s’
    100

      95                                 High values

      90                  RR 1.25 per cm/s; P<0.04
                                   Medium values

      85                                 Low values
                1       2   3    4   5   6
                    Follow-up in years
                           8 cm/s vs. 3 cm/s           RR 3.0
 Survival - %              a’
     100

      95                                 High values

      90                  RR 1.25 per cm/s; P<0.001
                                    Medium values

      85                                 Low values



                           10
  Kaplan-Meier Survival Plot for e’

         Survival - %         e’
            100
                                             High values
             95
                                             Medium values
              90

              85
                                              Low values
              80
                    1       2   3    4   5    6
                        Follow-up in years


Multivariate analysis                        Relative Risk 1.02
                                             (0.90-1.16); P=0.77




                              11
s’, e’, and a’ according to increasing age
                                   < 40 years
                                  40-50 years
          s’        e’       a’   50-60 years
   cm/s                           60-70 years
                                  70-80 years
    10                             > 80 years
    8
    6
    4
    2




                    12
s’, e’, and a’ according to increasing age
                                   < 40 years
                                  40-50 years
          s’        e’       a’   50-60 years
   cm/s                           60-70 years
                                  70-80 years
    10                             > 80 years
    8
    6
    4
    2




                    13
s’, e’, and a’ according to increasing age
                                       < 40 years
                                      40-50 years
          s’        e’         a’     50-60 years
   cm/s                               60-70 years
                                      70-80 years
    10               r=-0.8            > 80 years
          r=-0.4              r=0.3
    8
    6
    4
    2




                    14
e’/a’

  s’




Systole        Diastole
                          a’
               e’/a’
          e’




 15
Interdependence of s’, e’, and a’

                s’




              Systole        Diastole
                                        a’
                             e’/a’
                        e’




               16
Interdependence of s’, e’, and a’

                s’




              e’/s’
              Systole        Diastole
                                        a’
                             e’/a’
                        e’




               17
          eas-index
Interdependence of s’, e’, and a’

                s’
                      (e’/a’)/s’



              e’/s’
                                    a’
                            e’/a’
                       e’




               18
Kaplan-Meier Survival Plot for the eas-index

          Survival - %
              100

               95                                     1. tertile

               90                                     2. tertile

               85                                     3. tertile

                         1     2    3     4       5   6
                             Follow-up in years


   Multivariate analysis                Relative Risk 2.6
                     Adjusted for age and sex
    3.tertile vs. 1.tertile              (1.4-4.7); P<0.003



                                   19
                            Conclusions
     Tissue Doppler imaging is a powerful prognosticator, even in the
1
     presence of a normal conventional echocardiographic examination
2    Low values of s’ and a’ were significant predictors of death

     Combining the information of systolic and diastolic performance
3
     strengthens the prognostic value of tissue Doppler imaging
     Tissue Doppler imaging is a powerful prognosticator -
12                 of s’
      Low values Survivaland a’ were significant predictors
     even in the presence of a normal conventional
      of death inthe information of systolic and diastolic
      Combining the general population
     echocardiographic examinationTDI Normal
3     performance strengthens the prognostic value of
      tissue Doppler imaging

                                             TDI Abnormal

                                                 Time