Vol 28, No 6 (2021)
Original Article
Published online: 2019-03-26

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Diastolic dyssynchrony and its exercise-induced changes affect exercise capacity in patients with heart failure with reduced ejection fraction

Jakub Stępniewski1, Grzegorz Kopeć1, Wojciech Magoń1, Piotr Podolec1
Pubmed: 30994185
Cardiol J 2021;28(6):932-940.


Background: Left ventricular diastolic dyssynchrony is common in patients with heart failure with reduced ejection fraction (HFREF). Little is known however, about its pathophysiology and clinical effects. Herein is hypothesized that presence of diastolic dyssynchrony at rest or at exercise may importantly contribute to HF symptoms. The aim was to investigate the influence of diastolic dyssynchrony and its exercise-induced changes on exercise capacity in HFREF patients.
Methods: Patients with stable, chronic HF, left ventricular ejection fraction < 35%, sinus rhythm and QRS ≥ 120 ms were eligible for the study. Rest and cyclo-ergometer exercise echocardiography were performed. Diastolic dyssynchrony was defined as opposing-wall-diastolic-delay ≥ 55 ms measured in tissue-Doppler imaging. Exercise capacity was assessed by peak oxygen consumption (VO2peak). Association between diastolic dyssynchrony and VO2peak was assessed in univariate regression analysis and further adjusted for possible confounders.
Results: Fourty eight patients were included (aged 63.7 ± 12.2). Twenty-seven (56.25%) had diastolic dyssynchrony at rest and 13 (27%) at exercise. Twenty-two (46%) experienced a change in diastolic dyssynchrony status during exercise. In univariate models diastolic dyssynchrony at rest or at exercise were associated with lower VO2peak (beta coefficient = –3.8, p = 0.004; beta coefficient = –3.6, p = 0.02, respectively). However, the ability to restore diastolic synchronicity during exercise was associated with higher VO2peak (beta coefficient = 3.4, p = 0.04) and remained an important predictor of exercise capacity after adjustment for age and HF etiology.
Conclusions: The ability to restore diastolic synchronicity at exercise predicts exercise capacity in patients with HFREF.

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  1. Yu CM, Lin H, Zhang Q, et al. High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration. Heart. 2003; 89(1): 54–60.
  2. Schuster I, Habib G, Jego C, et al. Diastolic asynchrony is more frequent than systolic asynchrony in dilated cardiomyopathy and is less improved by cardiac resynchronization therapy. J Am Coll Cardiol. 2005; 46(12): 2250–2257.
  3. Shanks M, Bertini M, Delgado V, et al. Effect of biventricular pacing on diastolic dyssynchrony. J Am Coll Cardiol. 2010; 56(19): 1567–1575.
  4. Yu CM, Zhang Q, Yip GWK, et al. Diastolic and systolic asynchrony in patients with diastolic heart failure: a common but ignored condition. J Am Coll Cardiol. 2007; 49(1): 97–105.
  5. Wang J, Kurrelmeyer KM, Torre-Amione G, et al. Systolic and diastolic dyssynchrony in patients with diastolic heart failure and the effect of medical therapy. J Am Coll Cardiol. 2007; 49(1): 88–96.
  6. Friedberg MK, Roche SL, Mohammed AF, et al. Left ventricular diastolic mechanical dyssynchrony and associated clinical outcomes in children with dilated cardiomyopathy. Circ Cardiovasc Imaging. 2008; 1(1): 50–57.
  7. Stępniewski J, Kopeć G, Magoń W, et al. Ischaemic aetiology predicts exercise dyssynchrony in patients with heart failure with reduced ejection fraction. Kardiol Pol. 2018; 76(10): 1450–1457.
  8. Lang R, Badano L, Mor-Avi V, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015; 16(3): 233–271.
  9. Galderisi M, Henein MY, D'hooge J, et al. European Association of Echocardiography. Recommendations of the European Association of Echocardiography: how to use echo-Doppler in clinical trials: different modalities for different purposes. Eur J Echocardiogr. 2011; 12(5): 339–353.
  10. Stoylen A. Left Ventricular Mechanics During Exercise: A Doppler and Tissue Doppler Study. Eur J Echocardiogr. 2003; 4(4): 286–291.
  11. Gorcsan J, Abraham T, Agler DA, et al. American Society of Echocardiography Dyssynchrony Writing Group, American Society of Echocardiography Dyssynchrony Writing Group, Heart Rhythm Society. Echocardiography for cardiac resynchronization therapy: recommendations for performance and reporting--a report from the American Society of Echocardiography Dyssynchrony Writing Group endorsed by the Heart Rhythm Society. J Am Soc Echocardiogr. 2008; 21(3): 191–213.
  12. Balady GJ, Arena R, Sietsema K, et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, Interdisciplinary Council on Quality of Care and Outcomes Research. Clinician's Guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association. Circulation. 2010; 122(2): 191–225.
  13. McMurray JJV, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012; 33(14): 1787–1847.
  14. Lafitte S, Bordachar P, Lafitte M, et al. Dynamic ventricular dyssynchrony: an exercise-echocardiography study. J Am Coll Cardiol. 2006; 47(11): 2253–2259.
  15. Jung IH, Seo HS, Kim MJ. P569. Diastolic dyssynchrony is associated with exercise intolerance in hypertensive patients with left ventricular hypertrophy. Eur Heart J Cardiovasc Imaging. 2016; 17(suppl_2): ii102–ii109.
  16. Cheng A, Helm RH, Abraham TP. Pathophysiological mechanisms underlying ventricular dyssynchrony. Europace. 2009; 11 Suppl 5: v10–v14.
  17. Kasner M, Westermann D, Schultheiss HP, et al. Diastolic heart failure and LV dyssynchrony. Curr Pharm Biotechnol. 2012; 13(13): 2539–2544.
  18. Kass DA. An epidemic of dyssynchrony: but what does it mean? J Am Coll Cardiol. 2008; 51(1): 12–17.
  19. Zhang Q, Yu CM. Clinical implication of mechanical dyssynchrony in heart failure. J Cardiovasc Ultrasound. 2012; 20(3): 117–123.
  20. Miura T, Bhargava V, Guth BD, et al. Increased afterload intensifies asynchronous wall motion and impairs ventricular relaxation. J Appl Physiol (1985). 1993; 75(1): 389–396.
  21. Yano M, Kohno M, Konishi M, et al. Influence of left ventricular regional nonuniformity on afterload-dependent relaxation in intact dogs. Am J Physiol. 1994; 267(1 Pt 2): H148–H154.
  22. Aoyagi T, Iizuka M, Takahashi T, et al. Wall motion asynchrony prolongs time constant of left ventricular relaxation. Am J Physiol. 1989; 257(3 Pt 2): H883–H890.
  23. Waggoner AD, Rovner A, de las Fuentes L, et al. Clinical outcomes after cardiac resynchronization therapy: importance of left ventricular diastolic function and origin of heart failure. J Am Soc Echocardiogr. 2006; 19(3): 307–313.
  24. Bleeker GB, Mollema SA, Holman ER, et al. Left ventricular resynchronization is mandatory for response to cardiac resynchronization therapy: analysis in patients with echocardiographic evidence of left ventricular dyssynchrony at baseline. Circulation. 2007; 116(13): 1440–1448.
  25. Atherton J, Moore T, Lele S, et al. Diastolic ventricular interaction in chronic heart failure. Lancet. 1997; 349(9067): 1720–1724.
  26. Wiśniowska-Śmiałek S, Dziewięcka E, Holcman K, et al. Kinetics of selected serum markers of fibrosis in patients with dilated cardiomyopathy and different grades of diastolic dysfunction of the left ventricle. Cardiol J. 2018 [Epub ahead of print].
  27. Bonow RO, Vitale DF, Bacharach SL, et al. Asynchronous left ventricular regional function and impaired global diastolic filling in patients with coronary artery disease: reversal after coronary angioplasty. Circulation. 1985; 71(2): 297–307.
  28. Lee PW, Zhang Q, Yip GWK, et al. Left ventricular systolic and diastolic dyssynchrony in coronary artery disease with preserved ejection fraction. Clin Sci (Lond). 2009; 116(6): 521–529.
  29. Turan B, Daşli T, Erkol A, et al. Diastolic dyssynchrony in acute ST segment elevation myocardial infarction and relationship with functional recovery of left ventricle. J Cardiovasc Ultrasound. 2016; 24(3): 208–214.
  30. Onishi T, Uematsu M, Watanabe T, et al. Objective interpretation of dobutamine stress echocardiography by diastolic dyssynchrony imaging: a practical approach. J Am Soc Echocardiogr. 2010; 23(10): 1103–1108.
  31. Liu J, Murata K, Fujino T, et al. Effect of dobutamine on regional diastolic left ventricular asynchrony in patients with left ventricular hypertrophy. Circ J. 2003; 67(2): 119–124.