Method
Performance of Conventional Echocardiographic Parameters and Myocardial Measurements in the Sequential Evaluation of Left Ventricular Function

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Echocardiography is frequently used for sequential evaluation of left ventricular (LV) function, although the reproducibility of such conventional measurements as LV ejection fraction (EF) have been questioned. The utility of such newer measurements as tissue Doppler imaging and left atrial (LA) size in serial clinical testing are undefined. The magnitude and clinical relevance of changes in conventional and new measurements of LV function were investigated and compared in 346 consecutive patients undergoing sequential echocardiography. Change in LA area, LVEF, tissue E velocity (Em), and transmitral E to Em ratio (E/Em) were compared over 304 ± 239 days. Changes within and between parameters (after mean correction to make measurements comparable) were assessed in groups designated as stable (n = 144) or unstable (n = 202) according to clinical progress. A single observer remeasured these parameters in stable patients individually and with paired studies side by side. Significant variability was seen in all measurements, with change in LVEF the only parameter differing between stable and unstable groups (6.4 ± 8.9% vs 9.4 ± 5.4%; p <0.001). Tissue Em and E/Em ratio were more variable than LA area or LVEF. In stable patients, LVEF changed the least and E/Em changed the most over time (p <0.05). With a single blinded observer, Em had improved reproducibility (1.5 ± 1.9 vs 2.3 ± 2.6 cm/s; p <0.001), as did visual EF. In conclusion, variability in all measurements was high irrespective of clinical status. Newer measurements were no better than LVEF in detecting changes in clinical status. Sequential LV assessment should be interpreted with caution, and more robust measurements are needed.

Section snippets

Clinical evaluation

We studied 346 consecutive patients referred for sequential 2-dimensional echocardiography at a major tertiary hospital from November 2001 to January 2006. Patients were categorized as either stable or unstable according to clinical progress. This differentiation was made to investigate any potential influence of clinical status on measurement variability. These reviews were performed by a single physician blinded to sequential echocardiographic measurements and based on a comprehensive review

Patient characteristics

Of 346 patients (age 61 ± 15 years; 56% men) undergoing sequential echocardiography (692 studies), 144 (42%) were classified as clinically stable, and 202 (58%), as unstable. Mean time between studies was 305 ± 239 days, and stable patients had significantly longer follow-up times compared with unstable patients (p <0.001). Overall mean LVEF was significantly lower in unstable patients compared with clinically stable patients (p <0.001), as was tissue Em velocity (p <0.01). Overall population

Discussion

Newer measurements of LV function, such as tissue Em, LA area, and E/Em ratio, have been used in cross-sectional and longitudinal studies of LV function.5, 6, 7 However, this study of their incorporation into the clinical echocardiographic laboratory indicated they are subject to significant levels of variability when used to monitor patient LV function in a sequential fashion. Disappointingly, they appeared no more robust, and possibly worse, than the more conventional measurement of LVEF in

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