Prognostic significance of exercise stress echocardiography using two and three diastolic variable approaches

Background: The prognostic utility of comprehensive, guideline-defined assessment of diastolic measures during routine exercise echocardiography remains unclear. Objectives: The purpose of the study was to pragmatically assess the prognostic role of obtainable Doppler-derived diastolic variables during treadmill exercise echocardiography. Methods: In this retrospective study, the authors included 1910 patients undergoing exercise echocardiography. The guideline-defined diastolic measures included resting septal e’ velocity, post-exercise E/e’ ratio and post-exercise tricuspid regurgitant jet velocity. Since tricuspid regurgitant jet velocity is not routinely obtainable, the authors examined 2 approaches: 2 variable approach using only resting septal e’ velocity and post-exercise E/e’ ratio and 3 variable approach with all diastolic variables. Results: The mean age of study subjects was 57.6 ± 16 years and 1068 (56 %) were women. The tricuspid jet velocity was not reliably obtained in 501(26 %) of patients. All 3 diastolic variables were associated with the hard outcomes (mortality, acute coronary syndrome, cardiac hospitalization), soft outcomes (subsequent revascularization and cardiac testing), as well as the composite outcome. In the 2-variable approach, the presence of 2 abnormal variables was associated with a worse composite outcome. In the 3 variable approach, the presence of 2 or 3 abnormal variables was associated with a worse composite outcome. The associations persisted after multivariable adjustment and in the propensity matched subgroups. Conclusions: Guideline-defined diastolic variables during treadmill exercise echocardiography offer prognostic utility when used in combination, especially if all 3 variables are obtainable.