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European Journal of Echocardiography 2003 4(4):306-312; doi:10.1016/S1525-2167(03)00034-9
© 2003 by European Society of Cardiology
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Copyright © 2003, The European Society of Cardiology

Impact of Essential Hypertension and Diabetes Mellitus on Left Ventricular Systolic and Diastolic Performance{star}

N. H. Andersen1, S. H. Poulsen2, K. Helleberg3, P. Ivarsen4, S. T. Knudsen1 and C. E. Mogensen

1Department of Internal Medicine (Diabetes and Endocrinology), Aarhus University Hospital, Denmark
2Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
3Department of Internal Medicine, Viborg County Hospital, Viborg, Denmark
4Department of Nephrology, Aarhus University Hospital, Skejby, Denmark

Received 18 December 2002; received in revised form 20 March 2003; received in revised form 20 March 2003; .


   Abstract
Top
 Notes
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Aims: To investigate left ventricular systolic and diastolic function in patients with essential hypertension and diabetes mellitus associated with hypertension by the myocardial performance index (MPI).

Methods and Results: The study included 45 patients with essential hypertension, 45 patients with diabetes mellitus and hypertension and 45 normal subjects, who underwent a complete two-dimensional and Doppler echocardiography including assessment of the isovolumetric Doppler time intervals for the estimation of the Doppler-derived MPI.

The MPI was significantly higher in patients with essential hypertension and diabetes with hypertension, compared to controls (Essential hypertension=0.51±0.12; Diabetes=0.51±0.12 vs. controls 0.40±0.05, P=0.001). The isovolumetric contraction time was significantly prolonged in essential hypertension (56±26 msec vs. 40±17 msec, P<0.01 respectively) and among diabetes patients isovolumetric relaxation time was prolonged compared to normal subjects (100±20 ms vs. 87±16 ms, P<0.01, respectively). The index was not related to left ventricular mass, age or ejection fraction, but significantly correlated to E-wave deceleration time ({rho}=0.48, P<0.001)

Conclusions: The MPI is increased, in both essential hypertensive patients and diabetes patients with associated hypertension, despite normal ejection fraction.

Keywords: hypertension; diabetes; echocardiography; left ventricle; systole; diastole

{star} Project performed at the Department of Internal Medicine (Diabetes and Endocrinology), Aarhus University Hospital, Denmark. Back


   Introduction
Top
 Notes
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Patients with essential hypertension and hypertensive diabetes patients with normal left ventricular (LV) ejection fraction are closely associated with the development of congestive heart failure. Heart failure in the primary stages is caused by diastolic dysfunction with preserved systolic function assessed by LV ejection fraction[1,2].

However, recent studies have suggested the coexistence of impaired systolic function in patients with presumed isolated diastolic dysfunction and normal ejection fraction[3,4]. Conventional measures of LV systolic function like ejection fraction or fractional shortening may have some limitations in assessing the contractile properties of the left ventricle and does not reflect all aspects of the systole.

The Doppler-derived myocardial performance index (MPI) however, is a non-geometrical non-invasive assessment of global LV function including components from both systole and diastole[5]. The MPI correlates to invasive measures of both systolic and diastolic function[6] and provides prognostic information about morbidity and mortality in patients with ischemic heart disease[7] and cardiomyopathy[8]. The aim of the present study was to investigate the global function of the left ventricle in non-diabetic and diabetic patients with hypertension and normal ejection fraction, evaluated by the MPI. Secondarily to investigate differences between patient subgroups and influence from LV hypertrophy and diastolic dysfunction.


   Materials and Methods
Top
 Notes
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
The study population consisted of 90 consecutive patients. Forty-five patients with essential hypertension, 45 hypertensive patients with diabetes mellitus (DM) (20 type 1 DM and 25 type 2 DM), and 45 age matched controls. All included were in sinus rhythm with a 12 lead electrocardiogram without right or left bundle branch block or signs of ischemia. LV ejection fraction was in all cases <55% and fractional shortening ≥25%, evaluated by echocardiography. Exclusion criteria were secondary arterial hypertension, angina pectoris, prior myocardial infarction, chronic obstructive lung disorder, severe renal failure, or atrial fibrillation.

The study was conducted in accordance with the Helsinki II declaration and approved by the Local Ethics Committee. All participants gave a written informed consent.

Echocardiography
All echocardiography examinations were performed on a GE Vivid Five ultrasound machine (GE Medical System, Horden, Norway) with a 2.5 MHz transducer.

LV mass was estimated according to the American Society of Echocardiography recommendations based on the average of five measurements of LV diameters and wall thickness.

When optimal orientations of M-mode recordings were impossible, linear dimension measurements were made using two-dimensional imaging[9].

LV hypertrophy was defined as <104 g/m2 in women and <116 g/m2 in men[10,11].

Concentric hypertrophy was defined as LV hypertrophy with increased ratio between wall thickness and LV cavity dimension (2xposterior wall diameter/LV diastolic diameter <0.43). Concentric LV remodelling was defined as increased ratio with LV mass within normal limits. Eccentric hypertrophy was defined as LV hypertrophy without increased ratio[12,13].

LV volumes and ejection fraction were estimated using Simpson's modified biplane method based on three measurements. LV mass and volume measurements were corrected for body surface[9]. Endocardial border detection was enhanced by use of Coded second harmonic imaging[14].

Pulsed Doppler measurements were obtained with the transducer in the apical four-chamber view, with the Doppler beam aligned perpendicular to the plane of the mitral annulus. The sample volume was placed between the tips of the mitral leaflets[15]. Five consecutive beats were used for calculation of the Doppler variables.

Doppler time intervals were measured from mitral inflow and LV outflow velocity-time intervals as described by Tei et al.[5]. The interval a from the cessation to the onset of mitral inflow was equal to the sum of isovolumetric contraction time (ICT), ejection time, and isovolumetric relaxation time (IRT). LV ejection time b was the duration of LV outflow velocity profile. Thus the sum of ICT and IRT was obtained by subtracting b from a. The index of combined LV systolic and diastolic function (the sum of ICT and IRT divided by ejection time) was calculated as (a–b)/b. The IRT can be measured by subtracting the interval d, between the R wave and the cessation of LV outflow, from the interval c, between the R wave and the onset of mitral inflow. ICT was calculated by subtracting the IRT from a–b (Fig. 1).


Figure 1
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  		Figure 1 Schematic drawing of the MPI in a hypertensive patient. Reversed E/A ratio, short ejection time (EJT) and prolonged ICT and IRT. The index (ICT + IRT/EJT) is derived as (a–b/b), according to Tei et al..[6].

 
Assessment of colour M-mode flow propagation recordings were performed in the apical four-chamber view and with the M-mode cursor aligned parallel with the LV inflow. Adjustments were made to obtain the longest column of flow from the mitral annulus to the apex of the left ventricle. The M-mode cursor was positioned through the centre of the inflow, to avoid boundary regions. The velocity flow propagation was measured as the slope of the first aliasing velocity (41 cm/s) from the mitral annulus in early diastole to 4 cm distally into the LV cavity[16].

All echocardiograms were performed and analysed by one observer.

Diastolic filling was classified on the basis of the mitral inflow Doppler parameters and colour M-mode flow propagation (Vp). E-deceleration time ≥140 ms and <240 ms, and an E/A ratio between 1 and 2 and Vp <45 cm/s indicated normal diastolic filling. Impaired relaxation was defined as E-deceleration time above 240 ms and E/A ratio <1. Pseudonormal filling was defined as E-deceleration time ≥140 ms and <240 ms and Vp <45 cm/s. E-deceleration time <140 ms was suggestive of a restrictive filling pattern. The cut points were chosen based on recent recommendations[17].

Statistics
All data are expressed as mean standard deviation (SD). Analysis of equal variance (ANOVA) was used to detect differences between groups.

Comparisons of all measurements were made with paired Student's t-test and rank sum tests. Simple and multiple linear regression analysis determined all correlations.

Results were corrected for multiple comparisons by Bonferroni's method.

Receiver operating characteristic (ROC) curve analysis was generated to test the predictive capability of the MPI.

The P-values were considered significant at P<0.05.


   Results
Top
 Notes
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Patient demographics are shown in Table 1.


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  		Table 1 Demographic data.

 
Patients with essential hypertension were comparable with the diabetes group regarding systolic blood pressure, whereas diastolic blood pressure was significantly higher among patients with essential hypertension compared to both diabetes patients and controls.

Standard Echocardiographic Parameters
Patients with hypertension and diabetes had enlarged left atrial dimension, increased wall thickness and LV mass index. LV ejection fraction was comparable between groups whereas fractional shortening was slightly decreased in the diabetes group, however within the normal range. A-peak velocity, E/A ratio, E-deceleration time, isovolumetic relaxation time and E/Vp ratio were comparable between hypertensive and diabetes patients but were significantly increased compared to normal subjects (Table 2).


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  		Table 2 Echocardiographic variables of LV function in patients with diabetes mellitus and controls.

 
MPI in Essential Hypertension and Diabetes
The MPI was significantly increased in both patients with hypertension and diabetes (Table 3). This was primarily due to prolongation of ICT in patients with hypertension and prolongation of the IRT among diabetes patients and shortening of the ejection time in both groups.


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  		Table 3 Myocardial performance index and Doppler time intervals.

 
There was not any difference between type 1 and type 2 patients on the MPI (0.51±0.08 vs. 0.52±0.12, P=NS), or in the subsections of the index; IRT (103±18 ms vs. 100±20 ms, P=NS), ejection time (284±25 ms vs. 280±28 ms, P=NS) and ICT (44±17 msec vs. 47±23 msec, P=NS).

We did not find any correlations to either diabetes duration, HbA1c or urine albumine excretion.

The index was similar in essential hypertension with geometric LV abnormality (concentric remodelling[11], eccentric hypertrophy (n=9) or concentric hypertrophy (n=12)) compared to patients without geometric changes (0.52±0.11 vs. 0.51±0.12, P=NS). Similar findings were found in diabetes patients with geometrical changes of the left ventricle (LV remodelling (n=9); eccentric hypertrophy (n=9); concentric hypertrophy (n=13). This subgroup had also a comparable index value compared to patients with normal geometry (0.53±0.12 vs. 0.49±0.11, P=NS).

MPI in Relation to Mitral LV Filing Patterns
The prevalence of abnormal diastolic filling was equal in patients with hypertension (12 patients with impaired relaxation, 10 with pseudonormal filling) and diabetes (12 patients with impaired relaxation and 11 with pseudonormal filling). The index was significantly increased in patients with essential hypertension and diastolic dysfunction compared to patients without.

Patients with essential hypertension without diastolic dysfunction had a non-significant increase in MPI but a significantly prolonged ICT.

In contrast the index was comparable in the diabetes group regardless of the presence or absence of diastolic dysfunction (Table 4).


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  		Table 4 Myocardial performance index and diastolic filling.

 
ROC curve analysis was performed (n=90), to test the predictive capability of the MPI to detect patients with diastolic dysfunction. We found a significant separation between patients with diastolic dysfunction and patients without diastolic dysfunction (area under the curve (AUC)=0.69±0.05, P<0.01. Separate receiver operational curve analysis of the non-diabetic group was also significant (AUC: 0.77±0.07, P<0.01), but in the diabetes group the AUC was 0.54±0.09, P=NS.

With an MPI-cut point of 0.51 (median value) we found a sensitivity of 70% and specificity of 50% in detecting diastolic dysfunction in the overall population, whereas in the non-diabetic group the values were slightly higher (sensitivity 75% and specificity 60%).

Correlations to the MPI
In all patients the index significantly correlated to heart rate ({rho}=0.22, P=0.016), E-wave-deceleration time ({rho}=0.43, P<0.001), IRT ({rho}=0.26, P<0.01), and to E/A ratio ({rho}=–0.31, P<0.01). No correlations to mass index, wall thickness, left atrial diameter, age, systolic and diastolic blood pressure, fractional shortening or LV ejection fraction were found.

In a multiple regression analysis only E-wave deceleration time ({rho}=0.48, P<0.001) was found to have an independent influence on the index.


   Discussion
Top
 Notes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
The present study demonstrated that the MPI was significantly increased to the same level in essential hypertension and diabetes mellitus with associated hypertension despite normal LV ejection fraction and relatively short disease duration. The increase of the MPI was related to abnormalities of the LV systolic as well as the diastolic myocardial function. However, the underlying myocardial dysfunction seemed to differ between non-diabetic and diabetic patients with hypertension. In patients with essential hypertension the MPI was primarily increased due to prolongation of the isovolumetric contraction and shortening of the ejection time indicating abnormalities of the systolic performance. These results are similar to findings from other investigators, who report a reduced ratio of pre-ejection time and ejection time in patients with reduced systolic LV function[18].

The MPI was increased in essential hypertension regardless of the presence of abnormal diastolic filling, however, the increase of the index was most pronounced in patients with diastolic dysfunction. These findings were supported by the correlation to E-wave deceleration time and are properly due to the obviously wide degree of diastolic dysfunction in this type of disease and the incorporation of diastolic parameters in the index itself. Additionally E-wave deceleration time reflects global LV compliance which is decreased in hypertensive patients, and will have additional impact on the LV performance.

Essential hypertension is associated with LV hypertrophy, increased myocardial fibrosis and subendocardial ischemia, factors believed to influence myocardial function[19]. However, in the present study we did not find any relation between the MPI and seated blood pressure, LV mass or changes in LV geometry, which corresponds well to previous studies[5,8].

Myocardial Performance and Diabetes Mellitus
In the diabetes group the increased MPI was primarily due to prolongation of the IRT, shortening of the ejection time and elevated IRT/EJT, which is well correlated to the invasive parameter of –dp/dt[6].

By analysis of the mitral inflow and colour M-mode flow propagation we found abnormal diastolic filling in approximately half of the patients with diabetes in consistence with previous reports[20,21]. However, the index was increased to the same extent in diabetes patients without signs of diastolic filling abnormalities compared to patients with abnormal filling. This suggests that the MPI might supplement the traditional methods of assessing myocardial function in diabetes with associated hypertension.

The impact of the coexistence of diabetes and hypertension on LV function has recently been investigated both in the Strong Heart study and the HyperGen study[20,22], where apparent implications of a specific diabetes effect on LV relaxation of the myocardium were found in hypertensive type 2 diabetes patients[20]. This can be due to impaired glycemic control, microangiopathy or interstitial accumulation of elastin and collagen which also increase LV stiffness and mass in diabetes patients[23]. Silent myocardial ischemia is also a potential factor with influence on abnormal LV relaxation[24–26] but is also found present in diabetes patients without coronary artery disease[27,28].

The MPI only had a moderate capability to detect abnormal diastolic function by ROC curve analysis. Even though moderate, it has previously been stated that the MPI was not at all able to significantly distinguish patients with diastolic dysfunction in a broad population with heart disease[29]. The rather moderate results are possibly also due to the fact that the index is global, containing both systolic and diastolic elements.

Clinical Value
When using the MPI in hypertensive patients, we found global decreased performance compared to matching normal subjects although we do not know whether this upholds any prognostic information, as it does in other types of cardiac disease[7,30,31].

The strength of the MPI is the incorporation of both systolic and diastolic parameters, that otherwise are difficult to gather in the traditional echocardiographic examination. This could be findings of slightly prolonged IRT and a fractional shortening just within normal limits where the use of a global index could be relevant as a supplement to these conventional measurements of LV function.

Limitations
The medical therapy among patients with essential hypertension and diabetes with associated hypertension was different, which can possibly have influenced our results. But the medical therapy was in correspondence with recommended regimens.

Furthermore the existence of ischemic heart disease cannot be ruled out since no stress test or angiography were performed in these patients.


   Conclusion
Top
 Notes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
The MPI is increased in non-diabetic and diabetic patients with hypertension and normal ejection fraction. The MPI adds information to the evaluation of the LV systolic and diastolic function, which might be helpful in the evaluation of patients with hypertension, diastolic heart failure and normal ejection fraction.


   Notes
Top
 Notes
Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
{star} Project performed at the Department of Internal Medicine (Diabetes and Endocrinology), Aarhus University Hospital, Denmark. Back


   References
Top
 Notes
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Hartford M., Wikstrand J., Wallentin I., Ljungman S., Wilhelmsen L., Berglund G. Diastolic function of the heart in untreated primary hypertension. Hypertension (1984) 6(3):329–338.[Abstract/Free Full Text]
  2. Snider A.R., Gidding S.S., Rocchini A.P., et al. Doppler evaluation of left ventricular diastolic filling in children with systemic hypertension. Am J Cardiol (1985) 56(15):921–926.[CrossRef][Web of Science][Medline]
  3. Yu C.M., Lin H., Yang H., Kong S.L., Zhang Q., Lee S.W. Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction. Circulation (2002) 105(10):1195–1201.[Abstract/Free Full Text]
  4. Aurigemma G.P., Williams D., Gaasch W.H., Reda D.J., Materson B.J., Gottdiener J.S. Ventricular and myocardial function following treatment of hypertension. Am J Cardiol (2001) 87(6):732–736.[CrossRef][Web of Science][Medline]
  5. Tei C., Ling L.H., Hodge D.O., et al. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function—a study in normals and dilated cardiomyopathy. J Cardiol (1995) 26(6):357–366.[Medline]
  6. Tei C., Nishimura R.A., Seward J.B., Tajik A.J. Noninvasive Doppler-derived myocardial performance index: correlation with simultaneous measurements of cardiac catheterization measurements. J Am Soc Echocardiogr (1997) 10(2):169–178.[CrossRef][Web of Science][Medline]
  7. Poulsen S.H., Jensen S.E., Tei C., Seward J.B., Egstrup K. Value of the Doppler index of myocardial performance in the early phase of acute myocardial infarction. J Am Soc Echocardiogr (2000) 13(8):723–730.[CrossRef][Web of Science][Medline]
  8. Tei C., Dujardin K.S., Hodge D.O., Kyle R.A., Tajik A.J., Seward J.B. Doppler index combining systolic and diastolic myocardial performance: clinical value in cardiac amyloidosis. J Am Coll Cardiol (1996) 28(3):658–664.[Abstract]
  9. Schiller N.B., Shah P.M., Crawford M., et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of two-dimensional echocardiograms. J Am Soc Echocardiogr (1989) 2(5):358–367.[Medline]
  10. Levy D., Garrison R.J., Savage D.D., Kannel W.B., Castelli W.P. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham heart study. N Engl J Med (1990) 322(22):1561–1566.[Abstract]
  11. Wachtell K., Palmieri V., Olsen M.H., et al. Urine albumin/creatinine ratio and echocardiographic left ventricular structure and function in hypertensive patients with electrocardiographic left ventricular hypertrophy: the LIFE study. Losartan intervention for endpoint reduction. Am Heart J (2002) 143(2):319–326.[CrossRef][Web of Science][Medline]
  12. Roman M.J., Pickering T.G., Schwartz J.E., Pini R., Devereux R.B. Relation of arterial structure and function to left ventricular geometric patterns in hypertensive adults. J Am Coll Cardiol (1996) 28(3):751–756.[Abstract]
  13. Ganau A., Devereux R.B., Roman M.J., et al. Patterns of left ventricular hypertrophy and geometric remodelling in essential hypertension. J Am Coll Cardiol (1992) 19(7):1550–1558.[Abstract]
  14. Kim W.Y., Sogaard P., Egeblad H., Andersen N.T., Kristensen B. Three-dimensional echocardiography with tissue harmonic imaging shows excellent reproducibility in assessment of left ventricular volumes. J Am Soc Echocardiogr (2001) 14(6):612–617.[CrossRef][Web of Science][Medline]
  15. Little W.C., Ohno M., Kitzman D.W., Thomas J.D., Cheng C.P. Determination of left ventricular chamber stiffness from the time for deceleration of early left ventricular filling. Circulation (1995) 92(7):1933–1939.[Abstract/Free Full Text]
  16. Takatsuji H., Mikami T., Urasawa K., et al. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol (1996) 27(2):365–371.[Abstract]
  17. Nishimura R.A., Tajik A.J. Evaluation of diastolic filling of left ventricle in health and disease: Doppler echocardiography is the clinician's Rosetta Stone. J Am Coll Cardiol (1997) 30(1):8–18.[Abstract]
  18. Burwash I.G., Otto C.M., Pearlman A.S. Use of Doppler-derived left ventricular time intervals for noninvasive assessment of systolic function. Am J Cardiol (1993) 72(17):1331–1333.[CrossRef][Web of Science][Medline]
  19. Querejeta R., Varo N., Lopez B., et al. Serum carboxy-terminal propeptide of procollagen type I is a marker of myocardial fibrosis in hypertensive heart disease. Circulation (2000) 101(14):1729–1735.[Abstract/Free Full Text]
  20. Liu J.E., Palmieri V., Roman M.J., et al. The impact of diabetes on left ventricular filling pattern in normotensive and hypertensive adults: the Strong Heart Study. J Am Coll Cardiol (2001) 37(7):1943–1949.[Abstract/Free Full Text]
  21. Palmieri V., Bella J.N., Arnett D.K., et al. Effect of type 2 diabetes mellitus on left ventricular geometry and systolic function in hypertensive subjects: Hypertension Genetic Epidemiology Network (HyperGEN) Study. Circulation (2001) 103(1):102–107.[Abstract/Free Full Text]
  22. Bella J.N., Devereux R.B., Roman M.J., et al. Separate and joint effects of systemic hypertension and diabetes mellitus on left ventricular structure and function in american indians (the Strong Heart Study). Am J Cardiol (2001) 87(11):1260–1265.[CrossRef][Web of Science][Medline]
  23. van Hoeven K.H., Factor S.M. A comparison of the pathological spectrum of hypertensive, diabetic, and hypertensive-diabetic heart disease. Circulation (1990) 82(3):848–855.[Abstract/Free Full Text]
  24. Reduto L.A., Wickemeyer W.J., Young J.B., et al. Left ventricular diastolic performance at rest and during exercise in patients with coronary artery disease. Assessment with first-pass radionuclide angiography. Circulation (1981) 63(6):1228–1237.[Abstract/Free Full Text]
  25. Appleton C.P., Hatle L.K., Popp R.L. Relation of transmitral flow velocity patterns to left ventricular diastolic function: new insights from a combined hemodynamic and Doppler echocardiographic study. J Am Coll Cardiol (1988) 12(2):426–440.[Abstract]
  26. Brutsaert D.L. Nonuniformity: a physiologic modulator of contraction and relaxation of the normal heart. J Am Coll Cardiol (1987) 9(2):341–348.[Abstract]
  27. Zabalgoitia M., Ismaeil M.F., Anderson L., Maklady F.A. Prevalence of diastolic dysfunction in normotensive, asymptomatic patients with well-controlled type 2 diabetes mellitus. Am J Cardiol (2001) 87(3):320–323.[CrossRef][Web of Science][Medline]
  28. Poirier P., Bogaty P., Garneau C., Marois L., Dumesnil J.G. Diastolic dysfunction in normotensive men with well-controlled type 2 diabetes: importance of maneuvers in echocardiographic screening for preclinical diabetic cardiomyopathy. Diabetes Care (2001) 24(1):5–10.[Abstract/Free Full Text]
  29. Bruch C., Schmermund A., Dagres N., Katz M., Bartel T., Erbel R. Tei-Index in coronary artery disease—validation in patients with overall cardiac and isolated diastolic dysfunction. Z Kardiol (2002) 91(6):472–480.[CrossRef][Web of Science][Medline]
  30. Harjai K.J., Scott L., Vivekananthan K., Nunez E., Edupuganti R. The Tei index: a new prognostic index for patients with symptomatic heart failure. J Am Soc Echocardiogr (2002) 15(9):864–868.[CrossRef][Web of Science][Medline]
  31. Dujardin K.S., Tei C., Yeo T.C., et al. Prognostic value of a Doppler index combining systolic and diastolic performance in idiopathic-dilated cardiomyopathy. Am J Cardiol (1998) 82(9):1071–1076.[CrossRef][Web of Science][Medline]

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