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Pediatr Cardiol (2008) 29:108112 DOI 10.

1007/s00246-007-9101-3

ORIGINAL ARTICLE

Measuring Stress Velocity Index Using Mean Blood Pressure: Simple yet Accurate?
Sanjeev Aggarwal Michael D. Pettersen Joellyn Gurckzynski Thomas LEcuyer

Received: 10 April 2007 / Accepted: 28 June 2007 / Published online: 3 October 2007 Springer Science+Business Media, LLC 2007

Abstract The stress velocity index, or the relationship of the rate-corrected mean velocity of circumferential shortening (VCFc) to the end systolic wall stress (ESWS), is a sensitive, load-independent measure of left ventricular contractility. ESWS is technically difcult to obtain and requires simultaneous blood pressure measurement, carotid artery tracing, and phonocardiogram. We report our comparison of two simpler methods of measuring ESWS and, therefore, stress velocity index. Patients with normal cardiac anatomy who had completed anthracycline chemotherapy were evaluated. ESWS as measured by the standard method using a carotid artery tracing (ESWScar) was compared to ESWS obtained using mean arterial pressure (ESWSmap) or systolic blood pressure (ESWSsbp). The cohort included 63 patients, with 37 (59%) males and a median age of 13.1 years. The mean (SD) ESWScar was 53.315.3 g/cm2 (range, 26.394 g/cm2); ESWSmap, 53 13.4 g/cm2 (range, 27.186.1 g/cm2); and ESWSsbp, 72.9 18.2 g/cm2 (range, 40.8117.2 g/cm2). ESWSmap and ESWSsbp closely correlated with ESWScar (coefcient correlation r = 0.88 and r = 0.87, respectively). Using ESWSmap, all patients were correctly classied as having normal or abnormal contractility as dened by stress velocity index, whereas ESWSsbp detected only two of the six patients with impaired contractility. We conclude that ESWSmap is a simple, highly sensitive and specic method for assessing left ventricular contractility. ESWSmap correlates closely with ESWScar and can be

incorporated into the monitoring of cardiac dysfunction in the anthracycline-treated population. Further studies are needed to determine if this simplied measure accurately assesses the ESWS in other cardiac disease states. Keywords Left ventricle Systolic function Echocardiogram Load independent

S. Aggarwal (&) M. D. Pettersen J. Gurckzynski T. LEcuyer Division of Cardiology, Department of Pediatrics, Childrens Hospital of Michigan, Wayne State University, 3901 Beaubien Boulevard, Detroit, MI 48201, USA e-mail: ssanjeev@dmc.org

Left ventricular (LV) function may be impaired in various congenital heart defects, in myocarditis, after ischemic injury, and secondary to drug toxicity. LV function is routinely evaluated using echocardiographic parameters such as ejection fraction and shortening fraction. The disadvantages of these parameters are that they are dependent on the heart rate, preload, afterload, and ventricular contractility [3, 8]. Therefore, they do not provide a specic direct assessment of left ventricular contractility. The stress velocity index, or the relationship of the ratecorrected mean velocity of circumferential ber shortening (VCFc) and end-systolic wall stress (ESWS), has previously been established as a sensitive, noninvasive measure of LV contractility [4]. The index is independent of preload and incorporates afterload, heart rate, and LV dimensions. However, its measurement requires simultaneous acquisition of an M-mode echocardiogram, carotid pulse tracing, phonocardiogram, and blood pressure measurement. The phonocardiogram is required to determine the timing of end systole by the rst component of the second heart sound. The carotid pulse tracing is used to obtain intraventricular end-systolic pressure by assignment of systolic blood pressure (SBP) to the peak and diastolic blood pressure to the nadir and then by linear interpolation to the level of dicrotic notch (Fig. 1). The dicrotic notch on a carotid pulse tracing corresponds to end-systolic pressure

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SBP

A DBP

P = DBP+ {(SBP-DBP)XB/A}
P=left ventricular end systolic pressure SBP=Systolic blood pressure DBP= Diastolic blood pressure

Fig. 1 Carotid artery tracing depicting the method of calculating intraventricular end-systolic pressure

in the left ventricle. Obtaining a carotid artery tracing is especially difcult in the pediatric population due to shortness of the neck, discomfort, and fast heart rate, which preclude the routine use of this measure. Two previous studies have evaluated an alternative simpler method of obtaining this index using mean blood pressure (MAP) [6, 9]. One study used a direct invasive measure of blood pressure during cardiac catheterization and the other involved patients with a variety of congenital heart defects, which might affect the correlation of MAP and end-systolic pressures. Peak systolic stress using the SBP has also been described as a simpler approach to measuring stress velocity index [11]. The slope of the regression line of the peak systolic wall stress-VCFc was found to be nearly identical to, and the y intercept slightly higher than, the regression line relating ESWS-VCFc [11]. The present report compares the stress velocity indexes obtained by conventional carotid artery tracing with those obtained by MAP and SBP in a homogeneous pediatric cohort with structurally normal hearts.

machine. All studies were performed in the quiet, awake, and nonsedated state. All measurements were performed off-line by a single cardiologist (M.P.). End-systolic wall stress (ESWScar) was measured by the method described by Colan et al. [4]. Wall Stress [g/cm2] = (1.35) (P)(LVEDd)/(4)(LVPWs)(1+LVPWs/LVEDs), where P is the intraventricular end-systolic pressure obtained from carotid artery tracing (Fig. 1). LVEDd is the left ventricular internal dimension at end diastole (dened as the onset of QRS complex); LVEDs and LVPWS are the left ventricle internal dimensions and left ventricle posterior wall thickness, respectively, at end systole dened by the aortic component of the second heart sound. Similarly, ESWSmap was obtained by replacing P with MAP as obtained by Dinamap. ESWSsbp was obtained by using SBP in place of P. Mean velocity of circumferential shortening was calculated using LVEDd LVEDs/LVEDs ETc, where ETc is the heart rate-corrected ejection time as measured by Doppler interrogation of left ventricular outow.

Statistics Data were analyzed using SPSS software version 12 for PC. Data are expressed as mean SD, median, or numbers as appropriate. The two methods for calculating ESWS were compared to the standard measurement of ESWS by plotting the difference between the methods against their means [2]. ESWS was dened as abnormal at values [60 gm/cm2 [7]. Sensitivity, specicity, positive and negative predictive values, and 95% condence intervals of the simpler methods of calculating ESWS were computed using ESWScar as gold standard.

Results The study group consisted of 63 patients who had completed AC chemotherapy and underwent echocardiographic assessment of LV function. There were 37 (59%) males and 26 (41%) females. The median age at enrollment was 13.1 years (range, 6.5 to 26.5 years) and the median interval since completion of AC treatment was 3.8 years (range, 1.1 to 17.5 years). The clinical diagnoses included acute lymphocytic leukemia in 29 (46%), Wilms tumor in 12 (19%), osteosarcoma in 12 (19%), and lymphoma in 10 (16%) patients. The mean (SD) cumulative dose of AC received was 215.5 116.7 mg/m2 (range, 45520 mg/m2; median 160 mg/m2). The average ( SD) MAP as measured by Dinamap was 77.4 10.65 mm Hg (range, 51107 mm Hg), while the mean intraventricular pressure as calculated by carotid

Materials and Methods The study included 63 patients who underwent detailed echocardiograms as part of a research protocol for assessment of ventricular function in anthracycline (AC)-treated children. Each patient underwent an echocardiogram including M-mode, two-dimensional, and color Doppler using a Phillips Sono5500 ultrasound machine. Standard technique was used to obtain M-mode measurements [10]. Simultaneous carotid artery tracing, electrocardiogram, phonocardiogram, and blood pressure were recorded. Each measurement was obtained for three to ve cardiac cycles. Blood pressure was recorded using a Dinamap automatic

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Fig. 2 Relationship of intraventricular pressure obtained using carotid artery tracing versus mean arterial pressure

Fig. 3 Relationship of ESWSmap and ESWScar

artery tracing was 77.4 16.1 mm Hg (range, 50106 mm Hg). The mean (SD) SBP as measured by Dinamap was 106.52 13.4 mm Hg (range, 77137 mm Hg). The mean (SD) difference between the intraventricular pressure by carotid tracing and the MAP was 0.045 9.5 (range, 22.2 to 28.98 mmHg) and the correlation coefcient between the two was 0.66 (p \ 0.0001) (Fig. 2). The mean (SD) difference between the intraventricular pressure by carotid tracing and the SBP was 9.08 10.4 mm Hg (range, 61.7 to 2.97 mmHg) and the correlation coefcient between the two was 0.67 (p \ 0.0001). The mean (SD) ESWS using the traditional method (ESWScar) was 53.3 15.3 g/cm2 (range, 26.394 g/cm2), while it was 53 13.4 g/cm2 (range, 27.186.1 g/cm2) and 72.9 18.2 g/ cm2 (range, 40.8117.2 g/cm2) using the MAP and SBP, respectively. ESWScar correlated closely with both ESWSmap (r = 0.88, p = 0.0001) (Fig. 3) and ESWSsbp (r = 0.87, p = 0.0001). Using the Altman and Bland bias analysis, the mean (SD) difference between ESWScar and ESWSmap was 0.31 7.33 g/cm2 (range, 16.8 to 24.8 g/cm2), whereas that between ESWScar and ESWSsbp was 9.6 8.2 g/cm2 (range, 45.2 to 1.8 g/ cm2). Figure 4 depicts the difference in the MAP and its relationship to the intraventricular pressure as measured by carotid artery tracing. Similarly Fig. 5 shows the difference in ESWScar versus ESWSmap and its relationship with ESWScar and that the difference did not change over the range of ESWS observed. The relationship of VCFc and ESWSmap for estimating stress velocity index is shown in Fig. 6. In our cohort, 19 (30%) had abnormal ESWScar and 6 (9.5%) had abnormal contractility. Using ESWSmap, all patients were correctly classied as having normal or abnormal contractility, whereas ESWSsbp detected only two of the six patients with impaired contractility. The

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Fig. 4 Difference in individual measurements of mean blood pressure as measured by Dinamap versus intraventricular pressure as obtained by carotid artery tracing

sensitivity, specicity, and positive and negative predictive values (95% condence intervals) of EWSWmap and ESWSsbp using ESWScar as the gold standard are reported in Table 1.

Discussion Our report validates two simpler methods of obtaining ESWS in a pediatric cohort with structurally normal hearts, although a signicant proportion had impaired ESWS and six had impaired contractility. The ESWS obtained using MAP and SBP both correlated closely with the conventional ESWS obtained using a carotid pulse tracing. The MAP method, however, had superior specicity and

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111 Table 1 The sensitivity, specicity, and positive and negative predictive values (95% condence intervals) of EWSWmap and ESWSsbp using ESWScar as the gold standard ESWSmap (CI) Sensitivity Specicity Positive predictive value Negative predictive value 95% (82%99%) 96% (90%97%) 90% (77%94%) 98% (92%99%) ESWSsbp (CI) 100% (86%100%) 37% (30%37%) 40% (35%40%) 100% (84%100%)

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Note. ESWSmap, end-systolic wall stress using mean blood pressure; ESWSsbp, end-systolic wall stress using systolic blood pressure; CI, 95% condence interval

ESWScar (g/cm2)
ESWScar: End systolic wall stress using carotid tracing ESWSmap: End systolic wall stress using mean blood pressure

Fig. 5 Difference in the individual measurements of ESWSmap and ESWScar versus their means

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ESWSmap: End systolic wall stress using mean blood pressure VCFc: rate corrected mean velocity of circumferential fiber shortening

Fig. 6 Relationship of VCFS and ESWSmap for estimating the stress velocity index for assessing left ventricular contractility

positive predictive values compared to the SBP method. In addition, the mean (SD) difference between ESWScar and ESWSsbp was signicantly greater than that between ESWScar and ESWSmap. The relationship between velocity of circumferential ber shortening and ESWS is a sensitive, load-independent index for assessment of LV systolic function. It has been shown to reliably detect patient deterioration and response to medications in critically ill pediatric patients [5]. The index is reproducible over time and is considered ideal for longitudinal studies, especially when the preload status is abnormal such as with anemia, with fever, or in the postoperative period [4]. In the AC-treated population, 40% of

patients have late cardiotoxicity even at low cumulative AC doses, previously thought to be safe [1]. Therefore, longitudinal surveillance for prolonged periods is indicated for life in patients after receiving AC. In this vulnerable group, ESWS is well known to be a superior early marker of cardiac dysfunction [7]. Unfortunately, this measurement is difcult to obtain, at least partly due to difculty in obtaining a carotid pulse tracing. Therefore, simpler methods of measuring contractility are of clinical value. Two previous studies have reported an excellent correlation between ESWS and ESWSmap [6, 9]. One of these compared direct arterial pressures from femoral arterial/ aortic pressure transducer obtained during cardiac catheterization and LV end-systolic pressure. The mean difference reported was 0.3 mm Hg (SD, 2.9 mm Hg) [9]. In another study, the MAP obtained by a Dinamap machine was used to calculate ESWS [6]. The correlation coefcient between MAP and pressure obtained with carotid artery tracing was 0.84. The correlation coefcient between ESWScar and ESWSmap was 0.98, similar to our results. However, the patient group was diverse and included patients receiving chemotherapy, with congenital heart defects, dilated cardiomyopathy, hypertension, and transplanted heart. A single study evaluated LV contractility using the relationship of VCFc to stress at peak systole in 25 normal children [11]. The reported correlation coefcient between ESWScar and ESWSsbp was 0.91. In our group, the correlation coefcient was comparable, at 0.87. This method, however, had poor specicity and positive predictive value for ESWS and identied only two of the six patients with impaired contractility. To the best of our knowledge, ours is the rst study comparing ESWS obtained by the standard method to ESWS obtained using MAP and SBP.

VCFc (c/s)

Conclusion We conclude that ESWS and, therefore, stress velocity index can be measured easily and with excellent sensitivity and specicity by using MAP obtained by a Dinamap

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machine in place of obtaining a carotid pulse tracing. This method can be incorporated into the long-term monitoring of LV contractility in AC-treated children. Further studies are needed to validate this simplied measure in other cardiac conditions.

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