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      Application of a simplified definition of diastolic function in severe sepsis and septic shock

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          Abstract

          Background

          Left ventricular diastolic dysfunction is common in patients with severe sepsis or septic shock, but the best approach to categorization is unknown. We assessed the association of common measures of diastolic function with clinical outcomes and tested the utility of a simplified definition of diastolic dysfunction against the American Society of Echocardiography (ASE) 2009 definition.

          Methods

          In this prospective observational study, patients with severe sepsis or septic shock underwent transthoracic echocardiography within 24 h of onset of sepsis (median 4.3 h). We measured echocardiographic parameters of diastolic function and used random forest analysis to assess their association with clinical outcomes (28-day mortality and ICU-free days to day 28) and thereby suggest a simplified definition. We then compared patients categorized by the ASE 2009 definition and our simplified definition.

          Results

          We studied 167 patients. The ASE 2009 definition categorized only 35 % of patients. Random forest analysis demonstrated that the left atrial volume index and deceleration time, central to the ASE 2009 definition, were not associated with clinical outcomes. Our simplified definition used only e′ and E/e′, omitting the other measurements. The simplified definition categorized 87 % of patients. Patients categorized by either ASE 2009 or our novel definition had similar clinical outcomes. In both definitions, worsened diastolic function was associated with increased prevalence of ischemic heart disease, diabetes, and hypertension.

          Conclusions

          A novel, simplified definition of diastolic dysfunction categorized more patients with sepsis than ASE 2009 definition. Patients categorized according to the simplified definition did not differ from patients categorized according to the ASE 2009 definition in respect to clinical outcome or comorbidities.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13054-016-1421-3) contains supplementary material, which is available to authorized users.

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          Most cited references16

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          Diastolic dysfunction and left atrial volume: a population-based study.

          We examined the association between diastolic function and left atrial volume indexed to body surface area (LAVi) in a population-based study. Atrial enlargement has been suggested as a marker of the severity and duration of diastolic dysfunction (DD). However, the association between DD and atrial enlargement and their individual prognostic implications in the population is poorly defined. A cross-sectional sample of Olmsted County, Minnesota, residents > or =45 years of age (n=2,042) underwent comprehensive Doppler echocardiography and medical record review. The LAVi increased with worsening DD: 23 +/- 6 ml/m2 (normal), 25 +/- 8 ml/m2 (grade I DD), 31 +/- 8 ml/m2 (grade II DD), 48 +/- 12 ml/m2 (grades III to IV DD). In bivariate analyses, age, left ventricular mass index, and DD grade were positively associated, whereas female gender and ejection fraction (EF) were inversely associated with LAVi (p <0.001 for all). When controlling for age, gender, cardiovascular (CV) disease, EF, and left ventricular mass, grade II DD was associated with a 24%, and grade III to IV DD was associated with a 62% larger LA volume (p <0.0001 for both). The area under the receiver-operator characteristic curve for LAVi to detect grade I, grade II, or grade III to IV DD was 0.57, 0.81, and 0.98, respectively. Both DD and LAVi were predictive of all-cause mortality, but when controlling for DD, LAVi was not an independent predictor of mortality. These data suggest that DD contributes to LA remodeling. Indeed, DD is a stronger predictor of mortality; presumably it better reflects the impact of CV disease within the general population.
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            Troponin elevation in severe sepsis and septic shock: the role of left ventricular diastolic dysfunction and right ventricular dilatation*.

            Serum troponin concentrations predict mortality in almost every clinical setting they have been examined, including sepsis. However, the causes for troponin elevations in sepsis are poorly understood. We hypothesized that detailed investigation of myocardial dysfunction by echocardiography can provide insight into the possible causes of troponin elevation and its association with mortality in sepsis.
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              Prediction of hospital outcome in septic shock: a prospective comparison of tissue Doppler and cardiac biomarkers

              Introduction Diastolic dysfunction as demonstrated by tissue Doppler imaging (TDI), particularly E/e' (peak early diastolic transmitral/peak early diastolic mitral annular velocity) is common in critical illness. In septic shock, the prognostic value of TDI is undefined. This study sought to evaluate and compare the prognostic significance of TDI and cardiac biomarkers (B-type natriuretic peptide (BNP); N-terminal proBNP (NTproBNP); troponin T (TnT)) in septic shock. The contribution of fluid management and diastolic dysfunction to elevation of BNP was also evaluated. Methods Twenty-one consecutive adult patients from a multidisciplinary intensive care unit underwent transthoracic echocardiography and blood collection within 72 hours of developing septic shock. Results Mean ± SD APACHE III score was 80.1 ± 23.8. Hospital mortality was 29%. E/e' was significantly higher in hospital non-survivors (15.32 ± 2.74, survivors 9.05 ± 2.75; P = 0.0002). Area under ROC curves were E/e' 0.94, TnT 0.86, BNP 0.78 and NTproBNP 0.67. An E/e' threshold of 14.5 offered 100% sensitivity and 83% specificity. Adjustment for APACHE III, cardiac disease, fluid balance and grade of diastolic function, demonstrated E/e' as an independent predictor of hospital mortality (P = 0.019). Multiple linear regression incorporating APACHE III, gender, cardiac disease, fluid balance, noradrenaline dose, C reactive protein, ejection fraction and diastolic dysfunction yielded APACHE III (P = 0.033), fluid balance (P = 0.001) and diastolic dysfunction (P = 0.009) as independent predictors of BNP concentration. Conclusions E/e' is an independent predictor of hospital survival in septic shock. It offers better discrimination between survivors and non-survivors than cardiac biomarkers. Fluid balance and diastolic dysfunction were independent predictors of BNP concentration in septic shock.
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                Author and article information

                Contributors
                michael.lanspa@imail.org
                andrea.gutsche@hsc.utah.edu
                emily.wilson@imail.org
                troy.olsen2@imail.org
                ellie.hirshberg@imail.org
                daniel.knox@umassmemorial.org
                samuel.brown@imail.org
                colin.grissom@imail.org
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                4 August 2016
                4 August 2016
                2016
                : 20
                : 243
                Affiliations
                [1 ]Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84157 USA
                [2 ]Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT 84132 USA
                [3 ]Department of Anesthesiology, University of Utah, 30 North 1900 East, 701 Wintrobe, Salt Lake City, UT 84132 USA
                [4 ]Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108 USA
                [5 ]Division of Pulmonary, Allergy, and Critical Care Medicine, University of Massachusetts, 55 Lake Avenue North, Worchester, MA 01655 USA
                Article
                1421
                10.1186/s13054-016-1421-3
                4973099
                27487776
                3b5e9aa0-e5e4-44ee-bb0d-a16a927da029
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 9 March 2016
                : 20 July 2016
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000057, National Institute of General Medical Sciences;
                Award ID: K23GM0904465
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2016

                Emergency medicine & Trauma
                diastolic,sepsis,echocardiography,classification,shock
                Emergency medicine & Trauma
                diastolic, sepsis, echocardiography, classification, shock

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