Author + information
- Masaaki Takeuchi, MD, PhD∗ (, )
- Hiroshi Kuwaki, MD,
- Victor Chien-Chia Wu, MD and
- Yutaka Otsuji, MD, PhD
- ↵∗University of Occupational and Environmental Health, School of Medicine, Second Department of Internal Medicine, 1.1. Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan
We are grateful to Dr. Fontes-Carvalho and colleagues for their interest in our study (1). A different prevalence of grade Ia diastolic dysfunction between our study subjects and their cohort study subjects could be primarily related to the difference in the patients' background cardiovascular disease. A recent study from the Mayo Clinic also showed a high prevalence of grade Ia diastolic dysfunction in the study population, although they used different cutoff criteria to define grade Ia diastolic dysfunction (2). Of note, when we encounter patients at a higher risk for cardiovascular disease, there is increased prevalence and diagnosis of grade Ia diastolic dysfunction, and the recognition of this entity becomes important for appropriate management.
We acknowledge the high prevalence of mitral annular calcification (MAC) in grade Ia diastolic dysfunction in our study. Although the E-wave velocity (75 ± 20 cm/s vs. 66 ± 16 cm/s; p = 0.0017) and ε′ at the lateral corner of the mitral annulus (5.0 ± 1.5 cm/s vs. 4.8 ± 1.4 cm/s; p = 0.3477) were greater in grade Ia diastolic dysfunction patients with MAC (n = 44) compared with those in grade Ia diastolic dysfunction patients without MAC (n = 183), the difference in E/ε′ between the 2 groups was nonsignificant (15.9 ± 6.1 vs. 14.6 ± 5.0; p = 0.1318). Kaplan-Meier survival analysis revealed nearly the same outcome for major adverse cardiovascular events between the 2 groups. Thus, although MAC itself might have affected E-wave velocity as well as mitral annular velocity, it did not degrade the importance of grade Ia diastolic dysfunction, and the conclusion drawn from using the value of E/ε′ in defining this new diastolic dysfunction grade remained valid.
In our study, we aimed to take a keen interest in deciphering the role of left ventricular filling pressure (E/ε′) as the turning point in the progressive decline from impaired relaxation (diastolic dysfunction grade 1) to pseudonormal (diastolic dysfunction grade 2). Diastolic dysfunction grade Ia marks the transition of E/ε′ <10 to ≥10, while both left atrial mechanics and future major adverse cardiovascular events take their toll. In other words, as the editorial by Tajik and Jan (3) in iJACC pointed out, the importance of emphasizing E/ε′ in diastolic function could have powerful implications as assessing ejection fraction in systolic function. Moreover, the inclusion of diastolic dysfunction grade Ia in the existing classification of diastolic dysfunction also can refine clinical judgment, with improved intra- and interobserver agreement.
Finally, we fully agree that there was certain difficulty in correctly classifying diastolic dysfunction grades in some clinical cases. However, the new diastolic grading system could reduce the number of indeterminate patients and provide clear-cut information regarding subsequent prognosis as well as left atrial mechanics.
- American College of Cardiology Foundation
- Kuwaki H.,
- Takeuchi M.,
- Wu V.C.,
- et al.
- Tajik A.J.,
- Jan M.F.