Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Original Article

Volume 2, Number 4, August 2011, pages 139-149

Exercise Tolerance and the Post Exercise Diastolic Filling Pattern in Patients With the Resting Impaired Relaxation

Figure 1. (A) A composite average transmitral flow in patients with normal diastolic filling is plotted against time both at rest and post exercise. Post exercise, there is an increased atrial filling velocity and atrial filling velocity. (B) A composite average transmitral flow in patients with E/A reversal at rest (impaired diastolic filling) is plotted against time both at rest and post exercise. Post exercise, there is an increased rapid filling velocity only and the the mean E/A remains < 1. Ev = Peak rapid filling velocity; Av = Peak atrial filling velocity.

Figure 2. (A) A composite average transmitral flow in patients with E/A reversal at rest with no change in the E/A ratio post exercise. (B) A composite average transmitral flow in patients with E/A reversal at rest with an increased E/A post exercise due to a greater degree of augmentation in the peak rapid filing velocity. Ev = Peak rapid filling velocity; Av = Peak atrial filling velocity.

**Table 1.** General Characteristics of Patients With and Without E/A Reversal at Rest
General Characteristics	E/A Reversal at Rest (n = 49)	No E/A Reversal at Rest (n = 49)	P values
E/A: Peak rapid filling velocity/peak atrial filling velocity.
Age (yrs)	46 ± 11	42 ± 13	0.623
Male (%)	67%	77%	0.041
Resting Heart Rate	76 ± 11	73 ± 11	0.426
Peak Exercise Heart Rate (beats/min)	148 ± 26	164 ± 15	0.008
Peak Systolic Blood Pressure (mm Hg)	149 ± 18	156 ± 10	0.664
Exercise Time (min)	8.8 ± 1.6	9.7 ± 2.0	0.0007
Left Ventricular Hypertrophy (%)	34	0	0.006
Hypertension (%)	35	0	< 0.0001
Diabetes mellitus (%)	23	0	0.036
LV End Diastolic Volume (cc)	119 ± 33	112 ± 32	0.518
LV End Systolic Volume (cc)	46 ± 28	44 ± 25	0.712
Ejection Fraction (%)	62 ± 9	61 ± 10	0.862
E/A	0.78 ± 0.11	1.41 ± 0.24	< 0.0001
Deceleration Time (msec)	266 ± 32	196 ± 26	0.008

Table 1. General Characteristics of Patients With and Without E/A Reversal at Rest

General Characteristics

E/A Reversal at Rest (n = 49)

No E/A Reversal at Rest (n = 49)

P values

E/A: Peak rapid filling velocity/peak atrial filling velocity.

Age (yrs)

46 ± 11

42 ± 13

0.623

Male (%)

67%

77%

0.041

Resting Heart Rate

76 ± 11

73 ± 11

0.426

Peak Exercise Heart Rate (beats/min)

148 ± 26

164 ± 15

0.008

Peak Systolic Blood Pressure (mm Hg)

149 ± 18

156 ± 10

0.664

Exercise Time (min)

8.8 ± 1.6

9.7 ± 2.0

0.0007

Left Ventricular Hypertrophy (%)

0.006

Hypertension (%)

< 0.0001

Diabetes mellitus (%)

0.036

LV End Diastolic Volume (cc)

119 ± 33

112 ± 32

0.518

LV End Systolic Volume (cc)

46 ± 28

44 ± 25

0.712

Ejection Fraction (%)

62 ± 9

61 ± 10

0.862

E/A

0.78 ± 0.11

1.41 ± 0.24

< 0.0001

Deceleration Time (msec)

266 ± 32

196 ± 26

0.008

**Table 2.** Changes With Exercise in Patients With and Without E/A Reversal at Rest
Doppler variables	E/A Reversal at Rest	No E/A Reversal at Rest
HR: heart rate; SBP: systolic blood pressure; DBP: diastolic blood pressure; E: peak rapid filling velocity; RVI: rapid filling integral; RFP: rapid filling period; RR: cycle length; A: peak atrial filling velocity; AVI: annular velocity integral; DVI: diastolic velocity integral; AFP: atrial filling period; DFP: diastolic filling period; DCT: deceleration time; IRT: isovolumic relaxation time.
P < 0.05; P < 0.01; **P < 0.001 versus Rest; ∧P < 0.05; ∧∧P < 0.01; ∧∧∧P < 0.001 E/A rest versus No E/A reversal rest; ^xP < 0.05; ^xxP < 0.01; ^xxxP < 0.001 E/A reversal with exercise versus No E/A reversal with exercise.
HR (beats/min)	76 ± 11	148 ± 26^***	73 ± 11	164 ± 15^***x
SBP (mmHg)	128 ± 15	149 ± 18^**	119 ± 9	156 ± 10^**
DBP (mmHg)	81 ± 12	78 ± 12	70 ± 5^∧	69 ± 4
E (cm/s)	66 ± 20	79 ± 22^**	73 ± 13	96 ± 23^**x
RVI (cm)	9.8 ± 4.3	9.2 ± 4.6	11.7 ± 3.3	13.5 ± 5.6^xx
RFP (msec)	201 ± 50	158 ± 46^***	231 ± 63	174 ± 48^***
RFP/RR	0.25 ± 0.05	0.25 ± 0.05	0.27 ± 0.05	0.28 ± 0.06
A (cm/s)	85 ± 23	92 ± 21	54 ± 10^∧∧∧	86 ± 23^***
E/A (m/s)	0.78 ± 0.11	0.85 ± 0.13	1.41 ± 0.24^∧∧∧	1.14 ± 0.19^**xxx
AVI (cm)	9.5 ± 3.3	8.8 ± 2.9	4.5 ± 1.2^∧∧∧	7.0 ± 1.8^**x
DVI (cm)	19.7 ± 6.8	18.4 ± 6.8	17.5 ± 3.3	19.9 ± 3.5
AFP (msec)	152 ± 33	128 ± 25^***	112 ± 31^∧∧	106 ± 22^xx
AFP/RR	0.19 ± 0.04	0.21 ± 0.03^*	0.13 ± 0.03^∧∧	0.16 ± 0.05^*^x
DFP (msec)	417 ± 109	319 ± 107^***	463 ± 134	440 ± 212^xx
DFP/RR	0.51 ± 0.07	0.50 ± 0.07	0.54 ± 0.11	0.69 ± 0.29^*^xx
DCT (msec)	266 ± 32	261 ± 38	196 ± 26^∧∧	211 ± 32^xx
IRT (msec)	87 ± 41	66 ± 46^*	69 ± 19	28 ± 24^*^xx
IRT/RR	0.11 ± 0.06	0.11 ± 0.07	0.07 ± 0.02^∧	0.05 ± 0.04^*^x
RR (msec)	810 ± 127	632 ± 135^***	855 ± 158	620 ± 97^***

Table 2. Changes With Exercise in Patients With and Without E/A Reversal at Rest

Doppler variables

E/A Reversal at Rest

No E/A Reversal at Rest

Rest

Exercise

Rest

Exercise

HR: heart rate; SBP: systolic blood pressure; DBP: diastolic blood pressure; E: peak rapid filling velocity; RVI: rapid filling integral; RFP: rapid filling period; RR: cycle length; A: peak atrial filling velocity; AVI: annular velocity integral; DVI: diastolic velocity integral; AFP: atrial filling period; DFP: diastolic filling period; DCT: deceleration time; IRT: isovolumic relaxation time.

*P < 0.05; **P < 0.01; ***P < 0.001 versus Rest; ∧P < 0.05; ∧∧P < 0.01; ∧∧∧P < 0.001 E/A rest versus No E/A reversal rest; ^xP < 0.05; ^xxP < 0.01; ^xxxP < 0.001 E/A reversal with exercise versus No E/A reversal with exercise.

HR (beats/min)

76 ± 11

148 ± 26^***

73 ± 11

164 ± 15^***x

SBP (mmHg)

128 ± 15

149 ± 18^**

119 ± 9

156 ± 10^**

DBP (mmHg)

81 ± 12

78 ± 12

70 ± 5^∧

69 ± 4

E (cm/s)

66 ± 20

79 ± 22^**

73 ± 13

96 ± 23^**x

RVI (cm)

9.8 ± 4.3

9.2 ± 4.6

11.7 ± 3.3

13.5 ± 5.6^xx

RFP (msec)

201 ± 50

158 ± 46^***

231 ± 63

174 ± 48^***

RFP/RR

0.25 ± 0.05

0.27 ± 0.05

0.28 ± 0.06

A (cm/s)

85 ± 23

92 ± 21

54 ± 10^∧∧∧

86 ± 23^***

E/A (m/s)

0.78 ± 0.11

0.85 ± 0.13

1.41 ± 0.24^∧∧∧

1.14 ± 0.19^**xxx

AVI (cm)

9.5 ± 3.3

8.8 ± 2.9

4.5 ± 1.2^∧∧∧

7.0 ± 1.8^**x

DVI (cm)

19.7 ± 6.8

18.4 ± 6.8

17.5 ± 3.3

19.9 ± 3.5

AFP (msec)

152 ± 33

128 ± 25^***

112 ± 31^∧∧

106 ± 22^xx

AFP/RR

0.19 ± 0.04

0.21 ± 0.03^*

0.13 ± 0.03^∧∧

0.16 ± 0.05^*^x

DFP (msec)

417 ± 109

319 ± 107^***

463 ± 134

440 ± 212^xx

DFP/RR

0.51 ± 0.07

0.50 ± 0.07

0.54 ± 0.11

0.69 ± 0.29^*^xx

DCT (msec)

266 ± 32

261 ± 38

196 ± 26^∧∧

211 ± 32^xx

IRT (msec)

87 ± 41

66 ± 46^*

69 ± 19

28 ± 24^*^xx

IRT/RR

0.11 ± 0.06

0.11 ± 0.07

0.07 ± 0.02^∧

0.05 ± 0.04^*^x

RR (msec)

810 ± 127

632 ± 135^***

855 ± 158

620 ± 97^***

**Table 3.** Transmitral Doppler Changes With Exercise in Patients With and Without E/A Reversal at Rest
Transmitral Doppler Changes	E/A reversal at Rest	No E/A Reversal at Rest	P Values
Abbreviations See Table 2 for abbreviations.
HR Change	+ 72 ± 21	+ 91 ± 16	0.009
RVI Change (cm)	- 0.7 ± 4.4	+ 1.8 ± 5.9	0.092
E Change (cm/s)	+ 12 ± 21	+ 23 ± 18	0.456
A Change (cm/s)	+ 8 ± 22	+ 32 ± 18	0.0006
EA Change	+ 0.08 ± 0.15	- 0.27 ± 0.25	< 0.0001
AVI Change (cm)	- 0.8 ± 3.0	+ 1.4 ± 2.4	0.009
DVI Change (cm)	- 1.4 ± 6.6	+ 2.4 ± 3.7	0.035
DFP/RR	- 0.1 ± 0.5	0.15 ± 0.16	0.006

Table 3. Transmitral Doppler Changes With Exercise in Patients With and Without E/A Reversal at Rest

Transmitral Doppler Changes

E/A reversal at Rest

No E/A Reversal at Rest

P Values

Abbreviations See Table 2 for abbreviations.

HR Change

+ 72 ± 21

+ 91 ± 16

0.009

RVI Change (cm)

- 0.7 ± 4.4

+ 1.8 ± 5.9

0.092

E Change (cm/s)

+ 12 ± 21

+ 23 ± 18

0.456

A Change (cm/s)

+ 8 ± 22

+ 32 ± 18

0.0006

EA Change

+ 0.08 ± 0.15

- 0.27 ± 0.25

< 0.0001

AVI Change (cm)

- 0.8 ± 3.0

+ 1.4 ± 2.4

0.009

DVI Change (cm)

- 1.4 ± 6.6

+ 2.4 ± 3.7

0.035

DFP/RR

- 0.1 ± 0.5

0.15 ± 0.16

0.006

**Table 4.** Effects of Exercise in Patients With E/A Reversal at Rest on Transmitral Doppler Parameters Who Developed Either an E/A Increase or Decrease With Exercise
Transmitral Doppler Parameters	E/A Increase with Exercise (n = 32)	E/A Decrease with Exercise (n = 17)	P value
Abbreviations please see above tables.
Peak HR Change (beats/min)	72 ± 22	75 ± 21	0.886
% Male	50%	27%	0.024
Age (yrs)	56 ± 10	52 ± 13	0.715
Exercise Time (min)	9.6 ± 1.2	7.4 ± 1.3	0.0009
LVH (%)	33	38	0.716
HBP (%)	35	33	0.881
E Change (cm/s)	+ 19 ± 21	- 1 ± 16	0.009
RVI Change (cm)	+ 7.8 ± 3.7	- 3.4 ± 4.5	0.008
A change (cm/s)	+ 12 ± 25	+ 6 ± 20	0.533
EA Change	+ 0.16 ± 0.12	- 0.06 ± 0.08	< 0.0001
AVI Change (cm)	- 1.1 ± 3.1	- 0.2 ± 2.9	0.244
DVI Change (cm)	- 0.3 ± 6.6	- 3.4 ± 6.3	0.182
DFP Change (msec)	- 84 ± 77	- 124 ± 84	0.162
IRT Change (msec)	- 25 ± 51	- 3 ± 46	0.133

Table 4. Effects of Exercise in Patients With E/A Reversal at Rest on Transmitral Doppler Parameters Who Developed Either an E/A Increase or Decrease With Exercise

Transmitral Doppler Parameters

E/A Increase with Exercise (n = 32)

E/A Decrease with Exercise (n = 17)

P value

Abbreviations please see above tables.

Peak HR Change (beats/min)

72 ± 22

75 ± 21

0.886

% Male

50%

27%

0.024

Age (yrs)

56 ± 10

52 ± 13

0.715

Exercise Time (min)

9.6 ± 1.2

7.4 ± 1.3

0.0009

LVH (%)

0.716

HBP (%)

0.881

E Change (cm/s)

+ 19 ± 21

- 1 ± 16

0.009

RVI Change (cm)

+ 7.8 ± 3.7

- 3.4 ± 4.5

0.008

A change (cm/s)

+ 12 ± 25

+ 6 ± 20

0.533

EA Change

+ 0.16 ± 0.12

- 0.06 ± 0.08

< 0.0001

AVI Change (cm)

- 1.1 ± 3.1

- 0.2 ± 2.9

0.244

DVI Change (cm)

- 0.3 ± 6.6

- 3.4 ± 6.3

0.182

DFP Change (msec)

- 84 ± 77

- 124 ± 84

0.162

IRT Change (msec)

- 25 ± 51

- 3 ± 46

0.133

**Table 5.** Forward Stepwise Regression
Determinants	Individual Correlation	Stepwise Correlation	Individual P value	Stepwise P value
Abbreviations see previous tables.
Determinants of E/A Change in all Patients
Exercise Time	0.598	0.598	0.0031	< 0.0001
RVI Change	0.469	0.701	0.0029
Determinants of E/A Change in Patients with E/A Reversal at Rest
Exercise Time	0.648	0.648	0.0002	< 0.0001
RVI Change	0.470	0.727	0.0189
Determinants of Exercise Time in all Patients
E/A Change	0.625	0.625	0.0008	0.0008
Determinants of Exercise Time in Patients with E/A Reversal at Rest
E/A Change	0.584	0.584	0.0028	0.0028
Determinants of Exercise Time in Patients without E/A Reversal at Rest
DVI Change	0.695	0.695	0.0084	0.0084

Table 5. Forward Stepwise Regression

Determinants

Individual Correlation

Stepwise Correlation

Individual P value

Stepwise P value

Abbreviations see previous tables.

Determinants of E/A Change in all Patients

Exercise Time

0.598

0.0031

< 0.0001

RVI Change

0.469

0.701

0.0029

Determinants of E/A Change in Patients with E/A Reversal at Rest

Exercise Time

0.648

0.0002

< 0.0001

RVI Change

0.470

0.727

0.0189

Determinants of Exercise Time in all Patients

E/A Change

0.625

0.0008

Determinants of Exercise Time in Patients with E/A Reversal at Rest

E/A Change

0.584

0.0028

Determinants of Exercise Time in Patients without E/A Reversal at Rest

DVI Change

0.695

0.0084