Combining tissue Doppler echocardiography and B-type natriuretic peptide in the evaluation of left ventricular filling pressures: Review of the literature and clinical recommendationsL’association de l’imagerie Doppler tissulaire et de la mesure du peptide natriurétique de type B dans l’évaluation de la pression de remplissage du ventricule gauche : Analyse documentaire et recommandations cliniques

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Tissue Doppler imaging is an echocardiographic technique that directly measures myocardial velocities. Diastolic tissue Doppler velocities reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (transmitral early diastolic velocity/mitral annular early diastolic velocity [E/Ea]) have been developed to noninvasively estimate left ventricular (LV) filling pressure. Consequently, mitral E/Ea can help to establish the presence of clinical congestive heart failure in patients with dyspnea. However, E/Ea has a significant ‘gray zone’, and is not well validated in nonsinus rhythm and mitral valve disease. B-type natriuretic peptide (BNP) is a protein released by the ventricles in the presence of myocytic stretch, and has been correlated to LV filling pressure and, independently, to other cardiac morphological abnormalities. In addition, BNP is significantly affected by age, sex, renal function and obesity. Given its correlation with multiple cardiac variables, BNP has high sensitivity, but low specificity, for the detection of elevated LV filling pressures. Taking into account the respective strengths and limitations of BNP and mitral E/Ea, algorithms combining them can be used to more accurately estimate LV filling pressures in patients presenting with dyspnea.

L’imagerie Doppler tissulaire est une technique d’échocardiographie qui mesure directement les vitesses myocardiques. Les vitesses Doppler tissulaires diastoliques sont un reflet du degré de relaxation du myocarde, et leur association à des mesures Doppler classiques a donné lieu à l’élaboration de rapports (vitesse protodiastolique transmitrale/vitesse protodiastolique annulaire mitrale [VP/VPA]) permettant d’évaluer de façon non effractive la pression de remplissage du ventricule gauche (VG). Le rapport VP/VPA mitral peut donc aider à déterminer la présence d’insuffisance cardiaque congestive clinique chez des patients dyspnéiques. Cependant, le rapport VP/VPA est associé à une grande « zone grise », et son utilisation n’est pas vraiment validée dans les cas de rythme non sinusal et de valvulopathie mitrale. De son côté, le peptide natriurétique de type B (PNB) est une protéine libérée par les ventricules lorsqu’il y a étirement des myocytes et il est corrélé avec la pression de remplissage du VG et, de façon indépendante, avec d’autres anomalies morphologiques du coeur. De plus, le PNB est grandement influencé par l’âge, le sexe, le fonctionnement rénal et l’obésité. Comme il est en corrélation avec de nombreuses variables cardiaques, le PNB a une forte sensibilité mais une faible spécificité pour la détection de pressions élevées de remplissage du VG. Compte tenu des atouts et des lacunes du PNB et du VP/VPA mitral, il est possible d’appliquer des algorithmes associant les deux mesures afin d’évaluer plus précisément qu’on le fait aujourd’hui les pressions de remplissage du VG chez des patients dyspnéiques.

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