Diagnostic accuracy of mitral E/e' and time between E and e' in predicting elevated left ventricular filling pressure in patients with nonvalvular atrial fibrillation undergoing coronary angiography
Authors: Acosta K , Acuna G , Ofilas M , Ubaldo R , Ines P , Mendoza-Reyes C , Ladlad-Pua E , Santos R , Flores V , Tucay E 
Published: November 2023

Abstract

Background
Assessment of left ventricular (LV) diastolic function using Doppler echocardiography is very challenging in atrial fibrillation (AF) because of the absence of mitral A wave and beat-to-beat variability. While mitral E/e’ retains its value in predicting elevated LV filling pressure (LVFP) in patients with AF, cut-off points remain variable. Moreover, the diagnostic accuracy of this parameter and the time between E and e’ (T E-e’) in predicting elevated LVFP in AF is unknown. Therefore, this study aims to determine the sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV, NPV) of mitral E/e’ and T E-e’ in predicting elevated LVFP among adult patients with nonvalvular AF undergoing coronary angiography in the Philippines from October 2022 to January 2023.

Purpose
Knowledge about the diagnostic accuracy of mitral E/e’ and T E-e’ in predicting elevated LVFP in adult Filipino patients with nonvalvular AF can lead to better management of left ventricular diastolic dysfunction (LVDD) in the Philippines. This study can also serve as a baseline for further studies to develop international recommendations for classifying LVDD in patients with nonvalvular AF.

Methods
A total of 44 adult patients with nonvalvular AF who underwent invasive measurement of LVEDP during coronary angiography then Doppler assessment of LVFP within 24 hours were included in this cross-sectional study. The primary outcome was determination of diagnostic accuracy of mitral E/e’ and T E-e’ in predicting elevated LVFP in the study population. Independent Samples T-test and Fisher’s Exact test were used to determine the difference of mean and frequency between patients with and without elevated LVFP. Area under the receiver operating characteristic curve (AUROC), Sn, Sp, NPV and PPV were used to determine the diagnostic accuracy of mitral E/e’ and T E-e’ to predict elevated LVFP. All statistical tests were two-tailed tests. Shapiro-Wilk test was used to test the normality of the continuous variables. STATA v13.1 was used for data analysis at 95% confidence interval.

Results
Overall, lateral E/e’ ≥ 9.8 has the highest diagnostic accuracy (82%) in predicting elevated LVFP in patients with nonvalvular AF with Sn of 83%, Sp of 80%, PPV of 89% and NPV of 70%. Average E/e’ ≥ 10.7 is also specific at 80%. Average E/e’ ≥ 10.7 and lateral TE-e’ ≥ 4.3 have the largest AUROC of 0.79 (95% CI 0.6550 to 0.9358) and 0.67 (95% CI 0.4888 to 0.8445), respectively. Of the T E-e’, lateral ≥ 4.3 ms has the highest diagnostic accuracy (70%) in predicting the same outcome but with poor AUROC (0.67; 95% CI 0.49 to 0.84).

Conclusion
Mitral E/e’ is accurate in predicting elevated LVFP in adult Filipino patients with nonvalvular AF. Lateral E/e’ ≥ 9.8 and average E/e’ ≥ 10.7 can be used as cut-offs to predict elevated LVFP in this population. T E-e’ has no additional diagnostic value to mitral E/e’ in predicting elevated LVFP in this study.