E/e′ ratio and outcome prediction in hypertrophic cardiomyopathy: the influence of outflow tract obstruction

Diastolic dysfunction is thought to be an important pathophysiologic component of hypertrophic cardiomyopathy (HCM). However, there are conflicting data on the potential value of the mitral E/e′ ratio. We examined whether left ventricular outflow tract (LVOT) obstruction influences the value of E/e′ in predicting outcomes in HCM.

Patients who met diagnostic criteria for HCM were enrolled. Diastolic function was assessed with complete two-dimensional and Doppler echocardiography. A composite clinical outcome including new onset atrial fibrillation, sustained ventricular tachycardia/fibrillation, heart failure, transplantation, and death was examined over a mean follow-up period of 4.2 years. Among 604 patients, 206 patients had an E/e′ level ≥20. Patients with higher septal E/e′ level were older, with more severe NYHA class, and more severe LVOT obstruction. Higher E/e′ was associated with worse event-free survival in non-obstructive group and total HCM cohort. In addition, E/e′ and LVOT pressure gradient were highly correlated in non-obstructive and total HCM, but not in labile or obstructive group. During follow-up period, 95 patients underwent myectomy. Post-op E/e′ correlated significantly with LVOT pressure gradient (R = 0.306, P = 0.004). In these patients, post-op E/e′ was associated with worse event-free survival (log-rank P = 0.030).

Assessment of E/e′ is useful for risk stratification in HCM patients. Nevertheless, the predictive power is confounded by dynamic LVOT obstruction. Higher E/e′ predicts worse clinical outcomes in non-obstructive HCM and in labile/obstructive after myectomy.