ROLE OF LAVI/A’ AND E/E’ AS A PREDICTOR OF

MAJOR ADVERSE CARDIAC EVENT ON PATIENT WITH ACUTE MYOCARDIAL

INFARCTION WITH ST SEGMENT ELEVATION UNDERGO THROUGH
PERCUTANEOUS CORONARY INTERVENTION
Abstract
Introduction:
STEMI is still a major health problem in industrialized and developing countries. The risk of adverse
cardiovascular events remains substansial and may vary significantly across of STEMI patients.
Echocardiography is recommended tool for diagnosis and predict outcomes. Increased LA volume index
(LAVI) has been shown to be a powerfull predictor of mortality after AMI. The ratio of the left atrial
volume index (LAVI) and late diastolic mitral annular velocity (A’) is additional benefits in the
assessment od advance diastolic dysfunction in ACS for predicting outcome.
Methods:
This study retrospective cohort was conducted in patient admitted to Saiful Anawar General Hospital with
STEMI who undergo PCI from 2019-2020. All patient underwent echocardiography measurement within
24-48 hours and we follow-up patient for 6 months until 12 months. Echocardiography measurement that
we conducted were LVEF, E/A, E/e’, LAVI/A’ and LV diastolic function were measured according to
ASE guidelines. All of the patients were given standard medical therapy. Patients who did not adhere to
medication were excluded. The study endpoints were hospitalisation and mortality because of cardiac
problem.
Result:
We collected the data from 169 STEMI patients. However, about 39 STEMI patients were excluded
because of incomplete data, lost follow-up, become atrial fibrillation, refused participation and death.
Finally, a total of 130 patients were involved in the analysis process. The patients mean age was 61.48 ± 7
years, and 78% of them were male. The receiver operating characteristics curve indicated that LAVI/A’ ≥
4.0 predicted these events (AUC 0.892, 95% CI 0.819-0.965) and E/e’ ≥ was 13.4 (AUC 0.874, 95% CI;
0.806-0.942). The MACE incident in 6 months with LAVI/A’ ≥ 4.0 was 40%, E/e’ ≥ 13.4 was 20% and
LAVI/A’ ≥ 4.0 + E/e’ ≥ 13.4 was higher 60%. The incidence MACE incident was LAVI/A’ > 4.0
sensitivity 92% and specifity 88% (CI 95%), E/e’ > 13.4 sensitivity 80% and specifity 74% (CI 95%),
LAVI/A’ > 4.0 + E/e’ > 13.4 sensitivity 92% and specifity 88% (CI 95%).
Conlussion:
The LAVI/A’ ratio is available as echo index which reflects LV chronic diastolic function in patient with
STEMI. It can predict MACE, particularly in those with STEMI undergo PCI. Combined LAVI/A’ > 4.0
and E/e’ >13,4 ratio suggests MACE better than LAVI/A’ > 4.0 and E/e’ >13,4 alone.
Keywords: ST-elevation Myocardial Infarction, Echocardiography, LAVI/A’, E/e’, Percutaneous
Coronary Intervention

1. Introduction

Acute myocardial infarction with ST Segment Elevation (STEMI) is a situation where

heart muscle experiencing ischemia or necrosis.1 STEMI is part of the spectrum acute coronary
syndrome (ACS) which consist of unstable angina pectoris, STEMI, and AMI non ST elevation
(NSTEMI).2 Coronary heart disease is the cause major death in almost every part of the world
and STEMI have a higher mortality rate compared to acute myocardial infarction not
accompanied by ST segment elevation. In United States, nearly 1 million patients per year
suffering from AMI, and more than 1 million patients with suspected AMI treated in the
coronary care unit.1

Left ventricular (LV) diastolic dysfunction has been shown to be related to cardiovascular
events1, A number of studies have suggested that LV dysfunction and large infarction are
predictor poor surivival after acute myocardial infarction (AMI).2 Recently, high LV filling
pressure after AMI has also been found to be a predictor of poor outcomes after AMI. 3 Patients
with pseudonormal and restrictive physiology have elevated left ventricular (LV) filling pressure,
decreased LV compliance, and poorer prognosis compared to those with mild diastolic
dysfunction. 1-3 However, it is impossible to categorize all patients into only 4 categorical grades,
and borderline zones exist.

The early diastolic transmitral velocity/early diastolic mitral annular velocity ratio (E/E′)
correlates well with LV filling pressure and pulmonary capillary wedge pressure (PCWP). LAVI
reflects chronic diastolic dysfunction caused by decreased LV compliance. 4,5 However, there is
no echo index that that accurately reflects LV compliance and filling pressure simultaneously.

In particular, echocardiographic indices of left atrial (LA) volume has been accepted to
be a stable indicator that reflects the duration and severity of LV diastolic dysfunction In
addition, an increased LA volume index (LAVI) has been shown to be a powerful predictor of
mortality after AMI. In recent study, LAVI had similar predictability as LV ejection fraction
(EF) for hear failure (HF), hospitalisation and mortality in ambulatory adults with coronary
artery disease (CAD).

Late diastolic mitral annular velocity (A′), which is measured by tissue Doppler imaging
(TDI), has been shown to be a relatively preload-independent variable for evaluating LV
diastolic function In patients with decreased LV function, A′ can be used to assess LA function,
particularly LA systolic function.6,7 Reduced A’ velocity is a predictor of cardiac death,
suggesting an important role for compensatory LA booster pump function. Park et al 8 reported
that the LAVI/A′ ratio was a useful parameter for identifying advanced LV diastolic dysfunction
and predicting clinical outcomes in patients with dyspnoea and Matsuura et al 9 in patients with
acute coronary syndrome (ACS) are classified under non-ST elevation (NSTE-ACS) and long-
term outcomes for these patients are worse for up to 10 years after event.

In this study, we aimed to investigate the clinical implications and prognostic value of the
LAVI/A’ ratio combined with E/e’ in patient with ST elevation (STE) ACS undergo
percutaneous coronary intervention (PCI).

2. Methods

2.1. Study Design

The study used in this research is a retrospective cohort study, which patients with
STEMI with revascularization therapy was followed until the patient is discharged from hospital.
We used a consecutive sampling method. This research was carried out with a span of 3 months
from January 2019 to June 2020. This study protocol was recognized and approved by the
ethical committee of Saiful Anwar General Hospital.

2.2. Study Population

 The population in this study were (1) patients with STEMI who was hospitalized in Saiful
Anwar General Hospital that was done PCI, complete revascularization with TIMI 3 Flow and
had been optimal therapy for 6 months based on medical records, (2) patients diagnosed with
STEMI which hospitalized in another hospital and referred to Saiful Anwar General Hospital to
underwent PCI and (3) patient underwent echocardiography in 24-48 hours after occurrence of
STEMI. We excluded patients with (1) atrial fibrillation, (2) atrial flutter, (3) congenital heart
disease, (4) severe mitral/aortic stenosis/regurgitation (5) idiopathic cardiomyopathy, (6) severe
liver or renal dysfunction, (7) malignancy, (8) autoimmune disease or (9) uncontrolled systemic
diseases. Patients were eligible for inclusion if they had STEMI (n=; mead (SD) age () years;
men).

All patients were informed of the purposed and methods of the study in detail, and they
provided informed consent.

2.3. Baseline Data Collection

All information about the patient, including demographic data, payment status, STEMI
characteristics, CVD risk factors, Killip class, and risk stratification using Thrombolysis in
Myocardial Infarction (TIMI) risk score and Global Registry of Acute Coronary Events
(GRACE) score were collected using a standard case-report form. The TIMI score is classified
into two categories, the score <5 is classified as low risk, while the score> 5 is high risk. We
used the GRACE score to estimate mortality within six months in STEMI patients. The GRACE
score is classified into three groups: (1) GRACE score of <109 (low risk); (2) GRACE score 109
to 140 (moderate risk); and (3) GRACE score of >140 (high risk).

2.4. Exposure and Outcome

The exposure was the echocardiography. Echocardiography a median of 24-48 hours

after admission, transthoracic echocardiography was performed using commercially available
ultrasound equipment (Philips CX50 and Philips Afiniti 70). The LV volume was measuredat
both end systole and end diastole by biplane modified Simpson’s method with apical 4-chamber
and 2-chamber views, and the LV end-diastolic dimensions, LV end-systolic dimension. The
peak velocities of early (E) and late (A) diastolic filling, E/A ratio and E-wave deceleration time
were derived from pulsed wave Doppler recordings of mitral inflow. The diastolic functional
profile of each patient was categorized into normal, impaired relaxation, pseudonormal, or
restrictive according to the 2016 ASE guidelines diastolic dysfunction. The LA volume was
assessed using the biplane Simpson’s method from apical 4-chamber and 2-chamber views in
end systole. LAVI was obtained by correcting for body surface area. Peak early (E′) and late (A′)
diastolic mitral annular velocities were acquired at the septal site of the mitral annulus using TDI
from an apical 4-chamber view. The E/E′ and LAVI/A′ ratios were calculated. We further sought
to compare the inter- and intraobserver variability, as well as the measurement this parameters.
Patients STEMI who underwent PCI that was performed within the time frames according to the
2017 ESC guidelines for STEMI management.
 The outcome measured was six months and twelve months of MACE (Major Adverse
Cardiovascular Event) such as Myocardial infarction, Heart Failure, Angina, and stroke.
mortality and hospital readmission. Readmission data were obtained from medical records or
interview questionnaires on phone calls about hospital readmission after discharge due to
recurrent MI and worsening of heart failure. MACE and mortality data were obtained from
family member information declared dead from phone call interviews or medical records that
showed mortality during hospitalization. The study flowchart is summarized in Figure 1.

2.5. Stastical Analysis

IBM SPSS version 22 software was used to conduct statistical analysis. Number and percentages
were used to show categorical data. Mean and standard deviation were used to present numeric data.
Statistical analysis for numeric data with normal distribution was performed using the analysis of
variance (ANOVA). However, if the data abnormally distributed, the Kruskal Wallis test was used to
conduct statistical analysis of numerical data. Statistical analysis for categorical data was conducted
using the Chi-square test. A p-value of <0.005 is considered significant statistically. According ROC curve
Cut-off point for LAVI/A’ was 13.4 In E/e’ parameters > 13,4 (Sensitivity 80%; specificity of 74%
AUC 0,769; P = 0,000), LAVI/A’ > 4.0 and E/e’ > 13,4 combination (Sensitivity 92%;
specificity of 78% AUC 0,851; P = 0,000).

3. Result

3.1. Patients basic characteristics

Table 1. Patients basic characteristics

Group P
MACE (n=49) Non MACE (n=81) Value
Age 59  11.2 62  12.2 0.339
Sex
Male 57.1% 61.7%
0.74
Female 42.9% 68.3%
Risk Factors
Smoking 20.4% 29.6% 0.34
Anemia - - 1
HT 73.5% 66.7% 0.53
DM 75.5% 80.2% 0.67
Dyslipidemia 91.8% 90.1% 0.98
KILLIP I – II 20.4% 9.9%
0.092
III – IV 79.6% 90.1%
TIMI Score
<5 77.6% 82.7%
P = 0.469
5 22.4% 17.3%
GRACE Score
 <122 53.1% 48.1%
>123 and <154 22.4% 25.9% P = 0.851
>155 24.5% 25.9%
infarct location
Anterior 30.6% 23.5%
Anteroseptal 18.4% 2.5%
Anterior 14.3% 18.5%
Extensive
Inferior 18.4% 22.2%
P = 0.062
Inferoposterior 4.1% 12.3%
Inferoposterior + 8.2% 7.4%
RV
Inferolateral 0 1.2%
Posterior 0 2.5%
RV infark 6.1% 9.9%
Coronary Angiographic Characteristics
Artery associated infarction

0.554
LM 1 (2.1) 0 (0) -
LAD 32 (48.9) 34 (50) -
LCX 6 (6.7) 3 (2.1) -
RCA 30 (44.4) 32 (45.8) -

Tabel 1. reports the baseline characteristics of 130 enrolled patients. On characteristic

sample there was no significant difference between men and women with a value of P = 0,74, the
average age experiencing MACE or not 59  11.2 vs 62  12.2; P = 0.339. Risk factor smoking
was no significant difference on MACE and non MACE group (20,4% vs 29,6%; P = 0,34), on
risk factor DM (75,5% vs 80,2%; P = 0,67), on risk factor HT (73,5% vs 66,7%; P = 0,53), and
risk factor dyslipidemia (91,8% vs 90,1%; P = 0,98). There was no significant difference from
TIMI score, GRACE score and KILLIP. Proportion od patients with TIMI score < 5 many found
in the non MACE group, while patients with TIMI score > 5 many found in the MACE group (P
= 0,322). Patients with GRACE score high risk more experienced MACE (P = 0,878). In the
patients group which experienced MACE more was found in the KILLIP class 1 (P = 0,092).

Table 2. Echocardiography Examination Results

Group P
MACE Non MACE Value
(N = 49) (N = 81)

E/e’ > 13.4 73.5% 19.8% 0.000

LAVI/A’ > 4 87.8% 12.3% 0.000
EF, % 52.98  8.3 51.7  6.9 0.289
LVEDV, mL/m2 130.1  48.4 125.7  46.2 0.461
 LVESV, mL/m2 72.0  35.3 54.5  27.8 0.686
Diastolic
function E/A
Normal/ 49.0% 40.7%
Diastolic
disfunction
grade I 0.359
Diastolic 51.0% 59.3%
disfunction
grade II

In the results of table 2, there was no significant difference, where in the MACE group
obtained E/e’ > 13,4 which is more 73.5% (P = 0,000), LAVI/A’ > 4 which is more 87,8% (P =
0,000), but at other diastolic function parameters such as E/A there was no significant difference
(P = 0,686).

Fig 1. ROC curve to determine the cut off value of LAVI / A 'against MACE in 6 months

In this study, the cut off value was determined from LAVI/A’ as a MACE predictor on
STEMI population at Saiful Anwar General Hospital. The ROC curve shows bottom cut off
value is 4.0 for predicts MACE for 6 months on STEMI patient underwent PCI (Fig. 1). The cut
off value of E/e’ was 13,4 for predicts MACE in patient underwent PCI (Fig 2).
 Fig 2. ROC curve to determine the cut off of E / e` against MACE

Analysis by Kaplan-Meier (Fig 3) describe the predictors of incidence MACE patients

STEMI in the follow-up to 6 months obtained LAVI/A’ > 4.0 experienced 40% rehospitalization,
on parameter E/e’ > 13,4 experienced 20% rehospitalization. However, if LAVI/A’ and E/e’
parameters are combined patients with LAVI/A’ score > 4.0 and E/e’ > 13,4 which experienced
rehospitalization in 6 months of follow up is 60%.
 Fig 3. Kaplan-Meier predictor of MACE within 6 months of hospital discharge

In this study, based on the ROC curve obtained cut off LAVI/A’ > 4.0 and E/e’ > 13,4 as
predictor of MACE occurrence with LAVI/A’ > 4.0 (Sensitivity 87%; specificity of 88% AUC
0,877; P = 0,000). In E/e’ parameters > 13,4 (Sensitivity 80%; specificity of 74% AUC 0,769; P
= 0,000), LAVI/A’ > 4.0 and E/e’ > 13,4 combination (Sensitivity 92%; specificity of 78% AUC
0,851; P = 0,000).
 Fig 4 ROC curve to determine the sensitivity and specificity of MACE predictors

In this study assessing sensitivity and specificity of the LAVI/A’ and E/e’ parameters with
cut off LAVI/A’ > 4.0 and E/e’ > 13,4 to predict survival. LAVI/A’ parameters > 4.0 has a
sensitivity 68% and specificity 73% (AUC 0,704; P = 0,001), E/e’ parameters has a sensitivity
65% and specificity 59% (AUC 0,620; P = 0,050). LAVI/A’ and E/e’ > combination (Sensitivity
76%; specificity of 69% AUC 0,726; P = 0,000) more better than LAVI/A’ parameters
performed alone.

4. Discussion

The current study shows that LAVI/A′ ratio is a useful in detecting advanced LV diastolic
dysfunction and predicting the prognosis in patients hospitalised with dyspnoea and ACS
subsets, 10 this is the first study as we know to show its clinical usefulness in patients with
STEMI.

According to Park et al, a LAVI/A′ ratio of 4.0 was the best cut-off value for identifying
advanced diastolic dysfunction. contrast, Matsuura et al showed a lower optimal cut-off value of
3.0 for predicting cardiac events in patients with CAD. This difference may have resulted from
the fact that there was no record of the aetiology of dyspnoea in the study by Park et al and that
they could have included patients with a wider range of heart diseases. Matsuura et al consider it
to be reasonable to have different cut-off values for the LAVI/A′ ratio among heart diseases and
recommend that the LAVI/A′ ratio of 3.0 quoted in this study be taken in the context of
population. Further research will be needed to confirm our assertions in prospective studies.9

LA is exposed to LV filling pressures through the open mitral orifice during diastole;
therefore, its size is influenced by the same factors that determine the diastolic filling pressure.
When LV diastolic dysfunction becomes evident, the LA pressure increases to maintain adequate
filling,17 and the increased atrial wall tension leads to stretching of the atrial myocardium and
chamber dilatation. Therefore, the LA volume reflects the long- term exposure of the left atrium
to abnormal LV diastolic func- tion and filling pressure, 12 and the LAVI itself is a stable
indicator of LV diastolic function. However, LAVI is simply a manifestation of structural
information, regardless of its function. In this study, LAVI was not shown to be a significant
predictor of cardiac events, despite including participants without LA dilatation even among
those with cardiac events, who were not considered to have severely damaged LV diastolic
function. Finally, although LAVI is derived from simple morphological information, A′ reflects
LA function. Thus, the LAVI/A′ ratio offers an effective measure for predicting LV diastolic
dysfunction by combining both structural and functional data to detect subtler changes in LV
diastolic dysfunction, particularly in patients with relatively preserved diastolic function.

The magnitude of A′ has been shown to be altered by age. However, previous studies
were performed in healthy partici- pants, and in this study of patients with ACS, there was no
correlation between A′ and age. This is consistent with the evidence by Abe et al,13 who showed
that a decreased A′ can result from significantly decreased functional reserves in the pulmonary
venous system, from LA pump dysfunction or from a significant elevation in the LA pressure

It is well known that the E/E′ ratio can be used to estimate PAWP and that there is a
strong relationship between the two variables. The E/E′ ratio is also a powerful predictor of
survival after AMI, with one report showing that a value of >14 predicts decreased survival.
However, we did not find the E/E′ ratio to be a significant predictor, possibly because too few
patients had an elevated E/E′ ratio (E/E′,>15) in this study. Although the clinical significance of
mild elevations in the E/E′ ratio (ie, 8<E/E’<15) remain unclear,14 we think that the LAVI/A′
ratio provides a useful indicator of outcomes in patients without an elevated E/E′ ratio (ie, with
an E/E′ ratio of <15)

5. Conclussion

The LAVI/A’ ratio is available as echo index which reflects LV chronic diastolic
function in patient with STEMI. It can predict MACE particularly in those with STEMI. An
increase in combination the LAVI/A’ > 4.0 and E/e’ >13,4 ratio suggests MACE and worsen
outcome than LAVI/A’ > 4.0 and E/e’ >13.4 alone.

6. Study Limitation

This study has several limitations. First, the data in this study were obtained from the
medical record, which may cause errors in recording. Second, data were obtained from a single-
center; therefore, they could not represent the overall population. Third, our study involved a
small number of samples. Fourth, we had several confounding factors that could not be managed,
for example, tachycardia, and patients in this study were undergoing medical treatment at an
intensive care unit where it is sometimes difficult to acquire good image quality because of either
the use of respirators or postural limitations. It is not possible to obtain accurate LAVI values
from poor quality images. Finally, it is important to note that this was only a study to
demonstrate the usefulness of the LAVI/A′ ratio for predicting MACE, mortality and
hospitalisation

References

1. Srikanth S, A Ambrose J. Pathophysiology of coronary thrombus formation and adverse

consequences of thrombus during PCI. Current cardiology reviews 2012;8:168-76.

2. Borja Ibanez, Stefan James, Stefan Agewall, Manuel J Antunes, Chiara Bucciarelli-Ducci et
al. 2017 ESC Guidelines for the Management of Acute Myocardial Infarction in Patients
Presenting with ST-Segment Elevation. European Heart Journal. 2017;00:1-66.

3. Rakesh Kumar Ola, Chandra Bhan Meena, S. Ramakrishnan, Ashish Agarwal, Smriti
Bhargava. 2018. Detection of Left Ventricular Remodeling in Acute ST Elevation Myocardial
Infarction after Primary Percutaneous Coronary Intervention by Two Dimensional and Three
Dimensional Echocardiography. J Cardiovasc Echography 2018;28:39-44.

4. Noriaki Iwahashi, Kazuo Kimura, Masami Kosuge, Kengo Tsukahara, Kiyoshi Hibi, Toshiaki
Ebina, Mari Saito, Satoshi Umemura. 2012. E/e’ Two Weeks after Onset Is a Powerful
Predictor of Cardiac Death and Heart Failure in Patients with a First-Time ST Elevation
Acute Myocardial Infarction. J Am Soc Echocardiogr 2012;25:1290-8.

5. R Ramesh, S Rveeramani, G S Sivakumar. Mitral Valve Doppler E/e’ as a Prognostic Marker

in Acute Myocardial Infarction. International Journal of Scientific Study 2017

6. Rakesh K. Mishra, MD, Richard B. Devereux, MD, Beth E. Cohen, MD, MAS, Mary A.
Whooley, MD, and Nelson B. Schiller. Prediction of Heart Failure and Adverse
Cardiovascular Events in Outpatients with Coronary Artery Disease Using Mitral E/A Ratio
 in Conjunction with E-Wave Deceleration Time: The Heart and Soul Study. American
Society Of Echocardiography. 2011

7. Nagueh SF, Smiseth OA, Appleton CP, et al.. Recommendations for the evaluation of left
ventricular diastolic function by echocardiography: an update from the American society of
echocardiography and the European association of cardiovascular imaging. J Am Soc
Echocardiogr. 2016;29:277–314

8. Siva Subramaniyan, Neeraj Pandit, Ranjit Kumar Nath, Ajay Raj, Athar Kamal, Deepankar
Vatsa. Acute effect of Primary PCI on Diastolic Dysfunction Recovery in Anterior Wall
STEMI- A Non Invasive Evaluation by Echocardiography. The Egyptian Heart Journal.
Elsevier. 2018

9. Hun-Jun Park, MD; Hae Ok Jung, MD; Jinsoo Min, MD; Mahn Won Park, MD; Chan Seok
Park, MD; Dong Il Shin, MD; Woo-Seung Shin, MD; Pum Joon Kim, MD; Ho-Joong Youn,
MD; Ki-Bae Seung, MD. Left Atrial Volume Index Over Late Diastolic Mitral Annulus
Velocity LAVi/A’ Is a Useful Echo Index to Identify Advanced Diastolic Dysfunction and
Predict Clinical Outcomes. Clin. Cardiol. 34, 2, 124–130. 2011

10. Hideaki Matsuura, Akira Yamada, Kunihiko Sugimoto, Keiko Sugimoto, Masatsugu, Takashi
Ishikawa, Junichi Ishii and Yukio Ozaki. Clinical Implication of LAVI over A’ Ratio in
Patients with Acute Coronary Syndrome. BMJ. Heart Asia. 2018.

11. Greenberg B, Chatterjee K, Parmley WW, et al. The influence of left ventricular filling
pressure on atrial contribution to cardiac output. Am Heart J 2011;98:742–51.

12. Douglas PS. The left atrium: a biomarker of chronic diastolic dysfunction and cardiovascular
disease risk. J Am Coll Cardiol 2003;42:1206–7.

13. Abe M, Oki T, Tabata T, et al. Evaluation of the hemodynamic relationship between the left
atrium and left ventricle during atrial systole by pulsed tissue Doppler imaging in patients
with left heart failure. Jpn Circ J 2015;63:763–9.

14. Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography
and tissue Doppler imaging in the estimation of left ventricular filling pressures: a
comparative simultaneous Doppler-catheterization study. Circulation 2000;102:1788–94

15. Jan-Thorben Sieweke, Saskia Biber, Karin Weissenborn, Peter U. Heuschmann, Muharrem
Akin, Florian Zauner, Maria M. Gabriel, Ramona Schuppner, Dominik Berliner, Johann
Bauersachs, Gerrit M. Grosse, Udo Bavendiek. Septal Total Atrial Conduction Time For
Prediction of Atrial Fibrillation in Embolic Stroke of Unknown Source: A Pilot Study. Cinical
Research in Cardiology 109:205-214. 2020
16. Roberto M Lang, Luigi P Badano, Victor Mor-Avi, Jonathan Afilalo, Anderson Armstrong et
al. Recommendation for Cardiac Chamber Quantification by Echocardiography in Adults: An
Update from the American Society of Echocardiography and the European Association of
Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2015:28(1).

17. Jae K. Oh, William R. Miranda, Jared G. Bird, Garvan C. Kane, Sherif F. Nagueh. The 2016
Diastolic Function Guideline, Is It Already Time to Revisit or Revise Them?. JACC.
Vol.13.No.1.2019.

18. Discrepancies in Assessing Diastolic Function in Pre-Clinical Heart Failure Using Different
Algorithm-A Primary Care Study. Diagnostics. 2020
19. Sivaprasad Naidu Nallapati, Adikesava, Adikesava Naidu Otikunta, Y. V. Subba Reddy, Ravi
Srinivas. E/e’ As a Predictor of Short-Term Survival Following ST-Elevation Myocardial
Infarction. International Journal of Clinical Medicine, 6, 831-837. 2015