Evaluation of diastolic function (DF) increases the prognostic value of exercise echocardiography. A protocol including both systolic and diastolic evaluation could predict different types of events.

Systolic and DF were evaluated during exercise echocardiography in 2519 patients: left ventricular systolic function at peak-exercise (step 1), and E/e’/systolic pulmonary pressure postexercise (step 2). Abnormal systolic function was defined as ischemia or fixed wall motion abnormalities; abnormal DF was defined as postexercise E/e’> 15. The endpoint was to analyze the predictive value of systolic and DF for cardiac failure/cardiovascular death (CF/CVD), and for ischemic events.

Systolic abnormalities were found in 806 patients (32%) and diastolic abnormalities in 451 (18%). Patients with CF/CVD more frequently had abnormal postexercise DF than those with ischemic events (48% vs 27%; P <.001), whereas the percentage of systolic abnormalities was higher in the latter group (78% vs 40%; P <.001). During follow-up, there were 477 events. Independent overall predictors included Δ wall motion score index (Δ WMSI) (HR, 8.08; 95%CI, 6.15-10.60; P <.001), and postexercise E/e’ (HR, 1.02; 95%CI, 1.01-1.04; P=.004). Predictors of CF/CVD also included postexercise DF (E/e’: sHR, 1.04; 95%CI, 1.00-1.07; P=.035) but not systolic function. Conversely, predictors of ischemic events included systolic function (Δ WMSI: sHR=12.81; 95%CI, 8.8- 18.71; P <.001) but not DF.

Two-step exercise echocardiography assessing systolic and diastolic function predicts different types of events. Exercise echocardiography based only on systolic function might not capture the full spectrum of abnormalities.