Renewed 2012
Newer Examples of Presso Test for you
For more information: contact me any time at:
Email: diastolicstresstest.com
Month's Diastolic Words
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It is rarely realized and even more rarely mentioned that..we still do not have any simple/universally applicable diagnostic tool in Clinical Cardiology. Using an External Pressure Transducer (Presso Test) assessing the left ventricular (LV) diastolic behaviour with Handgrip Exercise (Presso Test) could become a safe/convenient pre-test before proceeding to more sophisticated/expensive/expertise needing + radiation etc) In addition, a “Combined Echo-Presso Handgrip Stress Test” with automated evaluation could help greatly in echo labs.
There is no conflict of interest & I have nothing to disclose. This web site does not represent a commercial action. To our knowledge, no commercially available device is hitherto available worldwide with automated assessment of exactly defined LV diastolic Behaviour with Exercise.
INTRODUCTION
[Revised & New Examples: February-2012]
In > 2 decades, diastolic LV function is evaluated clinically using exclusively “pure volumetric” imaging techniques (Echo, Radio nuclides etc). However, diastolic LV pressure (LVP) measures are widely accepted and used correctly as the “absolute gold standard” in most “imaging diastolic studies".
The challenging "Diastolic Stress Test" concept using an optimal external pressure transducer with handgrip exercise (Presso Test) has been introduced, based on exactly defined criteria of "diastolic Types" & "Patterns” of LV diastolic Behaviour with exercise, recognizing its clinical value, in years 1990-1995 (Manolas J, Z Kardiol 1990 & Cl Cardiol 1993 & Cardiology 1995).
The “Diastolic Stress Test” concept using an external Pressure Transducer can contribute greatly in solving 2 of the greatest unsolved diagnostic problems not only in hospitals (CPUs etc), but above even in daily Practice out-of-hospitals by every Non-expert:
A. The assessment of LV diastolic dysfunction, and
B. The Initial Screening of Unknown/Silent Myocardial diseases in early/subclinical asymptomatic stage –above CAD
To A : Based on several thorough cath studies in USA & Europe, it has been now proved-and- finally recognized that even novel “excellent TDI indexes (E/E’ etc) are rather “misleading” (Solomon & Stevenson 2010) being “dubious estimates of LV diastolic dysfunction” (Tschoepe & Paulus, 2009)!.
To B : Based on cath data from nearly 400.000 to 600.00 American pts in Duke University, all combinations of our current non-invasive diagnostic tools (incl. Ex-ECG + Stress-echo etc) have been recently proved to show a too low sensitivity of < 70% (Patel et al, NEJM, 2010) and specificity of <50% (Douglas et al, JACC 2011).
Hemodynamic Basis of Pressocardiography: Conclusive evidence exists that LVP and external recordings obtained simultaneously with similar and partly identical pressure transducers, showed in a wide range of myocardial dysfunctional states a great similarity in time, slope and relative ("pulse") amplitude in diastole (s. figures). Therefore, the term PRESSOCARDIOGRAM is more suitable for naming these tracings that reflect firmly LVP curve changes. Above, the pressocardiographic relative A wave to total height (A/H) has been proved to correlate closely with LV end-diastolic (LVEDP) and LV stiffness indexes and the total relaxation time, termed TORET or TART, to min dP/dt and other more sophisticated LVP relaxation indexes.
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| Simultanepus PressoCG and LVP (conventional-catheter) -Hygeia Hospital showing the similar slopes |
Simultaneous Micromanometer for PressoCG and LVP -Univ. of Zurich the similarity in Slopes & indexes -but not of systolic parts.
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Basic Formal Changes of Pressocardiogram
[Diastolic Types of Abnormalities]
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Normal Pressocardiogram & 2 abnormal PressoCGs showing the 2 Basic Diastolic Types; the 3rd is the "Mixed or RC-typeThese 3 types can occur at rest, during or after Handgrip exercise. Type -deterioration with handgrip (R-->RC-->C) represents one of main criteria for defining a so-called "Coronary Differential form" which is associated with non-obstructive or obstructive CAD in >70-80% of cases.Pathophysiologically, this deterioration has been proved by cath studies demonstrating the early occurring prolongation of relaxation followed by icreasing LV stiffness with LVEDP rise. |
ADVANTAGES of Presso Test
1. Isometric Handgrip Exercise vs. Dynamic/Pharmacological Stress testing:
- Short (2 min) & Low level exercise, therefore convenient/friendly and safe
- Less HR rise, therefore less often occurring no merging of diastolic waves
- Performable even by disabled, obese, very elderly etc persons
- Handgrip induces Nor-epinephrine and Endothelin-1 secretion resulting in abnormal vasomotion/vasoconstriction of atherosclerotic coronary arteries due to endothelial dysfunction, as proved angiographically by Brown et al., and. Handgrip-induced ischemia is proved metabolically being associated with worse prognosis even in non-obstructive CAD (Johnson et al., Circulation 2004) as well as with dramatic LVEDP rise showed by numerous studies.
2. Advantages of used devices:
a. Balloon Dynamometer: more convenient and user-friendly for every patient
b. Presso Device: is portable and –in future- even handheld or ev. Incorporated in an elec. Stethoscope (!), and inexpensive
3. Pressure Transducer vs. ECG and Imaging Tests:
- Pressure curve indexes are more exactly-and-objectively definable (sharp lines-and-points) definable by every non-expert
- Easier and more exact automated calculation & evaluation of amplitude of exercise-induced changes
- Pressure transducer is fixed by elastic strap over LV beat. In contrast, Echo Probe’s position/angle etc is changing depending on skillfulness/experience/expertise etc of the examiner (angle-dependence, noise etc!).
4. Diastolic Indexes, Types, Patterns and Differential Forms:
- There are only “few classical” Pressocardiographic diastolic indexes, remaining the same since decades.. In contrast, "myriads diastolic echo variables" using numerous high-tech “modern imaging techniques” have been introduced; being often initially “widely accepted/ used-and-included in Guidelines.!”, but sooner or later ..abandoned (!) + replaced by “newer” even more “complex/too sophisticated” indexes…. And this “academic game” is going o in >2 decades!…; whereas million of $ are spent & thousands of lectures are done and hundreds of papers are published….
- Based on large cohorts of healthy subjects, the normal limits of pressocardiographic diastolic indexes at rest and handgrip exercise have been exactly defined. Additionally, some diastolic types & Patterns & even diastolic “Differential forms” of LV diastolic behaviour have been exactly defined. As to volumetric echo diastolic indexes, similar definitions are debatable, absent or frequently changing.
- Moreover, volumetric early diastolic echo indexes (E, E’) are now used –included even in guidelines!- for estimating…end-diastolic… pressure indexes (LVEDP, LAP).! A really pathophysiologically unacceptable.. paradox!...
5. Spectrum of Clinical Implications:
- Presso Test can applied everywhere by every practitioner or personnel in or above out-of-hospitals. The recently introduced “diastolic echo stress test” for estimating ‘”diastolic reserve” needs (super)experts in academic labs, is still desperately attempted by such groups to be further explored without any exact definitions of grading, types or patterns of changes in early and late diastole. Therefore, no automated objective evaluation/diagnosis for physicians can be ever be done..
- The high-amplitude diastolic changes in CAD patients, representing a characteristic sign for presence of ischemia as shown by micromanometer measuring of LV pressure as well as by Presso Test, could not be found by diastolic stress echo. Today, a pressocardiographic automated evaluation of diastolic patterns could be developed and successfully applied in clinical practice for differentiating an "ischemic" from a "non-ischemic" pattern of diastolic response. In recent years, the "diastolic stress test" concept has been tried using TDI with dynamic exercise; however, although even whole sessions have been organized -as in the last annual ESC meeting in Stockholm analyzing Stress-TDI(!), the results are really frustrating: E/E' showed only minor changes in % of baseline value (<20%) in CAD pts!...
- Presso Test can become helpful in screening subclinical/asymptomatic-silent myocardial diseases and partially even differentiating among an “Ischemic” vs. “Non-ischemic” diastolic response as well as among early stage CAD vs. Cardiomyopathies vs. HTN vs. heart failure..
Clinical Value of “Diastolic Handgrip Stress Test”
vs. “Handheld Echo” for
“Out-of-Hospitals Family Screening”
Although most modern “imaging experts” wish to establish the “Handheld echoCG” devices and are promoting them as “excellent and very useful screening tools”, they obviously forget some basic great limitations of all echo devices. Namely, that echo is really very useful for evaluating above-and-mainly: “structural disease states” (valvular, pericardial, dilation or hypertrophies etc) and advanced “systolic dysfunction”!..Most of these cardiac diseases are symptomatic and/or advanced and/or already detected in our civilized world and their diagnosis needs rather significant expertise.
In the west world, an early stage diagnosis of asymptomatic/subclinical myocardial diseases is really needed by an initial screening test that can be applied by every non-expert to every person out-of-hospitals, since “healthy looking-and-feeling” persons with some kind of “silent” myocardial disease” –above silent CAD or early stage Cardiomyopathies are rarely coming to us in tertiary hospitals and even more rarely are coming to echo labs for being examined by experienced experts of stress-echo or nuclear stress tests..
Thus, the existing excellent imaging techniques, obviously do not enable an effective identification of silent myocardial diseases –the great killers of west population!..
A “Diastolic Stress Test” device by means of the convenient/short/low level/safe Handgrip exercise represents, in fact, a widely acceptable-and-applicable exercise modality, which has –however, according to hitherto published findings- failed to provide us diagnostically useful information using our widely applied diagnostic techniques (ECG, Echo, Nuclear etc). Low level isometric exercise represents the really only stress mode that can be applied out-of-hospitals! And the only measures that change significantly with Handgrip are those being ....PRESSURE TRANSDCUER- derived!..
Using angiography and micromanometers for LVP curves, it has extensively be proved in last 3 decades that in CAD pts, handgrip induces a vasospasm of atheromatic coronary vessels (Brown et al in Washington University) and some characteristic dramatic diastolic LVP changes – but much less-and-“noncharacteristic” volumetric and no ECG changes (Flessas et al in Boston University, Caroll et al in Zurich etc). More recently, handgrip has been found to induce ischemia by an endothelial dysfunction leading to a shift into anaerobic metabolism (Johnson et al in many US Hospitals, Circulation 2004).
My clinical experience with a portable Presso Test device and handgrip exercise out-of-hospitals and at patient’s home, showed very promising results, since a great part of asymptomatic “healthy” family members showing an “ischemic diastolic response” or so-called “coronary differential form” (s. enclosed text/figures) have been subsequently found to suffer from Non-obstructive or even obstructive CAD or beginning “diastolic HF” (the elderly members) or early stage cardiomyopathies...
I hope that sooner or later such useful Presso Test’s data can be collected by numerous clinicians in a much larger cohort of “family members”, before every practitioner can obtain a Presso Test by a handheld cost-effective device as routine initial screening tool...
The “Diastolic Stress Echo-Presso Test” Concept
(s. European Patent, Manolas J, 2009)
More recently, we have introduced a new, pathophysiologically even more accurate concept that could be used as complementary test to the classical “Systolic Stress-echo” in echo labs using simultaneous external PRESSURE TRANSDUCER & Doppler echo (TFV, TDI etc) recordings by means of a “combined ECHO-PRESSO probe”. This “Echo-Presso Handgrip Stress Test” would represent the only pathophysiologically correct way to assess accurately diastolic LV function behaviour with exercise (!).
Many exciting novel combined diastolic indexes could be tested in future by incorporating my “Presso test system” in ECHO devices and performing a HANDGRIP exercise instead of dynamic/pharma tests, which all are more sophisticated/time consuming/less convenient and nor completely safe for patients.
(s. European Patent Application, published 2009” )
LINK:
http://v3.espacenet.com/publicationDetails/biblio?CC=EP&NR=2067438&KC=&FT=E
Pathophysiological Facts: In non-dilated/good contracting ventricles in the steep part of the PV diagram, diastolic pressure is more dramatically changing than volume. Correspondingly, early in course of diastolic failure states or in presence of induced ischemia, pressure transducer-derived diastolic indexes are clearly more suitable than all “pure volumetric diastolic methods for assessing LV function changes in early and above late diastole. Even less suitable in this evaluation are all pure-volumetric echo techniques, reflecting basically just some minor LA-LV pressure (LVP) differences/ intraventricular propagation changes/"untwisting" etc. and – therefore- not enabling an accurate estimation of changes in level of LV filling pressures and pressure decay.
Above, it is unreasonable-and-unacceptable trying to estimate late diastolic pressure changes by... early diastolic pure-volumetric-echo indexes.!... Therefore, the use of an internal or external pressure transducer is essential for assessing the degree and mode of diastolic change with exercise in non-dilated ventricles, whereas “pure volumetric techniques –like echo- are less accurate with exercise.
Hemodynamic Basis of Presso Test: Using optimal external pressure transducers with low level handgrip stress and based on exact criteria, we have first explored the challenging "Diastolic Stress Test" concept since >20 years and published data from a wide spectrum of myocardial disease states, above CAD. Pressocardiograms with handgrip (Presso Test): showed in several studies in USA & Greece in coronary artery disease (CAD) patients, a high-magnitude increase of A wave to total excursion during low level HG exercise (both 54%-100% of baseline) which is very similar –if not identical- with those showing LVEDP with handgrip (50-122% of baseline).
The clinical usefulness of this "Diastolic Stress Test Using External Pressure Transducer" (Presso Test) is based on published data in US journals proving its firm hemodynamic background as well as sensitivity in myocardial disease, but above by its successful clinical application in >8.000 pts in Athens and >20.000 pts in Europe by practitioners & hospital cardiologists.
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| CAD: A wave at rest normal & increasing dramatically within <1min of Handgrip (!) due to increasing "ischemic" Stiffness in left ventricle (Typical/severe "Ischemic Diastolic response" & Coronary Differential Form=DF) | HTN/NoCAD: A wave is only slightly abnormal at rest and decreases with Handgrip at borderline level (Non-ischemic Pattern & Htn-DF) |
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| HTN: Slight LV diastolic dysfunction/R-type/Non-ischemic Pattern and "Htn-DF | Heart Failure with severe LVEF decrease: Severe LV diastolic dysfunction with already at rest very increased A wave which is decreasing with Handgrip due to LA failure: Non-ischemic C-type/Non-ischemic Pattern and Congetsive DF |
Dr. Jan Manolas has studied Medicine in University of Bern & Cardiology in University of Zurich. He was working in Medical Policlinic, University Hospital of Zurich for years with his teachers and pioneers in myocardial function research Prof. Dr. W. Rutishauser & Prof. HP Krayenbuehl as well as his friends and contributors in his scientific work Dr. AR Gruentzig & Dr. U. Sigwart – the genius creators of PTCA and Stents, respectively (s. also chapter "Creation & Developments")..
In last 2 decades, Dr. Manolas has introduced the following new entities:
* The "Diastolic Types" Concept (Manolas, Z Kardiol 1990 & Cl Cardiol 1993) recognizing their Prognosic significance (Manolas, Am J Noninv Cardiol 1993)
* The "Ischemic Diastolic Response" Concept (Manolas, HJC-editorial 1994 & Cardiology 1995) for differentiating patients with inducible ischemia from "Non-ischemic" diastolic dysfunction,
* The "Four Diastolic Dialysis Types" Concept (Manolas, 1999) for risk stratification of end-stage renal failure patients on Hemodialysis and an improved regulation of dialysis session, and finally
* The "Diastolic Differential forms" Concept (USA patent application in 2003 –receiving USA patent 2006) for discriminating patients with various myocardial diseases independently of symptoms or result in other diagnostic methods.
For the whole spectrum of new criteria with exact definitions and range of the diastolic Types, Patterns and Forms of diastolic behaviour of the left ventricle with exercise as well as technical details of device development, please visit the German patent (in 2002) and a US patent (in 2006).
The basis of both patents consists in the of automated evaluation of LV diastolic behavior with Handgrip exercise by means of positive or negative test result & a differentiation of "Diastolic Types, Patterns and Forms" according to exact definitions aiming a differentiation of the underlying myocardial disease using a portable –in future even… pocket sized (PDA)- equipment!
By introduction of these Concepts, the entire spectrum of the LV behaviour with exercise has been for the 1st time worldwide exactly defined, opening a new challenging area in diagnostic Non-invasive Cardiology and making Presso Test a useful tool in the daily practice; this stress test being already applied successfully in Europe both at Practitioner offices and in Outpatient clinic.
1st Device fro PressoCG
Zurich's Office-Raemi str. 100
1st "External Tipmanometer Transducer"
As Chief of Non-invasive/Mechanocardiopgraphic Laboratory of Medical Policlinic, University Hospital of Zurich, he published his first studies about the clinical value of Non-invasive Assessment of LV diastolic function using optimal external pressure transducer applied transthoracically over the left ventricle. He worked for years comparing simultaneous recordings of internal and external identical optimal pressure transducers (invasive and non-invasive "micromanometers") for exploring the temporal and amplitude relations between LV pressure (LVP) and external pressure transducer-derived (pressocardiogram) curves.
Already from early 80s, working in his private practice in Kolonaki-Athens, Dr. Manolas has recognized the great diagnostic value of assessing diastolic LV pressure behavior with isometric exercise and its potential great power developing further and exactly defining the challenging “Diastolic Stress Test” concept as well as using it as an Initial Screening Test for identifying myocardial disease patients at office-based daily practice. Dr. Manolas has recognized the great diagnostic value of assessing diastolic LV pressure behavior with isometric exercise.
1st Diastolic Stress Test at an Office in Kolonaki-Athens Can an "Ischemic Diastolic Response" exactly defined?..
As Practitioner, Dr. Manolas recognized the potential great power of "Diastolic Stress Test" and developed further and exactly defining the challenging “Diastolic Stress Test” concept as well as using it as an Initial Screening Test for identifying myocardial disease patients at office-based daily practice (s. Creation & Developments” section).
With his studies in 90s from Athens, Dr. Manolas introduced and defined exactly for the 1st time the "Diastolic Stress Test" Concept using for the 1st time worldwide exact diastolic criteria for defining "Diastolic Types" & "Positivity" of a short isometric handgrip (HG) exercise using an optimal Pressure Transducer (Presso test).
For examining the clinical value of the LVP diastolic behavior during HG exercise in daily practice, he used 1) A modified pre-amplifier, 2) An optimal External Pressure Transducer directly applicable to the thoracic wall (="external Tipmanometer"), and 3) a Heart Sounds Microphone.
By analyzing for >2 decades the difference in LVP diastolic behaviour among various myocardial diseases, he introduced for 1st time exact diastolic criteria for differentiating myocardial disease states ("Differential forms" Concept -USA patent application, published in 2003).
According to all published data based on > 400 catheterized patients and >8.000 diastolic stress tests. The hitherto clinical experience with Presso Test in Hospitals & Offices with > 20.000 patients, this novel diagnostic modality showed a high sensitivity and normalcy in separating "healthy" subjects from "Myocardial disease" patients even in absence of symptoms and beyond the information of ECG & Doppler-echocardiography (s. also www.diastoolicstresstest.com).
Dr. med. Jan Manolas, MD, Ph.D., F.A.C.C. Consultant of Clinical Cardiology, Dep. of Check Up, Diagnostic Center of Athens
Mobile Presso Test Unit for Screening Out-of-Hospitals
TEL/FAX: + 30 210 6718444 E mail: diastolicstressstest@gmail.com
You can ask me about any further information any time at: Tel/Fax: +30 210 6718.444 or ask me for a Teleconference by e mail at diastolicstresstest@gmail.com
