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Value of echocardiography in chronic dyspneaJahrestagung Schweizerische Gesellschaft für Kardiologie/Schweizerische Gesellschaft für Pneumologie

B. Kaufmann

16.06.2016

Kardiologie

Chronic dyspnea

Kardiologie

•Shortness of breath lasting longer than 1 month1

•Cardiac and pulmonary etiologies predominate

•Multifactorial in up to one third of patients1

1 Wahls SA et al. Am Fam Physician. 2012

Chronic dyspnea – value of history, physical exam and chest x-ray

Kardiologie

Correct Incorrect

Overall Less common

diseases

Cardiomyopathy

Asthma

COPD

Interstitial lung disease

%

Pratter MR et al. Arch Intern Med. 1989;149:2277-2282

Differential diagnosis of chronic dyspnea

Kardiologie

Cardiac Myocardial disease

Cardiac arrhythmias

Pericardial disease

Valvular heart disease

Pulmonary Chronic obstructive pulmonary disease

Asthma

Interstitial lung disease

Pleural effusion

Malignancy

Bronchiectasis

Differential diagnosis of chronic dyspnea (II)

Kardiologie

Noncardiac/ Thromboembolic disease

Nonpulmonary Pulmonary hypertension

Deconditioning

Obesity

Severe anemia

Gastroesophageal reflux disease

Metabolic conditions

Liver cirrhosis

Thyroid disease

Neuromuscular disorders

Chest wall deformities

Upper airway obstruction

Psychogenic causes

Differential diagnosis of chronic dyspnea

Kardiologie

Cardiac Myocardial disease

Cardiac arrhythmias

Pericardial disease

Valvular heart disease

Pulmonary Chronic obstructive pulmonary disease

Asthma

Interstitial lung disease

Pleural effusion

Malignancy

Bronchiectasis

Heart Failure

Differential diagnosis of chronic dyspnea (II)

Kardiologie

Noncardiac/ Thromboembolic disease

Nonpulmonary Pulmonary hypertension

Deconditioning

Obesity

Severe anemia

Gastroesophageal reflux disease

Metabolic conditions

Liver cirrhosis

Thyroid disease

Neuromuscular disorders

Chest wall deformities

Upper airway obstruction

Psychogenic causes

Chronic dyspnea – initial diagnostic testing

Kardiologie

•Complete blood count

•Metabolic profile

•Chest x-ray

•Electrocardiogram

•Spirometry

•Pulse oximetry

1 Wahls SA et al. Am Fam Physician. 2012

Echocardiography for the assessment of heart failure

Kardiologie

Patient with suspected HF

Assessment of HF probability

-Clinical history

-Physical examination

-ECG

Natriuretic peptides

-NT-proBNP≥125pg/ml

-BNP≥35pg/ml

HF unlikely:

consider other diagnosis

ECHOCARDIOGRAPHY

If HF confirmed:

determine etiology

all absent

normal

no

≥1present

yes

Ponikowski P et al. Eur Heart J 2016

How to assess left ventricular ejection fraction?

Kardiologie

1. Eye-balling

• Subjective

• Experience dependent

• Lack of standardisation

• Large inter- and intraobserver

variability

2. Biplane Simpson‘s method

• Time consuming

• Geometric assumptions

• Apical foreshortening

• Image quality

3. Left ventricular opacification 4. 3D echocardiography

• iv line

• Geometric

assumptions

• Image quality

• Frame rate

Left ventricular ejection fraction

Kardiologie

Kardiologie

LV ejection fraction: reliability in a heartfailure population

-

Kaufmann BA et al. Int J Cardiovasc Imaging. 2012

413 patients participating in the TIME-CHF trial

LVEF analyzed at the recruiting center and at the core lab

Image quality optimal in 191 and suboptimal in 222

0 10 20 30 40 50 60 70 80

0

10

20

30

40

50

60

70

80

EF

recru

itin

g c

en

tre [

%]

EF biplane [%]

y = 0.71x + 10.4

R2 = 0.62

p<0.0001

LV ejection fraction vs. Systolic function

Kardiologie

Preload

Afterload

Contractility

Heart rate

Ejection fraction

LV ejection fraction vs. systolic function: Strain imaging

Kardiologie

60 patients with normal ejection fraction ≥50%

LVEDP<15mmHg LVEDP≥15mmHg

Longitudinal peak

systolic strain (%)-19.1±3.0 -17.1±2.4*

Nguyen JS et al. J Am Soc Echocardiogr 2010;23:1273-80.

Diastolic dysfunction – heart failure with preserved ejection fraction

Kardiologie

• Symptoms ± Signs

• LVEF ≥ 50%

• Elevated levels of natriuretic peptides (BNP

≥35pg/ml, NT-proBNP ≥125pg/ml)

• At least one additional criterion

• relevant structural heart disease (left ventricular

hypertrophy, dilated LA)

• diastolic dysfunction

Ponikowski P et al. Eur Heart J 2016

LV Mass

Kardiologie

Cubed formula

LV mass = 0.8x1.04x[(IVS+LVID+PWT)3- LVID3] +0.6g

2D based formulas

Area length

Truncated ellipsoid

• Cube formula has a 20% correction factor that is historical

• Cube formula overestimates mass in basal septal hypertrophy

• 2D based formulas underestimate mass in basal septal hypertrophy

• Correction for BSA may mask hypertrophy in obese patients

Lang RM et al. J Am Soc Echocardiogr 2015;28:1-39

LV hypertrophy

Kardiologie

LV mass 141 g/m2

Measurement of LA Volume

Kardiologie

Lester SJ et al. J Am Coll Cardiol. 2008;51(7):679-689

Buechel R et al. J Am Soc Echocardiogr 2013;26:428-35

Normal LA volume

<34ml/m2 BSA

2D biplane Simpson‘s method 3 Dimensional

no normative data!

Diastolic dysfunction

Kardiologie

Left atrial size Mitral inflow Mitral anular motion

Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314

Diastolic dysfunction – E/e’

Kardiologie

• 43 patients with normal ejection fraction with diastolic dysfunction confirmed

by pressure-volume loop analysis

• 12 control subjects

Diastolic dysfunction Control

Kasner M et al. Circulation. 2007;116:637-647

Diastolic dysfunction in normal ejection fraction

Kardiologie

1. Average E/e‘ > 14

2. Septal e‘ velocity < 7cm/s or lateral e‘ velocity <10cm/s

3. TR velocity > 2.8 m/s

4. LA volume index >34ml/m2

<2 positive 2 positive >2 positive

Normal diastolic

functionIndeterminate Diastolic dysfunction

Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314

Myocardial disease - etiology

Myocardial disease - etiologyCoronary artery disease Hypertrophic obstructive cardiomyopathy

Left ventricular non-compaction Amyloidosis

Valvular heart disease – aortic stenosis

Kardiologie

Mean PG 23mmHg

Valvular heart disease – aortic stenosis

Kardiologie

Mean PG 44mmHg

Valvular heart disease – aortic stenosisbe prepared for the rare case!

Kardiologie

Valvular heart disease – mitral regurgitation

Kardiologie

Pericardial constriction

Kardiologie

Pericardial constriction

Kardiologie

• 130 patients with surgically confirmed pericardial constriction, 30

control patients

• blinded analysis of echocardiographic data

Welch TD et al. Circ Cardiovasc Imaging. 2014;7:526-534

Sensitivity % Specificity %

Change in mitral E velocity ≥14.6% 84 73

Hepatic vein flow reversal ratio ≥0.79 76 88

Chronic thromboembolic disease

Kardiologie

Pulmonary artery hypertension

Kardiologie

Value of echocardiography in chronic dyspnea

Kardiologie

• First line diagnostic imaging test for

• Myocardial disease

• Valvular heart disease

• Pericardial disease

• May aid in the diagnosis of

• Thromboembolic disease

• Pulmonary artery hypertension

• Importance of the clinical context

Thank you for yourattention!

Beat Kaufmannbeat.kaufmann@usb.ch

Kardiologie