Download - Subodh K. Agrawal, MD,FACC
Evaluation of Patient with Shortness Evaluation of Patient with Shortness of Breath and Normal Ejection of Breath and Normal Ejection
Fraction Fraction & &
How to Diagnose Diastolic Heart How to Diagnose Diastolic Heart FailureFailure
Subodh K. Agrawal, MD,FACC
Paradigm Shift in cardiac care
Beta Blocker in Heart Failure
Not Recommended
Must Have
Left Ventricular EF in Heart Failure
Mostly Low Low or Normal
56 year old Caucasian female who has history of hypertension, DM tupe 2 with 3 days of increasing sob, chest tightness pnd which develop to dysnoea at rest, cough with pink frothy cough
Exam: dysnoe at rest, heart rate 110/min. BP 180/100, cold clamy skin, rales on both lung upto scapula, Jvd is not visible , S3 gallop and 2 pluse pedal edema
Ekg : ST, LVH, x-ray pulmonary edema
Patient with Shortness breath in Patient with Shortness breath in the emergency roomthe emergency room
HCT 45% creatinine 1.4mg/dl, BNP 800ng/dl, troponin RX in ER Lasix 40mg iv resulted in 1200ml of urine out put
with resolution of sob and admitted for further management. After admission we found No evidence copd, no infection ,Meds enalpril 10mg/day, asa 81mg /day metformin 1000mg
twice a day This 3rd admission in last 2 years, she had, she non compliant
of medication previos cath with nl lv and normal coronar yyarteries
Previous 3 echo has shown NL LVEF and lvh
Patient with Shortness breath in Patient with Shortness breath in the emergency roomthe emergency room
The Art of Physical The Art of Physical ExaminationExamination
The history and physical exam remain the backbone of medical evaluation and assessment
"Observe, record, tabulate, communicate. Use your five senses….Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert."– Sir William Osler Sir William Osler at a patient's bedside.
Reprinted with permission.
Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.
Patient with Shortness breath in Patient with Shortness breath in the cath labthe cath lab
Once again Normal coronary arteries Normal LVEF 65% LVEDP is 25mm/Hg We proceed to do right heart cath: co 3.8L/min, CI
2.0L/Min/M square, Pcwp25, pa 60/40 mean 50. RV 60/15/ RA 10
Under these circumstances, a relatively small increase in central blood volume or an increase in venous tone, arterial stiffness, or both can cause a substantial increase in LA and pulmonary venous pressures and may result in acute pulmonary edema.
NEJM 2004;351:1097-1105
Systolic vs Dialstolic Congestive heart failure
Exertional Dyspnea
Paroxysmal Nocturnal Dyspnea
Jugular Venous Distinction
Orthopnea
Lung Crackles
Displaced Aprical Impulse
S3
S4
Systolic Heart Failure
Diastolic Heart Failure
Adapted from Echeverria et al, 1983
N Engl J Med 2006; 355; 251
Increased prevalence of heart failure with normal EFA. A large study of patients (n=4596) hospitalized with HF at a single institution over a 15 year period demonstrated that the percentage of patients who have a normal EF has increased over time
B. This was the result of an increased number of admissions for HF with a normal EF; the number of admissions for HF with reduced EF remained stable
JACC 1997;30:8-18
Diastolic Filling of the LV
PhysiologyPhysiology
Diastole encompasses the period during which the myocardium loses its ability to generate force and shorten and then returns to resting force and length.
Normal diastolic function allows the ventricle to fill adequately during rest and exercise, without an abnormal increase in diastolic pressures.
PhysiologyPhysiology Diastolic function is complex, but most
important components are the processes of:– Active LV relaxation– Passive Stiffness
LV relaxation is an active, energy dependent process that begins during the ejection phase of systole and continues through IVR and rapid filling phase
Process during which the contractile elements are deactivated and the myofibrils return to their original (pre-contraction) length
JACC 1997;30:8-18
•Patient has dyspnea with risk factors such as hypertension, diabetes, ischemia, elderly •Clinical exam shows signs of HF , S4. •CXR confirms pulmonary congestion with a normal sized cardiac silhouette •ECG may show LVH, AF.•BNP elevated
When to suspect Diastolic Heart When to suspect Diastolic Heart Failure?Failure?
Diastolic Dysfunction made Diastolic Dysfunction made simple for primary caresimple for primary care
Order:
Echocardiography, doppler, color flow doppler to rule out left ventricular diastolic dysfunction.
Left Atrial VolumeLeft Atrial VolumeDuring diastole, when the mitral valve is
open, the left atrium is exposed to the loading pressure within the left ventricle
Over time, exposure of LA to increased filling pressure will result in its remodeling and increased volume
Left atrial size is a useful marker for chronicity of diastolic dysfunction (“HgbA1c of heart disease”)
JACC 2003;41:1036-1043
Diastolic DysfunctionDiastolic Dysfunction
LVLVpressurepressure
LVLVpressurepressure
Grade 1Grade 1Grade 1Grade 1 Grade 2Grade 2Grade 2Grade 2 Grade 3Grade 3Grade 3Grade 3 Grade 4Grade 4Grade 4Grade 4
Mitral flowMitral flowMitral flowMitral flow
TissueTissueDopplerDopplerTissueTissue
DopplerDoppler
PulmonaryPulmonaryveinvein
PulmonaryPulmonaryveinvein
CP1008785-63
E/e’E/e’
EE
e’e’
< 10< 10 10 -1510 -15 >15>15 >15>15
Nagueh et al: JACC, 1997Nagueh et al: JACC, 1997Ommen et al: Circ, 2000 Ommen et al: Circ, 2000
4545
4040
3535
3030
2525
2020
1515
1010
5500 101055 1515 2020 2525 3030 3535
E/e’
PCWP (mm Hg)
r = 0.87r = 0.87
n = 60n = 60
Annulus eAnnulus e
Mitral EMitral E
E/eE/e
As LV fillingAs LV fillingpressure pressure As LV fillingAs LV fillingpressure pressure
Mottram, P. M et al. Heart 2005;91:681-695
Stepwise approach to clinical evaluation of the dyspnoeic patient with normal LV systolic function for the presence of diastolic heart failure.
ConclusionsConclusions
Diastolic Dysfunction is responsible for about one-half of cases of CHF.
Morbidity and mortality associated is high and similar to LV systolic dysfunction.
Older age, hypertension and female sex are commonly associated.
Non invasive imaging techniques can be used for diagnosis.
At this time, further studies are needed to determine optimal treatment strategies.