DIASTOLOGY “DON’T BE SUCH A STIFF” CF2013.pdf · DIASTOLOGY “DON’T BE SUCH A STIFF” CASE 1 – ROOM 8 • 74 yo female ... CHF – Call Cards, Start Nitro gtt, BiPAP,

Michael Mallin, MD University of Utah

Director Emergency Ultrasound www.ultrasoundpodcast.com

Warning: The education found within this presentation is not approved by anyone who does

approvals

DIASTOLOGY “DON’T BE SUCH A STIFF”

CASE 1 – ROOM 8 •  74 yo female presents with SOB

•  Hx of COPD, CHF, DM •  As you walk in the room she is sitting

up in bed tripoding and tachypnic. •  She can only speak in 2-3 word

sentences and complains of pleuritic chest pain and difficulty breathing.

•  Vitals: •  HR 104 •  BP 144/86 •  O2: 72% on RA, 94% on NRB

CASE 1 •  PE:

•  Decreased BS bilaterally •  Mild Wheezes bilaterally

•  Increased AP diameter

•  Heart sounds difficult to auscultate

•  Mild LE edema

•  +JVD, but you’ve seen worse

CASE 1 – DIFFERENTIAL •  Differential Diagnosis?

•  COPD Exacerbation •  CHF Exacerbation

•  Pneumotohorax

•  Pneumonia

•  Pulmonary Embolus

•  Pericardial Effusion

CASE 1 – WHAT NEXT •  You got this. •  You did your required 150 ultrasound scans in residency……….

At least 30 were cardiac. •  You’ve seen multiple ultrasounds of people in heart failure……

you even watched a podcast or 2 about it.

CASE 1 - ULTRASOUND •  Bammm! Diagnosisism

CASE 1 - ULTRASOUND •  DX: CHF – Call Cards, Start Nitro gtt, BiPAP, Lasix, Admit – too easy

CASE 2 - ROOM 9 •  59 yo male presents with SOB

•  Hx of COPD, CHF, DM •  As you walk in the room he his sitting

up in bed tripoding and tachypnic. •  He can only speak in 2-3 word

sentences and complains of pleuritic chest pain and difficulty breathing.

•  Vitals: •  HR 104 •  BP 144/86 •  O2: 72% on RA, 94% on NRB

CASE 2 •  PE:

•  Decreased BS bilaterally •  Mild Wheezes bilaterally

•  Increased AP diameter

•  Heart sounds difficult to auscultate

•  Mild LE edema

•  +JVD, but you’ve seen worse

CASE 2 – DIFFERENTIAL •  Differential Diagnosis?

•  COPD Exacerbation •  CHF Exacerbation

•  Pneumothorax

•  Pneumonia

•  Pulmonary Embolus

•  Pericardial Effusion

CASE 2 – WHAT NEXT? •  Didn’t we just do this, I just proved my Ultrasound dominance.

CASE 2 – WHAT NEXT? •  No Heart failure: must be COPD: pred, nebs, O2, admit

CASE 2 -WHOOPS

•  Patient SOB worsens. •  Requires intubation prior to admission. •  Post-intubation X-ray shows bilateral pulmonary

interstitial edema and BNP comes back at 2,543. •  What Happened? •  How did US fail you?

DIASTOLIC HEART FAILURE •  Under recognized •  Can occur with normal EF!

•  5 Million Americans with heart Failure

•  50% of acute failure is diastolic only (EF>50%)

PHYSICAL EXAM – GOOD IDEA?

•  Your physical exam put to the test •  Sensitivity of JVD: 30% •  Sensitivity of S3: 24%

ECHO – GOOD IDEA?

MISPLACED CONFIDENCE •  Cardiac Ultrasound by POC Physicians •  Just because the EF is normal: •  Does not mean there is not acute failure

DIASTOLIC FAILURE •  RELAXATION: Ability of the myocardium to relax during

Diastole •  COMPLIANCE: Ability of the myocardium to accept a volume of

blood in Diastole

RELAXATION •  Muscle relaxation in early diastole. •  Descent of base. •  How well do I pull?

COMPLIANCE •  Compliance - •  Myocardial compliance determines pressure required for

diastolic filling •  How hard do I have to push?

PUSHING OR PULLING?

DIASTOLIC FAILURE – HOW DOES IT OCCUR •  HTN thickens myocardium and impairs filling •  Decreased Filling = Decreased CO •  Decreased CO = Activation of Renin/ATII •  Renin/ATII = Fluid retention •  Fluid retention = Increased Preload •  Increased Preload = Increased filling pressure

CAN I EVEN DO THIS?

THE PUDDING •  Diagnostic Accuracy of Emergency Doppler Echocardiography for Identification of Acute

Left Ventricular Heart Failure in Patients with Acute Dyspnea: Comparison with Boston Criteria and N-terminal Prohormone Brain Natriuretic Peptide. Peiman, N. Acad Emerg Med. 2009; 17:18-26.

•  145 Patients: evaluated by ED docs with Echo for “restrictive” diastolic dysfunction and compared to BNP

•  Pulsed Doppler Sensitivity 82%, Specificity 90%

•  Performed better than BNP or Boston heart failure criteria

THE QUESTION IS: •  Who is getting admitted for a CHF exacerbation?

QUALITATIVE ASSESSMENT

LA area >20cm2

Very sensitive

MEASURING DIASTOLIC FAILURE •  Mitral inflow – POWER DOPPLER

EA

MEASURING DIASTOLIC FAILURE •  Mitral inflow

Normal Impaired Relax Pseudonormal Restrictive

MEASURING DIASTOLIC FAILURE •  TISSUE DOPPLER

e’ a’

MEASURING DIASTOLIC FAILURE •  Tissue Doppler


THE SPECTRUM


Diuresis

Overload

GOOD! BAD!


THE SPECTRUM


Diuresis

Overload


FILLING PRESSURE

•  E/e’ ≅ Filling Pressure (LVEDP, PCWP) Normal: E/e’ < 8

Elevated Filling Pressure: E/e’ >15

THE SPECTRUM


Diuresis

Overload

E/e’ <8 E/e’ >15


Clinical Application •  Acute heart failure - Dyspnea

•  Volume overload – Monitor response to therapy

•  Critical patients requiring massive volume resuscitation

DIASTOLIC FAILURE SUMMARY •  Diastolic Failure can occur with normal Systolic Function ~ 50% of the time

•  Systolic Normal Acute Heart Failure- Under diagnosed by ED physicians

•  Diastolic Failure: E/e’>15

•  Normal

•  Impaired Relaxation

•  Pseudonormal

•  Restrictive


Diastolic Failure: E/e’ >15

DIASTOLIC FAILURE

DIASTOLOGY REFERENCES •  1) Nagueh S, Appleton C, Gillebert T, et al. Recommendations for the Evaluation of Left

Ventricular Diastolic Funciton by Echocardiography. J Am Soc Echocard. 2009;(22):2; 107-133.

•  2) Paulus W, Tschope C, Sanderson J, et al. How to diagnose diastolic heart failure. European Heart Journal (2007):28; 2539-2550.

•  3) Labovitz A, Noble N, Bierig M, et al. Focused Cardiac Ultrasound in the Emergent Setting. J Am Soc Echocard. 2010(23):12,1225-1230.

•  4) Banerjee P, Clark A, Nikitin N, et al. Diastolic heart failure. Paroxysmal or Chronic? Eur J Heart Failure. 2004(6);427-431.

•  5) Unluer EE, Bayata S, Postaci N, et al. Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure. Emerg Med J. 2012;29(4):280-3.

Documents

DIASTOLOGY “DON’T BE SUCH A STIFF” CF2013.pdf · DIASTOLOGY “DON’T BE SUCH A STIFF” CASE 1 – ROOM 8 • 74 yo female ... CHF – Call Cards, Start Nitro gtt, BiPAP,