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.