evaluation of patient with shortness of breath and normal ejection fraction & how to diagnose...
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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
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
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
N Engl J Med 2006; 355; 251
Survival curves for patients with heart failure with normal EF has not improved. Whereas survival for patients with HF with reduced EF was shown to be improving over time in this study from Olmsted County (A), no such improvement was observed for patients with HF normal EF (B).
Framingham Criteria for Dx of Framingham Criteria for Dx of Heart FailureHeart Failure
Major Criteria:– PND– JVD– Rales– Cardiomegaly– Acute Pulmonary Edema
– S3 Gallop
– Positive hepatic Jugular reflex
– ↑ venous pressure > 16 cm H2O
Dx of Heart Failure (cont.)Dx of Heart Failure (cont.)
Minor Criteria LL edema,
Night cough
Dyspnea on exertion
Hepatomegaly
Pleural effusion ↓ vital capacity by 1/3 of normal
Tachycardia 120 bpm
Weight loss 4.5 kg over 5 days management
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
EPICA StudyEPICA Study
Eur Journal Heart Failure 2002;4:531-539
Population based study showing increased prevalence of Diastolic HF with age and with female gender
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
•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?
Tissue DopplerTissue DopplerMitral Annulus VelocityMitral Annulus Velocity
Sohn et al: JACC, 1997Sohn et al: JACC, 1997
Mitral flowMitral flow
Mitral annulusMitral annulusvelocityvelocity
Normal Ab Relax Pseudo RestrictiveNormal Ab Relax Pseudo Restrictive
Grade 1Grade 1 Grade 2 Grade 2 Grade 3Grade 3
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
1
2
3
4
5
6
7
8
9
10
0 10 20 30 40 50
0
5
10
15
20
25
30
35
40
0 10 20 30 40 50
Ln
BN
PL
n B
NP
PCWP (mm Hg)PCWP (mm Hg)
Correlations of PCWP to BNPversus PCWP to Mitral E/e’
Correlations of PCWP to BNPversus PCWP to Mitral E/e’
CP1156944-1
Dokainish et al: Circ, May 25, 2004Dokainish et al: Circ, May 25, 2004
Ln BNP vs PCWPLn BNP vs PCWP Mitral E/e’ vs PCWPMitral E/e’ vs PCWP
Mit
ral E
/e’
Mit
ral E
/e’
PCWP (mm Hg)PCWP (mm Hg)
r=0.32p=0.02r=0.32p=0.02
r=0.69p<0.001r=0.69p<0.001
EF <50%EF <50%EF 50%EF 50%
EF 50%EF 50%EF 50%EF 50%
Prognosis of Patients with E/e’ Ratio of <15 vs >15Prognosis of Patients with E/e’ Ratio of <15 vs >15
0.0
0.2
0.4
0.6
0.8
1.0
0 6 12 18 24
0.0
0.2
0.4
0.6
0.8
1.0
0 6 12 18 24
Su
rviv
al
Su
rviv
al
Follow-up (months)Follow-up (months)
EF <40%EF <40%
Hillis et al: JACC 43(3):360, 2004Hillis et al: JACC 43(3):360, 2004
E/e’<15E/e’<15
E/e’ >15E/e’ >15
7272 5252 2929 1111 44No. atrisk
No. atrisk
EF >40%EF >40%
E/e’ <15E/e’ <15
E/e’ >15E/e’ >15
178178 143143 8484 3838 1111
CP1141593-3
Follow-up (months)Follow-up (months)
e’ = 18 cm/se’ = 18 cm/s
ConstrictionConstriction
MyocardialMyocardial
e’ = 5 cm/s
Tissue Doppler Early diastolic mitral annulus velocity (e’)
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
Left Atrial VolumeLeft Atrial Volume
LA volume measurement has been shown to be predictive of an individual’s risk of stroke, MI, A fib and heart failure
In clinical practice, volumes are more useful because they allow accurate assessment of asymmetric remodeling of the chamber
LA volumes are best calculated using ellipsoid model or Simpson’s rule
JACC 2003;41:1036-1043
JASE 2004;17;3:290
Because E/A ratio, DT and IVRT are altered by filling pressures, they follow a parabolic curve pattern. Further measurements which are less load dependent may be necessary to accurately assess degree of diastolic abnormality.
JASE 2004;17:290-297
Patient with Shortness of breath in out Patient with Shortness of breath in out patient clinicpatient clinic
Seventy year old male with shortness of breath for last six months. He was recently admitted to hospital for acute pulmonary adema and cardiac workup was negative. Shortness of breath has worsened and has persistent severe hypertension. He has been treated with severe hypertension, on four anti hypertensive medication and office blood pressure is 180/110 mm/Hg.How to evaluate this patient in office setting?
Overnight Pulse Oximeter:
Overnight Pulse Oxymetery
Prevalence of Sleep Apnea Prevalence of Sleep Apnea Co-morbiditiesCo-morbidities
Sjostrom et al.Thorax 2002
Logan et al.J. Hypertension 2001
Javaheri et al.Circulation 1999
O’Keefe, Patterson.Obes Sugery 2004
Einhorn et al.Amer Diab 2005
Somers et al.ATS Pres. 2004
80%
50%
45%
35%
77%
50%Diabetes
Morbidly Obese
All Hypertension
Atrial Fibrillation
Congestive HeartFailure
Drug-ResistantHypertension
Mottram, P. M et al. Heart 2005;91:681-695
Suggested schema for echo Doppler categorisation of diastolic function in patients with normal LV systolic function.
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.
ACC/AHA 2005 Guideline Update for the Management
of Patients with Chronic Heart Failure, JACC 2005
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.