“dyspnea” a cardiologist’s perspective. disclosures i will not discuss off label use or...

“Dyspnea”A Cardiologist’s

Perspective

Disclosures

•I will not discuss off label use or investigational use in my presentation.

•I have no financial relationships to disclose.

•Employee of MaineHealth Cardiology

Case

62 year old white female with a history of hypertension, hyperlipidemia, mild obesity (BMI of 31) and remote tobacco use (1/2 pack per year for ten years but quit at age of 30) presents as a new patient as she has recently moved to Maine for retirement. You are her third primary care physician in two years. Her only complaint is persistent dyspnea on exertion that she has had for the past three years. She reports that she has dyspnea when walking quickly or walking up hill. She denies dyspnea at rest, PND or orthopnea though at times she has a mild cough and a a wheeze when laying down at night. She reports having undergone two cardiac evaluations and pulmonary function tests in the past and was told that she was “overweight and out of shape.” She began walking with her husband every night for the past six months but she is frustrated because she cannot keep up with him and is not getting better.

62 year old white female with a history of hypertension, hyperlipidemia, mild obesity (BMI of 31) and remote tobacco use (1/2 pack per year for ten years but quit at age of 30) presents as a new patient as she has recently moved to Maine for retirement. You are her third primary care physician in two years. Her only complaint is persistent dyspnea on exertion that she has had for the past three years. She reports that she has dyspnea when walking quickly or walking up hill. She denies dyspnea at rest, PND or orthopnea though at times she has a mild cough and a a wheeze when laying down at night. She reports having undergone two cardiac evaluations and pulmonary function tests in the past and was told that she was “overweight and out of shape.” She began walking with her husband every night for the past six months but she is frustrated because she cannot keep up with him and is not getting better.

Dyspnea

LVEDP

LeftVentricular

EndDiastolic Pressure

Phases of Diastole

LVEDP

Ischemia

Ischemia

Ischemia

Ischemia

How Do We Assess LVEDP?

• History

• Physical Exam

• Non-Invasive testing

• Invasive Testing

History

History• Rest or Exertion?

– Risk stratify and quality of life

– Ischemia, mitral valve disease, aortic stenosis (but not aortic regurgitation)

– “Bendopnea”

• What time of day-PND and orthopnea?

– Night time-ischemia, Heart Failure, Obstructive Sleep Apnea

• Associated symptoms ?

– Chest pain-ischemia, pulmonary embolus, pericardial effusion, heart

failure.

– Cough-Bronchitis/pneumonia/asthma but also heart failure and GERD

– Wheezing-Asthma/COPD, allergies, but also heart failure and GERD.

– Peripheral edema-heart failure, PAH

CaseReview of Systems: Negative except for mild joint pain and mild fatigue.

PMH: Hypertension, Hyperlipidemia, Obesity

PSH: Appendectomy and cholecystectomy.

Allergies: Penicillin

Medications: Atorvastatin 20mg daily, lisinopril 5mg Daily.

Social History: Married, quit smoking at age 30 with 5 pack year history, glass of wine with dinner.

Family History: Mother Colon Cancer age 77, Father diabetes and coronary artery disease at age 72. One sister with aortic stenosis and aortic valve replacement at age 45.

Review of Systems: Negative except for mild joint pain and mild fatigue.

PMH: Hypertension, Hyperlipidemia, Obesity

PSH: Appendectomy and cholecystectomy.

Allergies: Penicillin

Medications: Atorvastatin 20mg daily, lisinopril 5mg Daily.

Social History: Married, quit smoking at age 30 with 5 pack year history, glass of wine with dinner.

Family History: Mother Colon Cancer age 77, Father diabetes and coronary artery disease at age 72. One sister with aortic stenosis and aortic valve replacement at age 45.

CasePhysical ExamOverweight white female in no acute distressHeight 170cm (5’ 7”), Weight 81kg (178lbs) BMI 28Blood Pressure R arm 138/88, L arm 143/91Pulse 84 and RegularRR 14 and comfortableHEENT: NormalNeck: No JVD, normal carotid upstrokes, no bruits, no thyromegallyLungs: Clear to percussion and auscultationCardiac: Regular rate. Normal S1, S2. Soft S4, No S3, rub or gallop. Grade II/VI early peaking systolic murmur at the LUSB PMI not palpable.Lungs: Clear to percussion and auscultation.Abdomen: Benign.Extremities: No peripheral edema, no clubbing. Normal peripheral pulsesNeurologic exam: Normal

Physical ExamOverweight white female in no acute distressHeight 170cm (5’ 7”), Weight 81kg (178lbs) BMI 28Blood Pressure R arm 138/88, L arm 143/91Pulse 84 and RegularRR 14 and comfortableHEENT: NormalNeck: No JVD, normal carotid upstrokes, no bruits, no thyromegallyLungs: Clear to percussion and auscultationCardiac: Regular rate. Normal S1, S2. Soft S4, No S3, rub or gallop. Grade II/VI early peaking systolic murmur at the LUSB PMI not palpable.Lungs: Clear to percussion and auscultation.Abdomen: Benign.Extremities: No peripheral edema, no clubbing. Normal peripheral pulsesNeurologic exam: Normal

Blood Pressure• Hypertension

• Hypertensive Crisis: Acute diastolic heart failure,

ischemia

• LVH=HFpEF or HFrEF

– Hypotension– End Stage Systolic Heart Failure, tamponade

– Narrow pressure-Pulse pressure proportion

» SBP-DBP/SBP=less than 25%-Poor Cardiac Output-

End Stage Heart Failure

– Pulsus Paradoxus-Tamponade, pleural effusion, COPD

Heart Rate

– Tachycardia

• Afib/flutter with RVR and Diastolic HF

• Afib/flutter with RVR and Systolic HF

• Sometimes JUST AFIB

– Bradycardia

• Sick sinus syndrome, heart block (BUT usually

fatigue and dizziness/syncope are chief

complaints)

Respiration

• Tachypnea: The most sensitive vital

sign for heart failure!

PPV NPV Sensitivity Specificity

Rales/crackles 100% 35% 24% 100

S3 gallop 86% 48% 68% 73%

J VD 95% 47% 57% 93%

CXR Vascular re-distribution

89% 48% 65% 85%

CXR-Interstitial edema

83% 33% 27% 87%

Butman et al. J Am Coll Cardiol

1993;22:968-74

Butman et al. J Am Coll Cardiol

1993;22:968-74

Jugular Venous Distention

• Assessment of Right Atrial Pressure

– Rarely palpable

– Three elevations and three troughs (though

only two may be seen)

– Timing (arterial always during systole)

– Pulsations eliminated by light palpation

– Level changes with position (unlike arterial)

Normal JVP

• a-atrial contraction

• x-atrial filling

• c- initial tricuspid closure

• x’-continued atrial filling

• v-rise in atrial pressures

during tricuspid valve

closure

• y-ventricular filling

S1 S2

JVP Assessment

• Head of bed at 30 degrees

• Determine venous

waveform from arterial

pulsation

• Measure maximum

pulsation height above

sternal angle

• Add 5cm (sternal angle

5cm above RA)

JVD to LVEDP

• LVEDP≈ 2 times Right Atrial Pressure

• 0.74 times cm H20 equals mmHg

• 1.36 times mmHg equals cm H2O

• 14cm JVD (times .74) is 10.4 times 2 equals

LVEDP of 21mmHg

• Double LVEDP to get rough estimate of

pulmonary artery systolic pressure!

Square Sign-Assessing LVEDP at the Bedside

SBP

10mmHg

Normal Physiology-Biphasic

Valsalva

Release “Overshoot”


SBP

10mmHg

Heart Failure-LVEDP<25mmHgMonophasic but not sustained

Valsalva

Release “Absent Overshoot”


SBP

10mmHg

Heart Failure-LVEDP>25mmHg-Monophasic and sustained-Square Sign

Valsalva

Sustained Release

Physical Exam-Pearls• Lungs: Crackles heart failure, pulmonary fibrosis, bronchiectasis

– Wheezing (COPD, heart failure “cardiac asthma”

– Ronchi: bronchitis, pneumonia

– Absent lung sounds: Obstruction (lung cancer), pneumothorax, pleural

effusion

• Cardiac: S3 (low sensitivity, high specificity but can be normal in

young pt)

– Murmurs (AS, AR, MS, MR)

– Severe MR may not have a murmur and only an S3

– Laterally displaced PMI-LVH (HFpEF or aortic stenosis)

– Loud P2: Pulmonary hypertension (either primary or secondary)

– S4: LVH-think HFpEF

– Aortic Regurgitation best heard in RUSB bending over and exhaling

Physical Exam

• Abdominal Exam

– Hepatomegally: Heart failure due to liver

congestion (hemochromatosis)

• Extremities:

– Clubbing: cyanotic heart disease

– Edema: heart failure, pulmonary artery

hypertension

– Quincke’s pulses: aortic regurgitation

Case

You request the cardiac evaluation and PFTs that were done last year. In the meantime, you order a CBC, TSH and chest X ray that return are normal. You even check a BNP that returns at 88. Her ECG shows sinus rhythm with possible left atrial enlargement and a left anterior hemi-block with late transition.

She is not interested in repeating any tests unless you think it is really necessary.

You request the cardiac evaluation and PFTs that were done last year. In the meantime, you order a CBC, TSH and chest X ray that return are normal. You even check a BNP that returns at 88. Her ECG shows sinus rhythm with possible left atrial enlargement and a left anterior hemi-block with late transition.

She is not interested in repeating any tests unless you think it is really necessary.

Initial Work Up

• CBC

• Chest X-ray

• TSH (hyper or hypothyroid)

• ECG

Secondary Work Up

• Usually with either Pulmonary, Cardiology or

Both

• Echo

• BNP

• PFTs

• Stress Test

• Stress Echo with Doppler

• Invasive Hemodynamic Evaluation

Biology of the natriuretic peptide system.

Kim H , and Januzzi J L Circulation. 2011;123:2015-2019

Copyright © American Heart Association, Inc. All rights reserved.

T1/2 =120 min

T1/2 =120 min

T1/2 =20 min

T1/2 =20 min

BNP and Body Weight in Normals

Wang TJ et al. Circulation. 2004;109:594–600.

BN

P (

pg

/mL

)

25

20

15

10

5

0Men Women

Normal

Overweight

Obese

13.113.1

21.421.4

15.515.5

12.712.7

21.121.1

16.316.3

Framingham participants without CVD (N = Framingham participants without CVD (N = 3389)3389)

BNP and Body Weight in Decompensated CHF

Patients

McCord J, et al, Arch Int Med 2004

CaseTesting From Six Months Ago

Arrives • PFTs were normal.

• Echocardiogram: The echocardiogram showed normal

left and right ventricular systolic function. Mild left

ventricular hypertrophy with mild diastolic

dysfunction. The E:e’ ratio was 9. Diastolic filling

pressures were reportedly normal. There was mild left

atrial enlargement. Aortic sclerosis, mild mitral and

tricuspid regurgitation. Mild pulmonary artery

hypertension with an estimated PA systolic pressure of

36mmHg. No pericardial effusion.

Case

• Stress Test: She exercised for 4 minutes and 35

seconds of a standard Bruce Protocol. She reached a

heart rate of 157 beats per minute (99% max

predicted), Blood pressure 188/95. No ischemic ECG

changes. She had mild chest pressure at the end of

exercise but it resolved within a minute in recovery.

• She was referred to a cardiologist who recommended

diagnostic coronary angiography because of the chest

pain in the setting of her poor exercise capacity.

Case

• Coronary angiography showed non-

obstructive coronary disease. Her LV

gram showed normal systolic function

that was calculated at 67%. A comment

was made that her LVEDP was 18mmHg

but this was after the dye load.

Case She now returns to your office to review the results of the testing and to develop a treatment strategy.

You recommend the following:

A: Nuclear stress test.

B: Stress echocardiogram with Doppler

C: Continue walking with your husband and reassurance that “things will get better eventually.”

D: Discontinue atorvastatin (drug holiday for muscle weakness) and Lisinopril (ACEi Cough) and consult a nutritionist for weight loss.

E: Repeat PFTS and referral to Dr Wirth

She now returns to your office to review the results of the testing and to develop a treatment strategy.

You recommend the following:

A: Nuclear stress test.

B: Stress echocardiogram with Doppler

C: Continue walking with your husband and reassurance that “things will get better eventually.”

D: Discontinue atorvastatin (drug holiday for muscle weakness) and Lisinopril (ACEi Cough) and consult a nutritionist for weight loss.

E: Repeat PFTS and referral to Dr Wirth

Case A stress echo with Doppler was performed one week later:

She exercised for 4’ 20” and achieved 100% of her maximum predicted. Her peak blood pressure was 195/100. Exercise was again limited by dyspnea and mild chest discomfort at peak exercise. Echocardiographic Images:

Resting: Normal systolic function and mild LVH. Grade I diastolic dysfunction. E:e’ was 10. Aortic sclerosis. Mild mitral and tricuspid regurgitation. PASP 37mmHg.

Post Exercise: Hyperdynamic systolic function without ischemia or change in valvular findings. E:e’ was 18. Pulmonary systolic pressures were 55mmHg.

A stress echo with Doppler was performed one week later:

She exercised for 4’ 20” and achieved 100% of her maximum predicted. Her peak blood pressure was 195/100. Exercise was again limited by dyspnea and mild chest discomfort at peak exercise. Echocardiographic Images:

Resting: Normal systolic function and mild LVH. Grade I diastolic dysfunction. E:e’ was 10. Aortic sclerosis. Mild mitral and tricuspid regurgitation. PASP 37mmHg.

Post Exercise: Hyperdynamic systolic function without ischemia or change in valvular findings. E:e’ was 18. Pulmonary systolic pressures were 55mmHg.

Echo Clues in Dyspnea

• Left atrial size is a marker of either chronic

pressure or volume overload!

• Pulmonary artery hypertension is one of

the most common findings of an elevated

LVEDP!

• E:e’ +4 ≈LVEDP!

• Diastolic filling pressures are DYNAMIC!

Dr Douglas Zile, HF Board Review, Sept 2012


Dr Douglas Zile, HF Board Review, Sept

2012

Dr Douglas Zile, HF Board Review, Sept

2012

Zile et al, Circulation 118: 1433-41, 2008

Zile et al, Circulation 118: 1433-41, 2008

Dr Margaret Redman, HF Board Review 2012

Dr Margaret Redman, HF Board Review 2012

Invasive Cardiopulmonary Stress Test

• Right Heart Catheter and Radial artery catheter with

hemodynamic monitoring during upright bicycle.

• Measure filling pressures, direct arterial and venous

oxygen concentration during standard parameters of a

cardiopulmonary stress test.

• Best to diagnose

– HFpEF

– Exercise induced Pulmonary Arterial Hypertension

– Preload Dependent Limitations of Cardiac Output

The elements of an invasive cardiopulmonary exercise test.

Maron B A et al. Circulation. 2013;127:1157-1164


A diagnostic algorithm for interpreting iCPET results.

Maron B A et al. Circulation. 2013;127:1157-1164


HFpEF-Diastolic Heart FailureTeaching Points

• Greatly under diagnosed.

• Usually clues by history, ECG, stress testing, and echo.

• Mostly older women with a history of hypertension and or

diabetes.

• BNP usually normal or only mildly elevated.

• Stress Echo with Doppler is preferred non-invasive test. If

uncertain, an invasive cardiopulmonary exercise test should

be considered.

• Blood pressure control will improve diastolic function.

• Prevention of tachycardia will usually improve symptoms by

preventing the development of elevated LVEDP.

Teaching Points• “Good days and bad days” typical and probably related to fluctuations in

salt and fluid intake.

• Cough or wheezing could be due to elevated diastolic filling pressures.

• A mean LV diastolic pressure probably correlates best to symptoms of

dyspnea.

• JVD usually not present, lungs are usually clear, S3 is usually absent.

• BNP usually not high, chest Xray is usually normal.

• Left atrial enlargement is common-HgA1C of left ventricular filling

pressures.

• Pulmonary hypertension is often seen.

• If the resting echocardiogram shows elevated diastolic filling pressures,

moderate or severe diastolic dysfunction and/or pulmonary artery

hypertension, heart failure is highly likely and a loop diuretic, Heart rate

and blood pressure control should be initiated.

• Avoid NSAIDS, steroids, “glitizones” and other medications that expand

intravascular volume.

General Differential

Pulmonary

Pulmonary

Deconditioning

Deconditioning

Metabolic

Metabolic

CardiacCardiac

General Differential

Case

You call her at home and inform her of the results.

You diagnose her with HFpEF. You believe that her mild chest pain is from endomyocardial ischemia from elevated diastolic filling pressures.

You start metoprolol succinate 50mg daily.

She calls you one week later very excited to tell you just how well she feels. She is elated that a “little pill” makes such a big difference in her quality of life. On her 30 min evening walks, she is now able to keep up with her husband and he even is asking her to “slow down.”

You call her at home and inform her of the results.

You diagnose her with HFpEF. You believe that her mild chest pain is from endomyocardial ischemia from elevated diastolic filling pressures.

You start metoprolol succinate 50mg daily.

She calls you one week later very excited to tell you just how well she feels. She is elated that a “little pill” makes such a big difference in her quality of life. On her 30 min evening walks, she is now able to keep up with her husband and he even is asking her to “slow down.”

Thank You!

“dyspnea” a cardiologist’s perspective. disclosures i will not discuss off label use or...

Documents