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Page 1: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 2: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure 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

Page 3: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure 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

Page 4: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 5: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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.

Page 6: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 7: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 8: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 9: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 10: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 11: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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).

Page 12: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 13: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 14: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 15: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 16: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

JACC 1997;30:8-18

Diastolic Filling of the LV

Page 17: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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.

Page 18: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 19: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 20: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 21: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

•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?

Page 22: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 23: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 24: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 25: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 26: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 27: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 28: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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%

Page 29: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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)

Page 30: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

e’ = 18 cm/se’ = 18 cm/s

ConstrictionConstriction

MyocardialMyocardial

e’ = 5 cm/s

Tissue Doppler Early diastolic mitral annulus velocity (e’)

Page 31: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 32: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 33: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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.

Page 34: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

JASE 2004;17:290-297

Page 35: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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?

Page 36: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

Overnight Pulse Oximeter:

Page 37: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

Overnight Pulse Oxymetery

Page 38: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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

Page 39: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 40: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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.

Page 41: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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.

Page 42: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

ACC/AHA 2005 Guideline Update for the Management

of Patients with Chronic Heart Failure, JACC 2005

Page 43: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC
Page 44: Evaluation of Patient with Shortness of Breath and Normal Ejection Fraction & How to Diagnose Diastolic Heart Failure Subodh K. Agrawal, MD,FACC

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.