Diagnosing Diastolic Dysfunction:
Echocardiography is the key.
Nina Radford M.D.
Director, Cardiovascular Medicine
Cooper, Clinic, Dallas TX
November 2, 2009
Diagnosing Diastolic Dysfunction:
Echocardiography is the key.
“If I have the key, why is
this lock so hard to open?”
November 2, 2009
Diagnosing Diastolic Dysfunction:
Plan of Attack
What is diastolic function?
What causes diastolic dysfunction?
Why is diastolic dysfunction important?
– What is diastolic heart failure?
– What is the prognosis of diastolic heart
failure?
How is diastolic dysfunction diagnosed?
Diagnosing Diastolic Function:
What is diastolic function?
Diagnosing Diastolic Function:
What is diastolic function?
Sliding Filaments
When muscle
contracts,
actin slides
over myosin
The Z discs
come closer
Diagnosing Diastolic Dysfunction:
What is diastolic function?
The optimal performance of the left
ventricle depends on its ability to cycle
between two states:
– (1) a compliant chamber in diastole that allows
the left ventricle to fill from low LA pressure and
(2) a stiff chamber (rapidly rising pressure) in
systole that ejects the stroke volume at arterial
pressures.
The ventricle has two alternating functions:
systolic ejection and diastolic filling.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
What causes diastolic dysfunction?
Diastolic dysfunction occurs when the
events during diastole are prolonged,
slowed, or are incomplete.
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Diagnosing Diastolic Dysfunction:
What causes diastolic dysfunction?
Aging is associated with decreases in the
elastic properties of the heart and great
vessels, which leads to an increase in
systolic blood pressure and an increase in
myocardial stiffness.
The rate of ventricular filling decreases in
part because of structural changes in the
heart (due to fibrosis) and because of a
decline in relaxation and compliance.
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Diagnosing Diastolic Dysfunction:
What causes diastolic dysfunction?
Hypertension promotes:
– myocyte hypertrophy (secondary to
increased afterload)
– myocardial fibrosis (increased
collagen synthesis and decreased
degradation)
– loss of myocardial contractile tissue
(through increased incidence of MI).
AHA Guidelines. Prevention of Heart Failure Circulation. 2008;117:2544-2565
Diagnosing Diastolic Dysfunction:
Why is diastolic dysfunction
important?
Diastolic Dysfunction can lead to heart
failure.
Heart Failure (HF) is bad.
Diagnosing Diastolic Dysfunction:
Why is heart failure bad?
The prevention of HF is an urgent public
health need with national and global
implications.
According to the AHA, ≈ 550, 000 new cases
occur each year.
More than 5 million Americans have HF.
Among Medicare beneficiaries, HF is the
leading cause of hospitalization.
In 2007, ≈ $33 billion was spent on HF.
AHA Guidelines. Prevention of Heart Failure Circulation. 2008;117:2544-2565
Diagnosing Diastolic Dysfunction:
Why is heart failure (HF) bad?
Framingham investigators estimate that the
lifetime risk for developing HF at age 40 yrs
was 21% for men and 20% for women.
In the absence of a documented MI, the risk
of developing HF for a 40-year-old was 11%
in men and 15% in women.
Lifetime risk was strongly associated with
blood pressure.
AHA Guidelines. Prevention of Heart Failure Circulation. 2008;117:2544-2565
Diagnosing Diastolic Dysfunction:
Why is heart failure (HF) bad?
Heart failure is a complex clinical syndrome
that can result from any structural or
functional cardiac disorder that impairs the
ability of the ventricle to fill with or eject
blood.
The cardinal manifestations of HF are
dyspnea (shortness of breath) and fatigue,
which may limit exercise tolerance, and
fluid retention, which may lead to
pulmonary congestion and peripheral
edema.
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Diagnosing Diastolic Dysfunction:
What is diastolic heart failure?
As many as 20% to 60% of patients with
HF have a near normal LVEF and, in the
absence of valvular disease, are believed to
have reduced ventricular compliance as a
major contributor to the clinical syndrome,
ie Diastolic Heart Failure.
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Diagnosing Diastolic Dysfunction:
What is diastolic heart failure?
The diagnosis of diastolic heart failure is
generally based on the finding of typical
symptoms and signs of HF in a patient who
is shown to have a normal LVEF and no
valvular abnormalities (aortic stenosis or
mitral regurgitation, for example).
Every effort should be made to exclude
other possible explanations or disorders
that may present in a similar manner.
Diagnosing Diastolic Dysfunction:
What is diastolic heart failure?
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Diagnosing Diastolic Dysfunction:
Why is diastolic dysfunction
important?
A number of recent investigations have
focused on the differences between HF with
preserved EF and that with low LVEF.
Myocardial infarction or other evidence of
atherosclerotic disease appears to be less
common in HF with normal LVEF, but
hypertension is at least as common in this
subgroup.
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Diagnosing Diastolic Dysfunction:
What is diastolic heart failure?
Frequent and repeated hospitalizations
characterize the patient with HF and a
normal LVEF.
Most, but not all, series of patients with HF
and preserved LVEF have shown better
survival than is seen in patients with HF
and reduced LVEF.
However, these comparisons are difficult to
interpret, because in some patients the
diagnosis of HF is likely to be erroneous.
2009 Focused Update of the ACC/AHA 2005 Guidelines for the Diagnosis
and Management of Heart Failure in Adults Circulation. 2009;119:e391– e479.
Heart Failure is a Continuum.
AHA Heart Failure Guidelines 2005
Diagnosing Diastolic Dysfunction:
How is diastolic dysfunction diagnosed?
Noninvasive methods (especially those that
rely on Doppler echocardiography) have
been developed to assist in the diagnosis of
HF with normal LVEF.
These tests have significant limitations,
because cardiac filling patterns are readily
altered by nonspecific and transient
changes in loading conditions in the heart
and by aging, changes in heart rate, or the
presence of mitral regurgitation.
Diagnosing Diastolic Dysfunction:
Mitral Inflow Velocities
Bess et al. Technical Aspects of Diastology: Why Mitral Inflow and Tissue Doppler Imaging Are the Preferred
Parameters? ECHO., 23; 2006.
Diagnosing Diastolic Dysfunction:
Mitral Inflow Velocities
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Mitral Inflow Velocities
Age is a primary consideration when defining
normal values of mitral inflow velocities and
time intervals.
With increasing age, the mitral E velocity and
E/A ratio decrease, whereas DT and A velocity
increase.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
How is diastolic dysfunction diagnosed?
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Mitral Inflow Velocities
A number of variables other than LV diastolic
function and filling pressures affect mitral
inflow:
– heart rate and rhythm,
– PR interval,
– cardiac output,
– mitral annular size,
– LA function.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Mitral Inflow Velocities
Diagnosing Diastolic Dysfunction:
Mitral Inflow Velocities
Diagnosing Diastolic Dysfunction:
Mitral Inflow/Valsalva Maneuver
The Valsalva maneuver is performed by
forceful expiration (about 40 mm Hg) against
a closed nose and mouth, producing a
complex hemodynamic process involving 4
phases.
In cardiac patients, a decrease of 50% in the
E/A ratio is highly specific for increased LV
filling pressures, but a smaller magnitude of
change does not always indicate normal
diastolic function.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Mitral Inflow/Valsalva Maneuver
Khouri et al. Practical Approach to the Echocardiographic Evaluation of Diastolic Function. Am Soc Echo 2004;17:290-7.
Diagnosing Diastolic Dysfunction:
Tissue Doppler Imaging (TDI)
Bess et al. Technical
Aspects of Diastology:
Why Mitral Inflow and
Tissue Doppler Imaging
Are the Preferred
Parameters? ECHO., 23;
2006.
Diagnosing Diastolic Dysfunction:
Tissue Doppler Imaging (TDI)
Diagnosing Diastolic Dysfunction:
Tissue Doppler Imaging (TDI)
Primary measurements include the
systolic (S), early diastolic, and late
diastolic velocities.
The early diastolic annular velocity has
been expressed as Ea, Em, E’, or e’,
and the late diastolic velocity as Aa,
Am, A’, or a’.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Tissue Doppler Imaging (TDI)
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Pulmonary Vein Flow
Bess et al. Technical
Aspects of Diastology:
Why Mitral Inflow and
Tissue Doppler Imaging
Are the Preferred
Parameters? ECHO., 23;
2006.
Diagnosing Diastolic Dysfunction:
Pulmonary Vein Flow
Measurements of pulmonary venous
waveforms include peak systolic (S) velocity,
peak anterograde diastolic (D) velocity, the
S/D ratio, systolic filling fraction and the
peak Ar velocity in late diastole.
Pulmonary venous flow can be obtained in
80% of ambulatory patients…..
One of the important limitations in
interpreting pulmonary venous flow is the
difficulty in obtaining high-quality recordings
suitable for measurements.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Pulmonary Vein Flow (PVF)
Diagnosing Diastolic Dysfunction:
Echocardiogram Algorithm 2004
Khouri et al. Practical Approach to the Echocardiographic Evaluation of Diastolic Function.
Am Soc Echo 2004;17:290-7.
Khouri et al. Practical Approach to the Echocardiographic Evaluation of Diastolic Function. Am Soc Echo 2004;17:290-7.
Diagnosing Diastolic Dysfunction:
Echocardiogram Algorithm 2004
Khouri et al. Practical Approach to the Echocardiographic Evaluation of Diastolic Function. Am Soc Echo 2004;17:290-7.
Diagnosing Diastolic Dysfunction:
New Tricks for Old Dogs…..
Strain Rate: measured by 2D speckle-tracking
echocardiography, measures strain by
tracking speckles in grayscale
echocardiographic images.
Systolic strain rate represents the rate or
speed of myocardial shortening or thickening,
respectively.
Myocardial strain and strain rate are excellent
parameters for the quantification of regional
contractility and may also be of use in
evaluating diastolic function.
Diagnosing Diastolic Dysfunction:
New Tricks for Old Dogs…..
Propagation Velocity
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
Flow Propagation Velocity
Relaxation index
Preload independent
To distinguish normal and pseudo normal mitral
inflow
Recordable in 80% of patients
Limits : influence of age
Vp is most reliable as an index of LV relaxation in
patients with depressed
EFs and dilated left ventricles. In the other patient
groups, it is preferable to use other indices.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
How is diastolic dysfunction diagnosed?
American Society of Echocardiography
(ASE): Recommendations for the
Evaluation of Left Ventricular Diastolic
Function by Echocardiography 2009
New Theme: Less is More.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
ASE 2009: Age is important!
Assessment should take into consideration
patients’ ages and heart rates.
In older individuals w/o history of CVD,
caution should be exercised before
concluding that grade I diastolic
dysfunction is present.
Because the majority of subjects > 60 yrs
w/o history of CVD disease have E/A ratios
<1 and DTs 200 ms, such values in the
absence of indicators of CVD (eg, LVH) can
be considered normal for age.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
ASE 2009: LA volume is important!
The measurement of left atrial (LA) volume
is highly feasible and reliable, with the most
accurate measurements obtained using the
apical 4-chamber and 2-chamber views.
This assessment is clinically important,
because there is a significant relation
between LA remodeling and
echocardiographic indices of diastolic
function.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
ASE 2009: LA volume is important!
Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography’s Guidelines and
Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association
of Echocardiography, a Branch of the European Society of Cardiology. J Am Soc Echo. 2005;18:1440-1463.
Diagnosing Diastolic Dysfunction:
ASE 2009: LA volume is important
Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography’s Guidelines and
Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association
of Echocardiography, a Branch of the European Society of Cardiology. J Am Soc Echo. 2005;18:1440-1463.
Diagnosing Diastolic Dysfunction:
How is diastolic dysfunction diagnosed?
Importantly, observational studies including
6,657 patients without baseline histories of
atrial fibrillation and significant valvular
heart disease have shown that LA volume
index 34 mL/m2 is an independent
predictor of death, heart failure, atrial
fibrillation, and ischemic stroke.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
How is diastolic dysfunction diagnosed?
Dilated left atria may be seen in patients with
bradycardia and 4-chamber enlargement, anemia
and other high-output states, atrial flutter or
fibrillation, significant mitral valve disease, in the
absence of diastolic dysfunction. Likewise, it is
often present in elite athletes in the absence of
cardiovascular disease.
Therefore, it is important to consider LA volume
measurements in conjunction with a patient’s
clinical status, other chambers’ volumes, and
Doppler parameters of LV relaxation.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
How is diastolic dysfunction diagnosed?
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Diagnosing Diastolic Dysfunction:
How to Approach an Echocardiogram
Report : looking back and forward
Khouri et al. Practical Approach to the Echocardiographic Evaluation of Diastolic Function. Am Soc Echo 2004;17:290-7.
ASE. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography 2009
Case 1.
DOB:04/20/42
Age: 67
Normal LV wall thickness
(No LVH)
LVEF 60%
Left atrial enlargement
Case 1.
DOB:04/20/42
Age: 67
Normal LV wall thickness
(No LVH)
LVEF 60%
Left atrial enlargement
Case 2.
Age: 57
Vital signs
LV wall thickness
LA volume
Aortic Root
Case 2.
Questions?