Evaluation of Patient with Shortness
of Breath and Normal Ejection
Fraction
&
How to Diagnose Diastolic Heart
Failure
Subodh K. Agrawal,
MD,FACC
Paradigm Shift in cardiac care
Beta Blocker in Heart Failure
Not Must Have
Recommended
Left Ventricular EF in Heart Failure
Mostly Low Low or Normal
Patient with Shortness breath in
the emergency room
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
the 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
The Art of Physical
Examination
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
the 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
Orthopnea
Jugular Venous Distinction
Lung Crackles
Displaced Aprical Impulse
S4
S3
Systolic Heart Failure
Diastolic Heart Failure
Adapted from Echeverria et al, 1983
Increased prevalence of heart failure with normal EF
A. 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
Diastolic
Filling of the
LV
JACC 1997;30:8-18
Physiology
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.
Physiology
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
When to suspect Diastolic Heart
Failure?
•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
Diastolic Dysfunction made
simple for primary care
Order:
Echocardiography, doppler, color flow doppler to rule out
left ventricular diastolic dysfunction.
Left Atrial Volume
During 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 Dysfunction
Grade 1 Grade 2 Grade 3 Grade 4
LV
pressure
E
Mitral flow
Tissue
Doppler e’
Pulmonary
vein
E/e’ 15 >15
CP1008785-63
PCWP (mm Hg)
As LV filling 45
40
pressure 35
r = 0.87
n = 60
30
Mitral E 25
20
Annulus e 15
10
E/e 5
0 5 10 15 20 25 30 35
Nagueh et al: JACC, 1997 E/e’
Ommen et al: Circ, 2000
Stepwise approach to clinical evaluation of the
dyspnoeic patient with normal LV systolic function for
the presence of diastolic heart failure.
Mottram, P. M et al. Heart 2005;91:681-695
Conclusions
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.