Diastolic Heart Failure

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

• Subodh K. Agrawal, MD,FACC

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Paradigm Shift in cardiac care
Beta Blocker in Heart Failure
Not Recommended
Must Have
Left Ventricular EF in Heart Failure
Mostly Low
Low or Normal
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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

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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

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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.
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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

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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 20043511097-1105
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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
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Increased prevalence of heart failure with normal
EF A. A large study of patients (n4596)
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
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Diastolic Filling of the LV
JACC 1997308-18
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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.

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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 1997308-18
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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

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Diastolic Dysfunction made simple for primary care
Order Echocardiography, doppler, color flow
doppler to rule out left ventricular diastolic
dysfunction.
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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 2003411036-1043
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Diastolic Dysfunction
Grade 1
Grade 2
Grade 3
Grade 4
LVpressure
E
Mitral flow
TissueDoppler
e
Pulmonaryvein
E/e
lt 10
10 -15
gt15
gt15
CP1008785-63
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As LV fillingpressure ?
Nagueh et al JACC, 1997 Ommen et al Circ, 2000

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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 200591681-695
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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.

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