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

5. 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

6. 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 the emergency room

7. 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 Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions. Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.

8. 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

16. 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.

17. 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

19. Diastolic Dysfunction made simple for primary care

26. 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�)

27. Diastolic Dysfunction Using these Doppler variables, we can grade diastolic dysfunction as we grade heart failure symptoms using NYHA classification. This grading system was proposed by Dr. Tajik of our institution and corrleates well with degree of diastolic dysfunction, filling pressure, and naturally patient�s prognosis. Grade 1 diastolic dysfunction represents mild dysfunction with impaired myocardial relaxation, but filling pressure is normal. In this situation, as long as diastolic filling period is well preserved, patient does not experience significant symptoms. Grade 2 diastolic dysfunction is same as pseudonormalized filling pattern with mild to moderate elevation of filling pressure. Grade 3 and 4 diastolic dysfunction represents most advanced stage, called restrictive pattern, with marked elevation of filling pressure and decreased LV operating compliance. The difference between grade 3 and 4 is reversibility of restrictive diastolic filling. It is important to remember that myocardial relaxation is impaired in all stages of diastolic dysfunction so that (Click) mitral annulus E� velocity is decreased and mitral flow propagation velocity is reduced. Using these Doppler variables, we can grade diastolic dysfunction as we grade heart failure symptoms using NYHA classification. This grading system was proposed by Dr. Tajik of our institution and corrleates well with degree of diastolic dysfunction, filling pressure, and naturally patient�s prognosis. Grade 1 diastolic dysfunction represents mild dysfunction with impaired myocardial relaxation, but filling pressure is normal. In this situation, as long as diastolic filling period is well preserved, patient does not experience significant symptoms. Grade 2 diastolic dysfunction is same as pseudonormalized filling pattern with mild to moderate elevation of filling pressure. Grade 3 and 4 diastolic dysfunction represents most advanced stage, called restrictive pattern, with marked elevation of filling pressure and decreased LV operating compliance. The difference between grade 3 and 4 is reversibility of restrictive diastolic filling. It is important to remember that myocardial relaxation is impaired in all stages of diastolic dysfunction so that (Click) mitral annulus E� velocity is decreased and mitral flow propagation velocity is reduced.

28. Therefore, as LV filling pressure increases, mitral inflow E velocity increases, but mitral annulus E� velocity decreases. As a result, E/E� ratio increases. According to the investigations from Baylor and our institution by Dr. Steve Ommen, E/E� ratio of 15 or greater usually indicates PCWP 20 mmHg or higher.Therefore, as LV filling pressure increases, mitral inflow E velocity increases, but mitral annulus E� velocity decreases. As a result, E/E� ratio increases. According to the investigations from Baylor and our institution by Dr. Steve Ommen, E/E� ratio of 15 or greater usually indicates PCWP 20 mmHg or higher.

33. 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.