Subodh K. Agrawal, MD,FACC

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

3. 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

5. 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

6. 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

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 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.

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

9. 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

12. 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

13. 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

15. Diastolic Filling of the LV JACC 1997;30:8-18

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 JACC 1997;30:8-18

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

19. Diastolic Dysfunction made simple for primary care Order: Echocardiography, doppler, color flow doppler to rule out left ventricular diastolic dysfunction.

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”) JACC 2003;41:1036-1043

27. Diastolic Dysfunction Grade 1 Grade 2 Grade 3 Grade 4 LVpressure E Mitral flow TissueDoppler e’ Pulmonaryvein E/e’ < 10 10 -15 >15 >15 CP1008785-63

28. PCWP (mm Hg) 45 40 r = 0.87 35 n = 60 30 Mitral E 25 20 Annulus e 15 10 E/e 5 0 5 10 15 20 25 30 35 E/e’ As LV fillingpressure  Nagueh et al: JACC, 1997 Ommen et al: Circ, 2000

31. 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

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.