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Echo in Context 2002: Heart Failure 1 http://www.echoincontext.org Diastolic Dysfunction in Heart Failure Harry Rakowski, MD University of Toronto 2002 Echo in Context 2002: Heart Failure 2 http://www.echoincontext.org Diastolic Heart Failure g Occurs with systolic failure or alone g Impaired relaxation g Increased myocardial stiffness g LV fills with elevated pressures g Increasing problem with age g High morbidity and mortality g Echo Doppler essential There are many reasons for Diastolic heart failure. Echo and Doppler are essential for its measurement. Echo in Context 2002: Heart Failure 3 http://www.echoincontext.org Study Pts % DHF DHF SHF /age %mort %mort Cohen 1999 623 13 / 60 8 19 Permenkil 1997 501 34 / 81 28 38 McAllister 1999 566 21 / 65 12 17 Ansari 2001 376 27 / 72 20 20 Diastolic Failure Health Care Crisis l ii Diastolic heart failure is deadly and a disease of the elderly Echo in Context 2002: Heart Failure 4 http://www.echoincontext.org Diastolic Dysfunction Impaired relaxation Elevated filling pressures g Ischemic heart disease g Cardiomyopathies g Systemic disease g Hypertension g Valvular heart disease Diastolic dysfunction frequently complicates these conditions. There is usually a progression from impaired relaxation to elevated filling pressures Echo in Context 2002: Heart Failure 5 http://www.echoincontext.org ■ Ischemia ■ Impaired Ca++ handling ■ Small end systolic volume ■ LV hypertrophy ■ Myocardial fibrosis LV relaxation LV stiffness Diastolic Dysfunction: Hypertension In hypertension, the causes of decreased relaxation and increased stiffness are many. Echo in Context 2002: Heart Failure 6 http://www.echoincontext.org Progression of Inadequately Treated Hypertension LV mass index Men 131 g/m2 Women 100 g/m2 Rx LAP Prevent LVH Maintain normal diastolic function 30 0 60 Progression of LVH and diastolic dysfunction in hypertension Echo in Context 2002: Heart Failure 7 http://www.echoincontext.org Different LV and LA Pressures Mean LAP V-wave - A-wave - LV LA LVEDP LV pre-A - LV RFW LVmin i A-wave - LV LA LV+LA Filling pressures that can be evaluated by Doppler studies Echo in Context 2002: Heart Failure 8 http://www.echoincontext.org Patterns of MV Inflow E A E A E A IVRT I Normall Delay Relax l l High LA Pressure i (normal LVFP) ( l ) IVRT I IVRT I A normal mitral inflow and those with restrictive disease (bottom) may be similar. The whole story of diastole is not in the mitral tracings alone. Echo in Context 2002: Heart Failure 9 http://www.echoincontext.org Naqueh et al, Am J Cardiol 75: 1256, 1995 Mean PCWP = 17 + 5.3EA - 0.11IVRT . . I Prospective group i Catheter Pressure (mmHg) Doppler Estimate (mmHg)Doppler Estimate (mmHg)0 10 20 30 40 0 10 20 30 40 R=0.88 Y=4+0.7x . . Formula for wedge pressure in patients with decreased EF Echo in Context 2002: Heart Failure 10 http://www.echoincontext.org Echo Doppler Pitfalls Technical Aging Volume depletion Normal EF, HCM Pseudonormal MV all methods relaxation relaxation pressures by MV need other methods ll l i l i Issue Pitfalls exist everywhere in Doppler but can be categorized. Echo in Context 2002: Heart Failure 11 http://www.echoincontext.org Quantitating LV Filling Pressures g What do Echo-Doppler studies measure LV Pre A (mean LAP), LVEDP g Integrated approach to quantitation mitral inflow, pulmonary vein flow, tissue Doppler annular velocities, color flow propagation, caval flow, use of Valsalva g LV and LA size and function g Understanding limitations hypertrophic cardiomyopathy, normal LV fx l i ( ), I i i it l ifl , l i fl , ti l l l iti , l fl ti , l fl , f l l i i i li i i t i i t , l f Echo in Context 2002: Heart Failure 12 http://www.echoincontext.org Normal Doppler Velocities E/A >1 PVs = PVd Pva<.35m/s Ea>.1m/s E/Ea<7 E A S D To fully evaluate diastolic filling, multiple sites need to be sampled Echo in Context 2002: Heart Failure 13 http://www.echoincontext.org Doppler Evaluation of Elevated LV Filling Pressures Mitral: DT< 200ms E/A>1.5 Pulmonary vein: PVa dur>MVa; PVa>.35m/sec PVs<50% of PVd Mitral annular: E/Ea >10 Dilated LA with decreased LA contraction Echo in Context 2002: Heart Failure 14 http://www.echoincontext.org MVO: Pseudonormalization E/A >1.5 Ea/Aa 1 PVs 0.44 0.44 0.33 0.49 0.73 0.41 Mitral flow looks normal due to the combination of impaired relaxation and elevated filling pressures Echo in Context 2002: Heart Failure 15 http://www.echoincontext.org LVEDP PVa - Mitral A duration i l i Mayo Clinic ∆∆∆∆d (ms)∆∆∆∆d (ms)0 10 20 30 40 EDP (mmHg) -100 - -50 - 50 100 0 r = 0.73 p< 0.01 Echo in Context 2002: Heart Failure 16 http://www.echoincontext.org Restrictive Physiology: High LAP S D Annulus l E A Pressure Mitral i l E Pulm Vein l i Echo in Context 2002: Heart Failure 17 http://www.echoincontext.org Calculation of LAP by E/Ea LAP= E/Ea x1.25+1.9 Can be used in: g afib and g sinus tach / . . i i i E/Ea / 5 20 Nagueh et al 1997 t l PCWP (mmHg)PCWP (mmHg)0 5 10 15 20 25 30 35 40 Y=2+1.3X R=0.87 N=180 Echo in Context 2002: Heart Failure 18 http://www.echoincontext.org LAP = (E/Ea x 1.25) + 1.9 g An E/Ea ratio > 10 is: 95% sensitive 82% specific g Mean LAP > 15 mmHg g Allows estimation of pressures in the absence of sinus rhythm Relation of LAP to E/Ea Nagueh et al, JACC 1997;30:1527 t l, ; : Echo in Context 2002: Heart Failure 19 http://www.echoincontext.org 55 y.o. female with CHF Referred for evaluation of HCM l i Echo in Context 2002: Heart Failure 20 http://www.echoincontext.org DT 110 Mitral Flow propagation Pulm Vein S Tricuspid Hep Vein Abnormal right and left sided flow suggests biventricular diastolic dysfunction and infiltrative disease Echo in Context 2002: Heart Failure 21 http://www.echoincontext.org Cardiac Amyloidosis Prognosis worse when: g LV thickness>14mm g Restrictive physiology g LV dysfunction Echo in Context 2002: Heart Failure 22 http://www.echoincontext.org Echo Assessment of Diastolic Failure g Systolic/diastolic failure or both g Evaluate relaxation/filling pressures g Determine etiology/staging/prognosis g Evaluate therapy
