Diastolic Heart Failure 2010. 08. 24 Staff Lecture Diastolic Heart Failure 김 우 식 경희대학교 의과대학병원

Cardiac Function？ Ability Adequte Diastolic filling of LV with Low Pressure + Eject Enough blood into whole body. Ability 압력 증가 없이 적절히 심실이 채워짐　＝　이완 기능 + 혈액을 신체 각 부위에 전달　＝　수축 기능

ICT:Isovolumic Contraction Time LV volume Aortic pressure LV pressure LA pressure Index of Systolic fn LVmax+ dP/dt ICT ICT:Isovolumic Contraction Time LV volume

Index of systolic function Aortic pressure LV pressure LA pressure Index of systolic function ;EF, CO ICT ET LV volume ET: Ejection Time

Isovolumic Relaxation Time Aortic pressure LV pressure Index of diastolic fn LVmax- dP/dt 　τ LA pressure ICT IRT ET IRT: Isovolumic Relaxation Time LV volume

ICT IRT ET Aorta LV Diastolic Function: LV stiffness = dP/dV LA LV volume Diastolic Mid - Late stage

심기 능 평가 지표 수축 기능 Ejection fraction Cardia output LVmax + dP/dt Emax … 이완 기능 LVmax - dP/dt  LV stiffness LV filling pressures mean pulmonary wedge P mean LA pressure LVEDP pre-A LV diastolic P

Standard Systolic Function:EF Advantage: EF is a essential component of cardiac output Limitation: Cannot detect diastolic function in case of MR EF increased not related to Prognosis not related to Quality of Life

EF Advantage and Limitation CASE End-stage of old MI : EF < 25％ Restrictive cardiomyopathy : EF - normal DCM – symptom not related with EF

적절하게 이완기 충만이 이루어지면, (수축기능이 정상이면) 정상적인 구출량(stroke volume)이 가능하게된다. Diastolic Function 정상 이완기능이란? 안정시와 운동시에 심방의 압력 증가 없이 심실이 적절히 채워지는 경우 적절하게 이완기 충만이 이루어지면, (수축기능이 정상이면) 정상적인 구출량(stroke volume)이 가능하게된다. 12

Evaluation of Diastolic Function (좌심실 이완 기능의 평가)

Pressure and MV inflow E A Aorta pressure LV pressure LA pressure ECG MV level에서 시행한 pulse Doppler 파형 14

Determinants of LV filling Klein C10 p117,

승모판 혈류속도는 LA・LV 압력 차에 의해 결정 LV pressure LA pressure LV volume 。 dV(LV volume)/dt = 승모판 혈류량 Ohno M, et al. Circulation 1994;89:2241

LA・LV 압력 차는 좌심방압과 좌심실 탄성에 의해 결정 Ohno M, et al. Circulation 1994;89:2241

Diastolic Function → Start with Mitral Inflow 좌심실 이완기능 평가 1 혈류속도 측정 Diastolic Function → Start with Mitral Inflow E LV RV A RA LA DT Apical 4-chamber Pulse Doppler

Diastolic Function → Start with Mitral Inflow 좌심실 이완기능 평가 1 혈류속도 측정 Diastolic Function → Start with Mitral Inflow Measurements E-wave (peak early filling velocity) A-wave (late diastolic filling velocity) E/A ratio Deceleration time (DT or Mdt) of early filling velocity IVRT (Isovolumic relaxation time) A-wave duration

Mitral Inflow Pattern 전부하 Impaired Relaxation Normal Pseudonormal Restrictive LV dysfunction （－） （１＋） （２＋） （３＋） 전부하

Deceleration Time (DT) Mitral Inflow Pattern Impaired Relaxation Deceleration Time (DT) Normal Pseudonormal Restrictive LV dysfunction （－） （１＋） （２＋） （３＋） 전부하

Deceleration Time (DT) 의 유용성 DT (ms) DT (ms) LVEDP (mmHg) LVEDP (mmHg) EF ５０％ EF ＞５０％ Yamamoto K, et al. JACC 1997;30:1819

Tissue Doppler Annular Diastolic Velocities 좌심실 이완기능 평가 1 혈류속도 측정 Tissue Doppler Annular Diastolic Velocities systolic (S) velocity early diastolic (Ea, Em, E’, e’) velocity late diastolic (Aa, Am, A’, a’) velocity E/e’ ratio RV LV S e’ a’ RA LA 24

Patterns of mitral inflow and mitral annulus velocity Mitral flow Mitral annulus velocity Normal Relaxation abnormality Pseudo- normalization Restrictive physiology Sohn. JACC 1997

Grading of Diastolic Dysfunction (Diastolic Filling Pattern) Grade 1 Impaired Relaxation (LVEDP 정상) 1a Impaired Relaxation (LVEDP 증가) Grade 2 Pseudonormal Grade 3 Restrictive (reversible) Grade 4 Restrictive (irreversible)

Grading of Diastolic Dysfunction Mitral Inflow Pulmonary Venous Flow Color M-mode: Vp Annulus Velocity JASE 2004;17:290-7

Evaluation of LV filling pressure E ∝ myocardial relaxation x filling pressure ∴ Filling pressure = Myocardial relaxation E E’

E/E’과 pulmonary capillary wedge pressure (PCWP)의 관계

LV filling pressure  Prediction of LV Filling Pressure by Flow to Annular Tissue E Velocity Ratio LV filling pressure  Mitral E  PCWP (mmHg) Annulus E’  E / E’  E/Ea (Flow E/Tissue E) Nagueh SF, et al. JACC 1997;30:1527, Ommen, et al. Circulation 2000 32

Tissue Doppler Annular Diastolic Velocities E/e’ ratio 60-year-old patient, Heart failure, normal EF (JASE 2009) Mitral inflow ; E = 80 cm/s Annulus TDI ; Septal e’ = 4 Lateral e’ = 5

좌심실의 이완기능 평가 좌심방 대동맥 좌심방 좌심실

좌심방의 용적을 재는 방법 Prolate ellipse Biplane area-length

좌심방의 용적을 재는 방법 Simpson’s method

좌심실 이완기능의 평가 Pattern Grading Filling Pressure LA 11:05~11-30

Population based cohort study Epidemiology Prevalence of Diastolic Dysfunction (2) Prognosis of Diastolic Dysfunction (3) Population based cohort study

2042 randomly selected residents of Olmsted County, Minnesota JAMA 2003

N = 2042 45 yrs Diastolic dysfunction = 28% Mild = 20.8% Moderate = 6.6 % Severe = 0.7 % Systolic dysfunction EF 50% --- 6% EF 40% --- 2%

Redfield, M. M. et al. JAMA 2003;289:194-202.

Redfield, M. M. et al. JAMA 2003;289:194-202. In-Stent Restenosis Redfield, M. M. et al. JAMA 2003;289:194-202.

N = 1274, Age 25 years (mean age = 51 yrs) Echo evaluation Prevalence of diastolic abnormalities in the setting of a preserved EF (EF 45%) – 11% ; normal IVRT = 92~105 msec E/A ratio = 1 : 0.5 (depending on age) Prevalence of diastolic dysfunction – 3% ; Diastolic abnormalities + LA enlargement or treatment of diuretics Diastolic abnormalities : 2.3% had an EF 45%

In-Stent Restenosis

In-Stent Restenosis Prevalences of diastolic abnormalities and diastolic dysfunction in different clinical subgroups.

Prognosis

Cardiovascular Health Study In-Stent Restenosis Cardiovascular Health Study ; 2,671 participants ; coronary heart disease (-), CHF (-) or atrial fibrillation (-) ; Mean follow-up : 5.2 yrs ; 170 participants (6.4 % of cohort) developed CHF

Prognosis

Bella, J. N. et al. Circulation 2002;105:1928-1933 Incidence of all-cause and cardiac death among SHS participants with E/A <0.6 (open bars), 0.6 to 1.5 (striped bars), and >1.5 (closed bars)

Prognosis

In-Stent Restenosis

Definition of Heart Failure "The situation when the heart is incapable of maintaing a cardiac output adequate to accommodate metabolic requirements and the veous return" E. Braunwald in Heart Diseases. W. B. saunders Co. 1992

Definition of Heart Failure “the pathological state in which the heart is unable to pump blood at a rate required by the metabolizing tissues or can do so only with an elevated filling pressure" Fukuda H, Little WC in Diastology

Definitions Diastolic Dysfunction : Abnormal diastolic properties of LV (abnormal relaxation, filling dynamics, distensibility) - EF may be normal or low - Patient may be symptomatic or asymptomatic. Diastolic Heart Failure : Clinical heart failure, normal EF, abnormal diastolic function Systolic Dysfunction : Abnormal systolic properties of LV (abnormal performance, function, contractility) - EF is low (and diastolic dysfunction may coexist). Systolic Heart Failure : Clinical heart failure, low EF, abnormal systolic function (From Circulation 2006;113:296)

It is accepted that abnormalities of diastolic function Heart Failure HF_PEF: Heart failure with preserved EF HF_REF: Heart failure with reduced EF It is accepted that abnormalities of diastolic function 58

Diagnosis of diastolic Heart Failure In-Stent Restenosis Diagnosis of diastolic Heart Failure Symptoms and Signs

Prevalence of specific symptoms and signs in systolic and diastolic HF Systolic HF Diastolic HF Symptoms Dyspnea on exertion 96 % 85 % Paroxysmal nocturnal dyspnea 50 % 55 % Othophea 73 % 60 % Circulation 2002;105:1387

Prevalence of specific symptoms and signs in systolic and diastolic HF In-Stent Restenosis Prevalence of specific symptoms and signs in systolic and diastolic HF Systolic HF Diastolic HF Physical examination Jugular venous distension 46 % 35 % Rales 70 % 72 % Displaced apical impulse 60 % 50 % S3 65 % 45 % S4 66 % 45 % Hepatomegaly 16 % 15 % Edema 40 % 30 % Circulation 2002;105:1387

Prevalence of specific symptoms and signs in systolic and diastolic HF In-Stent Restenosis Prevalence of specific symptoms and signs in systolic and diastolic HF Systolic HF Diastolic HF Chest radiograph Cardiomegaly 96 % 90 % Pulmonary venous hypertension 80 % 75 % Circulation 2002;105:1387

Diastolic Heart Failure In-Stent Restenosis Diastolic Heart Failure Clinical evidence of HF Normal Systolic function (LVEF>0.5) Objective evidence of impaired LV relaxation or LV passive stiffness

Wang JACC 2005;45:272

Practical Recommendations Clinical evidence of HF EF (72h 내에 측정) EF <50 % EF 50 % LV hypertrophy Concentric remodelling LA enlargement Systolic HF Diastolic HF Diastolic fn Prognosis

Half of patients with HF have an normal EF

Circulation. 1998;98:2282

HF with normal EF Older Female less likely to have had prior MI & LBBB

Prognosis of Diastolic HF

Circulation. 1998;98:2282

Vasan RS. JACC 1999;33:1948 In-Stent Restenosis During a median follow-up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects (adjusted hazards ratio = 4.06, 95% confidence interval 1.61 to 10.26). Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects (adjusted hazards ratio = 4.31, 95% confidence interval 1.98 to 9.36). CONCLUSIONS Normal LV systolic function is often found in persons with CHF in the community and is more common in women than in men. Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF. Vasan RS. JACC 1999;33:1948

How to diagnose HFNEF In-Stent Restenosis How to diagnose HFNEF (P71, EHJ 2007;28(21)2686)

Diastolic Heart failure – Diagnostic Criteria Required criteria Clinical evidence of heart failure - Framingham or Boston criteria - Plasma BNP and/or chest x-ray - Cardiopulmonary exercise testing Normal EF (= 50%) Confirmatory Evidence LVH or concentric remodelling LA enlargement (in absence of AF) Echo doppler or catheter evidence of diastolic dysfunction Exclusion Nonmyocardial disease

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