1. Diastolic Dysfunction as Diagnosed and Quantified by Echocardiography LAM-1965AO (07/13) For Broker/Dealer Use Only

2. Diastole and Systole Diastole: The normal rhythmically occurring relaxation and dilatation of the heart chambers, especially the ventricles, during which they fill with blood. Systole: The contraction, or period of contraction, of the heart, especially of the ventricles, during which blood is forced into the aorta and pulmonary artery.

3. Cardiac Cycle

5. What is Diastolic Dysfunction? Changes in the ventricle which may result in impaired relaxation, reduced compliance and elevated pressures Diastolic Dysfunction ≠ Diastolic Heart Failure

6. What is Diastolic Dysfunction? Who is more likely to develop DD? Elderly* Women Obese What diseases are more likely to produce DD? HTN LVH CAD VHD (AS) Text book Example: Older lady overweight with long history of hypertension with exercise intolerance

7. What is Diastolic Dysfunction? 3 Stages to Diastolic Dysfunction I) Impaired Relaxation II) Pseudonormal III) Restrictive Primary measurements include peak E & A transmitral velocities, E/A ratio, DT (Deceleration Time) and IVRT (Isovolumetric Relaxation Time) Additional measurements E/e’, LA volume index, Pulmonary Vein Flow ( S/D & AR) and Vp (Propagation Velocity)

8. What is Diastolic Dysfunction? Figure 2 Doppler echocardiogram shows normal pattern of diastolic filling. Opening of the mitral value produces increased flow velocity through the valve annulus, which is represented as a large E wave (E). During late diastolic filling, the transmitral pressure gradient increases once again, with atrial contraction producing a smaller A wave (A). (3)

9. What is Diastolic Dysfunction?

12. I: impaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV compliance), ECG: electrocardiogram, MI: mitral inflow, MA: mitral annular velocities, PVF: pulmonary venous flow, Vp: velocity of flow progression, LA: left atrium, PASP: pulmonary artery systolic pressure.

13. What is Diastolic Dysfunction? 1 st use E/A, DT, and IVRT 2 nd use E/e’ ( 15) and LA vol index ( 34 ml/M 2 increased mortality) 3 rd use Pulmonary Vein Flow ( S/D & AR) and Vp (Propagation Velocity)

14. What is Diastolic Dysfunction? Normal E/A Ratio (>1) Good: 15, S<D, inc AR, dec Vp ) Not Good: > 70 yo with risk factors (HTN/LVH, CAD, ♀ ), evidence of increased filling pressures E/A < 1 ( Grade I DD, Impaired Relaxation) NBD: > 70 yo and no HTN/LVH or CAD BD: < 50 yo with HTN/LVH or CAD Grade II DD, Pseudonormal and LA vol index (> 34 ml/M 2 ) BAD ( until proven otherwise) Grade III or IV, Restrictive BAD BAD BAD

15. Diastolic Dysfunction Case Study 74 yo male applying for $5 mil, no h/o HTN, heart disease, diabetes or cancer 6’ 0”, 185 lbs, 125/82 mmHg, 62 reg Labs and EKG WNL APS: 2012 echo….LV size and function WNL, EF 65%, LVPWd 1.1 cm, R & L atrium WNL, Grade I DD, no significant valvular disease….GXT: exercised 13 min to 14 METS, no ischemic changes Offer?

16. Diastolic Dysfunction Case Study 72 yo female applying for $5 mil, long h/o HTN, no heart disease, diabetes or cancer 5’2”, 220 lbs, 154/92 mmHg, 92 reg Labs WNL except NTproBNP 320 pg/ml and EKG LAD, LVH & LAE APS: 2012 echo….LV size and function WNL, EF 65%, LVPWd 1.6 cm, L atrium 5.2 cm, E:A 2.2, E/e’ 20, no significant valvular disease….GXT: exercised 3 min to 4 METS, no ischemic changes Offer?