2. Subodh K. Agrawal, MD,FACC
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
Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.
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:

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:

27. Diastolic Dysfunction
Grade 1
Grade 2
Grade 3
Grade 4
LV pressure E
Mitral flow
Tissue Doppler e’
Pulmonary vein
E/e’
< 10
10 -15
>15
>15
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. CP

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

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:

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.