Diastolic Function. Rick Nishimura Leighton Professor of CV Diseases Mayo Clinic No Disclosures
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1 Diastolic Function Rick Nishimura Leighton Professor of CV Diseases Mayo Clinic No Disclosures
2 Heart = Pump
3 Heart Failure Systolic Dysfunction Diastolic Dysfunction
4 Diastole is a complex sequence of multiple interrelated events Relaxation, suction, erectile coronary effect, viscoelastic forces, pericardial restraint, ventricular interaction, atrial contraction, chamber stiffness, myocardial stress/strain relations, Langranian forces CP
5 Out of intense complexities, intense simplicities may emerge Winston Churchill
6 Diastolic Function A Simplified Approach for Clinicians
7 Contraction Passive Filling Relaxation AC
8 Transmitral Doppler reflects relative driving pressures from LA to LV LV/LA gradient pushes blood into LV Rapid relaxation "suction" pulls blood into LV Effective compliance - rise in LV Contribution of atrial contraction
9
10 Poor Relaxation Relaxation
11 Poor Relaxation Relaxation
12 Poor compliance Passive Filling
13 Poor compliance Passive Filling
14 Diastolic Dysfunction A Progression Normal Relaxation Compliance
15 Diastolic Dysfunction A Progression Normal Relaxation Compliance
16 Diastolic Dysfunction A Progression Normal Relaxation Compliance
17 In reality, it has become more complicated.. Energetic factors ADP/ATP ratio Rate of crossbridge cycling Creatinine kinase rxn Role of PDE5A inhib Calcium handling from Troponin to SR and cytosol SERCA Phospholamban Effect of calcineurin Cytosolic Ca++ concn Na/K pump Cellular apparatus Cardiomyocyte skeleton Contractile proteins (myosin, actin, troponin) Endosarcomeric proteins (titin, alfa actinin) Cytoskeletal proteins (tubulin, desmin) Membrane associated (dystrophin, spectrin) Intercalated disc protein (desmosomal) Affects myocardial viscoelastic forces Extracellular matrix Collagen Type I and III Collagenase expression Metalloproteinase TIMP (inhibit MMP)
18 Grading Scale Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 Mean LAP TAU NYHA I-II II-III III-IV IV Grade I II III IV diastolic dysfunction
19 Grading Scale Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 If start with abnormal function Higher E:A or shorter DT Worse filling
20 Low filling pressures No diuresis needed High filling pressures Better diurese more
21 In patients with systolic dysfunction Higher E:A and shorter DT Higher filling pressure Poorer prognosis What about patients with normal EF?
22 The Answer Suckers Vs Pushers
23 Good Relaxation Faster rate of relaxation Suction of blood Allows more volume into LV Relaxation
24 Good Relaxation Relaxation
25 Diastolic Function BEST GOOD BAD WORST Drive force
26 Diastolic Function BEST GOOD BAD WORST Suction Drive force
27 Diastolic Function EF 60% Normal (good) vs. Pseudonormal (bad)
28 Diastolic Function Doppler Tissue Imaging
29 Diastolic Function End diastole RA LA RV LV
30 Diastolic Function End diastole Systole RA LA RA LA RV LV RV PS IS LV AL AL S L
31 Diastolic Function End diastole Systole Relaxation RA LA RA LA RA LA RV LV RV PS IS LV AL AL RV LV S L
32 Diastolic Function Tissue Doppler Annular motion E is the rate of ventricular relaxation Higher E = faster relaxation
33 Grading Scale - Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 Grade I II III IV diastolic dysfunction
34 Grading Scale - Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 Grade I II III IV diastolic dysfunction
35 Diastolic Function
36 Diastolic Function BEST GOOD BAD WORST E/E < 8 E/E > 15
37 Clinical Application
38 Heart 72 y/o woman Failure heart failure with preserved EF EF = 65% HFpEF
39 PA = 70/30 Mean LAP = 30 with V 55 mmhg
40 BP 122/65 PA = 35/15 mmhg Mean LAP = 12 with V 20 mmhg BP 185/70 PA = 70/30 mmhg Mean LAP = 30 with V 55 mmhg
41 Heart Failure with Preserved EF Example of the dynamic nature of diastolic filling abnormalities
42 Normal Relaxation Compliance No Dyspnea Increase BP No Dyspnea
43 Normal Relaxation Compliance FC II Dyspnea Ventricular-vascular coupling Increase BP Ischemia FC III/IV Dyspnea
44 Ischemia Exquisitely sensitive filling pressures
45 Afterload Exquisitely sensitive filling pressures BP 150 mmhg PAWP 18 BP 180 mmhg PAWP 30 BP 220 mmhg PAWP 48
46 Grading Scale - Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 Ventricular vascular Stiffness Heart failure normal EF
47 Normal Relaxation Compliance FC II Dyspnea Muscle Stiffness Ventricular-vascular coupling Increase BP Ischemia FC III/IV Dyspnea FC III/IV Dyspnea
48 Grading Scale - Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 Muscle Stiffness Severe RCM
49 Treatment Conventional Reduce afterload Prolong diastolic filling period New areas of investigation
50 Renin-angiotensin pathway Hypertension I-Preserve NEJM 2008:359:2456 Ibesartan PEP-CHF Eur Ht J 2006:27:2338 Perindopril Hypertrophy CHARM-Preserve Lancet 2003:362:777 Candesartan Hong Kong Diast HF Heart 2008:94:373 Ramipril Irbesartan Interstitial Fibrosis TOPCAT Aldosterone Antagonist
51 Randomized trials HFpEF I PRESERVE CHARM Preserved PEP CHF DIG preserved OPTIMIZE BB OPTIMIZE ACE RELAX - Sildenafil No effect
52 PARAMOUNT RCT using ARB vs ARB/neprilysin inhibitor (LCZ696) Neprilysin metalloproteinase inhibitor of the enzyme that breaks down endogenous natriuretic peptides Thus suppress RAAS and increase NP Solomon S Lancet 2012
53
54 Let s put this all together for your patient
55 75 y/o woman Severe SOB BP 185/70 P 80 Elevated JVP Rales S3
56 Ejection Fraction Low EF
57 Grading Scale Diastole Normal Abnormal relaxation Pseudonormalization Restriction (reversible) Restriction (irreversible) 40 0 If start with abnormal function Higher E:A or shorter DT Worse filling
58 Etiology of LV dysfunction ACE inhibitor Beta blocker Low filling pressures Look for something else Causing SOB High filling pressures Diuresis Afterload reduction
59 Ejection Fraction Low EF Normal EF Look for HTN Ischemia HFpEF
60 Normal Relaxation Compliance FC II Dyspnea Ventricular-vascular stiffness Increase BP Ischemia FC III/IV Dyspnea
61 Ejection Fraction Low EF Normal EF Look for HTN Ischemia?
62 Normal Relaxation Compliance FC II Dyspnea Stiff Muscle Ventricular-vascular stiffness Increase BP Ischemia FC III/IV Dyspnea FC III/IV Dyspnea
63 Severe heart failure BP 90/60 Severe myocardial restrictive disease Amyloid Radiation heart disease
64 Or
65 Ejection Fraction Low EF Normal EF Look for HTN Ischemia Myocardial Restriction Constrictive Pericarditis
66 Diastolic Function Rick Nishimura Leighton Professor of CV Diseases Mayo Clinic No Disclosures
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