Thierry C. Gillebert University of Ghent ESC Education Committee THE DIASTOLIC STRESS TEST: A NEW CLINICAL TOOL? THE CONCEPT OF DIASTOLIC RESERVE 1
Case: Ann, 63 years Suffered from metabolic syndrome and hypertension for many years. BMI 32 Treated with perindopril 10 mg and amlodipine 5 mg (combination pill). She still works halftime as a secretary She complains about dyspnea when carrying files, when walking upstairs, or when cleaning the home (NYHA II-III) 2
Ann, 63 years Clinical nl. BP 135/85 mmhg Exercise testing. 80 watts, BP 210/80 mmhg, HR 125 pm Interrupted because of dyspnea Normal pulmonary testing Echo LV mass 95 gr/m²; EF.62; LAV 35 ml/m² E/A 1.1 and E/e 0.10 PASP 33 mm Hg NT-pro-BNP = 110 pg/ml 3
European Study Group on HFNEF Paulus et al. European Heart Journal (2007) 28, 2539 2550. 4
Haemodynamics of Ann Resting hemodynamics BP 137/94 mmhg; HR 72 pm PCW = 11 mm Hg PASP = 31 mmhg Exercise hemodynamics 50 watts; 182/90 mmhg; HR 104 pm PCW = 28 mmhg PASP =59 mmhg 5
Exercise Hemodynamics Enhance Diagnosis of Early Heart Failure with Preserved Ejection Fraction. 55 patients with exertional dyspnea EF > 0.50 No CHD Normal BNP Normal resting hemodynamics Stratification Exercise PCW 25 mm Hg n=32 (age 63) Exercise PCW 25 mm Hg n=23 (age 45) Borlaug BA et al. Circ Heart Fail. 2010 Jun 11. [Epub ahead of print] 6
Exercise Hemodynamics Enhance Diagnosis of Early Heart Failure with Preserved Ejection Fraction. Borlaug BA et al. Circ Heart Fail. 2010 Jun 11. [Epub ahead of print] 7
Diastolic dysfunction Myocardial relaxation Load, inactivation (calcium homeostasis, myofilaments, energetics) non-uniformity End-diastolic properties of ventricular wall myocardial stiffness (cytoskeleton, extracellular matrix) Wall thickness and chamber geometry Variations in myocardial tone Other determinants structures surrounding the ventricle (pericardium, lungs, remaining cardiac chambers) left atrium, pulmonary veins and mitral valve heart rate Leite-Moreira, Heart 2006 92: 712-718. 8
Impaired diastolic reserve Definition Under baseline conditions: No or mild degree of diastolic dysfunction Normal filling pressures Under stress or during exercise: Overt diastolic dysfunction Elevated filling pressures Complaints of dyspnea 9
Diastolic reserve and systolic pressure in peroperative CABG patients Leite-Moreira et al. JACC (submitted) 10
Diastolic reserve and systolic pressure Leite-Moreira et al. JACC (submitted) 11
Diastolic reserve and systolic pressure Leite-Moreira et al. JACC (submitted) 12
Maximum tolerated pressure Leite-Moreira & Gillebert. Circulation1994;90:2481. Leite-Moreira Correia-Pinto & Gillebert. CVR.1999;43:344. 13
Caval occlusion in the normal and the failing heart Ishizaka et al, reproduced in Gillebert, Circulation 1997;95:745-752 Copyright 1997 American Heart Association 14
Maximum tolerated pressure Leite-Moreira et al. JACC (submitted) 15
Combined afterload and preload Importance of time available to relax Leite-Moreira et al. JACC (submitted) Leite-Moreira & Correia-Pinto AJP 2001;280:H51. 16
Take home messages Changes in body position Increase venous return Prolong systole, shorten diastole Mildly increase systolic pressures Physical exercise Increases systolic pressures Increases venous return Increases heart rate Both interventions challenge diastolic function and exhaust the diastolic reserve 17
Contraction-Relaxation Coupling and Impaired Left Ventricular Performance in Coronary Surgery Patients. De Hert, Gillebert, et al. Anesthesiology. 1999;90:748-757. Figure 4. Plots relating individual values of R to corresponding changes in dp/dtmax and EDP before (pre-cpb) and after (post-cpb) CPB. A close relation was observed between R and the corresponding changes in dp/dtmax and EDP with leg raising before and after CPB. Of the 120 patients, 15 needed inotropic support after CPB. These patients are represented by the filled symbols. These patients developed a decrease in dp/dtmax, had high R values, and showed an important increase in EDP 2 with leg raising. In these patients, leg raising was not performed after CPB, and therefore they were not included in the post-cpb data. 18