Value of echocardiography in chronic dyspnea

Value of echocardiography in chronic dyspnea Jahrestagung Schweizerische Gesellschaft für /Schweizerische Gesellschaft für Pneumologie B. Kaufmann 16.06.2016

Chronic dyspnea Shortness of breath lasting longer than 1 month 1 Cardiac and pulmonary etiologies predominate Multifactorial in up to one third of patients 1 1 Wahls SA et al. Am Fam Physician. 2012

% Chronic dyspnea value of history, physical exam and chest x-ray Correct Incorrect Overall Cardiomyopathy Asthma COPD Interstitial lung disease Less common diseases Pratter MR et al. Arch Intern Med. 1989;149:2277-2282

Differential diagnosis of chronic dyspnea Cardiac Pulmonary Myocardial disease Cardiac arrhythmias Pericardial disease Valvular heart disease Chronic obstructive pulmonary disease Asthma Interstitial lung disease Pleural effusion Malignancy Bronchiectasis

Differential diagnosis of chronic dyspnea (II) Noncardiac/ Nonpulmonary Thromboembolic disease Pulmonary hypertension Deconditioning Obesity Severe anemia Gastroesophageal reflux disease Metabolic conditions Liver cirrhosis Thyroid disease Neuromuscular disorders Chest wall deformities Upper airway obstruction Psychogenic causes

Differential diagnosis of chronic dyspnea Cardiac Pulmonary Myocardial disease Cardiac arrhythmias Heart Failure Pericardial disease Valvular heart disease Chronic obstructive pulmonary disease Asthma Interstitial lung disease Pleural effusion Malignancy Bronchiectasis

Differential diagnosis of chronic dyspnea (II) Noncardiac/ Nonpulmonary Thromboembolic disease Pulmonary hypertension Deconditioning Obesity Severe anemia Gastroesophageal reflux disease Metabolic conditions Liver cirrhosis Thyroid disease Neuromuscular disorders Chest wall deformities Upper airway obstruction Psychogenic causes

Chronic dyspnea initial diagnostic testing Complete blood count Metabolic profile Chest x-ray Electrocardiogram Spirometry Pulse oximetry 1 Wahls SA et al. Am Fam Physician. 2012

Echocardiography for the assessment of heart failure Patient with suspected HF Assessment of HF probability -Clinical history -Physical examination -ECG 1present all absent Natriuretic peptides -NT-proBNP 125pg/ml -BNP 35pg/ml no HF unlikely: consider other diagnosis yes ECHOCARDIOGRAPHY normal If HF confirmed: determine etiology Ponikowski P et al. Eur Heart J 2016

How to assess left ventricular ejection fraction? 1. Eye-balling Subjective Experience dependent Lack of standardisation Large inter- and intraobserver variability 2. Biplane Simpson s method Time consuming Geometric assumptions Apical foreshortening Image quality 3. Left ventricular opacification 4. 3D echocardiography iv line Geometric assumptions Image quality Frame rate

Left ventricular ejection fraction

EF recruiting centre [%] LV ejection fraction: reliability in a heart failure population 413 patients participating in the TIME-CHF trial LVEF analyzed at the recruiting center and at the core lab Image quality optimal in 191 and suboptimal in 222-80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 EF biplane [%] y = 0.71x + 10.4 R 2 = 0.62 p<0.0001 Kaufmann BA et al. Int J Cardiovasc Imaging. 2012

LV ejection fraction vs. Systolic function Preload Afterload Heart rate Ejection fraction Contractility

LV ejection fraction vs. systolic function: Strain imaging 60 patients with normal ejection fraction 50% Longitudinal peak systolic strain (%) LVEDP<15mmHg LVEDP 15mmHg -19.1±3.0-17.1±2.4* Nguyen JS et al. J Am Soc Echocardiogr 2010;23:1273-80.

Diastolic dysfunction heart failure with preserved ejection fraction Symptoms ± Signs LVEF 50% Elevated levels of natriuretic peptides (BNP 35pg/ml, NT-proBNP 125pg/ml) At least one additional criterion relevant structural heart disease (left ventricular hypertrophy, dilated LA) diastolic dysfunction Ponikowski P et al. Eur Heart J 2016

Cubed formula LV Mass 2D based formulas LV mass = 0.8x1.04x[(IVS+LVID+PWT) 3 - LVID 3 ] +0.6g Area length Truncated ellipsoid Cube formula has a 20% correction factor that is historical Cube formula overestimates mass in basal septal hypertrophy 2D based formulas underestimate mass in basal septal hypertrophy Correction for BSA may mask hypertrophy in obese patients Lang RM et al. J Am Soc Echocardiogr 2015;28:1-39

LV hypertrophy LV mass 141 g/m2

Measurement of LA Volume 2D biplane Simpson s method 3 Dimensional Normal LA volume <34ml/m2 BSA no normative data! Lester SJ et al. J Am Coll Cardiol. 2008;51(7):679-689 Buechel R et al. J Am Soc Echocardiogr 2013;26:428-35

Diastolic dysfunction Left atrial size Mitral inflow Mitral anular motion Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314

Diastolic dysfunction E/e 43 patients with normal ejection fraction with diastolic dysfunction confirmed by pressure-volume loop analysis 12 control subjects Diastolic dysfunction Control Kasner M et al. Circulation. 2007;116:637-647

Diastolic dysfunction in normal ejection fraction 1. Average E/e > 14 2. Septal e velocity < 7cm/s or lateral e velocity <10cm/s 3. TR velocity > 2.8 m/s 4. LA volume index >34ml/m 2 <2 positive 2 positive >2 positive Normal diastolic function Indeterminate Diastolic dysfunction Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314

Myocardial disease - etiology

Myocardial disease - etiology Coronary artery disease Hypertrophic obstructive cardiomyopathy Left ventricular non-compaction Amyloidosis

Valvular heart disease aortic stenosis Mean PG 23mmHg

Valvular heart disease aortic stenosis Mean PG 44mmHg

Valvular heart disease aortic stenosis be prepared for the rare case!

Valvular heart disease mitral regurgitation

Pericardial constriction

Pericardial constriction 130 patients with surgically confirmed pericardial constriction, 30 control patients blinded analysis of echocardiographic data Sensitivity % Specificity % Change in mitral E velocity 14.6% 84 73 Hepatic vein flow reversal ratio 0.79 76 88 Welch TD et al. Circ Cardiovasc Imaging. 2014;7:526-534

Chronic thromboembolic disease

Pulmonary artery hypertension

Value of echocardiography in chronic dyspnea First line diagnostic imaging test for Myocardial disease Valvular heart disease Pericardial disease May aid in the diagnosis of Thromboembolic disease Pulmonary artery hypertension Importance of the clinical context

Thank you for your attention! Beat Kaufmann beat.kaufmann@usb.ch