DIASTOLOGY DON T BE SUCH A STIFF Michael Mallin, MD University of Utah Director Emergency Ultrasound www.ultrasoundpodcast.com Warning: The education found within this presentation is not approved by anyone who does approvals
CASE 1 ROOM 8 74 yo female presents with SOB Hx of COPD, CHF, DM As you walk in the room she is sitting up in bed tripoding and tachypnic. She can only speak in 2-3 word sentences and complains of pleuritic chest pain and difficulty breathing. Vitals: HR 104 BP 144/86 O2: 72% on RA, 94% on NRB
CASE 1 PE: Decreased BS bilaterally Mild Wheezes bilaterally Increased AP diameter Heart sounds difficult to auscultate Mild LE edema +JVD, but you ve seen worse
CASE 1 DIFFERENTIAL Differential Diagnosis? COPD Exacerbation CHF Exacerbation Pneumotohorax Pneumonia Pulmonary Embolus Pericardial Effusion
CASE 1 WHAT NEXT You got this. You did your required 150 ultrasound scans in residency. At least 30 were cardiac. You ve seen multiple ultrasounds of people in heart failure you even watched a podcast or 2 about it.
CASE 1 - ULTRASOUND Bammm! Diagnosisism
CASE 1 - ULTRASOUND DX: CHF Call Cards, Start Nitro gtt, BiPAP, Lasix, Admit too easy
CASE 2 - ROOM 9 59 yo male presents with SOB Hx of COPD, CHF, DM As you walk in the room he his sitting up in bed tripoding and tachypnic. He can only speak in 2-3 word sentences and complains of pleuritic chest pain and difficulty breathing. Vitals: HR 104 BP 144/86 O2: 72% on RA, 94% on NRB
CASE 2 PE: Decreased BS bilaterally Mild Wheezes bilaterally Increased AP diameter Heart sounds difficult to auscultate Mild LE edema +JVD, but you ve seen worse
CASE 2 DIFFERENTIAL Differential Diagnosis? COPD Exacerbation CHF Exacerbation Pneumothorax Pneumonia Pulmonary Embolus Pericardial Effusion
CASE 2 WHAT NEXT? Didn t we just do this, I just proved my Ultrasound dominance.
CASE 2 WHAT NEXT? No Heart failure: must be COPD: pred, nebs, O2, admit
CASE 2 -WHOOPS Patient SOB worsens. Requires intubation prior to admission. Post-intubation X-ray shows bilateral pulmonary interstitial edema and BNP comes back at 2,543. What Happened? How did US fail you?
DIASTOLIC HEART FAILURE Under recognized Can occur with normal EF! 5 Million Americans with heart Failure 50% of acute failure is diastolic only (EF>50%)
PHYSICAL EXAM GOOD IDEA? Your physical exam put to the test Sensitivity of JVD: 30% Sensitivity of S3: 24% ECHO GOOD IDEA?
MISPLACED CONFIDENCE Cardiac Ultrasound by POC Physicians Just because the EF is normal: Does not mean there is not acute failure
DIASTOLIC FAILURE RELAXATION: Ability of the myocardium to relax during Diastole COMPLIANCE: Ability of the myocardium to accept a volume of blood in Diastole
RELAXATION Muscle relaxation in early diastole. Descent of base. How well do I pull?
COMPLIANCE Compliance - Myocardial compliance determines pressure required for diastolic filling How hard do I have to push?
PUSHING OR PULLING?
DIASTOLIC FAILURE HOW DOES IT OCCUR HTN thickens myocardium and impairs filling Decreased Filling = Decreased CO Decreased CO = Activation of Renin/ATII Renin/ATII = Fluid retention Fluid retention = Increased Preload Increased Preload = Increased filling pressure
CAN I EVEN DO THIS?
THE PUDDING Diagnostic Accuracy of Emergency Doppler Echocardiography for Identification of Acute Left Ventricular Heart Failure in Patients with Acute Dyspnea: Comparison with Boston Criteria and N-terminal Prohormone Brain Natriuretic Peptide. Peiman, N. Acad Emerg Med. 2009; 17:18-26. 145 Patients: evaluated by ED docs with Echo for restrictive diastolic dysfunction and compared to BNP Pulsed Doppler Sensitivity 82%, Specificity 90% Performed better than BNP or Boston heart failure criteria
THE QUESTION IS: Who is getting admitted for a CHF exacerbation?
QUALITATIVE ASSESSMENT LA area >20cm 2 Very sensitive
MEASURING DIASTOLIC FAILURE Mitral inflow POWER DOPPLER E A
MEASURING DIASTOLIC FAILURE Mitral inflow Normal Impaired Relax Pseudonormal Restrictive
MEASURING DIASTOLIC FAILURE TISSUE DOPPLER e a
MEASURING DIASTOLIC FAILURE Tissue Doppler Normal Impaired Relax Pseudonormal Restrictive
THE SPECTRUM Overload Diuresis Normal Impaired Relax Pseudonormal Restrictive GOOD! BAD!
Normal Impaired Relax Pseudonormal Restrictive
THE SPECTRUM Overload Diuresis Normal Impaired Relax Pseudonormal Restrictive Normal Impaired Relax Pseudonormal Restrictive
FILLING PRESSURE E/e Filling Pressure (LVEDP, PCWP) Normal: E/e < 8 Elevated Filling Pressure: E/e >15
THE SPECTRUM Overload Diuresis Normal Impaired Relax Pseudonormal Restrictive Normal Impaired Relax Pseudonormal Restrictive E/e <8 E/e >15
Clinical Application Acute heart failure - Dyspnea Volume overload Monitor response to therapy Critical patients requiring massive volume resuscitation
DIASTOLIC FAILURE SUMMARY Diastolic Failure can occur with normal Systolic Function ~ 50% of the time Systolic Normal Acute Heart Failure- Under diagnosed by ED physicians Diastolic Failure: E/e >15 Normal Impaired Relaxation Pseudonormal Restrictive Normal Impaired Relax Pseudonormal Restrictive Diastolic Failure: E/e >15
DIASTOLIC FAILURE
DIASTOLOGY REFERENCES 1) Nagueh S, Appleton C, Gillebert T, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Funciton by Echocardiography. J Am Soc Echocard. 2009;(22):2; 107-133. 2) Paulus W, Tschope C, Sanderson J, et al. How to diagnose diastolic heart failure. European Heart Journal (2007):28; 2539-2550. 3) Labovitz A, Noble N, Bierig M, et al. Focused Cardiac Ultrasound in the Emergent Setting. J Am Soc Echocard. 2010(23):12,1225-1230. 4) Banerjee P, Clark A, Nikitin N, et al. Diastolic heart failure. Paroxysmal or Chronic? Eur J Heart Failure. 2004(6);427-431. 5) Unluer EE, Bayata S, Postaci N, et al. Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure. Emerg Med J. 2012;29(4):280-3.