DIASTOLOGY “DON’T BE SUCH A STIFF” CF2013.pdf · 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

DIASTOLOGY “DON’T BE SUCH A STIFF”

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 >20cm2

Very sensitive

MEASURING DIASTOLIC FAILURE •  Mitral inflow – POWER DOPPLER

EA

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

Normal Impaired Relax Pseudonormal Restrictive

Diuresis

Overload

GOOD! BAD!

Normal Impaired Relax Pseudonormal Restrictive

THE SPECTRUM

Normal Impaired Relax Pseudonormal Restrictive

Diuresis

Overload

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

Normal Impaired Relax Pseudonormal Restrictive

Diuresis

Overload

E/e’ <8 E/e’ >15

Normal Impaired Relax Pseudonormal Restrictive

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.