Transcript Diastolic Dysfunction - Nationwide Mutual Insurance Company

Diastolic Dysfunction as Diagnosed and
Quantified by Echocardiography
LAM-1965AO (07/13) For Broker/Dealer Use Only
Diastole and Systole
• Diastole: The normal rhythmically occurring relaxation and dilatation of the
heart chambers, especially the ventricles, during which they fill with blood.
• Systole: The contraction, or period of contraction, of the heart, especially of
the ventricles, during which blood is forced into the aorta and pulmonary
artery.
Cardiac Cycle
What is Diastolic Dysfunction?
• Changes in the ventricle which may result in
impaired relaxation, reduced compliance and
elevated pressures
• Diastolic Dysfunction ≠ Diastolic Heart Failure
What is Diastolic Dysfunction?
•
Who is more likely to develop DD?
Elderly*
Women
Obese
•
What diseases are more likely to produce DD?
HTN
LVH
CAD
VHD (AS)
•
Text book Example:
Older lady overweight with long history of
hypertension with exercise intolerance
What is Diastolic Dysfunction?
•
•
3 Stages to Diastolic Dysfunction
I) Impaired Relaxation
II) Pseudonormal
III) Restrictive
Primary measurements include peak E & A transmitral
velocities, E/A ratio, DT (Deceleration Time) and IVRT
(Isovolumetric Relaxation Time)
• Additional measurements E/e’, LA volume index,
Pulmonary Vein Flow ( S/D & AR) and
Vp (Propagation Velocity)
What is Diastolic Dysfunction?
Figure 2 Doppler echocardiogram shows normal pattern of diastolic filling. Opening of the mitral
value produces increased flow velocity through the valve annulus, which is represented as a
large E wave (E). During late diastolic filling, the transmitral pressure gradient increases once
again, with atrial contraction producing a smaller A wave (A).
(3)
What is Diastolic Dysfunction?
What is Diastolic Dysfunction?
What is Diastolic Dysfunction?
I: impaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV compliance), ECG:
electrocardiogram, MI: mitral inflow, MA: mitral annular velocities, PVF: pulmonary venous flow, Vp: velocity of flow progression, LA: left
atrium, PASP: pulmonary artery systolic pressure.
What is Diastolic Dysfunction?
• 1st use E/A, DT, and IVRT
• 2nd use E/e’ (<8,8-15,>15) and LA vol index (< 28 ml/M2
WNL and > 34 ml/M2 increased mortality)
• 3rd use Pulmonary Vein Flow ( S/D & AR) and
Vp (Propagation Velocity)
What is Diastolic Dysfunction?
Normal E/A Ratio (>1)
• Good: < 60 yo, no risk factors, no evidence of increased filling
pressures ( E/e’ > 15, S<D, inc AR, dec Vp )
• Not Good: > 70 yo with risk factors (HTN/LVH, CAD, ♀ ), evidence of
increased filling pressures
E/A < 1 ( Grade I DD, Impaired Relaxation)
• NBD: > 70 yo and no HTN/LVH or CAD
• BD: < 50 yo with HTN/LVH or CAD
Grade II DD, Pseudonormal and LA vol index (> 34 ml/M2)
• BAD ( until proven otherwise)
Grade III or IV, Restrictive
• BAD BAD BAD
Diastolic Dysfunction Case Study
• 74 yo male applying for $5 mil , no h/o HTN, heart
disease , diabetes or cancer
• 6’ 0” , 185 lbs, 125/82 mmHg , 62 reg
• Labs and EKG WNL
• APS: 2012 echo….LV size and function WNL , EF 65%,
LVPWd 1.1 cm, R & L atrium WNL, Grade I DD, no
significant valvular disease….GXT: exercised 13 min to
14 METS, no ischemic changes
• Offer?
Diastolic Dysfunction Case Study
• 72 yo female applying for $5 mil , long h/o HTN,
no heart disease , diabetes or cancer
• 5’2” , 220 lbs, 154/92 mmHg , 92 reg
• Labs WNL except NTproBNP 320 pg/ml and EKG
LAD, LVH & LAE
• APS: 2012 echo….LV size and function WNL , EF
65%, LVPWd 1.6 cm, L atrium 5.2 cm, E:A 2.2, E/e’
20, no significant valvular disease….GXT:
exercised 3 min to 4 METS, no ischemic changes
• Offer?