Value of echocardiography in chronic dyspneaJahrestagung Schweizerische Gesellschaft für Kardiologie/Schweizerische Gesellschaft für Pneumologie
B. Kaufmann
16.06.2016
Kardiologie
Chronic dyspnea
Kardiologie
•Shortness of breath lasting longer than 1 month1
•Cardiac and pulmonary etiologies predominate
•Multifactorial in up to one third of patients1
1 Wahls SA et al. Am Fam Physician. 2012
Chronic dyspnea – value of history, physical exam and chest x-ray
Kardiologie
Correct Incorrect
Overall Less common
diseases
Cardiomyopathy
Asthma
COPD
Interstitial lung disease
%
Pratter MR et al. Arch Intern Med. 1989;149:2277-2282
Differential diagnosis of chronic dyspnea
Kardiologie
Cardiac Myocardial disease
Cardiac arrhythmias
Pericardial disease
Valvular heart disease
Pulmonary Chronic obstructive pulmonary disease
Asthma
Interstitial lung disease
Pleural effusion
Malignancy
Bronchiectasis
Differential diagnosis of chronic dyspnea (II)
Kardiologie
Noncardiac/ Thromboembolic disease
Nonpulmonary 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
Kardiologie
Cardiac Myocardial disease
Cardiac arrhythmias
Pericardial disease
Valvular heart disease
Pulmonary Chronic obstructive pulmonary disease
Asthma
Interstitial lung disease
Pleural effusion
Malignancy
Bronchiectasis
Heart Failure
Differential diagnosis of chronic dyspnea (II)
Kardiologie
Noncardiac/ Thromboembolic disease
Nonpulmonary 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
Kardiologie
•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
Kardiologie
Patient with suspected HF
Assessment of HF probability
-Clinical history
-Physical examination
-ECG
Natriuretic peptides
-NT-proBNP≥125pg/ml
-BNP≥35pg/ml
HF unlikely:
consider other diagnosis
ECHOCARDIOGRAPHY
If HF confirmed:
determine etiology
all absent
normal
no
≥1present
yes
Ponikowski P et al. Eur Heart J 2016
How to assess left ventricular ejection fraction?
Kardiologie
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
Kardiologie
Kardiologie
LV ejection fraction: reliability in a heartfailure population
-
Kaufmann BA et al. Int J Cardiovasc Imaging. 2012
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
0 10 20 30 40 50 60 70 80
0
10
20
30
40
50
60
70
80
EF
recru
itin
g c
en
tre [
%]
EF biplane [%]
y = 0.71x + 10.4
R2 = 0.62
p<0.0001
LV ejection fraction vs. Systolic function
Kardiologie
Preload
Afterload
Contractility
Heart rate
Ejection fraction
LV ejection fraction vs. systolic function: Strain imaging
Kardiologie
60 patients with normal ejection fraction ≥50%
LVEDP<15mmHg LVEDP≥15mmHg
Longitudinal peak
systolic strain (%)-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
Kardiologie
• 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
LV Mass
Kardiologie
Cubed formula
LV mass = 0.8x1.04x[(IVS+LVID+PWT)3- LVID3] +0.6g
2D based formulas
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
Kardiologie
LV mass 141 g/m2
Measurement of LA Volume
Kardiologie
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
Normal LA volume
<34ml/m2 BSA
2D biplane Simpson‘s method 3 Dimensional
no normative data!
Diastolic dysfunction
Kardiologie
Left atrial size Mitral inflow Mitral anular motion
Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314
Diastolic dysfunction – E/e’
Kardiologie
• 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
Kardiologie
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/m2
<2 positive 2 positive >2 positive
Normal diastolic
functionIndeterminate Diastolic dysfunction
Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314
Myocardial disease - etiology
Myocardial disease - etiologyCoronary artery disease Hypertrophic obstructive cardiomyopathy
Left ventricular non-compaction Amyloidosis
Valvular heart disease – aortic stenosis
Kardiologie
Mean PG 23mmHg
Valvular heart disease – aortic stenosis
Kardiologie
Mean PG 44mmHg
Valvular heart disease – aortic stenosisbe prepared for the rare case!
Kardiologie
Valvular heart disease – mitral regurgitation
Kardiologie
Pericardial constriction
Kardiologie
Pericardial constriction
Kardiologie
• 130 patients with surgically confirmed pericardial constriction, 30
control patients
• blinded analysis of echocardiographic data
Welch TD et al. Circ Cardiovasc Imaging. 2014;7:526-534
Sensitivity % Specificity %
Change in mitral E velocity ≥14.6% 84 73
Hepatic vein flow reversal ratio ≥0.79 76 88
Chronic thromboembolic disease
Kardiologie
Pulmonary artery hypertension
Kardiologie
Value of echocardiography in chronic dyspnea
Kardiologie
• 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