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Μαρία Μπόνου
Διευθύντρια ΕΣΥ, ΓΝΑ Λαϊκό
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Pathophysiologic condition: impaired relaxation, ↓ LV compliance, ↑ LV filling pressures
DD: Diastolic Dysfunction DHF: Diastolic HF
DD DHFNormal LVEF plusSigns/symptoms of HF due to DD
Normal LVEF plusSigns/symptoms of HF not only due to DD (excluding severe valve disease, constriction etc)
HFpEF
HFpEF: HF with preserved EF
Diastolic HF
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1. Symptoms ± Signs
2. LVEF >50%
3. Elevated levels of natriuretic peptides(BNP > 35 pg/mL and/or NT-proBNP > 125 pg/mL)
4. At least one additional criterion:
a. Relevant structural heart disease (LVH and/or LAE)
b. Diastolic dysfunction
Eur Heart J 2016;37:2129–2200
Definition of HFpEF2016 ESC Guidelines
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Older population
Female predominant
Comorbidities
Average: 4 Co-morbid Conditions- Hypertension- Atrial fibrillation- Coronary Artery Disease
Eur Heart J 2016;37:2129–2200
Characteristics of patients with HFpEF
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HFpEF Comorbitidies
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1 9 8 7 - 2 0 0 1 , 4 5 9 6 p t s w i t h H F
Owan et al. N Engl J Med 2006;355:251-9
Prevalence of HFpEF
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Mortality is High in HFpEF and Similar to HFrEF
EF ≥ 50%
EF < 50%
Owan et al. N Engl J Med 2006;355:251-9
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• Echo plays a pivotal role in the diagnosis of diastolic dysfunction
• Don’t‘ miss a “non-HFpEF” cause of HFpEF
Diagnosis of HFpEF is challenging
Non-cardiac causes Cardiac causes
Anaemia Hypertrophic cardiomyopathy
Infiltrative or restrictive cardiomyopathy
Constrictive pericarditis
High output heart failure
Valvular heart disease
Coronary artery disease
Pulmonary embolism
Right ventricular myopathies
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Diastolic dysfunction
Myocardial stiffness Arterial stiffness
Ventricular–Arterial (V–A) coupling
Chronotropic incompetence
Abnormal LV systolic function
Pathophysiology of HFpEF
Inadequate increase in heart rate and CO
during exercise
I N F L A M M A T I O N
Systolic Abnormalities in HFpEF Systolic Abnormalities in HFpEFDiastolic and Systolic Dyssynchrony is common in HFpEF
Echo with TDI
Mitral regurgitation
Atrial fibrillation
Exertional dyspnea and fatigue
Activity avoidance
Peripheral limitations
↓ Cardiac output reserve
Oedema, ascites and cachexia
Hoeper et al. Eur Heart J 2017; 2869–73
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E/e’: Marker of LV Filling Pressure
E/e’=27
Transmitral pulsed-wave Doppler
Mitral annular tissue Doppler
Assessment of LV Diastolic Function
Echocardiographic Assessment of Diastolic Function
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↑
• E/A > 0,8• Normal e’ for age• E DT normal
• E/A < 0,8• ↓ e’ for age• E DT prolonged
• E/A >0,8 (often >1)• ↓ e’ for age• Look for:
↑ E/e’ and/or↑ LA size
• E/A > 1,5-2• E DT < 140 ms• ↓↓ e’ for age• ↓ A wave and a’
PEARLS
Echocardiographic Assessment of Diastolic Function
Mitter et al. JACC 2017;1451-64
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Valsalva maneuver
Pulmonary Venous Flow
Echocardiographic Assessment of Diastolic Function
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• Severe impaired relaxation
• high LA pressure
• E/e’>11(septal e’)
• E/a<1(LA underfilled)
• Lateral e’ is preserved
• Respiratoryvariation
• Septal e’≥lateral e’
• Small ↑E• ↓ e’• Falsely ↑E/e’
Special Scenarios for Assessing Diastolic Function and LV Filling Pressures
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Algorithm for diagnosis of LV diastolic dysfunction 2016 ESC Guidelines
Diastolic Stress Testing
Heart Catheterization
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PATIENT WITH SUSPECTED HFpEF
Consider alternative causes
Inconclusive results
Assessment of HFpEF probability
1. Clinical History : > 60 yr of ageComorbidities
2. Physical examination 3. ECG
Natriuretic peptides NT-proBNP ≥125 pg/mL, BNP ≥35 pg/mL
Cardiac echo: ejection fraction >50%
Are there complicating factors or is image quality poor? (tachycardia, bradycardia, AV block, arrhythmia, MAC, MV prosthesis, any MS, ≥3+ MR)
Assess for increased LV filling pressure (LVFP)
Likely normalSeptal E/e' < 8Lateral E/e’ < 8
IndeterminateSeptal E/e' 8-15Lateral E/e’ 8-12
Likely elevatedSeptal E/e' > 15Lateral E/e’ > 12
Check for presence of diastolic dysfunction
Average E/e’ > 14 Septal e’ < 7 cm/s or Lateral e’ <10 cm/s
TR velocity > 2.8 m/sLA volume index >34ml/m2
H E A R T C A T H E T E R I Z A T I O N
No
Perform alternative
testing(i.e. invasive
hemodynamic
testing)
Yes
Grade diastolic dysfunction
NormalE/A > 0.8
e’ normal for age Normal LA volume
Grade IE/A < 0.8
Reduced e’ for ageLAVI normal or↑
Grade IIE/A > 0.8
Reduced e’ for age↑ LAVI
Grade IIIE/A > 1.5
Reduced e’ for age ↑ LAVI, DT < 140 ms
Diastolic
Stress Testing
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T h a n k y o u
Diagnostic dilemmas in HFpEF