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systolic vs. diastolic vs. combined heart failure

Discussion in 'Cardiology' started by WnderWmn10, Sep 20, 2009.

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  1. WnderWmn10

    WnderWmn10

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    I'm a fourth year medical student, and I have to give a learning talk at rounds about the differences between sytolic vs. diastolic vs. combined disorder, and how to diagnose what the patient has. From my research, I have a good understanding about the pathophysiology... However, I still don't understand how to make a diagnosis based on an 2D echo (they never just say systolic vs. diastolic on the report), and whatever other signs and symptoms they have. Other than EF what other objective findings can help distinguish between the two, and how do you tell if the patient has both systolic AND diastolic failure (aka, combined). Can anyone help direct me to some resources to help me out. Thanks.
  2. J-Rad

    J-Rad Moderator Emeritus

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    http://eurheartj.oxfordjournals.org/cgi/content/full/28/20/2539
    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=274046
    (Caveats: I haven't read either in entirety and the second may be slightly dated)

    If you've read the pathophys, then you know systolic HF is the failure to squeeze well and diastolic HF (o/w [when isolated] known as heart failure with preserved EF) is failure to relax well. Either decreases cardiac output.

    Upon cardiac catheterization (which can detect diastolic dysfunction of either the RV or LV) shows elevated end-diastolic pressure for the ventricle. An LV EF can be estimated on angiography as well. If the patient doesn't have a PFO (thereby no way of directly measuring an LA mean pressure without a trans-septal perforation) then a left or right pulmonary capillary wedge pressure will approximate LA pressure. If the LV is not compliant (fails to relax) then LA pressures may be elevated (not necessary to do this in the cath lab; can be done on ICU). Likewise RA pressures may be elevated due to poor RV compliance. Stiff ventricles can also cause changes in the wave forms of the pressure tracings of the atria (A and V waves).

    As for echo estimation of diastolic dysfunction a quick bullet (I'm trying to dig out a review article that I thought I had): Based on a combination of doppler assessments. Mitral valve inflow velocities (changes in the MV "E" [rapid inflow into the LV] & "A" [atrial kick]waves and E/A ratio), Doppler signal of pulmonary veins (stiff LV will back up flow into the low pressure PVeins changing the typical signal pattern), and tissue Doppler (taken at the lateral hinge of the MV, the crux, and the lateral hinge of the TV) wave forms (E, e') are the primary echo indices of diastolic dysfunction. Obviously you can have an impaired EF and indications of diastolic dysfunction. Thickened or dilated ventricles may not squeeze or relax well.

    As an interesting aside, in my world (pediatric and adult congenital heart disease) diastolic dysfunction is quite common, and probably is present earlier more often than systolic dysfunction. Many thickened ventricles in my world that can squeeze just fine. We also see quite a bit of RV failure (syst. a/o diast.) which is hard to dx on echo but becomes evident on cath. Hypoplastic left hearts and older Tets and so forth.

    Hope this may help.
  3. BlackNDecker

    BlackNDecker Paid da cost 2 be da bo$$

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    I think you overwhelmed the poor kid.

    Diagnosis of diastolic heart failure by cardiac ultrasound is controversial...as evidenced by numerous position statements in JACC as of late.

    Just to clarify a few points:

    Two most commonly used indices of diastolic dysfunction are:
    1) E/A ratio (measured by conventional 2D echo)
    2) E/E' ratio (E' requires tissue doppler Echo)

    ***the caveat here is that these indices are flow dependent and rely heavily on preload, relaxation, and the integrity of the EKG rhythm.

    Basically, all indexes of myocardial early and late diastolic properties are derived from trans-mitral flow patterns. Other indices, including dT or relaxation time are helpful but, are not as powerful independent predictors of the presence or absence of diastolic dysfunction.

    Where the controversy lies, is that patients with pulmonary and peripheral edema (of cardiac origin) will be called "diastolic heart failure" by default if the Echo shows a normal EF despite normal E/A and E/E' ratios. This just isn't so, and I caution you on jumping to this conclusion. Certainly you can bill it that way a la ICD-9 codes, however, it is important to conceptually understand the difference in pathophysiology as it affects long-term management.

    There is now a third emerging classification, Heart Failure with Normal EF, which I would encourage you to read more on. It makes sense that 2D ECHO does not adequately quantify the 3-D movements (transverse, longitudinal, and spiral) of the heart in many patients.

    No one would expect this of you. Nor would they expect this of a medicine resident. Even Cardiologists often cannot make the diagnosis based on the Echo for numerous reasons (suboptimal images, inadequate visualization of cardiac segments, acoustic windows, etc.).

    There is a JAMA "Rational clinical exam" article from 1997 assessing the accuracy of the physical exam in diagnosing systolic vs. diastolic dysfunction. The most powerful independent predictor of diastolic dysfunction was "currently elevated BP." This paper is somewhat dated, as it assumed that all heart failure with a normal EF is "diastolic." It is worth a read however, in that it discusses common clinical findings in systolic and diastolic dysfunction.

    This is a lot for a 4th year to chew on...also a heck of a topic to present in 5-10 minutes.

    Good luck.
  4. Adcadet

    Adcadet Long way from Gate 27

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  5. CanIMakeIt

    CanIMakeIt Fellow

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