Download Noninvasive Evaluation of Right Atrial Pressure

Dr W Arshad & Dr AS Kurbaan
Cardiology Department
Homerton University Hospital, London
Topics
1. GP Open access echo
2. GP Open access Holter
GP OPEN ACCESS ECHOCARDIOGRAPHY
“GP open access echocardiography refers to cardiac ultrasound imaging
which is requested by, reported to, and acted upon by GPs.”
AIMS OF PRESENTATION
 Structured approach to reading echo reports.
 Address issues encountered by referring GPs.
AIMS OF PRESENTATION
 Structured approach to reading echo reports.
 Address issues encountered by referring GPs.
ECHO REPORT
HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST
GP OPEN ACCCESS ECHOCARDIOGRAPHY REPORT
SURNAME
FORENAME
DATE OF BIRTH
GENDER
HOSPITAL NUMBER
DATE OF STUDY
INDICATION
MEASUREMENTS
Men
Women
Ventricular septal thickness (mm)
6-12
6-12
Mitral E velocity (m/s)
LV end diastolic dimension (mm)
42-59
39-53
Mitral A velocity (m/s)
LV posterior wall thickness (mm)
6-12
6-12
Aortic flow (mmHg)
30-40
27-38
≥55
≥55
LV end systolic dimension (mm)
Left atrium (mm)
Pulmonary flow (mmHg)
Aorta (mm)
LV ejection fraction (%)
FINDINGS
ECG shows sinus rhythm.
LEFT VENTRICLE: Normal left ventricular size. No left ventricular hypertrophy. No regional wall motion abnormality.
Good long axes function. Overall good left ventricular function.
LEFT ATRIUM: Normal size. No colour flow across atrial septum.
AORTIC VALVE: Trileaflet, opens well.
MITRAL VALVE: Mobile leaflets. Normal filling pattern.
RIGHT VENTRICLE: Normal size. No right ventricular hypertrophy. Good long axis function. Overall good right
ventricular function.
RIGHT ATRIUM: Normal size.
PULMONARY VALVE: Normal.
TRICUSPID VALVE: Normal.
CONCLUSION
Normal study.
OPERATOR
Dr Waleed Arshad
POSITION
Associate Specialist Cardiologist
The operator holds Accreditation in Transthoracic Echocardiography by British Society of Echocardiography,
Accreditation in Transthoracic Echocardiography by European Society of Echocardiography, Diplomate Adult
Comprehensive Echocardiography by National Board of Echocardiography USA and Fellowship of American Society
of Echocardiography.
ECHO REPORT
INDICATION:
The value of echocardiogram is greatest when a single focused
question can be asked, answered by echocardiographer, & lead to
change in management by GP.
If trends in improvement or deterioration are of interest,
echocardiographer needs results of previous studies, especially if they
are carried outside Homerton Hospital.
ECHO REPORT
DATE OF STUDY:
Does this report reflect the patient’s current clinical status?
RHYTHM:
Was the rhythm interpretable?
What was the rhythm? Sinus rhythm/Sinus rhythm with ectopics/Atrial
fibrillation
Did the rhythm interfere with assessment of left and right ventricular
function?
ECHO REPORT
IMAGE QUALITY:
Can vary from excellent to uninterpretable.
In technically difficult/sub optimal studies, pathology “not seen” does
not necessarily mean “not present”.
What was the reason for technical difficult/sub optimal study?
ECHO REPORT
Good quality
Sub optimal quality
ECHO REPORT
CHAMBER SIZES:
The table lists the measured
chamber size (diameters) and
compares them with normal
values.
Increased
values
chamber dilatation.
indicate
Transverse
diameter
under
estimates true volume of an
enlarged left atrium.
Men
Women
Ventricular septal thickness (mm)
6-12
6-12
LV end diastolic dimension (mm)
42-59
39-53
LV posterior wall thickness (mm)
6-12
6-12
30-40
27-38
≥55
≥55
LV end systolic dimension (mm)
Left atrium (mm)
Aorta (mm)
LV ejection fraction (%)
ECHO REPORT
VENTRICULAR HYPERTROPHY:
Wall thickness indicate ventricular
hypertrophy.
Sigmoid septum (or septal bulge)
is common in the elderly.
ECHO REPORT
LV SYSTOLIC FUNCTION
 Circumferential/Radial
Mid wall
Base
 Longitudinal
Subendocardial
Subepicardial free wall
Papillary muscles
ECHO REPORT
LV SYSTOLIC FUNCTION
Radial
Ejection fraction is a poor indicator of LV function
Wall motion
Global abnormalities suggest cardiomyopathy
Regional abnormalities suggest ischaemia/infarction
Wall motion score Index
Longitudinal
Amplitude
Velocity
Timing
ECHO REPORT
LV DIASTOLIC FUNCTION
LV diastolic dysfunction precedes
development of LV systolic
dysfunction.
Increased LA size is
morphologic
expression
diastolic dysfunction.
a
of
Redfield MM, Jacobsen SJ, Burnett JC Jr, et al.
Burden of systolic and diastolic ventricular dysfunction in the community:
Appreciating the scope of the heart failure epidemic.
JAMA 2003; 289:194.
ECHO REPORT
VALVES
Morphology
 Cannot always be identified in
technically difficult scans.
 Bicuspid aortic valve is a
common congenital variant.
Regurgitation
 Trivial regurgitation is normal.
Stenosis
ECHO REPORT
MASS OR THROMBUS:
Ability to detect mass or thrombus
is only as good as the images.
TTE does not image the left atrial
appendage adequately, therefore
TOE is needed.
ECHO REPORT
PERICARDIUM:
Thickened or calcified.
Thin patients can have a highly
echogenic, normal pericardium that
appears to be calcified.
Uncomplicated pericarditis has no
pathognomonic features on echo.
Small effusions are often physiologic,
of no clinical significance.
ECHO REPORT
CONCLUSION:
Important cardiac findings.
Referral to Cardiology team might be advised – ideally clinical decisions
should be made by physicians who have knowledge of their patients.
AIMS OF PRESENTATION
 Structured approach to reading echo reports.
 Address issues encountered by referring GPs.
Left ventricular ejection fraction was different in another recent echo.
Which study was correct?
Probably both.
Ejection fraction depends on preload and afterload, both of which can
change dramatically and quickly according to patient’s condition.
Ejection fraction also depends upon the method by which it is
calculated. Ejection fraction is rarely measured properly by Simpson’s
method but more often by Teicholtz.
What is importance of longitudinal function?
Long axes is abnormal in
hypertension,
hypertrophy,
coronary
artery
disease,
cardiomyopathy and conduction
disease.
Long axes is an independent
predictor
of
prognosis
in
cardiovascular disease.
How should I manage longitudinal dysfunction?
Systolic or diastolic dysfunction
Systolic – Same treatment as radial systolic dysfunction
Diastolic – Same treatment as global diastolic dysfunction
How should I manage LV diastolic dysfunction?
The treatment remains empiric since trial data are limited.
The general principles are:
 Control of systolic & diastolic hypertension.
 Control of heart rate, particularly in patients with atrial fibrillation.
 Control of pulmonary congestion and peripheral oedema with
diuretics.
 Coronary revascularisation in patients with coronary heart disease.
2013 ACCF/AHA Guideline for the management of heart failure.
J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019
2012 ESC Guidelines for the diagnosis & treatment of acute & chronic heart failure.
European Heart Journal. 20121;33:1787–1847 doi:10.1093/eurheartj/ehs104
How should I manage valvular heart disease (VHD)?
History & Physical examination
A careful history is of great importance in the evaluation of patients with
VHD, because decisions about treatment are based on the presence or
absence of symptoms. Due to the slow, progressive nature of many
valve lesions, patients may not recognize symptoms because they may
have gradually limited their daily activity levels.
A detailed physical examination should be performed to diagnose and
assess the severity of valve lesions based on a compilation of all
findings made by inspection, palpation and auscultation.
How should I manage valvular heart disease (VHD)?
Investigations
 ECG - to confirm heart rhythm.
 Chest x-ray to assess the presence or absence of pulmonary
congestion and other lung pathology.
 Echocardiogram to correlate findings with initial impressions based on
the initial clinical evaluation. The Echocardiogram will also be able to
provide additional information, such as the effect of the valve lesion
on the cardiac chambers and great vessels, and to assess for other
concomitant valve lesions.
How should I manage valvular heart disease (VHD)?
Frequency of echocardiograms
Aortic
stenosis
Aortic
regurgitation
Mitral stenosis
Mitral
regurgitation
Mild
3–5 y
3–5 y
3–5 y
3–5 y
Moderate
1–2 y
1–2 y
3–5 y
1–2 y
6–12 months
6–12 months
1–2 y
6–12 months
Dilating LV: more
frequently
Once every year
when MVA <1.0
Dilating LV: more
frequently
Severe
cm2
2014 AHA/ACC Guideline for the management of patients with valvular heart disease.
J Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536
How should I manage bicuspid aortic valve?
Surveillance for aortic valve dysfunction (stenosis, regurgitation, or both)
and for disease of the aortic root and ascending aorta.
The bicuspid aortic valve is inherited as an autosomal dominant
condition with incomplete penetrance and also appears in sporadic
cases. Therefore, screening by echocardiography for first degree
relatives for bicuspid aortic valve and aortic root & ascending aorta
dilation.
Mitral valve prolapse was reported on previous echo but not now.
Which echo is wrong?
Probably neither.
Echo criteria for diagnosing mitral
valve prolapse is more stringent
now than they were in the past.
Can echo rule out thoracic aortic aneurysm?
Echo routinely images the aortic
root.
The ascending aorta, arch of aorta
and descending aorta are only
visualised in patients with good
suprasternal echo windows.
How should I manage thoracic aortic aneurysm?
General principles of cardiovascular prevention:
 Strict control of hypertension
 Cessation of smoking
Imaging:
When an aortic aneurysm is identified at any location, assessment of
the entire aorta and aortic valve is recommended at baseline and during
follow-up.
2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.
European Heart Journal. 2014;35:2873–2926 doi:10.1093/eurheartj/ehu281
How frequent should be surveillance of thoracic aortic aneurysm?
Every six months for large aneurysms and annually for those with
smaller aneurysms.
Patient with large thoracic aortic aneurysms should be under care of
Cardiology/Cardiothoracic teams.
Summary
Echo is essential for cardiovascular evaluation and follow up.
A structured approach to reading echo reports is necessary.
This brief review has tried to address many issues encountered by
referring GPs.
PRINCIPLES
1. How ‘severe’ is the abnormality?
E.g. 4 beats of VT vs 30 secs
2. What are the symptoms?
Chest pain, syncope etc.
3. Is there an associated cardiac abnormality
Impaired ventricular function
SEVERITY OF THE ABNORMALITY
‘Abnormal findings not uncommon
Ectopy <1% usually ok, 2% or more consider assessment
Bigeminy/Trigeminy (?frequency)
PAF (30s or multiple runs)
SVT (15-20 beats)
VT (>8 beats, multifocal)
‘HIGH RISK’ SYMPTOMS/HISTORY
Known IHD, angina, heart attack, CABG, PCI
Known arrhythmia
Impaired LV
Previous stroke
Known peripheral arterial disease
Syncope/presyncope
Family history of sudden cardiac death
Multiple vascular risk factors: HTN/DM
‘HIGH RISK’ CARDIAC INVESTIGATIONS
Impaired LV <55% EF impaired, <30% severely impaired
Regional wall motion abnormality
Moderate/severe valvular abnormality
Known IHD e.g. high calcium score
EXAMPLE: 15 BEATS OF ‘SVT’
Patient 1: 25, female palpitations long standing otherwise well
Patient 2: 73, female, previous TIA (no cause found)
Patient 3: 18 male, almost blacked out at gym
SUMMARY
How ‘bad’ is what they have got?
Are there other worrying aspects of the case?
Rapid Access Atrial Fibrillation Clinic
Why?
- To provide a rapid diagnosis of atrial fibrillation in patients presenting
for the first time in the community or in patients with ongoing
unresolved issues with their management.
- To facilitate the early initiation of anticoagulation and other treatments
for atrial fibrillation.
Rapid Access Atrial Fibrillation Clinic
What will the clinic offer?
- One stop
- Echo (if needed) on the day
- Holter (if needed) fitted on the day
- Accurate diagnosis
- Access to Consultant Cardiologist/Electrophysiologist