Download “Dyspnea” A Cardiologist Perspective

“Dyspnea”
A Cardiologist’s Perspective
Disclosures
•I will not discuss off label use or investigational use in my
presentation.
•I have no financial relationships to disclose.
•Employee of MaineHealth Cardiology
Case
62 year old white female with a history of hypertension, hyperlipidemia, mild obesity
(BMI of 31) and remote tobacco use (1/2 pack per year for ten years but quit at age of 30)
presents as a new patient as she has recently moved to Maine for retirement. You are
her third primary care physician in two years.
Her only complaint is persistent dyspnea on exertion that she has had for the past three
years. She reports that she has dyspnea when walking quickly or walking up hill. She
denies dyspnea at rest, PND or orthopnea though at times she has a mild cough and a a
wheeze when laying down at night. She reports having undergone two cardiac
evaluations and pulmonary function tests in the past and was told that she was
“overweight and out of shape.” She began walking with her husband every night for the
past six months but she is frustrated because she cannot keep up with him and is not
getting better.
Left
Ventricular
End
Dyspnea
LVEDP
Diastolic
Pressure
Phases of Diastole
LVEDP
Systolic
Dysfunction
“HFrEF”
Cardiac Shunt
Congenital or
Acquired
(ruptured
Sinus)
Ischemia
Diastolic
Dysfunction
“HFpEF”
Aortic
Stenosis
LVEDP
Pericardial
Disease
Aortic
Regurgitation
Mitral
Regurgitation
Ischemia
Mitral
Stenosis
How Do We Assess LVEDP?
• History
• Physical Exam
• Non-Invasive testing
• Invasive Testing
History
•
First: Is this Dyspnea or “Breathlessness”
•
Duration? Acute or chronic?
: Ischemia or recent infarct, arrhythmia, new pericardial effusion, valve
disease (ruptured mitral valve chordae)
: Stable or Progressing (systolic or diastolic heart failure, valve
disease, ischemia)
• Good days and bad days?
– Heart failure-often due to fluctuating salt intake.
– Reactive airways disease-allergens, humidity
History
•
Rest or Exertion?
– Risk stratify and quality of life
– Ischemia, mitral valve disease, aortic stenosis (but not aortic regurgitation)
– “Bendopnea”
•
What time of day-PND and orthopnea?
– Night time-ischemia, Heart Failure, Obstructive Sleep Apnea
•
Associated symptoms ?
– Chest pain-ischemia, pulmonary embolus, pericardial effusion, heart failure.
– Cough-Bronchitis/pneumonia/asthma but also heart failure and GERD
– Wheezing-Asthma/COPD, allergies, but also heart failure and GERD.
– Peripheral edema-heart failure, PAH
Case
Review of Systems: Negative except for mild joint pain and mild fatigue.
PMH: Hypertension, Hyperlipidemia, Obesity
PSH: Appendectomy and cholecystectomy.
Allergies: Penicillin
Medications: Atorvastatin 20mg daily, lisinopril 5mg Daily.
Social History: Married, quit smoking at age 30 with 5 pack year history, glass of wine
with dinner.
Family History: Mother Colon Cancer age 77, Father diabetes and coronary artery
disease at age 72. One sister with aortic stenosis and aortic valve replacement at age
45.
Case
Physical Exam
Overweight white female in no acute distress
Height 170cm (5’ 7”), Weight 81kg (178lbs) BMI 28
Blood Pressure R arm 138/88, L arm 143/91
Pulse 84 and Regular
RR 14 and comfortable
HEENT: Normal
Neck: No JVD, normal carotid upstrokes, no bruits, no thyromegally
Lungs: Clear to percussion and auscultation
Cardiac: Regular rate. Normal S1, S2. Soft S4, No S3, rub or gallop. Grade II/VI early
peaking systolic murmur at the LUSB PMI not palpable.
Lungs: Clear to percussion and auscultation.
Abdomen: Benign.
Extremities: No peripheral edema, no clubbing. Normal peripheral pulses
Neurologic exam: Normal
Blood Pressure
• Hypertension
• Hypertensive Crisis: Acute diastolic heart failure, ischemia
• LVH=HFpEF or HFrEF
– Hypotension
– End Stage Systolic Heart Failure, tamponade
– Narrow pressure-Pulse pressure proportion
» SBP-DBP/SBP=less than 25%-Poor Cardiac OutputEnd Stage Heart Failure
– Pulsus Paradoxus-Tamponade, pleural effusion, COPD
Heart Rate
– Tachycardia
• Afib/flutter with RVR and Diastolic HF
• Afib/flutter with RVR and Systolic HF
• Sometimes JUST AFIB
– Bradycardia
• Sick sinus syndrome, heart block (BUT usually fatigue
and dizziness/syncope are chief complaints)
Respiration
• Tachypnea: The most sensitive vital sign for
heart failure!
PPV
NPV
Sensitivity
Specificity
Rales/crackles
100%
35%
24%
100
S3 gallop
86%
48%
68%
73%
J VD
95%
47%
57%
93%
CXR Vascular redistribution
89%
48%
65%
85%
CXR-Interstitial
edema
83%
33%
27%
87%
Butman et al. J Am Coll
Cardiol 1993;22:968-74
Jugular Venous Distention
• Assessment of Right Atrial Pressure
– Rarely palpable
– Three elevations and three troughs (though only two
may be seen)
– Timing (arterial always during systole)
– Pulsations eliminated by light palpation
– Level changes with position (unlike arterial)
Normal JVP
• a-atrial contraction
• x-atrial filling
• c- initial tricuspid closure
• x’-continued atrial filling
• v-rise in atrial pressures
during tricuspid valve
closure
• y-ventricular filling
S1
S2
JVP Assessment
• Head of bed at 30 degrees
• Determine venous waveform
from arterial pulsation
• Measure maximum pulsation
height above sternal angle
• Add 5cm (sternal angle 5cm
above RA)
JVD to LVEDP
• LVEDP≈ 2 times Right Atrial Pressure
• 0.74 times cm H20 equals mmHg
• 1.36 times mmHg equals cm H2O
• 14cm JVD (times .74) is 10.4 times 2 equals LVEDP of
21mmHg
• Double LVEDP to get rough estimate of pulmonary
artery systolic pressure!
Square Sign-Assessing LVEDP at
the Bedside
10mmHg
SBP
Valsalva
Release
“Overshoot
”
Normal Physiology-Biphasic
Square Sign-Assessing LVEDP at
the Bedside
10mmHg
SBP
Valsalva
Release
Heart Failure-LVEDP<25mmHg
Monophasic but not sustained
“Absent
Overshoot”
Square Sign-Assessing LVEDP at
the Bedside
10mmHg
SBP
Valsalva
Sustained
Release
Heart Failure-LVEDP>25mmHg-Monophasic and sustained-Square Sign
Physical Exam-Pearls
•
Lungs: Crackles heart failure, pulmonary fibrosis, bronchiectasis
– Wheezing (COPD, heart failure “cardiac asthma”
– Ronchi: bronchitis, pneumonia
– Absent lung sounds: Obstruction (lung cancer), pneumothorax, pleural effusion
•
Cardiac: S3 (low sensitivity, high specificity but can be normal in young pt)
– Murmurs (AS, AR, MS, MR)
– Severe MR may not have a murmur and only an S3
– Laterally displaced PMI-LVH (HFpEF or aortic stenosis)
– Loud P2: Pulmonary hypertension (either primary or secondary)
– S4: LVH-think HFpEF
– Aortic Regurgitation best heard in RUSB bending over and exhaling
Physical Exam
• Abdominal Exam
– Hepatomegally: Heart failure due to liver congestion
(hemochromatosis)
• Extremities:
– Clubbing: cyanotic heart disease
– Edema: heart failure, pulmonary artery hypertension
– Quincke’s pulses: aortic regurgitation
Case
You request the cardiac evaluation and PFTs that were done last year. In the meantime,
you order a CBC, TSH and chest X ray that return are normal. You even check a BNP that
returns at 88. Her ECG shows sinus rhythm with possible left atrial enlargement and a
left anterior hemi-block with late transition.
She is not interested in repeating any tests unless you think it is really necessary.
Initial Work Up
• CBC
• Chest X-ray
• TSH (hyper or hypothyroid)
• ECG
Secondary Work Up
• Usually with either Pulmonary, Cardiology or Both
• Echo
• BNP
• PFTs
• Stress Test
• Stress Echo with Doppler
• Invasive Hemodynamic Evaluation
Biology of the natriuretic peptide system.
T1/2 =120 min
T1/2 =20 min
Kim H , and Januzzi J L Circulation. 2011;123:2015-2019
Copyright © American Heart Association, Inc. All rights reserved.
BNP and Body Weight in Normals
Framingham participants without CVD (N = 3389)
25
BNP (pg/mL)
20
15
21.4
Normal
Overweight
Obese
21.1
16.3
15.5
12.7
10
13.1
5
0
Men
Wang TJ et al. Circulation. 2004;109:594–600.
Women
BNP and Body Weight in
Decompensated CHF Patients
McCord J, et al, Arch Int Med 2004
Case
Testing From Six Months Ago Arrives
• PFTs were normal.
• Echocardiogram: The echocardiogram showed normal left and
right ventricular systolic function. Mild left ventricular hypertrophy
with mild diastolic dysfunction. The E:e’ ratio was 9. Diastolic
filling pressures were reportedly normal. There was mild left atrial
enlargement. Aortic sclerosis, mild mitral and tricuspid
regurgitation. Mild pulmonary artery hypertension with an
estimated PA systolic pressure of 36mmHg. No pericardial
effusion.
Case
• Stress Test: She exercised for 4 minutes and 35 seconds of a
standard Bruce Protocol. She reached a heart rate of 157 beats per
minute (99% max predicted), Blood pressure 188/95. No ischemic
ECG changes. She had mild chest pressure at the end of exercise
but it resolved within a minute in recovery.
• She was referred to a cardiologist who recommended diagnostic
coronary angiography because of the chest pain in the setting of
her poor exercise capacity.
Case
• Coronary angiography showed non-
obstructive coronary disease. Her LV gram
showed normal systolic function that was
calculated at 67%. A comment was made that
her LVEDP was 18mmHg but this was after
the dye load.
Case
She now returns to your office to review the results of the testing and to develop a
treatment strategy.
You recommend the following:
A: Nuclear stress test.
B: Stress echocardiogram with Doppler
C: Continue walking with your husband and reassurance that “things will get better
eventually.”
D: Discontinue atorvastatin (drug holiday for muscle weakness) and Lisinopril (ACEi
Cough) and consult a nutritionist for weight loss.
E: Repeat PFTS and referral to Dr Wirth
Case
A stress echo with Doppler was performed one week later:
She exercised for 4’ 20” and achieved 100% of her maximum predicted. Her peak blood
pressure was 195/100. Exercise was again limited by dyspnea and mild chest discomfort
at peak exercise.
Echocardiographic Images:
Resting: Normal systolic function and mild LVH. Grade I diastolic dysfunction.
E:e’ was 10. Aortic sclerosis. Mild mitral and tricuspid regurgitation. PASP 37mmHg.
Post Exercise: Hyperdynamic systolic function without ischemia or change in
valvular findings. E:e’ was 18. Pulmonary systolic pressures were 55mmHg.
Echo Clues in Dyspnea
• Left atrial size is a marker of either chronic
pressure or volume overload!
• Pulmonary artery hypertension is one of the
most common findings of an elevated LVEDP!
• E:e’ +4 ≈LVEDP!
• Diastolic filling pressures are DYNAMIC!
Dr Douglas Zile, HF Board Review, Sept 2012
Dr Douglas Zile,
HF Board Review,
Sept 2012
Dr Douglas Zile, HF Board Review, Sept 2012
Zile et al, Circulation 118: 1433-41, 2008
Dr Margaret Redman, HF Board Review 2012
Invasive Cardiopulmonary Stress Test
• Right Heart Catheter and Radial artery catheter with
hemodynamic monitoring during upright bicycle.
• Measure filling pressures, direct arterial and venous oxygen
concentration during standard parameters of a cardiopulmonary
stress test.
• Best to diagnose
– HFpEF
– Exercise induced Pulmonary Arterial Hypertension
– Preload Dependent Limitations of Cardiac Output
The elements of an invasive cardiopulmonary exercise test.
Maron B A et al. Circulation. 2013;127:1157-1164
Copyright © American Heart Association, Inc. All rights reserved.
A diagnostic algorithm for interpreting iCPET results.
Maron B A et al. Circulation. 2013;127:1157-1164
Copyright © American Heart Association, Inc. All rights reserved.
HFpEF-Diastolic Heart Failure
Teaching Points
• Greatly under diagnosed.
• Usually clues by history, ECG, stress testing, and echo.
• Mostly older women with a history of hypertension and or diabetes.
• BNP usually normal or only mildly elevated.
• Stress Echo with Doppler is preferred non-invasive test. If uncertain, an
invasive cardiopulmonary exercise test should be considered.
• Blood pressure control will improve diastolic function.
• Prevention of tachycardia will usually improve symptoms by preventing
the development of elevated LVEDP.
Teaching Points
•
“Good days and bad days” typical and probably related to fluctuations in salt and
fluid intake.
•
Cough or wheezing could be due to elevated diastolic filling pressures.
•
A mean LV diastolic pressure probably correlates best to symptoms of dyspnea.
•
JVD usually not present, lungs are usually clear, S3 is usually absent.
•
BNP usually not high, chest Xray is usually normal.
•
Left atrial enlargement is common-HgA1C of left ventricular filling pressures.
•
Pulmonary hypertension is often seen.
•
If the resting echocardiogram shows elevated diastolic filling pressures,
moderate or severe diastolic dysfunction and/or pulmonary artery hypertension,
heart failure is highly likely and a loop diuretic, Heart rate and blood pressure
control should be initiated.
•
Avoid NSAIDS, steroids, “glitizones” and other medications that expand
intravascular volume.
General Differential
Cardiac
Pulmonary
Deconditioning
Metabolic
General Differential
Case
You call her at home and inform her of the results.
You diagnose her with HFpEF. You believe that her mild chest pain is from
endomyocardial ischemia from elevated diastolic filling pressures.
You start metoprolol succinate 50mg daily.
She calls you one week later very excited to tell you just how well she feels. She is
elated that a “little pill” makes such a big difference in her quality of life. On her 30 min
evening walks, she is now able to keep up with her husband and he even is asking her to
“slow down.”
Thank You!