Evaluation of heart failure

1. HFpEF
A CASE BASED DISCUSSION
Dr.Shanmuga sundaram MD DM
Consultant-Heart failure and Echocardiography
GKNM Hospital
Coimbatore

3. Diagnosis of HFpEF - A work in progress

4. Case scenario 1
• 75yr old lady, systemic hypertension, recent onset breathlessness on
minimal exertion, mild swelling of the legs.
• O/E
• 90/min, 150/90 mmHg, JVP elevated, Bilateral basal creps, SpO2:96%
• S1 and S2 normal
• CBC Normal, HB 14, Creatinine 1.1, NTpro BNP: 2000
• C X Ray PA: CTR- Normal, Mild PVH, Pulmonary parenchyma is normal
• ECG: Mild LAE, SR, No LVH
• ECHO: No RWMA, Good LV systolic function, Grade II LV DD, E/e’18,Medial
annular velocity 6 cms/s, LAE, Mild TR, RVSP 50mmHg

5. Case scenario 2
• 30 year old lady, no HT/DM/CAD, BMI 26
• Recent onset exertional breathlessness and swelling of the legs
• HR: 80/min, regular, 110/80, JVP elevated, Mild PE
• CVS: S1 S2 normal, no additional sounds, RS: normal
• CBC normal, HB: 14gms, Creat:0.7, LFT including albumin: normal
• TSH: 2.3, NTproBNP: 402
• ECG:SR, Normal
• C X Ray: CTR normal, No PVH
• ECHO: No RWMA, Good LV systolic function, Grade I LV diastolic
dysfunction, e’ 10cms/s, E/e’ 8 No LAE/RAE , No TR

6. Case scenario 3
• 13/boy, Exertional breathlessness, No BA
• No pallor
• 90/min, reg, 90/60 mmHg, JVP – Prominent a wave
• S4 +, P2 loud, RS Clear
• CBC: Hb 14 gms, RFT/LFT/TSH: normal
• C X Ray: Mild PVY, Cardiomegaly
• ECHO: Good LV systolic function, Concentric LVH,Grade III LV diastolic
dysfunction, e’ 4 cms/s, E/e’: 17,BAE, Mild TR, RVSP 50mmHg,
Normal RV systolic function.

7. AHA ACC guidelines

8. ESC guidelines
Key structural alterations are LAVI >34 mL/m2 or LVMI ≥115 g/m2 for males and ≥95 g/m2 for females.
Key functional alterations are E/e′ ≥13 and a mean e’ septal and lateral wall less than 9 cm/s
Diastolic stress testing and invasive hemodynamic measurement may be done if needed to confirm

10. ASE / EACVI guidelines

11. Fallacies in current approach
• The ACC/AHA guidelines works well for patients with a high likelihood
of disease based upon clinical indicators of congestion.
• To address the patients without overt congestion, ESC require
objective evidence of high LV filling pressures.
• These approaches are not prospectively tested comparing with gold
standard

12. HFpEF
An entity which is over diagnosed as well as under diagnosed

13. Pathophysiology

14. HFpEF diagnosis
• HFpEF ≠ Breathlessness with normal ejection fraction
• HFpEF ≠ Volume overload with normal ejection fraction
• HFpEF ≠ Elevated BNP/NTproBNP with normal ejection fraction
Myths
Normal levels of natriuretic peptides rules out HFpEF
Normal levels of E/e’ excludes HFpEF

15. • All patients referred for exercise stress testing in the evaluation of
exertional dyspnea. Subjects with either HFpEF or non-cardiac
dyspnea.
• HFpEF was defined when patients had typical clinical symptoms
(dyspnea, fatigue), normal LVEF (≥50%), elevated PCWP at rest
(>15mmHg) and/or with exercise (≥25mmHg).
• Exclusion of alternative causes of the clinical syndrome of HF: primary
cardiomyopathies (hypertrophic, infiltrative or restrictive), CCP, high
output heart failure, significant valvular heart disease (>moderate
regurgitation or >mild stenosis), PE and RV CMY.

16. Role of NTproBNP
18% of subjects with invasively-proven HFpEF displayed completely
normal NT-proBNP (<125 pg/ml), a level proposed in the most recent
ESC guidelines statement to effectively exclude HF

20. ESC approach – 2018 ESC heart failure congress
( Unpublished )

21. Steps in evaluation
• 1. Symptoms and signs of heart failure
• 2. Non cardiac causes for symptoms
• 3. HFpEF mimics
• 4. Assess the pre test probability - H2PEFF score
• 5. Role of diastolic stress testing
• 6. Evaluate the etiology for diastolic dysfunction
• 7. Evaluate for comorbidities

22. Step 1.Typical presentation
• Symptoms
• Exertional breathlessness, Orthopnoea, PND
• Fatigue
• Effort intolerance
• Swelling of the legs
• Signs
• Elevated JVP
• Rales
• Pedal edema

23. Symptoms of HFpEF – PARAGON HF

24. Step 2:Non cardiac causes for symptoms and signs
• Anemia
• Pulmonological causes
• CKD
• Hypo albuminemia

25. Step 3:HFpEF mimics
1. Pericardial diseases- CCP
2. Pulmonary hypertension
3. RV cardiomyopathies / Primary TR
3. High output heart failure
4. Cardiomyopathies ( HCM, Infiltrative heart diseases )
5. Severe left sided valvular heart diseases
(Patients with HFpEF may also have some valvular heart disease, but
not in the severe range. Mild to moderate valve lesions in patients with
HFpEF are generally considered to be "bystanders" rather than causal
of HF symptoms)

26. Step 4: H2FPEF score

27. Step 5
Role of diastolic stress testing
1. Stress ECHO
2. RHC with exercise

28. Stress ECHO
• In normal subjects, mitral early diastolic E velocity increases with the
augmented LV suction.
• Mitral annular e velocity likewise increase proportionally with E
velocity with exercise so that E/e ratio remains unchanged from
resting state to exercise.

29. Stress ECHO
• Patients with diastolic dysfunction may not be able to augment
myocardial relaxation with exercise compared with normal subjects
• These patients can only achieve the required cardiac output at the
expense of increased LV filling pressures.
• In patients with diastolic dysfunction, the E/e ratio increases with
exercise.
• Good correlation between E/e ratio and invasively obtained
pulmonary capillary pressure, LAP or LV mean diastolic pressure with
variable levels of effort

30. Stress ECHO
• Diastolic stress testing is indicated in patients with dyspnea and grade 1
diastolic dysfunction at rest.
• It is performed using supine bike or treadmill stress testing.
• At rest, mitral E and annular e velocities should be recorded, along with
the peak velocity of TR jet from multiple windows. The same parameters
are recorded during exercise or 1 to 2 min after termination of exercise
when E and A velocities are not merged, because increased filling pressures
usually persist for few minutes.
• The test is considered positive when all of the following three conditions
are met during exercise: average E/e > 14 or septal E/e ratio > 15, peak TR
velocity > 2.8 m/sec and septal e velocity < 7 cm/sec.

31. RHC with exercise
• Baseline hemodynamics along with exercise testing
• Arm or leg exercises
• Intensity of exercise: 20W (sub maximal) or symptom limited
• PCWP >15 at rest and > 25 on exercise is considered abnormal

33. Step 6: Identification of etiology
• Non invasive stress testing / Coronary angiogram
• Cardiac MRI
• Nuclear Imaging
• Endomyocardial biopsy

34. Step 7: Evaluation of comorbidities
• Hypertension
• Coronary heart disease
• Diabetes mellitus
• Sleep disordered breathing
• Obesity
• Kidney disease
• Anemia

35. HFA PEFF – 2018

37. Case scenario
• 75yr old lady, SHT on single drug, recent onset DOE, mild PE. BMI 28
• O/E: 90/min, 150/90 mmHg, JVP elevated, Bilateral basal creps, SpO2:96%
• S1 and S2 normal
• CBC Normal, HB 14, Creatinine 1.1, NTpro BNP: 2000
• C X Ray PA: CTR- Normal, Mild PVH, Pulmonary parenchyma is normal
• ECG: Mild LAE, SR, No LVH
• ECHO: No RWMA, Good LV systolic function, Grade II LV DD, Medial e’6
cms/s, E/e’ 18 LAE, Mild TR, RVSP 50mmHg

38. Step 4: H2FPEF score

39. Case scenario
• 30 year old lady, no HT/DM/CAD, BMI 26
• Recent onset exertional breathlessness and swelling of the legs
• HR: 80/min, regular, 110/80, JVP elevated, Mild PE
• CVS: S1 S2 normal, no additional sounds, RS: normal
• CBC normal, HB: 14gms, Creat:0.7, LFT including albumin: normal
• TSH: 2.3, NTproBNP: 402
• ECG:SR, Normal
• C X Ray: CTR normal, No PVH
• ECHO: No RWMA, Good LV systolic function, Grade I LV diastolic
dysfunction, e’ 10cms/s, E/e’ 8 No LAE/RAE , No TR

40. Step 4: H2FPEF score

41. Case scenario
• 13/boy, Exertional breathlessness, No BA
• No pallor
• 90/min, reg, 90/60 mmHg, JVP – Prominent a wave
• S4 +, P2 loud, RS Clear
• CBC: Hb 14 gms, RFT/LFT/TSH: normal
• C X Ray: Mild PVY, Cardiomegaly
• ECHO: Good LV systolic function, Concentric LVH,Grade III LV diastolic
dysfunction, e’ 4 cms/s, E/e’: 17,BAE, Mild TR, RVSP 50mmHg,
Normal RV systolic function.

42. Step 4: H2FPEF score

43. Take home messages
• Assessment of pretest probability is helpful for further evaluation
• No single clinical/Echocardiographic finding is diagnostic of HFpEF
• Normal levels of BNP of NT pro BNP does not rule out the diagnosis of
HFpEF
• Elevated natriuretic peptides supports the diagnosis
• Definite role for exercise testing in intermediate probability
• RHC is the gold standard