THE DIASTOLIC STRESS TEST: A NEW CLINICAL TOOL?
18
THE DIASTOLIC STRESS TEST: A NEW CLINICAL TOOL? THE CONCEPT OF DIASTOLIC RESERVE Thierry C. Gillebert University of Ghent ESC Education Committee 1
Transcript of THE DIASTOLIC STRESS TEST: A NEW CLINICAL TOOL?
THE DIASTOLIC STRESS TEST:
A NEW CLINICAL TOOL?
THE CONCEPT OF DIASTOLIC RESERVE
Thierry C. GillebertUniversity of Ghent ESC Education Committee
1
Case: Ann, 63 years
Suffered from metabolic syndrome and hypertension for many years. BMI 32
Treated with perindopril 10 mg and amlodipine5 mg (combination pill).
She still works halftime as a secretary
She complains about dyspnea when carrying files, when walking upstairs, or when cleaning the home (NYHA II-III)
2
Ann, 63 years
Clinical nl. BP 135/85 mmHg
Exercise testing.
◦ 80 watts, BP 210/80 mmHg, HR 125 pm
◦ Interrupted because of dyspnea
Normal pulmonary testing
Echo
◦ LV mass 95 gr/m²; EF .62; LAV 35 ml/m²
◦ E/A 1.1 and E/e’ 0.10
◦ PASP 33 mm Hg
NT-pro-BNP = 110 pg/ml
3
European Study Group on HFNEF
Paulus et al.
European Heart Journal (2007) 28, 2539–2550.4
Haemodynamics of Ann
Resting hemodynamics◦ BP 137/94 mmHg; HR 72 pm
◦ PCW = 11 mm Hg
◦ PASP = 31 mmHg
Exercise hemodynamics◦ 50 watts; 182/90 mmHg; HR 104 pm
◦ PCW = 28 mmHg
◦ PASP =59 mmHG
5
Exercise Hemodynamics Enhance Diagnosis of
Early Heart Failure with Preserved Ejection Fraction.
55 patients with exertional dyspnea EF > 0.50
No CHD
Normal BNP
Normal resting hemodynamics
Stratification Exercise PCW ≥ 25 mm Hg n=32 (age 63)
Exercise PCW 25 mm Hg n=23 (age 45)
Borlaug BA et al. Circ Heart Fail. 2010 Jun 11. [Epub ahead of print] 6
Exercise Hemodynamics Enhance Diagnosis of
Early Heart Failure with Preserved Ejection Fraction.
Borlaug BA et al. Circ Heart Fail. 2010 Jun 11. [Epub ahead of print] 7
Diastolic dysfunction
Myocardial relaxation
Load, inactivation (calcium homeostasis, myofilaments,
energetics) non-uniformity
End-diastolic properties of ventricular wall
myocardial stiffness (cytoskeleton, extracellular matrix)
Wall thickness and chamber geometry
Variations in myocardial tone
Other determinants
structures surrounding the ventricle (pericardium, lungs,
remaining cardiac chambers)
left atrium, pulmonary veins and mitral valve
heart rate
Leite-Moreira, Heart 2006 92: 712-718. 8
Impaired diastolic reserve
Definition
Under baseline conditions:◦ No or mild degree of diastolic dysfunction
◦ Normal filling pressures
Under stress or during exercise: ◦ Overt diastolic dysfunction
◦ Elevated filling pressures
◦ Complaints of dyspnea
9
Diastolic reserve and systolic pressure
in peroperative CABG patients
Leite-Moreira et al. JACC (submitted) 10
Diastolic reserve and systolic pressure
Leite-Moreira et al. JACC (submitted) 11
Diastolic reserve and systolic pressure
Leite-Moreira et al. JACC (submitted) 12
Maximum tolerated pressure
Leite-Moreira & Gillebert. Circulation1994;90:2481.
Leite-Moreira Correia-Pinto & Gillebert. CVR.1999;43:344. 13
Copyright ©1997 American Heart Association
Ishizaka et al, reproduced in Gillebert, Circulation 1997;95:745-752
Caval occlusion in the normal and the failing heart
14
Maximum tolerated pressure
Leite-Moreira et al. JACC (submitted) 15
Combined afterload and preloadImportance of time available to relax
Leite-Moreira et al. JACC (submitted)
Leite-Moreira & Correia-Pinto AJP 2001;280:H51. 16
Take home messages
Changes in body position
◦ Increase venous return
◦ Prolong systole, shorten diastole
◦ Mildly increase systolic pressures
Physical exercise
◦ Increases systolic pressures
◦ Increases venous return
◦ Increases heart rate
Both interventions challenge diastolic function and
exhaust the diastolic reserve
17
2
Figure 4 . Plots relating individual values of R to corresponding changes in dP/dtmax and EDP before (pre-CPB) and after (post-CPB) CPB. A close relation was observed between R and the corresponding changes in dP/dtmax and EDP with leg raising before and after CPB. Of the 120 patients, 15 needed inotropic support after CPB. These patients are represented by the filled symbols. These patients developed a decrease in dP/dtmax, had high R values, and showed an important increase in EDP with leg raising. In these patients, leg raising was not performed after CPB, and therefore they were not included in the post-CPB data.
Contraction-Relaxation Coupling and Impaired Left Ventricular Performance in Coronary Surgery Patients.
De Hert, Gillebert, et al. Anesthesiology. 1999;90:748-757.
18
