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Sanjiv J. Shah, MD

18 Dec, 6 tweets, 2 min read

#HFpEF pearl of the day: Always look at echo LVOT VTI when eval. HFpEF pts. Normal 18-22 cm at HR 60-100. ⬆️LVOT VTI: look for NASH, anemia, cirrhosis, AVMs, etc. If ⬇️LVOT VTI: infiltrative/restrictive CM, constriction, LA failure, PAH, RV failure, obstructive lung dz, MS, etc.

If ⬆️LVOT, measure volumes/dimensions of all 4 cardiac chambers to look for enlargement. Case: 31 yo woman previously healthy presents with dyspnea, leg swelling, BNP 166 pg/ml. Training for a marathon. Urine pregnancy test negative.

Echo shows normal LVEF (65%). E/e’ = 6. Lateral e’ velocity = 15 cm/s. LV dilated (LVEDVI = 85 ml/m2) and LA dilated (LA volume index = 50 ml/m2). ⬆️LVOT VTI = 30 cm.

She was given a treatment and 12 days later, symptoms improved, leg swelling went away, BNP normalized, LVOT VTI came down, and LV and LA volumes decreased, as shown below. What treatment was she given?

This is a case of severe thiamine deficiency causing high output HF (wet beriberi). The pt was on a starvation diet and only eating small amounts of pita and hummus intermittently while training for a marathon. We ruled out anemia, hyperthyroidism, and liver disease.

A treatable case of “HFpEF”! :)

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More from @HFpEF

Sanjiv J. Shah, MD

@HFpEF

16 Dec

#HFpEF pearl of the day: In HFpEF pts with #CardioMEMS devices, bike stress echo + continuous CardioMEMS PA pressure recording can help evaluate underlying pathophysiologic abnormalities.

Case: 71 yo woman w/apical HCM, AF s/p ablation, pacemaker, HTN, CKD with cardiorenal syndrome and PH-HFpEF presents with worsening overload. Echo shows preserved LVEF with apical HCM, PASP 85 mmHg, RAP 15 mmHg, RVOT PW notching consistent with ⬆️PVR.

Read 17 tweets

Sanjiv J. Shah, MD

@HFpEF

15 Dec

#HFpEF pearl of the day: Bike stress echo is very helpful in the evaluation of HFpEF. In 1 test you can diagnose HFpEF (E/e') and evaluate for CAD (WMA), health of the LA (Δ LA strain), LV contractile reserve (Δ LV strain), dynamic MR, and dynamic LV outflow tract obstruction.

If RV free wall strain goes down with exercise, could be a sign of dynamic pulmonary vasoconstriction during exercise (i.e., ⬆️PVR with exercise) or intrinsic RV dysfunction.

Here is an example. 72 yo woman w/HFpEF. With just 25W exercise, E velocity goes way up. And a' velocity goes down dramatically, indicative of LA contractile dysfunction and ⬆️LV end-diastolic stiffness.

Read 12 tweets

Sanjiv J. Shah, MD

@HFpEF

12 Dec

Answer to today's case: the pt had a very stiff LA, poss. due to AF ablation. But stiff LA alone cannot cause big V waves. Sympathetic activation➡️splanchnic vasoconstriction w/redistribution of volume from gut/liver➡️lungs/heart with minimal exertion + stiff LA = big V waves.

@corviamedical

This pt also had significant coronary microvascular dysfxn. Exercise➡️myocardial ischemia➡️LV diastolic dysfunction➡️increased load on LA. I tried everything to treat him, nothing worked for 7 years. And then he got an IASD as part of the @corviamedical REDUCE LAP-HF I trial.

Huge improvement in symptoms, now NYHA class I-II.

Read 4 tweets

Sanjiv J. Shah, MD

@HFpEF

11 Dec

Case: 64 yo man w/HFpEF, HTN, obesity, CAD, AF s/p ablation, NYHA 3. Invasive hemodynamics shown below. PCWP 11 at rest, ⬆️ to 32 with V waves up to 75 with 20W bike exercise. Only 1+ MR at rest/exercise. What caused the severe elevation in PCWP and V waves with minimal exercise?

Read 5 tweets

Sanjiv J. Shah, MD

@HFpEF

11 Dec

#HFpEF pearl of the day: There are both "slow" and "fast" mechanisms of congestion in HFpEF patients. The "fast" mechanism is mediated by splanchnic vasoconstriction, which also may have implications for cardiorenal syndrome.

See: ahajournals.org/doi/10.1161/CI…

Read 4 tweets

Sanjiv J. Shah, MD

@HFpEF

9 Dec

Case: 74-year-old woman with HTN, obesity (BMI 46 kg/m2) with dyspnea, leg edema, ⬆️JVP, BNP = 28 pg/ml, LVEF 60%. What is the cause of HFpEF and abnormal septal motion?

Invasive hemodynamics: RA 18, PA 44/20 (mean 28), PCWP 20, CO 5.1 L/min.

Answer: Obesity HFpEF phenotype with severe pericardial, epicardial fat over the RV causing pericardial constraint (not constrictive pericarditis--pericardium was normal). See: ahajournals.org/doi/10.1161/CI…

Read 9 tweets

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