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Sanjiv J. Shah, MD

@HFpEF

21 Dec

#HFpEF pearl of the day: Eval of filling pressures is critical for HFpEF management. Use entire echo and integrate info for filling pressures assessment: E, E/A, decel time, pulm vein flow, LA volume, LA strain, PASP, PR end-diastolic gradient, IVC, hepatic vein, tricuspid E/e'.

⬆️E, ⬇️DT, ⬆️E/A, and D-dominant pulm vein flow (in older pts); ⬆️E/e’, ⬆️LA volume (esp. ⬆️LA min volume), ⬇️LA reservoir strain; ⬆️PASP, ⬆️PREDP gradient (in absence of PAH); ⬆️tricuspid E/e’ > 6, ⬆️size ⬇️collapsibility of IVC, hep. vein flow reversal all = ⬆️filling pressures

Alternatively, continuous flow by 2D doppler into RA (in RV inflow views) or continuous forward flow on hepatic vein tracing can be helpful signs of normal RA pressure.

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Sanjiv J. Shah, MD

@HFpEF

21 Dec

#HFpEF pearl of the day: Once the Dx of HFpEF is made, the 1st step is looking for and Rx'ing congestion, then Rx'ing comorbidities, and then exercise/weight loss program. I use sequential nephron blockade to minimize loop diuretic dose, always try to use MRAs when possible.

@SumeetMitter

If strictly following TOPCAT protocol for MRA use in HFpEF, here is an algorithm published here (with @SumeetMitter): pubmed.ncbi.nlm.nih.gov/26408016/

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Sanjiv J. Shah, MD

@HFpEF

18 Dec

#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.

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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.

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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.

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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.

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