Diastolic Stress

Echocardiography!
Mefri  Yanni,  MD  
Department  of  Cardiology  and  Vascular  Medicine  
Medical  Faculty  Universitas  Andalas  /  DR.M.Djamil  Hospital  Padang  

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TTE  is  recommended  for  the  assessment  of  myocardial  
structure  and  funcHon  in  subjects  with  suspected  HF  in  order   I   C  
to  establish  a  diagnosis  of  either  HFrEF,  HRmrEF  or  HFPEF  

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Progression  of  HFPEF  

Wan SH et al. J Am Coll Cardiol 2014;63:407–16!

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Progression of Diastolic Dysfunction
and Risk of Heart Failure

 
Kane  et  al.  JAMA.  2011;306(8):856-­‐863  

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 Prevalence of Subclinical Diastolic
Dysfunction in the community
Mild Diastolic Dysfunction Moderate to Severe Diastolic Dysfunction
50  

37.5  

25  

12.5  

0  
General High
Adult Population Risk Population
 
Redfield  et  al.  JAMA  2003;289:194-­‐202    

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 Diagnosis  HFPEF  :  
• The  presence  of  symptoms  and/or  signs  of  HF  
• Preserved  EF  (defined  as  LVEF  ≥50%)  
• Elevated  levels  of  NPs  (BNP  >  35  pg/mL  and/or  NT-­‐proBNP  >  125  pg/mL)  
• Evidence  of  LV  dysfuncHon  

In  case  of  uncertainty,  a  stress  test  or  invasively  measured  elevated  

LV  filling  pressure  may  be  needed  to  confirm  the  diagnosis  
Redfield MM. N Engl J Med. 2016;375:1868–1877.!

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 In  Pa2ents  with  Normal  EF  
 Average  E/e’  >  14  
Septal  e’  velocity  <  7  cm/s  or  Lateral  e’  velocity  <  10  cm/s  
TR  velocity  >  2.8  m/s  
LA  Volume  Index  >  34  ml/m2  

0  or  1  Posi2ve   2  Posi2ve   3  or  4  Posi2ve  

Normal  Diastolic  Func2on   Indeterminate   Diastolic  Dysfunc2on  

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Nagueh S. et al. J Am Soc Echocardiography 2016;29:277-314
Grading  LV  Filling  Pressures  in    Depressed  EF  and  Normal  EF  
When  Is  Diastolic  Stress  Tes2ng  Indicated  ?  

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Diastolic  stress  tesHng  is  indicated  when  resHng  echocardiography  
does  not  explain  the  symptoms  of  heart  failure  or  dyspnea,  
especially  with  exerHon.  

Nagueh S. et al. J Am Soc Echocardiography 2016;29:277-314

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J  Am  Soc  Echocardiogr  2005;18:63–8  

Ha JW, Oh JK, et al. J Am Soc Echocardiogr. 2005;18:63–68.!

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 When  Do  We  Need    
Diastolic  Stress  Echo  ?  
•  PaHent  with  unexplained  dyspnea,  with  resHng  
echo  does  not  explain  symptoms  of  heart  failure  
or  dyspnea,  especially  with  exerHon  
•  Most  appropriate  :  diastolic  dysfunc2on  grade  I,  
indicates  delayed  myocardial  relaxaHon  and  
normal  LA  pressure  at  rest    

Ha JW, Oh JK, et al. J Am Soc Echocardiogr. 2005;18:63–68.!

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 Dynamic  Diastology  
Filling  Pressure  (E/e’)  with  Exercise  
E   e’   E/e’  

Normal  

Abnormal  

E/e’  does  not  increase  much  with  exercise  in  normal  heart,but  increases    
in  symptomaHc  paHents  with  diastolic  dysfuncHon    
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 Basis  for  Diastolic  Stress  Test  
•  Normal Cardiac response to Exercise
✦  Increased stroke volume
✦  Increased myocardial relaxation
✦  Increased early diastolic filling
✦  No change in LV filling pressures
•  Abnormal Response
✦  Reduced ventricular relaxation
✦  Unable to increase cardiac output
appropriately without an increase in filling
pressures

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 Diastolic  Stress  Test  Protocol  
•  Best performed with exercise and not using Dobutamine.
•  PROTOCOL :
★  Supine Bike Ergometry
increase by 25 W every 3 min
Assess Baseline — Each Stage of Exercise — Recovery
★  Symptom-limited Treadmill exercise test :
Assess Baseline — Early recovery
•  Assess LVEF, size and wall motion
Diastolic  abnormali.es  persists  longer  than  WMA  so  assess  WMA  first    
Acquire  data  within  60  sec  for  RWMA  

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 Parameter acquired!
Mitral inflow velocities

Mitral annulus tissue doppler velocity

E = 72 cm/sec > E = 106 cm/sec

E / e’ Ratio

Peak TR Velocity

E/e’ = 9 > E/e’ = 17.6 e’ = 7 cm/sec > e’ =6 cm/sec

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K Oh et L, J Am Soc Echocardiogr 2005;18:63–8.)

Mean  LVDP  vs  E/e’  
rest  and  exercise  

ResHng  data  
Exercise  data  

Burgess et al: JACC 2006; 47:1891

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 Diastolic  Stress  Test  
InterpretaHon  
DEFINITELY ABNORMAL
Meet 3 criterias of
•  Septal E/e’ ratio > 15 or Lateral E/e’ > 13, or Average E/e’ > 14 with exercise
•  Peak TR velocity > 2.8 m/s with exercise
•  Septal e’ < 7 cm/s or lateral e’ < 10 cm/s at baseline

NORMAL
•  Average, Septal or Lateral E/e’ < 10 with exercise
•  TR velocity < 2.8 m/s with exercise

Otherwise                                Indeterminate  !  

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Proposed  diagnos2c  approach  for  HFpEF.  

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CirculaHon.  2017;135:825–838.  
 Female,  50  years  old  with  hypertension  and  
exer2onal  dyspnea,  no  ischemia  
REST  

E    50  cm/s   e’    5  cm/s   TR      2.6  m/s  

AYer  TMT  

E    95  cm/s     e’    5  cm/s   TR    3.5  m/s  

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 Take  Home  Message  

• Diagnosis  of  HFpEF  is  challenging  and  relies  largely  on  

demonstraHon  of  elevated  cardiac  filling  pressures  
• PaHent  with  exerHonal  dyspnea  but  normal  resHng  filling  pressure,  
diastolic  funcHon  needs  to  be  evaluated  with  exercise    
• Diastolic  stress  test  is  an  ideal  noninvasive  stress  test  in  paHents  
with  dyspnea,  to  assess  diastolic  funcHon  and  filling  pressure  in  
addiHon  to  assessment  of  myocardial  ischemia.  

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To  assess  exer6onal  breathlessness  ,  
we  must  exert  the  breathless  !  

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Thank You

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