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Monthly Archives: December 2018

Diastolic Dysfunction

Causes: increased age, ischemia, and LV hypertrophy are common causes of impaired LV relaxation. Myocardial fibrosis and scarring is a common mechanism for decreased ventricular compliance and elevated filling pressures.

Stages of Diastolic Dysfunction:

  • Stage 1: 
    • Impaired relaxation
      • Relaxation simulates negative pressure allowing an inflow of blood from the left atrium into the left ventricle. 
    • Normal Atrial Pressure
    • E/A < 1
  • Stage 2:
    • Psudonormal filling pattern with or without elevated pressures 
    • E/A > 1
    • Increased Atrial Pressure
  • Stage 3: 
    • Restrictive LV filling pattern with elevated pressures
    • Reversible: Pattern Normalized with valsalva
    • Atrial Enlargement 
    • E/A > 2
  • Stage 4: 
    • Non Reversible restriction.
    • Atrial Enlargement

Tissue Doppler Imaging In the Setting of Diastolic Dysfunction: 

Tissue doppler imaging (TDI) detects a shift in frequency of ultrasound signals from myocardial tissue motion. The motion is measured in a parallel plane to the ultrasound beam. It visualizes long axis shortening and relaxation velocities of the heart. 

Cardiac Cycle on Ultrasound

  • There are three waveforms that can be visualized on ultrasound, which depict the cardiac cycle: rapid filling, diastasis, and atrial contraction. 
  • (KB) Lateral & Septal Placement of Ultrasound Probe during Diastolic Examination:
    • Placement of the ultrasound probe: tissue doppler sampling is done 1cm below the mitral plane. The sample can be placed at the septal and lateral borders of the mitral annulus. 
      • Mitral annular velocities measured at the medial aspect are normally <8 cm/s, whereas those measured at the lateral aspect are normally <10 cm/s. These measurements are combined to form a mean mitral annular valve velocity. Of note, young and healthy patients may display higher velocities. The medial annular velocity is typically lower than the lateral because the lateral can move more freely as the medial annular ring is tethered to the rigid intervalvular fibrosa. Medial ring movement may also be blunted by the motion of the right ventricle. 
      • When medial and lateral velocities are measured, the mean value is used. This is useful when there are regional wall motion abnormalities. 
    • Example: Measuring the E/e’ ratio and the Left Ventricular End-Diastolic Pressure
      • E/e’ = the peak E wave velocity divided by the peak e’ velocity. 
      • The American Society of Echocardiography recommends measuring the E/e’ ratio …***

Pulmonary Vein Flow: this looks at the flow from the RSPV pulmonary vein to the left atrium.

There are three things to evaluate via ultrasound (apical 4 chamber view) using pulsed-wave Doppler.

  1. The Systolic peak (S)
    1. forward flow (from the pulmonary vein perspective) 
  2. The antegrade diastolic peak (D)
    1. Should be smaller than S in pulmonary blood flow
    2. filling of the ventricle
  3. Peak AR velocity (Ar)
    1. reverse flow (left atrium to the pulmonary vein, from the pulmonary vein perspective)
    2. This is caused by the contraction of the atria pushing blood both forward into the ventricle but also some blood back into the pulmonary veins.

A caveat to a normal pulmonary venous pattern is that many young individuals and athletes will have an S < D relationship. This is thought to be secondary to exaggerated pulmonary venous inflow during diastole from a powerful suction during the early rapid filling phase of diastole.

Diastolic Function | Thoracic Key

(Link)

Diastolic Dysfunction Assessment - Normal, Mild, Moderate ...

E = rapid filling 

A = atrial contraction 

S = forward flow (from the pulmonary vein perspective) 

D = filling of the ventricle 

A = reverse flow (left atrium to the pulmonary vein, from the pulmonary vein perspective)

Severe Diastolic Dysfunction: [ Adur – adur >=30 ] 

Adur = reversed flow (LA to pulmonary vein) caused by atrial contraction 

adur = atrial contraction (from the ‘mitral inflow’ perspective) 

The ‘Adur’ duration will be longer in a restrictive diastolic dysfunction pattern because blood that cannot fill the left ventricular space backs up into the left atrium. This leftover blood will then cause the duration of blood flow from the left atrium to the pulmonary vein to be increased in comparison with the mitral inflow perspective. In other words, the blood flow duration represented by the ‘Adur’ variable will continue long past the closing of the mitral valve and subsequent ending of the duration of flow across the mitral inflow tract (represented by ‘adur’). 

Other Parameters for evaluating diastolic dysfunction:

  • left atrial (LA) maximum volume index: looking at patients body surface and end atrial diastole. >34 ml/m2
  • tricuspid regurgitant systolic jet velocity: calculated with continuous wave doppler from apical 4 chamber. >2.8 m/s
  • valsalva for dynamically assessing reversal mitral inflow velocity E/A
  • E/e’ >14

References

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100236/
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1768877/#r7
  3. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

Please feel free to add 😀 

General Tips

  • Always ask for the patient’s date of birth instead of their name if not sure
  • Make sure to check the patient in and copy over the previous note
  • If patient was seen recently and their labs are not in their documents section, ask the front desk staff to check Quest for their results
  • Please don’t stand in the hallways due to COVID precautions. Prepare presentations in empty patient rooms (1 or 2)

Patient Education Tips

  • Plant-based diet: vegetables, beans, nuts, seeds, and fruits. Anything grown from the ground.
  • Fruits: Any type of fruit including apple, bananas, grapes, strawberries, citrus fruits, etc.
  • Vegetables: Plenty of veggies including peppers, corn, lettuce, spinach, kale, peas, collards, etc.
  • Tubers: Root vegetables like potatoes, carrots, parsnips, sweet potatoes, beets. Etc.
  • Legumes: Beans of any kind, plus lentils, pulses, etc. nuts, seeds, avocados, tofu, tempeh

Note Writing Tips

  • Read other notes’ assessments to get idea of how to write 
  • Add initials to Encounter so staff can reference/ask 
  • Add Summary section to Others @ end of Plan for the next student for quick reference 
    • Include date of visit, chief complaint, work up and follow up plan
  • Always utilize the spell check function and minimize abbreviations 
  • Don’t change the color (status) of the note until someone has reviewed it 
  • Always double check that vitals are included and physical exam section is correct (toggle physical exam performed or not)
  • Carefully read the assessment and plan sections. Check for completion, flow, spelling and grammar mistakes. 

Topics to Study/Review

  • Generic & brand names of common medications (HTN meds, HLD meds, DM meds, blood thinners)
  • Review BP medication classes and side effects 
  • If you don’t know medication quickly look it up prior to presenting- might ask about it
  • STATINS, doses, mechanism of action, side effects (myalgia – monitor CK, myopathy, headache, GI)
  • PCSK9 inhibitor, Praulent and Repatha, mechanism of action, monthly and every 2 weeks, side effects (myalgia), sinus congestion is a common side effect of repatha
    • You want to warm up repatha before administering it (have patient hold in hands) if pen, make sure all the med is administered before removing

Oral presentation blueprint

  1. Mr/Mrs./Miss ____
  2. Age/ gender
  3. PMH- including cardiac surgeries
    1. For aortic stenosis include most recent valve surface area
    2. For CHF include NYHA class
    3. For aortic aneurysms include most recent measurement 
    4. For MI include date and area of stent placement
  4. Coronary Calcium Score
  5. Last lipids Date and LDL #
  6. Statin therapy, if not why not?
  7. ASCVD 
  8. CHAD-VASC (only if hx of afib or on anticoagulant)
  9. Chief Complaint and HPI
  10. Cardiac sx
  11. Home blood pressures and home blood glucose 
  12. Last visit medication changes
  13. Any questions for Dr. Ben-Zur?

Primary Hyperaldosteronism 

Background: Excess aldosterone secretion from the adrenal cortex. Most common cause of primary hyperaldosteronism is bilateral adrenal hyperplasia. 

Clinical Presentation: Refractory hypertension in young or middle aged adults commonly failing multiple anti-hypertensive drug regimens. Associated symptoms include headaches, fatigue, flushing and excess sweating.

Diagnostics: 

  • Hypokalemia
    • Metabolic alkalosis may be present due to counter exchange of potassium and hydrogen in the kidneys
  • Plasma aldosterone concentration (PAC) to plasma renin assay (PRA) ratio
    • PAC/PRA ratio of > 20
    • PAC is often greater than 15 ng/dL
  • Confirmatory test: 24 urine aldosterone >20 mcg/24hrs
  • MRI or CT scan can be used to differentiate adrenal hyperplasia from an adrenal adenoma (Conn Syndrome) 

Treatment:

  • Spironolactone is the mainstay of treatment
  • Laparoscopic surgery can be performed for unilateral adrenal hyperplasia or adrenal adenoma


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