CME INDIA Presentation by Dr. Brij Mohan MD, FICP, FIACM, Fellow Diabetes India, Kanpur (UP), Dr. Jayant Panda, SCB Medical College, Cuttack, Odisha, Dr. N. K. Singh, MD, FICP, Director, Diabetes & Heart Research Centre, Dhanbad & Dr. Shailaja Kale, MD FRCP(London) FACE FACP, Professor in Medicine, KEM Hospital, Director, Orange Diabetes Foundation, Pune.
Based on a workshop at IDEACON-2022, Kolkata on 1st July.
What we are going to explore?
- Dyspnea also called a shortness of breath.
- Patients perceived difficulty in breathing.
- However, shortness of breath is present with exercise and improves with rest.
- Can be primary manifestation of Respiratory Cardiac, Neuromuscular, Psychogenic, or systemic illness.
- Or combination of these.
SOB a symptom of various diseases than a disease itself
| Cardiac: Congestive Heart Failure, Coronary Artery Disease, Arrhythmia, Pericarditis, Acute Myocardial Infarction, Anemia |
| Pulmonary: Chronic Obstructive Pulmonary Disease, Asthma, Pneumonia, Pneumothorax, Pulmonary Embolism, Pleural Effusion, Metastatic Disease, Pulmonary Edema, Gastroesophageal Reflux Disease With Aspiration, Restrictive Lung Disease |
| Psychogenic: Panic Attacks, Hyperventilation, Pain, Anxiety |
| Upper Airway Obstruction: Epiglottitis, Foreign Body, Croup, Epstein-Barr Virus |
| Endocrine: Metabolic Acidosis, Salicylate Poisoning, Carbon Monoxide Poisoning, Diabetic Ketoacidosis, Thyrotoxicosis, Organophosphate Poisoning, Toxic Ingestions. |
| Central: Neuromuscular Disorders (Myasthenia Gravis, Guillain-Barre Syndrome, Multiple Sclerosis Amyotrophic Lateral Sclerosis) Pain, Ischemic Stroke, Intracranial Hemorrhage, Spinal Cord Injury. |
| Pediatric: Bronchiolitis, Croup, Epiglottitis, Foreign Body Aspiration, Myocarditis. |
| Findings – Look for these and GET AN IDEA to Proceed | Possible diagnosis |
| Wheezing, pulsus paradoxus, accessory muscle use | Acute asthma, COPD exacerbation |
| Wheezing, clubbing, barrel chest, decreased breath sounds | COPD exacerbation |
| Fever, crackles, increased fremitus | Pneumonia |
| Edema, neck vein distension, S3 or S4 hepatojugular reflux, murmurs, rales, hypertension, wheezing | Congestive heart failure, pulmonary edema |
| Wheezing, friction rub, lower extremity swelling | Pulmonary embolism |
| Absent breath sounds, hyperresonance | Pneumothorax |
| Inspiratory stridor, rhonchi, retractions | Croup |
| Stridor, drooling, fever | Epiglottitis |
| Stridor, wheezing, persistent pneumonia | Foreign body aspiration |
| Wheezing, flaring, intercostal retractions, apnea | Bronchiolitis |
| Sighing | Hyperventilation |
Credit: Ravi Singh on @rav7ks
Diabetes itself can give rise to Diabetic Lung Disease?
Credit: S Kolahian, V Leiss & B Nürnberg. Metab Disord 20, 303–319 (2019). https://doi.org/10.1007/s11154-019-09516-w
Fundamental to Management is to the cause of SOB
How to Assess CV Risk, how much aggressive approach?
- Standard Risk Factors – Smoking, FH, Obesity, Dyslipidemia Duration of diabetes.
- ECG TMT ECHO.
- CAC Score.
- Perfusion scans… Stress ECHO, CT angio, etc.
- Biomarkers.
- Different scores Ceramides etc.
- Standard RF predict the risk much better
Where do we go wrong?
- Defining patient’s CV Risk after ASCVD NO.
- Cardiovascular Risk Assessment Aggressive.
- Not using Statins correctly.
- Duration of diabetes is important.
- Family History of CAD in first degree relative.
- Age at diagnosis of diabetes.
- What about SGLT 2 Inhibitor as Primary Prevention?
Importance of CAC (Coronary artery calcium)
- CAC testing is useful in diagnosing subclinical CAD.
- It is useful in predicting the risk of future cardiovascular events and death.
- It has high negative predictive value of the test.
- It can serve to reclassify risk in patients beyond traditional risk factors.
- Elevated calcium scores can guide the initiation of statin or aspirin therapy.
- A high score in an asymptomatic patient needs comprehensive discussion of the risks and benefits.
Credit: Cleveland Clinic Journal of Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097.
Look for if SOB is Acute, Sub-acute or Chronic
Most Important STEP
Cut-off label of Natriuretic peptide matters
11 key principles underlying their clinical use of Natriuretic peptide (NP)
| Use NP in conjunction with all other clinical information. |
| It is reasonable surrogates for intracardiac volumes and filling pressures. |
| Measure in all patients presenting with symptoms suggestive of HF such as dyspnoea and/or fatigue, as their use facilitates the early diagnosis and risk stratification of HF. |
| It has very high diagnostic accuracy in discriminating HF from other causes of dyspnoea: the higher the NP, the higher the likelihood that dyspnoea is caused by HF. |
| Remember: Optimal NP cut-off concentrations for the diagnosis of acute HF (very high filling pressures) in patients presenting with acute dyspnoea are higher compared with those used in the diagnosis of chronic HF in patients with dyspnoea on exertion (mild increase in filling pressures at rest). |
| Obese patients have lower concentrations, mandating the use of lower cut-off concentrations (about 50% lower). |
| In stable HF patients, but also in patients with other cardiac disorders such as myocardial infarction, valvular heart disease, atrial fibrillation or pulmonary embolism, its concentrations have high prognostic accuracy for death and HF hospitalization. |
| Do screen NP for the early detection of relevant cardiac disease including left ventricular systolic dysfunction in patients with cardiovascular risk factors may help to identify patients at increased risk, therefore allowing targeted preventive measures to prevent HF. |
| BNP, NT-proBNP and MR-proANP have comparable diagnostic and prognostic accuracy. |
| In patients with shock, it cannot be used to identify cause (e.g. cardiogenic vs. septic shock), but remain prognostic. |
| It cannot identify the underlying cause of HF and, therefore, if elevated, must always be used in conjunction with cardiac imaging. |
Credit: Mueller C, et al. Eur J Heart Fail 2019
Credit: Mueller C, et al. Eur J Heart Fail 2019
Principles of diagnosis of HF/ All diagnostic steps are equally important
- Consider: Medical history, signs, symptoms
- Confirm: Natriuretic peptides, Echocardiography
- Assess clinical phenotype: HFrEF vs. HFpEF
- Assess etiology: Angiography, cMRI, Biopsy
- Risk stratification
- Workup for targeted therapies
More recently, two score-based algorithms (H2FPEF and HFA-PEFF) have been proposed to aid the diagnosis.
There are specific echocardiographic indicators of diastolic function that include
- Transmitral Doppler inflow velocity patterns
- Pulmonary venous Doppler flow patterns
- Tissue Doppler velocities
- Color M-mode flow propagation velocity
Echo is an excellent tool
Alert for HFpEF in Echo
- LA size (LA volume index >32 mL/m2).
- Mitral E velocity >90 cm/s, septal e′ velocity <9 cm/s.
- E/e′ ratio >9 have.
- If resting echocardiographic and laboratory markers are equivocal, a diastolic stress test is recommended.
- The confirmatory test for the diagnosis of HFpEF is invasive haemodynamic exercise testing.
- An invasively measured pulmonary capillary wedge pressure (PCWP) of ≥15 mmHg (at rest) or ≥25 mmHg (with exercise) or LV end-diastolic pressure ≥16 mmHg (at rest) is generally considered diagnostic.
- However, instead of an exercise PCWP cut-off, some have used an index of PCWP to cardiac output for the invasive diagnosis of HFpEF.
Never Forget that Heart Failure diagnosis starts with Clinical assessment
Credit: Mueller C, et al. Eur J Heart Fail 2019
Do know the latest categorisation of HF
HFpEF is the largest unmet need in Cardiology and Diabetes
Essential Take aways (European Society of Cardiology (ESC) recommends)
- Signs and symptoms of HF, an LVEF of more than or equal to 50%, and objective evidence of cardiac structural and/or functional abnormalities consistent with presence of left ventricular (LV) diastolic dysfunction/raised LV filling pressures (such as LV hypertrophy, left atrial enlargement or raised natriuretic peptides)
- Diagnosis involves the use of history, clinical examination, natriuretic peptide levels and echocardiography.
- However, some patients with HFpEF will get symptoms only on exertion, but do not have clinical signs at rest and therefore the aforementioned diagnostic testing may be inconclusive; this is where other investigations such as exercise stress testing, cardiopulmonary exercise testing and invasive haemodynamic testing can also be used to diagnose HFpEF or else confirm or exclude other diagnoses too.
- Patients with HFpEF tend to be older, female and are more likely to have comorbidities such as hypertension, atrial fibrillation, diabetes mellitus (DM), chronic lung disease, chronic kidney disease and anaemia.
- Risk factors for HFpEF appear to stem from comorbidities such as hypertension, obesity and diabetes, as well as being more prevalent with increasing age and in female individuals.
Now we have more insights to treat HF
- The SGLT2i dapagliflozin and empagliflozin are now part of the standard “quadruple therapy” which is indicated for every HFrEF patient independent of diabetes status.
- (Angiotensin converting enzyme inhibitor [ACEi] / angiotensin neprylisin inhibitor [ARNi]
- Beta-blocker
- Mineralocorticoid receptor antagonist [MRA])
- Empa/or DAPA
- SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers in this population.
Credit: AHA,2022
CME INDIA Tail Piece
Treatment of HFrEF Stages C and D
Credit: 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure. Journal of Cardiac Failure Vol. 28 No. 5 2022
References:
- Mueller C, McDonald K, de Boer RA, Maisel A, et al.Heart Failure Association of the European Society of Cardiology. Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail. 2019 Jun;21(6):715-731. doi: 10.1002/ejhf.1494. PMID: 31222929.
- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. 1 April 2022https://doi.org/10.1161/CIR.0000000000001063Circulation. 2022;145:e895–e1032
- https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure
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Very good
Very useful to all the clinicians and to the students of Medicine
Very comprehensive, educative