Principal Financial Group®
Life New Business & Underwriting
Basics of the Echocardiogram:
Diastolic Dysfunction & Left Ventricular
Hypertrophy (LVH)
Cindy Miller
Senior Underwriting Consultant
Jon Leinen
Technical Underwriting Director
For producer information only. Not for use in sales situations.
The Echo
History
• The technology of sonar or echosonography was
originally developed during World War II to detect
submarines
• The first “echo” was in the early 1950s. A Swedish
physicist borrowed a sonar device from a local
shipyard, modified it, and recorded echo’s from his
own heart
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The Echo
Uses of the Ultrasound (US)
• Gynecology and obstetrics
• Vascular issues
• Musculoskeletal issues
• Detection of tumors in various areas in the body: prostate,
colon, breast, heart, gastointestinal tract and other organs
• Cardiology
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The Echo
Cardiac Arena used for:
•
Identification of structures of the heart (normal and abnormal)
•
Allows for assessment of the motion and function of the heart and it’s
various structures
•
Follows blood flow through the heart and measures velocity of the
blood flow
•
Serves as a compliment to other diagnostic tests (eg. confirms EKG
findings for LVH or chest x ray finding; can be helpful assessing
degree of coronary plaque - via US that is done simultaneously with
cath.)
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The Echo
How is it completed?
• It involves a US machine, a wand which is known as a
transducer that is connected to a US machine
• The patient lies on stretcher and the echosonographer who
has been specifically trained in techniques of
echosonography performs the scan
• The scan is completed in a very systematic format to obtain
specific views of the heart that the cardiologists expects to
see on any given echo
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The Echo
• 3 inter-related processes utilized
during an ECHO
– M mode
– 2-D component
– Doppler (continuous wave/pulses wave/
color flow)
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The Echo
M Mode
– Single dimension picture
– Enables us to look closely and measure the heart
chambers and structures, the aorta (helpful with
LVH, myxomatous valves, valvular stenosis,
hypertrophic & dilated cardiomyopathies)
– Can also play a role in the assessment of some
valve functions
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The Echo
M Mode (LVID and Wall measurements / MV motion)
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The Echo
2D Mode
– Two dimensional picture of the heart is produced as result of sound waves
going out of the transducer and bouncing off a structure and then returning
back to the transducer
2D - 4 Chamber apical view
Diastole
Systole
MV open
MV closed
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The Echo
2D -parasternal
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The Echo
Doppler Mode
– Evaluates the path of the blood flow
– Evaluates the blood flow velocity as it moves through the
heart and its structures
3 Types Doppler :
– Pulsed Wave
– Continuous Wave
– Color Flow
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The Echo
Pulsed Wave Doppler
Measures velocity of blood as it moves through the heart
•
Helps to assess how heart muscle squeezes (systole) & relaxes (diastole)
E/A ratio
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The Echo
Continuous Wave Doppler
• Measures blood flow velocity as it moves through the
valves
• Measure degree of valvular regurgitation measuring the
density, length and shape of the wave forms
• Helps to quantify how severely a valve is leaking
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The Echo
Continuous Wave
Doppler
Aortic Insufficiency
Mitral Regurgitation
• CW- Aortic Regurg
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The Echo
Color Flow Doppler
• Measures the velocity and direction of blood flow via color
patterns
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The Echo
Color Flow Doppler
MV Open
MV Closed
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The Echo
Putting it all together
• During the test the images that have been obtained (M
mode/2 D images and Doppler) are recorded for later
viewing by the MD
• The technician writes a report of their interpretation of the
findings and prepares the report and a recording of the
entire echo for the MD to review
• MD provides a final analysis from the recording/the
interpretation
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The Echo
What Underwriters should note when reviewing the
report:
• Why was it completed?
• Patient data (being aware of the persons age/any disease
processes/body size )
• Quality of the image
• Assess the entire report and try not to focus on just
one aspect *****
• Do the findings make sense with the overall clinical
picture? *****
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The Echo
Limitations & Variables
• Interpretation of the echo can be somewhat subjective
• Body habitus and other physical deformities can alter the
findings and ability to accurately obtain some of the images
• Equipment variables
• Sonographer technique and experience
• Some of the findings can’t be reproduced and are time
specific
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The Echo
Additional Considerations
• Don’t take an isolated reading and automatically rate it,
instead consider the following…
– Compare to prior echos
– Take age and body habits into consideration
– Note the BP and other impairment history
– Note why the test was done in the first place
– What if any clinical signs/symptoms are present
– What other clinical data is present that support the findings
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The Echo
Common Abnormal Echo Findings
•
LVH
• Concentric (hypertension, valve diseases, aortic stenosis,
cardiomyopathies, obesity)
• Asymmetric Septal Hypertrophy (ASH), Valve disease
• Abnormal Wall Motion
• Global hypokensis (HK) (cardiomyopathies)
• Segmental HK or akinesia (AK) (ischemic heart disease)
• Dyskinesia (aneurysms, LBBB)
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The Echo
Common Abnormal Echo Findings cont…
– Abnormal Valves - stenosis , insufficiency, bicuspid AV
– MAC (Mitral annular calcification), thickened cusps, calcium deposits
– Diastolic dysfunction
– PFO / ASD
– Atrial Enlargements (valve disease, diastolic dysfunction or atrial fib)
– Aortic Root enlargements (CTD, valve disease)
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The Echo
Less Common Findings…
• Tumors (malignant or benign)
• Pericardial effusions
• Congenital defects (great vessel anomalies)
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The Echo
Normal findings on a typical Elderly person ..
• LV wall thickness increases 15%;
• LV mass increases 1 gm/yr from ages 65-80
– senile septum ( septum thickens slightly )
• LA dimensions increase ~ 16%
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The Echo
Normal findings on Elderly person cont…
• LV dimension unchanged
• Aortic Root diameter increases ~ 22%
• E/A velocity is often reversed ( diastolic dysfunction )
• Valvular disease and MAC
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The Echo
Normal Dimensions / Adult 2D-Echo
Right ventricular dimension (RVD)
1.9 - 2.8
Left ventricular end diastolic dimension
(LVEDD)
3.5 - 6.0
Left ventricular end systolic dimension
(LVESD)
2.1 - 4.0
Posterior LV wall thickness (PW)
0.6 - 1.1
Interventricular septum wall thickness (IVS)
0.6 - 1.1
Mild enlargement 1.2 – 1.3
Mod 1.4 – 1.5
Severe 1.6 – 1.7
Left atrial dimension (LA)
1.9 - 4.0
Aortic root dimension (AR)
2.0 - 3.7
Cusp separation - aortic valve
1.5 - 2.6
Fractional shortening (FS)
25 – 42%
Ejection fraction (EF)
50 – 59%
Pulmonary Artery Pressure (RSVP)
Up to 40
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Echocardiogram Reference RangesLeft Atrium
Female
Normal
Range
Mildly Abnormal
Moderately
Abnormal
Severely
Abnormal
LA Diameter, cm
2.7 – 3.8
3.9 – 4.2
4.3 – 4.6
≥ 4.7
LA Diameter BSA, cm
1.5 – 2.3
2.4 – 2.6
2.7 – 2.9
≥ 3.0
≤ 20
21 – 30
31 – 40
≥ 40
22 – 52
Normal
Range
53 – 62
Mildly Abnormal
63 - 72
Moderately
Abnormal
≥ 73
Severely
Abnormal
LA Diameter, cm
3.0 – 4.0
4.1 – 4.6
4.7 – 5.2
≥ 5.3
LA Diameter BSA, cm
1.5 – 2.3
2.4 – 2.6
2.7 – 2.9
≥ 3.0
≤ 20
21 – 30
31 – 40
≥ 40
18 – 58
59 – 68
69 - 78
≥ 79
LA Area
LA Volume, ml
Male
LA Area
LA Volume, ml
Women and Men:
LA Volume Index: Normal ≤ 28 ml/m²; Mild to Moderate- 29-39ml/m²; Severe- >40 ml/m²
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Diastolic Dysfunction
LEFT VENTRICULAR DYSFUNCTION
• The Basics
– The heart is a pump: it has to be able to fill up (diastole) and then it
has to be able pump the blood out (systole)
• Systolic dysfunction
– Pump failure equates to a low Ejection Fraction (EF) Cardiomyopathy / CAD
– Heart muscle is damaged and is unable to pump the blood out to
the body normally
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Diastolic Dysfuntion
Diastolic dysfunction
• LV can’t fill normally due to impaired relaxation/or restriction
• Ventricular systolic function is preserved
• Incidence increases with age and is seen in some degree in
at least 50% of older patients
• More prevalent in women
• Signs and symptoms may be the same as in systolic failure
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Diastolic Dysfunction
Pathophysiology of Diastolic dysfunction:
• Normally the LV is passively filled, and then the atria
contract and that provides additional “atrial packing.”
• In diastolic dysfunction the left ventricle cannot fill up with
blood normally due to a hard stiff and non compliant LV and
the blood has to be forced in
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Diastolic Dysfuntion
Causes of Diastolic Dysfunction
• Aging - lose general elasticity
• HTN - general wear and tear on the heart muscle causing it
to hypertrophy and become stiff
• Aortic stenosis - LV becomes stiff because it’s
overworked
• MI - scarring, damaged muscle
• Ischemic heart disease - damaged muscle
• Obesity - increases the workload and the muscle
hypertrophies and becomes stiff and non compliant
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Diastolic Dysfuntion
Prognosis
• Depends on the degree of diastolic dysfunction
• If severe, can be as grim as systolic failure
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Diastolic Dysfunction
Signs & Symptoms
• Shortness of Breath / Dyspnea on Exertion
• SM and or S4 present
• Pedal edema
• Systolic Hypertension
• Increased proBNP (brain naturetic peptide - hormone made by the
heart that increases when the heart is stressed
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Diastolic Dysfuntion
Echo findings that support diagnosis of Diastolic
Dysfunction:
•
Abnormal E/A ratio –
– E/A ratio is the ratio between passive filling and active
filling of the LV (normally the E wave is 80% process and
A wave is 20%; in diastolic dysfunction this ratio is
reversed)
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Diastolic Dysfunction
Normal E/A ratio
First spike = E wave / Second smaller spike = A wave
.
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Diastolic Dysfunction
Diastolic Dysfunction
– Equates to reversed
E/A ratio (smaller E
wave - taller A wave)
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Diastolic Dysfunction
Four Echocardiographic Patterns of Diastolic
Dysfunction
• Grade I
– Abnormal relaxation
– Reversal of E/A ratio
– Some of this is normal with aging
– No significant clinical signs or symptoms
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Diastolic Dysfuntion
Four Echocardiographic Patterns of Diastolic
Dysfunction
• Grade II
– Pseudo-normal filling (poorer prognosis at this stage)
– Moderate diastolic dysfunction
– Clinical symptoms apparent as well as have LAE and increased
filling pressures
– Having more symptoms of SOB and possibly some edema
– Decreased exercise capacity
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Diastolic Dysfunction
• Grade III - IV Diastolic Dysfunction
– Restrictive filling
– Advanced diastolic dysfunction
– Left Atrial enlarged significantly
– May also have reduced EF
– This would be diastolic heart failure rather than systolic
failure. (Often hard to differentiate whether its systolic or
diastolic failure at this because of the complex issues at play
and it’s probable they could be experiencing both at this
point)
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Diastolic Dysfuntion
Treatment
Treat the cause / reduce the workload……
• Control hypertension
• Control the heart rate - maximize diastole/filling period (beta blockers)
• Improve LV relaxation (calcium channel blockers/ace
inhibitors/angiotensin receptor blockers)
• Decrease the resistance the heart pumps against (afterload) and or
decrease the filling pressure/pre-load by use of vasodilators
• Monitor build and salt intake
• Lose weight and exercise
• Regular follow up
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The Echo: Case Study #1
– 73 male NS
– 72 inches 260 #
– NIDDM & HTN.
– Six months ago went to Emergency room complaining of SOB. No
chest pain or palpitations. Last year had EBCT calcium score 10.
– BP 180/100
– Grade II/VI SEM ; S4
– 2 + Pedal edema
– Ecg increased voltage
– Chest x-ray mild cardiomegaly
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Case Study
Echo
- Mild Aortic stenosis
- EF 50%
- Reversed E/A ratio
-
IVS-1.2 ; PW-1.3
-
LVID 5.6; LA 4.6
- Right sided chambers mildly dilated.
- Mild TR and RSVP 39
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Case Study
RECAP ----Indicators that he may have significant diastolic dysfunction
– NL EF and still having unexplained symptoms not otherwise
accounted for by another disease
– Age and build
– Long standing htn not optimally controlled
– AS
– S4 ( noncompliant ventricle)
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Left Ventricular Hypertrophy (LVH)
LVH …
Ecg- increased voltage on the ecg tracing
– Chest x-ray- cardiomegaly
– Echocardiogram- measurement of the thickness of the LV
wall
The most specific test for LVH is from the echo
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LVH
• Normal LV wall thickness: 0.6 cm to 1.1 cm
• LVH (LV wall thickness)
• Mild: 1.2-1.3 cm
• Moderate: 1.4-1.5 cm
• Severe: 1.6-1.7 cm
• Extreme: >1.7 cm
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LVH
• 2 measurements to look for on the echocardiogram
for LVH:
• Posterior LV wall thickness (PW) - normal -0.6 - 1.1
• Interventricular septum wall thickness (IVS) - 0.6 - 1.1
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LVH
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LVH
• What is 1 cm wide?
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LVH
• Not much in actual difference between 1.0 and 1.7
cm. However there is very significant mortality risk
with this relatively small difference when talking about
the left ventricle wall thickness
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LVH
• Concentric - enlargement of the wall that is the same
for both the posterior wall and the septal wall
• Asymetrical - differences in thickness of the walls.
10% of cases, left ventricular hypertrophy may
manifest on echocardiograms in an asymmetric
– May indicate possible hypertrophic cardiomyopathy
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Causes of LVH
• Hypertension
• Heart valve disorder such as aortic valve stenosis
• Ischemia
• Cardiomyopathy
• Nutritional disorder
• Endocrine disorder
• Congenital heart disease
• Toxins- alcohol, drugs
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What is LV Mass
• Takes into account gender and size of the individual
as well as LVEDd, PWT, and IVS to determine the
relative size (mass) of the LV
• Increased LV mass is also associated with an
increased risk for sudden cardiac death
• Measurements of LV mass must be interpreted in the
clinical context
• In clinical practice, however, the presence of LVH is
more commonly defined by wall thickness
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LVH: Assessment
How do we assess LVH?
•
Look for underlying cause, any clinical
symptoms/findings- primary reasons for LVH are
hypertension and valve disorder
•
Mild- as good as standard/preferred, depending on
history
•
Moderate- likely mildly to moderate ratable
•
Severe- highly rated, if we can offer
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Contact for Questions
Contact information:
Cindy Miller: Miller.cindy@principal.com
PH: 515-235-9285
Jon Leinen: Leinen.jon@principal.com
PH: 515-247-6672
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Questions
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