What is the diagnosis for a 65-year-old female with normal left ventricular systolic function, grade II diastolic dysfunction, mild mitral valve stenosis, trace mitral valve regurgitation, and mild pulmonary hypertension?

From the Guidelines

The patient should be managed with a focus on controlling systolic and diastolic hypertension, and monitoring for symptoms of heart failure, as grade II diastolic dysfunction is present, according to the 2009 ACC/AHA guidelines for the diagnosis and management of heart failure in adults 1.

Patient Profile

The echocardiogram shows a 65-year-old female with normal left ventricular systolic function (ejection fraction 70%) but grade II diastolic dysfunction, indicating impaired relaxation of the heart during filling. Her right ventricular function is normal with good parameters (S' 13.2 cm/s, TAPSE 2.9 cm). The patient has an enlarged left atrium and a calcified mitral valve annulus with mild mitral stenosis (mean pressure gradient 4 mmHg) and trace mitral regurgitation. There is mild pulmonary hypertension (PASP 35 mmHg), but normal right atrial pressure (3 mmHg) as evidenced by normal inferior vena cava collapse. No pericardial effusion is present, and the proximal ascending aorta is normal in size.

Management Approach

The management of this patient should prioritize controlling systolic and diastolic hypertension, as recommended by the 2009 ACC/AHA guidelines for the diagnosis and management of heart failure in adults 1. This approach is crucial in reducing the symptoms of heart failure and slowing the progression of diastolic dysfunction.

• Controlling hypertension is essential, as it can help minimize symptoms of heart failure, according to the 2009 ACC/AHA guidelines 1.
• The use of diuretics may be considered to control pulmonary congestion and peripheral edema, as recommended by the 2009 ACC/AHA guidelines 1.
• Blood pressure optimization may also benefit the patient, as it can help reduce the severity of diastolic dysfunction and mild pulmonary hypertension.
• Regular follow-up echocardiograms every 6-12 months should be performed to track the progression of mitral stenosis and pulmonary hypertension.
• Symptoms of dyspnea, especially with exertion, should be assessed at each visit to determine the need for adjustments in management.

Considerations

The patient's grade II diastolic dysfunction, mild pulmonary hypertension, and enlarged left atrium suggest that she is at risk for developing more severe heart failure symptoms. Therefore, close monitoring and management of her condition are essential to prevent morbidity and mortality. The 2016 recommendations for the evaluation of left ventricular diastolic function by echocardiography provide a framework for assessing diastolic function and guiding management decisions 1.

From the Research

Echocardiogram Results

• The patient's left ventricular systolic function is normal with an ejection fraction of 70% by Biplane Method of Discs 2.
• The left ventricular diastolic function is grade II diastolic dysfunction.
• Right ventricular systolic function is normal with S' 13.2 cm/s and TAPSE 2.9 cm.
• The left atrial chamber dimension is enlarged.
• The mitral valve has a calcified annulus with mild mitral valve stenosis (mean PG 4 mm Hg at 65 bpm) and trace mitral valve regurgitation.
• Mild pulmonary hypertension is present with an estimated pulmonary arterial systolic pressure of 35 mmHg.
• The inferior vena cava is normal with >50% collapse upon inspiration, consistent with normal right atrial pressure (3 mmHg).
• There is no pericardial effusion.
• The proximal ascending aorta is normal, measuring 3.3 cm with an index of 1.7 cm/m2.

Treatment Considerations

• Beta blockers and angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) are commonly used in the treatment of heart failure and coronary artery disease 3, 4, 5, 6.
• The combination of beta blockers and ACE inhibitors/ARBs may be beneficial in patients with cardiovascular disease, including those with hypertension, heart failure, and coronary artery disease 3, 4, 5, 6.
• The use of beta blockers and ACE inhibitors/ARBs in patients with diastolic dysfunction, such as the patient in this case, may be considered to improve symptoms and reduce the risk of cardiovascular events 3, 4, 5, 6.