USMLE WORLD STEP 1

PATHOPHYSIOLOGY

Q NO 11: A 45-year-old Caucasian male presents to your office with exertional dyspnea and easy fatigability. He has not seen a physician for 10 years and has no knowledge of any medical problems. He does not take any medications. and admits to cigarette smoking and alcohol use. His BP is 170/90 mmHg and his heart rate is 80 beats per minute. There are bilateral lung crackles on physical exam. Which of the following set of laboratory findings would be most consistent with diastolic heart failure in this patient?

Left Ventricular Cavity A. B. C. D. E. F. Dilated Dilated Normal Normal Normal Dilated

Left Ventricular Ejection Fraction Decreased Decreased Decreased Decreased Normal Normal

Left Ventricular End-Diastolic Pressure Increased Normal Decreased Increased Increased Normal

Explanation: This patient has symptoms of heart failure, defined broadly as a pathophysiological state wherein the heart either cannot pump enough blood to meet tissue metabolic requirements, or can do so only from an elevated ventricular filling pressure. Heart failure may be systolic and/or diastolic. Diastolic heart failure designates a pathologic reduction in diastolic ventricular compliance. Left ventricular end-diastolic volume (LVEDV) and therefore stroke volume and cardiac output are reduced at normal filling pressures (LVEDP). The Frank-Starling curve relating stroke volume to LVEDV, and therefore ejection fraction (EF)I is normal. LVEDP must be increased to abnormally high values to achieve a normal LVEDV and thereby restore cardiac output to near normal. Left ventricular systolic failure implies that stroke volume and cardiac output are reduced at a normal LVEDV. The FrankStarling curve relating stroke volume to LVEDVI and therefore EF, is depressed. To maintain a near normal cardiac output, both LVEDV and thus LVEDP must be abnormally increased. In summary, LVEDP must be abnormally increased to restore cardiac output in both systolic and diastolic heart failure. However, LVEDV remains normal in diastolic failure but is increased in systolic failure. Thus we can eliminate Choices A, B, and F. Choice E is correct because it indicates a normal LVEDV and a normal ventricular performance (EF) with an elevated LVEDP. Isolated diastolic failure may result from hypertrophic or restrictive cardiomyopathy. (Choice A) This choice characterizes isolated systolic left ventricular failure which could result from an acute massive myocardial infarction, for example. (Choices B and C) These choices describe states with systolic left ventricular failure (reduced EF) and increased diastolic left ventricular compliance. (Choice D) This option represents a state with both decreased left ventricular contractile performance (EF) and decreased diastolic left ventricular compliance indicating a combination of both systolic and diastolic left ventricular failure, which may be seen in chronic ischemic heart disease. (Choice F) This choice describes a state with normal left ventricular contractile function (EF), but increased diastolic left ventricular compliance.

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USMLE WORLD STEP 1

PATHOPHYSIOLOGY

Educational Objective: Diastolic heart failure is characterized by normal ventricular contractile performance (EF) but a decrease in ventricular diastolic compliance. As a result, ventricular enddiastolic pressure (EDP) must be increased to achieve a normal ventricular enddiastolic volume (EDV) and stroke volume. Systolic heart failure is a decrease in ventricular contractile performance which requires increases of ventricular EDV and therefore also EDP to achieve a normal stroke volume. In summary, diastolic failure increases only FDP, whereas systolic failure increases both EDP and FDV.

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