GP Frequently Asked Questions

How should I manage a young patient with regional wall motion abnormalities with no previous history of MI?

Whilst patients under 40 often have left ventricular ejection fractions at the lower limit of normal, regional wall motion abnormalities should not occur and should therefore be investigated in the absence of significant valve disease. The commonest conditions causing this feature in the young are cardiomyopathy, myocarditis and coronary artery disease.

At what point should I administer heart failure treatment for a patient with LV systolic dysfunction?

The diagnosis of heart failure is clinical so treatment with diuretics should be administered based on clinical features alone. Echo and BNP support the diagnosis and provide prognostic information. Patients with systolic heart failure benefit from ACE inhibitors, beta blockers and aldosterone antagonists.

When should diastolic dysfunction be considered significant?

In the community, diastolic dysfunction with preserved LV systolic function is responsible for 40% of all cases of heart failure. Echo is critical for the diagnosis. Generally, patients with echo evidence of preserved left ventricular systolic function and grade 2 or above (moderate or severe) diastolic dysfunction in combination with an elevated BNP or significant left atrial dilatation (> 4cm) should be considered as having diastolic heart failure if they have supporting clinical features.

How should I manage grades 2 to 4 LV diastolic dysfunction?

Unfortunately, beta blockers, ACE inhibitors and aldosterone antagonists do not have the same benefits in patients with diastolic heart failure. The main purpose of echo is to establish a diagnosis for the patient. Underlying coronary artery disease should be excluded in these patients.

Should I refer a patient with a PFO?

PFO (patent foramen ovale) occurs in one third of the population so generally such patients do not need referral. The only exception is young patients with cryptogenic stroke or possibly refractory migraine.

Do I need to arrange routine repeat echo's for mild valve disease?

Patients with mild valve disease should have a repeat echo in 2 years to look for disease progression.

Is diastolic dysfunction important in the elderly?

Grade 1 (mild) diastolic dysfunction is extremely common in the elderly and is of little significance. However, the presence of Grade 2 to 4 diastolic dysfunction in conjunction with a dilated left atrium or left ventricular hypertrophy would suggest significant diastolic dysfunction in these patients.

How should I manage a patient with a mildly dilated aortic root and what should the follow up be?

In a young patient with no evidence of hypertension, these patients should be referred to look for an underlying cause. In patients with hypertension, good blood pressure control should be achieved and annual echocardiograms organised to look for disease progression. Once the aortic root is > 4.5cm, the patient should be referred.

If a study is technically difficult and an alternative imaging modality is suggested, which imaging modality should I choose for a patient with suspected heart failure?

There are several possibilities depending on local expertise. These include a contrast echocardiogram, a cardiac MRI or a MUGA scan.

What should the follow up be for a patient with LVH?

Generally, if the left ventricular hypertrophy (LVH) is unexplained by valve disease or hypertension, a referral should be considered to look for an underlying cause. If the patient has hypertension, a referral should still be considered for symptoms such as chest pain, breathlessness, dizziness or syncope or a family history of sudden death. Hypertrophic cardiomyopathy needs to be excluded.

How should I manage a patient with a bicuspid aortic valve?

Patients with moderate or severe disease with symptoms should be referred. Patients with mild disease should have a repeat echo at 2 years. Patients with moderate disease who are asymptomatic should have a repeat echo after 1 year.

How should I manage a patient with RV systolic dysfunction?

Patients with RV systolic dysfunction do not benefit from ACE inhibitors, beta blockers or aldosterone antagonists. If there are signs of right heart failure, diuretics should be administered. Referral should be considered to look for an underlying cause. These include arrythmogenic right ventricular complex, intracardiac shunt, underlying respiratory disease, pulmonary embolus and pulmonary hypertension.

I have a patient with 0.5cm global pericardial effusion. Is this significant?

A small pericardial effusion < 0.5 cm seen only in the anterior space is a normal finding. However, any size pericardial effusion that is global should be considered pathological and investigated.