Diastolic Heart Failure

By Lisa Tang, MDMay 9, 2006

Case Vignette: (1) A 78 year old woman with a history of

hypertension is admitted to the hospital with congestive heart failure. Physical examination reveals a blood pressure of 180/90 mm Hg, increased jugular venous pressure, peripheral edema, and pulmonary rales. A chest radiograph shows pulmonary edema and mild cardiomegaly. An echocardiogram shows increased thickness of the left ventricular wall, a left ventricular cavity of normal size, left atrial enlargement, and a left ventricular ejection fraction of 70 percent. The left ventricular Doppler filling pattern is abnormal and consistent with an elevated pulmonary capillary wedge pressure. How should this patient be treated?

The Echocardiogram:

Definition:Diastolic Dysfunction

An abnormality of diastolic distensibility, filling, or relaxation of the left ventricle

Irrespective of ejection fraction, whether or not it is normal or abnormal

Irrespective of whether or not patient is symptomatic or asymptomatic

Diastolic Heart Failure

In a patient with diastolic dysfunction who now has dyspnea

In the setting of venous congestion and pulmonary edema

Epidemiology of Congestive Heart Failure: (2) Approximately 5 million people in the U.S. have

CHF. Over 550,000 patients are diagnosed with CHF

for the first time each year. Primary reason for 12-15 million office visits and

6.5 million hospital days each year The incidence of CHF approaches 10 per 1000

population over age 65. Rate of hospitalization is similar to that

associated with systolic heart failure Fewer published data on diastolic heart failure

than systolic heart failure

Epidemiology of Diastolic Heart Failure: About one third of all patients with

congestive heart failure have diastolic heart failure

Prevalence is highest in patients older than 75 years old

Mortality rate is about 5-8 % annually as compared to 10-15% among patients with systolic heart failure

Mortality rate is directly related to age and the presence/absence of coronary disease.

Factors that Exacerbate Diastolic Heart Failure: Uncontrolled hypertension Atrial Fibrillation Non-compliance with or inappropriate

discontinuation of medications for heart failure Myocardial ischemia Anemia Renal insufficiency Use of NSAIDS or thiazolidinediones Dietary indiscretion with overindulgence in

salty foods

Pathophysiological Features of Diastolic Dysfunction:

Abnormal passive elastic properties of the left ventricle

Increased myocardial mass Alterations in the extramyocardial

collagen network Increased stiffness of the left

ventricle

Left Ventricular Diastolic Pressure in Relation to Volume:

The curse is shifted upward and to the left.

The chamber compliance is reduced.

The time course of filling is altered. The diastolic pressure is elevated.

Left Ventricular Pressure-Volume Loops in Systolic and Diastolic

Dysfunction

Characteristics of Diastolic Heart Failure: Low stroke volume Reduced cardiac output despite a

normal ejection fraction Limited exercise tolerance as a

result of elevated left ventricular diastolic and pulmonary venous pressure -> reduction in lung compliance -> increase in the work of breathing

Characteristics of Diastolic Heart Failure as Compared with Those of Systolic Heart Failure

Diagnosis:

A clinical diagnosis based on the finding of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular ejection fraction and no valvular abnormalities on echocardiogram according to the American College of Cardiology and the American Heart Association

Diagnostic Techniques: Echocardiogram Doppler echocardiography: measures

the velocity of intracardiac blood flow Diastolic flow from the left atrium and

left ventricle across the mitral valve has two components: the E wave, early diastolic filling and A wave, atrial contraction in late diastole

Diagnostic Techniques- cont: E wave velocity is influenced by both the rate

of early diastolic relaxation and the left atrial pressure.

Alterations in the pattern of E wave velocity reflects the degree of left ventricular diastolic dysfunction and prognosis.

Doppler assessment of flow into the left atrium through the pulmonary veins.

Tissue Doppler imaging which directly measures the velocity of change in myocardial length, as an index of left ventricular relaxation.

Patterns of Left Ventricular Diastolic Filling as Shown by Standard Doppler

Echocardiography

Management of Diastolic Heart Failure:Goals:

To reverse the consequences of diastolic dysfunction, i.e. venous congestion, exercise intolerance

To eliminate or reduce the factor responsible for the diastolic dysfunction

Initial Management:Goal: To reduce pulmonary venous pressure and congestion

Diuretics –use with caution; aggressive diuresis may result in serious hypotension given the steep curve of the left ventricular diastolic pressure in relation to volume

Supplemental oxygen, morphine, and nitroglycerin

Goal: To prevent tachycardia and/or to slow the heart rate Heart rate: determines the length

of coronary perfusion time -tachycardia causes a decrease in coronary perfusion time and increases in demand for myocardial oxygen

B-blockers Non-dihydropyridine calcium

channel blockers

Long Term Management: From the Candesartan in Heart Failure

Assessment of Reduction in Mortality (CHARM) Preserved study:

A study that compared candesartan with placebo in patients with a history of class II, III, or IV heart failure, a hospitalization for cardiac reasons, and an EF > 40 %, who are taking b-blockers, diuretics, calcium channel blockers, and/or spironolactone.

Results of CHARM Preserved Study: Over a median follow up period of 36

months, treatment with candesartan was associated with significantly fewer hospitalizations for heart failure.

Non-significant trend toward a reduction in the composite primary end point of hospitalization for heart failure and death from cardiac causes

No significant reduction in the risks of stroke, MI, and coronary revascularization

Long Term Management:Goal: To prevent and treat myocardial

ischemia

Revascularization via percutaneous techniques or CABG

Long Term Management:Goal: To treat hypertension

ACE-Inhibitors or Angiotensin Receptor Blocker

Goal: To promote regression of left ventricular hypertrophy

ACE-Inhibitors

Goal: To prevent fibrosis

Spironolactone

Management Principles for Patients with Diastolic Heart Failure

References: Aurigemma, G MD and Gaasch, W MD, Diastolic Heart Failure, New

England Journal of Medicine 2004;351:1097-1105 ACC/AHA 2005 Guideline Update for the Diagnosis and Management

of Chronic Heart Failure in the Adult Jessup, M MD and Brozena, S MD, Medical Progress: Heart Failure,

New England Journal of Medicine 2003;348:2007-2018 Kitzman, D MD et al, Pathophysiological Characterization of Isolated

Diastolic Heart Failure in Comparison to Systolic Heart Failure, JAMA 2002;288:2144-2150

Zile, M MD, Baicu, C PhD, and Gaasch, W MD, Diastolic Heart Failure –Abnormalities in Active Relaxation and Passive Stiffness of the Left Ventricle, New England Journal of Medicine 2004:350:1953-1959

Redfield, M MD et al Burden of Systolic and Diastolic Ventricular Dysfunction in the Community, Appreciating the Scope of the Heart Failure Epidemic, JAMA January 8, 2003;289:194-202

Yusuf, S, Pfeffer MA, Swedberg K, et al. Effects of Candesartan in Patients with Chronic Heart Failure and Preserved Left Ventricular Ejection Fraction: the CHARM-Preserved Trial. Lancet 2003;362:777-781