Diastolic Heart Failure

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Diastolic Heart Failure

• By Lisa Tang, MD
• May 9, 2006

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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?

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The Echocardiogram
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DefinitionDiastolic 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

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Diastolic Heart Failure

• In a patient with diastolic dysfunction who now
  has dyspnea
• In the setting of venous congestion and pulmonary
  edema

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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

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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.

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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

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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

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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.

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Left Ventricular Pressure-Volume Loops in
Systolic and Diastolic Dysfunction
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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 -gt reduction in lung compliance
  -gt increase in the work of breathing

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

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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

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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.

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Patterns of Left Ventricular Diastolic Filling as
Shown by Standard Doppler Echocardiography
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Management of Diastolic Heart FailureGoals

• To reverse the consequences of diastolic
  dysfunction, i.e. venous congestion, exercise
  intolerance
• To eliminate or reduce the factor responsible for
  the diastolic dysfunction

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Initial ManagementGoal 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

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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

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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 gt 40 , who are taking
  b-blockers, diuretics, calcium channel blockers,
  and/or spironolactone.

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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

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Long Term ManagementGoal To prevent and treat
myocardial ischemia

• Revascularization via percutaneous techniques or
  CABG

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Long Term ManagementGoal To treat hypertension

• ACE-Inhibitors or Angiotensin Receptor Blocker

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Goal To promote regression of left ventricular
hypertrophy

• ACE-Inhibitors

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Goal To prevent fibrosis

• Spironolactone

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Management Principles for Patients with Diastolic
Heart Failure
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References

• Aurigemma, G MD and Gaasch, W MD, Diastolic Heart
  Failure, New England Journal of Medicine
  20043511097-1105
• 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
  20033482007-2018
• Kitzman, D MD et al, Pathophysiological
  Characterization of Isolated Diastolic Heart
  Failure in Comparison to Systolic Heart Failure,
  JAMA 20022882144-2150
• 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
  20043501953-1959
• 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,
  2003289194-202
• 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
  2003362777-781