Diastolic dysfunction and heart failure physiology historical features and clinical perspective
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DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE. Medicine Resident Rounds September 28, 2007 Jacobi Hospital. TERMINOLOGY. Diastolic dysfunction Alteration in active or passive relaxation of the LV Diastolic heart failure

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Diastolic dysfunction and heart failure physiology historical features and clinical perspective

DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE

Medicine Resident Rounds

September 28, 2007

Jacobi Hospital


Terminology
TERMINOLOGY HISTORICAL FEATURES AND CLINICAL PERSPECTIVE

  • Diastolic dysfunction

    • Alteration in active or passive relaxation of the LV

  • Diastolic heart failure

    • Signs/symptoms of heart failure w normal ventricular function/size and findings of abnormal diastolic function

  • Systolic heart failure

    • Signs/symptoms of heart failure w abnormal ventricular function/size.


Isovolumic early relaxation energy dependent
ISOVOLUMIC (EARLY) RELAXATION HISTORICAL FEATURES AND CLINICAL PERSPECTIVEENERGY DEPENDENT


Phases of diastole
Phases of diastole HISTORICAL FEATURES AND CLINICAL PERSPECTIVE



Historical concepts of diastolic function
HISTORICAL CONCEPTS OF DIASTOLIC FUNCTION Pulmonary Congestion

  • 1940-1965 Experimental Heart failure was associated with increased diastolic pressures (volume overload or global ischemia)

    • Objective confirmation of Heart failure was an elevated diastolic pressure (during cardiac catheterization)

  • 1965 Braunwald editorial noting that marked increases observed in hypertrophic hearts without evidence of clinical heart failure.

  • 1970 Report of reversible diastolic pressure increase without enlargement of the LV heart size during ischemia .

  • 1975 Non invasive techniques of evaluating diastolic volume changes, wall thickness and LV diastolic diameter


Spontaneous angina effect on systolic diastolic pressure
SPONTANEOUS ANGINA Pulmonary CongestionEFFECT ON SYSTOLIC & DIASTOLIC PRESSURE


Lv diastolic pressure changes during exercise induced angina
LV DIASTOLIC PRESSURE CHANGES Pulmonary CongestionDURING EXERCISE INDUCED ANGINA

50---

50---


Changes in lv diastolic pressure and volume diuring angina induced by atrial pacing
CHANGES IN LV DIASTOLIC PRESSURE AND VOLUME DIURING ANGINA -- INDUCED BY ATRIAL PACING

DWYER CIRC 1970


Lv anatomic changes alters distensibility in chronic non ischemic disorders
LV ANATOMIC CHANGES ALTERS DISTENSIBILITY -- INDUCED BY ATRIAL PACINGin CHRONIC NON-ISCHEMIC DISORDERS

  • Myocardial cell Hypertrophy occurs and corresponds to wall thickness as per Echocardiogram

  • Active fibrotic process occurs with increase in the amount of collagen and shift to less pliable collagen


Lv diastolic distensibility
LV DIASTOLIC DISTENSIBILITY -- INDUCED BY ATRIAL PACING

  • Stiffness- Compliance- Distensibility are best quantified by the LV pressure / volume relationship


Assessment of diastolic function
Assessment of Diastolic Function -- INDUCED BY ATRIAL PACING

Echocardiogram

  • Normal Heart size and normal contraction pattern

  • E/A flow velocity ratio : in DD E declines and A increases (normal: 1.2- 2 & Abnormal <1) ; alsoAbnormal pulmonary venous flow velocity

    Cardiac Catheterization

  • Normal heart size and contraction pattern

  • LV end diastolic pressure (normal =12 mmHg) Greater specificity when 16 mmHg used as upper normal.

E

A

E

E

A


Common causes of diastolic dysfunction
COMMON CAUSES OF DIASTOLIC DYSFUNCTION -- INDUCED BY ATRIAL PACING

  • Ischemia(potentially reversible delay in or incomplete early relaxation)

  • Acute Hypertension (potentially reversible delay in or incomplete early relaxation)

  • Infarction(increased passive stiffness)

  • Chronic Hypertension with Hypertrophy(increased passive stiffness)

  • Aortic Stenosis & IHSS (increased passive stiffness)

  • Idiopathic Hypertrophic Cardiomyopathy (increased passive stiffness)

  • Diabetes and Obesity(increased passive stiffness)


Triggers to pulmonary congestion in patients with diastolic dysfunction
TRIGGERS TO PULMONARY CONGESTION -- INDUCED BY ATRIAL PACING IN PATIENTS WITH DIASTOLIC DYSFUNCTION

  • Volume overload

    • Increased salt & water intake

    • Chronic renal disease

    • Iatrogenic (procedure or surgery related)

    • Severe chronic anemia

  • Tachycardia

  • Atrial Fibrillation with and without rapid VR

  • Hypertension (>200 mmHg)

  • Ischemia


RELATIONSHIP BETWEEN LV SYSTOLIC PRESSURE AND LV DIASTOLIC PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES

R = .44

DWYER ET AL AHJ 2000


Exercise response in diastolic dysfunction
EXERCISE RESPONSE IN DIASTOLIC DYSFUNCTION PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES


Acute treatment of diastolic heart failure
ACUTE TREATMENT OF PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES DIASTOLIC HEART FAILURE

  • Reduce intravascular volume carefully

    • Morphine, diuretic, NTG

  • Control Systolic BP in obvious hypertensive state

    • Morphine, diuretic, NTG, ACE inhibitors, betablocker

  • Treat any ischemia

    • NTG, anti-thrombotic Rx, if indicated

  • Control ventricular heart rate

    • Beta blocker, Ca++ channel blocker


Chronic treatment of diastolic heart failure
CHRONIC TREATMENT OF PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES DIASTOLIC HEART FAILURE

  • Standard management of underlying disorder(s)

  • In Hypertrophic and/or fibrotic disorders, including hypertension, Diabetes and Obesity, consider

    ACE inhibitors, ARBs, Spironalactone & beta-blocker to promote regression of LV mass and prevention of further fibrosis.

  • Greater emphasis on maintaining sinus rhythm in patients with paroxysmal atrial fibrillation


Recurrent pulmonary edema rx surgical intervention
RECURRENT PULMONARY EDEMA PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES Rx: SURGICAL INTERVENTION

1985


Diastolic dysfunction and outcome
DIASTOLIC DYSFUNCTION PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES AND OUTCOME

  • SETARO et al 1992; AJC

    • 52 pts WITH CHF & INTACT SYSTOLIC FUNCTION

    • F/U 7 YRS

    • 50% CAD; 31% HTN

    • MEAN AGE = 71

  • COHN et al 1990; CIRC

    • 83 pts

    • F/U 5 YRS

    • 27% CAD; 53% HTN

  • BROGAN et al 1992;AJM

    • 51 pts

    • F/U 6 YRS

    • NO CAD


Framingham study
FRAMINGHAM PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES STUDY

25% CAD

80% CAD

80% CAD

VARSAN JACC 1999


Prognosis of diastolic dysfunction nomal coronary arteries
PROGNOSIS OF DIASTOLIC DYSFUNCTION PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES NOMAL CORONARY ARTERIES

BRADY & DWYER 2006 Clin Card


Summary
SUMMARY PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES

  • Diastolic dysfunction and Diastolic Heart failure is common

  • It is present in many common disorders. Beware and be skeptical of the patient with the diagnosis of “asthma”

  • It’s easy to treat the acute heart failure and fun too! Patients are usually ready to go home within hours and probably can.

  • Managing the progression and chronic state is more problematic.

  • Patients with many admissions with diastolic heart failure is a often physician failure in managing the underlying disorders.

  • Prognosis is heavily influenced by the presence of coronary disease and the age of the patient. Can’t live forever!


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