Clinical manifestations and diagnosis of diastolic heart failure.pdf

Clinical manifestations and diagnosis of diastolic heart failurehttp://www.uptodate.com/online/content/topic.do?topicKey=hrt_fail/57... Official reprint from UpToDate® www.uptodate.com Print | Back Clinical manifestations and diagnosis of diastolic heart failure Author Michael R Zile, MD Section Editor Wilson S Colucci, MD Deputy Editor Susan B Yeon, MD, JD, FACC Last literature review for version 16.1: January 31, 2008 | This topic last updated: February 14, 2008 INTRODUCTION — Diastolic heart failure (HF) refers to a clinical syndrome in which patients have symptoms and signs of HF, normal or near normal left ventricular systolic function, and evidence of diastolic dysfunction (eg, abnormal left ventricular filling and elevated filling pressures) ( show table 1) [1-3] . Among patients with HF, as many as 40 to 60 percent have a normal or near normal left ventricular ejection fraction (LVEF) [1,4-9] . This condition has been labeled diastolic heart failure (DHF) or "heart failure with normal ejection fraction" (HFNEF) [ 10] . In such patients, diastolic dysfunction is the presumed cause of the HF, which can be confirmed by objective measures [1,11,12] . However, heart failure with normal ejection fraction can occur due to conditions other than diastolic dysfunction ( show table 2) [13] . The etiology, clinical manifestations, and diagnosis of patients with diastolic heart failure will be reviewed here. Issues related to treatment, prognosis, and pathophysiology are discussed separately. ( See "Treatment and prognosis of diastolic heart failure" and see "Pathophysiology of diastolic heart failure" and see "Cellular mechanisms of diastolic dysfunction" ). PREVALENCE AND DEMOGRAPHICS — The prevalence of diastolic heart failure as the cause of HF increases with age [1,6,14] . This was illustrated in a review in which the estimated prevalence of diastolic heart failure among patients with HF was 15, 33, and 50 percent at ages less than 50, 50 to 70, and more than 70 years, respectively [1] . In addition, another 15 percent of elderly patients with HF have only mildly abnormal systolic function (LVEF 45 to 54 percent), which should not produce symptoms on its own and is therefore probably associated with an important component of diastolic dysfunction [14] . The development of diastolic dysfunction in the elderly may be independent of left ventricular mass, heart rate, contractility, or systemic blood pressure [15] . A greater proportion of women than men have diastolic heart failure [ 16-19] . In a chart study of over 19,000 Medicare beneficiaries hospitalized with the principal discharge diagnosis of HF, 35 percent had a normal ejection fraction [16] . Among patients with normal ejection fraction, 79 percent were women, while among those with decreased ejection fraction, 49 percent were women. Asymptomatic diastolic dysfunction is much more common than symptomatic disease. This was illustrated in a community-based survey from the Mayo Clinic, which evaluated 2042 subjects ≥45 years of age [5] . The prevalence of symptomatic HF was 2.2 percent overall, 44 percent of whom had diastolic heart failure. Among subjects without symptoms of HF, 28.1 percent had some degree of diastolic dysfunction, which was moderate or severe in 7.3 percent using Doppler echocardiographic criteria. ( See "Echocardiographic evaluation of left ventricular diastolic function" ). Using data from more than 100,000 hospitalizations due to acute decompensated heart failure, the 50 percent of patients with a normal ejection fraction (ie, those with diastolic heart failure) had the following 1 of 15 7/23/2008 7:24 PM do?topicKey=hrt_fail/57. The contribution of atrial contraction is relatively small. Lower in-hospital mortality (3 versus 4 percent) but similar ICU and hospital length of stay.23] . The patients with diastolic heart failure had similar. which can be idiopathic or caused by infiltrative diseases of the heart (see "Idiopathic restrictive cardiomyopathy" and see "Cardiac sarcoidosis" and see "Clinical manifestations of hereditary hemochromatosis" and see "Amyloid cardiomyopathy") PATHOPHYSIOLOGY — Diastolic function is determined by two factors. (See "Pathophysiology of diastolic heart failure" ). which is a passive phenomenon [ 2] . CLINICAL MANIFESTATIONS — As mentioned above. the normal LV is composed of completely relaxed myocytes and is very compliant and easily distensible.. ETIOLOGY — The major causes of diastolic heart failure include [ 1] : Chronic hypertension with left ventricular hypertrophy (LVH) [ 20] . Relaxation of the contracted myocardium occurs at the onset of diastole. The net effect is a relative shift of LV filling to the later part of diastole with a greater dependence on atrial contraction ( show figure 1 and show figure 2). During the later phases of diastole. and pulmonary venous and pulmonary capillary pressures. due to either structural (eg. As a result. The pathophysiology of diastolic dysfunction is discussed in detail separately. impairs LV filling ( show table 3). LVH) or functional (eg. The rapid pressure decay and the concomitant "untwisting" of the left ventricle (LV) produces a suction effect that augments the left atrial-to-left ventricular pressure gradient. When present. female. offering minimal resistance to LV filling over a normal volume range. the symptoms of diastolic HF do not appear to differ significantly from those of systolic HF. ischemia) causes. although 2 of 15 7/23/2008 7:24 PM . the process of myocardial relaxation (which is an active process that requires metabolic energy) and the elasticity or distensibility of the left ventricle.Clinical manifestations and diagnosis of diastolic heart failure http://www. preserving a low pulmonary capillary pressure (<12 mmHg). left atrial. and hypertensive Less likely to have had a prior myocardial infarction or to be receiving an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker. thereby promoting diastolic filling.22. This results in increases in LV diastolic. This was illustrated in a report in which 59 patients aged at least 60 years with symptoms of HF and an LVEF ≥50 percent (diastolic heart failure) were compared with 60 patients of the same age with an LVEF ≤35 percent (systolic heart failure) and with 28 age-matched healthy controls [25] . LV filling can normally be accomplished by very low filling pressures in the left atrium and pulmonary veins. clinical characteristics compared to those with systolic dysfunction [ 9] : More likely to be older. although it is challenged by some [24] .uptodate.com/online/content/topic. a hypertensive hypertrophic cardiomyopathy with LVEF above 75 percent has been described in the elderly [ 6] Hypertrophic cardiomyopathy (HCM) (see "Clinical manifestations of hypertrophic cardiomyopathy") Aortic stenosis with a normal LVEF [21] Ischemic heart disease Restrictive cardiomyopathy. This analysis of diastolic heart failure is accepted by most experts in the field [ 1.. Loss of normal LV diastolic relaxation and distensibility. asymptomatic diastolic dysfunction is more prevalent than symptomatic disease [5] . They do not tolerate tachycardia well. or presumed. which can worsen myocardial relaxation in patients with diastolic heart failure. LV filling. DIAGNOSIS — The diagnosis of diastolic heart failure is often made.. inadequate cardiac output during exercise leads to fatigue of skeletal muscles. on echocardiography.com/online/content/topic. ( See "Treatment of hypertension in heart failure". and LV stroke volume.29] . manifestations (reduced exercise capacity." Episodes of hemodynamic decompensation may result in pulmonary congestion or edema severe enough to be life-threatening.25] . The acute induction or worsening of diastolic dysfunction by ischemia raises left atrial and therefore pulmonary venous pressure. LVH and a normal LVEF. In addition. and diminished quality of life). Evidence of LV diastolic dysfunction via invasive or noninvasive methods Limitations of the ESC consensus criteria for HFNEF include [ 31] : 3 of 15 7/23/2008 7:24 PM .27] . shortness of breath. Elevations in systemic blood pressure. since the loss of atrial contraction can dramatically reduce left atrial emptying. every patient had one or more of the indices of abnormal diastolic function [ 11] . including wheezing. in patients who have symptoms of HF and a normal LVEF by echocardiography [30] .do?topicKey=hrt_fail/57. an inability to take a deep breath. since the increase in heart rate shortens the duration of diastole and truncates the important late phase of diastolic filling. others insist that it is necessary to have objective evidence of abnormal left ventricular relaxation and distensibility [ 22. The 2007 consensus statement of the Heart Failure and Echocardiography Associations of the European Society of Cardiology requires the following three conditions for diagnosis of DHF or HFNEF ( show table 1) [3] : Signs or symptoms of HF. The exercise intolerance seen with diastolic heart failure is largely due to the impairment in left ventricular filling. This explains why many patients with coronary heart disease (CHD) have respiratory symptoms with their anginal pain. In one report of 63 patients with a history of HF and.uptodate. generally less severe. neurohumoral activation. especially the abrupt. These respiratory symptoms can occur in the absence of anginal pain and are often referred to as "anginal equivalents. Patients with diastolic heart failure have particular difficulty in tolerating certain kinds of hemodynamic stress: They tolerate atrial fibrillation (AF) poorly.. especially the leg muscles and the accessory muscles of respiration [ 28. (See "Pathophysiology and evaluation of acute decompensated heart failure" ). Normal or mildly abnormal LV systolic function (both LVEF >50 percent and an LV end-diastolic volume <97 mL/m2).23] . increase left ventricular wall stress.Clinical manifestations and diagnosis of diastolic heart failure http://www. or refractory elevations often seen with renovascular hypertension. severe. and overt pulmonary edema. which leads to elevations in left atrial and pulmonary venous pressures and pulmonary congestion [26. called flash pulmonary edema. Some experts argue that specific testing confirms but is not needed to establish the diagnosis [ 11. ( See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm" ). section on Diastolic dysfunction and see "Who should be screened for renovascular or secondary hypertension?"). is discussed in detail separately. This phenomenon. There is controversy about whether such patients require further testing to establish the diagnosis of diastolic heart failure [ 4] . However. 33] . It can also identify many of the causes of HFNEF. and the end-diastolic pressure can all be determined from hemodynamic tracings ( show figure 1). In addition.5 and DT >280 ms) but do not include parameters for restrictive filling (eg E/A >1.uptodate. Changes in pressure of a few mmHg. or paroxysmal nocturnal dyspnea) may be due to disorders such as obesity. The 2007 ESC statement also proposed an algorithm for excluding HFNEF in a patient with breathlessness without signs of fluid overload ( show table 4). With the addition of volume measurements. The electrocardiogram may be abnormal. the rise in diastolic pressure with atrial contraction. poorly controlled atrial fibrillation.do?topicKey=hrt_fail/57. showing evidence of marked LVH or a prior myocardial infarction.. lung disease. the combination of symptomatic HF and a normal LVEF is often used in epidemiologic studies. cardiac catheterization is of limited importance as a diagnostic tool in evaluating diastolic dysfunction. ankle edema. In one study of 47 patients with clinical HF and a normal LVEF (diastolic heart failure) compared to 10 controls without HF. Echocardiography — Echocardiography can demonstrate that the LVEF and LV volume are normal in a patient with HF [2] . Furthermore. but is not diagnostic.33. Better pressure measurements can be made with a micromanometer catheter.12.. but such equipment is not in routine use. "Echo .bloodflow Doppler" criteria include E/A ratio and DT (deceleration time) parameters consistent with impaired relaxation (E/A <0.Clinical manifestations and diagnosis of diastolic heart failure http://www. those with HF had a significantly higher mean end-diastolic pressure (25 versus 8 mmHg) and a significantly smaller mean end-diastolic volume (103 versus 115 mL) [ 12] . as a practical matter the accurate measurement of diastolic function in the cardiac catheterization laboratory is difficult [ 4. However. In practice. The rate of decline in left ventricular pressure in early diastole. and volume can be determined with a conductance catheter. which may be of significance in patients with diastolic dysfunction. symptoms suggestive of HF (such as shortness of breath. with the evolution of practical noninvasive methods such as Doppler echocardiography. Among patients who have intact left ventricular systolic function. the pressure-volume relationship can also be determined ( show figure 2). Cardiac catheterization — The hemodynamic features of diastolic dysfunction can be detected by direct measurement in the catheterization laboratory [ 1. Differential diagnosis — It is important to consider possible mimics of diastolic heart failure.12. Other causes include volume overload (as in renal failure) and increased afterload (as in hypertensive crisis).com/online/content/topic. (See "Noninvasive methods for measurement of left ventricular systolic function" ). are not reliably assessed with fluid-filled catheters. while further testing (usually Doppler echocardiography) is typically performed in the clinical setting. not all cases of cardiogenic pulmonary edema in patients with a normal LVEF are due to diastolic heart failure (show table 2).34] . (See "Pathophysiology and evaluation of acute decompensated heart failure"). The tissue Doppler requirement of E/E'> 8 which would exclude patients with normal resting filling pressures but elevated diastolic pressure with exercise. These include the following causes of diastolic dysfunction: LVH (show echocardiogram 1 show echocardiogram 2 show echocardiogram 3 Regional wall motion abnormalities due to ischemic heart disease show echocardiogram 4 show echocardiogram 5 Amyloidosis (show echocardiogram 11 show echocardiogram 12 Other cardiomyopathies such as hemochromatosis and sarcoidosis 4 of 15 7/23/2008 7:24 PM . and occult coronary ischemia [ 32] .5 and DT <140) or a pseudonormal pattern. (See "Pathophysiology of diastolic heart failure" . the presence of multiple risk factors for atherosclerosis.uptodate. whether by echocardiography or by other means. sophisticated imaging techniques (eg. Systolic function — Patients with diastolic HF have. such as stroke work. is important. assessment of mitral valve inflow velocity may demonstrate diminished early diastolic filling velocity.46] .Clinical manifestations and diagnosis of diastolic heart failure http://www. the pathophysiology of diastolic HF does not appear to be associated with significant abnormalities in systolic function [ 42] . These abnormalities are usually noted in longitudinal contraction and motion of the basal left ventricle in the region of the mitral annulus. in several series. by definition an LVEF >50 percent. The clinical significance of these abnormalities has not been established. Regional wall abnormalities are common in but are not specific for ischemia. Tissue Doppler imaging and measurement of pulmonary vein blood flow velocity also may be helpful. it is a relatively common finding in patients with systolic heart failure.11. other causes of HFNEF can be identified including: Constrictive pericarditis (show echocardiogram 6) Severe mitral regurgitation show echocardiogram 7 show echocardiogram 8 Severe aortic regurgitation (show echocardiogram 9 show echocardiogram 10 The distinction among causes of HFNEF. In a study of cardiac transplant recipients. as a result. However. Thus. section on Systolic function in DHF). manifested by an abnormally low E wave. manifested by an increased A wave. Findings suggesting the possible presence of ischemic cardiomyopathy include dyspnea at rest or on exertion (symptoms that may reflect anginal equivalents). There was no difference between the two groups in a variety of measures of LV systolic performance. patients with reduced LV compliance have a restrictive pattern.35. In addition. ( See "Treatment and prognosis of diastolic heart failure" ). When attempting to diagnose coronary ischemia. and the peak dP/dt. which is associated with an increased E/A ratio. the E/A ratio is less than one (show figure 3) [1] . the presence of LVH on the surface ECG may preclude an accurate evaluation with exercise ECG testing. Occult CHD — Occult CHD is a potentially reversible cause of diastolic heart failure [ 43] . 5 of 15 7/23/2008 7:24 PM . IDC is typically associated with an enlarged heart and systolic dysfunction.do?topicKey=hrt_fail/57. evidence of ischemia can be detected by myocardial perfusion imaging or stress echocardiography. the relationship between stroke work and end-diastolic volume. because some are responsive to specific therapies directed at the underlying disease. and increased late diastolic filling. ( See "Echocardiographic evaluation of left ventricular diastolic function" ). since they also occur in 50 to 60 percent of patients with IDC [ 45.36] . In contrast.. Although there are limited data on how often this occurs in patients with diastolic heart failure [ 32] . In patients with impaired relaxation. Doppler echocardiography — Doppler echocardiography is an effective method to establish the presence of abnormalities in diastolic function [ 1. ischemic cardiomyopathy was found in 9 of 38 patients with a pretransplant diagnosis of idiopathic dilated cardiomyopathy (IDC) and in three of four with presumptive alcoholic cardiomyopathy [ 44] . However. This issue was directly assessed in a study in which the systolic properties of the left ventricle was evaluated by echocardiography and cardiac catheterization in 75 patients with diastolic heart failure and 75 normal controls [41] . tissue Doppler imaging) have identified subtle abnormalities of regional systolic function in approximately 20 to 50 percent of patients with diastolic dysfunction [37-40] .com/online/content/topic. ( See "Exercise myocardial perfusion imaging in the diagnosis and prognosis of coronary heart disease" and see "Stress echocardiography in the diagnosis and prognosis of coronary heart disease").5. and ischemic changes on exercise testing. In such patients.. for example. JC Jr. MR. Circulation 2002. 312:277. Khand. TA. such as identifying a specific infiltrative disease or monitoring for anthracycline cardiotoxicity. Plasma BNP and N-terminal pro-BNP also elevated in patients with diastolic heart failure. but could not discriminate systolic from diastolic dysfunction. pseudonormal. respectively. or restrictive filling patterns based upon the E/A ratio and deceleration time ( show figure 3). Mean plasma BNP was significantly higher in the patients with diastolic dysfunction than in normals (286 versus 33 pg/mL). symptoms. We encourage you to print or e-mail these topic reviews. Patients were classified by echocardiography as having normal. plasma BNP was measured in 400 patients referred for echocardiography to evaluate left ventricular function [ 47] . www. Topol. INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. T. 351:1097. Banerjee. Use of UpToDate is subject to the Subscription and License Agreement. Fortuin. A plasma BNP ≥75 pg/mL had a sensitivity of 85 percent and a specificity of 97 percent in detecting any ventricular dysfunction. which includes these and other topics. and 402 pg/mL. 4. New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis. or to refer patients to our public web site. Endomyocardial biopsy — Endomyocardial biopsy may be helpful in selected settings. and diagnosis" and see "Patient information: Heart failure treatments").uptodate. MM. Hypertensive hypertrophic cardiomyopathy of theelderly. the mean plasma BNP was 30 pg/mL. Those with impaired relaxation. 5. N Engl J Med 1985. which included some patients from the previous report [ 49] . a plasma BNP ≥57 pg/mL detected the 28 patients with isolated abnormal diastolic function with 100 percent positive predictive value. Burnett. Eur Heart J 2007. WH. A. Banerjee. P. In one report. (See "Indications for endomyocardial biopsy"). but cannot be used to distinguish diastolic from systolic dysfunction [ 47-50] . Gaasch. (See "Brain natriuretic peptide measurement in left ventricular dysfunction and other cardiac diseases"). et al. Among patients with normal systolic function on echocardiogram. and measurements of diastolic function. DL. and restrictive filling patterns had plasma BNP concentrations of 202. Paulus. impaired relaxation. pseudonormal. J Am Coll Cardiol 2002. et al. Brutsaert. A plasma BNP ≥62 pg/mL had a sensitivity of 85 percent and a specificity of 83 percent for the diagnosis of diastolic dysfunction. WJ. Traill. 6 of 15 7/23/2008 7:24 PM . 105:1387.do?topicKey=hrt_fail/57. Tschope. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.uptodate. 294. Zile. ( See "Patient information: Heart failure causes. 3. Among those with normal left ventricular function. JE. GP.com/online/content/topic.com/patients.. JAMA 2003. prognosis. N Engl J Med 2004. Jacobsen. et al. 39:138. 2. REFERENCES 1. Another report evaluated 294 patients referred for echocardiography who had normal left ventricular function. EJ. Redfield.. The indications for this procedure are discussed elsewhere. Diastolic heart failure: neglected or misdiagnosed?. 289:194. Diastolic heart failure. NJ. 6. C. Sanderson. Clinical practice. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. Plasma BNP — The plasma concentrations of brain natriuretic peptide (BNP) and N-terminal pro-BNP are increased in patients with asymptomatic and symptomatic left ventricular systolic dysfunction and can be used for both diagnosis and prognosis. SJ. 28:2539. Aurigemma.Clinical manifestations and diagnosis of diastolic heart failure http://www. FA. 15. Kitzman. 17:1065. Gottdiener. JK. 288:2144. Circulation 1986. LaManca. Defining diastolic heart failure: a call for standardized diagnostic criteria. Cobb. Gaasch. Little. and prognosis. Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure?. M. EP. R. clinical characteristics. et al. 29. K. MR. 98:2282.do?topicKey=hrt_fail/57. 86:1090. Circulation 2001. Circulation 2003. Vasan. and heart failure with preserved left ventricular systolic function. CF. Lopatin. M. and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. contractility and loading conditions. Circulation 1987. D. CM. J Am Coll Cardiol 1991. Kitzman. Circulation 1990. Arch Intern Med 1996.. et al. Levy D. et al. Bourdillon. LW. RS. J Am Coll Cardiol 1991. et al.. G. 20. Liu. WC. Gottdiener. Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic function. L. RB. Beere. 24. readmission. Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography. 19:990. 47:500. 25. J Am Coll Cardiol 2003. Yonge. 17. Tajik. AJ. Marshall. FR. M. V. et al. Higginbotham. Senni. Conway. CW. WC. RL. 76:1009. 47:76. 7 of 15 7/23/2008 7:24 PM . Hogg. M. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. 8. JS. 156:1789. 18. J Am Coll Cardiol 2004. MB. 7. et al. 9. 43:317. JAMA 1994. A clinical mechanistic overview.com/online/content/topic. Lorell. Masoudi. Circulation 2000. Kitzman. 19. 81:III78. Heart failure with a normal ejection fraction: is it really a disorder of diastolic function?. Vaccarino. Swedberg. 74:675. The role of hypertension in the pathogenesis of heart failure. PH. Congestive heart failure in the community: a study of all incident cases in Olmsted County. Am J Cardiol 2001. Tribouilloy. Gender. RS. Smith. Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure. Abnormalities of diastolic function as a potential cause of exercise intolerance in chronic heart failure. Sheikh. DW. Hatle. 23. Outcomes in heart failure patients with preserved ejection fraction: mortality. Brubaker. 41:217. JE. Smith. Burkhoff. Altered left ventricular diastolic properties during pacing induced anginain patients with aortic stenosis. Congestive heart failure despite normal left ventricular systolic function in a population-based sample: the Strong Heart Study. J Am Coll Cardiol 2006. RJ. GL. K. heart rate. Gaasch. Yancy. 14. Heart failure with preserved left ventricular systolic function. 271:1276. MJ. J. 18:1243. B. 107:656. Packer. Masoudi. Ann Intern Med 2002. BH. Circulation 1998. 87:413. Minnesota. Zile. McClelland. Kitzman. and functional decline. 27. et al. Roman. 101:2118. Importance of heart failure with preserved systolic function in patients>/=65 years of age.uptodate. JM. Clinical presentation. MA. D. 22. epidemiology. age. Stevenson. The Cardiovascular Health Study. JD. Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: Failure of the Frank-Starling mechanism. J Am Coll Cardiol 2003. Rodeheffer. 28. Massie. Devereux. J. Eur Heart J 1998. Fifer. JAMA 2002. Respiratory muscle function and dyspnea in 10. et al. DW. Baicu. management. Henson. DM. Packer. 21. PD. MR. Zile. Gardin. Little. 350:1953. et al. Age-related alterations of Doppler left ventricular filling indexes in normal subjects are independent of left ventricular mass. McMurray. Oh. Skeletal muscle metabolism in patients with congestive heart failure: relation to clinical severity and blood flow. Am J Cardiol 2000. N Engl J Med 2004. JS. J Am Coll Cardiol 2006.Clinical manifestations and diagnosis of diastolic heart failure http://www. DW. Carroll. 11. PA. Mancini. DW. How to diagnose diastolic heart failure. D. 41:1510. Vasan. Levy. WH. 13. R. Gaasch. FA. MS. 26. et al. M. 16. WH. European Study Group on Diastolic Heart Failure. 12. Diastolic heart failure--abnormalities in active relaxation and passive stiffness of the left ventricle. Havranek. KH. et al. 137:631. in 1991. 104:779. WH. Maurer. Clinical manifestations and diagnosis of diastolic heart failure http://www. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. S. J. 33. McMurray. Segmental wall motion abnormalities in dilatedcardiomyopathy: Hemodynamic characteristics and comparison with thallium-201 myocardial scintigraphy. 114:836. et al. Baicu. MC. Grossman. KK. Gaasch. JJ. et al. Glamann. Eur Heart J 2007. Gheorghiade. H. Nikitin. NP. Angeja. WT. Krishnaswamy. Contractile behavior of the left ventricle in diastolic heart failure: with emphasis on regional systolic function. Heart 2002. L. 49. 105:595. Coronary artery disease in patients with heart failure and preserved systolic function. Left ventricular systolic performance. DB. M. Clopton. C. Krishnaswamy. L. Circulation 1992. Witte. 87:29.uptodate. Clark. S. 38. 111:2306. 90:1174. 112:e154. G. Cleland. Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. 105:1195. Corbett. GP. et al. 42. Yip. Circulation 2006. et al. P. 26:2277. RA. AP. Abraham. Am J Cardiol 2002.do?topicKey=hrt_fail/57. DA. Yu. K. CF. McMurray. Cardiol Clin 2000. JG. MR. 8 of 15 7/23/2008 7:24 PM . Hillis. Circulation 2002. Odell. JF. Bortman. 46. Arch Intern Med 1992. Invasive modalities. 40. AJ. point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction. Assessment of diastolic dysfunction. Pearson. DS. Am Heart J 1987. C. Bonow. 321:215. 47. 39. Discrepancy between pre. Tschope. L. W. Lubien. Am J Med 2001.and post-transplant diagnosis of end-stage dilated cardiomyopathy. Zile. 32. GP. 27:1753. BMJ 2000. Heart 2002. 48. Yasui. Utility of various radionuclide techniques for distinguishing ischemic from nonischemic dilated cardiomyopathy. Circulation 2002. AC. Koon. Petrie. 113:1123. 30. Labovitz. Y. 152:769. Pietrolungo. The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. et al. GI. Am Heart J 1987. Am J Cardiol 2002. A. Zile. Color tissue Doppler-derived long-axis left ventricular function in heart failure with preserved global systolic function. 43. 41. Aurigemma. L. Davie. et al. "Diastolic heart failure" or heart failure caused by subtle left ventricular systolic dysfunction?. 31. Choudhury. Petrie. 35. Circulation 2003. Utility of B-natriuretic peptide as a rapid. M. SA. Circulation 2005. D.. 50. et al. 111:274. M. DeMaria. et al. 44. J Am Coll Cardiol 1996.. M. A practical guide to assessment of ventricular diastolic function using Doppler echocardiography. Caruana. 36. MR. Thomas. and contractility in patients with diastolic heart failure. BG. JJ. 107:659. 89:719. Circulation 2005. Hayasaka. P. Kass. 86:909. Yang. Lin. MC. P. 141:367. function. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. M. Berry. H. Kasner. MH. Chin. 37. WH. Am J Cardiol 1994. G. Lange. E. Hatle. Am Heart J 2001. Krishnaswamy. Caruana. P.com/online/content/topic. Tsuiki. Zhang. Aurigemma. Westermann. Wang. 34. Left ventricular long axis function in diastolic heart failure is reduced in both diastole and systole: time for a redefinition?. JD. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study. J. AS. Cohen. RO. 28:2421. patients with chronic congestive heart failure. JR. Hunt. LD. AL. CM. Evaluation and management of diastolic heart failure. Yamaguchi. Maisel. Lubien. Evaluation of left ventricular diastolic function: Clinical relevance and recent Doppler echocardiographic insights. 87:121. 45. 113:296. 74:921. Gaasch. Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction. 18:571. Koon. How to diagnose diastolic heart failure a consensus statement. Eur Heart J 2005. E. Sellanes. WH. Tschope. Ard: duration of reverse pulmonary vein atrial systole flow. WJ. 28:2539. LVMI: left ventricular mass index. E: early mitral valve flow velocity. Copyright ©2007 Oxford University Press. JE. TD: tissue Doppler. et al. b: constant of left ventricular chamber stiffness. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.do?topicKey=hrt_fail/57. Sanderson. DT: deceleration time. LAVI: left atrial volume index. LVEDP: left ventricular end-diastolic pressure.. GRAPHICS Diagnostic flowchart on "How to diagnose HFNEF" in a patient suspected of HFNEF LVEDVI: left ventricular end-diastolic volume index. mPCW: mean pulmonary capillary wedge pressure. E/A: ratio of early (E) to late (A) mitral valve flow velocity. Reproduced with permission from: Paulus.com/online/content/topic. NT-proBNP: N-terminal-pro brain natriuretic peptide.. Eur Heart J 2007.uptodate. Ad: duration of mitral valve atrial wave flow. E': early TD lengthening velocity. BNP: brain natriuretic peptide. t: time constant of left ventricular relaxation. Examples of heart failure with normal left ventricular ejection fraction Diastolic heart failure 9 of 15 7/23/2008 7:24 PM .Clinical manifestations and diagnosis of diastolic heart failure http://www. C. amyloid) Increased vascular turgor Concentric LVH Post-MI hypertrophy and fibrosis LV chamber dilation LV: left ventricular. Hatle. Little.uptodate. time to peak filling: time to dV/dt max.Clinical manifestations and diagnosis of diastolic heart failure http://www. AJ.. Tau: time constant of isovolumic pressure decay. IVRT: isovolumic relaxation time. 10 of 15 7/23/2008 7:24 PM . increased diastolic P/V relationship: upward shift and/or increased slope of LV diastolic pressure/volume relationship. 47:500. stiffness constant: Kp. Hypertension Restrictive cardiomyopathy Infiltrative cardiomyopathy Hypertrophic cardiomyopathy Noncompaction cardiomyopathy Right heart failure Severe pulmonary hypertension Right ventricular infarct Arrhythmogenic right ventricular dysplasia Atrial septal defect Valvular heart diseases Severe valvular stenosis Severe valvular regurgitation Pericardial disease Cardiac tamponade Constrictive pericarditis Intracardiac mass Atrial myxoma Apical eosinophilic thrombus Pulmonary vein stenosis Congenital heart diseases Oh.com/online/content/topic. Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography. L.. E/A ratio: ratio of early and late LV inflow as detected by Doppler echocardiography. WC. Tajik. Mechanisms and causes of diastolic dysfunction Physiologic abnormality Alteration in parameter of assessment Common etiology Delayed or incomplete relaxation Increased tau Increased IVRT Reduced E/A ratio LV hypertrophy Myocardial ischemia LV asynchrony Abnormal loading Early diastolic filling abnormalities Reduced peak filling rate Increased time to peak filling Reduced E/A ratio Delayed relaxation LV asynchrony Late diastolic filling abnormalities Increased diastolic P/V relationship Normal or increased E/A ratio Increased LV passive chamber stiffness Increased diastolic P/V relationship Increased stiffness constant LV chamber dilation Restrictive/constrictive filling pattern Increased collagen and fibrosis Myocardial infiltration (eg. JK. LVH: LV hypertrophy.do?topicKey=hrt_fail/57. peak filling rate: dV/dt max. J Am Coll Cardiol 2006. In contrast. Although the systolic and diastolic pressures are normal. normal subjects have an increase in left ventricular end diastolic volume (LVEDV). J Am Coll Cardiol 1991. but no change in LVEDV.Clinical manifestations and diagnosis of diastolic heart failure http://www. often to levels associated with pulmonary edema (blue arrow). MJ.com/online/content/topic. Reproduced with permission from Kern. Higginbotham.do?topicKey=hrt_fail/57. DW. Diagnostic flow chart on "How to exclude HFNEF" in a patient presenting with breathlessness and no signs of fluid overload 11 of 15 7/23/2008 7:24 PM . diastolic dysfunction. 1997.. ACC Current Journal Review. 17:1065. Data from Kitzman. the pressure waveform in diastole is abnormal. there is a continuing decline of pressure over the mid-diastolic period (as opposed to the gradual rise seen in normal subjects) with the pressure nadir occurring midway through the diastolic period and there is a prominent "a" wave generated by left atrial contraction. patients with normal systolic function who have left ventricular hypertrophy. This is consistent with exercise-induced ischemia and an exaggerated impairment of diastolic relaxation of the hypertrophied myocardium. associated with a modest increase in pulmonary capillary wedge pressure (PCWP) which remains within a normal range (red arrow). and a stiff. Left ventricular pressure tracing in diastolic dysfunction The left ventricular pressure is initially recorded with a scale of 0 to 200 mmHg and then at 0 to 40 mmHg. PCWP increases during exercise in diastolic dysfunction During symptom-limited upright exercise. Cobb. et al. MB.. FR.uptodate. nondistensible left ventricle have a marked increase in PCWP with exercise. 28:2539. Eur Heart J 2007.uptodate. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. et al. JE.do?topicKey=hrt_fail/57. Sanderson. Left ventricular hypertrophy 12 of 15 7/23/2008 7:24 PM .com/online/content/topic. C. WJ. S: TD shortening velocity. Reproduced with permission from: Paulus...Clinical manifestations and diagnosis of diastolic heart failure http://www. Tschope. Copyright ©2007 Oxford University Press. just below the level of the mitral valve annulus. Constrictive pericarditis Two dimensional echocardiogram in constrictive pericarditis. Left panel shows two thickened layers of pericardium separated by a clear layer devoid of echoes. this process appears to be circumferential (as indicated by the two sets of arrows) and is seen in constrictive pericarditis. The IVC did not collapse with inspiration. The right panel shows a plethoric or dilated inferior vena cava (IVC) and hepatic vein (hv) and the right atrium (RA). The appearance of the bright pericardium circumferentially.do?topicKey=hrt_fail/57. M mode echocardiogram recorded within the left ventricle. Concentric left ventricular hypertrophy is seen as both the left ventricular septum and posterior left ventricular wall are significantly thickened. Continuous wave Doppler in aortic regurgitation 13 of 15 7/23/2008 7:24 PM . produces the "halo sign. IVS: interventricular septum. PWLV: posterior wall of the LV. M-mode echocardiogram of amyloid cardiomyopathy The M-mode echocardiogram in a patient with amyloid cardiomyopathy shows a small left ventricular (LV) cavity. The thoracic aorta (TAO) sits posterior to the thickened pericardium. and markedly reduced systolic function." In real time. the clear area in both the lateral area (horizontal arrows) and apical wall (vertical arrows) maintained the same dimension throughout the cardiac cycle. brightly reflective myocardium.. measuring almost 3 cm..Clinical manifestations and diagnosis of diastolic heart failure http://www.com/online/content/topic.uptodate. seen with a dark anechoic layer between the layers. this finding strongly suggests that the pericadial thickening is associated with constrictive physiology. and an increased peak diastolic flow velocity with atrial contraction (A).com/online/content/topic. MR.uptodate. PVa. In addition. in this patient the PHT is 99 msec. Sm. 105:1387.. DL.do?topicKey=hrt_fail/57. Values of less than 200 msec identify severe aortic regurgitation. Compared to the normal pattern. but a shortened DDT and a decrease in A. PVd. Doppler of mitral flow in patients with an abnormality in relaxation due to diastolic dysfunction shows a reduced peak early diastolic flow velocity (E). diastolic pulmonary vein velocity. pulmonary vein velocity resulting from atrial contraction. there is an increase in E. Doppler findings in diastolic heart failure Schematic representation of LV and left atrial (LA) pressures during diastole.. pulmonary vein Doppler velocity. prognosis. 14 of 15 7/23/2008 7:24 PM . which is computed by placing a line (arrow) along the slope of velocity decay or deceleration time (A to B). IVRT indicates isovolumic relaxation time. myocardial velocity during early filling. a prolonged E wave diastolic deceleration time of early diastolic filling (DDT).Clinical manifestations and diagnosis of diastolic heart failure http://www. PVs. and Doppler tissue velocity in normals and in different types of diastolic heart failure. Circulation 2002. New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis. With myocardial restriction. The severity of aortic regurgitation can be established by the continuous wave Doppler using the pressure half time (PHT). Copyright © 2002 Lippincott Williams &Wilkins. myocardial velocity during systole. the density of the regurgitant diastolic signal is nearly equal to the systolic signal. transmitral Doppler LV inflow velocity. Em. systolic pulmonary vein velocity. and measurements of diastolic function. Brutsaert. myocardial velocity during filling produced by atrial contraction. and Am. Reproduced with permission from: Zile. 15 of 15 7/23/2008 7:24 PM .do?topicKey=hrt_fail/57. | Subscription and License Agreement | Support Tag: [ecapp1003p.uptodate. Inc.com/online/content/topic.com-82.. © 2008 UpToDate.152-6EBAB4CF9B-2579] Licensed to: UpToDate Guest Pass | Your UpToDate subscription will expire in 9 day(s). 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