Diastolic dysfunction pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby

Overview

Diastolic dysfunction is the impairment of the heart muscle in its ability to properly relax and fill with blood during diastole. Diastolic dysfunction is mainly the result of either impaired myocardial relaxation or increased cardiac muscle stiffness. As a result, the pressure in the left ventricle increases at the end of diastole and causes a build up of pressure in the left atrium and consequently in the pulmonary circulation. The result is pulmonary edema and dyspnea.

Pathophysiology

Normally, with reference to the left side of the heart, blood flows from the lungs, into the pulmonary veins, into the left atrium, through the mitral valve, and finally into the left ventricle. Diastolic dysfunction is the inability of the heart to properly relax and fill with blood during diastole.

Underlying Pathophysiological Mechanisms of Diastolic dysfunction

Impaired Extent and/or Speed of Myocardial Relaxation

  • Myocardial relaxation is an ATP dependent process regulated by the rate of re-uptake of cytoplasmic calcium into the sarcoplasmic reticulum.
  • Low concentration of calcium, as seen in ischemia, is associated with a slowed down myocardial relaxation.

Increased Myocardial Stiffness

  • Myocardial stiffness can be secondary to cardiac muscle hypertrophy (for example as seen in hypertension). Concentric hypertrophy (increased mass and relative wall thickness) and remodelling (normal mass but increased wall thickness) are associated with diastolic dysfunction due to impaired filling.
  • Myocardial stiffness can be the result of infiltrative diseases like amyloidosis.
  • Scarred heart muscle, occurring after a heart attack, are relatively stiff.
  • Diabetes can be a cause of cardiac stiffness as a result of glycosylation of the heart muscle.

Extrinsic Constraints

  • Extrinsic constraints can be seen in pericardial compression.

Chamber Dilatation

  • Severe systolic dysfunction that has led to ventricular dilation can be associated with diastolic dysfunction. When the ventricle has been stretched to a certain point, any further attempt to stretch it more, as by blood trying to enter it from the left atrium, meets with increased resistance and thus decreased compliance.

Miscelleneous

Sequence of Events in Diastolic dysfunction

  • Impaired cardiac muscle relaxation or/and decreased left ventricular compliance leads to delay in left ventricular filling.
  • Left ventricular end diastolic pressure will become high.
  • Pulmonary capillary pressure increases.[1]
    • As a result of hydrostatic forces, this high pressure leads to leaking of fluid (i.e. transudate) from the lung's blood vessels into the air-spaces (alveoli) of the lungs. The result is pulmonary edema, a condition characterized by difficulty breathing, inadequate oxygenation of blood, and, if severe and untreated, death. Life threatening episodes of pulmonary edema can occur due to sudden decompensation. This is called flash pulmonary edema. The left ventricle diastolic pressure rises progressively prior to the acute onset failure[2][3][4].
  • It is worth re-emphasizing that the pulmonary edema that can develop as a result of diastolic dysfunction is not due to poor pumping function of the left ventricle. Indeed, it has resulted from the left ventricle's inability to readily accept blood trying to enter it from the left atrium.
  • In the setting of a stiff left ventricle, it is more difficult for blood to flow into it from the left atrium. In such a situation, filling can be maintained by a combination of coordinated left atrial pumping (i.e. beating) and a relatively slow heart rate. The former actively pumps blood into the stiff left ventricle, and the latter can allow for sufficient time for blood to passively enter the left ventricle from the left atrium.
  • Conditions that increase the heart rate, for example exercise and pregnancy, decrease the diastolic filling time and hence worsens the diastolic dysfunction in the setting of a non-compliant heart.

Associations with other diseases

Diastolic dysfunction is associated with:

  • Pulmonary hypertension[5]
  • Chronic kidney disease[6]

In these studies, it is not clear whether these association are unique to diastolic heart failure or whether they may also be associated with systolic heart failure. It is not clear how well the observational studies control for the degree of hypertension as the studies only measured the presence of absence of a history of hypertension.

References

  1. 1.0 1.1 Mann D.L., Chakinala M. (2012). Chapter 234. Heart Failure and Cor Pulmonale. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine, 18e.
  2. Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF; et al. (2008). "Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures". Circulation. 118 (14): 1433–41. doi:10.1161/CIRCULATIONAHA.108.783910. PMID 18794390.
  3. Zile MR, Adamson PB, Cho YK, Bennett TD, Bourge RC, Aaron MF; et al. (2011). "Hemodynamic factors associated with acute decompensated heart failure: part 1--insights into pathophysiology". J Card Fail. 17 (4): 282–91. doi:10.1016/j.cardfail.2011.01.010. PMID 21440865.
  4. Adamson PB, Zile MR, Cho YK, Bennett TD, Bourge RC, Aaron MF; et al. (2011). "Hemodynamic factors associated with acute decompensated heart failure: part 2--use in automated detection". J Card Fail. 17 (5): 366–73. doi:10.1016/j.cardfail.2011.01.011. PMID 21549292.
  5. Borlaug BA, Obokata M (2017). "Is it time to recognize a new phenotype? Heart failure with preserved ejection fraction with pulmonary vascular disease". Eur Heart J. 38 (38): 2874–2878. doi:10.1093/eurheartj/ehx184. PMID 28431020.
  6. Unger ED, Dubin RF, Deo R, Daruwalla V, Friedman JL, Medina C; et al. (2016). "Association of chronic kidney disease with abnormal cardiac mechanics and adverse outcomes in patients with heart failure and preserved ejection fraction". Eur J Heart Fail. 18 (1): 103–12. doi:10.1002/ejhf.445. PMC 4713321. PMID 26635076.

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