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==Prognosis==
==Prognosis==
Until recently, it was generally assumed that the prognosis for individuals with diastolic dysfunction and associated, intermittent pulmonary edema was better than those with systolic dysfunction. In fact, in two studies appearing in the [[New England Journal of Medicine]] in 2006, evidence was presented to suggest that the prognosis in diastolic dysfunction is the same as that in systolic dysfunction<ref name="pmid16855265">{{cite journal| author=Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM| title=Trends in prevalence and outcome of heart failure with preserved ejection fraction. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 3 | pages= 251-9 | pmid=16855265 | doi=10.1056/NEJMoa052256 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16855265  }} </ref><ref name="pmid16855266">{{cite journal| author=Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A et al.| title=Outcome of heart failure with preserved ejection fraction in a population-based study. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 3 | pages= 260-9 | pmid=16855266 | doi=10.1056/NEJMoa051530 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16855266  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17213179 Review in: Evid Based Med. 2006 Dec;11(6):185]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17080990 Review in: ACP J Club. 2006 Nov-Dec;145(3):78] </ref>
Until recently, it was generally assumed that the prognosis for individuals with diastolic dysfunction and associated, intermittent pulmonary edema was better than those with systolic dysfunction. In fact, in two studies appearing in the [[New England Journal of Medicine]] in 2006, evidence was presented to suggest that the prognosis in diastolic dysfunction is the same as that in systolic dysfunction<ref name="pmid16855265">{{cite journal| author=Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM| title=Trends in prevalence and outcome of heart failure with preserved ejection fraction. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 3 | pages= 251-9 | pmid=16855265 | doi=10.1056/NEJMoa052256 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16855265  }} </ref><ref name="pmid16855266">{{cite journal| author=Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A et al.| title=Outcome of heart failure with preserved ejection fraction in a population-based study. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 3 | pages= 260-9 | pmid=16855266 | doi=10.1056/NEJMoa051530 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16855266  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17213179 Review in: Evid Based Med. 2006 Dec;11(6):185]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17080990 Review in: ACP J Club. 2006 Nov-Dec;145(3):78] </ref>
==Diagnosis==
==Common Symptoms==
The clinical manifestations of diastolic heart failure are as follows-
* [[Dyspnea|Dyspnea on ordinary exertion]] or greater shortness of breath with usual activities
* [[Paroxysmal nocturnal dyspnea]] or [[awakening at night with shortness of breath]]
* [[Ankle edema]] or [[swelling of the feet]] and legs
* [[Orthopnea]] or [[sleeping on pillows]]
* [[Hemoptysis]] or frothy sputum
* [[Paroxysmal nocturnal dyspnea]] or [[awakening at night with shortness of breath]]
* [[Syncope]] or [[passing out]]
* [[Weakness]]
==Less Common Symptoms==
* [[Fainting]]
* [[Fatigue]]
* [[Syncope]] or [[passing out]]
* Life threatening flash [[pulmonary edema]]<ref name="pmid18794390">{{cite journal| author=Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF et al.| title=Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. | journal=Circulation | year= 2008 | volume= 118 | issue= 14 | pages= 1433-41 | pmid=18794390 | doi=10.1161/CIRCULATIONAHA.108.783910 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18794390  }} </ref>.
In a cross sectional survey of 2042 randomly selected residents of Olmstead County, Minnesota, diastolic dysfunction was often not accompanied by recognized CHF but was associated with marked increases in all-cause mortality. Thus, possibility of asymptomatic diastolic heart failure should also be kept in mind.<ref name="pmid12517230">{{cite journal| author=Redfield MM, Jacobsen SJ, Burnett JC, Mahoney DW, Bailey KR, Rodeheffer RJ| title=Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. | journal=JAMA | year= 2003 | volume= 289 | issue= 2 | pages= 194-202 | pmid=12517230 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12517230  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12954043 Review in: ACP J Club. 2003 Sep-Oct;139(2):51] </ref>.
The manifestations of overt systolic and diastolic heart failure are similar. Patients with diastolic dysfunction may have an exacerbation of their symptoms in the following settings:
* [[Tachycardia]], increased heart rate would hamper proper and complete filling of left ventricle.
* [[Hypertension]], especially if it is acute in onset or refractory to treatment increases the stress on the walls of the ventricle, which in turn leads to [[hypertrophy]] and impaired filling.
* [[Atrial fibrillation]] leads to poor coordination between atrial and ventricular contraction and contributes to further reduction in filling.
* Acute ischemia, leads to diastolic dysfunction which increases left atrial pressure and causes [[pulmonary edema]].


==Laboratory Findings==
==Laboratory Findings==

Revision as of 17:38, 21 October 2012

Diastolic dysfunction Microchapters

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Overview

Classification

Pathophysiology

Causes

Differentiating Diastolic dysfunction from other Diseases

Epidemiology and Demographics

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

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Physical Examination

Laboratory Findings

Echocardiography

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

Overview

Congestive heart failure and cardiac dysfunction are not interchangeable definitions. Whereas heart failure is a clinical definition that illustrates the occurrence of symptoms of fatigue, dyspnea, and fluid overload; cardiac dysfunction is a mechanical definition that includes abnormalities in heart contraction (called systolic dysfunction) or abnormalities in heart relaxation and filling (called diastolic dysfunction) or both.

Therefore, diastolic dysfunction refers to a mechanical dysfunction of the heart during the diastolic phase of the cardiac cycle in the presence or absence of any clinical symptoms. When clinical symptoms are present on top of the mechanical dysfunction of the heart, the condition is called diastolic heart failure[1].

Diastole is the phase of the cardiac cycle when the heart ( i.e. ventricle) is not contracting but is actually relaxed and filling with blood that is being returned to it, either from the body (into right ventricle) or from the lungs ( into left ventricle). The mechanical abnormality in diastolic dysfunction is characterized by a decrease in the ventricular filling in the context of an elevated left ventricular end diastolic pressure and a normal ejection fraction.

Diastolic dysfunction is caused by decrease cardiac muscle relaxation or increased stiffness. The ejection fraction of the heart is preserved in this type of dysfunction.

Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Pathophysiology

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.

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 Causes 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 lead to delay in left ventricular filling.
  • Left ventricular end diastolic pressure will become high.
  • Pulmonary capillary pressure increases.[3]
    • 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[4][5][6].
  • 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.

Causes

In alphabetical order:

Differentiation of Diastolic Dysfunction from Systolic Dysfunction

  • Characteristics of systolic dysfunction:
  • Characteristics of diastolic dysfunction:
    • Small, thickened, concentrically hypertrophied ventricles
    • Large atria
    • Impaired blood filling during diastole
    • Normal ejection fraction
    • Systemic elevation of the blood pressure
    • Occurs mainly in elderly women
    • Presence of S4 gallop [7]

Differentiation of Diastolic Dysfunction from other Disorders


Epidemiology and Demographics

The prevalence of diastolic dysfunction has increased and it is more common in females and the elderly.

Prognosis

Until recently, it was generally assumed that the prognosis for individuals with diastolic dysfunction and associated, intermittent pulmonary edema was better than those with systolic dysfunction. In fact, in two studies appearing in the New England Journal of Medicine in 2006, evidence was presented to suggest that the prognosis in diastolic dysfunction is the same as that in systolic dysfunction[8][9]

Diagnosis

Common Symptoms

The clinical manifestations of diastolic heart failure are as follows-

Less Common Symptoms

In a cross sectional survey of 2042 randomly selected residents of Olmstead County, Minnesota, diastolic dysfunction was often not accompanied by recognized CHF but was associated with marked increases in all-cause mortality. Thus, possibility of asymptomatic diastolic heart failure should also be kept in mind.[10].

The manifestations of overt systolic and diastolic heart failure are similar. Patients with diastolic dysfunction may have an exacerbation of their symptoms in the following settings:

  • Tachycardia, increased heart rate would hamper proper and complete filling of left ventricle.
  • Hypertension, especially if it is acute in onset or refractory to treatment increases the stress on the walls of the ventricle, which in turn leads to hypertrophy and impaired filling.
  • Atrial fibrillation leads to poor coordination between atrial and ventricular contraction and contributes to further reduction in filling.
  • Acute ischemia, leads to diastolic dysfunction which increases left atrial pressure and causes pulmonary edema.

Laboratory Findings

Plasma brain natriuretic peptide (BNP) or N-terminal pro b-type natriuretic peptide (NT-proBNP) can be used to diagnose heart failure when diagnosis is unclear. BNP levels are lower in diastolic dysfunction when compared with systolic dysfunction[11].

Echocardiography

Echocardiography can be used to diagnose diastolic dysfunction. No one single echocardiographic parameter can confirm a diagnosis of diastolic heart failure. Multiple echocardiographic parameters have been proposed as sufficiently sensitive and specific, including mitral inflow velocity patterns, pulmonary vein flow patterns, E:A reversal, tissue Doppler measurements, and M-mode echo measurements (i.e. of left atrial size). Algorithms have also been developed which combine multiple echocardiographic parameters to diagnose diastolic heart failure.

Treatment

The chronic treatment of diastolic dysfunction involves aggressive management of the underlying disorder that is causing the diastolic dysfunction such as diabetes or hypertension. Mild diastolic dysfunction that is well tolerated requires no specific treatment. Rate control is an important part of the acute therapy of the patient with diastolic heart failure. It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy of diastolic dysfunction.

Acute Treatment of Diastolic Heart Failure

Rate Control

It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy diastolic dysfunction. Furthermore, in atrial fibrillation there is a failure of atrial kick to augment the filling of the left ventricle.

Diuresis

Diuresis may reduce acute volume overload.

Relief of Ischemia

Acute myocardial ischemia leads to diastolic dysfunction which increases left atrial pressure and causes pulmonary edema.

Chronic Treatment of Diastolic Heart Failure

Afterload Reduction

There is some evidence that calcium channel blocker drugs may be of benefit in reducing ventricular stiffness in some cases. Likewise, treatment with angiotensin converting enzyme inhibitors such as enalapril, ramipril, and other ACE inhibitors may be of benefit due to their effect on ventricular remodeling.

Medical Therapy

ACA/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults: Patients With Heart Failure and Normal Left Ventricular Ejection Fraction[12] (DO NOT EDIT)

Class I

"1. Physicians should control systolic and diastolic hypertension in patients with heart failure and normal left ventricular ejection fraction, in accordance with published guidelines. (Level of Evidence: C)"

"2. Physicians should control ventricular rate in patients with heart failure and normal left ventricular ejection fraction and atrial fibrillation. (Level of Evidence: C)"

"3. Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with heart failure and normal left ventricular ejection fraction. (Level of Evidence: C)"

Class IIa

"1. Coronary revascularization is reasonable in patients with heart failure and normal left ventricular ejection fraction and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function. (Level of Evidence: C)"

Class IIb

"1. Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and heart failure and normal left ventricular ejection fraction might be useful to improve symptoms. (Level of Evidence: C)"

"2. The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with heart failure and normal left ventricular ejection fraction and controlled hypertension might be effective to minimize symptoms of heart failure. (Level of Evidence: C)"

"3. The usefulness of digitalis to minimize symptoms of heart failure in patients with heart failure and normal left ventricular ejection fraction is not well established. (Level of Evidence: C)"

References

  1. Zile MR, Brutsaert DL (2002). "New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis, prognosis, and measurements of diastolic function". Circulation. 105 (11): 1387–93. PMID 11901053.
  2. 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.
  3. 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.
  4. 4.0 4.1 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.
  5. 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.
  6. 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.
  7. Francis G.S., Tang W., Walsh R.A. (2011). Chapter 26. Pathophysiology of Heart Failure. In V. Fuster, R.A. Walsh, R.A. Harrington (Eds), Hurst's The Heart, 13e.
  8. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM (2006). "Trends in prevalence and outcome of heart failure with preserved ejection fraction". N Engl J Med. 355 (3): 251–9. doi:10.1056/NEJMoa052256. PMID 16855265.
  9. Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A; et al. (2006). "Outcome of heart failure with preserved ejection fraction in a population-based study". N Engl J Med. 355 (3): 260–9. doi:10.1056/NEJMoa051530. PMID 16855266. Review in: Evid Based Med. 2006 Dec;11(6):185 Review in: ACP J Club. 2006 Nov-Dec;145(3):78
  10. Redfield MM, Jacobsen SJ, Burnett JC, Mahoney DW, Bailey KR, Rodeheffer RJ (2003). "Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic". JAMA. 289 (2): 194–202. PMID 12517230. Review in: ACP J Club. 2003 Sep-Oct;139(2):51
  11. Maisel AS, McCord J, Nowak RM, Hollander JE, Wu AH, Duc P; et al. (2003). "Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study". J Am Coll Cardiol. 41 (11): 2010–7. PMID 12798574.
  12. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation". Circulation. 119 (14): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966.

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