DIASTOLIC DYSFUNCTION and DIASTOLIC HEART FAILURE Original slides courtesy of Drs. David O’Halloran and Craig Walsh 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Definitions Diastolic dysfunction: normal venous return during rest or exercise results in abnormal increase in LV diastolic pressure Diastolic heart failure: Congestive heart failure with a normal LV ejection fraction and evidence of diastolic dysfunction 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series HOW COMMON IS IT? 2.2% of over 45s have symptomatic CHF In patients with heart failure 1/3 of those 50-70 have DD ½ of those >70 have DD 28% of over 45s have some degree of diastolic dysfunction More common in women 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series 4 phases of diastole 1. Isovolumic relaxation 2. Rapid filling 3. Diastasis 4. Atrial contraction Now is the time 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series DURING DIASTOLE… LV “untwists” – the elastic recoil will “suck” blood into the LV Occurs during early diastole Energy dependent During later diastole Cardiomyocytes are relaxed Minimal resistance to filling Left atrial (and hence wedge) pressures are low 2008 Zoll Firm Lecture Series
HOW DO PATIENTS PRESENT? Similar to patients with systolic HF Dyspnea Reduced exercise tolerance Fatigue Diminished quality of life 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series WHAT CAUSES IT? Chronic hypertension and LVH Ischemic heart disease Aortic stenosis Hypertrophic cardiomyopathy Restrictive cardiomyopathy Amyloid Sarcoid Hemochromatosis 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series HOW DOES ECHO HELP? LV morphology. Evaluate for Aortic stenosis Assess other causes Diastolic function LV inflow Tissue Doppler 2008 Zoll Firm Lecture Series
Diastolic Dysfunction Two-dimensional Echo Dilated Cardiomyopathy Restrictive Cardiomyopathy Normal Eccentric LVH Concentric LVH Atrial enlargement Atrial enlargement 2008 Zoll Firm Lecture Series
Mitral Inflow Velocity LV relaxation LV stiffness/LA pressure Transmitral Pressure Gradient Mitral Inflow Velocity 2008 Zoll Firm Lecture Series
Mitral Valve Inflow Velocity Pulse Wave Doppler Signal LA AC MO PW Doppler IVRT 2008 Zoll Firm Lecture Series
Mitral Valve Inflow Velocity Pulse Wave Doppler Signal LA E AC MO PW Doppler IVRT 2008 Zoll Firm Lecture Series
Mitral Valve Inflow Velocity Pulse Wave Doppler Signal LA E AC MO PW Doppler IVRT DT 2008 Zoll Firm Lecture Series
Mitral Valve Inflow Velocity Pulse Wave Doppler Signal LA E A AC MO PW Doppler IVRT DT 2008 Zoll Firm Lecture Series
Mitral Valve Inflow Velocity Pulse Wave Doppler Signal LA E A AC MO MC PW Doppler IVRT DT 2008 Zoll Firm Lecture Series
Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure Myocardial Relaxation 2008 Zoll Firm Lecture Series
Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure IVRT 2008 Zoll Firm Lecture Series
Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure IVRT 2008 Zoll Firm Lecture Series
Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure DT IVRT 2008 Zoll Firm Lecture Series
Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure E/A E IVRT DT 2008 Zoll Firm Lecture Series
Myocardial Relaxation Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure Normal Pseudonormalization Myocardial Relaxation and LA Pressure 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure Normal Pseudonormalization IVRT 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure Normal Pseudonormalization E IVRT 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure Normal Pseudonormalization E DT IVRT 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure Normal Pseudonormalization E/A E A IVRT DT 2008 Zoll Firm Lecture Series
Myocardial Relaxation Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure Normal Restriction Myocardial Relaxation and LA Pressure 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure Normal Restriction IVRT 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure Normal Restriction E IVRT 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure Normal Restriction E IVRT 2008 Zoll Firm Lecture Series DT
Zoll Firm Lecture Series Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure Normal Restriction E/A E A IVRT DT 2008 Zoll Firm Lecture Series
Diastolic Dysfunction Summary of Mitral Inflow Parameters MV Inflow 2008 Zoll Firm Lecture Series
Tissue Doppler Imaging Mitral Annular Motion 2008 Zoll Firm Lecture Series
Tissue Doppler Imaging Mitral Annular Motion normal Diastolic dysfunction E < A E > A 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series WHAT’S WITH E/e’ Ratio of E wave on MV inflow to e’ on tissue Doppler <8 – normal filling pressures >15 – PCWP above 12mm Hg 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series WHAT ABOUT TREATMENT? Treatment is directed to the associated problems Hypertension LV hypertrophy Ischemia Maintaining slow sinus rhythm Diuretics Underlying cause (if known) Sarcoid/amyloid/hemochromatosis 2008 Zoll Firm Lecture Series
PRINCIPLES OF TREATMENT Unfortunately no good specific treatment for diastolic heart failure: Control hypertension ACE-I/ARB are 1st line since they cause regression of LVH and has mild benefit shown in the CHARM-PRESERVE trial. Control ventricular rate Allow longer time for filling. Control pulmonary congestion Mainstay is diuretics Revascularize if appropriate 2008 Zoll Firm Lecture Series
Zoll Firm Lecture Series PROGNOSIS Annual mortality rate for patients with diastolic heart failure is 5-8%, compared with 10-15% for patients with systolic heart failure. In men older than 70, mortality rates for systolic and diastolic heart failure is almost equal. Closely associated with presence of comorbidities such as ischemic heart disease. 2008 Zoll Firm Lecture Series