Diastolic Heart Failure “The very essence of cardiovascular medicine is recognition of early heart failure.” Sir Thomas Lewis 1933 “The very essence of cardiovascular medicine is recognition of early heart failure.” Sir Thomas Lewis 1933 Carmen B. Gomez MD Eugene Yevstratov MD

Introduction Diastolic heart failure has emerged over the last 10 years as a separate clinical entity. Diastolic heart failure accounts for approximately one third of all heart failure cases, especially in an elderly population, and its natural history, with an annual mortality rate of 8%, is more benign than other forms of heart failure with an annual mortality of 19%. A need has therefore grown to establish precise criteria for the iagnosis of diastolic heart failure. Diastolic heart failure has emerged over the last 10 years as a separate clinical entity. Diastolic heart failure accounts for approximately one third of all heart failure cases, especially in an elderly population, and its natural history, with an annual mortality rate of 8%, is more benign than other forms of heart failure with an annual mortality of 19%. A need has therefore grown to establish precise criteria for the iagnosis of diastolic heart failure.

Requirments for Diagnostic of the DHF  Presence of sighs or symptoms of congestive heart failure  Presence of normal or only midly abnormal left ventricular systolic function  Evidence of abnormal left ventricular relaxation(filling,diastolic distensibility or diastolic stiffness)

Pathophysiology  Impaired relaxation  Increase passive stiffness  Endocardial and pericardial disordersw  Microvascular flow.Myocardial turgor  Neurohormonal regulation

 Epicardial or microvascular ischemia  Myocite hypertrophy  Cardiomyopathies  Aging  Hypothyroidism Pathophysiology Impaired Relaxation

 Diffuse fibrosis  Post-infarct scarring  Myocyte hypertrophy  Infiltrative (amyloidosis, hemochromatosis, Fabry´s disease) Pathophysiology Increase Passive Stiffness

 Fibroelastosis  Mitral or tricuspid stenosis  Pericardial constriction  Pericardial tamponade Pathophysiology Endocadial, Pericardial Disorders

Pathophysiology Endocadial, Pericardial Disorders

 Capillary compression  Venouse engorgement Pathophysiology Microvascular Flow,Myocardial Turgor

 Upregulated renin-angiotensin system  Volume overload of the contralatetal ventricle  Extrinsic compression by tumor Pathophysiology Neurohormonal Regulation, Other

Diagnosis  Increased ventricular filling pressure with normal systolic function.  Incresed ventricular pressure with preserved systolic function and normal ventricular volumes.  Increased left atrial and pulmonary capillary wedge pressure.  Clinical symptoms and signs.

Clinical Signs and Symptoms  Evidence of raised left atrial pressure  Exertional dyspnoea  Orthopnoea  Gallop sounds  Lung crepitations  Pulmonary oedema  Exercise intolerance

Pathology

Clinical Signs and Symptoms

Evidence of Abnormal left Ventricular Relaxation  LVdP/dt min<1100 mmHg  IVRT 92 ms, IVRT30–50y>100 ms, IVRT>50y>105 ms and/or Ù >48 ms  LVEDP>16 mmHg or mean PCW>12 mmHg  PV A Flow >35 cm. s " 1  b>0·27 and/or b * >16

 Reduce symptoms  Control hypertension  Prevent myocardial ischemia There is no specific therapy for DHF There is no specific therapy for DHF Management of DHF

 Diuretics – provide the most symptoms relief if fluid retentionn is a future  ACE inhibitors and β Blockers – complement diuretics well  Central sympatholytics – hypertensive episodes  Nitrates – preventing ischemia  Trimetazidine – as a metabolic support Management of DHF

Conclusion Until further evidence is available from randomized therapeutic trials, clinicians should focus on a few general principles in the treatment of DHF: Reduce volume overload Slow the heart rate Control hypertension, Relieve myocardial ischemia.

Eugene Yevstratov MD FUNDACION FAVALORO FUNDACION FAVALORO INSTITUTO DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR Carmen B. Gomez MD