1. Diastolic Heart Failure
Diagnosis and Treatment
Paul J. Kovack, DO, FACOI, FACC

2. Disclosure
I have no conflict of interest for this presentation

3. Outline Background Definition and Diagnostic Criteria Etiology
Pathophysiology
Clinical Diagnosis
Management

4. Backround CHF affects 5 million Americans
400,000 new cases & 800,000 hospitalizations annually
CHF : primarily a disorder of the elderly
Among the elderly, it is the most frequent hospital discharge
Over 10 billion health care dollars

5. Backround
Among the elderly, cardiovascular disease is the MOST common cause of mortality and morbidity.
In 1900, 4% of population was over 65. Now 30%
10,000 people turn 65 every day
In the US currently, 5 million people have CHF. ½ these cases are from CHF with preserved LV function.

6. Mortality SHF vs DHF

7. DHF more likely to die from non-CV cause

8. Definition Diastolic dysfunction is not the same as Diastolic CHF
Diastolic dysfunction characterizes abnormal relaxation of the LV. It is essentially an echo finding.
Diastolic CHF describes a clinical syndrome of CHF in patient with preserved LV function.
Diastolic heart failure (DHF) or HFpEF

9. Diagnostic Criteria
For diastolic dysfunction, this relies on echo criteria
Multiple factors enter into the equation
Most are related to aging and hypertension

12. Normal diastolic function
Occupies about 2/3 of the cardiac cycle. Takes longer than systole
Active process, requires energy
Abnormalities of diastolic function ALWAYS precede those of systolic function.
So patients with systolic dysfunction always have diastolic dysfunction

13. CHF is a Clinical Diagnosis
Patient has dyspnea with risk factors such as hypertension, diabetes, ischemia, elderly
Subjective signs such as orthopnea and PND
Clinical exam shows signs of HF , S4.
CXR confirms pulmonary congestion with a normal sized cardiac silhouette
ECG may show LVH, Atrial fibrillation.
BNP elevated

14. BNP is lower in DHF
1/3 that of SHF
Can be normal

15. BNP is lower in DHF

18. Systolic vs Diastolic Congestive heart failure
Exertional Dyspnea
Paroxysmal Nocturnal Dyspnea
Orthopnea
Jugular Venous Distinction
Lung Crackles
Displaced Aprical Impulse S4 S3
Systolic Heart Failure
Diastolic Heart Failure
Adapted from Echeverria et al, 1983

19. Is it systolic heat failure or is it diastolic heart failure?
Physical exam
CXR
BNP
Need to look at echo

20. Normal Diastolic filling
1. Isovolumic Relaxation
2. Early rapid diastolic filling phase
3. Diastasis
4. Late diastolic filling due to atrial contraction
Quinones, ASE Review 2007

21. Normal Diastolic function
When LV pressure becomes less than LA pressure, MV opens
Rapid early diastolic filling begins.
Driving force is predominantly elastic recoil and normal relaxation.
~80% LV filling during this phase

22. Normal Diastolic function
As a result of rapid filling, LV pressure rapidly equilibrates with and may exceed LA pressure.
Results in deceleration of MV inflow.
Late diastolic filling is from atrial contraction. It’s ~ 20% LV filling.

23. MV inflow Patterns
5 stages – Normal and Stages I – IV diastolic dysfunction
Stage I – Impaired relaxation
Stage II – Pseudo-normal
Stage III – Restrictive Filling, reversible
Stage IV – Restrictive Filling, irreversible

24. MV PW inflow patterns

25. Stage I

26. Stage I

27. Stage II, Pseudonormal

28. Stage II

29. Stage II
Valsalva
➔➔➔

30. Stage III

31. Stage III

32. Diastolic Dysfunction
Grade 1
Grade 2
Grade 3
Grade 4
LV pressure E
Mitral flow
Tissue Doppler e’
Pulmonary vein
Using these Doppler variables, we can grade diastolic dysfunction as we grade heart failure symptoms using NYHA classification. This grading system was proposed by Dr. Tajik of our institution and corrleates well with degree of diastolic dysfunction, filling pressure, and naturally patient’s prognosis.
Grade 1 diastolic dysfunction represents mild dysfunction with impaired myocardial relaxation, but filling pressure is normal. In this situation, as long as diastolic filling period is well preserved, patient does not experience significant symptoms. Grade 2 diastolic dysfunction is same as pseudonormalized filling pattern with mild to moderate elevation of filling pressure. Grade 3 and 4 diastolic dysfunction represents most advanced stage, called restrictive pattern, with marked elevation of filling pressure and decreased LV operating compliance. The difference between grade 3 and 4 is reversibility of restrictive diastolic filling. It is important to remember that myocardial relaxation is impaired in all stages of diastolic dysfunction so that (Click) mitral annulus E’ velocity is decreased and mitral flow propagation velocity is reduced.
E/e’
< 10
10 -15
>15
>15 CP

33. As LV filling pressure ↑45 40 35 30 25 20 15 10 5
E/e’
PCWP (mm Hg)
r = 0.87
n = 60
As LV filling pressure ↑
Mitral E
Annulus e
Therefore, as LV filling pressure increases, mitral inflow E velocity increases, but mitral annulus E’ velocity decreases. As a result, E/E’ ratio increases. According to the investigations from Baylor and our institution by Dr. Steve Ommen, E/E’ ratio of 15 or greater usually indicates PCWP 20 mmHg or higher.
E/e
Nagueh et al: JACC, 1997
Ommen et al: Circ, 2000

34. E/E’ is a robust clinical marker
What the ratio means?
> 15  elevated filling pressures
< 8  Nl
8 – 15  ???
Nagueh et al, JACC 1997; 30:

35. Etiology

36. Causes of Diastolic dysfunction  Heart Failure
Hypertension
Obesity
Sleep apnea
Atrial fibrillation

37. Other Causes Cardiomyopathy CAD Valvular heart disease Diabetes
Hypertrophic
Restrictive,
Infiltrative, eg Amyloid
CAD
Valvular heart disease
Diabetes
Obesity
Sleep Apnea
Constrictive pericarditis

38. Pathophysiology
An inability to increase stroke volume by Frank-Starling mechanism despite severely increased LV filling pressure is indicative of diastolic dysfunction
Impairment of ventricular relaxation and decreased compliance of the left ventricle.
With mild dysfunction, the ventricle can compensate with an increase in the late filling phase until the end- diastolic volume returns to normal.
In severe cases, the ventricle is so stiff that the left atrium fails, and the end-diastolic volume cannot be normalized.
This leads to reduced stroke volume and cardiac output.

39. DHF is an important cause of pulmonary hypertension

40. Group 2 Pulmonary hypertension includes SFH, valvular heart disease and DHF

41. Management Primary prevention Smoking cessation
Aggressive control of hypertension, hyperlipidemia and CAD including revascularization
Weight loss
Limiting alcohol intake
Diastolic dysfunction can be present for many years before it is clinically evident
Early diagnosis and treatment prevents irreversible structural abnormalities and systolic dysfunction

42. Alcohol and atrial fibrillation
J Am Coll Cardiol 2016;68:

45. TOPCAT trial

46. DIG Trial – HFpEF cohort
No effect on mortality
Fewer HF hospitalizations with dig
More ACS hospitalizations with dig

47. Beta blockers in DHF: Very little data

49. Taylor, International Journal of Cardiology 2012 Effects of exercise training for heart failure with preserved EF

50. Heart failure is covered for rehab
Only if it is due to systolic dysfunction

51. Interatrial shunt device for HFpEF Outcomes at 1 year
Device implanted in 64 patients to allow small amount of left to right shunting to reduce elevated left atrial pressure
Improvemant in 6 minute walk test
Improvement in NYHA class
Improvement in HF quality of life scores
REDUCE LAP-HF Circulation 2016 Nov 16; doi

52. Guideline driven treatment of DHF
ACC/AHA guidelines
2005 similar to 2001
2009 similar to 2005
2013 similar to 2009
2016 is pharmacologic update to now include ARNI. No new information regarding DHF

53. Class I indications

54. ACC/AHA Guidelines 2009 (and 2013) Class IIa
Coronary revascularization if ischemia is thought to be causing diastolic dysfunction

56. ACE/ARB/BB/CaB in DHF Use if you have another indication
Hypertension
Diabetes
CAD
A fib
If you have to choose between diuretic and ACE/ARB/BB/CaB
Choose diuretic is there is congestion

57. Conclusions
There has been a steady rise in prevalence of CHF with preserved LV function.
By the 7th decade, incidence of diastolic CHF = systolic CHF
By the 8th decade, incidence of diastolic CHF > systolic CHF
The survival of patients with the clinical syndrome of heart failure is similar in those with preserved versus those with a reduced LV ejection fraction

58. Conclusions Recognize (amyloid, constriction, restriction)
An important component of Group 2 PHT
Treatment:
Remove iatrogenic agents (eg NSAIDS)
Diuretics
BP control
HR control
Ischemia. Dyspnea as angina equivalent
Rhythm control in A fib if still symptomatic with rate control