Diastolic heart failure Up to a third of patients have clinical heart failure with normal LV systolic function Underlying pathophysiology relates to diastolic dysfunction Commonest underlying pathologies Normal ageing Hypertension Myocardial ischaemia

Mechanisms of diastolic dysfunction Impaired ventricular relaxation Energy dependent process Susceptible to myocardial ischaemia Decreased myocardial compliance Altered compliance mediated by collagen Fibrosis related to activation of RAAS

Echocardiographic assessment 2D echo to assess systolic function Doppler echo Transmitral flow E/A wave ratio E wave deceleration time IVRT

Area-length method for calculation of LV mass LVmass=1.05[5/6(A1xL1)-5/6(A2xL2)] Divide by body surface area to get LV mass index Reichek et al. Circulation 1983;67:348-52

Doppler patterns of diastolic dysfunction Impaired relaxation Reduced E/A ratio Increased EDT Increased IVRT Restriction LA pressure increases due to myocardial stiffness High peak E wave velocity Short EDT Very short IVRT

Treatment of diastolic heart failure Treat underlying cause eg ischaemia Impaired relaxation Theoretically rate-limiting agents effective Beta-blockers, verapamil Reduce HR and prolong diastole Reduce myocardial oxygen demand Lower BP and reduce LVH

Treatment of diastolic heart failure Restriction Drugs which reduce fibrosis and lower LA pressure theoretically should be effective ACEI AII blockers Diuretics If LA pressure lowered too much cardiac output significantly worsened Can cause significant morbidity

Colour Doppler Tissue Imaging

Colour Doppler Tissue Imaging

Figure 1. Pulsed wave Doppler sample of basal septum of normal subject S wave A wave E wave

Figure 2. Pulsed wave Doppler sample of basal inferior wall of subject with previous inferior myocardial infarction due to right coronary artery occlusion. S wave E wave A wave