DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE Medicine Resident Rounds September 28, 2007 Jacobi Hospital

TERMINOLOGY Diastolic dysfunction –Alteration in active or passive relaxation of the LV Diastolic heart failure –Signs/symptoms of heart failure w normal ventricular function/size and findings of abnormal diastolic function Systolic heart failure –Signs/symptoms of heart failure w abnormal ventricular function/size.

ISOVOLUMIC (EARLY) RELAXATION ENERGY DEPENDENT

Phases of diastole

Elevated Left Ventricular Diastolic Pressure Causes Pulmonary Congestion

HISTORICAL CONCEPTS OF DIASTOLIC FUNCTION Experimental Heart failure was associated with increased diastolic pressures (volume overload or global ischemia) –Objective confirmation of Heart failure was an elevated diastolic pressure (during cardiac catheterization) 1965 Braunwald editorial noting that marked increases observed in hypertrophic hearts without evidence of clinical heart failure Report of reversible diastolic pressure increase without enlargement of the LV heart size during ischemia Non invasive techniques of evaluating diastolic volume changes, wall thickness and LV diastolic diameter

SPONTANEOUS ANGINA EFFECT ON SYSTOLIC & DIASTOLIC PRESSURE

LV DIASTOLIC PRESSURE CHANGES DURING EXERCISE INDUCED ANGINA 50---

CHANGES IN LV DIASTOLIC PRESSURE AND VOLUME DIURING ANGINA -- INDUCED BY ATRIAL PACING DWYER CIRC 1970

LV ANATOMIC CHANGES ALTERS DISTENSIBILITY in CHRONIC NON-ISCHEMIC DISORDERS Myocardial cell Hypertrophy occurs and corresponds to wall thickness as per Echocardiogram Active fibrotic process occurs with increase in the amount of collagen and shift to less pliable collagen

LV DIASTOLIC DISTENSIBILITY Stiffness- Compliance- Distensibility are best quantified by the LV pressure / volume relationship

Assessment of Diastolic Function Echocardiogram –Normal Heart size and normal contraction pattern –E/A flow velocity ratio : in DD E declines and A increases (normal: & Abnormal <1) ; also Abnormal pulmonary venous flow velocity Cardiac Catheterization –Normal heart size and contraction pattern –LV end diastolic pressure (normal =12 mmHg) Greater specificity when 16 mmHg used as upper normal. E A E E A

COMMON CAUSES OF DIASTOLIC DYSFUNCTION Ischemia (potentially reversible delay in or incomplete early relaxation) Acute Hypertension (potentially reversible delay in or incomplete early relaxation) Infarction (increased passive stiffness) Chronic Hypertension with Hypertrophy (increased passive stiffness) Aortic Stenosis & IHSS (increased passive stiffness) Idiopathic Hypertrophic Cardiomyopathy (increased passive stiffness) Diabetes and Obesity (increased passive stiffness)

TRIGGERS TO PULMONARY CONGESTION IN PATIENTS WITH DIASTOLIC DYSFUNCTION Volume overload –Increased salt & water intake –Chronic renal disease –Iatrogenic (procedure or surgery related) –Severe chronic anemia Tachycardia Atrial Fibrillation with and without rapid VR Hypertension (>200 mmHg) Ischemia

R =.44 RELATIONSHIP BETWEEN LV SYSTOLIC PRESSURE AND LV DIASTOLIC PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES DWYER ET AL AHJ 2000

EXERCISE RESPONSE IN DIASTOLIC DYSFUNCTION

ACUTE TREATMENT OF DIASTOLIC HEART FAILURE Reduce intravascular volume carefully – Morphine, diuretic, NTG Control Systolic BP in obvious hypertensive state –Morphine, diuretic, NTG, ACE inhibitors, betablocker Treat any ischemia –NTG, anti-thrombotic Rx, if indicated Control ventricular heart rate –Beta blocker, Ca++ channel blocker

CHRONIC TREATMENT OF DIASTOLIC HEART FAILURE Standard management of underlying disorder(s) In Hypertrophic and/or fibrotic disorders, including hypertension, Diabetes and Obesity, consider ACE inhibitors, ARBs, Spironalactone & beta-blocker to promote regression of LV mass and prevention of further fibrosis. Greater emphasis on maintaining sinus rhythm in patients with paroxysmal atrial fibrillation

RECURRENT PULMONARY EDEMA Rx: SURGICAL INTERVENTION 1985

DIASTOLIC DYSFUNCTION AND OUTCOME SETARO et al 1992; AJC –52 pts WITH CHF & INTACT SYSTOLIC FUNCTION –F/U 7 YRS –50% CAD; 31% HTN –MEAN AGE = 71 COHN et al 1990; CIRC –83 pts –F/U 5 YRS –27% CAD; 53% HTN BROGAN et al 1992;AJM –51 pts –F/U 6 YRS –NO CAD

FRAMINGHAM STUDY VARSAN JACC % CAD 25% CAD

PROGNOSIS OF DIASTOLIC DYSFUNCTION NOMAL CORONARY ARTERIES BRADY & DWYER 2006 Clin Card

SUMMARY Diastolic dysfunction and Diastolic Heart failure is common It is present in many common disorders. Beware and be skeptical of the patient with the diagnosis of “asthma” It’s easy to treat the acute heart failure and fun too! Patients are usually ready to go home within hours and probably can. Managing the progression and chronic state is more problematic. Patients with many admissions with diastolic heart failure is a often physician failure in managing the underlying disorders. Prognosis is heavily influenced by the presence of coronary disease and the age of the patient. Can’t live forever!