1. Diastolic Heart Failure
Staff Lecture
Diastolic Heart Failure
김 우 식
경희대학교 의과대학병원

2. Cardiac Function？ Ability
Adequte Diastolic filling of LV with Low Pressure
+ Eject Enough blood into whole body.
Ability
압력 증가 없이 적절히 심실이 채워짐　＝　이완 기능
+ 혈액을 신체 각 부위에 전달　＝　수축 기능

3. ICT:Isovolumic Contraction Time LV volume
Aortic pressure
LV pressure
LA pressure
Index of Systolic fn
LVmax+ dP/dt
ICT
ICT:Isovolumic Contraction Time
LV volume

4. Index of systolic function
Aortic pressure
LV pressure
LA pressure
Index of systolic function
;EF, CO
ICT ET
LV volume
ET:
Ejection Time

5. Isovolumic Relaxation Time
Aortic pressure
LV pressure
Index of diastolic fn
LVmax- dP/dt 　τ
LA pressure
ICT
IRT ET
IRT:
Isovolumic Relaxation Time
LV volume

6. ICT IRT ET Aorta LV Diastolic Function: LV stiffness = dP/dV LA
LV volume
Diastolic Mid - Late stage

7. 심기 능 평가 지표 수축 기능 Ejection fraction Cardia output LVmax + dP/dt Emax …
이완 기능
LVmax - dP/dt 
LV stiffness
LV filling pressures mean pulmonary wedge P mean LA pressure LVEDP pre-A LV diastolic P

8. Standard Systolic Function:EF
Advantage: EF is a essential component of cardiac output
Limitation: Cannot detect diastolic function
in case of MR EF increased
not related to Prognosis
not related to Quality of Life

9. EF Advantage and Limitation
CASE
End-stage of old MI
: EF < 25％
Restrictive cardiomyopathy
: EF - normal
DCM – symptom not related with EF

12. 적절하게 이완기 충만이 이루어지면, (수축기능이 정상이면) 정상적인 구출량(stroke volume)이 가능하게된다.
Diastolic Function
정상 이완기능이란?
안정시와 운동시에 심방의 압력 증가 없이 심실이 적절히 채워지는 경우
적절하게 이완기 충만이 이루어지면, (수축기능이 정상이면) 정상적인 구출량(stroke volume)이 가능하게된다. 12

13. Evaluation of Diastolic Function (좌심실 이완 기능의 평가)

14. Pressure and MV inflow E A Aorta pressure LV pressure LA pressure ECG
MV level에서 시행한 pulse Doppler 파형 14

15. Determinants of LV filling
Klein C10 p117,

17. 승모판 혈류속도는 LA・LV 압력 차에 의해 결정
LV pressure
LA pressure
LV volume 。
dV(LV volume)/dt = 승모판 혈류량
Ohno M, et al. Circulation 1994;89:2241

18. LA・LV 압력 차는 좌심방압과 좌심실 탄성에 의해 결정
Ohno M, et al. Circulation 1994;89:2241

19. Diastolic Function → Start with Mitral Inflow
좌심실 이완기능 평가 1
혈류속도 측정
Diastolic Function → Start with Mitral Inflow E LV RV A RA LA DT
Apical 4-chamber
Pulse Doppler

20. Diastolic Function → Start with Mitral Inflow
좌심실 이완기능 평가 1
혈류속도 측정
Diastolic Function → Start with Mitral Inflow
Measurements
E-wave (peak early filling velocity)
A-wave (late diastolic filling velocity)
E/A ratio
Deceleration time (DT or Mdt) of early filling velocity
IVRT (Isovolumic relaxation time)
A-wave duration

21. Mitral Inflow Pattern 전부하 Impaired Relaxation Normal Pseudonormal
Restrictive
LV dysfunction
（－）
（１＋）
（２＋）
（３＋）
전부하

22. Deceleration Time (DT)
Mitral Inflow Pattern
Impaired Relaxation
Deceleration Time (DT)
Normal
Pseudonormal
Restrictive
LV dysfunction
（－）
（１＋）
（２＋）
（３＋）
전부하

23. Deceleration Time (DT) 의 유용성
DT (ms)
DT (ms)
LVEDP (mmHg)
LVEDP (mmHg)
EF ５０％
EF ＞５０％
Yamamoto K, et al. JACC 1997;30:1819

24. Tissue Doppler Annular Diastolic Velocities
좌심실 이완기능 평가 1
혈류속도 측정
Tissue Doppler Annular Diastolic Velocities
systolic (S) velocity
early diastolic (Ea, Em, E’, e’) velocity
late diastolic (Aa, Am, A’, a’) velocity
E/e’ ratio RV LV S e’ a’ RA LA 24

25. Patterns of mitral inflow and mitral annulus velocity
Mitral flow
Mitral annulus velocity
Normal
Relaxation abnormality
Pseudo- normalization
Restrictive physiology
Sohn. JACC 1997

26. Grading of Diastolic Dysfunction (Diastolic Filling Pattern)
Grade 1 Impaired Relaxation (LVEDP 정상)
1a Impaired Relaxation (LVEDP 증가)
Grade 2 Pseudonormal
Grade 3 Restrictive (reversible)
Grade 4 Restrictive (irreversible)

28. Grading of Diastolic Dysfunction
Mitral
Inflow
Pulmonary
Venous
Flow
Color
M-mode: Vp
Annulus
Velocity
JASE
2004;17:290-7

30. Evaluation of LV filling pressure
E ∝ myocardial relaxation x filling pressure
∴ Filling pressure =
Myocardial relaxation E E’

31. E/E’과 pulmonary capillary wedge pressure (PCWP)의 관계

32. LV filling pressure  Prediction of LV Filling Pressure
by Flow to Annular Tissue E Velocity Ratio
LV filling pressure 
Mitral E 
PCWP (mmHg)
Annulus E’ 
E / E’ 
E/Ea (Flow E/Tissue E)
Nagueh SF, et al. JACC 1997;30:1527, Ommen, et al. Circulation 2000 32

33. Tissue Doppler Annular Diastolic Velocities
E/e’ ratio
60-year-old patient, Heart failure, normal EF (JASE 2009)
Mitral inflow ; E = 80 cm/s
Annulus TDI ; Septal e’ = Lateral e’ = 5

34. 좌심실의 이완기능 평가
좌심방
대동맥
좌심방
좌심실

35. 좌심방의 용적을 재는 방법
Prolate ellipse
Biplane area-length

36. 좌심방의 용적을 재는 방법
Simpson’s method

37. 좌심실 이완기능의 평가
Pattern
Grading
Filling Pressure LA
11:05~11-30

38. Population based cohort study
Epidemiology
Prevalence of Diastolic Dysfunction (2)
Prognosis of Diastolic Dysfunction (3)
Population based cohort study

39. 2042 randomly selected residents of Olmsted County, Minnesota
JAMA 2003

42. N = 2042
45 yrs
Diastolic dysfunction = 28%
Mild = 20.8%
Moderate = 6.6 %
Severe = 0.7 %
Systolic dysfunction
EF 50% --- 6%
EF 40% --- 2%

43. Redfield, M. M. et al. JAMA 2003;289:194-202.

44. Redfield, M. M. et al. JAMA 2003;289:194-202.
In-Stent Restenosis
Redfield, M. M. et al. JAMA 2003;289:

46. N = 1274,
Age 25 years (mean age = 51 yrs)
Echo evaluation
Prevalence of diastolic abnormalities in the setting of a preserved EF (EF 45%) – 11% ; normal IVRT = 92~105 msec E/A ratio = 1 : 0.5 (depending on age)
Prevalence of diastolic dysfunction – 3% ; Diastolic abnormalities + LA enlargement or treatment of diuretics
Diastolic abnormalities : 2.3% had an EF 45%

47. In-Stent Restenosis

48. In-Stent Restenosis
Prevalences of diastolic abnormalities and diastolic dysfunction in different clinical subgroups.

49. Prognosis

50. Cardiovascular Health Study
In-Stent Restenosis
Cardiovascular Health Study
; 2,671 participants
; coronary heart disease (-), CHF (-) or atrial fibrillation (-)
; Mean follow-up : 5.2 yrs
; 170 participants (6.4 % of cohort) developed CHF

51. Prognosis

52. Bella, J. N. et al. Circulation 2002;105:1928-1933
Incidence of all-cause and cardiac death among SHS participants with E/A <0.6 (open bars), 0.6 to 1.5 (striped bars), and >1.5 (closed bars)

53. Prognosis

54. In-Stent Restenosis

55. Definition of Heart Failure
"The situation when the heart is incapable of maintaing a cardiac output adequate to accommodate metabolic requirements and the veous return"
E. Braunwald in Heart Diseases. W. B. saunders Co. 1992

56. Definition of Heart Failure
“the pathological state in which the heart is unable to pump blood at a rate required by the metabolizing tissues or can do so only with an elevated filling pressure"
Fukuda H, Little WC in Diastology

57. Definitions
Diastolic Dysfunction : Abnormal diastolic properties of LV
(abnormal relaxation, filling dynamics, distensibility)
- EF may be normal or low
- Patient may be symptomatic or asymptomatic.
Diastolic Heart Failure : Clinical heart failure, normal EF, abnormal diastolic function
Systolic Dysfunction : Abnormal systolic properties of LV (abnormal performance, function, contractility)
- EF is low (and diastolic dysfunction may coexist).
Systolic Heart Failure : Clinical heart failure, low EF, abnormal systolic function (From Circulation 2006;113:296)

58. It is accepted that abnormalities of diastolic function
Heart Failure
HF_PEF: Heart failure with preserved EF
HF_REF: Heart failure with reduced EF
It is accepted that abnormalities of diastolic function 58

61. Diagnosis of diastolic Heart Failure
In-Stent Restenosis
Diagnosis of diastolic Heart Failure
Symptoms and Signs

62. Prevalence of specific symptoms and signs in systolic and diastolic HF
Systolic HF Diastolic HF
Symptoms
Dyspnea on exertion 96 % 85 %
Paroxysmal nocturnal dyspnea 50 % 55 %
Othophea % 60 %
Circulation 2002;105:1387

63. Prevalence of specific symptoms and signs in systolic and diastolic HF
In-Stent Restenosis
Prevalence of specific symptoms and signs in systolic and diastolic HF
Systolic HF Diastolic HF
Physical examination
Jugular venous distension 46 % 35 %
Rales % 72 %
Displaced apical impulse 60 % 50 %
S % 45 %
S % 45 %
Hepatomegaly % 15 %
Edema % 30 %
Circulation 2002;105:1387

64. Prevalence of specific symptoms and signs in systolic and diastolic HF
In-Stent Restenosis
Prevalence of specific symptoms and signs in systolic and diastolic HF
Systolic HF Diastolic HF
Chest radiograph
Cardiomegaly % 90 %
Pulmonary venous hypertension 80 % 75 %
Circulation 2002;105:1387

65. Diastolic Heart Failure
In-Stent Restenosis
Diastolic Heart Failure
Clinical evidence of HF
Normal Systolic function (LVEF>0.5)
Objective evidence of impaired LV relaxation or LV passive stiffness

69. Wang JACC 2005;45:272

70. Practical Recommendations
Clinical evidence of HF
EF (72h 내에 측정)
EF <50 %
EF 50 %
LV hypertrophy
Concentric remodelling
LA enlargement
Systolic HF
Diastolic HF
Diastolic fn
Prognosis

71. Half of patients with HF have an normal EF

72. Circulation. 1998;98:2282

73. HF with normal EF
Older
Female
less likely to have had prior MI & LBBB

74. Prognosis of Diastolic HF

75. Circulation. 1998;98:2282

76. Vasan RS. JACC 1999;33:1948 In-Stent Restenosis
During a median follow-up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects (adjusted hazards ratio = 4.06, 95% confidence interval 1.61 to 10.26). Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects (adjusted hazards ratio = 4.31, 95% confidence interval 1.98 to 9.36).
CONCLUSIONS
Normal LV systolic function is often found in persons with CHF in the community and is more common in women than in men. Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF.
Vasan RS. JACC 1999;33:1948

77. How to diagnose HFNEF In-Stent Restenosis
How to diagnose HFNEF (P71, EHJ 2007;28(21)2686)

78. Diastolic Heart failure – Diagnostic Criteria
Required criteria
Clinical evidence of heart failure - Framingham or Boston criteria - Plasma BNP and/or chest x-ray - Cardiopulmonary exercise testing
Normal EF (= 50%)
Confirmatory Evidence
LVH or concentric remodelling
LA enlargement (in absence of AF)
Echo doppler or catheter evidence of diastolic dysfunction
Exclusion
Nonmyocardial disease

79. Thank you