Diastolic Heart Failure

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  • ? What are the typical symptoms and signs of heart failure? ? Why is an echocardiogram needed to rule out other conditions? Acute severe mitral regurgitation and other circulatory congestive states, i.e. constrictive pericarditis Brain natriuretic peptide (BNP) to rule out pulmonary causes of dyspnea
  • Diastolic Heart Failure

    1. 1. Diastolic Heart Failure By Lisa Tang, MD May 9, 2006
    2. 2. Case Vignette: (1) <ul><li>A 78 year old woman with a history of hypertension is admitted to the hospital with congestive heart failure. Physical examination reveals a blood pressure of 180/90 mm Hg, increased jugular venous pressure, peripheral edema, and pulmonary rales. A chest radiograph shows pulmonary edema and mild cardiomegaly. An echocardiogram shows increased thickness of the left ventricular wall, a left ventricular cavity of normal size, left atrial enlargement, and a left ventricular ejection fraction of 70 percent. The left ventricular Doppler filling pattern is abnormal and consistent with an elevated pulmonary capillary wedge pressure. How should this patient be treated? </li></ul>
    3. 3. The Echocardiogram:
    4. 4. Definition: Diastolic Dysfunction <ul><li>An abnormality of diastolic distensibility, filling, or relaxation of the left ventricle </li></ul><ul><li>Irrespective of ejection fraction, whether or not it is normal or abnormal </li></ul><ul><li>Irrespective of whether or not patient is symptomatic or asymptomatic </li></ul>
    5. 5. Diastolic Heart Failure <ul><li>In a patient with diastolic dysfunction who now has dyspnea </li></ul><ul><li>In the setting of venous congestion and pulmonary edema </li></ul>
    6. 6. Epidemiology of Congestive Heart Failure: (2) <ul><li>Approximately 5 million people in the U.S. have CHF. </li></ul><ul><li>Over 550,000 patients are diagnosed with CHF for the first time each year. </li></ul><ul><li>Primary reason for 12-15 million office visits and 6.5 million hospital days each year </li></ul><ul><li>The incidence of CHF approaches 10 per 1000 population over age 65. </li></ul><ul><li>Rate of hospitalization is similar to that associated with systolic heart failure </li></ul><ul><li>Fewer published data on diastolic heart failure than systolic heart failure </li></ul>
    7. 7. Epidemiology of Diastolic Heart Failure: <ul><li>About one third of all patients with congestive heart failure have diastolic heart failure </li></ul><ul><li>Prevalence is highest in patients older than 75 years old </li></ul><ul><li>Mortality rate is about 5-8 % annually as compared to 10-15% among patients with systolic heart failure </li></ul><ul><li>Mortality rate is directly related to age and the presence/absence of coronary disease. </li></ul>
    8. 8. Factors that Exacerbate Diastolic Heart Failure: <ul><li>Uncontrolled hypertension </li></ul><ul><li>Atrial Fibrillation </li></ul><ul><li>Non-compliance with or inappropriate discontinuation of medications for heart failure </li></ul><ul><li>Myocardial ischemia </li></ul><ul><li>Anemia </li></ul><ul><li>Renal insufficiency </li></ul><ul><li>Use of NSAIDS or thiazolidinediones </li></ul><ul><li>Dietary indiscretion with overindulgence in salty foods </li></ul>
    9. 9. Pathophysiological Features of Diastolic Dysfunction: <ul><li>Abnormal passive elastic properties of the left ventricle </li></ul><ul><li>Increased myocardial mass </li></ul><ul><li>Alterations in the extramyocardial collagen network </li></ul><ul><li>Increased stiffness of the left ventricle </li></ul>
    10. 10. Left Ventricular Diastolic Pressure in Relation to Volume: <ul><li>The curse is shifted upward and to the left. </li></ul><ul><li>The chamber compliance is reduced. </li></ul><ul><li>The time course of filling is altered. </li></ul><ul><li>The diastolic pressure is elevated. </li></ul>
    11. 11. Left Ventricular Pressure-Volume Loops in Systolic and Diastolic Dysfunction
    12. 12. Characteristics of Diastolic Heart Failure: <ul><li>Low stroke volume </li></ul><ul><li>Reduced cardiac output despite a normal ejection fraction </li></ul><ul><li>Limited exercise tolerance as a result of elevated left ventricular diastolic and pulmonary venous pressure -> reduction in lung compliance -> increase in the work of breathing </li></ul>
    13. 13. Characteristics of Diastolic Heart Failure as Compared with Those of Systolic Heart Failure
    14. 14. Diagnosis: <ul><li>A clinical diagnosis based on the finding of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular ejection fraction and no valvular abnormalities on echocardiogram according to the American College of Cardiology and the American Heart Association </li></ul>
    15. 15. Diagnostic Techniques: <ul><li>Echocardiogram </li></ul><ul><li>Doppler echocardiography: measures the velocity of intracardiac blood flow </li></ul><ul><li>Diastolic flow from the left atrium and left ventricle across the mitral valve has two components: the E wave, early diastolic filling and A wave, atrial contraction in late diastole </li></ul>
    16. 16. Diagnostic Techniques- cont: <ul><li>E wave velocity is influenced by both the rate of early diastolic relaxation and the left atrial pressure. </li></ul><ul><li>Alterations in the pattern of E wave velocity reflects the degree of left ventricular diastolic dysfunction and prognosis. </li></ul><ul><li>Doppler assessment of flow into the left atrium through the pulmonary veins. </li></ul><ul><li>Tissue Doppler imaging which directly measures the velocity of change in myocardial length, as an index of left ventricular relaxation. </li></ul>
    17. 17. Patterns of Left Ventricular Diastolic Filling as Shown by Standard Doppler Echocardiography
    18. 18. Management of Diastolic Heart Failure: Goals: <ul><li>To reverse the consequences of diastolic dysfunction, i.e. venous congestion, exercise intolerance </li></ul><ul><li>To eliminate or reduce the factor responsible for the diastolic dysfunction </li></ul>
    19. 19. Initial Management: Goal: To reduce pulmonary venous pressure and congestion <ul><li>Diuretics –use with caution; aggressive diuresis may result in serious hypotension given the steep curve of the left ventricular diastolic pressure in relation to volume </li></ul><ul><li>Supplemental oxygen, morphine, and nitroglycerin </li></ul>
    20. 20. Goal: To prevent tachycardia and/or to slow the heart rate <ul><li>Heart rate: determines the length of coronary perfusion time -tachycardia causes a decrease in coronary perfusion time and increases in demand for myocardial oxygen </li></ul><ul><li>B-blockers </li></ul><ul><li>Non-dihydropyridine calcium channel blockers </li></ul>
    21. 21. Long Term Management: <ul><li>From the Candesartan in Heart Failure Assessment of Reduction in Mortality (CHARM) Preserved study: </li></ul><ul><li>A study that compared candesartan with placebo in patients with a history of class II, III, or IV heart failure, a hospitalization for cardiac reasons, and an EF > 40 %, who are taking b-blockers, diuretics, calcium channel blockers, and/or spironolactone. </li></ul>
    22. 22. Results of CHARM Preserved Study: <ul><li>Over a median follow up period of 36 months, treatment with candesartan was associated with significantly fewer hospitalizations for heart failure. </li></ul><ul><li>Non-significant trend toward a reduction in the composite primary end point of hospitalization for heart failure and death from cardiac causes </li></ul><ul><li>No significant reduction in the risks of stroke, MI, and coronary revascularization </li></ul>
    23. 23. Long Term Management: Goal: To prevent and treat myocardial ischemia <ul><li>Revascularization via percutaneous techniques or CABG </li></ul>
    24. 24. Long Term Management: Goal: To treat hypertension <ul><li>ACE-Inhibitors or Angiotensin Receptor Blocker </li></ul>
    25. 25. Goal: To promote regression of left ventricular hypertrophy <ul><li>ACE-Inhibitors </li></ul>
    26. 26. Goal: To prevent fibrosis <ul><li>Spironolactone </li></ul>
    27. 27. Management Principles for Patients with Diastolic Heart Failure
    28. 28. References: <ul><li>Aurigemma, G MD and Gaasch, W MD, Diastolic Heart Failure, New England Journal of Medicine 2004;351:1097-1105 </li></ul><ul><li>ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult </li></ul><ul><li>Jessup, M MD and Brozena, S MD, Medical Progress: Heart Failure, New England Journal of Medicine 2003;348:2007-2018 </li></ul><ul><li>Kitzman, D MD et al, Pathophysiological Characterization of Isolated Diastolic Heart Failure in Comparison to Systolic Heart Failure, JAMA 2002;288:2144-2150 </li></ul><ul><li>Zile, M MD, Baicu, C PhD, and Gaasch, W MD, Diastolic Heart Failure –Abnormalities in Active Relaxation and Passive Stiffness of the Left Ventricle, New England Journal of Medicine 2004:350:1953-1959 </li></ul><ul><li>Redfield, M MD et al Burden of Systolic and Diastolic Ventricular Dysfunction in the Community, Appreciating the Scope of the Heart Failure Epidemic, JAMA January 8, 2003;289:194-202 </li></ul><ul><li>Yusuf, S, Pfeffer MA, Swedberg K, et al. Effects of Candesartan in Patients with Chronic Heart Failure and Preserved Left Ventricular Ejection Fraction: the CHARM-Preserved Trial. Lancet 2003;362:777-781 </li></ul>

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