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Definitions
Diastole encompasses the time period during which the myocardium loses its ability to generate force and shorten and returns to an unstressed length and force. Diastolic Dysfunction occurs when these processes are prolonged, slowed or incomplete. Diastolic Dysfunction is an abnormality of diastolic function and does not characterize clinical status of an individual. It can occur regardless of whether the EF is normal or abnormal and whether the patient is symptomatic or asymptomatic.
Diastolic Function
As many as 30 to 50 percent of patients with symptomatic HF exhibit diastolic rather than systolic dysfunction. Diastolic dysfunction is more common in women and the elderly, and in the latter it may be the dominant form of HF. Additional risk factors for diastolic dysfunction include a history of hypertension and diabetes mellitus.
VISUALPATTERNS
PREVALENCE
AGEDISTRIBUTION
SURVIVALPATTERNS
A dramatic 5-year excess mortality was observed in patients with preserved and reduced EF compared to the expected survival
THEDIAGNOSISOFHFPEFREQUIRESTHREE CONDITIONSTOBESATISFIED:
Presence of signs or symptoms of CHF Presence of normal or only mildly abnormal left ventricular systolic function (LVEF > 4550%) Evidence of diastolic dysfunction (abnormal left ventricular relaxation or diastolic stiffness) ESC Guidelines for the Diagnosis and Treatment
of Acute and Chronic Heart Failure Eur Heart J 2008;29:2388-2442
PLASMABNPLEVELS
PHYSIOLOGYOFDIASTOLE
PATTERNSOFDIASTOLICDYSFUNCTION
INDICESOFCARDIACPERFORMANCE
LVSYSTOLICDYSFUNCTION(MUSCULARPUMP) INHFNEF
Left Ventricular Pressure-Volume Loops in Systolic and Diastolic Dysfunction A .In systolic dysfunction, LV contractility is depressed, and the end-systolic pressure-volume line is displaced downward and to the right. B. Normal C. In diastolic dysfunction, the diastolic pressure-volume line is displaced upward and to the left.
NEJM 2004;351:1097-1105
JACC 1997;30:8-18
Diastolic Dysfunction
Epidemiology
A. A large study of patients (n=4596) hospitalized with HF at a single institution over a 15 year period demonstrated that the percentage of patients who have a normal EF has increased over time B. This was the result of an increased number of admissions for HF with a normal EF; the number of admissions for HF with reduced EF remained stable
EPICA Study
Population based study showing increased prevalence of Diastolic HF with age and with female gender
JAMA 2003;289:194-202
Zile MR. Treatment and prognosis o f diast olic heart failure . www .utdol. Com 3/ 2/ 07
The survival rate was higher among patients with preserved ejection fraction although, the difference was small
Survival for patients with heart failure with normal EF has not improved
Survival for patients with HF with reduced EF was shown to be improving over time
Morbidity Myth
Treatment
In contrast to treatment of HF due to reduced LVEF, few clinical trials are available to guide the management of patients with HF and relatively preserved LVEF Trials done have been small or have produced inconclusive results
JAMA 2003;289:194-202
Comorbid Conditions
Age HTN- most commonly associated cardiac condition in pts with HF and normal EF Obesity Atrial fibrillation Female gender Diabetes Renal dysfunction Ischemic Heart Disease
JAMA 2003;289:194-202
Treatment
The management of patients with Diastolic Dysfunction is based on control of physiological factors that are known to exert important effects on ventricular relaxation: Blood pressure - Heart rate - Blood volume - Myocardial Ischemia
JAMA 2003;289:194-202
Regression of LVH
Zile MR. Treatment and prognosis o f diast olic heart failure . www .utdol. com
Regression of LVH
Zile MR. Treatment and prognosis o f diast olic heart failure . www .utdol. com
ImCardia Device
Conclusions
Diastolic Dysfunction is responsible for about one- half of cases of CHF. Morbidity and mortality associated is high and similar to LV systolic dysfunction. Older age, hypertension and female sex are commonly associated. Non invasive imaging techniques can be used for diagnosis. Further studies are needed to determine optimal treatment strategies.