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

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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.

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ISOVOLUMIC (EARLY) RELAXATION ENERGY DEPENDENT

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Phases of diastole

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Elevated Left Ventricular Diastolic Pressure Causes Pulmonary Congestion

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HISTORICAL CONCEPTS OF DIASTOLIC FUNCTION 1940-1965 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. 1970 Report of reversible diastolic pressure increase without enlargement of the LV heart size during ischemia. 1975 Non invasive techniques of evaluating diastolic volume changes, wall thickness and LV diastolic diameter

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SPONTANEOUS ANGINA EFFECT ON SYSTOLIC & DIASTOLIC PRESSURE

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

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

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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

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

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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: 1.2- 2 & Abnormal

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

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

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EXERCISE RESPONSE IN DIASTOLIC DYSFUNCTION

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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

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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

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RECURRENT PULMONARY EDEMA Rx: SURGICAL INTERVENTION 1985

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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

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FRAMINGHAM STUDY VARSAN JACC 1999 80% CAD 25% CAD

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

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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 Its 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. Cant live forever!