Diastolic Heart Diastolic Heart FailureFailure

“ “The very essence of The very essence of cardiovascular medicine is cardiovascular medicine is recognition of early heart recognition of early heart failure.” Sir Thomas Lewis failure.” Sir Thomas Lewis 19331933

Carmen B. Gomez MD Carmen B. Gomez MD Eugene Yevstratov MDEugene Yevstratov MD

Introduction

Diastolic heart failure has emerged over the Diastolic heart failure has emerged over the last 10 years as a separate clinical entity. last 10 years as a separate clinical entity. Diastolic heart failure accounts for Diastolic heart failure accounts for approximately one third of all heart failure approximately one third of all heart failure cases, especially in an elderly population, cases, especially in an elderly population, and its natural history, with an annual and its natural history, with an annual mortality rate of 8%, is more benign than mortality rate of 8%, is more benign than other forms of heart failure with an annual other forms of heart failure with an annual mortality of 19%. A need has therefore mortality of 19%. A need has therefore grown to establish precise criteria for the grown to establish precise criteria for the iagnosis of diastolic heart failure.iagnosis of diastolic heart failure.

Requirments for Diagnostic of the DHF

Presence of sighs or symptoms of Presence of sighs or symptoms of congestive heart failurecongestive heart failure

Presence of normal or only midly Presence of normal or only midly abnormal left ventricular systolic abnormal left ventricular systolic functionfunction

Evidence of abnormal left ventricular Evidence of abnormal left ventricular relaxation(filling,diastolic relaxation(filling,diastolic distensibility or diastolic stiffness)distensibility or diastolic stiffness)

Pathophysiology

Impaired relaxationImpaired relaxationIncrease passive stiffnessIncrease passive stiffnessEndocardial and pericardial Endocardial and pericardial

disorderswdisorderswMicrovascular flow.Myocardial Microvascular flow.Myocardial

turgorturgorNeurohormonal regulationNeurohormonal regulation

Epicardial or microvascular Epicardial or microvascular ischemiaischemia

Myocite hypertrophyMyocite hypertrophyCardiomyopathiesCardiomyopathiesAgingAgingHypothyroidismHypothyroidism

PathophysiologyImpaired Relaxation

Diffuse fibrosisDiffuse fibrosis Post-infarct scarringPost-infarct scarring Myocyte hypertrophyMyocyte hypertrophy Infiltrative (amyloidosis, Infiltrative (amyloidosis,

hemochromatosis, Fabry´s disease)hemochromatosis, Fabry´s disease)

PathophysiologyIncrease Passive Stiffness

FibroelastosisFibroelastosis Mitral or tricuspid stenosisMitral or tricuspid stenosis Pericardial constrictionPericardial constriction Pericardial tamponadePericardial tamponade

PathophysiologyEndocadial, Pericardial Disorders

                          

PathophysiologyEndocadial, Pericardial Disorders

Capillary compressionCapillary compression Venouse engorgementVenouse engorgement

PathophysiologyMicrovascular Flow,Myocardial Turgor

PathophysiologyMicrovascular Flow,Myocardial Turgor

Upregulated renin-angiotensin Upregulated renin-angiotensin systemsystem

Volume overload of the Volume overload of the contralatetal ventriclecontralatetal ventricle

Extrinsic compression by tumorExtrinsic compression by tumor

PathophysiologyNeurohormonal Regulation, Other

Diagnosis

Increased ventricular filling pressure with Increased ventricular filling pressure with normal systolic function.normal systolic function.

Incresed ventricular pressure with Incresed ventricular pressure with preserved systolic function and normal preserved systolic function and normal ventricular volumes.ventricular volumes.

Increased left atrial and pulmonary Increased left atrial and pulmonary capillary wedge pressure.capillary wedge pressure.

Clinical symptoms and signs.Clinical symptoms and signs.

Clinical Signs and Symptoms

Evidence of raised left atrial pressureEvidence of raised left atrial pressure Exertional dyspnoeaExertional dyspnoea OrthopnoeaOrthopnoea Gallop soundsGallop sounds Lung crepitationsLung crepitations Pulmonary oedemaPulmonary oedema Exercise intoleranceExercise intolerance

Pathology

Evidence of Abnormal left Ventricular Relaxation

LVdP/dtLVdP/dt min<1100 mmHg min<1100 mmHg IVRT<30y>92 ms, IVRT30–50y>100 IVRT<30y>92 ms, IVRT30–50y>100

ms, IVRT>50y>105 msms, IVRT>50y>105 ms and/or and/or ÙÙ>48 ms>48 ms

LVEDP>16 mmHg or mean LVEDP>16 mmHg or mean PCW>12 mmHgPCW>12 mmHg

PV A Flow >35 cm . sPV A Flow >35 cm . s""11 b>0·27b>0·27 and/or band/or b**>16>16

Reduce symptomsReduce symptoms Control hypertensionControl hypertension Prevent myocardial ischemiaPrevent myocardial ischemia

There is no specific There is no specific therapy for DHFtherapy for DHF

Management of DHF

Diuretics – Diuretics – provide the most symptoms relief if provide the most symptoms relief if fluid retentionn is a futurefluid retentionn is a future

ACE inhibitors and β Blockers – ACE inhibitors and β Blockers – complement diuretics wellcomplement diuretics well

Central sympatholytics –Central sympatholytics – hypertensive hypertensive episodesepisodes

Nitrates – Nitrates – preventing ischemiapreventing ischemia

Trimetazidine – Trimetazidine – as a metabolic supportas a metabolic support

Management of DHF

Conclusion Until further evidence isUntil further evidence is available from randomized available from randomized therapeutictherapeutic trials, clinicians trials, clinicians should focus on a fewshould focus on a few general general principles in the treatment ofprinciples in the treatment of DHF:DHF: RReduce volume overload educe volume overload SlowSlow the heart ratethe heart rateCControl hypertension,ontrol hypertension,RRelieve myocardial ischemia.elieve myocardial ischemia.

Eugene Eugene Yevstratov MDYevstratov MD

FUNDACION FAVALOROFUNDACION FAVALOROINSTITUTO DE CARDIOLOGIA Y CIRUGIA INSTITUTO DE CARDIOLOGIA Y CIRUGIA

CARDIOVASCULARCARDIOVASCULAR

Carmen B. Gomez Carmen B. Gomez MDMD

http://myprofile.cos.com/eugenefox