diastolic heart failure a disorder of the elderly patient - 46p (2)

8/8/2019 Diastolic Heart Failure A Disorder of the Elderly Patient - 46P (2)

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Diastolic Heart Failure DefinedDiastolic Heart Failure Defined11::

Clinical presentation and symptoms of heartClinical presentation and symptoms of heart

failure with preserved LV systolic functionfailure with preserved LV systolic function

Stiff ventricle equals decreased compliance andStiff ventricle equals decreased compliance and

impaired relaxation leading toimpaired relaxation leading to oo LVEDPLVEDP


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Background:Background:

Prevalence:Prevalence: as of 2004, 4.8 million Americans areas of 2004, 4.8 million Americans areaffected by diastolic heart failure (HF)affected by diastolic heart failure (HF)1,2,31,2,3

Diastolic HF prevalence increases with ageDiastolic HF prevalence increases with age4,5,6,74,5,6,7::

< 50 years old: 15%< 50 years old: 15%

5050--70 years old: 33%70 years old: 33%

> 70 years old: 50%> 70 years old: 50%


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Background (cont.)Background (cont.)

Incidence:Incidence: about 500,000 new cases diagnosedabout 500,000 new cases diagnosed

per yearper year1,2,3,41,2,3,4

HF is the leading cause of hospitalization inHF is the leading cause of hospitalization in

persons over the age of 65persons over the age of 654,84,8


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Background (cont.)Background (cont.)

More thanMore than 5050%% of patients with HF haveof patients with HF have

preserved LV functionpreserved LV function44,,99

Mortality rates for patients with diastolic HF:Mortality rates for patients with diastolic HF:

Advanced disease:Advanced disease: 3030--4040%% mortality inmortality in 55--1010yearsyears44,,1010

Mortality rates are comparable to those seen inMortality rates are comparable to those seen in

systolic HFsystolic HF44,,99


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A 68A 68--yearyear--old woman is hospitalized with palpitations andold woman is hospitalized with palpitations andshortness of breath. She has a history of hypertension andshortness of breath. She has a history of hypertension andchronic atrial fibrillation, and her medications includechronic atrial fibrillation, and her medications include

furosemide, candesartan, and warfarin. On physicalfurosemide, candesartan, and warfarin. On physicalexamination, the heart rate is 120/min with an irregularlyexamination, the heart rate is 120/min with an irregularlyirregular rhythm, and blood pressure is 130/80 mm Hg; sheirregular rhythm, and blood pressure is 130/80 mm Hg; shehas an elevated jugular venous pulse, crackles in both lungs,has an elevated jugular venous pulse, crackles in both lungs,and marked lower extremity edema. Echocardiography showsand marked lower extremity edema. Echocardiography showsleft ventricular hypertrophy, an ejection fraction of 70%, andleft ventricular hypertrophy, an ejection fraction of 70%, and

no significant valvular disease. She is treated with intravenousno significant valvular disease. She is treated with intravenousdiuretics, with improvement in her symptoms and resolutiondiuretics, with improvement in her symptoms and resolutionof peripheral edema and of crackles on lung examination. Herof peripheral edema and of crackles on lung examination. Herheart rate is now 99/min and her blood pressure is 120/75heart rate is now 99/min and her blood pressure is 120/75mm Hg.mm Hg.

Which of the following would be the most appropriateWhich of the following would be the most appropriatemedication to add?medication to add?

A LisinoprilA Lisinopril

B SpironolactoneB Spironolactone

C AmlodipineC Amlodipine

D Metoprolol E HydrochlorothiazideD Metoprolol E Hydrochlorothiazide


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Risk Factors for Diastolic HFRisk Factors for Diastolic HF4,114,11::

1.1. ElderlyElderly

2.2. FemaleFemale

3.3. HypertensiveHypertensive


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EtiologyEtiology44::

1.1. LongLong--standing HTN with LVHstanding HTN with LVH1212::

A hypertensive hypertrophic cardiomyopathy with LVEFA hypertensive hypertrophic cardiomyopathy with LVEF>75% in the elderly>75% in the elderly66

2.2. Aortic Stenosis with normal LVEFAortic Stenosis with normal LVEF1313

3.3. Severe aortic or mitral regurgitationSevere aortic or mitral regurgitation4.4. Ischemic Heart DiseaseIschemic Heart Disease

Regional wall motion abnormalitiesRegional wall motion abnormalities

5.5. Restrictive CardiomyopathyRestrictive CardiomyopathyIdiopathic vs.Idiopathic vs.InfiltrativeInfiltrative Sarcoidosis, Amyloidosis, HemochromatosisSarcoidosis, Amyloidosis, Hemochromatosis

6.6. HOCMHOCM

7.7. HypothyroidismHypothyroidism


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Asymptomatic Diastolic HF:Asymptomatic Diastolic HF:

More common than symptomatic diastolic HFMore common than symptomatic diastolic HF

Mayo Clinic study ofMayo Clinic study of 22,,042042 subjects > agesubjects > age 4545::

Prevalence of symptomatic HF:Prevalence of symptomatic HF: 22..22%% Of those,Of those, 4444% had diastolic HF% had diastolic HF

In subjectsIn subjects withoutwithout symptoms of HF,symptoms of HF, 2828% had% haddiastolic HF by echo criteriadiastolic HF by echo criteria44,,1515..


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PathyphysiologyPathyphysiology4,164,16::

Diastolic FunctionDiastolic Function

Myocardial Relaxation ElasticityMyocardial Relaxation Elasticity-- An active process An active process -- A passive processA passive process

-- Requires energyRequires energy -- Requires no energyRequires no energy


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Pathophysiology (cont.)Pathophysiology (cont.)1717::

Normally, LV relaxation during diastole creates aNormally, LV relaxation during diastole creates a

negative LA to LV pressure gradient, therebynegative LA to LV pressure gradient, therebyaugmenting diastolic fillingaugmenting diastolic filling

Decrease in LV relaxation and distensibilityDecrease in LV relaxation and distensibilitycauses increased LA, LV, PV, and PCWcauses increased LA, LV, PV, and PCW

pressurespressures

Increase in LV filling during late diastole,Increase in LV filling during late diastole,

increase in dependence on atrial contractionincrease in dependence on atrial contraction


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Cardiac CycleCardiac Cycle

Reproduced from:Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Am Fam PhysicianAm Fam Physician20042004;;6969::26092609--1616..


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Pathophysiology (cont.)Pathophysiology (cont.)1717

Why do patients with diastolic dysfunction have poorWhy do patients with diastolic dysfunction have poorexercise tolerance?exercise tolerance?

1.1. During normal exercise, increase in HR associated withDuring normal exercise, increase in HR associated withincrease in SVincrease in SVpp (( CO = HR x SV )CO = HR x SV )

2.2. Increased HR leads to compensatory increase in relaxationIncreased HR leads to compensatory increase in relaxationrate, maintaining normal LVEDP & PCWPrate, maintaining normal LVEDP & PCWP3.3. Increased LVEDV normally leads to increased SV due toIncreased LVEDV normally leads to increased SV due to

FrankFrank--Starling mechanismStarling mechanism4.4. N

ormal LV distensibility allows normal LVEDP to beN

ormal LV distensibility allows normal LVEDP to bemaintained at increased LVEDVmaintained at increased LVEDV5.5. Thus,Thus, oo LVEDV causesLVEDV causes oo LVEDP and PCWP inLVEDP and PCWP in

response to exercise in patients with diastolic dysfunctionresponse to exercise in patients with diastolic dysfunction


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Increased PCWP During Exercise in Pts.Increased PCWP During Exercise in Pts.

With Diastolic HFWith Diastolic HF

Data from Kitzman, DW, Higginbotham, MB, Cobb, FR, et al, J Am Coll CardiolData from Kitzman, DW, Higginbotham, MB, Cobb, FR, et al, J Am Coll Cardiol 19911991;; 1717::10651065..


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Pathophysiology (cont.)Pathophysiology (cont.)

Why is diastolic dysfunction more common inWhy is diastolic dysfunction more common in

elderly persons?elderly persons?

AgeAge--related changesrelated changes1818,,1919

:: Increased collagen crossIncreased collagen cross--linkinglinking

Increased smooth muscle contentIncreased smooth muscle content

Loss of elastic fibersLoss of elastic fibers


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Clinical ManifestationsClinical Manifestations44::

Similar to systolic HFSimilar to systolic HF

AF poorly tolerated due to loss of atrial kickAF poorly tolerated due to loss of atrial kick

Tachycardia poorly tolerated due to shorteningTachycardia poorly tolerated due to shorteningof late diastolic filling timeof late diastolic filling time

Elevated systemic blood pressure increases LVElevated systemic blood pressure increases LVwall stress and further impairs relaxationwall stress and further impairs relaxation

AcuteAcute--onon--chronic diastolic dysfunction causedchronic diastolic dysfunction causedby ischemia increases LA and PV pressures,by ischemia increases LA and PV pressures,causing dyspnea, aka anginal equivalentscausing dyspnea, aka anginal equivalents


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DiagnosisDiagnosis44::

Controversy: does clinical HF + normal LVEFControversy: does clinical HF + normal LVEF= diagnosis of diastolic HF?= diagnosis of diastolic HF?

Most patients with overt clinical HF and normalMost patients with overt clinical HF and normalLV systolic function have some element ofLV systolic function have some element ofdiastolic dysfunctiondiastolic dysfunction

A study ofA study of 6363 HF patients with LVH andHF patients with LVH and

normal systolic function by echo found thatnormal systolic function by echo found that100100%% of patients had at least one index ofof patients had at least one index ofdiastolic dysfunctiondiastolic dysfunction2020..


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Diagnosis (cont.)Diagnosis (cont.)11

Gold standard for diagnosis is cardiacGold standard for diagnosis is cardiaccatheterization:catheterization: Direct measurement of LVEDPDirect measurement of LVEDP Risk outweighs benefit for routine use in diagnosingRisk outweighs benefit for routine use in diagnosing

diastolic dysfunctiondiastolic dysfunction

Doppler Echocardiography:Doppler Echocardiography: the primarythe primarydiagnostic modality for diagnosisdiagnostic modality for diagnosis


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Doppler EchocardiographyDoppler Echocardiography11

Tau = time constant of LV pressure decayTau = time constant of LV pressure decay

during isovolumetric relaxation that correlatesduring isovolumetric relaxation that correlateswith LV stiffnesswith LV stiffness

Diastolic transDiastolic trans--mitral valve blood flow:mitral valve blood flow:

Measurement of peak velocities during early diastolicMeasurement of peak velocities during early diastolicfilling:filling:

11)) EEwave =wave = EEarly diastolic fillingarly diastolic filling

22))AAwave =wave =AAtrial contractiontrial contraction


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Spectrum of Diastolic DysfunctionSpectrum of Diastolic Dysfunction11

Normal:Normal:

E wave > A waveE wave > A wave

RatioRatio 11..55::11..00


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Spectrum of Diastolic DysfunctionSpectrum of Diastolic Dysfunction11

1.1. Early Diastolic Dysfunction:Early Diastolic Dysfunction:

Abnormal RelaxationAbnormal Relaxation

EE--toto--A ratio reverses to


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Spectrum of Diastolic Dysfunction (cont.)Spectrum of Diastolic Dysfunction (cont.)11

2.2. Advanced Diastolic Dysfunction:Advanced Diastolic Dysfunction:Pseudonormal PatternPseudonormal Pattern

Abnormal relaxation &Abnormal relaxation & oo LVEDPLVEDP

Pseudonormalization can occur withPseudonormalization can occur withdecompensated HF anddecompensated HF and oo LA pressure, commonLA pressure, commontriggers include tachyarrhythmias, especially AF,triggers include tachyarrhythmias, especially AF,uncontrolled HTNuncontrolled HTN


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Spectrum of Diastolic Dysfunction (cont.)Spectrum of Diastolic Dysfunction (cont.)11

3.3. Severe Diastolic Dysfunction:Severe Diastolic Dysfunction:

Restrictive PatternRestrictive Pattern

oo LVEDPLVEDPpp LV diastolic filling occurs mostlyLV diastolic filling occurs mostlyduring early diastole because LVEDP so high thatduring early diastole because LVEDP so high thatatrial kick unable to effectively contribute to LVatrial kick unable to effectively contribute to LVfillingfilling

EE--toto--A ratio >A ratio > 22..00 pp poor prognosispoor prognosis


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Normal TransNormal Trans--MitralMitral--Valve Spectral Doppler Flow PatternValve Spectral Doppler Flow Pattern

Reproduced from:Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Am Fam PhysicianAm Fam Physician

20042004;;6969::26092609--1616..


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Abnormal RelaxationAbnormal Relaxation

Reproduced from:Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Am Fam PhysicianAm Fam Physician

20042004;;6969::26092609--1616..


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Severe (Restrictive) Diastolic DysfunctionSevere (Restrictive) Diastolic Dysfunction

Reproduced from:Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and Treatment.Am Fam PhysicianAm Fam Physician20042004;;6969::26092609--1616..


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Doppler Echocardiography (cont.)Doppler Echocardiography (cont.)

Adapted from:Adapted from: Zile MR. Clinical manifestations and diagnosis of diastolic heart failure.Zile MR. Clinical manifestations and diagnosis of diastolic heart failure. http://www.utdol.com/diastolichttp://www.utdol.com/diastolicheart failure/clinical manifestationsheart failure/clinical manifestations

and diagnosis of diastolic heart failure.and diagnosis of diastolic heart failure. 33//22//0707


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BNP (cont.)BNP (cont.)44

A study ofA study of 400400 randomly selected patientsrandomly selected patients

referred for echo to evaluate LV functionreferred for echo to evaluate LV function2121::

With normal LV functionWith normal LV function mean BNP wasmean BNP was 3030

BNP ofBNP of 7575: sensitivity of: sensitivity of 8585%% and specificity ofand specificity of 9797%%in detecting ventricular dysfunctionin detecting ventricular dysfunction

In the patients with normal LV systolic function,In the patients with normal LV systolic function,

BNP ofBNP of 5757 detecteddetected 2828 patients with isolatedpatients with isolateddiastolic dysfunction withdiastolic dysfunction with 100100%% PPVPPV


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BNP (cont.)BNP (cont.)

ACEACE--Is, ARBs, Spironolactone, and Diuretics:Is, ARBs, Spironolactone, and Diuretics:

qq BNP levelsBNP levels2626

Thus, monitoring of BNP levels may be a usefulThus, monitoring of BNP levels may be a usefulmethod of assessing response to treatmentmethod of assessing response to treatment


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TreatmentTreatment2727::

Trial data limited compared with systolic HFTrial data limited compared with systolic HF

Aim of therapy is to prevent or controlAim of therapy is to prevent or controlhemodynamic stressors.hemodynamic stressors.


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Treatment (cont.)Treatment (cont.)2727,,2828

20052005 ACC/AHA Task Force Guidelines onACC/AHA Task Force Guidelines onManagement of Chronic Diastolic HF:Management of Chronic Diastolic HF:

1)1) Control of systolic and diastolic HTNControl of systolic and diastolic HTN

2)2) Control of VR in patients with AFControl of VR in patients with AF

3)3) Control of pulmonary edema and peripheralControl of pulmonary edema and peripheralcongestion with diureticscongestion with diuretics

4)4) Coronary revascularization in CAD patients ifCoronary revascularization in CAD patients ifischemia thought to be contributing toischemia thought to be contributing todiastolic dysfunctiondiastolic dysfunction


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Pharmacologic TherapyPharmacologic Therapy 2727

Patients with small, stiff LV chamber are sensitive toPatients with small, stiff LV chamber are sensitive toexcessive preload reductionexcessive preload reduction

Diuretics, Nitrates,Diuretics, Nitrates, Dihydropyridine CCBs, ACEDihydropyridine CCBs, ACE--IsIsuse with caution due to potential to cause LV underfillinguse with caution due to potential to cause LV underfilling

FrankFrank--Starling curve has a steeper slopeStarling curve has a steeper slope

Monitor for symptoms of weakness, lightheadedness,Monitor for symptoms of weakness, lightheadedness,syncopesyncope


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FF--blockersblockers2727

Can cause regression of LVH and improvement ofCan cause regression of LVH and improvement ofdiastolic functiondiastolic function

CanCan qq HR,HR, oo diastolic filling time,diastolic filling time, qq oxygenoxygenconsumption,consumption, qq BPBP11

CarvedilolCarvedilol has been shown to improve Ehas been shown to improve E--toto--A ratioA ratio3131


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Calcium channel blockersCalcium channel blockers2727

N

onN

on--dihydropyridine CCBs (diltiazem, verapamil)dihydropyridine CCBs (diltiazem, verapamil) --more potent negative inotropesmore potent negative inotropes

CCBsCCBs -- can cause regression of LVH and improvementcan cause regression of LVH and improvementof diastolic functionof diastolic function

VerapamilVerapamil May have a lusitropic (relaxationMay have a lusitropic (relaxation--enhancing) effectenhancing) effect2727

A study onA study on 2020 patients with diastolic HF taking verapamil:patients with diastolic HF taking verapamil:

qq signs and symptoms of HFsigns and symptoms of HF

oo LV diastolic filling rate and treadmill exercise timeLV diastolic filling rate and treadmill exercise time3232

AmlodipineAmlodipine -- a study ofa study of 5959 patients with HTN, CAD,patients with HTN, CAD,and diastolic dysfunction showed improvement in echoand diastolic dysfunction showed improvement in echo

parameters (parameters (oo E wave)E wave) withwith 44 weeks of therapyweeks of therapy3333


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ACEACE--InhibitorsInhibitors2727

Afterload reduction not as important as with systolicAfterload reduction not as important as with systolicHF, but some evidence of benefitHF, but some evidence of benefit

ACEACE--IsIs can cause regression of LVH andcan cause regression of LVH andimprovement of diastolic functionimprovement of diastolic function

ACEACE--IsIs improve NYHA functional class, QOL, andimprove NYHA functional class, QOL, andmay prevent myocardial fibrosis associated with LVHmay prevent myocardial fibrosis associated with LVH


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Angiotensin II Receptor BlockersAngiotensin II Receptor Blockers2727

ARBsARBs -- can cause regression of LVH and improvementcan cause regression of LVH and improvementof diastolic functionof diastolic function

CHARMCHARM--Preserved trialPreserved trial3434::

30233023 patients with symptomatic HF and LVEF >patients with symptomatic HF and LVEF > 4040%%

Randomly assigned to receive candesartan or placebo x meanRandomly assigned to receive candesartan or placebo x mean

3737 monthsmonths

Small but almost significant reduction in incidence of primarySmall but almost significant reduction in incidence of primary

endpoints of CV death and hospitalization for HF in theendpoints of CV death and hospitalization for HF in thecandesartan groupcandesartan group


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Antihypertensives and LVHAntihypertensives and LVH2727

Regression of LVH may improve diastolic functionRegression of LVH may improve diastolic function3535

20032003 metameta--analysis examining the efficacy of variousanalysis examining the efficacy of variousantihypertensives in reversal of LVHantihypertensives in reversal of LVH3636

Relative reductions in LV mass index:Relative reductions in LV mass index:

ARBsARBs 1313%%

CCBsCCBs 1111%%

ACEACE--IsIs 1010%%

DiureticsDiuretics 88%%

FF--blockersblockers 66%%


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PrognosisPrognosis2727

Varies with symptomatic vs. asymptomatic HFVaries with symptomatic vs. asymptomatic HF

Framingham Heart Study and VFramingham Heart Study and V--HeFT trialsHeFT trials

showed better prognosis with diastolic HF thanshowed better prognosis with diastolic HF thanwith systolic HF, but worse than controlswith systolic HF, but worse than controls 3737--3939

A study ofA study of 522522 patients showed similarpatients showed similar 55--yearyear

mortality for diastolic vs. systolic HF (mortality for diastolic vs. systolic HF (2525% vs.% vs.4242%)%)4040


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SurvivalSurvival

Reproduced from:Reproduced from: Zile MR. Treatment and prognosis of diastolic heart failure.Zile MR. Treatment and prognosis of diastolic heart failure.www.utdol.comwww.utdol.com.. 33//22//0707

R fR f


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22.. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study.Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study.J Am Coll CardiolJ Am Coll Cardiol19931993;;2222((44 suppl A):suppl A):66AA--1313A.A.

33.. Berry C, Murdoch DR, McMurray JJ. The economics of chronic heart failure.Berry C, Murdoch DR, McMurray JJ. The economics of chronic heart failure. Eur J Heart FailEur J Heart Fail20012001;; 33::283283--9191..

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diastolic heart failure a disorder of the elderly patient - 46p (2)

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