DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE

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

2. 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.

3. ISOVOLUMIC (EARLY) RELAXATIONENERGY DEPENDENT

4. Phases of diastole

5. Elevated Left Ventricular Diastolic Pressure Causes Pulmonary Congestion

6. 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

7. SPONTANEOUS ANGINAEFFECT ON SYSTOLIC & DIASTOLIC PRESSURE

8. LV DIASTOLIC PRESSURE CHANGESDURING EXERCISE INDUCED ANGINA 50--- 50---

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

10. LV ANATOMIC CHANGES ALTERS DISTENSIBILITYin 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

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

12. 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 <1) ; alsoAbnormal pulmonary venous flow velocity Cardiac Catheterization • Normal heart size and contraction pattern • LV end diastolic pressure (normal =12 mmHg) Greater specificity when 16 mmHg used as upper normal. E A E E A

13. COMMON CAUSES OF DIASTOLIC DYSFUNCTION • Ischemia(potentially reversible delay in or incomplete early relaxation) • Acute Hypertension (potentially reversible delay in or incomplete early relaxation) • Infarction(increased passive stiffness) • Chronic Hypertension with Hypertrophy(increased passive stiffness) • Aortic Stenosis & IHSS (increased passive stiffness) • Idiopathic Hypertrophic Cardiomyopathy (increased passive stiffness) • Diabetes and Obesity(increased passive stiffness)

14. 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

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

16. EXERCISE RESPONSE IN DIASTOLIC DYSFUNCTION

17. 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

18. 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

19. RECURRENT PULMONARY EDEMARx: SURGICAL INTERVENTION 1985

20. 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

21. FRAMINGHAMSTUDY 25% CAD 80% CAD 80% CAD VARSAN JACC 1999

22. PROGNOSIS OF DIASTOLIC DYSFUNCTIONNOMAL CORONARY ARTERIES BRADY & DWYER 2006 Clin Card

23. 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” • It’s 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. Can’t live forever!