Diastolic dysfunction

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby

Congestive heart failure and cardiac dysfunction are not interchangeable definitions. Whereas heart failure is a clinical definition that illustrates the occurrence of symptoms of fatigue, dyspnea, and fluid overload; cardiac dysfunction is a mechanical definition that includes abnormalities in heart contraction (called systolic dysfunction) or abnormalities in heart relaxation and filling (called diastolic dysfunction) or both.

Therefore, diastolic dysfunction refers to a mechanical dysfunction of the heart during the diastolic phase of the cardiac cycle in the presence or absence of any clinical symptoms. When clinical symptoms are present on top of the mechanical dysfunction of the heart, the condition is called diastolic heart failure^[1].

Diastole is the phase of the cardiac cycle when the heart ( i.e. ventricle) is not contracting but is actually relaxed and filling with blood that is being returned to it, either from the body (into right ventricle) or from the lungs ( into left ventricle). The mechanical abnormality in diastolic dysfunction is characterized by a decrease in the ventricular filling in the context of an elevated left ventricular end diastolic pressure and a normal ejection fraction.Diastolic dysfunction is caused by decrease cardiac muscle relaxation or increased stiffness. The ejection fraction of the heart is preserved in this type of dysfunction.Systolic and diastolic dysfunction commonly occur in conjunction with each other.

There are four basic echocardiographic patterns of diastolic heart failure, which are graded I to IV. Grade I is called an “abnormal relaxation pattern”, grade II is called “pseudonormal filling dynamics”, grade III is called “restrictive filling dynamics”, and grade IV is called “reversible restrictive diastolic dysfunction”.

Diastolic dysfunction is the impairment of the heart muscle in its ability to properly relax and fill with blood during diastole. Diastolic dysfunction is mainly the result of either impaired myocardial relaxation or increased cardiac muscle stiffness. As a result, the pressure in the left ventricle increases at the end of diastole and causes a build up of pressure in the left atrium and consequently in the pulmonary circulation. The result is pulmonary edema and dyspnea.

Diastolic dysfunction is the mechanical abnormality of the heart to properly relax and fill with blood during diastole. Several medical conditions may cause this to occur; namely cardiovascular conditions, genetic conditions, pulmonary conditions, rheumatologic conditions, and diabetes.

Diastolic heart failure is one of the examples of heart failure with preserved ejection fraction. Other causes that cause heart failure and do not affect ejection fraction need to be differentiated from this condition.

About half of patients with heart failure have a normal ejection fraction^[2]. The prevalence of diastolic dysfunction has increased, although mortality rates have stayed the same. Diastolic dysfunction is more common in females than in males, and more common in the elderly.

Heart failure associated with diastolic dysfunction has a slightly better prognosis than that of systolic heart failure. However, the presence or absence of coronary artery disease, the age, and the left ventricular ejection fraction cut off level must all be taken into consideration in stratifying patients and assessing their prognosis.^[3]

The evaluation of the presence of diastolic dysfunction in patients presenting with symptoms of heart failure is of paramount importance. The diagnosis of diastolic dysfunction or diastolic heart failure is not clinical and requires a work up that goes beyond the history, physical exam, echocardiography and chest X-rays. Several studies have evaluated the diagnostic criteria to follow in differentiating systolic dysfunction from diastolic dysfunction.

The classic symptoms of heart failure include dyspnea, fatigue, and fluid retention. Patients with diastolic heart failure may present in different ways. Some patients present with exercise intolerance but show little evidence of congestion or edema. Other patients present with mild symptoms of edema and pulmonary congestion.

In general, signs of both left sided heart failure and right sided heart failure are present. Signs that represent acute left sided failure include cool clammy skin, cyanosis, rales and a gallop rhythm. Signs that represent right sided failure include an elevated JVP, pedal edema, ascites, hepatomegaly, a parasternal heave and hepatojugular reflux.

The initial laboratory tests in diastolic dysfunction or failure include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. The measurement of BNP is done only when diagnosis is unclear.

Diastolic dysfunction, in the presence or absence of diastolic heart failure, is a challenging diagnosis that has several diagnostic approaches. While cardiac catheterization can be used to establish the diagnosis of diastolic dysfunction by the invasive measurement of elevated left ventricular end diastolic pressure and mean pulmonary capillary pressure, echocardiography provides an alternative noninvasive diagnostic tool.

Cardiac catheterization can be used to measure the PCWP and the LVEDP. These are important predictors of the filling pressure and the degree of myocardial disease progression in dilated cardiomyopathy.

The chronic treatment of diastolic dysfunction involves aggressive management of the underlying disorder that is causing the diastolic dysfunction such as diabetes or hypertension. Mild diastolic dysfunction that is well tolerated requires no specific treatment. Rate control is an important part of the acute therapy of the patient with diastolic heart failure. It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy of diastolic dysfunction.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

There are four basic echocardiographic patterns of diastolic heart failure, which are graded I to IV. Grade I is called an “abnormal relaxation pattern”, grade II is called “pseudonormal filling dynamics”, grade III is called “restrictive filling dynamics”, and grade IV is called “reversible restrictive diastolic dysfunction”.

The mildest form is called an “abnormal relaxation pattern”, or grade I diastolic dysfunction. On the mitral inflow Doppler echocardiogram, there is reversal of the normal E/A ratio. This pattern may develop normally with age in some patients, and many grade I patients will not have any clinical signs or symptoms of heart failure.

Grade II diastolic dysfunction is called “pseudonormal filling dynamics”. This is considered moderate diastolic dysfunction and is associated with elevated left atrial filling pressures. These patients more commonly have symptoms of heart failure, and many have left atrial enlargement due to the elevated pressures in the left heart.

Grade III diastolic dysfunction is associated with “restrictive filling dynamics”. This is a severe forms of diastolic dysfunction, and patients tend to have advanced heart failure symptoms. Class III diastolic dysfunction patients will demonstrate reversal of their diastolic abnormalities on echocardiogram when they perform the Valsalva maneuver. This is referred to as “reversible restrictive diastolic dysfunction”.

Grade III diastolic dysfunction is associated with “restrictive filling dynamics”. This is a severe forms of diastolic dysfunction, and patients tend to have advanced heart failure symptoms.Class IV diastolic dysfunction patients will not demonstrate reversibility of their echocardiogram abnormalities, and are therefore said to suffer from “fixed restrictive diastolic dysfunction”.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby

Diastolic dysfunction is the mechanical abnormality of the heart to properly relax and fill with blood during diastole. Several medical conditions may cause this to occur; namely cardiovascular conditions, genetic conditions, pulmonary conditions, rheumatologic conditions, and diabetes.

• Amyloidosis
• Aortic stenosis
• Constrictive pericarditis
• Diabetes
• Effusive-constrictive pericarditis
• Glycogen storage disease
• Hemochromatosis
• Hypereosinophilic syndrome
• Hypertrophic heart diseases(for example, as seen in hypertension)
• Hypertrophic obstructive cardiomyopathy (HOCM)
• Infiltrative diseases ( for example, amyloidosis)
• Ischemia
• Mitral stenosis
• Myocardial infarction and scar
• Pericardial effusion
• Restrictive cardiomyopathy
• Sarcoidosis
• Systolic dysfunction

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby

Diastolic heart failure is one of the examples of heart failure with preserved ejection fraction. Other causes that cause heart failure and do not affect ejection fraction need to be differentiated from this condition.

• Large, dilated, eccentrically hypertrophied ventricles
• Impaired blood ejection during systole
• Decreased cardiac output and ejection fraction
• Normal or decreased blood pressure
• Can occur in any age and more frequent in men than in women
• Presence of an S3 gallop

• Small, thickened, concentrically hypertrophied ventricles
• Large atria
• Impaired blood filling during diastole
• Normal ejection fraction
• Systemic elevation of the blood pressure
• Occurs mainly in elderly women
• Presence of an S4 gallop^[1]

• Diastolic dysfunction is characterized by a normal ejection fraction, elevated left ventricular filling pressure and presence or absence of heart failure symptoms. Restrictive cardiomyopathy is one of the medical conditions that cause diastolic dysfunction due to impaired myocardial relaxation.
• On the other hand, constrictive cardiomyopathy is also characterized by normal ejection fraction, elevated filling pressures and symptoms of heart failure; however, there is no diastolic dysfunction.
• Thus, when normal ejection fraction and elevated filling pressure are present in the context of a patient presenting with heart failure symptoms, it is important to differentiate diastolic heart failure (that can be caused by restrictive cardiomyopathy) and constrictive pericarditis where no diastolic dysfunction is present. The differentiation between the two medical conditions is crucial because it helps tailor the treatment plan.

• Elevated left ventricular filling pressure in both conditions

• Elevated E/A ratio and decreased DT (consistent with pseudo-normal or restrictive filling pattern) in both conditions

• Mitral septal annular e’>7cm/s in constrictive pericarditis
• Mitral septal annular e'<7 cm/s in restrictive cardiomyopathy

• An increase of more than 25% with expiration is noted in constrictive pericarditis
• Absent in restrictive cardiomyopathy

• Diastolic flow reversal during expiration in constrictive pericarditis
• Diastolic flow reversal during inspiration in restrictive pericarditis^[2]

• Right heart failure
• Valvular heart disease
• Pericardial diseases – constrictive pericarditis, cardiac tamponade
• Cardiac tumors
• High output cardiac failure

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2]

The prevalence of diastolic dysfunction has increased, although mortality rates have stayed the same. Diastolic dysfunction is more common in females than in males, and more common in the elderly.

• There is an increasing prevalence of heart failure with preserved ejection fraction. ^{[1] [2]}
• Death rates have remained unchanged.
• The prevalence of diastolic dysfunction increases with age^[3][4].
• It is more common in women than men^[5].

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Heart failure associated with diastolic dysfunction has a slightly better prognosis than that of systolic heart failure. However, the presence or absence of coronary artery disease, the age, and the left ventricular ejection fraction cut off level must all be taken into consideration in stratifying patients and assessing their prognosis.^[1]

• Until recently, it was generally assumed that the prognosis for individuals with diastolic dysfunction and associated intermittent pulmonary edema was better than those with systolic dysfunction. In fact, in two studies appearing in the New England Journal of Medicine in 2006, evidence was presented to suggest that the prognosis in diastolic dysfunction is the same as that in systolic dysfunction.^[2][3]
• Other studies have shown that the prognosis of diastolic heart failure is slightly better than that of systolic heart failure. In general, the annual mortality associated with diastolic heart failure was estimated to be 5 to 8 % compared to an estimated annual mortality of 10 to 15% in systolic heart failure and an annual mortality of 1% in the general population. However, the 3 to 5% annual mortality from diastolic heart failure was estimated without any adjustment for the presence or absence of coronary artery disease, age and the cut off value of left ventricular ejection fraction used for the diagnosis of diastolic heart failure. Hence, if patients with coronary artery disease have been excluded, the annual mortality of patients with diastolic heart failure drops to 2-3%. If the age is taken into account, patients who are 70 years of age and have diastolic heart failure are estimated to have a similar annual mortality rate to that of patients within the same age range and having systolic heart failure. ^[1]

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