Diagnosis And Management Of Diastolic Dysfunction And .
Diagnosis and Management of DiastolicDysfunction and Heart FailureCHHABI SATPATHY, M.D., and TRINATH K. MISHRA, M.D.Sriram Chandra Bhanja Medical College, Cuttack, Orissa, IndiaRUBY SATPATHY, M.D., HEMANT K. SATPATHY, M.D., and EUGENE BARONE, M.D.Creighton University Medical Center, Omaha, NebraskaDiastolic heart failure occurs when signs and symptoms of heart failure are present but left ventricular systolic functionis preserved (i.e., ejection fraction greater than 45 percent). The incidence of diastolic heart failure increases with age;therefore, 50 percent of older patients with heart failure may have isolated diastolic dysfunction. With early diagnosisand proper management the prognosis of diastolic dysfunction is more favorable than that of systolic dysfunction. Distinguishing diastolic from systolic heart failure is essential because the optimal therapy for one may aggravate the other.Although diastolic heart failure is clinically and radiographically indistinguishable from systolic heart failure, normalejection fraction and abnormal diastolic function in the presence of symptoms and signs of heart failure confirm diastolic heart failure. The pharmacologic therapies of choice for diastolic heart failure are angiotensin-converting enzymeinhibitors, angiotensin receptor blockers, diuretics, and beta blockers. (Am Fam Physician 2006;73:841-6. Copyright 2006 American Academy of Family Physicians.)Three million Americans havecongestive heart failure (CHF),and 500,000 new cases are diagnosed each year. The condition isthe most common discharge diagnosis forpatients older than 65 years1 and is the mostexpensive disease for Medicare.2 Systolic anddiastolic dysfunction can cause CHF.3 Allpatients with systolic dysfunction have concomitant diastolic dysfunction; therefore,a patient cannot have pure systolic heartfailure.4 In contrast, certain cardiovasculardiseases such as hypertension may lead todiastolic dysfunction without concomitantsystolic dysfunction.5 Although diastolicheart failure accounts for approximately40 to 60 percent of patients with CHF, thesepatients have a better prognosis than thosewith systolic heart failure.6Definition and Diagnostic CriteriaDiastolic heart failure is defined as a condition caused by increased resistance to thefilling of one or both ventricles; this leads tosymptoms of congestion from the inappropriate upward shift of the diastolic pressurevolume relation.7 Although this definitiondescribes the principal pathophysiologicmechanism of diastolic heart failure, it is notclinically applicable. A more practical defini tion for use in clinical practice is: a condition that includes classic CHF findings andabnormal diastolic and normal systolic function at rest.8,9 A study group7 proposed thatphysicians combine clinical and echocardiographic information to categorize patientswith diastolic heart failure according to thedegree of diagnostic certainty (Table 110).Prevalence and EtiologyOn average, 40 percent of patients with heartfailure have preserved systolic function.11-13The incidence of diastolic heart failureincreases with age, and it is more commonin older women.14,15 Hypertension and cardiac ischemia are the most common causesof diastolic heart failure (Table 2). Commonprecipitating factors include volume overload; tachycardia; exercise; hypertension;ischemia; systemic stressors (e.g., anemia,fever, infection, thyrotoxicosis); arrhythmia (e.g., atrial fibrillation, atrioventricularnodal block); increased salt intake; and useof nonsteroidal anti-inflammatory drugs.PathophysiologyDiastole is the process by which the heartreturns to its relaxed state. During thisperiod, the cardiac muscle is perfused. Conventionally, diastole can be divided into fourDownloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2008 American Academy of Family Physicians. For the private, noncommercialuse of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
SORT: KEY RECOMMENDATIONS FOR PRACTICEClinical recommendationsEvidenceratingReferencesSystolic and diastolic hypertension should be controlled in accordance with published guidelines.A22Ventricular rate should be controlled in patients with atrial fibrillation.C22Diuretics should be used to control pulmonary congestion and peripheral edema.C22Coronary revascularization should be used in patients with coronary artery disease in whom symptomaticor demonstrable myocardial ischemia is judged to have an adverse effect on diastolic function.C22Sinus rhythm should be restored in patients with atrial fibrillation.C22Beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers,or calcium antagonists should be used in patients with controlled hypertension to minimize symptomsof heart failure.C22Digitalis should be used to minimize symptoms of heart failure.C22A consistent, good-quality patient-oriented evidence; B inconsistent or limited-quality patient-oriented evidence; C consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 755 or http://www.aafp.org/afpsort.xml.phases: isovolumetric relaxation, caused by closure ofthe aortic valve to the mitral valve opening; early rapidventricular filling located after the mitral valve opening; diastasis, a period of low flow during mid-diastole;and late rapid filling during atrial contraction.16 Broadlydefined, isolated diastolic dysfunction is the impairmentof isovolumetric ventricular relaxation and decreasedcompliance of the left ventricle. With diastolic dysfunction, the heart is able to meet the body’s metabolicneeds, whether at rest or during exercise, but at a higherfilling pressure. Transmission of higher end-diastolicpressure to the pulmonary circulation may cause pulmonary congestion, which leads to dyspnea and subsequent right-sided heart failure. With mild dysfunction,late filling increases until the ventricular end-diastolicvolume returns to normal. In severe cases, the ventriclebecomes so stiff that the atrial muscle fails and enddiastolic volume cannot be normalized with elevatedfilling pressure. This process reduces stroke volume andcardiac output, causing effort intolerance. Figure 117 summarizes the pathophysiology of diastolic heart failure.DiagnosisHeart failure can present as fatigue, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, jugularvenous distention, rales, tachycardia, third or fourthheart sounds, hepatomegaly, and edema. Cardiomegalyand pulmonary venous congestion commonly are foundtable 1Diagnostic Criteria for Diastolic Heart FailureDefinitive diastolic heart failureProbable diastolic heart failure*Possible diastolic heart failureDefinitive evidence of congestiveheart failure†Same as definitiveSame as definitiveandObjective evidence of normal left ventricularsystolic function in proximity of event‡andObjective evidence of left ventriculardiastolic dysfunction§andandSame as definitiveandLeft ventricular ejection fraction of 50 percentor more not measured within 72 hours of eventandNo conclusive information on leftventricular diastolic functionSame as probable*—Patients who have definitive evidence of congestive heart failure and objective evidence of normal left ventricular systolic function in proximityof event are accepted as having probable diastolic heart failure provided that mitral valve disease, cor pulmonale, primary volume overload, andnoncardiac causes are excluded.†—Clinical symptoms and signs, supporting chest radiography, typical clinical response to diuretics with or without elevated left ventricular fillingpressure, or low cardiac index.‡—Left ventricular ejection fraction of 50 percent or more within 72 hours of event.§ —Abnormal left ventricular relaxation or filling or distensibility indices on catheterization.Adapted with permission from van Kraaij DJ, van Pol PE, Ruiters AW, de Swart JB, Lips DJ, Lencer N, et al. Diagnosing diastolic heart failure. Eur J HeartFailure 2002;4:427.842 American Family Physicianwww.aafp.org/afpVolume 73, Number 5 March 1, 2006
Diastolic Dysfunction and Heart Failuretable 2Causes of Diastolic Dysfunctionand Heart FailureCommon causes*decreases to less than 1.0. As the disease progresses, leftventricular compliance is reduced, which increases leftatrial pressure and, in turn, increases early left ventricular filling despite impaired relaxation. This paradoxicalnormalization of the E/A ratio is called pseudonormalization. In patients with severe diastolic dysfunction,left ventricular filling occurs primarily in early diastole, creating an E/A ratio greater than 2.0. The E- andA-wave velocities are affected by blood volume, mitralvalve anatomy, mitral valve function, and atrial fibrillation, making standard echocardiography less reliable.In these cases, tissue Doppler imaging is useful for measuring mitral annular motion (a measure of transmitralflow that is independent of the aforementioned factors).Cardiac catheterization remains the preferred methodfor diagnosing diastolic dysfunction. However, in dayto-day clinical practice, two-dimensional echocardiography with Doppler is the best noninvasive tool toconfirm the diagnosis. Rarely, radionuclide angiographyis used for patients in whom echocardiography is technically difficult.Cardiac ischemiaHypertensionAgingObesityAortic stenosisUncommon causesMyocardial disordersMyocardial diseasesInfiltrative disease (e.g., amyloidosis, sarcoidosis, fattyinfiltration)Noninfiltrative diseases (e.g., idiopathic and hypertrophiccardiomyopathy)Endomyocardial diseasesHypereosinophilic syndromeStorage diseasesGlycogen storage diseaseHemochromatosisPericardial disordersConstrictive pericarditisEffusive-constrictive pericarditisPericardial effusion*—Common causes are listed in order of prevalence.on chest radiography. However, these findings are nonspecific and often occur in noncardiac conditions such aspulmonary disease, anemia, hypothyroidism, and obesity.Furthermore, it is difficult to distinguish diastolic fromsystolic heart failure based on physical findings alone.18The serum brain natriuretic peptide (BNP) test canaccurately differentiate heart failure from noncardiacconditions in a patient with dyspnea, but it cannot distinguish diastolic from systolic heart failure. Table 319 summarizes the accuracy of BNP levels for diagnosing heartfailure. Physicians also should consider that patients’ NewYork Heart Association severity class affects BNP levels.In addition to providing fundamental information onchamber size, wall thickness and motion, systolic function, the valves, and the pericardium, two-dimensionalechocardiography with Doppler is used to evaluate thecharacteristics of diastolic transmitral and pulmonaryvenous flow pattern.20 On echocardiography, the peakvelocity of blood flow across the mitral valve during earlydiastolic filling corresponds to the E wave. Similarly,atrial contraction corresponds to the A wave. From thesefindings, the E/A ratio is calculated. Under normal conditions, E is greater than A and the E/A ratio is approximately 1.5.21In early diastolic dysfunction, relaxation is impairedand, with vigorous atrial contraction, the E/A ratioMarch 1, 2006 Volume 73, Number 5ManagementPrimary prevention of diastolic heart failure includessmoking cessation and aggressive control of hypertension, hypercholesterolemia, and coronary artery disease.Lifestyle modifications such as weight loss, smokingcessation, dietary changes, limiting alcohol intake, andexercise are equally effective in preventing diastolic andsystolic heart failure. Diastolic dysfunction may be presentfor several years before it is clinically evident (Figure 117).Early diagnosis and treatment is important in preventingirreversible structural alterations and systolic dysfunction. However, no single drug has pure lusitropic properties (i.e., selective enhancement of myocardial relaxationwithout inhibiting left ventricular contractility or function). Therefore, medical therapies for diastolic dysfunction and diastolic heart failure often are empirical andnot as well defined as therapies for systolic heart failure.On the surface, it appears that the pharmacologic treatments of diastolic and systolic heart failure do not differdramatically; however, the treatment of diastolic heartfailure is limited by the lack of large and conclusive randomized control trials.22 Furthermore, the optimal treatment for systolic heart failure may exacerbate diastolicheart failure. Most clinical trials to date have focusedexclusively on patients with systolic heart failure; onlyrecently have trials addressed the treatment of diastolicheart failure.Although conclusive data on specific therapies fordiastolic heart failure are lacking, the American Collegewww.aafp.org/afp American Family Physician 843
Diastolic Dysfunction and Heart Failureof Cardiology and the American Heart Association jointguidelines22 recommend that physicians address bloodpressure control, heart rate control, central blood volumereduction, and alleviation of myocardial ischemia whentreating patients with diastolic heart failure. These guidelines target underlying causes and are likely to improveleft ventricular function and optimize hemodynamics.Table 4 lists treatment goals for diastolic heart failure.antagonizing the excessive adrenergic stimulation during heart failure. Beta blockers have been independentlyassociated with improved survival in patients with diastolic heart failure.23 These medications should be usedto treat diastolic heart failure, especially if hypertension,coronary artery disease, or arrhythmia is present.optimizing hemodynamicsOptimizing hemodynamics primarily is achieved byreducing cardiac preload and afterload. AngiotensinWhen treating a patient with diastolic dysfunction, it is converting enzyme (ACE) inhibitors and angiotensinimportant to control the heart rate and prevent tachycar- receptor blockers (ARBs) directly affect myocardial relaxdia to maximize the diastolic filling period. Beta blockers ation and compliance by inhibiting production of orare particularly useful for this purpose; however, they do blocking angiotensin II receptors, thereby reducing internot directly affect myocardial relaxation. In addition to stitial collagen deposition and fibrosis.24,25 The indirectslowing heart rate, beta blockers have proven benefits in benefits of optimizing hemodynamics include improvingreducing blood pressure and myocardial ischemia, pro- left ventricular filling and reducing blood pressure. Moremoting regression of left ventricular hypertrophy, and importantly, there is improvement in exercise capacityand quality of life.26 One retrospectivestudy27 showed that improved survivalPathophysiology of Diastolic Heart Failurewas associated with ACE inhibitor therapy in patients with diastolic heart failure.Pressure overloadHypertrophyOne arm of the CHARM (Candesartan inIschemiaMyocardial infarctionHeart Failure Assessment of Reduction inMorbidity and Mortality) trial,28 whichAbnormal relaxationAbnormal relaxationIncreased stiffnessstudied the effect of candesartan (Ataand increased stiffnesscand) in patients with normal ejectionfraction for 36.6 months, did not show aElevated left ventricularsignificant mortality benefit. However, itfilling pressuresreduced the incidence of hospitalizationfor CHF exacerbation.Abnormal early fillingElevated pulmonaryElevated left atrialDiuretics are effective in managingpressure during exercisepressure and sizeoptimal intravascular volume, and theyminimize dyspnea and prevent acuteheart failure in patients with diastolicNormalReducedAtrial fibrillation andexerciseexercisedecreased cardiac outputdysfunction. Although diuretics controltolerancetoleranceblood pressure, reverse left ventricularhypertrophy, and reduce left ventricularReduced exercise tolerance andstiffness, some patients with diastolicsigns of congestive heart failureheart failure are sensitive to the preloadreduction and may develop hypotensionDiastolic dysfunctionDiastolic heart failureDiastolic abnormalitiesor severe prerenal azotemia. Intravenousdiuretics should only be used to relieveFigure 1. Algorithm for pathophysiology of diastolic heart failure. Abnor- acute symptoms.mal relaxation and increased stiffness are associated with diastolic fillingThe hormone aldosterone promotesabnormalities and normal exercise tolerance in the early phase of diastolic fibrosis in the heart and contributesdysfunction. When the disease progresses, pulmonary pressures increaseabnormally during exercise, producing reduced exercise tolerance. When to diastolic stiffness. The aldosteronefilling pressures increase further, left atrial pressure and size increase and antagonist spironolactone (Aldactone)has been studied in a large clinical trialexercise tolerance falls as clinical signs of congestive heart failure appear.of systolic heart failure,29 which showedAdapted with permission from Mandinov L, Eberli FR, Seiler C, Hess OM. Diastolic heart failure.a reduction in mortality related to heartCardiovasc Res 2000;45:822.improving left ventricular function844 American Family Physicianwww.aafp.org/afpVolume 73, Number 5 March 1, 2006
table 3Accuracy of BNP Levels for Diagnosing Heart FailureCongestive heart failure vs. noncongestive heart failureSystolic heart failure vs. nonsystolic heart failureBNP level(pg per mL)Sensitivity(%)Specificity(%)LR LR–Sensitivity(%)Specificity(%)LR .52BNP brain natriuretic peptide; LR positive likelihood ratio; LR– negative likelihood ratio.Adapted with permission from Maisel AS, McCord J, Nowak RM, Hollander JE, Wu AH, Duc P, et al. Bedside B-Type natriuretic peptide in the emergencydiagnosis of heart failure with reduced or preserved ejection fraction. J Am Coll Cardiol 2003;41:2015.failure. However, the specific effects of spironolactoneon diastolic dysfunction are unclear.Calcium channel blockers have been shown to improvediastolic function directly by decreasing cytoplasmiccalcium concentration and causing myocardial relaxationor indirectly by reducing blood pressure, reducing or preventing myocardial ischemia, promoting regression of leftventricular hypertrophy, and by slowing the heart rate.However, non-dihydropyridine calcium channel blockers (e.g., diltiazem [Cardizem]) and verapamil (Calan),should not be used in patients with bradycardia, conduction defects, or severe heart failure caused by left ventricular systolic dysfunction.30 Instead nondihydropyridinessuch asdiltiazem and verapamil, should be used for rate controland angina when beta blockers are contraindicated orineffective. Finally, large randomized controlled trialshave not proved that calcium channel blockers reducemortality in patients with isolated diastolic dysfunction.Vasodilators (e.g., nitrates, hydralazine [Apresoline])may be useful because of their preload-reducing and antiischemic effects, particularly when ACE inhibitors cannotbe used. The Vasodilator Heart Failure Trial,31 however, didnot show significant survival benefit in patients with diastolic heart failure. Vasodilators should be used cautiouslybecause decreasing preload may worsen cardiac output.Unlike other medications used for diastolic heart failure,vasodilators have no effect on left ventricular regression.The exact role of digoxin for treating patients withdiastolic heart failure remains unclear. Digoxin can bedeleterious in older patients with left ventricular hypertrophy and hypertrophic obstructive cardiomyopathy;therefore, digoxin is only appropriate for patients withdiastolic heart failure and atrial fibrillation.32CHHABI SATPATHY, M.D., is professor in the Department of Cardiology atUtkal University’s Sriram Chandra
Diastolic heart failure occurs when signs and symptoms of heart failure are present but left ventricular systolic function is preserved (i.e., ejection fraction greater than 45 percent).
92. Mildly elevated blood pressure (Systolic 140-159 mm of Hg and/or Diastolic 90-99 mm of Hg) (%) 10.9 na 93. Moderately or severely elevated blood pressure (Systolic 160mm of Hg and/or Diastolic 100mm of Hg) (%) 4.8 na 94. Elevated blood pressure (Systolic 140 mm of Hg and/or Diastolic 90 mm of Hg) or taking medicine to
cardiomyopathy (HCM) and restrictive cardiomyopathy (RCM) share a common feature of diastolic dysfunction [3, 4]. Diastolic dysfunction is an important clinical . ing that green tea extract EGCg is able to reverse diastolic dysfunction and improve cardiac relaxation in RCM mice.
CARDIOVASCULAR ICD-10 Angina, unstable I20.0 Angina, prinzmetal (coronary spasm) I20.1 Stable Angina I20.8 Angina, pectoris, NEC/NOS I20.9 Left heart failure, unspecified I50.1 Systolic heart failure, chronic I50.22 Systolic heart failure, acute on chronic I50.23 Diastolic heart failure, chronic I50.32 Diastolic heart failure, acute on chronic I50.33 Systolic and diastolic heart failure .
Section 1: Understand the diagnosis of Specific Learning Difficulties. 4. LCG 2017 . In this section, you will learn about diagnosis of Specific Learning Difficulties. You will . find out about the importance of gaining a diagnosis and gaining diagnosis as early as possible, and the impact of delayed or non-diagnosis. You will look at how diagnosis
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ANATOMY PHYSIOLOGY WORKBOOK 7a. Complete the table below to show the short-term and long-term effects of exercise in healthy adults for both systolic and diastolic blood pressure: Blood pressure Short-term effects Long-term effects Systolic pressure Diastolic pressure 7b. Explain why the short-term changes in systolic pressure that you have identified occur: 7c. Explain in more detail the long .
resonance (CMR) were performed sequentially on some of the monkeys. One monkey with moderate diastolic dysfunction, together with one ND monkey was sacri-ficed for histopathological and protein study. Some of the pathology was detailed by use of transmission electron microscope for observing microstructure and ultrastructure.
modern slavery:classical and Bayesian approaches Bernard W. Silverman University of Nottingham, UK [Read before The Royal Statistical Society on Wednesday, November 13th, 2019, Professor R.HendersonintheChair] Summary. Multiple-systems estimation is a key approach for quantifying hidden populations such as the number of victims of modern slavery.The UK Government published an estimate of 10000 .
