DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE...
23
DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE Medicine Resident Rounds September 28, 2007 Jacobi Hospital
DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL PERSPECTIVE Medicine Resident Rounds September 28, 2007 Jacobi Hospital
DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY, HISTORICAL
FEATURES AND CLINICAL PERSPECTIVE Medicine Resident Rounds
September 28, 2007 Jacobi Hospital
Slide 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.
Slide 3
ISOVOLUMIC (EARLY) RELAXATION ENERGY DEPENDENT
Slide 4
Phases of diastole
Slide 5
Elevated Left Ventricular Diastolic Pressure Causes Pulmonary
Congestion
Slide 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
Slide 7
SPONTANEOUS ANGINA EFFECT ON SYSTOLIC & DIASTOLIC
PRESSURE
Slide 8
LV DIASTOLIC PRESSURE CHANGES DURING EXERCISE INDUCED ANGINA
50---
Slide 9
CHANGES IN LV DIASTOLIC PRESSURE AND VOLUME DIURING ANGINA --
INDUCED BY ATRIAL PACING DWYER CIRC 1970
Slide 10
LV ANATOMIC CHANGES ALTERS DISTENSIBILITY in 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
Slide 11
LV DIASTOLIC DISTENSIBILITY Stiffness- Compliance-
Distensibility are best quantified by the LV pressure / volume
relationship
Slide 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
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
Slide 15
R =.44 RELATIONSHIP BETWEEN LV SYSTOLIC PRESSURE AND LV
DIASTOLIC PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES DWYER
ET AL AHJ 2000
Slide 16
EXERCISE RESPONSE IN DIASTOLIC DYSFUNCTION
Slide 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
Slide 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
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
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 Its 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. Cant live forever!