Transcript DIASTOLIC DYSFUNCTION AND HEART FAILURE PHYSIOLOGY

DIASTOLIC DYSFUNCTION AND HEART FAILURE
PHYSIOLOGY, HISTORICAL FEATURES AND CLINICAL
PERSPECTIVE
Medicine Resident Rounds
September 28, 2007
Jacobi Hospital
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.
ISOVOLUMIC (EARLY) RELAXATION
ENERGY DEPENDENT
Phases of diastole
Elevated Left Ventricular Diastolic Pressure Causes
Pulmonary Congestion
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
SPONTANEOUS ANGINA
EFFECT ON SYSTOLIC & DIASTOLIC PRESSURE
LV DIASTOLIC PRESSURE CHANGES
DURING EXERCISE INDUCED ANGINA
50---
50---
CHANGES IN LV DIASTOLIC PRESSURE AND VOLUME
DIURING ANGINA -- INDUCED BY ATRIAL PACING
DWYER CIRC 1970
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
LV DIASTOLIC DISTENSIBILITY
• Stiffness- Compliance- Distensibility are best quantified by the LV
pressure / volume relationship
Pressure-Volume Curve
Diastolic Dysfunction
40
LV Pressure (mm Hg)
30
Increased Chamber Stiffness
20
10
0
50
100
LV Volume (ml)
150
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) ; also Abnormal pulmonary venous flow velocity
E
A
EE
&
A
Cardiac Catheterization
– Normal heart size and contraction pattern
– LV end diastolic pressure (normal =12 mmHg) Greater specificity when
16 mmHg used as upper normal.
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)
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
RELATIONSHIP BETWEEN LV SYSTOLIC PRESSURE AND LV DIASTOLIC
PRESSURE IN PATIENTS WITH NORMAL CORONARY ARTERIES
RELATIONSHIP OF SYSTOLIC AND DIASTOLIC PRESSURE
DIASTOLIC PRESSURE (m m Hg)
45
40
35
30
25
Series1
20
15
10
5
0
0
50
100
150
200
SYSTOLIC PRESSURE (m m Hg)
R = .44
0.44
250
EXERCISE RESPONSE IN
DIASTOLIC DYSFUNCTION
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
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
RECURRENT PULMONARY EDEMA
Rx: SURGICAL INTERVENTION
1985
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
120
– 83 pts
– F/U 5 YRS
– 27% CAD; 53% HTN
100
BROGAN et al 1992;AJM
– 51 pts
– F/U 6 YRS
– NO CAD
SETARO
80
V-HEFT
60
BROGAN
40
20
V-HEFTLO EF
0
0
3
6
FRAMINGHAM STUDY
25% CAD
80% CAD
80% CAD
VARSAN JACC 1999
PROGNOSIS OF DIASTOLIC DYSFUNCTION
NOMAL CORONARY ARTERIES
BRADY & DWYER 2006 Clin Card
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!