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Transcript
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!