Diastolic Heart Failure

Carmen B. Gomez MD
Eugene Yevstratov MD
The very essence of cardiovascular medicine is recognition of early heart failure. Sir Thomas Lewis 1933

Introduction
Diastolic heart failure has emerged over the last 10 years as a separate clinical entity. Diastolic heart failure accounts for approximately one third of all heart failure cases, especially in an elderly population, and its natural history, with an annual mortality rate of 8%, is more benign than other forms of heart failure with an annual mortality of 19%. A need has therefore grown to establish precise criteria for the iagnosis of diastolic heart failure.

Requirments for Diagnostic of the DHF

Presence

of sighs or symptoms of congestive heart failure Presence of normal or only midly abnormal left ventricular systolic function Evidence of abnormal left ventricular relaxation(filling,diastolic distensibility or diastolic stiffness)

Pathophysiology
Impaired

relaxation Increase passive stiffness Endocardial and pericardial disordersw Microvascular flow.Myocardial turgor Neurohormonal regulation

Pathophysiology
Impaired Relaxation
Epicardial

or microvascular

ischemia Myocite hypertrophy Cardiomyopathies Aging Hypothyroidism

Pathophysiology Increase Passive Stiffness

Diffuse fibrosis Post-infarct scarring Myocyte hypertrophy Infiltrative (amyloidosis, hemochromatosis, Fabrys disease)

Pathophysiology
Endocadial, Pericardial Disorders

Fibroelastosis Mitral or tricuspid stenosis Pericardial constriction Pericardial tamponade

Pathophysiology
Endocadial, Pericardial Disorders

Pathophysiology
Microvascular Flow,Myocardial Turgor

Capillary compression Venouse engorgement

Pathophysiology
Microvascular Flow,Myocardial Turgor

Pathophysiology
Neurohormonal Regulation, Other

Upregulated renin-angiotensin system Volume overload of the contralatetal ventricle Extrinsic compression by tumor

Diagnosis
Increased ventricular filling pressure with normal systolic function. Incresed ventricular pressure with preserved systolic function and normal ventricular volumes. Increased left atrial and pulmonary capillary wedge pressure. Clinical symptoms and signs.

Clinical Signs and Symptoms

Evidence of raised left atrial pressure Exertional dyspnoea Orthopnoea Gallop sounds Lung crepitations Pulmonary oedema Exercise intolerance

Pathology

Evidence of Abnormal left Ventricular Relaxation

LVdP/dt min<1100 mmHg IVRT<30y>92 ms, IVRT3050y>100 ms, IVRT>50y>105 ms and/or >48 ms LVEDP>16 mmHg or mean PCW>12 mmHg PV A Flow >35 cm . s"1 b>027 and/or b*>16

Management of DHF
Reduce symptoms Control hypertension Prevent myocardial ischemia

There is no specific therapy for DHF

Management of DHF

Diuretics provide the most symptoms relief if

fluid retentionn is a future

ACE inhibitors and Blockers

complement diuretics well

Central sympatholytics
episodes

hypertensive

Nitrates preventing ischemia Trimetazidine as a metabolic support

Conclusion
Until further evidence is available from randomized therapeutic trials, clinicians should focus on a few general principles in the treatment of DHF:

Reduce volume overload

Slow the heart rate

Control hypertension,
Relieve myocardial ischemia.

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FUNDACION FAVALORO
INSTITUTO DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR

Carmen B. Gomez MD Eugene Yevstratov MD