Diastolic Heart

Failure
A Disorder of the Elderly
Patient
M Chadi Alraies, MD
Chief Medical Resident
St. Vincent Charity Hospital/Case Western Reserve
University
 Diastolic Heart Failure
Defined1:
 Clinical presentation and symptoms
of heart failure with preserved LV
systolic function

 Stiff ventricle equals decreased

compliance and impaired relaxation
leading to ↑ LVEDP

M Chadi Alraies 2
 Background:
 Prevalence: as of 2004, 4.8 million
Americans are affected by diastolic heart
failure (HF)1,2,3

 Diastolic HF prevalence increases with

age4,5,6,7:
< 50 years old: 15%
50-70 years old: 33%
> 70 years old: 50%

M Chadi Alraies 3
 Background (cont.)
 Incidence: about 500,000 new cases
diagnosed per year1,2,3,4

 HF is the leading cause of

hospitalization in persons over the
age of 654,8

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 Background (cont.)
 More than 50% of patients with HF
have preserved LV function4,9
 Mortality rates for patients with
diastolic HF:
 Advanced disease: 30-40% mortality
in 5-10 years4,10
 Mortality rates are comparable to
those seen in systolic HF4,9

M Chadi Alraies 5
 A 68-year-old woman is hospitalized with
palpitations and shortness of breath. She has a
history of hypertension and chronic atrial
fibrillation, and her medications include
furosemide, candesartan, and warfarin. On
physical examination, the heart rate is 120/min
with an irregularly irregular rhythm, and blood
pressure is 130/80 mm Hg; she has an elevated
jugular venous pulse, crackles in both lungs,
and marked lower extremity edema.
Echocardiography shows left ventricular
hypertrophy, an ejection fraction of 70%, and
no significant valvular disease. She is treated
with intravenous diuretics, with improvement in
her symptoms and resolution of peripheral
edema and of crackles on lung examination.
Her heart rate is now 99/min and her blood
pressure is 120/75 mm Hg.
 Which of the following would be the most
appropriate medication to add?
 A Lisinopril M Chadi Alraies 6
Risk Factors for Diastolic
HF 4,11
:
 Elderly
 Female
 Hypertensive

M Chadi Alraies 7
 Etiology4:
 Long-standing HTN with LVH12:
 A hypertensive hypertrophic cardiomyopathy
with LVEF >75% in the elderly6
 Aortic Stenosis with normal LVEF13
 Severe aortic or mitral regurgitation
 Ischemic Heart Disease
 Regional wall motion abnormalities
 Restrictive Cardiomyopathy –
Idiopathic vs. Infiltrative
 Sarcoidosis, Amyloidosis, Hemochromatosis
6. HOCM
7. Hypothyroidism M Chadi Alraies 8
 Asymptomatic Diastolic
HF:
 More common than symptomatic
diastolic HF
 Mayo Clinic study of 2,042 subjects >
age 45:
 Prevalence of symptomatic HF: 2.2%
 Of those, 44% had diastolic HF

 In subjects without symptoms of HF,

28% had diastolic HF by echo criteria4,15.

M Chadi Alraies 9
 Pathyphysiology 4,16
:
Diastolic Function

Myocardial Relaxation
Elasticity
- An active process - A passive process
- Requires energy - Requires no
energy

M Chadi Alraies 10
 Pathophysiology
(cont.)17:
 Normally, LV relaxation during
diastole creates a negative LA to LV
pressure gradient, thereby
augmenting diastolic filling
 Decrease in LV relaxation and
distensibility causes increased LA,
LV, PV, and PCW pressures
 Increase in LV filling during late
diastole, increase in dependence on
atrial contraction
M Chadi Alraies 11
 Cardiac Cycle

Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and
Treatment. Am Fam Physician 2004;69:2609-16.
M Chadi Alraies 12
 Pathophysiology (cont.)17
 Why do patients with diastolic
dysfunction have poor exercise
tolerance?
 During normal exercise, increase in HR
associated with increase in SV → ( CO = HR
x SV )
 Increased HR leads to compensatory
increase in relaxation rate, maintaining
normal LVEDP & PCWP
 Increased LVEDV normally leads to
increased SV due to Frank-Starling
mechanism
 Normal LV distensibility allows normal
LVEDP to be maintained at increased LVEDV
M Chadi Alraies 13

 Increased PCWP During
Exercise in Pts. With Diastolic
HF

 Data from Kitzman, DW, Higginbotham, MB, Cobb, FR, et al, J Am Coll Cardiol 1991;
M Chadi Alraies 14
 Pathophysiology (cont.)
 Why is diastolic dysfunction more
common in elderly persons?
 Age-related changes18,19:
 Increased collagen cross-linking
 Increased smooth muscle content

 Loss of elastic fibers

M Chadi Alraies 15
Clinical Manifestations : 4

 Similar to systolic HF
 AF poorly tolerated due to loss of
atrial kick
 Tachycardia poorly tolerated due to
shortening of late diastolic filling
time
 Elevated systemic blood pressure
increases LV wall stress and further
impairs relaxation
 Acute-on-chronic diastolic
dysfunction caused by ischemia
M Chadi Alraies 16
 Diagnosis : 4

 Controversy: does clinical HF +

normal LVEF = diagnosis of diastolic
HF?
 Most patients with overt clinical HF
and normal LV systolic function have
some element of diastolic
dysfunction
 A study of 63 HF patients with LVH
and normal systolic function by echo
found that 100% of patients had at
least one index of diastolic
M Chadi Alraies 17
 Diagnosis (cont.)1
 Gold standard for diagnosis is
cardiac catheterization:
 Direct measurement of LVEDP
 Risk outweighs benefit for routine use in
diagnosing diastolic dysfunction

 Doppler Echocardiography: the

primary diagnostic modality for
diagnosis
M Chadi Alraies 18
 Doppler
Echocardiography1
 Tau = time constant of LV pressure
decay during isovolumetric
relaxation that correlates with LV
stiffness
 Diastolic trans-mitral valve blood
flow:
 Measurement of peak velocities during
early diastolic filling:
1) E wave = Early diastolic filling
2) A wave = Atrial contraction
M Chadi Alraies 19
 Spectrum of Diastolic
Dysfunction1
 Normal:
 E wave > A wave
 Ratio 1.5:1.0

M Chadi Alraies 20
 Spectrum of Diastolic
Dysfunction1
1. Early Diastolic Dysfunction:
Abnormal Relaxation
 E-to-A ratio reverses to < 1.0
 Increased isovolumetric relaxation
time (stiff heart takes longer to relax)
 Abnormal relaxation is a nonspecific
finding

M Chadi Alraies 21
 Spectrum of Diastolic
Dysfunction (cont.)1
1. Advanced Diastolic Dysfunction:
Pseudonormal Pattern
 Abnormal relaxation & ↑ LVEDP
 “Pseudonormalization” can occur with
decompensated HF and ↑ LA pressure,
common triggers include
tachyarrhythmias, especially AF,
uncontrolled HTN

M Chadi Alraies 22
 Spectrum of Diastolic
Dysfunction (cont.)1

2. Severe Diastolic Dysfunction:

Restrictive Pattern
 ↑ LVEDP → LV diastolic filling occurs
mostly during early diastole because
LVEDP so high that atrial kick unable to
effectively contribute to LV filling
 E-to-A ratio > 2.0 → poor prognosis

M Chadi Alraies 23
Normal Trans-Mitral-Valve Spectral Doppler
Flow Pattern

Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and
Treatment. Am Fam Physician 2004;69:2609-16.
M Chadi Alraies 24
 Abnormal Relaxation

Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and
Treatment. Am Fam Physician 2004;69:2609-16.
M Chadi Alraies 25
 Severe (Restrictive) Diastolic
Dysfunction

 Reproduced from: Gutierrez C, Blanchard DG. Diastolic Heart Failure: Challenges of Diagnosis and
Treatment. Am Fam Physician 2004;69:2609-16.
M Chadi Alraies 26
 Doppler Echocardiography
(cont.)

 Adapted from: Zile MR. Clinical manifestations and diagnosis of diastolic heart failure. http://www.utdol.com/diastolic
heart failure/clinical manifestations and diagnosis of diastolic heart failure. 3/2/07
M Chadi Alraies 27
 Brain Natriuretic Peptide
(BNP)4
 BNP elevated in patients with both
systolic and diastolic HF, but cannot be
used to differentiate between the two21-24

 A study of 357 patients referred for

echocardiography based on clinical
suspicion for heart failure revealed the
following mean BNP levels25:
 Diastolic Dysfunction = 373 (+/- 335)
 Systolic Dysfunction = 550 (+/- 602)
 Combined Dysfunction = 919 (+/- 604)
M Chadi Alraies 28
 BNP (cont.) 4

 A study of 400 randomly selected

patients referred for echo to evaluate
LV function21:
 With normal LV function – mean BNP
was 30
 BNP of 75: sensitivity of 85% and
specificity of 97% in detecting
ventricular dysfunction
 In the patients with normal LV systolic
function, BNP of 57 detected 28 patients
with isolated diastolic
M Chadi Alraies dysfunction with 29
 BNP (cont.) 4

 A study of 294 patients with

echocardiographically normal LV
systolic function23:
 Mean BNP:
 All diastolic dysfunction = 286; normals = 33
 Impaired relaxation = 202
 Pseudonormal = 294
 Restrictive = 402

 For diagnosis of diastolic dysfunction, BNP

of 62: sensitivity 85%; specificity 83%
M Chadi Alraies 30
 BNP (cont.)
 ACE-Is, ARBs, Spironolactone, and
Diuretics:
↓ BNP levels26
 Thus, monitoring of BNP levels may
be a useful method of assessing
response to treatment

M Chadi Alraies 31
 Treatment : 27

 Trial data limited compared with

systolic HF
 Aim of therapy is to prevent or
control hemodynamic stressors.

M Chadi Alraies 32
 Treatment (cont.) 27,28

 2005 ACC/AHA Task Force

Guidelines on Management of
Chronic Diastolic HF:
2) Control of systolic and diastolic HTN
3) Control of VR in patients with AF
4) Control of pulmonary edema and
peripheral congestion with diuretics
5) Coronary revascularization in CAD
patients if ischemia thought to be
contributing to diastolic dysfunction
M Chadi Alraies 33
 Pharmacologic Therapy
27

 Patients with small, stiff LV chamber are

sensitive to excessive preload reduction

 Diuretics, Nitrates, Dihydropyridine

CCBs, ACE-Is – use with caution due to
potential to cause LV underfilling

 Frank-Starling curve has a steeper slope

 Monitor for symptoms of weakness,

lightheadedness, syncope
M Chadi Alraies 34
 Digoxin27
 No survival benefit29
 DIG ancillary trial: role of digoxin in
patients with HF and EF >45%
 At 37-month follow-up, no effect on all-cause or
CV hospitalization with digoxin
 A study examining the effect of IV digoxin
on echocardiographic diastolic parameters
demonstrated a
significant decrease of trans-mitral peak E
and E-to-A ratio, and a significant
lengthening of deceleration time30
 However, consensus is that digoxin should
be avoided in diastolic HF
M Chadi Alraies 35
 β -blockers
β -blockers27

 Can cause regression of LVH and

improvement of diastolic function

 Can ↓ HR, ↑ diastolic filling time, ↓ oxygen

consumption, ↓ BP1

 Carvedilol has been shown to improve E-

to-A ratio31

M Chadi Alraies 36
Calcium channel blockers27
 Non-dihydropyridine CCBs (diltiazem,
verapamil) - more potent negative
inotropes
 CCBs - can cause regression of LVH and
improvement of diastolic function
 Verapamil
 May have a “lusitropic” (relaxation-enhancing)
effect27
 A study on 20 patients with diastolic HF taking
verapamil:
 ↓ signs and symptoms of HF
 ↑ LV diastolic filling rate and treadmill exercise time32
 Amlodipine - a study of 59 patients with 37
M Chadi Alraies
 ACE-Inhibitors27
 Afterload reduction not as important as
with systolic HF, but some evidence of
benefit

 ACE-Is – can cause regression of LVH and

improvement of diastolic function

 ACE-Is – improve NYHA functional class,

QOL, and may prevent myocardial fibrosis
associated with LVH
M Chadi Alraies 38
 Angiotensin II Receptor
Blockers27
 ARBs - can cause regression of LVH and
improvement of diastolic function
 CHARM-Preserved trial34:
 3023 patients with symptomatic HF and LVEF >
40%
 Randomly assigned to receive candesartan or
placebo x mean 37 months
 Small but almost significant reduction in
incidence of primary endpoints of CV death and
hospitalization for HF in the candesartan group

M Chadi Alraies 39
 Antihypertensives and
LVH27
 Regression of LVH may improve diastolic
function35
 2003 meta-analysis examining the efficacy of
various antihypertensives in reversal of LVH36
 Relative reductions in LV mass index:
 ARBs – 13%
 CCBs – 11%
 ACE-Is – 10%
 Diuretics – 8%
 β-blockers – 6%
M Chadi Alraies 40
 Regression of LVH

M Chadi Alraies 41
Reproduced from: Zile MR. Treatment and prognosis of diastolic heart failure. www.utdol.com.
www.utdol.com. 3/2/07
 Prognosis 27

 Varies with symptomatic vs.

asymptomatic HF
 Framingham Heart Study and V-HeFT
trials showed better prognosis with
diastolic HF than with systolic HF, but
worse than controls 37-39
 A study of 522 patients showed
similar 5-year mortality for diastolic
vs. systolic HF (25% vs. 42%)40
M Chadi Alraies 42
 Survival

Reproduced from: Zile MR. Treatment and prognosis of diastolic heart failure. www.utdol.com.
M Chadi Alraies www.utdol.com. 3/2/0743
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Thank you