Diastolic heart failure

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Diastolic heart failure

• Up to a third of patients have clinical heart
  failure with normal LV systolic function
• Underlying pathophysiology relates to diastolic
  dysfunction
• Commonest underlying pathologies
• Normal ageing
• Hypertension
• Myocardial ischaemia

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Mechanisms of diastolic dysfunction

• Impaired ventricular relaxation
• Energy dependent process
• Susceptible to myocardial ischaemia
• Decreased myocardial compliance
• Altered compliance mediated by collagen
• Fibrosis related to activation of RAAS

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Echocardiographic assessment

• 2D echo to assess systolic function
• Doppler echo
• Transmitral flow
• E/A wave ratio
• E wave deceleration time
• IVRT

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Area-length method for calculation of LV mass
LVmass1.055/6(A1xL1)-5/6(A2xL2) Divide by
body surface area to get LV mass
index Reichek et al. Circulation
198367348-52
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Doppler patterns of diastolic dysfunction

• Impaired relaxation
• Reduced E/A ratio
• Increased EDT
• Increased IVRT
• Restriction
• LA pressure increases due to myocardial stiffness
• High peak E wave velocity
• Short EDT
• Very short IVRT

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Treatment of diastolic heart failure

• Treat underlying cause eg ischaemia
• Impaired relaxation
• Theoretically rate-limiting agents effective
• Beta-blockers, verapamil
• Reduce HR and prolong diastole
• Reduce myocardial oxygen demand
• Lower BP and reduce LVH

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Treatment of diastolic heart failure

• Restriction
• Drugs which reduce fibrosis and lower LA pressure
  theoretically should be effective
• ACEI
• AII blockers
• Diuretics
• If LA pressure lowered too much cardiac output
  significantly worsened
• Can cause significant morbidity

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Colour Doppler Tissue Imaging
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Colour Doppler Tissue Imaging
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Figure 1. Pulsed wave Doppler sample of basal
septum of normal subject
S wave
A wave
E wave
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Figure 2. Pulsed wave Doppler sample of basal
inferior wall of subject with previous inferior
myocardial infarction due to right coronary
artery occlusion.
S wave
E wave
A wave