Diastolic Heart Failure Definition, Diagnosis, Significance and Management

Allan L. Klein MD Professor of Medicine Director, Cardiovascular Imaging Research Director of Pericardial Center Heart and Vascular Institute Cleveland Clinic Intensive Review of Cardiology

Diastology • Case presentation • Epidemiology • Definition • Diseases • Assessment • Prognosis • Treatment

Intensive Review of Cardiology

Systolic Heart Failure vs Diastolic Heart Failure

Redfield M. NEJM 2004;350:19302004;350:1930-1

Intensive Review of Cardiology

Major Clinical Trials in Heart Failure β -Blockers

ACE inhibitors CONSENSUS -II V-HeFT -II SOLVD -T SOLVD -P SAVE AIRE TRACE ATLAS PEP -CHF

Vasodilators V- HeFT PRAISE -I & -II VMAC A-HeFT FUSION II

Aldo antagonists RALES EPHESUS

MDC U.S. Carvedilol ANZ Carvedilol MERIT -HF CIBIS -II BEST COPERNICUS CAPRICORN COMET CIBIS -III SENIORS

ARBs ELITE -II Val -HeFT OPTIMAAL CHARM I-PRESERVE

Cardiac Glycosides DIG

Inotropic agents PROMISE FIRST VEST DIG OPTIME -II ENOXIMONE SURVIVE / REVIVE

-II

Cytokine antagonists RENAISSANCE / RECOVER EARTH

Endothelin antagonists ENABLE -2 VERITAS

Sympatholytic agents MOXCON

Vaptans EVEREST

Intensive Review of Cardiology

Patterns of Diastolic Function

E A

Inflow Mitral Mitral inflow S

D

PV flow PV flow Sm Tissue Doppler TDE Em Color M-mode

CMM - Vp

Am

vp

Nl (young)

NL (Young)

Nl (adult)

NL (Adult)

Delayed Delayed relaxation Relaxation

Pseudo Pseudo normal normal

Restrictive

Restrictive

Intensive Review of Cardiology

Diastology • Case presentation • Epidemiology • Definition • Diseases • Assessment • Prognosis

Intensive Review of Cardiology

Diastology • Case presentation • Epidemiology • Definition • Diseases • Assessment • Prognosis • Treatment

Intensive Review of Cardiology

Scope of the Problem in US: Prevalence

Heart failure is common • 995,000 hospitalizations as primary diagnosis (↑164% over 15 years); 2.5 million hospitalizations as secondary diagnosis

• 12 to 15 million physician visits

• 6.5 million hospital days • In-hospital mortality 5-8% • 1-year mortality can be as high as 40-60%

• 0.8-1.2 million NYHA III-IV

AHA Statistics 2004

Intensive Review of Cardiology

Trends in Diastolic Heart Failure

Patients with Preserved Ejection Fraction (%)

No. of Admissions

70 r=0.92, P50% And And 2 LVEDVI LVEDVI 16 mmHg or r> 48ms or b > 0.27

Paulus WJ et al. Eur Heart J 2007

TD E/E’ E/E’ >15

15 > E/E’ E/E’ >8

Biomarkers NTNT-proBNP > 220 pg/mL or BNP >200 pg/mL

HFNEF

Biomarkers NTNT-proBNP > 220 pg/mL or BNP >200 pg/mL

EchoEcho-bloodflow Doppler E/A >50yr 50yr >280 ms or ArdArd-Ad >30ms or LAVI >40 mL/m2 Or LVMI >122 g/m2 ( O); >149 g/m2 (σ (σ) or Atrial fibrillation

TD E/E’ E/E’ >8

0108-209

Intensive Review of Cardiology

Diastolic Heart Failure vs Heart Failure With A Normal Ejection Fraction

• Is It Really A Disorder of Diastolic Function or Vascular-Cardiac Interaction?

Burkhoff et al.Circulation 2003;107 656-658 656--658

Intensive Review of Cardiology

Diastology • Case presentation • Epidemiology • Definition • Diseases • Assessment • Prognosis • Treatment

Intensive Review of Cardiology

Diseases with Diastolic Heart Failure • Hypertensive heart disease • Coronary artery disease • Diabetes • Cardiomyopathies – Hypertrophic, dilated and restrictive • Constrictive pericarditis • Sleep apnea

Intensive Review of Cardiology

Normal

Aurigemma et al Circulation 2006:113:296

Systolic Heart Failure Diastolic Heart Failure

Diastolic Heart Failure

Normal

Aurigemma et al

Circulation 2006:113:296

DCM-Systolic Heart Failure

Intensive Review of Cardiology

Diastolic Heart Failure

Normal

DCM Systolic Heart Failure Aurigemma et al Circulation 2006:113:296

Intensive Review of Cardiology

Flash Pulmonary Edema BP 220/120

Intensive Review of Cardiology

HOCM

Intensive Review of Cardiology

Diastolic Heart Failure • Isolated diastolic heart failure – Asymptomatic – Exertional – Severe CHF • Combined systolic and diastolic heart failure

Intensive Review of Cardiology

Systolic Function by Gender Among Elderly with CHF Diastolic Heart Failure

Women

Men

Mod/Sev

10%

Mod/Sev 31%

Normal 42%

Mild 23%

Mild 27%

Normal 67%

Hypertension CAD Diabetes Afib

Kitzman et al. Am J Cardiol 2001; 87:41387:413-419

Intensive Review of Cardiology

Differences In Characteristics Of Patients With Preserved And Depressed Left Ventricular Function

Lenzem et al., European Heart J (2004) 25, 1214-1220

Intensive Review of Cardiology

Diastology • Case presentation • Epidemiology • Definition • Diseases • Assessment • Prognosis • Treatment

Intensive Review of Cardiology

Assessment of Diastolic Function • Clinical exam • Cardiac catheterization • Radionuclide angiography • Echocardiography • MR/CT scanning • Exercise testing

Intensive Review of Cardiology

Clinical Exam

Constrictive Pericarditis

Restrictive Cardiomyopathy Intensive Review of Cardiology

Prevalence of Specific Symptoms and Signs in Systolic vs. Diastolic Heart Failure Diastolic

Systolic

Heart Failure

Heart Failure

(EF > 50%)

(EF < 50%)

Dyspnea on exertion

85

96

Paroxysmal nocturnal dyspnea

55

50

Orthopnea

60

73

Jugular venous distension

35

46

Rales

72

70

Displaced apical impulse

50

60

S3

45

65

S4

45

66

Hepatomegaly

15

16

Edema

30

40

Cardiomegaly

90

96

Pulmonary venous hypertension

75

80

Symptoms

Physical examination

Chest Radiograph

Zile and Brutsaert Circulation 2002;105:13872002;105:1387-93

Intensive Review of Cardiology

Pressure-Volume Loops for Diastolic Heart Failure

LV Pressure (mmHg)

160

Normal Diastolic HF NYHA III-IV Diastolic HF after treatment

140 120 100 80

P/V stiffness V/P compliance

60 40 20 0 0

20

40

60

80

100

120

140

160

Zile and Brutsaert Circulation 2002;105:13872002;105:1387-93

Intensive Review of Cardiology

Assessment of Diastolic Function Echo Methods

• Transmitral inflow • Pulmonary venous flow • Color- M-mode • Tissue Doppler Echo • LA Volume Index

Intensive Review of Cardiology

Pulmonary Vein and LV Inflow S S

D

Pulmonary Venous Flow Velocity 0 MVC

MVO E

AR

A

Left Ventricular Inflow Velocity AVC 0 IVRT

DT

Klein et al: Mayo Clin Proc 1994:69: 212212-24

Intensive Review of Cardiology

Doppler Flow Patterns

Mitral Inflow

Pulmonary Vein

Impaired Relaxation

Pseudonormal

Restriction

Cohen et al, JACC 1996;27:17531996;27:1753-60

Intensive Review of Cardiology

Tissue Doppler Imaging

S S

E A A E

Intensive Review of Cardiology

New Echo Indices and Prognosis in Systolic Heart Failure (ADEPT study) n=225 pts Event Free Survival % Event Free Survival % 100 100 E/Ea16

20

20

0 0

200

400

600

Below 105 Above 105

76 65

47 33

30 15

800

Events 18 (14) 2 (47)

0 0

200

400

600

104 103

69 69

41 38

31 16

800

Events 13 (23) 6 (38)

Troughton et al. Am J Cardiol 2005;96:257-262

Intensive Review of Cardiology

Indexed LA Volume vs Diastolic Function Grade Indexed LA volume (mL/m2) 80 60

n=7 n=61

n=28

40

n=44

20 0

Normal

Abnormal Pseudonormal Restrictive Relaxation Diastolic Function Profile

Tsang T et al. AmJ Cardiol 2002;90:12842002;90:1284-1289.

Intensive Review of Cardiology

Practical Approach to Grade Diastolic Dysfunction Septal e’ Lateral e’ LA volume Septal e’ ≥ 8 Lateral e’ ≥ 10 LA < 34 ml/m2

Normal. function

Septal e’ ≥ 8 Lateral e’ ≥ 10 LA ≥ 34 ml/m2

Normal function, Athlete’s heart, or constriction

Septal e’ < 8 Lateral e’ < 10 LA ≥ 34 ml/m2 E/A < 0.8 DT > 200 ms Av. E/e ≤ 8 Ar-A < 0 ms Val ∆E/A < 0.5

E/A 0.8-1.5 DT 160-200 ms Av. E/e 9-12 Ar-A ≥ 30 ms Val ∆E/A ≥ 0.5

E/A ≥ 2 DT < 160 ms Av. E/e ≥ 13 Ar-A ≥ 30 ms Val ∆E/A ≥ 0.5

Grade I

Grade II

Grade III

Nageuh et al JASE 2009 1208-116

Intensive Review of Cardiology

Estimation of Filling Pressures in Patients with Depressed EF Mitral E/A E/A 50 cm/s

E/A ≥2, DT 15 E/Vp ≥ 2.5 S/D < 1 Ar – A > 30 ms Valsalva ∆ E/A > 0.5 PAS >35 mmHg IVRT/TE-e’ 15 or Lat. E/e’ > 12 or Av. E/e’ > 13

E/e’ 9-14

(Sep, Lat, or Av.)

Normal LAP

LA volume < 34 ml/m2

LA volume ≥ 34 ml/m2

Ar – A < 0 ms

Ar – A ≥ 30 ms

Valsalva ∆ E/A < 0.5 PAS 0.5 PAS >35 mmHg

IVRT/TE-e’ >2

IVRT/TE-e’