Systolic and diastolic heart failure: differences and similarities

BackgroundDiastolic heart failure (DHF) and systolic heart failure (SHF) are 2 clinical subsets of the syndrome of chronic heart failure that are most commonly encountered in clinical practice.Methods and ResultsThe clinically overt DHF and SHF appear to be 2 separate syndromes with distinctive morphologic and functional changes although signs, symptoms, and prognosis are very similar. In DHF, the left ventricle is not dilated and the ejection fraction is preserved. In contrast in SHF, it is dilated and the ejection fraction is reduced. The neurohormonal abnormalities in DHF and SHF appear to be similar. The stimuli and the signals that ultimately produce these 2 different phenotypes of chronic heart failure remain, presently, largely unknown.ConclusionsAlthough there has been considerable progress in the management of SHF, the management of DHF remains mostly empirical because of lack of knowledge of the molecular and biochemical mechanisms which produce myocardial structural and functional changes in this syndrome. Further research and investigations are urgently required.     

Systolic and diastolic dyssynchrony in patients with diastolic heart failure and the effect of medical therapy.

OBJECTIVES: The purpose of this study was to determine the prevalence of systolic and diastolic dyssynchrony in diastolic heart failure (DHF) patients and identify the effects of medical therapy. BACKGROUND: The prevalence of systolic and diastolic dyssynchrony in DHF patients is unknown with no data on the effects of medical therapy on dyssynchrony. METHODS: Patients presenting with DHF (n = 60; 61 +/- 9 years old, 35 women) underwent echocardiographic imaging simultaneous with invasive measurements. An age-matched control group of 35 subjects and 60 patients with systolic heart failure (SHF) were included for comparison. Systolic and diastolic dyssynchrony were assessed by tissue Doppler and defined using mean and SD values in the control group. RESULTS: Systolic dyssynchrony was present in 20 patients (33%) with DHF and 24 patients (40%) with SHF and was associated in both groups with significantly worse left ventricular (LV) systolic and diastolic properties (p < 0.05 vs. control group and patients without systolic dyssynchrony). Diastolic dyssynchrony was present in 35 patients (58%) with DHF and 36 patients (60%) with SHF and had significant inverse correlations with mean wedge pressure and time constant of LV relaxation. In DHF patients, medical therapy resulted in significant shortening of diastolic time delay (39 +/- 23 ms to 28 +/- 20 ms; p = 0.02) but no significant change in systolic interval (p = 0.15). Shortening of diastolic time delay correlated well with tau shortening after therapy (r = 0.85; p < 0.001). CONCLUSIONS: Systolic dyssynchrony occurs in 33% of DHF patients, and diastolic dyssynchrony occurs in 58%. Medical therapy results in significant shortening of the diastolic intraventricular time delay which is closely related to improvement in LV relaxation.     

Systolic and diastolic functions in elderly patients with and without heart failure

BACKGROUND: A considerable number of patients with heart failure (HF) have a normal left ventricular ejection fraction (LVEF). In these subjects, HF has usually been related to diastolic heart failure (DHF), still a frequently overlooked clinical entity. METHODS: This study reports the clinical, instrumental, and conventional echocardiographic evaluation of 159 consecutive, hospitalized elderly patients, 87 admitted with HF and 72 admitted for other reasons without overt HF. RESULTS: All of the 87 HF patients had signs of diastolic dysfunction (DDYS), yet 44.8% of them had a normal LVEF. Forty-four of the 72 patients admitted without overt HF (61.1%) had mild DDYS and 14 (19.5%) also had a reduced LVEF. There was a clear relationship between LVEF reduction and the severity of DDYS. CONCLUSIONS: HF is often a combination of diastolic and systolic function abnormalities. DHF may be difficult to detect in HF subjects with normal LVEF because their DDYS is often mild. However, there are signs of DDYS in all HF patients that increase in severity as LVEF decreases. DDYS could be considered a marker for all forms of HF, especially in elderly patients.     

Systolic and diastolic heart failure--diagnostic and therapeutic dilemmas

Clinical suspicion of congestive heart failure (CHF) always requires a careful diagnostic workup. This comprises the verification of the presence of CHF (in contrast to other conditions that cause nonspecific phenomena such as shortness of breath and edema), evaluation of the underlying cause of heart failure, and assessment of left ventricular (LV) systolic function. In addition to clinical examination, echocardiography is warranted in most cases. On the basis of this information, patients can be selected for further studies, such as exercise testing, cardiac catheterization and coronary angiography. In view of the serious prognosis of heart failure, especially systolic CHF, the threshold for specialist consultation should be low. Although the classification of CHF into systolic and diastolic forms is complex, clinically meaningful data can be derived simply by determining whether LV systolic function is impaired (predominantly systolic CHF) or not (probable diastolic CHF). In the latter case, treatment is mainly symptomatic in addition to the management of the underlying condition (e.g. hypertension). In systolic CHF, considerable therapeutic advances have recently been made and it is important that patients receive appropriate care to improve their prognosis. These measures include angiotensin-converting enzyme inhibitors, beta-blockers and spironolactone.     

Systolic and diastolic heart function in SLE patients

Cardiovascular pathology is frequent in systemic lupus erythematosus (SLE). Left ventricular (LV) diastolic dysfunction is its common findings. The aim of the study was to assess the systolic and diastolic function of the left ventricle (LV) in SLE patients without clinically evident cardiovascular disease, using pulsed Doppler echocardiography. Another purpose was to estimate whether there is a correlation between the duration and severity of SLE and the degree of LV diastolic dysfunction. A comparison of the average values of echocardiographic measurements was made between the SLE group and control group, which constituted healthy volunteers. No statistically significant differences in systolic heart function between groups were observed, except for lower values of the fractional shortening (SF 35.9 ± 1.2 and 37.1 ± 0.9, P = 0.01) in SLE patients, particularly in long (more than 10 years) disease duration (34.9 ± 0.6 vs. 37.0 ± 0.8, P < 0.005) and the value of SLE Disease Activity Index (SLEDAI) higher than six points (35 ± 0.9 vs. 37.1 ± 0.5, P < 0.01) Left atrial end-systolic diameter (LA) was greater (3.69 ± 0.37 vs. 3.5 ± 0.28, P < 0.05) and the ejection fraction (EF) was lower (64.6 ± 1.5 vs. 66.3 ± 1.3, P < 0.05) in SLE subjects of long disease duration than in the controls. SLE patients demonstrated significantly higher late diastolic velocity (A’) and lower E’/A’ ratio than the control group. No differences were observed in A’ values between SLE subset of short disease duration and the controls. Isovolumetric relaxation time in turn was significantly longer and E/A ratio as well as E’/A’ ratio lower in SLE of long disease duration versus the short one. In older patients, peak velocity at the time of atrial contraction (A) and A’ values were higher and peak early velocity wave (E), early diastolic velocity (E’), E/A ratio and E’/A’ ratio lower than in the younger subset. Increased the value of SLEDAI correlated with increased A’ and decreased E, E/A ratio and E’/A’ ratio in SLE subjects. Further analysis concerning the strong connection of these parameters with patients’ age, however, revealed no statistically significant correlation between SLEDAI values and LV diastolic function parameters. In long (>10 years) disease duration LV diastolic properties were worse.     

Systolic heart failure in the elderly

Aging is associated with changes in cardiac and vascular structure, promoting the development of heart failure. An increase in vascular stiffness leads to an increase of systolic arterial pressure and pulse wave velocity. This augments the afterload of the heart, which contributes to cardiac hypertrophy and neuroendocrine activation in the elderly. On the molecular level the age-associated changes in the sympathetic nervous system are similar to alterations that can be found in congestive heart failure. Therapy of systolic heart failure does not differ between the elderly and younger patients. All drugs which have shown to improve the prognosis of younger patients are indicated in the elderly as well. This holds true for ACE-inhibitors or angiotensin receptor antagonists, betablockers and aldosterone antagonists. However, comorbidities as well as changes in the pharmacokinetics and pharmacodynamics might require a cautious initiation of the therapy, an individual adjustment of the dosage and a thoroughly monitoring of the elderly patients.     

Statins and diastolic heart failure

Although nearly 50% of patients with heart failure have normal ejection fraction, there are only few studies for guiding the treatment of this patient population. We emphasize the possible clinical benefit of statins therapy in these patients.     

Hypertension and diastolic heart failure

In patients with hypertension, pressure overload leads to left ventricular hypertrophy (LVH), myocardial fibrosis, and impaired diastolic filling without systolic dysfunction. Presently, diastolic heart failure accounts for about 50% of the heart failure population. Fatigue, dyspnea, reduced exercise tolerance, and peripheral edema are common presenting complaints. As a group, patients with diastolic heart failure are older and predominantly female. Diuretics are effective for treating congestive symptoms. β Blockers and heart rate-lowering calcium blockers show benefit in smaller studies but have not been evaluated in definitive clinical trials. Renin-angiotensin-aldosterone system blockers reduce blood pressure, LVH, and myocardial fibrosis; however, long-term studies with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers demonstrate little effect on symptoms or survival, and inconsistent effects on heart failure hospitalization. At present, evidence-based treatment includes antihypertensive therapy to reduce progression from hypertension to heart failure. In patients with established heart failure, diuretics and other empiric treatments are used to control symptoms.     

Primary diastolic heart failure

Diastolic heart failure is defined clinically when signs and symptoms of heart failure are present in the presence of preserved left ventricular systolic function (ejection fraction >45%). The incidence and prevalence of primary diastolic heart failure increases with age and it may be as high as 50% in the elderly. Age, female gender, hypertension, coronary artery disease, diabetes, and increased body mass index are risk factors for diastolic heart failure. Hemodynamic consequences such as increased pulmonary venous pressure, post-capillary pulmonary hypertension, and secondary right heart failure as well as decreased cardiac output are similar to those of systolic left ventricular failure, although the nature of primary left ventricular dysfunction is different. Diagnosis of primary diastolic heart failure depends on the presence of preserved left ventricular ejection fraction. Assessment of diastolic dysfunction is preferable but not mandatory. It is to be noted that increased levels of B-type natriuretic peptide does not distinguish between diastolic and systolic heart failure. Echocardiographic studies are recommended to exclude hypertrophic cardiomyopathy, infiltrative heart disease, primary valvular heart disease, and constrictive pericarditis. Myocardial stress imaging is frequently required to exclude ischemic heart disease. The prognosis of diastolic heart failure is variable; it is related to age, severity of heart failure, and associated comorbid diseases such as coronary artery disease. The prognosis of severe diastolic heart failure is similar to that of systolic heart failure. However, cautious use of diuretics and/or nitrates may cause hypotension and low output state. Heart rate control is essential to improving ventricular filling. Pharmacologic agents such as angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers are used in selected patients to decrease left ventricular hypertrophy. To decrease myocardial fibrosis, aldosterone antagonists have a potential therapeutic role. However, prospective controlled studies will be required to establish their efficacy in primary diastolic heart failure.     

Diagnosing diastolic heart failure

BACKGROUND: increasing evidence supports the existence of left ventricular diastolic dysfunction as an important cause of congestive heart failure, present in up to 40% of heart failure patients. AIM: to review the pathophysiology of LV diastolic dysfunction and diastolic heart failure and the currently available methods to diagnose these disorders. RESULTS: for diagnosing LV diastolic dysfunction, invasive hemodynamic measurements are the gold standard. Additional exercise testing with assessment of LV volumes and pressures may be of help in detecting exercise-induced elevation of filling pressures because of diastolic dysfunction. However, echocardiography is obtained more easily, and will remain the most often used method for diagnosing diastolic heart failure in the coming years. MRI may provide noninvasive determination of LV three-dimensional motion during diastole, but data on correlation of MRI data with clinical findings are scant, and possibilities for widespread application are limited at this moment. CONCLUSIONS: in the forthcoming years, optimal diagnostic and therapeutic strategies for patients with primary diastolic heart failure have to be developed. Therefore, future heart failure trials should incorporate patients with diastolic heart failure, describing precise details of LV systolic and diastolic function in their study populations.