Is 'diastolic heart failure' a diagnosis of exclusion? Echocardiographic parameters of diastolic dysfunction in patients with heart failure and normal systolic function

Background: Diastolic heart failure (DHF) is reported to account for 30–50% of heart failure presentations, but its prevalence in the absence of overt coronary disease is unclear. Diastolic heart failure is usually defined by exclusion (heart failure with normal left ventricular (LV) systolic function), and few studies have sought a specific diagnosis of diastolic dysfunction. The objective of the present study was to determine the prevalence of isolated DHF and characterise LV diastolic function in patients without clinical evidence of coronary disease, who were referred for LV function assessment.

Methods: Among 938 consecutive patients referred for assessment of LV function, diastolic dysfunction was sought in patients with clinical heart failure, normal systolic function, and no valvular or coronary disease. The evaluation was based on measurement of early (E) and late (A) transmitral velocities and E wave deceleration time (DT). Pulmonary vein systolic, diastolic and atrial reversal velocities were used to differentiate pseudonormal filling in patients with normal E/A and DT.

Results: Normal LV systolic function was present in 331 patients (35%), of whom 53 (6%) met criteria for a clinical diagnosis of DHF. Diastolic dysfunction was confirmed by echocardiography in 38 patients (72% of clinical DHF patients), of whom 27 had impaired LV relaxation, 10 had pseudonormal filling, and one had restrictive filling. Diastolic function was normal in 13 and indeterminate in two patients. Pseudonormal or restrictive LV filling were more prevalent in patients with acute heart failure (7/20, P < 0.05).

Conclusions: Carefully defined, isolated DHF is uncommon, but most of these patients demonstrate echocardiographic evidence of diastolic dysfunction.     

Intact systolic left ventricular function in clinical congestive heart failure

Clinical congestive heart failure (CHF) is traditionally associated wtih significant left ventricular (LV) systolic dysfunction. Over a 1-year period, 58 patients with CHF and intact systolic function (LV ejection fraction [EF] 62 ± 11%) were identified. An objective clinical-radiographic CHF score was used to document the clinical impression. Based on radionuclide evaluation of peak filling rate, 38 % of these patients were found to have a significant abnormality in diastolic function as measured by peak filling rate (< 2.50 end-diastolic volume/s). An additional 24% of the patients had probable diastolic dysfunction with borderline abnormal peak filling rate measurements (2.5 to 3.0 end-diastolic volume/s). The disease states most frequently associated with CHF and intact systolic function were coronary artery disease and systemic hypertension. During a 3-month sampling period 42% of patients with clinical diagnosis of CHF referred to the nuclear cardiology laboratory were found to have intact systolic function; thus, intact systolic function is not uncommon in patients with clinical CHF. Abnormal diastolic function is the most frequently encountered mechanism for the occurrence of CHF. Definition of systolic and diastolic function appears relevant for development of optimal therapeutic strategies for the treatment of patients with CHF.     

Diastolic Dysfunction as a Cause of Exercise Intolerance

Tachycardia accompanying exercise shortens the duration of diastole, reducing the time available for the left ventricular (LV) filling. Thus, the LV must fill more rapidly for the stroke volume to increase (or even be maintained) during exercise. Normally, this is accomplished without requiring an excessive increase in left atrial (LA) pressure by an acceleration of LV relaxation and a fall in LV early diastolic pressure during exercise. This response is lost following the development of heart failure due to systolic dysfunction, both in experimental animals and in patients. In fact, in such situations, LV relaxation slows and LV early diastolic pressure increases due to exercise. Thus, any diastolic dysfunction present at rest in CHF during systolic dysfunction is exacerbated during exercise. Similarly, patients with primary diastolic dysfunction heart failure with preserved systolic function may not be able to augment LV filling rates without an abnormal increase in LA pressure. Thus, diastolic dysfunction may contribute to exercise intolerance, both in systolic dysfunction and primary diastolic dysfunction. Acute studies suggest that treatment with angiotensin II receptor blockers or verapamil may improve exercise tolerance in some patients with primary diastolic dysfunction.     

Asymptomatic Left Ventricular Dysfunction and Metabolic Syndrome: Results from an Italian Multicenter Study

Context:

Metabolic syndrome (MS) is a cluster of interrelated common clinical disorders, including obesity, insulin resistance, glucose intolerance, hypertension and dyslipidemia, associated with a greater risk of atherosclerotic cardiovascular disease than any of its individual components. Although MS is associated with increased cardiovascular risk (CVR), its relationship with heart failure (HF) and left ventricular (LV) dysfunction is not fully understood.

Aims:

We sought to determine whether MS is associated to LV systolic and diastolic dysfunction in a sample of patients with MS and no symptoms for HF.

Subjects and Methods:

We enrolled 6422 consecutive asymptomatic patients admitted to echo-lab for a routine echocardiogram. We calculated LV systolic and diastolic function, by Simpson biplane method and validated Doppler parameters, respectively. MS was diagnosed if three or more CVR factors were found.

Results:

LV systolic function was evaluated in 6175 patients (96.2%). In the group of patients without MS (n = 5630), the prevalence of systolic dysfunction was 10.8% (n = 607) while in the group of patients with MS (n = 545) it was 12.5% (n = 87), (RR1.57; CI 95% 1.2-2.0; P < 0.001). Diastolic function was evaluated in 3936 patients (61.3%). In the group of patients without MS (n = 3566) the prevalence of diastolic dysfunction was 33.3% (n = 1187), while in patients with MS (n = 370) it was 45.7% (n = 169), (RR1.68; CI95% 1.3-2.0; P < 0.001). After adjustment for age and gender, MS proved to be an independent predictor of LV systolic and diastolic dysfunction.

Conclusions:

Our data show that asymptomatic LV systolic and diastolic dysfunction, is correlated with MS and demonstrate that echocardiography is a useful tool to detect patients at high risk for HF. Echocardiography in asymptomatic patients with MS may lead to a therapy initiation at early stages to prevent future cardiovascular events and HF.     

Study of left ventricular systolic dysfunction,left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients—A single centre cross-sectional study

IntroductionCardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.MethodsA cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35 mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction) ≤ 50% and LVDD as E/e′ ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.ResultsA total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.ConclusionIn our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.     

Association of Left Ventricular Longitudinal and Circumferential Systolic Dysfunction With Diastolic Function in Hypertension: A Nonlinear Analysis Focused on the Interplay With Left Ventricular Geometry

BackgroundThe relationships of left ventricular (LV) longitudinal and circumferential systolic dysfunction with diastolic performance in hypertensive patients have never been compared.Methods and ResultsIn 532 asymptomatic hypertensive patients, circumferential function was assessed with the use of midwall fractional shortening (mFS) and stress-corrected mFS (SCmFS), whereas longitudinal function was assessed with the use of left atrioventricular plane displacement (AVPD) and systolic mitral annulus velocity (s′). Early diastolic annular velocity (e′) and the E/e′ ratio were measured. Global longitudinal and circumferential strain were determined in a subset of 210 patients. e′ was linearly related to all systolic indexes (AVPD: R = 0.40; s′: R = 0.39; mFS: R = 0.16; SCmFS: R = 0.17; all P < .0001), but the correlations were stronger with longitudinal indexes than with circumferential ones (P < .0001). E/e′ was nonlinearly related to AVPD (R = −0.49; P < .0001) and s′ (R = −0.34; P < .0001) and showed no relationship with mFS and SCmFS. Longitudinal indexes were superior to circumferential ones in predicting e′ <8 cm/s, E/e′ <8, and E/e′ ≥13. The effect of LV geometry on LV diastolic function was evident among patients with preserved systolic longitudinal function, but was blunted among patients with impaired longitudinal function. In multivariable analyses, only longitudinal indexes remained associated with e′ and E/e′. Analyses using strains provided similar results.ConclusionsIn asymptomatic hypertensive subjects, LV diastolic performance is independently associated with longitudinal systolic dysfunction, but not with circumferential systolic dysfunction. Subtle longitudinal systolic impairment plays a role in mediating the effect of LV geometry on diastolic performance. These findings may support the need of critically revising the concept of isolated diastolic dysfunction in these patients.     

Effect of balloon mitral valvotomy on left ventricular function in rheumatic mitral stenosis

AimMitral stenosis (MS) is found to produce left ventricular (LV) dysfunction in some studies. We sought to study the left ventricular function in patients with rheumatic MS undergoing balloon mitral valvotomy (BMV). Ours is the first study to analyze effect of BMV on mitral annular plane systolic excursion (MAPSE), and to quantify prevalence of longitudinal left ventricular dysfunction in rheumatic MS.MethodsIn this prospective cohort study, we included 43 patients with severe rheumatic mitral stenosis undergoing BMV. They were compared to twenty controls whose distribution of age and gender were similar to that of patients. The parameters compared were LV ejection fraction (EF) by modified Simpson's method, mitral annular systolic velocity (MASV), MAPSE, mitral annular early diastolic velocity (E′), and myocardial performance index (MPI). These parameters were reassessed immediately following BMV and after 3 months of procedure.ResultsMASV, MAPSE, E′, and EF were significantly lower and MPI was higher in mitral stenosis group compared to controls. Impaired longitudinal LV function was present in 77% of study group. MAPSE and EF did not show significant change after BMV while MPI, MASV, and E′ improved significantly. MASV and E′ showed improvement immediately after BMV, while MPI decreased only at 3 months follow-up.ConclusionsThere were significantly lower mitral annular motion parameters including MAPSE in patients with rheumatic mitral stenosis. Those with atrial fibrillation had higher MPI. Immediately after BMV, there was improvement in LV long axis function with a gradual improvement in global LV function. There was no significant change of MAPSE after BMV.     

The Prevalence of Diabetic Cardiomyopathy: A Population-Based Study in Olmsted County,Minnesota

BackgroundDiabetic cardiomyopathy defined as either systolic or diastolic dysfunction in otherwise healthy diabetic persons is not clearly understood. The prevalence and outcomes of this disease in a community-based population have not been defined.Methods and ResultsCross-sectional survey of 2042 randomly selected residents of Olmsted County, Minnesota, aged 45 years or older between June 1997 and September 2000. All patients underwent Doppler echocardiographic assessment of systolic and diastolic function. Diabetic cardiomyopathy was defined in a person with diabetes and any systolic or at least moderate diastolic dysfunction without a history of coronary disease, hypertension, significant valvular disease, or congenital heart disease. The diagnosis of diabetic cardiomyopathy was made in 23 people, corresponding to a community population prevalence rate of 1.1%. Among diabetic patients, 16.9% met criteria for diabetic cardiomyopathy and 54.4% had diastolic dysfunction. Diabetes was associated with a 1.9-fold increase in risk of any left ventricular dysfunction, a 1.7-fold increase in risk of diastolic dysfunction, and a 2.2-fold increase in risk of systolic dysfunction. Among patients with diabetic cardiomyopathy, the cumulative probability of death was 18%, development of heart failure was 22%, and development of death or heart failure was 31% at 9 years.ConclusionDiabetic cardiomyopathy is relatively common in the community with a prevalence of 1.1%. The morbidity and mortality of patients with diabetic cardiomyopathy is high.     

Assessment of left ventricular global longitudinal strain in patients with type 2 diabetes: Relationship with microvascular damage and glycemic control

Background and aimsType 2 Diabetes mellitus (T2DM) is associated with a higher risk of Heart Failure; Left Ventricular (LV) diastolic dysfunction is often considered the first marker of Diabetic cardiomyopathy; however, early preclinical LV systolic dysfunction has also been observed by means of echocardiographic measurement of strain. This study is aimed at assessing determinants of impaired strain and diastolic ventricular dysfunction in patients with T2DM.Methods and resultsCross-sectional study, performed on a consecutive series of patients with T2DM aged 30–80 years, BMI<40 kg/m², free of cardiovascular disease, assessing metabolic control, microvascular complications, echocardiographic measures.Out of 206 patients, 19.6% had GLS lower than 18. GLS showed a significant inverse correlation with HBA1c, (p = 0.016), BMI (p = 0.002), waist (p < 0.0001), and mean L:H Ratio (p = 0.019). In a multivariate regression for LV GLS including HbA1c, age, sex, BMI and mean RR SDNN index, only HbA1c retained statistical significance: (B = ?0.050 [?0.091; ?0.009], p = 0.01. Among markers of LV diastolic function, only the E/E’ ratio was associated with HbA1c at a univariate analysis, and it retained statistical significance in a multivariate regression including HbA1c, age, sex and disease duration (B = 0.038 [0.03; ?0.073], p = 0.032). No significant difference in any parameter of systolic or diastolic function was observed between patients with or without microalbuminuria or diabetic retinopathy.ConclusionIn patients with T2DM, a reduced left ventricular global longitudinal strain appears to be independently associated with impaired glucose control and autonomic neuropathy, regardless of microvascular complications.     

Effects of exercise training on diastolic and systolic dysfunction in patients with chronic heart failure

BACKGROUNDChronic heart failure (CHF) is a complex syndrome characterized by a progressive reduction of the left ventricular (LV) contractility, low exercise tolerance, and increased mortality and morbidity. Diastolic dysfunction (DD) of the LV, is a keystone in the pathophysiology of CHF and plays a major role in the progression of most cardiac diseases. Also, it is well estimated that exercise training induces several beneficial effects on patients with CHF. AIMTo evaluate the impact of a cardiac rehabilitation program on the DD and LV ejection fraction (EF) in patients with CHF.METHODSThirty-two stable patients with CHF (age: 56 ± 10 years, EF: 32% ± 8%, 88% men) participated in an exercise rehabilitation program. They were randomly assigned to aerobic exercise (AER) or combined aerobic and strength training (COM), based on age and peak oxygen uptake, as stratified randomization criteria. Before and after the program, they underwent a symptom-limited maximal cardiopulmonary exercise testing (CPET) and serial echocardiography evaluation to evaluate peak oxygen uptake (VO_2peak), peak workload (W_peak), DD grade, right ventricular systolic pressure (RVSP), and EF.RESULTSThe whole cohort improved VO_2peak, and W_peak, as well as DD grade (P < 0.05). Overall, 9 patients (28.1%) improved DD grade, while 23 (71.9%) remained at the same DD grade; this was a significant difference, considering DD grade at baseline (P < 0.05). In addition, the whole cohort improved RVSP and EF (P < 0.05). Not any between-group differences were observed in the variables assessed (P > 0.05).CONCLUSIONExercise rehabilitation improves indices of diastolic and systolic dysfunction. Exercise protocol was not observed to affect outcomes. These results need to be further investigated in larger samples.     

Global and segmental left ventricular function in beta-thalassemia

The systolic and diastolic left ventricular (LV) function was studied by M-mode echocardiography in 60 patients with beta-thalassemia (mean age +/- SD, 17.1 +/- 7.5 years) and 30 healthy controls (15.4 +/- 3.8 years). In thalassemic patients, echocardiograms were obtained 48 h posttransfusion, with a mean hemoglobin level of 12.4 +/- 0.9 g/dl. To examination time, thalassemic patients had received 30-774 blood units (318 +/- 176). Congestive heart failure (CHF) was present in 14 thalassemic patients (19.6 +/- 3.4 years), while 46 (16.3 +/- 8.2 years) had no clinical signs of CHF. Global LV function study showed enlarged LV dimensions in thalassemic patients with CHF (p less than 0.001) and similar cavity size in controls and patients without CHF (p = NS). The same was true for velocity measurements, while diastolic LV indices had similar values in all groups (p = NS). Segmental LV function study showed no significant differences in systolic and diastolic LV posterior wall behavior between thalassemic patients and controls, and even more, between thalassemic patients with and without CHF, while it was independent of iron load. These findings indicate that global and segmental LV function in thalassemic patients remain within normal limits until the final stages of the disease. CHF onset marks the deterioration of LV systolic performance, while global and segmental diastolic indices do not change significantly. The above findings question the role of iron overload in the development of CHF in beta-thalassemia.     

Tissue Doppler imaging in the evaluation of left ventricular diastolic function

PURPOSE OF REVIEW: Describe the rationale behind, and clinical use of, tissue Doppler (TD) imaging in the assessment of left ventricular (LV) diastolic function, with a focus on recent developments. RECENT FINDINGS: Tissue Doppler imaging is a novel echocardiographic technique that directly measures myocardial velocities. Systolic TD measurements assess left and right ventricular myocardial contractile function. Diastolic TD values reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (E/Ea) have been developed to estimate LV filling pressures. TD values and derived ratios have been demonstrated to be valuable in the diagnosis of elevated LV filling pressures, clinical congestive heart failure (CHF), and the prognosis of patients with cardiac disease and CHF. New TD indices have now been developed to assess myocardial relaxation and LV filling pressures, and the impact of LV systolic function on the use of TD imaging has recently been described. TD echocardiography is being used in an ever-widening group of patients for the assessment of LV diastolic function, and its correlation to, and comparison with, B-type natriuretic peptide is an active area of current investigation. SUMMARY: This review focuses on new developments in the clinical use of TD echocardiography in the evaluation of left ventricular diastolic function.     

Left ventricular systolic dysfunction in 75-year-old men and women; a population-based study.

AIMS: To determine the prevalence of left ventricular systolic dysfunction in 75-year-old men and women. METHODS AND RESULTS: In a population-based random sample of 75-year-old subjects (n=433; response rate 70.1%) the left ventricular systolic function was determined using two echocardiographic methods: (1) wall motion in nine left ventricular segments was visually scored and wall motion index was calculated as the mean value of the nine segments and (2) ejection fraction as measured by the disc summation method. Presence of heart failure was determined by a cardiologist's clinical evaluation. Wall motion index was achievable in 95% of the participants while ejection fraction was measurable in 65%. Normal values were obtained from a healthy subgroup (n=108) and left ventricular systolic dysfunction was defined as the 0.5th percentile of the wall motion index (i.e. <1.7). In participants in whom both ejection fraction and wall motion index were achievable, wall motion index <1.7 predicted ejection fraction <43% with a sensitivity and specificity of 84.0% and 99.6%, respectively. The prevalence of left ventricular systolic dysfunction was 6.8% (95% CI, 5.6--8.0%) and was greater in men than in women (10.2% vs 3.4%, P=0.006). Clinical evidence of heart failure was absent in 46% of the participants with left ventricular systolic dysfunction. CONCLUSIONS: Left ventricular systolic dysfunction is common among 75-year-olds with a prevalence of 6.8% in our estimate. The condition is more likely to affect men than women. In nearly half of 75-year-olds with left ventricular systolic dysfunction there is no clinical evidence of heart failure.     

Validity of revised Doppler echocardiographic algorithms and composite clinical and angiographic data in diagnosis of diastolic dysfunction

BACKGROUND: Commonly used echocardiographic indices for grading diastolic function predicated on mitral inflow Doppler analysis have a poor diagnostic concordance and discriminatory value. Even when combined with other indices, significant overlap prevents a single group assignment for many subjects. We tested the relative validity of echocardiographic and clinical algorithms for grading diastolic function in patients undergoing cardiac catheterization. METHOD: Patients (n = 115), had echocardiograms immediately prior to measuring left ventricular (LV) diastolic (pre-A, mean, end-diastolic) pressures. Diastolic function was classified into the traditional four stages, and into three stages using a new classification that obviates the pseudonormal class. Summative clinical and angiographic data were used in a standardized fashion to classify each patient according to the probability for abnormal diastolic function. Measured LV diastolic pressure in each patient was compared with expected diastolic pressures based on the clinical and echocardiographic classifications. RESULT: The group means of the diastolic pressures were identical in patients stratified by four-stage or three-stage echocardiographic classifications, indicating that both classifications schemes are interchangeable. When severe diastolic dysfunction is diagnosed by the three-stage classification, 88% and 12%, respectively, were clinically classified as high and intermediate probability, and the mean LV pre-A pressures was >12 mmHg (P < 0.005). Conversely, the mean LV pre-A pressure in the clinical low probability or echocardiographic normal groups was <11 mmHg. CONCLUSION: Use of a standardized clinical algorithm to define the probability of diastolic function identifies patients with elevated LV filing pressure to the same extent as echocardiographic methods.     

Selective aldosterone blockade suppresses atrial tachyarrhythmias in heart failure

INTRODUCTION: Renin-angiotensin-aldosterone system activation may be involved in the pathogenesis of atrial arrhythmias in congestive heart failure (CHF). The effects of aldosterone blockade on atrial tachyarrhythmias have not been evaluated. This study's aim was to determine whether selective aldosterone blockade suppresses atrial tachyarrhythmia inducibility and modifies atrial electrical and/or structural remodeling in a canine model of rapid ventricular pacing (RVP)-induced CHF. METHODS AND RESULTS: Dogs were assigned randomly to treatment with oral placebo or eplerenone (50 mg/day) and divided into four groups: two sham-operated (no RVP) and two RVP groups. After 5 weeks of no RVP or RVP at 230 beats/min along with concurrent placebo or eplerenone treatment, dogs underwent electrophysiologic and echocardiographic studies. Sustained atrial tachyarrhythmia inducibility (>10-minute duration), atrial effective refractory periods (ERPs), systolic and diastolic function, and left atrial and left ventricular (LV) chamber sizes were assessed. Placebo-treated RVP dogs developed CHF with LV systolic and diastolic dysfunction, left atrial and LV enlargement, increased atrial ERPs, and inducible sustained atrial tachyarrhythmias. Eplerenone treatment in RVP dogs significantly suppressed sustained atrial tachyarrhythmia inducibility, nonuniformly prolonged atrial ERPs and attenuated LV diastolic dysfunction without modifying left atrial or LV dilation or ejection fractions in CHF. Isoproterenol (2-4 microg/min) reversed eplerenone's atrial antiarrhythmic and ERP prolonging effects in CHF. Eplerenone did not alter atrial ERPs in sham (no RVP) dogs without CHF. CONCLUSIONS: Eplerenone suppresses inducibility of sustained atrial tachyarrhythmias, selectively prolongs atrial ERPs, and attenuates LV diastolic remodeling in RVP-induced CHF. Aldosterone blockade may be a promising new approach for atrial tachyarrhythmia prevention in CHF.     

Utility of B-natriuretic peptide as a rapid, point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction

BACKGROUND: Although echocardiography is an important tool for making the diagnosis of left ventricular (LV) dysfunction, the cost of this procedure limits its use as a routine screening tool for this purpose. Brain natriuretic peptide (BNP) accurately reflects ventricular pressure, and preliminary studies have found it to be highly sensitive and highly specific in diagnosing congestive heart failure in the emergency department. We hypothesized that BNP might therefore be useful as a screening tool before echocardiography in patients with suspected LV dysfunction. METHODS: Subjects included patients referred for echocardiography to evaluate the presence or absence of LV dysfunction. Patients with known LV dysfunction were excluded from analysis. BNP was measured by a point-of-care immunoassay (Biosite Diagnostics, San Diego, Calif). The results of BNP levels were blinded from cardiologists making the assessment of LV function. Patients were divided into those with normal ventricular function, abnormal systolic ventricular function, abnormal diastolic function, and evidence of both systolic and diastolic dysfunction. RESULTS: Two hundred patients in whom LV function was unknown were studied. In the 105 patients (53%) whose ventricular function was subsequently determined to be normal by echocardiography, BNP levels averaged 37 +/- 6 pg/mL. This was significantly less than in those patients with either ultimate diastolic dysfunction (BNP 391 +/- 89 pg/mL (P <.001) or systolic dysfunction (BNP 572 +/- 115 pg/mL (P <.001). A receiver-operator characteristic curve showing the sensitivity and specificity of BNP against the echocardiography diagnosis revealed the area under the curve (accuracy) was 0.95. At a BNP level of 75 pg/mL was 98% specific for detecting the presence or absence of LV dysfunction by echocardiography. CONCLUSIONS: A simple, rapid test for BNP, which can be performed at the bedside or in the clinic, can reliably predict the presence or absence of LV dysfunction on echocardiogram. The data indicate that BNP may be an excellent screening tool for LV dysfunction and may, in fact, preclude the need for echocardiography in many patients.     

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.

Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m(2). Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion. The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.     

Echocardiographic parameters of left ventricular systolic and diastolic function in infants,children and adolescents before and after surgical correction of secundum atrial septal defect

BACKGROUND: Left ventricular (LV) dysfunction has been described in adults with secundum atrial septal defect (ASD II) and heart failure (CHF). This anomaly has been rarely regarded as a cause of CHF in pediatric patients with ASD II. AIM: To assess LV systolic and diastolic function in patients with ASD II before and after cardiosurgery as well as to establish the prognostic value of these parameters in infants, children and adolescents with ASD II. METHODS: LV systolic (LVEF) and diastolic function parameters (E/A, DCT, IVRT) were studied using Doppler echocardiography in 104 patients aged between 1-18 years with ASD II before cardiosurgery and 4 years afterwards. These parameters were compared with similar variables in 150 healthy infants, children and adolescents. RESULTS: Before surgery LVEF was significantly lower only in infants with ASD II and CHF when compared with healthy controls. Relaxation abnormalities of LV diastolic function were observed before surgery in 40.4% of patients, especially in infants and adolescents with CHF. These disturbances were still present in about 20% of patients after surgery, especially in infants. Before and after surgery both LV and RV end-diastolic volumes were normal in about 6-10% of patients with LV diastolic dysfunction. CONCLUSIONS: In patients with ASD II and CHF diastolic dysfunction of LV is more common than systolic dysfunction. RV volume overload mainly affects LV diastolic function but it is not the only cause of CHF in patients with ASD II, especially in infants and adolescents. After surgery, normalisation of LV diastolic function is not observed in about 20% of patients with ASD II, especially in those who had CHF before operation. Special monitoring of the circulatory system is necessary in patients with ASD II operated in infancy and adolescence.     

Congestive heart failure arising from diastolic dysfunction in the presence of normal left-ventricular systolic function

Congestive heart failure due to diastolic dysfunction is a common clinical entity, particularly in the elderly. As outlined, such patients fall into a larger group of all patients with CHF symptoms and normal systolic function. When finding "normal" systolic function, the clinician should embark upon a carefully outlined diagnostic work-up geared toward eliminating confounding or treatable contributing causes of dyspnea or typical CHF symptoms. The prognosis for CHF patients with primarily diastolic dysfunction is not as poor as for those with LV systolic dysfunction, although the prevalence, associated morbidity, and costs are great. In contrast to the large number of successful clinical trials that have guided treatment of LV systolic failure, an extremely limited number of trials have specifically addressed themselves to diastolic dysfunction. Marked symptomatic relief can often be provided with careful attention to tailored therapy, although little is known with regard to outcome. Refinements in noninvasive imaging methods and hemodynamic indices of diastolic function may lead to improved patient care.     

Diastolic dysfunction in the presence of left ventricular systolic dysfunction: implications of beta-adrenergic blocking therapy

The contribution of left ventricular diastolic dysfunction to the impairment in overall left ventricular performance in patients with systolic dysfunction is underappreciated. This article summarizes the available data on diastolic dysfunction in patients with congestive heart failure in which the predominant abnormality was thought to be left ventricular systolic dysfunction. The prevalence and identification of diastolic abnormalities and their clinical relevance are addressed, particularly the role of beta-adrenergic blocking therapy. The potential benefits of beta-adrenergic blocking therapy to diastolic performance are discussed from both a hemodynamic and clinical standpoint, with the implication that diastolic performance and its modulation should be considered in future investigations. (c)2001 by CHF, Inc.