Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction

Circumferential 2D-strain imaging for the prediction of long term response to cardiac resynchronization therapy

BACKGROUND

Cardiac Resynchronization Therapy (CRT) leads to hemodynamic and clinical improvement in heart failure patients. The established methods to evaluate myocardial asynchrony analyze longitudinal and radial myocardial function. This study evaluates the new method of circumferential 2D-strain imaging in the prediction of the long-term response to CRT.

METHODS AND RESULTS

38 heart failure patients (NYHA II-III, QRS > 120 ms, LVEF < 0.35) received CRT and echocardiographic evaluation with a mean follow-up of 9.4 months. 18 (47.4%) of the patients were hemodynamic responders to long-term CRT. In the responder group, the maximum delay in the circumferential 2D-strain in the basal segments decreased (246 +/- 94 to 123 +/- 92 ms, p < 0.001). In the non-responder group there was no significant change (pre CRT: 195 +/- 86, post CRT 135 +/- 136 ms, p = 0.84). This was paralleled by a reduction of the maximum delay in the radial and longitudinal 2D strain in the basal segments. In ROC analysis, the baseline delay of circumferential 2D strain (AUC 0.66 (+/- 0.14)) does not predict a long-term response to CRT (p = 0.37).

CONCLUSION

There is a significant decrease in the circumferential 2D-strain derived delays after CRT, indicating that resynchronization induces improvement in all three dimensions of myocardial contraction. However, the resulting predictive values of 2D strain delays are not superior to longitudinal and radial 2D-strain or TDI delays.

Age-dependency of classic and new parameters of diastolic function

Age-dependency has been demonstrated for classic diastolic parameters but is less documented for novel markers. We compared wide spectrum of diastolic measurements in healthy subjects younger and older than 50 and 70 years.

METHOD

In 80 subjects (17 to 91 year, 38 male, mean age 53 +/- 16) we assessed in transthoracic echocardiography mitral inflow, pulmonary vein flow, propagation velocity, and tissue Doppler parameters. The data were compared between the groups: A < 50, B 50-70, and C > 70 years and their correlation with age was analyzed.

RESULT

In the older groups a longer duration of isovolumic relaxation, higher velocity of mitral inflow atrial phase, and lower early to atrial mitral inflow velocity ratio (E/A) were observed. In pulmonary veins ratio of peak systolic to diastolic velocity (S/D) was higher and atrial reversal flow faster. Among the new parameters in older groups a lower propagation velocity of early wave (Ep) (30 +/- 8 in C, 44 +/- 10 in B vs 49+/-9 cm/s in A;P< 0.05) and peak early diastolic velocity of mitral annulus (E' 9.5 +/- 1.8 in C and 11.2 +/- 2.9 in B vs 15.8 +/- 4.1 cm/s in A,P< 0.05) were recorded.

CONCLUSIONS

Besides the evolution of mitral inflow toward the delayed relaxation profile in elderly, a decrease of propagation and tissue Doppler velocities were documented. The strongest positive correlation with age was observed for atrial velocity of mitral inflow (A, r = 0.63) and inverse correlation for E/A ratio (r =-0.6) and early diastolic velocity of mitral annulus (r =-0.69).

Left ventricular abnormal response during dynamic exercise in patients with heart failure and preserved left ventricular ejection fraction at rest

BACKGROUND

The mechanisms that contribute to limit functional capacity are incompletely understood in patients with preserved resting ejection fraction (HFpREF). We assessed left ventricular (LV) systolic response to dynamic exercise in patients with HFpREF and in patients with similar comorbidities to HFpREF patients but without history or evidence of heart failure.

METHODS AND RESULTS

Twenty-five HFpREF patients in steady-state clinical condition without significant coronary artery disease and 25 hypertensive controls underwent exercise echocardiography. At rest, systolic pulmonary artery pressure, left atrial area, E/A and E/e' ratios were greater in patients with HFpREF than in control patients, whereas peak systolic mitral annular velocity was lower in HFpREF patients. The exercise-induced changes in LVEF, forward stroke volume, and cardiac output were significantly lower in HFpREF compared with control patients (-4 +/- 8 vs. +6 +/- 6 %, P = .001; -4 +/- 9 vs. +10 +/- 10 mL, P < .0001, and 1.6 +/- 1.2 vs. 3.5 +/- 1.8 L/min, P < .0001, respectively). Exercise-induced changes in effective arterial elastance significantly differed in HFpREF and control patients (0.5 +/- 0.6 vs. -0.2 +/- 0.5 mm Hg/mL, P < .0001). In addition, 7 of the 25 HFpREF patients developed functional mitral regurgitation during exercise and none in controls.

CONCLUSIONS

When compared with patients with similar comorbidities but without history or evidence of heart failure, patients with HFpREF experience greater arterial stiffening and thereby a deterioration of global LV systolic performance during dynamic exercise.

Noninvasively determined radial dP/dt is a predictor of mortality in patients with heart failure

BACKGROUND

The left ventricular (LV) developed pressure is a marker of contractility, associated with a poor prognosis during systolic heart failure. The maximal first derivative or slope of the radial pulse wave (Rad dP/dt) has been proposed as a marker of LV systolic function. This study sought to assess the prognostic value of the baseline dP/dt of the radial pulse in patients with heart failure.

METHODS

The Rad dP/dt was noninvasively measured by applanation tonometry, and its effect on mortality was analyzed by using multivariate Cox regression models. We studied 310 consecutive patients. Mean follow-up was 327 +/- 187 days, and 64 patients died or were transplanted during this period.

RESULTS

Death or transplantation was associated with New York Heart Association class III or IV, low systolic or mean blood pressure, low LV ejection fraction, and low Rad dP/dt (634.6 +/- 373.3 vs 730.2 +/- 367.4 mm Hg/s for patients who survived without transplantation, P < .02). A Rad dP/dt <440 mm Hg/s was associated with death or transplantation before and after adjustment for confounding variables (OR [95% CI] 2.19 [1.33-3.58] and 2.88 [1.29-6.38], respectively, P < .01 for both). This relationship was independent of pulse pressure and no significant interaction was found between the Rad dP/dt and the pulse pressure.

CONCLUSION

This study demonstrates, for the first time, that the Rad dP/dt, proposed as a noninvasive peripheral marker of LV systolic function, is an independent predictor of death or transplantation in patients with HF regardless of LV ejection fraction.

Current understanding of heart failure with preserved ejection fraction

PURPOSE OF REVIEW

A substantial proportion of patients with heart failure have preserved ejection fraction. Though patients with preserved ejection fraction experience a substantial burden of morbidity and mortality, the understanding of heart failure pathophysiology in this group remains incomplete and evidence-based therapeutic options are limited.

RECENT FINDINGS

The prevalence of heart failure in patients with preserved ejection fraction is increasing and prognosis in this population remains poor despite modern medical therapy. Though diastolic dysfunction is typically present, increasing evidence suggests that extracardiac factors such as renal dysfunction and enhanced central aortic stiffness may play an important role in the development and progression of heart failure symptoms. Results of the first randomized, controlled clinical trials in this population suggest a possible therapeutic role for renin-angiotensin system blockade in reducing heart failure-associated morbidity, but there is still no evidence-supported strategy for reducing mortality in this population.

SUMMARY

Though the epidemiology and impact of heart failure with preserved ejection fraction are increasingly clear, consensus regarding pathophysiology and the optimal therapeutic approach is still lacking. Pending completion of additional therapeutic trials in this population, treatment remains largely empiric and focused on optimizing myocardial performance in diastole by control of blood pressure, restoration or maintenance of sinus rhythm, and relief of volume overload.

Evolving changes in lung interstitial fluid content after acute myocardial infarction: mechanisms and pathophysiological correlates

In acute myocardial infarction (AMI), alveolar interstitium edema is generally attributed to a hydrostatic imbalance. However, inflammatory burden and/or neural/hormonal/hemodynamic stimulation might injure the microvascular endothelium, eliciting interstitial overflow and altering alveolar-capillary gas diffusion. In 118 patients with AMI (ejection fraction >or=50% and wedge pulmonary pressure <16 mmHg), admission alveolar-capillary gas diffusing membrane conductance (DM) averaged 35.1 ml.min(-1).mmHg(-1) and was 27% lower than in 25 controls (P < 0.01). Infusion of saline in the pulmonary circulation (to test sodium exchange across the pulmonary capillary wall) lowered DM by 7.1% (P < 0.01) and was neutral in controls. At 1 wk, 83 patients that showed DM improvement >5% were assigned to group 1, and 28 patients with DM worsening >5% were assigned to group 2. Saline retained efficacy in group 2 and had no DM effect in group 1 (supporting a link between changes in baseline DM and those in microvascular salt exchange). Ventricular function was unchanged in group 1, whereas group 2 had developed diastolic dysfunction. At 1 yr, 3% of cases in group 1 and 37% of cases in group 2 had alveolar edema. Thus, AMI is frequently associated with abnormal pulmonary microvascular sodium transport/water conductance that, in the case of ventricular dysfunction supervenience, may persist and worsen the outcome. In 37 AMI similar patients and 11 control subjects, nitric oxide overexpression with l-arginine improved baseline DM and in AMI patients prevented DM reduction by saline, suggesting a mechanistic role of an impaired nitric oxide pathway in the microvascular barrier dysfunction.

DEFEAT heart failure: clinical manifestations, diagnostic assessment, and etiology of geriatric heart failure

Aging is characterized by heterogeneity, both in health and in disease. Older adults who have heart failure (HF) often have atypical and delayed clinical manifestations and many have diastolic HF. The assessment and management of HF in older adults may be simplified by a 5-step process called DEFEAT HF: (1) establish a clinical Diagnosis of HF; (2) establish an Etiology for HF, preferably in collaboration with a cardiologist; (3) determine Fluid status and achieve euvolemia; (4) determine left ventricular Ejection frAction; and (5) provide evidence-based Therapy.

Detection of myocardial dysfunction in the presence of normal ejection fraction

Detection of subclinical myocardial involvement is of utmost importance in risk stratification and prognosis; the role of ejection fraction in the detection of subclinical disease may be unhelpful. Our aim was to evaluate the methodology and importance of early detection of myocardial involvement in the presence of normal ejection fraction. Most of the pertinent English and non-English articles published from 1980 to 2006 in Medline, Scopus, and EBSCO Host research databases have been reviewed. Serial assessment of systolic function with different techniques should be avoided, since imaging modalities and ejection fraction measurements are not interchangeable. Additional non-invasive tools still are needed for the identification of subclinical left ventricular dysfunction in certain diseases. The recognition of subclinical involvement will prompt initiation of specific therapy to prevent the development of overt left ventricular dysfunction. This also is needed for determining the best timing for intervention in asymptomatic patients with metabolic and valvular disorders.

Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Echocardiography represents the "gold standard" in the assessment of LV systolic dysfunction and in the recognition of systolic heart failure, since dilatation of the LV results in alteration of intracardiac geometry and hemodynamics leading to increased morbidity and mortality. The functional mitral regurgitation is a consequence of adverse LV remodelling that occurs with a structurally normal valve and it is a marker of adverse prognosis. Diastolic dysfunction plays a major role in signs and symptoms of HF and in the risk stratification, and provides prognostic information independently in HF patients and impaired systolic function. Ultrasound lung comets are a simple echographic sign of extravascular lung water, more frequently associated with left ventricular diastolic and/or systolic dysfunction, which can integrate the clinical and pathophysiological information provided by conventional echocardiography and provide a useful information for prognostic stratification of HF patients. Contractile reserve is defined as the difference between values of an index of left ventricular contractility during peak stress and its baseline values and the presence of myocardial viability predicts a favorable outcome. A non-invasive echocardiographic method for the evaluation of force-frequency relationship has been proposed to assess the changes in contractility during stress echo. In conclusion, in HF patients, the evaluation of systolic, diastolic function and myocardial contractile reserve plays a fundamental role in the risk stratification. The highest risk is present in HF patients with a heart that is weak, big, noisy, stiff and wet.

Coexistence and exercise exacerbation of intraleft ventricular contractile dyssynchrony in hypertensive patients with diastolic heart failure

BACKGROUND

Patients with heart failure (HF) and a normal left ventricular ejection fraction usually present with diastolic dysfunction (DD). Whether intraleft ventricular contractile dyssynchrony (IVCD) coexists with DD and contributes to the clinical manifestations of HF remains unclear. The study investigated the IVCD at rest and after exercise in hypertensive patients with diastolic HF (DHF).

METHODS

Echocardiography was performed in 60 hypertensive patients with narrow QRS, left ventricular ejection fraction > or = 50%, and no active ischemia. Patients were grouped as having DD (mitral E/A < 1 plus E deceleration time > 200 milliseconds, or mitral annular early diastolic velocity < 8 cm/s; n = 26), DD plus HF symptoms/signs (DHF, n = 13), or as non-DD (n = 21).

RESULTS

At rest, the IVCD index (SD of 12 left ventricular segmental electromechanical delays) was greater in the DHF and DD groups than that in the non-DD group (52.2 +/- 10.7 and 39.1 +/- 23.6 vs 23.1 +/- 19.9 milliseconds; P < .05 for both comparisons). Six-minute treadmill exercise induced exacerbation of dyssynchrony in the DHF group (67.0 +/- 12.9 vs 52.2 +/- 10.7 milliseconds; P < .001). Multivariate analysis revealed that the combination of IVCD index > or = 35 milliseconds at rest and > or = 50 milliseconds after exercise was independently associated with DHF (odds ratio = 20, 95% CI = 2-199, P = .009). Postexercise IVCD index correlated positively with plasma N-terminal pro-brain natriuretic peptide (r = 0.37, P = .004).

CONCLUSIONS

Exercise would aggravate intraventricular dyssynchrony in hypertensive patients with DHF, implicating a potential contribution of systolic dyssynchrony to clinical manifestations.

Quantitative left ventricular systolic function: From chamber to myocardium

One of the most common indications for obtaining a Doppler echocardiographic study is to ascertain left ventricular (LV) systolic function. There are many ways in which LV function can be determined, but an important assumption that is often overlooked is that every measure that we commonly use is only a surrogate marker of LV function due to the fact that it is impossible to characterize the complex geometric and volumetric function of the ventricle (or myocyte) in a single number. Stated in another way, there is no one perfect measure of LV function. The ejection fraction has emerged as the preeminent method to express LV performance, but although ejection fraction is universally accepted, there are a number of other techniques that can assess LV function and, when taken together, provide a more comprehensive picture both of global and regional LV function. Each of these measures (including ejection fraction) has variable dependence on loading conditions, heart rate, and geometric position that limits its accuracy. Understanding the limitations of each measure will allow the physician to more intelligently understand the true status of the myocardium.

Echocardiography in Heart Failure

Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure (HF) population. The recently-released American College of Cardiology/American Heart Association guidelines for the diagnosis and management of HF labeled echocardiography "the single most useful diagnostic test in the evaluation of patients with HF...," because of its ability to accurately and noninvasively provide measures of ventricular function and assess causes of structural heart disease. It can also detect and define the hemodynamic and morphologic changes in HF over time and might be equivalent to invasive measures in guiding therapy. In this article we will discuss: 1) the clinical uses of echocardiography in HF and their prognostic value; 2) the use of echocardiography to guide treatment in HF patients; and 3) promising future techniques for echocardiographic-based imaging in HF. In addition, we will highlight some of the limitations of echocardiography.

Velocity Tracking–A Novel Method for Quantitative Analysis of Longitudinal Myocardial Function

Doppler tissue imaging is a method for quantitative analysis of longitudinal myocardial velocity. Commercially available ultrasound systems can only present velocity information using a color Doppler-based overlapping continuous color scale. The analysis is time-consuming and does not allow for simultaneous analysis in different projections. We have developed a new method, velocity tracking, using a stepwise color coding of the regional longitudinal myocardial velocity. The velocity data from 3 apical projections are presented as static and dynamic bull's-eye plots to give a 3-dimensional understanding of the function of the left ventricle. The static bull's-eye plot can display peak systolic velocity, late diastolic tissue velocity, or the sum of peak systolic velocity and early diastolic tissue velocity. Conversely, the dynamic bull's-eye plot displays how the myocardial velocities change over one heart cycle. Velocity tracking allows for a fast, simple, and intuitive visual analysis of the regional longitudinal contraction pattern of the left ventricle with a great potential to identify characteristic pathologic patterns.

New Insight Into Left Ventricular Reverse Remodeling After Biventricular Pacing Therapy for Heart Failure

Biventricular pacing has been consistently shown to improve symptoms and exercise capacity in patients with advanced heart failure and wide QRS complexes. Recent data have shown that biventricular pacing has the propensity to reduce left ventricular volume, a condition referred to as reverse remodeling. Since the authors initial description of successful left ventricular reverse remodeling after biventricular pacing therapy, data from multicenter trials have grown and consistently support the observation. In addition to the volumetric change, there was also progressive improvement of left ventricular systolic function and clinical status. The authors subsequent data also illustrated that the benefits on reverse remodeling and left ventricular systolic function were pacing dependent and disappeared gradually when pacing was withdrawn. With the use of tissue Doppler imaging, a substantial proportion of patients were found who had mechanical delay in the free wall. During biventricular pacing, all the segments were homogenously delayed resulting in a late, albeit synchronous, systolic contraction.

Diagnosis of diastolic heart failure

Nearly half of patients with heart failure (HF) have a normal ejection fraction (EF) and have been labeled as having diastolic HF. Diastolic HF is characterized by a normal EF, a variable amount of concentric left ventricular hypertrophy, and abnormal diastolic function. Differentiating diastolic HF from HF with a reduced EF (systolic HF) is important because these two forms of HF have different pathophysiology and thus might require different therapeutic approaches. Nevertheless, patients with diastolic HF and those with systolic HF have similar clinical symptoms and signs. Thus, clinical history and physical examination do not differentiate between diastolic and systolic HF. There is accumulating evidence that diastolic dysfunction is related to the severity of HF and prognosis regardless of EF. Thus, it is important to evaluate both systolic and diastolic function not only to differentiate between diastolic and systolic HF but also to identify high-risk patients.

Comparison of angiotensin-converting enzyme inhibitor alone and in combination with irbesartan for the treatment of heart failure

OBJECTIVE

Angiotensin-converting enzyme inhibitor (ACEI) is beneficial in patients with congestive heart failure (CHF). Some, but not all, angiotensin receptor blocker (ARB) was demonstrated to be effective as "add-on" therapy. We investigated whether irbesartan is useful as an add-on therapy in CHF.

DESIGN

Randomized control trial.

SETTING

Single center.

PATIENTS

50 CHF patients on stable doses of ACEI.

INTERVENTIONS

Add-on therapy with irbesartan (300 mg/day) or continuation of conventional therapy (control group) for 1 year.

MAIN OUTCOME MEASURES

Serial clinical and echocardiographic assessment were performed as baseline, 3 months and 1 year after therapy.

RESULTS

There was no difference in clinical characteristics between 2 groups. Patients in the add-on therapy group had significant increase in 6-Minute Hall-Walk distance (351+/-89 to 392+/-84 m, P<0.01), achieved higher METs exercise time on treadmill test (3.9+/-1.1 to 4.6+/-1.3 METs, P=0.01), reduction of NYHA Class (2.4+/-0.5 to 2.0+/-0.8, P<0.005) and improvement of QOL score (28+/-19 to 17+/-18, P<0.05). These parameters were not improved in the control group and a worsening of exercise capacity was observed (P<0.05). A reduction of left ventricular end-systolic diameter (4.94+/-0.85 vs 4.30+/-1.17 cm, P<0.05) was observed in the add-on group. At the end of 1 year, more patients have normal or abnormal relaxation pattern in the add-on group than the control group (82% vs 53% chi(2)=7.1, P=0.02). Blood pressure and renal function were unchanged in both groups.

CONCLUSION

The addition of irbesartan to conventional ACEI therapy in CHF further improves symptoms, exercise capacity and quality of life without adverse effects on hemodynamics and renal function.

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.

Usefulness of right ventricular tissue Doppler imaging to predict outcome in left ventricular heart failure independent of left ventricular diastolic function

It is unknown whether right ventricular (RV) tissue Doppler (TD) predicts outcome in patients with left ventricular (LV) heart failure (HF) independently of contemporary echocardiographic Doppler variables of LV diastolic function. Comprehensive echocardiographic Doppler examination was performed before discharge in 107 patients hospitalized with LV HF. The primary end point was cardiac death or rehospitalization for HF. Follow-up was complete for 100 of 107 patients a mean of 527 days after hospital discharge. There were no significant differences in baseline clinical variables (mean age 58+/-12 years, 46% women, 77% hypertensive, 48% diabetic, 41% current smokers, and 23% known coronary artery disease) in prediction of the primary end point. Compared with patients without an event, patients with an event had a larger left atrial volume index (42+/-16 vs 33+/-13 ml/m2, p=0.001), lower LV ejection fraction (35+/-19% vs 46+/-22%, p=0.01), higher mitral peak early diastolic flow velocity/TD early diastolic velocity (19+/-7 vs 14+/-7, p=0.001), lower RV fractional area change (39+/-11% vs 43+/-10%, p=0.04), and lower RV TD systolic velocity (8+/-2 vs 10+/-3 cm/s, p=0.005). On Cox proportional hazards multivariate analysis, left atrial volume index (p=0.01), mitral peak early diastolic flow velocity/TD early diastolic velocity (p=0.03), and RV TD systolic velocity (p=0.04) were independent predictors of outcome. Even when contemporary echocardiographic Doppler measures of LV diastolic function are considered, RV TD systolic velocity is an independent predictor of cardiac death or rehospitalization for HF in patients hospitalized with HF and appears to be superior to conventional 2-dimensional parameters of RV function.

Systolic and diastolic heart failure: Different phenotypes of the same disease?

Traditional pathophysiological concepts of chronic heart failure have largely focused on the haemodynamic consequences of ventricular systolic dysfunction. How these concepts relate to the pathophysiology of diastolic heart failure, i.e., heart failure with a preserved ejection fraction is, however, unclear, causing uncertainty about pathophysiology, diagnosis and management. Recent measurements of regional myocardial systolic function in patients with diastolic heart failure indicate that systolic and diastolic heart failure may be more closely related than previously anticipated. Rather than being considered as separate diseases with a distinct pathophysiology, systolic and diastolic heart failure may be merely different clinical presentations within a phenotypic spectrum of one and the same disease. In this review, we will interpret these new insights in a broader conceptual context of chronic heart failure and design novel paradigms in which systolic and diastolic heart failure jointly progress in a pathophysiological time trajectory of only one disease.

Clinical manifestations, diagnostic assessment, and etiology of heart failure in older adults

Aging is characterized by heterogeneity, both in health and in dis-ease. Older adults who have heart failure (HF) often have a typical and delayed clinical manifestations and many have diastolic HF. The assessment and management of HF in older adults may be simplified by a 5-step process called DEFEAT HF: (1) Establish a clinical Diagnosis of HF; (2) Establish an Etiology for HF, preferably in collaboration with a cardiologist; (3) Determine Fluid status and achieve euvolemia; (4) Determine left ventricular Ejection frAction; and (5) Provide evidence-based Therapy.

Diastolic heart failure and left ventricular diastolic dysfunction: What we know, and what we don't know!

Diastolic heart failure is a common form of congestive heart failure that is responsible for significant morbidity and mortality. In contrast to heart failure caused by systolic left ventricular dysfunction, diastolic heart failure is harder to diagnose and less likely to be accepted as a diagnosis. In addition, treatment strategies are much less defined than those for heart failure caused by systolic dysfunction.

Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure

Among the general heart failure (HF) population, over half have diastolic HF (DHF). The proportion of DHF increases with age, from 46% in patients younger than 45 years to 59% in patients older than 85 years. The diagnosis of DHF is made by the combination of signs and symptoms of HF with preserved systolic function (left ventricular ejection fraction >50%), and evidence of diastolic dysfunction obtained by echocardiographic Doppler examination, invasive hemodynamic evaluation, or an elevation of serum B-type natriuretic peptide. The most common risk factors for the development of diastolic dysfunction and DHF include long-standing hypertension, older age, female sex, obesity, diabetes, chronic kidney disease, and coronary artery disease. Acute decompensation occurs in the setting of pressure overload, volume overload, or superimposed cardiac ischemia. The cornerstones of in-hospital management include blood pressure and volume control, heart rate control, and correction of precipitating factors. Priorities in the outpatient clinic include optimal blood pressure control, maintenance of euvolemia with minimal or no diuretics, and, potentially, use of disease-modifying drugs including angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor blockers, beta-blockers, and digoxin. Long-term regression of left ventricular hypertrophy, improvement in diastolic filling parameters, and sustained reductions in B-type natriuretic peptide may be future treatment targets for this condition.

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.

Contribution of Systolic and Diastolic Abnormalities to Heart Failure With a Normal and a Reduced Ejection Fraction

Heart failure (HF) has traditionally been divided into HF with a reduced ejection fraction (EF; systolic HF) and HF with a normal EF (diastolic HF). Both groups have reductions in exercise tolerance, neurohumoral activation, and abnormal left ventricular (LV) filling dynamics and impaired relaxation. Although the normal EF indicates that pump performance is adequately compensated, some of the patients with HF and a normal EF have reduced longitudinal systolic velocity indicating cardiac muscular contractile dysfunction. Regardless of EF, the severity of HF and its prognosis and degree of exercise intolerance are closely related to the degree of diastolic filling abnormalities. Patients with HF and a reduced EF have ventricular dilatation and elongated myocytes, whereas patients with HF and a normal EF do not. Thus, patients with HF have diastolic abnormalities regardless of EF and many patients with HF and a normal EF have contractile abnormalities despite preserved systolic pump performance. Heart failure with a normal EF and a reduced EF differs in the systolic LV pump performance and the type of remodeling. The mechanism of the differing remodeling responses is not known, but aging, sex differences, and diabetes may contribute.

Role of Exercise and Metabolism in Heart Failure with Normal Ejection fraction

Left ventricular dysfunction associated with metabolic disorders has a number of features that might shed light on the integrity of heart failure with normal ejection fraction. First, although these patients may be dyspneic and have a normal ejection fraction, their diastolic dysfunction is not isolated. Both experimental models and sensitive new parameters in humans have shown abnormal systolic function, even though the less sensitive parameters (such as ejection fraction) become abnormal only with stress. Moreover, the mechanistic contributors to myocardial dysfunction, including structural changes and metabolic influences on the cardiac myocyte, interstitial fibrosis, vascular disease, and altered loading, are likely to influence systolic as much as diastolic function. The responses of systolic and diastolic heart failure to exercise training show analogies, particularly with respect to the importance of peripheral adaptation, as well as a similar training response. Together, these features are more supportive of a continuum of pathophysiology between systolic and diastolic heart failure, rather than the 2 representing discreet phenomena.

Diastolic and Systolic Asynchrony in Patients With Diastolic Heart Failure

OBJECTIVES

The present study aimed to examine whether diastolic and systolic asynchrony exist in diastolic heart failure (DHF) and their prevalence and relationship to systolic heart failure (SHF) patients.

BACKGROUND

Few data exist on mechanical asynchrony in DHF.

METHODS

Tissue Doppler echocardiography was performed in 373 heart failure patients (281 with SHF and 92 with DHF) and 100 normal subjects. Diastolic and systolic asynchrony was determined by measuring the standard deviation of time to peak myocardial systolic (Ts-SD) and peak early diastolic (Te-SD) velocity using a 6-basal, 6-mid-segmental model, respectively.

RESULTS

Both heart failure groups had prolonged Te-SD (DHF vs. SHF vs. controls subjects: 32.2 +/- 18.0 ms vs. 38.0 +/- 25.2 ms vs. 19.5 +/- 7.1 ms) and Ts-SD (31.8 +/- 17.0 ms vs. 36.7 +/- 15.2 ms vs. 17.6 +/- 7.9 ms) compared with the control group (all p < 0.001 vs. control subjects). Based on normal values, the DHF group had comparable diastolic (35.9% vs. 43.1%; chi-square = 1.48, p = NS), but less systolic asynchrony than the SHF group (39.1% vs. 56.9%; chi-square = 8.82, p = 0.003). Normal synchrony, isolated systolic, isolated diastolic, and combined asynchrony were observed in 39.1%, 25.0%, 21.7%, and 14.1% of DHF patients, respectively, and these were 25.6%, 31.3%, 17.4%, and 25.6%, correspondingly, in SHF (chi-square = 10.01, p = 0.019). The correlation between systolic and diastolic asynchrony, and between the myocardial velocities and corresponding mechanical asynchrony appeared weak. A wide QRS duration (>120 ms) was rare in DHF (10.9% vs. 37.7% in SHF) (chi-square = 16.69, p < 0.001).

CONCLUSIONS

Diastolic and/or systolic asynchrony was common in 61% of DHF patients despite narrow QRS complex. The presence of asynchrony was not related to myocardial systolic or diastolic function. Systolic and diastolic asynchrony were not tightly coupled, implying distinct mechanisms.

Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction

OBJECTIVES

The purpose of this study was to identify cardiovascular features of patients with heart failure with preserved ejection fraction (HFpEF) that differ from those in individuals with hypertensive left ventricular hypertrophy (HLVH) of similar age, gender, and racial background but without failure.

BACKGROUND

Heart failure with preserved ejection fraction often develops in HLVH patients and involves multiple abnormalities. Clarification of changes most specific to HFpEF may help elucidate underlying pathophysiology.

METHODS

A cross-sectional study comparing HFpEF patients (n = 37), HLVH subjects without HF (n = 40), and normotensive control subjects without LVH (n = 56). All subjects had an EF of >50%, sinus rhythm, and insignificant valvular or active ischemic disease, and groups were matched for age, gender, and ethnicity. Comprehensive echo-Doppler and pressure analysis was performed.

RESULTS

The HFpEF patients were predominantly African-American women with hypertension, LVH, and obesity. They had vascular and systolic-ventricular stiffening and abnormal diastolic function compared with the control subjects. However, most of these parameters either individually or combined were similarly abnormal in the HLVH group and poorly distinguished between these groups. The HFpEF group had quantitatively greater concentric LVH and estimated mean pulmonary artery wedge pressure (20 mm Hg vs. 16 mm Hg) and shorter isovolumic relaxation time than the HLVH group. They also had left atrial dilation/dysfunction unlike in HLVH and greater total epicardial volume. The product of LV mass index and maximal left atrial (LA) volume best identified HFpEF patients (84% sensitivity, 82% specificity).

CONCLUSIONS

In an urban, principally African American, cohort, HFpEF patients share many abnormalities of systolic, diastolic, and vascular function with nonfailing HLVH subjects but display accentuated LVH and LA dilation/failure. These latter factors may help clarify pathophysiology and define an important HFpEF population for clinical trials.

Increased prevalence of concentric left ventricular hypertrophy in African-Americans: will an epidemic of heart failure follow?

Left ventricular hypertrophy (LVH), used in this review to denote abnormally increased left ventricular (LV) mass, is an important cardiac trait because of its association with numerous adverse cardiovascular outcomes including myocardial infarction and heart failure. LV mass is typically assessed by noninvasive cardiac imaging (echocardiography or MRI); electrocardiography is an insensitive measure. There are two predominant types of hypertrophy: concentric, where LV wall thickness is increased relative to cavity dimensions, and eccentric, where LV wall thickness is not increased relative to cavity dimensions. Several large studies indicate that the prevalence of concentric LVH is higher in African-Americans versus whites. Although there are data to suggest that concentric LVH results in systolic heart failure in animal models, such data are lacking in humans. How concentric LVH affects the prevalence of systolic and diastolic heart failure in African-Americans needs further study. Given the large burden of LVH among African-Americans, such data are needed to estimate the expected burden and type of heart failure which will occur in the future in this population.

Outcomes in ambulatory chronic systolic and diastolic heart failure: a propensity score analysis

BACKGROUND

Prior studies demonstrating significant difference in outcomes in systolic and diastolic heart failure (HF) are often limited to hospitalized acute HF patients, and may be confounded by residual bias. In this analysis, we examined long-term mortality and hospitalization in a propensity score matched cohort of ambulatory chronic systolic and diastolic HF patients.

METHODS

Of the 7788 patients in the Digitalis Investigation Group trial, 6800 had systolic HF (ejection fraction >45%) and 988 had diastolic HF (ejection fraction >45%). We restricted our analysis to 7617 patients without valvular heart disease: 916 diastolic HF and 6701 systolic HF. Propensity scores for diastolic HF, calculated for each patient by a non-parsimonious multivariable logistic regression model, were used to match 697 diastolic HF with 2091 systolic HF patients. Matched Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for outcomes in diastolic (versus systolic) HF.

RESULTS

During a median 38-month follow-up, compared with 32% mortality in systolic HF, 23% of diastolic HF patients died (HR=0.70; 95% CI=0.59-0.84; P<.0001). Respective HR (95%CI) for cardiovascular and HF mortality were 0.60 (0.48-0.74; P<.0001) and 0.56 (0.39-0.79; P=.001). All-cause hospitalizations occurred in 64% of systolic and 67% of diastolic HF patients (HR=0.99; 95% CI=0.87-1.11; P=0.801). Respective HR (95%CI) for cardiovascular and HF hospitalizations were 0.84 (0.73-0.96; P=.011) and 0.63 (0.51-0.77; P<.0001).

CONCLUSIONS

Despite lower mortality and cardiovascular morbidity, diastolic HF patients had similar overall hospitalizations as in systolic HF. Ejection fraction should be assessed in all HF patients to guide therapy, with special attention to non-cardiovascular morbidity in diastolic HF.

Mechanisms of Diastolic Dysfunction in Heart Failure

Abnormalities of diastole are common to most forms of congestive heart failure (HF). Diastolic function is broadly defined as the ability of the heart to fill adequately and at normal pressure to charge the ventricular pump for each subsequent contraction. It is determined by both active and passive processes occurring at the level of the myocyte, extracellular matrix, and left ventricular chamber. Forces extrinsic to the myocardium-such as the influence of right heart filling, pericardial and extracardiac constraints, and cardiac preload and afterload also contribute. Nearly half of patients with HF have apparently preserved systolic function, and this has focused attention on diastolic dysfunction as a dominant contributor to symptoms, sparking interest for understanding and treating diastolic abnormalities. This review focuses on the mechanisms determining normal and pathologic cardiac relaxation and distensibility and highlights how these abnormalities may be therapeutically targeted to improve diastolic function in human HF.

Prolonged mechanical systole and increased arterial wave reflections in diastolic dysfunction

OBJECTIVE

To evaluate whether left ventricular ejection time indexed for heart rate (left ventricular ejection time index (LVETI)) and arterial wave reflections (augmented pressure (AP)) are increased in patients with diastolic dysfunction (DD).

DESIGN

Prospective observational study.

SETTING

University teaching hospital providing primary and tertiary care.

SUBJECTS

235 consecutive patients undergoing left heart catheterisation were categorised as having definite DD, possible DD or no DD (controls) on the basis of their left ventricular end diastolic pressures and N-terminal brain natriuretic peptide concentrations.

MAIN OUTCOME MEASURES

LVETI and AP were prospectively assessed non-invasively by radial applanation tonometry. In addition, all patients underwent comprehensive echocardiography, including tissue Doppler imaging of mitral annulus velocity in early diastole (E').

RESULTS

LVETI was longer in patients with definite DD than in patients with possible DD and in controls (433.6 (SD 17.2), 425.9 (17.9) and 414.3 (13.6) ms, respectively, p < 0.000001). Arterial wave reflections were higher in definite DD than in possible DD and control groups (AP was 19.4 (SD 8.9), 15.2 (8.0) and 10.7 (6.8) mm Hg, respectively, p < 0.000001). In receiver operating characteristic curve analysis, LVETI detected DD as well as echocardiography (E:E'). Area under the curve for LVETI to differentiate patients with definite DD from normal controls was 0.81 (95% CI 0.72 to 0.89, p < 0.0001). In multivariable logistic regression analysis, LVETI added significant independent power to clinical and echocardiographic variables for prediction of DD.

CONCLUSIONS

Mechanical systole is prolonged and arterial wave reflections are increased in most patients with DD. Rapid non-invasive assessment of these parameters may aid in confirming or excluding DD.

Systolic Dysfunction in Heart Failure with Normal Ejection Fraction: Speckle-Tracking Echocardiography

Left ventricular (LV) ejection fraction (EF) and LV end-systolic volumes are important measures of LV global function. However, in many patients with symptoms of heart failure, these measures are within normal limits. This condition is classified as heart failure with normal ejection fraction (HFNEF). Reduced EF and increased end-systolic volume, however, require impaired function in a number of LV segments. Therefore, apparently normal systolic function in HFNEF may reflect limited sensitivity of global EF, and assessment of regional systolic function may provide important diagnostic information. The recently introduced method, speckle-tracking echocardiography (STE), represents a simplified, objective, and angle-independent modality for quantification of regional myocardial deformation. The software uses conventional gray-scale B-mode recordings and tracks myocardial speckles, which serve as natural acoustic markers. Radial and longitudinal myocardial deformation can be measured simultaneously from long-axis recordings, radial and circumferential deformation from short-axis recordings, and LV torsion from assessment of apical and basal short-axis rotation. Experimental and clinical studies have demonstrated that the STE method can assess myocardial function accurately in healthy subjects in the settings of acute and chronic ischemia, dyssynchrony, and cardiomyopathy. So far, no STE studies have been performed regarding HFNEF. The purpose of this article is therefore to illustrate the potential of this novel method.

Systolic Dysfunction in Heart Failure with a Normal Ejection Fraction: Echo-Doppler Measurements

Heart failure with a normal ejection fraction, also called heart failure with preserved ejection fraction or diastolic heart failure, is thought to be characterized by normal systolic function and disturbed diastolic function only. However, studies using newer Doppler-echocardiographic techniques have shown that ventricular function is not normal particularly in the long axis. Ejection is relatively preserved because of increased radial function. Similar findings are seen with normal ageing and the typical precursors of heart failure with a normal ejection fraction such as hypertension, diabetes, and ischemia. There appears to be a spectrum of abnormalities of systolic function from the truly normal to systolic heart failure with heart failure with a normal ejection fraction occupying an intermediate position. The use of ejection fraction, which has a normal distribution, to dichotomize patients with heart failure is not supported on theoretical or experimental grounds, and any cutoff is arbitrary. Patients with heart failure have a mixture of systolic and diastolic abnormalities and variable degrees of remodeling. It is more important to correctly identify these in the individual patient.

Are left ventricular diastolic function and diastolic asynchrony important determinants of response to cardiac resynchronization therapy?

Cardiac resynchronization therapy (CRT) has been shown to reduce symptoms and reverse left ventricular (LV) remodeling. It is not known, however, whether diastolic function will improve after CRT and diastolic asynchrony will predict LV reverse remodeling. Seventy-six patients (mean age 65 +/- 12 years, 74% men) who received CRT were studied at baseline and after 3 months. Diastolic function was assessed by transmitral Doppler and tissue Doppler imaging. LV systolic and diastolic asynchrony were assessed by the time to peak myocardial contraction (Ts) and early diastolic relaxation (Te) using the 6 basal, 6 mid-segmental model. There were 42 responders (55%) with LV reverse remodeling (defined as a reduction of LV end-systolic volume >or=15%). Parameters of systolic function were significantly improved only in the responders. For diastolic function, there were reductions of transmitral E velocity in the 2 groups, without any change in atrial velocity or the E/A ratio. Tissue Doppler imaging revealed that myocardial early diastolic velocity was unchanged in responders but was significantly worsened in nonresponders. The systolic asynchrony index (the SD of Ts of 12 LV segments) correlated significantly with LV reverse remodeling (r = -0.64, p <0.001) but not the diastolic asynchrony index (the SD of Te of 12 LV segments) (r = -0.10, p = NS). The systolic asynchrony index was the only independent predictor of reverse remodeling (beta = -0.99, 95% confidence interval -1.41 to -0.58, p <0.001). In conclusion, CRT improves systolic function and systolic asynchrony but has a neutral effect on diastolic function and diastolic asynchrony. LV reverse remodeling response is determined by the severity of prepacing systolic asynchrony but not diastolic asynchrony or the diastolic filling pattern.

Evolution and prognostic significance of diastolic filling pattern in cardiac resynchronization therapy

BACKGROUND

Cardiac resynchronization therapy (CRT) is an emerging treatment for heart failure patients with left bundle branch block; in these patients left ventricle filling pattern (LVFP) abnormalities are recognized as cause of symptoms and predictors of outcome. We investigated the effects of CRT on diastolic function and the prognostic value of LVFP in patients on CRT.

METHODS

65 patients treated with CRT were studied over a 12 months period. At baseline, according to defined echocardiographic criteria, restrictive LVFP (RFP) was present in 25 patients, whereas 40 patients showed no-RFP.

RESULTS

After CRT, opposite changes occurred in the two groups. In no-RFP patients, early-to-atrial filling velocity ratio (E/A) increased from 0.8+/-0.3 to 1.0+/-0.6 (p=0.006) and E wave deceleration time (DT) decreased from 234+/-83 ms to 196+/-51 ms (p=0.028). In 13 RFP patients, E/A decreased from 2.2+/-0.9 to 0.8+/-0.5 and DT increased from 128+/-43 ms to 205+/-52 ms (both p<0.001), leading to reversal of RFP. In both groups, clinical, functional and echographic benefits were evident, with mortality rates of 5% (2/40) and 15% (2/13) respectively. The remaining patients showed persistence of RFP (E/A and DT unchanged), no improvement and a mortality rate of 42% (5/12) (p=0.005, versus no-RFP).

CONCLUSIONS

CRT improves diastolic function, inducing also reversal of LVFP in a consistent number of RFP patients. The persistence of RFP after CRT is associated to an extremely poor prognosis.

Diastolic dysfunction and diastolic heart failure: mechanisms and epidemiology

Studies have demonstrated that diastolic dysfunction is frequently present in asymptomatic community-based individuals, especially in the elderly with hypertension, coronary artery disease, and diabetes. The presence of diastolic dysfunction is a predictor for the development of heart failure (HF) and confers a higher risk of mortality. These findings have raised the question of whether treating preclinical diastolic dysfunction will be helpful in preventing or delaying the onset of clinical HF and mortality, as has been proven with treatment of asymptomatic left ventricular systolic dysfunction. In addition, in some individuals, diastolic dysfunction in the presence of a normal ejection fraction is associated with exercise intolerance as well as symptomatic clinical HF, referred to as diastolic HF. Patients with diastolic HF, who are more often elderly women, have a significant mortality and morbidity burden compared with age-matched controls. Studies that further our understanding of mechanisms underlying diastolic dysfunction and diastolic HF will provide potential new targets for development of effective therapies for these conditions.

A clinical algorithm to differentiate heart failure with a normal ejection fraction by pathophysiologic mechanism

The incidence and prevalence of heart failure are increasing as the population ages. Epidemiologic studies demonstrate that more than half of heart failure patients have a normal ejection fraction. The pathophysiology of this disorder is not completely understood. It is primarily attributed to left ventricular diastolic dysfunction (a leftward- and upward-shifted end-diastolic pressure-volume relation), where left ventricular diastolic chamber size is normal or reduced despite greater-than-normal filling pressures, resulting in reduced stroke volume and cardiac output. Using classic measures derived from pressure-volume analysis, we delineate other possible combinations of the end-systolic and end-diastolic pressure-volume relation, and hence possible pathophysiologic mechanisms that could underlie the syndrome of heart failure with normal ejection fraction. We propose an algorithm for identifying the primary pathophysiologic mechanism of heart failure in the setting of a normal ejection fraction using three simple factors: blood pressure, electrocardiographic/echocardiographic evidence of left ventricular hypertrophy, and left ventricular size. The application of this algorithm may aid in guiding management and targeting much-needed therapies for this population.

Systo-diastolic ventricular function in patients with hypertension: an echocardiographic tissue doppler imaging evaluation study

BACKGROUND

Tissue Doppler imaging (TDI) has evolved to become a useful non invasive method that can complement other echocardiographic techniques in the assessment of left ventricular function in different clinical conditions. Spectral pulsed TDI can provide measurements of regional systolic and diastolic myocardial velocities and is particularly useful in detecting abnormalities of left ventricular systolic and diastolic function. We investigated the presence of systo-diastolic dysfunction in patients (pts) with hypertension compared with pts affected by hypertensive cardiomyopathy and normal control subjects.

METHODS

We evaluated 214 pts with traditional echocardiography and TDI: 69 normal control subjects (Group A); 145 pts with hypertension, divided according to base echocardiographic evaluation in 74 with no evidence of hypertensive cardiomyopathy (diastolic dysfunction and ventricular hypertrophy, Group B), and 71 with evidence of hypertensive cardiomyopathy (Group C). Pts groups were matched for age, sex, heart rate, smoking status and body surface area.

RESULTS

There were no significant differences in ventricular diameters, volumes, shortening and ejection fraction values; TDI showed a progressive systolic wave peak reduction from Group A to B and from Group B to C. Routinely Doppler diastolic function did not show any significant difference between Group A and B; TDI showed progressive E wave peak velocity decrease and A wave peak velocity increase from Group A to B and C and from Group B to C.

CONCLUSIONS

TDI evaluation showed a ventricular systolic dysfunction in pts with hypertensive cardiomyopathy; in addition, an early mild systo-diastolic dysfunction was detected in subjects with hypertension but no evidence of hypertensive cardiomyopathy.

Elevated Plasma Brain Natriuretic Peptide Level in Cardiac Sarcoidosis Patients with Preserved Ejection Fraction

We sought to examine whether the plasma brain natriuretic peptide (BNP) levels are elevated in the cardiac sarcoidosis patients even with a preserved ejection fraction. The data from the patients with either pulmonary sarcoidosis without any evidence of cardiac involvement (n = 13) or cardiac sarcoidosis (n = 8) with a preserved ejection fraction (>55%) on echocardiography were analyzed. The median plasma BNP levels were significantly higher in the patients with cardiac sarcoidosis than in those with pulmonary sarcoidosis (101.5 +/- 65.1 vs. 15.6 +/- 10.5 pg/ml, p < 0.001), although there was no significant difference in left ventricular ejection fraction between the two populations. The plasma BNP level is thus considered to be a useful non-invasive biomarker for identifying a possible cardiac involvement in the sarcoidosis patients with a preserved ejection fraction.

"Isolated" diastolic dysfunction in left ventricular outflow tract obstruction

We sought to investigate the prescence of "isolated" diastolic disease, defined as reduced long-axis early diastolic velocity with normal systolic velocity, in 21 young patients with left outflow tract obstruction. Most patients had depressed systolic velocities despite normal ejection fractions. The close relations amond long-axis velocities suggest isolated diastolic disease is unlikely.

The impact of hypertension on systolic and diastolic left ventricular function. A tissue Doppler echocardiographic study

BACKGROUND

The purpose of this study is to assess the impact of hypertension on systolic function and diastolic function using 2-dimensional echocardiography, conventional Doppler imaging of the transmitral inflow, and tissue Doppler imaging (TDI) of the mitral annulus.

METHODS

From an outpatient clinic population, 414 consecutive patients underwent 2-dimensional echocardiography, conventional Doppler imaging of the transmitral inflow, and TDI of the septal, lateral, inferior, and posterior walls near the mitral annulus. Parameters of systolic left ventricular (LV) function and diastolic LV function were assessed. Patients were divided according to the presence or absence of systemic hypertension (blood pressure > or = 140/90 mm Hg on > or = 3 measurements or treatment with antihypertensive medication).

RESULTS

A complete echocardiographic evaluation was obtained in 397 patients. Among these, 269 (68%) had hypertension. There was no difference with respect to age between patients with and without hypertension. Patients with hypertension had higher LV mass index and relative wall thickness and lower TDI peak systolic velocity (V(S)) when compared with patients without hypertension. In addition, indices of diastolic LV function were significantly impaired in hypertensive patients.

CONCLUSIONS

Quantitative echocardiography using TDI reveals that hypertensive patients with preserved global LV systolic function often have combined impairment of systolic function and diastolic function.

Diastolic heart failure: a myth

PURPOSE OF REVIEW

Until recently, patients with heart failure and preserved ejection fraction (HFprEF) have been excluded from nearly all large clinical trials in heart failure. Based on the conjecture that this clinical picture of heart failure, also known as diastolic heart failure, may be different from other forms of heart failure, several recent and ongoing clinical trials have targeted more specifically this patient population. The present review critically re-evaluates the pathophysiological rationale for such trials.

RECENT FINDINGS

Novel techniques to evaluate cardiac performance have revealed that HFprEF is a consequence of significant systolic dysfunction of the ventricular muscular pump in the presence of a preserved performance of the ventricular hemodynamic pump. Diastolic and systolic heart failure are the mere extremes of a spectrum of different phenotypes of one and the same disease. Ongoing research explores the various disease modifiers, or protective pathways, that delay the progression of remodeling in patients with HFprEF. Although, currently, therapy to improve the prognosis of HFprEF is essentially the same as for other forms of heart failure, the latter ongoing studies may help, in addition, in developing novel and more patient-specific therapeutic strategies in these patients.

SUMMARY

HFprEF constitutes a heterogenous group of different phenotypes within one continuous spectrum reflecting heart failure as one disease entity. No pathophysiological basis currently warrants setting up empirical clinical trials based on an arbitrary subdivision of patients with heart failure.