Diastolic heart failure: a myth

Estimation of the Risk of Postoperative Hypertension Following Minor to Moderate Surgery Using an Echocardiogram and Biomarkers

This study aimed to determine independent factors for developing postoperative hypertension using 4 biomarkers in patients receiving oral and maxillofacial surgery under general anesthesia. Brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity myocardial troponin T (hs-TnT), and high-sensitivity myocardial troponin I (hs-TnI) were measured and preoperative echocardiograms were examined. Episodes of systolic blood pressure (SBP) ≥ 170 mmHg or diastolic blood pressure ≥ 100 mmHg within 1 week after surgery were considered postoperative hypertension. We analyzed 213 (130 men; 83 women) patients, who were divided into a postoperative hypertension group (HT group, n = 32) and a normal group (N group, n = 181). The HT group showed a higher LVMI (113.5 versus 100.1), higher E/e' of the lateral wall (9.1 versus 7.7), and higher BNP (39.2 versus 22.9 pg/mL), NT-proBNP (400.1 versus 143.9 pg/mL), and hs-TnT (15.6 versus 10.3 ng/L) concentrations compared to the N group. NT-proBNP and hs-TnT concentrations positively associated with E/e', but BNP and hs-TnI did not. NT-proBNP (AUC = 0.64, cutoff value: 117.0 pg/mL) and hs-TnT (AUC = 0.61, cutoff value: 11.0 ng/L) concentrations were effective for discriminating E/e' ≥ 12. Multivariate logistic regression analyses showed that risk factors responsible for developing postoperative hypertension were NT-proBNP and hs-TnT using biomarkers and E/e' as independent variables, and NT-proBNP and SBP at admission using biomarkers and SBP at admission as independent variables. These findings suggest that NT-proBNP and hs-TnT concentrations, and SBP at admission, are useful to predict postoperative hypertension after minor to moderate surgery, and that left ventricular filling pressure is a primary factor associated with postoperative hypertension.

Clinical phenogroups are more effective than left ventricular ejection fraction categories in stratifying heart failure outcomes

Aims

Heart failure (HF) guidelines place patients into 3 discrete groups according to left ventricular ejection fraction (LVEF): reduced (<40%), mid‐range (40–49%), and preserved LVEF (≥50%). We assessed whether clinical phenogroups offer better prognostication than LVEF.

Methods and results

This was a sub‐study of the Patient‐Centered Care Transitions in HF trial. We analysed baseline characteristics of hospitalized patients in whom LVEF was recorded. We used unsupervised machine learning to identify clinical phenogroups and, thereafter, determined associations between phenogroups and outcomes. Primary outcome was the composite of all‐cause death or rehospitalization at 6 and 12 months. Secondary outcome was the composite cardiovascular death or HF rehospitalization at 6 and 12 months. Cluster analysis of 1693 patients revealed six discrete phenogroups, each characterized by a predominant comorbidity: coronary heart disease, valvular heart disease, atrial fibrillation (AF), sleep apnoea, chronic obstructive pulmonary disease (COPD), or few comorbidities. Phenogroups were LVEF independent, with each phenogroup encompassing a wide range of LVEFs. For the primary composite outcome at 6 months, the hazard ratios (HRs) for phenogroups ranged from 1.25 [95% confidence interval (CI) 1.00–1.58 for AF] to 2.04 (95% CI 1.62–2.57 for COPD) (log‐rank P < 0.001); and at 12 months, the HRs for phenogroups ranged from 1.15 (95% CI 0.94–1.41 for AF) to 1.87 (95% 1.52–3.20 for COPD) (P < 0.002). LVEF‐based classifications did not separate patients into different risk categories for the primary outcomes at 6 months (P = 0.69) and 12 months (P = 0.30). Phenogroups also stratified risk of the secondary composite outcome at 6 and 12 months more effectively than LVEF.

Conclusion

Among patients hospitalized for HF, clinical phenotypes generated by unsupervised machine learning provided greater prognostic information for a composite of clinical endpoints at 6 and 12 months compared with LVEF‐based categories.

Trial Registration: ClinicalTrials.gov Identifier: NCT02112227

The Role of Arterial Stiffness and Central Hemodynamics in Heart Failure

Whereas traditional understanding of left ventricular afterload was focused on a steady-state circulation model with continuous pressures and flow, a more realistic concept is emerging, taking the pulsatile nature of the heart and the arterial system into account. The most simple measure of pulsatility is brachial pulse pressure, representing the pulsatility fluctuating around the mean blood pressure level. Brachial pulse pressure is widely available, fundamentally associated with the development and treatment of heart failure (HF), but its analysis is often confounded in patients with established HF. The next step of analysis consists of arterial stiffness, central (rather than brachial) pressures, and of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodeling, diastolic dysfunction, exercise capacity, and, in the long term, the risk of new-onset HF. Wave reflection may also evolve as a suitable therapeutic target for HF with preserved and reduced ejection fraction. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals. This review provides a summary of current understanding of pulsatile hemodynamics in HF.

Pulsatile arterial haemodynamics in heart failure

Due to the cyclic function of the human heart, pressure and flow in the circulation are pulsatile rather than continuous. Addressing pulsatile haemodynamics starts with the most convenient measurement, brachial pulse pressure, which is widely available, related to development and treatment of heart failure (HF), but often confounded in patients with established HF. The next level of analysis consists of central (rather than brachial) pressures and, more importantly, of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodelling, diastolic dysfunction, exercise capacity, and, in the long-term, the risk of new-onset HF. Wave reflection may also represent a suitable therapeutic target. Treatments for HF with preserved and reduced ejection fraction, based on a reduction of wave reflection, are emerging. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals, which can be readily accomplished with contemporary non-invasive imaging and modelling techniques. This review provides a summary of our current understanding of pulsatile haemodynamics in HF.

Predictive Factors of Postoperative Blood Pressure Abnormalities Following a Minor-to-Moderate Surgery

Myocardial ischemic events after non-cardiac surgery is still a serious problem, especially in older, high-risk patients. However, the prevalence and risk factors of blood pressure (BP) abnormalities, which may possibly lead to myocardial ischemic attack, have not been reported. Our aim is to elucidate predictive factors of postoperative BP abnormalities following a minor-to-moderate surgery, employing preoperative left ventricular diastolic function. Patients who underwent cardiac echocardiogram examination and received oral and maxillofacial surgery under general anesthesia were enrolled. The echocardiographic parameters of diastolic function were compared between patients who had postoperative BP abnormalities (hypertension-systolic blood pressure [SBP] ≥ 170 mmHg-or hypotension-SBP < 80 mmHg-episode) that required therapeutic interventions until 7 days after surgery and those who had no BP abnormalities. Of the 173 patients analyzed, 25 (14.4%) had BP abnormalities. BP abnormalities patients were older, having a larger proportion of diabetes mellitus, lower E/A ratio and e', and larger E/e' and left atrial dimension than those without BP abnormalities. Subanalyses revealed that the independent risk factors responsible for hypertension episodes (14 patients) were the mean e' (odd ratio [OR]: 0.434; 95% confidence interval [CI]: 0.229-0.824), diabetes mellitus (OR: 5.018; 95% CI: 1.030-24.436), SBP at hospitalization (OR: 1.099; 95% CI: 1.036-1.165), and operation time (hour; OR: 1.326; 95%CI: 1.109-1.586), while hypotension episodes (11 patients) were associated solely with operation time (OR: 1.206; 95% CI: 1.046-1.391). In conclusion, left ventricular diastolic dysfunction, increased insulin resistance, boosted SBP at hospitalization, and prolonged operation should be taken into consideration as risk factors of postoperative BP abnormalities, especially hypertension, following minor-to-moderate surgery.

Revisiting the physiological effects of exercise training on autonomic regulation and chemoreflex control in heart failure: does ejection fraction matter?

Heart failure (HF) is a global public health problem that, independent of its etiology [reduced (HFrEF) or preserved ejection fraction (HFpEF)], is characterized by functional impairments of cardiac function, chemoreflex hypersensitivity, baroreflex sensitivity (BRS) impairment, and abnormal autonomic regulation, all of which contribute to increased morbidity and mortality. Exercise training (ExT) has been identified as a nonpharmacological therapy capable of restoring normal autonomic function and improving survival in patients with HFrEF. Improvements in autonomic function after ExT are correlated with restoration of normal peripheral chemoreflex sensitivity and BRS in HFrEF. To date, few studies have addressed the effects of ExT on chemoreflex control, BRS, and cardiac autonomic control in HFpEF; however, there are some studies that have suggested that ExT has a beneficial effect on cardiac autonomic control. The beneficial effects of ExT on cardiac function and autonomic control in HF may have important implications for functional capacity in addition to their obvious importance to survival. Recent studies have suggested that the peripheral chemoreflex may also play an important role in attenuating exercise intolerance in HFrEF patients. The role of the central/peripheral chemoreflex, if any, in mediating exercise intolerance in HFpEF has not been investigated. The present review focuses on recent studies that address primary pathophysiological mechanisms of HF (HFrEF and HFpEF) and the potential avenues by which ExT exerts its beneficial effects.

Who are patients classified within the new terminology of heart failure from the 2016 ESC guidelines?

Aims

The main terminology used to describe heart failure (HF) is based on measurement of the left ventricular ejection fraction (LVEF). LVEF in the range of 40–49% was recently defined as HF with mid‐range EF (HFmrEF) by the 2016 European Society of Cardiology guidelines. The purpose of our study was to assess the clinical profile and prognosis of patients with HF according to this new classification.

Methods and results

A total of 482 patients referred for HF were retrospectively included over a period of 1 year. There were 258 (53%), 115 (24%), and 109 (23%) patients with HF with reduced EF (HFrEF), HFmrEF, and HF with preserved EF (HFpEF), respectively. Patient age increased, whereas left block bundle branch, brain natriuretic peptide level, and the use of beta‐blocker and furosemide decreased from HFrEF to HFpEF. After adjustment for the age, patients with HFpEF and HFmrEF were more likely to have NYHA stage 2 dyspnea, had a higher systolic blood pressure, were less likely to have spironolactone, had lower furosemide dose, and had lower haemoglobin than those with HFrEF. Cardiovascular risk factors and medical history were similar in the three groups of patients. There was a 33% death rate after a mean follow‐up of 32.2 ± 14.3 months. The survival was the same among patients whatever the group of HF (P = 0.884).

Conclusions

Patients with HFrEF, HFmrEF, and HFpEF share the same cardiovascular risk factors, medical history, and prognosis. Patients with HFmrEF have a different clinical profile, which is nearly the same as patients with HFpEF, except for sex. These results question the relevance of this new classification of HF to stimulate research into this new group of patients.

Total average diastolic longitudinal displacement by colour tissue doppler imaging as an assessment of diastolic function

Background

The current method for a non-invasive assessment of diastolic dysfunction is complex with the use of algorithms of many different echocardiographic parameters. Total average diastolic longitudinal displacement (LD), determined by colour tissue Doppler imaging (TDI) via the measurement of LD during early diastole and atrial contraction, can potentially be used as a simple and reliable alternative.

Methods

In 206 patients, using GE Healthcare Vivid E7 and 9 and Echopac BT11 software, we determined both diastolic LD, measured in the septal and lateral walls in the apical 4-chamber view by TDI, and the degree of diastolic dysfunction, based on current guidelines. Of these 206 patients, 157 had cardiac anomalies that could potentially affect diastolic LD such as severe systolic heart failure (n = 45), LV hypertrophy (n = 49), left ventricular (LV) dilation (n = 30), and mitral regurgitation (n = 33). Intra and interobserver variability of diastolic LD measures was tested in 125 patients.

Results

A linear relationship between total average diastolic LD and the degree of diastolic dysfunction was found. A total average diastolic LD of 10 mm was found to be a consistent threshold for the general discrimination of patients with or without diastolic dysfunction. Using linear regression, total average diastolic LD was estimated to fall by 2.4 mm for every increase in graded severity of diastolic dysfunction (β = −0.61, p-value <0.001). Patients with LV hypertrophy had preserved total average diastolic LD despite being classified as having diastolic dysfunction. Reproducibility of LD measures was acceptable.

Conclusions

There is strong evidence suggesting that patients with a total average diastolic LD under 10 mm have diastolic dysfunction.

Electronic supplementary material

The online version of this article (doi:10.1186/s12947-016-0083-2) contains supplementary material, which is available to authorized users.

Genetics of systolic and diastolic heart failure

Heart failure accounts for a significant portion of heart diseases. Molecular mechanisms gradually emerge that participate in pathways leading to left ventricular dysfunction in common systolic heart failure (SHF) and diastolic heart failure (DHF). A human genome-wide association study (GWAS) identified two markers for SHF and no GWAS on DHF has been documented. However, genetic analyses in rat models of SHF and DHF have begun to unravel the genetic components known as quantitative trait loci (QTLs) initiating systolic and diastolic function. A QTL for systolic function was detected and the gene responsible for it is identified to be that encoding the soluble epoxide hydrolase. Diastolic function is determined by multiple QTLs and the Ccl2/monocyte chemotactic protein gene is the strongest candidate. An amelioration on diastolic dysfunction is merely transient from changing such a single QTL accompanied by a blood pressure reduction. A long-term protection can be achieved only via combining alleles of several QTLs. Thus, distinct genes in synergy are involved in physiological mechanisms durably ameliorating or reversing diastolic dysfunction. These data lay the foundation for identifying causal genes responsible for individual diastolic function QTLs and the essential combination of them to attain a permanent protection against diastolic dysfunction, and consequently will facilitate the elucidation of pathophysiological mechanisms underlying hypertensive diastolic dysfunction. Novel pathways triggering systolic and diastolic dysfunction have emerged that will likely provide new diagnostic tools, innovative therapeutic targets and strategies in reducing, curing and even reversing SHF and DHF.

Genetics of diastolic heart failure

Heart failure explains a large portion of heart diseases. Molecular mechanisms determining cardiac function, by inference dysfunction in heart failure, are incompletely understood, especially in the common (or congestive) systolic (SHF) and diastolic heart failure (DHF). Limited genome-wide association studies (GWASs) in humans are reported on SHF and no GWAS has been performed on DHF. Genetic analyses in a rodent model of true DHF, Dahl salt-sensitive (DSS) rats, have begun to unravel the genetic components determining diastolic function. Diastolic dysfunction of DSS rats can be ameliorated or even normalized by distinct quantitative trait loci (QTLs), designated as diastolic function/blood pressure QTLs (DF/BP QTLs), which also affect blood pressure (BP). However, an improvement in diastolic dysfunction is merely transitory from a single DF/BP QTL, despite a permanent lowering of BP. A long-term protection against diastolic dysfunction can be realized only through combining specific DF/BP QTLs. Moreover, the worsening diastolic dysfunction with age can also be reversed in a different combination of DF/BP QTLs. Thus, distinct genes in combinations must be involved in the physiological mechanisms ameliorating or reversing diastolic dysfunction. As not all the QTLs that influence BP can affect diastolic function, it is not BP reduction itself that restores diastolic function, but rather specific genes that are uniquely integrated into the pathways of blood pressure homeostasis as well as diastolic function. Thus, the elucidation of pathophysiological mechanisms causal to hypertensive diastolic dysfunction will not only provide new diagnostic tools, but also novel therapeutic targets and strategies in reducing, curing, and even reversing DHF.

Pathophysiology of diastolic dysfunction in chronic heart failure

Chronic heart failure is a disease with high morbidity and mortality, and its incidence is increasing rapidly worldwide. New therapies are needed that can halt or even reverse the progression of heart failure, but little progress has been made in the last 20 years. This is partly due to the fact that chronic heart failure is a heterogeneous disease with many different etiologies and clinical phenotypes. At present, a pathophysiological concept to unify these different phenotypes is missing. A prominent pathophysiological feature of chronic heart failure is diastolic dysfunction, which is almost universally present in heart failure patients. This review will examine the role and mechanisms of diastolic dysfunction in heart failure. We will study diastolic dysfunction at different levels of complexity of organization: the cardiovascular system, the heart as an organ, the myocardium as a tissue, the myocyte as a cell and the molecular aspects of diastolic dysfunction.

[Magnetic resonance imaging of hypertrophic cardiomyopathy : evaluation of diastolic function]

Hypertrophic cardiomyopathy (HCM) has a prevalence of approximately 0.2% and is clinically asymptomatic in many patients or presents with unspecific symptoms. This explains the importance of imaging for the diagnosis of HCM as well as for the assessment of the clinical course. The definitive finding in HCM is myocardial hypertrophy with thickening of the ventricular wall ≥ 15 mm. While echocardiography is an excellent screening tool magnetic resonance imaging (MRI) allows a comprehensive analysis of the heart in HCM. This includes a detailed analysis of the distribution and extent of myocardial hypertrophy, a thorough evaluation of systolic and diastolic cardiac function, the assessment of the presence and extent of dynamic outflow tract obstruction as well as the description of the systolic anterior motion (SAM) phenomenon of the mitral valve with secondary mitral insufficiency. When contrast material is administered, additional information about myocardial perfusion as well as the presence and extent of myocardial fibrosis can be obtained. This study compared systolic functional parameters as well as end systolic and end diastolic wall thickness of patients with and without diastolic dysfunction.

Diastolic dysfunction and heart failure with a preserved ejection fraction: Relevance in critical illness and anaesthesia

Epidemiological and clinical studies suggest that HF with a preserved ejection fraction will become the more common form of HF which clinicians will encounter. The spectrum of diastolic disease extends from the asymptomatic phase to fulminant cardiac failure. These patients are commonly encountered in operating rooms and critical care units. A clearer understanding of the underlying pathophysiology and clinical implications of HF with a preserved ejection fraction is fundamental to directing further research and to evaluate interventions. This review highlights the impact of diastolic dysfunction and HF with a preserved ejection fraction during the perioperative period and during critical illness.

The Effect of Metabolic Syndrome on Myocardial Contractile Reserve during Exercise in Non-Diabetic Hypertensive Subjects

Background

Metabolic syndrome (MS) is associated with increased left ventricular (LV) mass and diastolic dysfunction. This study uses relatively load-independent Doppler tissue echocardiography to examine whether MS is associated with decreased longitudinal contractile reserve during dynamic exercise.

Methods

A total of 112 patients with relatively well-controlled, treated hypertension who complained of exertional dyspnea were enrolled (average age: 56.7 ± 10.5 years). Fifty-six were non-diabetic patients with MS (Group 1), and 56 were age-sex matched hypertensive patients without MS (Group 2). Exercise stress echo was performed using a symptom-limited, multistage, supine bicycle exercise test. Multiple Doppler parameters were obtained at baseline, at each stage of exercise, and during recovery.

Results

There was no significant difference between the two groups in terms of age, gender, and hemodynamic variables. E/E', an index of LV filling pressure, was significantly higher in the MS group at rest and during exercise. The longitudinal contractile reserve, the change in S' (longitudinal tissue velocity) from baseline to peak exercise, was significantly lower in the MS group (2.00 ± 1.65 vs. 2.90 ± 1.66, p = 0.015). Multiple regression analysis showed independent association of MS with longitudinal contractile reserve when controlled for confounding factors, such as LV mass index, gender, blood pressure, and age (β = -0.235, p = 0.035).

Conclusion

Longitudinal contractile reserve was reduced in MS patients compared to others, although both groups demonstrated similar longitudinal contractile function at rest. We present the first demonstration that metabolic syndrome is independently associated with LV systolic dysfunction during exercise in hypertensive patients.

Hypertension as an underlying factor in heart failure with preserved ejection fraction

The unique pathophysiology of heart failure with a preserved ejection fraction (HF-PEF) and the involvement of hypertension in its development are only poorly understood. The upregulation of the renin-angiotensin-aldosterone system (RAAS) has been identified as a key pathologic pathway contributing to fibrosis, cardiomyocyte abnormalities, inflammation, and endothelial dysfunction, all of which have been implicated in the progression of hypertension to HF-PEF. In addition, pharmacologic inhibition of the RAAS has been shown in animal models of diastolic dysfunction and in clinical trials to reduce these deleterious processes and to improve diastolic function. Despite these data, clinical trials performed with RAAS inhibitors in patients with HF-PEF have failed to demonstrate morbidity and mortality benefits. To date, there is no proven effective therapy specifically for HF-PEF. The deleterious effects of hypertension on mechanisms underlying the development of HF-PEF underscore the importance of effective and early control of hypertension for the prevention of HF-PEF.

Prognostic value of left ventricular end-systolic volume index as a predictor of heart failure hospitalization in stable coronary artery disease: data from the Heart and Soul Study

OBJECTIVE

Left ventricular (LV) end-systolic volume indexed to body surface area (ESVI) is a simple yet powerful echocardiographic marker of LV remodeling that can be measured easily. The prognostic value of ESVI and its merit relative to other markers of LV remodeling in patients with coronary heart disease are unknown.

METHODS

We examined the association of ESVI with hospitalization for heart failure (HF) and mortality in a prospective study of patients with coronary heart disease.

RESULTS

Of the 989 participants, 110 (11%) were hospitalized for HF during 3.6 +/- 1.1 years of follow-up. Among participants in the highest ESVI quartile (> 25 mL/m(2)), 67 of 248 (27%) developed HF compared with 8 of 248 (3%) among those in the lowest quartile. The association between ESVI and HF hospitalization persisted after adjustment for potential confounders (hazard ratio 5.0, 95% confidence interval, 1.5-16.9; P = .01).

CONCLUSION

ESVI > 25 mL/m(2) is an independent predictor of hospitalization for HF in patients with stable coronary heart disease.

Distinct genomic replacements from Lewis correct diastolic dysfunction, attenuate hypertension, and reduce left ventricular hypertrophy in Dahl salt-sensitive rats

BACKGROUND

Hypertension and diastolic heart failure are two common cardiovascular diseases that inflict heavy morbidity and mortality, yet relatively little is understood about their pathophysiology. The identification of quantitative trait loci for blood pressure is important in unveiling the causes of polygenic hypertension. Although Dahl salt-sensitive strain is also an excellent model for the study of diastolic heart failure, virtually nothing is known about the quantitative trait loci determining diastolic heart failure. Diastolic dysfunction often represents the onset of diastolic heart failure.

METHODS

We first characterized the cardiac phenotype of Dahl salt-sensitive strain and normotensive Lewis control rats by echocardiography to ascertain diastolic function. We then analyzed corresponding features of four newly developed and two existing congenic strains, each of which carries a specific chromosome substitution of Dahl salt-sensitive strain by its Lewis homologue and each lowering blood pressure.

RESULTS

Dahl salt-sensitive strain displayed diastolic dysfunction that was rectified in two of six congenic strains, designated as positive congenic strains, which represent the first rodent models exhibiting functional normalization of diastolic dysfunction caused by naturally occurring genetic variants. The two positive congenic strains also showed a reduction in left ventricular mass. In contrast, four of six congenic strains did not change diastolic function despite their blood pressure-lowering effects.

CONCLUSION

Genes present in the replaced chromosome segments of the two positive congenic strains are not commonly known to affect blood pressure, diastolic function or left ventricular mass. Consequently, novel prognostic, diagnostic and therapeutic strategies for hypertensive diastolic heart failure likely emerge from this work.

The cardiac cycle and the physiologic basis of left ventricular contraction, ejection, relaxation, and filling

Heart failure is defined as the pathologic state in which the heart is unable to pump blood at a rate required by the metabolizing tissues or can do so only with an elevated filling pressure. Heart failure in adults most frequently results from the inability of the left ventricle to fill (diastolic performance) or eject (systolic performance) blood. The severity of heart failure and its prognosis are more closely related to the degree of diastolic filling abnormalities than the ejection fraction, which underscores the importance of understanding the mechanisms of diastolic abnormalities in heart failure.

Effect of Geometric Remodeling on Left Ventricular Longitudinal Contractile Reserve in Patients with Hypertension

Left ventricular hypertrophy (LVH) is associated with a reduction of subendocardial coronary flow reserve, which may be associated with abnormal myocardial longitudinal function during exercise. To test this hypothesis, 182 hypertensive patients underwent multistage supine bicycle exercise testing. Patients were classified as follows: patients with normal geometry (group 1, n = 116), concentric remodeling (group 2, n = 31), or LVH (group 3, n = 31). The results showed that the ratio of E/E', an index of left ventricular (LV) filling pressure, was significantly elevated in the LVH group at rest and during exercise. At rest, the mitral annular systolic velocity (S') was similar between the three groups at rest, whereas S' during exercise was significantly lower in the LVH group. The magnitude of change in S' during exercise was also significantly lower in the LVH group. Multiple linear regression analysis showed that peak double product (beta = 0.208, P = .006) and LV mass index (beta = -0.158, P = .028) were independently associated with LV longitudinal contractile reserve. Also, multiple linear regression analysis showed that changes in S' from baseline to peak were independently associated with exercise duration (beta = 0.123, P = .041) when controlled for age, male gender, baseline E', peak systolic blood pressure, and LV mass index. The results from this study demonstrate that LVH was significantly associated with abnormal LV longitudinal contractile reserve in hypertensive patients.

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.

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.

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.

Cardiac Dysfunction in Heart Failure: The Cardiologist's Love Affair with Time

Translating research into clinical practice has been a challenge throughout medical history. From the present review, it should be clear that this is particularly the case for heart failure. As a consequence, public awareness of this disease has been disillusionedly low, despite its prognosis being worse than that of most cancers and many other chronic diseases. We explore how over the past 150 years since Ludwig and Marey concepts about the evaluation of cardiac performance in patients with heart failure have emerged. From this historical-physiologic perspective, we have seen how 3 increasingly reductionist approaches or schools of thought have evolved in parallel, that is, an input-output approach, a hemodynamic pump approach, and a muscular pump approach. Each one of these has provided complementary insights into the pathophysiology of heart failure and has resulted in measurements or derived indices, some of which still being in use in present-day cardiology. From the third, most reductionist muscular pump approach, we have learned that myocardial and ventricular relaxation properties as well as temporal and spatial nonuniformities have been largely overlooked in the 2 other, input-output and hemodynamic pump, approaches. A key message from the present review is that relaxation and nonuniformities can be fully understood only from within the time-space continuum of cardiac pumping. As cyclicity and rhythm are, in some way, the most basic aspects of cardiac function, considerations of time should dominate over any measurement of cardiac performance as a muscular pump. Any measurement that is blind for the arrow of cardiac time should therefore be interpreted with caution. We have seen how the escape from the time domain-as with the calculation of LV ejection fraction-fascinating though as it may be, has undoubtedly served to hinder a rational scientific debate on the recent, so-called systolic-diastolic heart failure controversy. Lacking appreciation of early relaxation abnormalities and inappropriate degrees of nonuniformities has, indeed, led to some unfortunate misunderstandings about the pathophysiologic time progression of heart failure, in particular, heart failure with compensated hemodynamic pump function (ie, with normal or preserved LV ejection fraction). We have seen that with the introduction of newer powerful diagnostic techniques, as, for example, TDI and MRI, to evaluate ventricular "muscular pump" function, this debate can now be held in a more serene physiologic context. These aspects will be elaborated further in subsequent chapter papers of this symposium. With ongoing stem and other cell-based therapies and future reductionistic insights into cardiac cellular performance, we foresee the emergence of a fourth simple-parallel school of thought viewing the heart as a network of communicating different cell types, that is, cardiomyocytes, endothelial cells, fibroblasts, neurons. In this postgenomic age with the introduction of the rapidly evolving discipline of in vivo molecular imaging techniques, we anticipate that novel measurements of cardiac performance in patients with heart failure will soon become available and complement biopsy and other already available cardiac cellular biomarkers (cardiac troponin I; creatine kinase-MB; myoglobin; BNP). Through the use of these novel biomarkers as a fourth diagnostic track in the evaluation of cardiac performance in patients with heart failure, we will soon be able to increasingly understand the behavior of the heart as a complex biologic system-in other words, how these "low-level" biologic functions and signal transduction pathways at a cellular level contribute to the above "high-level" or system-level approach of cardiac performance at the muscular, the hemodynamic, and the input-output pump system levels and, hopefully, how they could contribute to an early diagnosis of chronic heart failure, in patients.