Hospital Medicine

Diastolic heart failure

Diastolic heart failure

I. Problem/Condition.

Diastolic heart failure or heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by preserved left ventricular (LV) systolic function (ejection fraction > 50 %), evidence of diastolic dysfunction, and clinical findings consistent with heart failure. It is estimated that diastolic failure accounts for approximately half of clinical heart failure cases with higher prevalence among the elderly and females (60%). The presence of clinical features consistent with heart failure is essential to define patients with the condition as an estimated 28% of people without heart failure have echocardiographic evidence of impaired diastolic function.

Despite the occurrence of diastolic dysfunction without overt heart failure, the finding is associated with increasing mortality. Furthermore, persons with the clinical syndrome of heart failure associated with diastolic dysfunction share a prognosis similar to heart failure associated with systolic dysfunction following hospitalization that emphasize the importance of blood pressure management to lower systemic blood pressure and diuretic therapy for volume overload. In addition to similar outcomes following hospitalization, mortality and hospital readmission rates are similar as well (22.2% mortality rate at 1-year and a 4.5% 30-day readmission rate). In addition to management of systemic blood pressure and volume status, it is important to treat associated conditions and comorbidities including obesity, diabetes mellitus, hyperlipidemia, atrial fibrillation, renal disease, and coronary artery disease that affect the clinical course including hospitalization.

The symptoms of diastolic heart failure are similar to systolic heart failure and include exercise intolerance, dyspnea on exertion, leg swelling, orthopnea, paroxysmal nocturnal dyspnea, cough, abdominal distention, and early satiety. In contrast, patients presenting with diastolic heart failure tend to have higher systemic blood pressure that may result in concentric hypertrophy of the left ventricle which is associated with increased extracellular matrix remodeling leading to decreased distensibility and abnormal relaxation and filling. Patients with diastolic heart failure also more frequently present with lower extremity edema and atrial fibrillation.

II. Diagnostic Approach

A. What is the differential diagnosis for this problem?

The list of differential diagnoses for diastolic heart failure may best be categorized by symptoms. Dyspnea may have a pulmonary or cardiac etiology. Potential pulmonary problems that cause dyspnea include pleural effusion, pulmonary hypertension and pulmonary edema; cardiac problems that may present as dyspnea include valvular disease (e.g., aortic valvular insufficiency and mitral valvular regurgitation), infiltrative processes such as amyloidosis or sarcoidosis and LV systolic dysfunction.

B. Describe a diagnostic approach/method to the patient with this problem

The initial approach relies on confirming the diagnosis of diastolic heart failure and stabilizing the patient prior to assessing and treating the underlying cause.

The diagnosis of diastolic heart failure relies on presenting signs and symptoms of congestive heart failure in a patient whose echocardiogram reveals normal to near-normal ejection fraction (>40%) and evidence of abnormal LV relaxation or diastolic distensibility.

In the patient with no previously known history of heart failure it is essential to obtain an echocardiogram prior to initiating therapy as the signs and symptoms of heart failure can be mimicked by different cardiac conditions such as cardiac tamponade or a constrictive/restrictive cardiac pathophysiologic process.

In those known to have congestive heart failure presenting with an acute exacerbation, it is safe to initiate therapy while investigating the precipitant of the exacerbation.

1. Historical information important in the diagnosis of this problem.

Diastolic heart failure is a disorder that can be secondary to systemic conditions.

Patients diagnosed with diastolic heart failure often have a history of hypertension, diabetes mellitus, atrial fibrillation, obstructive sleep apnea, and angina pectoris.

Important information to elicit in patients diagnosed with heart failure relate to precipitating conditions including medication compliance for treatment of associated conditions, estimation of dietary salt intake, and use of nocturnal continuous positive airway pressure to treat obstructive sleep apnea. A history of acute chest pain is concerning for acute coronary syndrome.

Among patients with diagnosed heart failure, it is important to assess diuretic response, i.e., determine the interval between diuretic ingestion and onset of urination. An appropriate time would be 15-30 minutes.

Review of systems should investigate a history of exercise intolerance, palpitations, dyspnea on exertion, leg swelling, orthopnea, paroxysmal nocturnal dyspnea, cough, abdominal distention, and early satiety.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

Physical examination is necessary to identify signs that suggest heart failure as an underlying cause for the patient's symptoms. However it does not aid in distinguishing systolic from diastolic heart failure.

The general exam should emphasize evaluation of volume status, assessing lower extremity, sacral and scrotal edema, elevated jugular venous pulsations, and abdominal distention and dullness to percussion.

Cardiac auscultation often reveals a third sound (S3) in acute exacerbations. A fourth heart sound (S4) is present in patients with longstanding uncontrolled hypertension with significant LV hypertrophy, along with a laterally displaced point of maximal impulse (PMI).

Pulsus alternans is not a typical feature found in diastolic heart failure. Examination of the right-sided jugular venous waveforms offers insight into the underlying pathophysiologic process, with large right-sided v waves in septal rupture and tricuspid regurgitation, and rapid x and y descents seen with constrictive pericarditis (only a rapid x descent is seen in tamponade).

Auscultation of lung fields may also reveal basilar crackles indicative of pulmonary edema.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

A routine electrocardiogram may show evidence of myocardial ischemia, signs of ventricular hypertrophy or bundle branch blocks.

Serial cardiac enzymes may indicate acute coronary syndrome as an underlying cause of acute heart failure exacerbation. Frequently a mild elevation in troponin-I could indicate myocardial stress rather than ischemic injury.

Brain natriuretic peptide (BNP) levels are useful in differentiating between pulmonary and cardiac causes of dyspnea. Elevated BNP is an indicator of cardiac stress and suggests a cardiac contribution to the presenting symptoms but does not rule out pulmonary causes. Of note, obese individuals may have low BNP levels due to increased catabolism of BNP in adipose tissue, and heart failure in these patients cannot be ruled out with low BNP levels.

In addition to providing a diagnosis, echocardiography is also necessary to rule out other conditions that may present in a similar manner such as constrictive pericarditis and acute mitral and aortic regurgitation.

Non-invasive evidence of diastolic dysfunction can be obtained with Doppler echocardiography by measuring the mitral inflow velocity in early diastole (E) and during atrial contraction (A). Changes in the pattern of these velocities and the resulting E/A ratio reflect progressive stages of diastolic dysfunction.

Direct measurement of the velocity of change in myocardial length via tissue Doppler (TD) imaging may provide a more accurate assessment of LV filling pressures as it is less sensitive to changes in preload. Invasive hemodynamic measurement of the LV end-diastolic pressures with cardiac catheterization confirms the diagnosis, however it is only performed to identify underlying ischemic heart disease.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

Echocardiographic criteria

  • LV ejection fraction greater than 50% and LV end-diastolic volume index (LVEDVI) less than 97 ml/m2

Cardiac catheterization

  • Mean pulmonary capillary wedge (PCW) pressure greater than 12mmHg

  • LV end diastolic pressure greater than 16 mmHg

  • Time constant of LV relaxation 48ms

Laboratory markers

  • BNP greater than 200 pg/mL (in non-obese individuals)

  • N-terminal prohormone of brain natriuretic peptide (NT-proBNP) greater than 220 pm/mL (in non-obese individuals)

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

N/A

III. Management while the Diagnostic Process is Proceeding

A. Management of acute diastolic heart failure.

The initial management of patients with acute diastolic heart failure is identical to that of patients with systolic heart failure and aims at relieving pulmonary and systemic vascular congestion.

Intravenous (IV) diuretics are the mainstay therapy in addition to antihypertensive therapy and the use of nitroglycerin and morphine to relieve pulmonary congestion. Suspicion of myocardial ischemia should prompt antiplatelet therapy and evaluation for acute coronary syndrome. Daily weight, strict intake/output monitoring and fluid restriction complement diuretic therapy.

Unlike systolic heart failure, evidence of benefit of neurohormonal antagonism in long-term management of diastolic heart failure is scarce despite its rising burden.

According to guidance from the American College of Cardiology/American Heart Association (ACC/AHA), the mainstay treatment of patients with diastolic heart failure relies on managing the underlying cause:

  • Aggressive blood pressure control

  • Coronary revascularization in patients with coronary artery disease

  • Control of ventricular rate

  • Treating hypervolemia

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem

Acute kidney injury and hypotension secondary to overdiuresis

Patient's volume status should be assessed regularly. Patients with acute diastolic heart failure may present with elevated creatinine, reflecting renovascular congestion.

Creatinine and glomerular filtration rate (GFR) levels typically improve initially with diuresis and cannot be relied on as an initial assessment of a patient's intravascular volume, until the patient is clinically euvolemic.

Overdiuresis may occur and may be reflected in blood, urea, nitrogen:creatinine (BUN:Cr) ratio elevation. Most of the time simply holding diuretics is enough for recovery of full kidney function. However, in the setting of a rising creatinine despite holding diuretics, cautious IV normal saline should be administered in small boluses with monitoring of urine output and creatinine levels for improvement.

IV. What’s the evidence/References

Borlaug, BA, Paulus, WJ. "Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment". Eur. vol. 32. Heart J 2011. pp. 670.

Aurigemma, GP, Gaasch, WH. "Clinical practice. Diastolic heart failure". N Engl J Med. vol. 351. 2004. pp. 1097.

Owan, TE, Hodge, DO, Herges, RM. "Trends in prevalence and outcome of heart failure with preserved ejection fraction". N Engl J Med. vol. 355. 2006. pp. 251.

(This longitudinal investigation among persons hospitalized from decompensates of heart failure demonstrates the increasing incidence of HFpEF over time as as a predilection among community patients.)

Masoudi, FA, Havranek, EP, Smith, G. "Gender, age, and heart failure with preserved left ventricular systolic function". J Am Coll Cardiol. vol. 41. 2003. pp. 217.

(An investigation of cross-sectional design of 19,710 Medicare beneficiaries detected the presence of heart failure among 35%. Following adjustment for patient factors, older age and female gender were associated with the diastolic heart failure.)

Redfield, MM, Jacobsen, SJ, Burnett, JC. "Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic". JAMA. vol. 289. 2003. pp. 194.

(This investigation establishes the prevalence of diastolic dysfunction among persons without diastolic heart failure.)

Wan, SH, Vogel, MW, Chen, HH. "Pre-clinical diastolic dysfunction". J Am Coll Cardiol. vol. 63. 2014. pp. 407.

(This investigation establishes the risk for increased mortality among persons with asymptomatic diastolic dysfunction.)

Owan, TE, Hodge, DO, Herges, RM. "Trends in prevalence and outcome of heart failure with preserved ejection fraction". N Engl J Med. vol. 355. 2006. pp. 251.

Bhatia, RS, Tu, JV, Lee, DS. "Outcome of heart failure with preserved ejection fraction in a population-based study". N Engl J Med. vol. 355. 2006. pp. 260.

(References 7 and 8 establish similar outcomes between people with heart failure due to systolic and diastolic dysfunction following hospitalization.)

Kitzman, DW, Little, WC, Brubaker, PH. "Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure". JAMA. vol. 288. 2002. pp. 2144.

(The report characterizes the clinical manifestations of diastolic and systolic heart failure.)
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