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Mr Sherif Nagueh
The speakers in this session summarized the criteria for diagnosing and grading diastolic dysfunction and heart failure, including stress testing. The session concluded by a presentation on the treatment of diastolic heart failure. Below is a summary of these presentations.The assessment of diastolic function plays an important role in the evaluation of patients with heart failure. The clinical evaluation is needed to determine the underlying factors that can lead to diastolic dysfyunction such as hypertension, obesity, diabetes mellitus and CAD. The presence of signs of pulmonary and systemic congestion is useful, along with echocardiography and biomarkers.In patients with systolic heart failure, mitral inflow is useful for determining left ventricular filling pressures. There are other useful echocardiographic measurements including left atrial volume, pulmonary artery systolic pressure, and tissue Doppler velocities.Diastolic heart failure is diagnosed with clinical heart failure findings, normal EF, and EDV index < 97 ml/m2. When mitral annulus velocities are available, an increased E/e’ ratio is useful in confirming the presence of increased filling pressures. With equivocal values of the ratio, additional measurements such as left atrial volume index, and BNP and pro-BNP levels are needed.Grading diastolic function starts with noting the mitral inflow pattern. An impaired relaxation pattern is characterized by a reduced E/A ratio and a prolonged deceleration time. A pseudonormal filling pattern corresponds to a moderate grade of diastolic dysfunction, and a restrictive filling pattern to severe diastolic dysfunction. In mild diastolic dysfunction mitral annulus e’ velocity is reduced and annular e’/a’ ratio is less than 1 as a’ velocity is normal or increased. The e’/a’ ratio increases with higher grades of diastolic dysfunction due to a decrease in a’ velocity. The grade of diastolic dysfunction is an important determinant of outcome that adds incremental information to other clinical and echocardiographic data. This was recently reported in patients with MI, where restrictive filling was associated with worse outcome even in patients with normal EF.In patients with exertional dyspnea and normal left ventricular filling pressures at rest, exercise testing is particularly useful in determining whether there is an underlying cardiac etiology. In normal patients, mitral E velocity and annular e’ velocity show a proportional increase with exercise such that E/e’ ratio is unchanged. On the other hand, with a cardiac etiology, mitral E has a much larger increase, whereas e’ changes little. Therefore, the E/e’ ratio increases in these patients. The accuracy of the ratio in predicting invasive LV diastolic pressures during exercise was tested against simultaneous pressure measurements in one study and a significant correlation was noted. In a number of studies, E/e’ ratio was also a predictor of exercise capacity. In addition to E/e’ ratio, one can determine pulmonary artery systolic pressure with exercise, and the absolute and relative change in e’ velocity. In general, one is more confident that a non cardiac etiology is the cause of dyspnea when the PA pressure increase with exercise is < 40 mmHg. The exercise protocol should allow for the acquistion of 2D images to assess global and regional function with exercise as well as the acquisition of the above Doppler parameters.Treatment of diastolic heart failure includes elements of prevention, general measures, and a number of potentially useful drugs. Addressing the obesity epidemic is important by promoting caloric restriction and regular exercise. In a small study, caloric restriction was associated with improved LV filling. There are studies showing that old healthy marathon runners have a more compliant left ventricle than sedentary subjects.The general measures include adequate control of blood pressure, heart rate and maintenance of sinus rhythm in patients with atrial fibrillation. Large randomized studies did not show a consistent benefit of ACE inhibitors and angiotensin receptor blockers in diastolic heart failure. Potential reasons for these findings are including patients who may not have had diastolic dysfunction or only a mild degree of diastolic dysfunction. There are retrospective studies showing some benefit for beta blockers in patients with EF more than 40%, but caution is needed when prescribing these drugs to patients with chronotropic incompetence. There are ongoing studies looking at aldosterone receptor blockers in diastolic heart failure, but their results are not yet available.
Debated concepts in diastolic function
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