II. Pathophysiology

  1. Hypertrophic heart with impaired relaxation
    1. Stiff, less compliant left ventricle that does not adequately fill
  2. Heart meets metabolic needs
    1. But cost is a higher diastolic pressure
    2. Transmits pressures to lung vasculature
    3. Results in pulmonary congestion
    4. Ultimately leads to right-sided Heart Failure
  3. Mechanisms
    1. Abnormal renal Sodium metabolism
    2. Decreased compliance of myocardial wall as well as arterial wall
    3. Decreased diastolic ventricular filling

III. Epidemiology

  1. Incidence increases with age (over 55 years)
  2. More common in elderly women
  3. Responsible for 30-40% of Congestive Heart Failure
  4. More common in black patients

V. Risk Factors: Exacerbating Factors

  1. Tachycardia
  2. Atrial Fibrillation
  3. Increased ventricular load (volume overload)
  4. Exercise
  5. Increased salt intake
  6. NSAIDs
  7. Hyperthyroidism
  8. Infection or fever
  9. Anemia

VI. Symptoms

  1. Dyspnea on exertion
  2. Fatigue

VII. Signs

  1. Symptoms and signs overlap with Systolic Dysfunction
  2. Establish Congestive Heart Failure diagnosis clinically
  3. Evaluate for Systolic Dysfunction
  4. Rule out other causes
    1. Significant valvular disease
    2. Pericardial disease (e.g. pericardial constriction)
    3. Inducible Myocardial Ischemia
  5. Document elevated left ventricle end diastolic pressure
    1. Often impractical to perform

VIII. Labs

IX. Diagnosis

  1. See Framingham Heart Failure Diagnostic Criteria
  2. Echocardiogram
    1. See Echocardiogram in Congestive Heart Failure
    2. Ejection Fraction >50%
    3. E-A Wave Ratio abnormal
      1. E Wave: Peak velocity diastolic mitral valve flow
      2. A Wave: Atrial contraction
      3. Interpretation
        1. Normal E-A Ratio: 1.5
        2. Early Diastolic Dysfunction: E-A Ratio <1
        3. Moderate Diastolic Dysfunction: E-A=1.5
        4. Severe Diastolic Dysfunction: E-A Ratio >2
    4. Measurement of Tau abnormal
  3. Coronary Angiography
    1. Indicated if Angina or ischemia on other testing

X. Management

  1. See Congestive Heart Failure Exacerbation Management
  2. Aggressively manage Hypertension
    1. Controlling Blood Pressure is single most important factor
  3. Manage other Coronary Risk Factors
    1. Hyperlipidemia
    2. Obesity
    3. Tobacco Abuse
    4. Diabetes Mellitus
    5. Encourage regular aerobic Exercise
  4. Reduce exacerbating factors
    1. Control Myocardial Ischemia
    2. Maintain sinus rhythm and prevent Tachycardia
    3. Manage Atrial Fibrillation
    4. Manage COPD and Sleep Apnea
  5. Preferred medications in Diastolic Dysfunction
    1. Beta Blockers
      1. Maximizes diastolic filling
      2. Decreases pulse, Coronary Artery Disease, LVH
    2. ACE Inhibitor (or Angiotensin Receptor Blocker)
      1. Improves myocardial relaxation and compliance
      2. Lowers Preload and Afterload
    3. Diuretics
      1. Decrease Dyspnea and acute exacerbations
      2. Thiazide Diuretics are preferred
      3. Loop Diuretics are indicated for Fluid Overload
        1. If not overloaded, Loop Diuretics may lower Preload and increase symptoms
      4. Spironolactone has uncertain efficacy, but is likely beneficial
      5. Risk of Hypotension, Prerenal Failure
  6. Medications to use with caution
    1. Nondihydropyrimidine Calcium Channel Blockers
      1. Example: Verapamil
      2. Improves diastolic function overall
      3. Avoid in Left Ventricular Dysfunction
      4. No survival benefit in Diastolic Dysfunction
    2. Dihydropyramidine Calcium Channel Blockers
      1. Example: Amlodipine
      2. Indications: Heart Rate control, Angina
      3. No survival benefit in Diastolic Dysfunction
      4. Limit use to when Beta Blocker is contraindicated
    3. Vasodilators (Nitrates, Hydralazine)
      1. Indications: Preload reduction and Angina
      2. No survival benefit in Diastolic Dysfunction
      3. Limit use to when ACE Inhibitor is contraindicated
  7. Medications to avoid
    1. Avoid Digoxin except in Atrial Fibrillation

XI. Prevention

XII. Complications

  1. Mortality from Diastolic Heart Failure is equivalent to Systolic Heart Failure mortality

XIII. Prognosis

  1. Chronic Kidney Disease
    1. Creatinine Clearance >60 ml/min/1.73 m2: Survival >80% 4 year
    2. Creatinine Clearance <20 ml/min/1.73 m2: Survival <20% 4 year

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Ontology: Diastolic dysfunction (C0520863)

Definition (NCI) Impairment in the filling of the ventricles during diastole. Causes include hypertrophic and restrictive cardiomyopathies, coronary artery disease, chronic high blood pressure, aortic stenosis, and aging.
Concepts Pathologic Function (T046)
SnomedCT 3545003
Italian Disfunzione diastolica
Japanese 拡張機能障害, カクチョウキノウショウガイ
English diastolic dysfunction, diastolic dysfunction (diagnosis), Diastolic Dysfunction, Diastolic dysfunction, Diastolic dysfunction (finding)
Czech Diastolická dysfunkce
Hungarian Diastolés működési zavar
Spanish disfunción diastólica (hallazgo), disfunción diastólica, Disfunción diastólica
Portuguese Disfunção diastólica
Dutch diastolische disfunctie
French Dysfonctionnement diastolique
German diastolische Dysfunktion

Ontology: Heart Failure, Diastolic (C1135196)

Definition (MSHCZE) Srdeční selhání způsobené abnormálním myokardiálním ochabnutím během DIASTOLY, což vede ke ztíženému plnění komor. R
Definition (MSH) Heart failure caused by abnormal myocardial relaxation during DIASTOLE leading to defective cardiac filling.
Concepts Disease or Syndrome (T047)
MSH D054144
ICD9 428.30, 428.3
ICD10 I50.30
SnomedCT 418304008
Spanish insuficiencia cardíaca diastólica (trastorno), insuficiencia cardíaca diastólica, Insuficiencia Cardíaca Diastólica, Insuficiencia cardiaca diastólica
English Heart Failure, Diastolic, Diastolic Heart Failures, Diastolic Heart Failure, Heart Failures, Diastolic, Diastolc hrt failure NOS, Unspecified diastolic (congestive) heart failure, Heart Failure, Diastolic [Disease/Finding], diastolic failure heart, diastolic heart failure, heart failure diastolic, Diastolic heart failure, unspecified, Diastolic heart failure, Diastolic heart failure (disorder)
Portuguese Insuficiência Cardíaca Diastólica, Insuficiência cardíaca diastólica
Finnish Diastolinen sydämen vajaatoiminta
French Défaillance cardiaque diastolique, Insuffisance cardiaque diastolique
German Herzinsuffizienz, Diastolische, DiastolischeHerzinsuffizienz, diastolische Herzinsuffizienz
Italian Scompenso cardiaco diastolico, Insufficienza cardiaca diastolica
Swedish Hjärtsvikt, diastolisk
Dutch diastolisch hartfalen
Czech Diastolické srdeční selhání, diastolické srdeční selhání, srdce - selhání diastolické
Japanese カクチョウキシンフゼン, 心不全-拡張期, 拡張期心不全
Polish Niewydolność serca rozkurczowa, Rozkurczowa niewydolność serca
Hungarian Diasztolés szívelégtelenség
Norwegian Diastolisk hjertesvikt, Hjertesvikt, diastolisk
Croatian Srčano zatajivanje, dijastoličko