Cardiovascular Medicine Book

Diastolic Heart Failure

Aka: Diastolic Heart Failure, Diastolic Dysfunction, Heart Failure with Preserved Ejection Fraction, HFpEF
  1. See Also
    1. Heart Failure
    2. Systolic Dysfunction
    3. See Framingham Heart Failure Diagnostic Criteria
    4. Congestive Heart Failure Exacerbation Decision Rule
    5. Ottawa Heart Failure Risk Score
  2. 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
  3. 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
  4. Causes
    1. See Heart Failure Causes
    2. Common causes
      1. Hypertension
        1. Longstanding Uncontrolled Hypertension is the most common underlying etiology
        2. Causes Left Ventricular Hypertrophy
      2. Coronary Artery Disease
      3. Aortic Stenosis
      4. Obesity
    3. Other causes
      1. Cardiomyopathy (e.g. Amyloidosis, Sarcoidosis)
      2. Hypertrophic Cardiomyopathy
      3. Glycogen Storage Disease
      4. Hypereosinophilic Syndrome
      5. Hemochromatosis
      6. Constrictive Pericarditis or Pericardial Effusion
      7. Valvular disease
  5. 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
  6. Symptoms
    1. Dyspnea on exertion
    2. Fatigue
  7. 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
  8. Labs
    1. See Systolic Dysfunction
    2. B-Type Natriuretic Peptide (BNP)
      1. Does not distinguish from Systolic Dysfunction
  9. 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
  10. 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
  11. Prevention
    1. Control Cardiac Risk Factors
    2. Consider Cardiac Rehabilitation
  12. Complications
    1. Mortality from Diastolic Heart Failure is equivalent to Systolic Heart Failure mortality
  13. 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
  14. References
    1. (2017) Presc Lett 24(4):20
    2. Senni (1997) Mayo Clin Proc 72:453-60 [PubMed]
    3. (1995) Circulation 92:2764-84 [PubMed]
    4. (1999) J Card Fail 5:357-82 [PubMed]
    5. Zile (2002) Circulation 105:1387-93 [PubMed]
    6. Zile (2002) Circulation 105:1503-8 [PubMed]

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
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

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