HEART FAILURE WITH (PREDOMINANT) LEFT VENTRICULAR DIASTOLIC DYSFUNCTION

• 30-40% of symptomatic heart failure cases.
• Increase incidence with advanced age and female.
• Clinical presentation is similar to heart failure with systolic dysfunction.
• Diagnosis criterias include:
  • Present of signs and symptoms of heart failure.
  • Present of normal or only mild abnormal left ventricular systolic dysfunction (left ventricular ejection fraction >40-45%)
  • Present of abnormal left ventricular diastolic function (left ventricular relaxation, filling diastolic distensibility, or diastolic stiffness).
• Combine echocardiographic and Doppler study is essential for noninvasive diagnosis.
• When combined with systolic dysfunction, manage for systolic dysfunction.
• Caution when use diuretics or vasodilators.
• Inotropic agents such as digitalis are not indicated
• General management includes adequately controlling blood pressure, decreasing heart rate, maintaining effective atrial contraction, preventing ischemia, improving relaxation and decreasing the degree of left ventricular hypertrophy.

 

CONDITIONS	MECHANISM	COMMENTS	TREATMENT
Systemic hypertension
	- LVH, impaired myocardial relaxation, increase resistance to ventricular inflow, decreased ventricular diastolic capacity.	- May have predominant LV diastolic function.	- Adequate BP control. - Prefer medicine that reduces LVH.
Coronary artery disease
S/P MI	- Scar, fibrosis, ischemia, LV remodeling, aneurysm.	- Usually has both LV systolic and diastolic dysfunction.	- Beta blocker. - ACEI to decrease LV remodeling. - Anti-ischemic treatment. - Treat LV systolic dysfunction, if present. - Revascularization, if suitable. - Risk modification.
Acute ischemia	- Ischemia, impaired myocardial relaxation	- Usually has both LV systolic and diastolic dysfunction.	- Requires hospitalization.
Chronic, persistent ischemia	- Ischemia, hybernating myocardium, impaired relaxation.	- Usually has both LV systolic and diastolic dysfunction.	- As in S/P MI.
Hypertrophic cardiomyopathy	.
	- LVH, impaired myocardial relaxation, increased resistance to ventricular inflow, decreased ventricular diastolic capacity.	- May have predominant LV diastolic dysfunction.	- Adequate BP control. - Use negative inotropic drugs (beta blocker, verapamil, disopyramide). - Dual chamber pacing. - Septal infarct/myectomy.
Valvular heart disease	.
Mitral stenosis	- Increased resistance to left atrial emptying.	.	- Mitral replacement, repair or valvuloplasty.
Aortic insufficiency, Mitral regurgitation	- Eccentric LVH, volume overload, increased diastolic volume relative to ventricular capacity.	.	- Afterload reduction. - Valvular surgery before development of LV systolic dysfunction.
Aortic stenosis	- LVH, impaired myocardial relaxation, increased resistance to ventricular inflow, decreased ventricular diastolic capacity.	- May have predominant LV diastolic dysfunction until late stage.	- Valvular replacement.
Constrictive pericarditis	.
	- Increased resistance to ventricular inflow, decreased diastolic capacity.	.	- Diuretic. - Pericardiectomy
Cardiac tamponade	.
	-Decreased diastolic capacity.	.	- Pericardiocenthesis. - Pericardial window.
Restrictive or infiltrative disease	.
Myocardium (Amyloidosis, sarcoidosis, hemochromatosis)	- Infiltration of abnormal material, increased resistance to ventricular inflow.	- Start with LV diastilic dysfunction.	- General treatment of LV diastolic dysfunction. - May require specific treatment for specific disease.
Endocardium (Endocardial fibroelastosis, Loefler's syndrome)	- Infiltration of abnormal material, increased resistance to ventricular inflow, decreased diastolic capacity.	.	- General treatment of LV diastolic dysfunction. - Requires specific treatment for specific disease.