CHF

Diastolic Heart Failure

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Diastolic Heart Failure, Diastolic Dysfunction, Heart Failure with Preserved Ejection Fraction, HFpEF

  • Definitions
  1. Heart Failure with Preserved Ejection Fraction (HFpEF or Diastolic Heart Failure)
    1. Signs and symptoms of Congestive Heart Failure AND
    2. Left ventricular ejection fraction >50% (some include EF >40%)
  • 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 (with reduced lung compliance)
    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
  • Epidemiology
  1. Incidence and Prevalence
    1. Prevalence: 5 Million in U.S.
    2. Incidence: 650,000 per year in U.S.
    3. Responsible for 30-50% of Congestive Heart Failure (increasing by 1% per year)
  2. Age
    1. Incidence increases with age (over 55 years)
    2. More common in elderly women
  3. Race
    1. More common in black patients
  • Causes
  • Risk Factors
  • Key Factors
  1. Advanced age
  2. Female gender
  3. Obesity
  4. Diabetes Mellitus
  5. Tobacco abuse
  • 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
  • Presentations
  • Typical patient
  • Symptoms
  1. Dyspnea on exertion
  2. Fatigue
  3. Generalized weakness
  4. Orthopnea or paroxysmal nocturnal Dyspnea
  5. Peripheral Edema
  • Signs
  1. Symptoms and signs overlap with Systolic Dysfunction
    1. S3 Gallup Rhythm (LR+ 4.4)
    2. Jugular Venous Distention (LR+ 7.4)
    3. Displaced apical impulse (LR+ 16)
    4. Madhok (2008) BMC Fam Pract 9:56 [PubMed]
  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
  • Labs
  1. See Systolic Dysfunction
  2. B-Type Natriuretic Peptide (BNP)
    1. Does not distinguish from Systolic Dysfunction
    2. BNP <100 or NT-BNP <300 excludes Acute Heart Failure in the Emergency Department (LR- 0.1)
    3. Martindale (2016) Acad Emerg Med 23(3); 223-42 [PubMed]
  • Diagnosis
  1. See Framingham Heart Failure Diagnostic Criteria
  2. Transthoracic Echocardiogram
    1. See Echocardiogram in Congestive Heart Failure
    2. Left Ventricular Ejection Fraction >50%
    3. E-A Wave Ratio abnormal (evaluates for Diastolic Dysfunction)
      1. Definitions
        1. E Wave: Peak velocity diastolic mitral valve flow
        2. A Wave: Atrial contraction
      2. 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. Other measures
      1. Left ventricular mass
      2. Valvular Disease
      3. Left atrial size
      4. Measurement of Tau abnormal
  3. Coronary Angiography
    1. Indicated if Angina or ischemia on other testing
  • Management
  • General
  1. See Congestive Heart Failure Exacerbation Management
  2. Goals
    1. Increase Exercise capacity and physical functioning
    2. Improve diastolic function
  3. Aggressively manage Hypertension
    1. Controlling Blood Pressure is single most important factor
  4. Manage other Coronary Risk Factors
    1. Hyperlipidemia
    2. Obesity
    3. Tobacco Abuse
    4. Diabetes Mellitus
    5. Encourage regular aerobic Exercise (Exercise training is effective)
      1. Fukuta (2016) Eur J Prev Cardiol 23(10: 78-85 [PubMed]
  5. Reduce exacerbating factors
    1. Control Myocardial Ischemia
      1. Revascularization as indicated
    2. Maintain sinus rhythm and prevent Tachycardia
    3. Manage Atrial Fibrillation
      1. Treat causative conditions (e.g. Hyperthyroidism)
      2. Atrial Fibrillation Rate Control
      3. Atrial Fibrillation Anticoagulation
    4. Manage COPD
    5. Screen and treat for Sleep Apnea
  • Management
  • Medications
  1. Precautions
    1. HFpEF patients are sensitive to excessive Preload reduction (e.g. Diuretics, nitrates)
    2. Risk of weakness, Dizziness, Syncope
  2. Preferred medications in Diastolic Dysfunction
    1. Beta Blockers
      1. Maximizes diastolic filling
      2. Decreases pulse, Coronary Artery Disease, Left Ventricular Hypertrophy
      3. No difference in mortality or hospitalizations
        1. van Veldhuisen (2009) J Am Coll Cardiol 53(23): 2150-8 [PubMed]
        2. Yamamoto (2013) Eur J Heart Fail 15(1): 110-8 [PubMed]
    2. ACE Inhibitor (or Angiotensin Receptor Blocker)
      1. Improves myocardial relaxation and compliance
      2. Lowers Preload and Afterload
      3. Angiotensin Receptor Blockers have not reduced mortality or hospitalizations
        1. Heran (2012) Cochrane Database Syst Rev (4):CD003040 [PubMed]
    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
  3. 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
      4. Associated with decreased Exercise tolerance
        1. Redfield (2015) N Engl J Med 373(24): 2314-24 [PubMed]
  4. Medications to avoid
    1. Digoxin
      1. Avoid except in Atrial Fibrillation
      2. No effect on mortality, but may increase hospitalizations
        1. Hashim (2014) Am J Med 127(2): 132-9 [PubMed]
  • Prevention
  • Complications
  1. Mortality from Diastolic Heart Failure is equivalent to Systolic Heart Failure mortality
  • Prognosis
  1. Hospitalizations
    1. Mortality at one year after first HFpEF admission: 25%
    2. Mortality at five years after first HFpEF admission
      1. Age over 60 years: 24%
      2. Age over 80 years: 54%
  2. Factors associated with worse prognosis
    1. Higher NT-BNP levels
    2. Advanced age
    3. Diabetes Mellitus
    4. Prior Myocardial Infarction
    5. Chronic Obstructive Pulmonary Disease
    6. 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