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PubMed2006

Prognosis of patients with left ventricular diastolic pressure abnormality: a long-term survival study in patients without coronary artery disease.

BACKGROUND: Given that an elevated left ventricular (LV) end-diastolic pressure reflects an abnormality of diastolic function, we analyzed the outcome of this finding in patients without coronary artery disease (CAD). HYPOTHESIS: The degree to which diastolic dysfunction influences mortality has been confounded in most studies by CAD and advanced age. METHODS: We performed a retrospective study of 876 patients with normal coronary arteries on arteriography. Of these, 115 patients had a left ventricular end-diastolic pressure of > or = 15 mmHg with an ejection fraction (EF) > or = 50%. We compared the mortality in this group (Group A) with the reported outcome in the general population, adjusted for age, gender, and race, as well as the mortality of a group of patients from the same cohort (Group B) with both diastolic and systolic dysfunction (n = 60), defined as a LVEF < 50%. RESULTS: Follow-up was for a mean of 63 months. In Group A, all-cause mortality was 5% (six patients); two deaths were from cardiac causes. The mean annual mortality in this group (1.2%) was similar to the adjusted annual mortality of the general population (1.1%), and it was significantly lower than the annual mortality (6%) in Group B (p < 0.03). CONCLUSIONS: Our study results indicate that diastolic dysfunction with a normal EF, in the absence of CAD and systolic dysfunction, has an excellent prognosis over a long period (5-6 years).

Aged↗
PubMed1992

Diastolic heart failure.

Diastolic heart failure is a distinct clinical entity increasingly seen in older patients and requires special awareness to make the diagnosis. Although no single laboratory test is identified for making a confident diagnosis of diastolic dysfunction as the pathogenetic mechanism for heart failure, a constellation of echocardiographic and radionuclear findings are helpful in most cases. Invasive assessment of LV diastole is laborious, requiring high-fidelity pressures and accurate measures of volumes, and these are rarely needed to diagnose the condition. It appears that prognosis is significantly better for those with normal systolic function, when compared with congestive heart failure caused by impaired systolic pump function. Finally, the therapeutic approaches are substantially different for the two groups. It must be emphasized that even patients with predominant myocardial systolic dysfunction have some combined diastolic dysfunction as well. This latter group is difficult to treat. However, improvement in systolic pump function, when markedly impaired, must take precedence in management strategies.

Diastole↗
PubMedDate not supplied

Congestive heart failure due to diastolic or systolic dysfunction. Frequency and patient characteristics in an ambulatory setting.

OBJECTIVE: To determine the age- and sex-specific frequencies and characteristics of patients with diastolic and systolic dysfunction heart failure. DESIGN: Retrospective medical record survey encompassing 1 year. SETTING: Community-based family practice office. PATIENTS: One hundred thirty-six patients who met the modified Framingham criteria for the diagnosis of congestive heart failure (CHF) and had a known left ventricular ejection fraction. Diastolic dysfunction was defined as an ejection fraction of 45% or greater and systolic dysfunction heart failure as an ejection fraction of less than 45%. MAIN OUTCOME MEASURES: Age- and sex-specific frequency; patient comorbid conditions; medications taken; and number of emergency department visits, hospitalizations, and deaths. RESULTS: The frequency of CHF increased with age for men and women (1.3% for patients 45-54 years old to 8.8% for patients > 75 years old). The distribution according to left ventricular ejection fraction and age varied according to sex. Women had later onset of CHF that was predominantly diastolic dysfunction heart failure. Men had proportionately more systolic dysfunction heart failure at all ages. Forty percent of all patients with CHF had diastolic heart failure, and these patients had fewer functional limitations (76% with New York Heart Association classes I and II), fewer hospitalizations for CHF, and a trend toward fewer deaths during the study year compared with patients with systolic dysfunction. CONCLUSIONS: Congestive heart failure is a heterogeneous condition in this family practice setting, and diastolic dysfunction heart failure occurs frequently. Further study of the natural history and treatment of diastolic dysfunction heart failure should be performed in the primary care setting.

Aged↗
PubMed2002

M-mode echocardiographic findings in a contemporary Afro-Caribbean population referred for evaluation of congestive cardiac failure.

Congestive cardiac failure is emerging as a significant public health problem around the world, including the Caribbean. Recent reports from developed countries suggest that 30 to 40% of patients with congestive cardiac failure have normal systolic function. This percentage may be even higher in non-Caucasian, non-male populations. This study was undertaken to determine the M-mode echocardiographic findings in a current, consecutive series of Afro-Caribbean patients referred for congestive cardiac failure. There were 165 patients, 51% male, mean and standard deviation (SD) age of 63 +/- 15 years, referred between May 1998 and June 2000. Echocardiographic findings included left atrial size (LA), left ventricular (LV) end systolic (ESD) and end diastolic dimension (EDD), LV posterior wall thickness (PWT) and ventricular septal thickness (VST). LV ejection fraction (EF) was derived. LA > 4 cm, PWT or VST > 13 mm and LVEF < 50% were considered abnormal. Increased LV wall thickness (LV hypertrophy) only was the most frequent finding, 68/165 (41%), consistent with possible diastolic dysfunction. If a less restrictive definition for abnormal LV wall thickness, 12 mm, is used, this finding increases to 79/165 (48%). Decreased LVEF (LV systolic dysfunction) was seen in 57/165, (35%) and was seen in significantly more men (42% versus 29%, p < 0.01). Valvular disease was seen in 13/165, 8%. Normal findings on echocardiography were found in 27/165 (16%), more commonly in women (19 versus 8, p < 0.05) and younger patients (54 years versus 65 years, p < 0.05) and in only 10% if 12 mm is used for LV wall limit. LV hypertrophy was seen in 42% of patients (61% if 12 mm is used for LV wall limit) with systolic dysfunction. Thus, congestive cardiac failure with LV hypertrophy is the most frequent finding in this Afro-Caribbean population, with LV systolic dysfunction in only 35% of patients. These findings are consistent with possible diastolic LV dysfunction due to hypertension as the primary cause of cardiac failure in the population.

Adult↗
PubMed2002

Tissue Doppler imaging in hypertrophic cardiomyopathy: impact of intraventricular obstruction on longitudinal left ventricular function.

BACKGROUND: In non-obstructive hypertrophic cardiomyopathy, tissue Doppler imaging of the mitral annulus shows severe systolic and diastolic dysfunction, with marked heterogeneity and asynchrony. In obstructive forms, the complexity of pathophysiological interactions makes conventional echocardiographic functional assessment extremely difficult and complex. OBJECTIVE: To study longitudinal left ventricular function with tissue Doppler imaging in the obstructive forms of hypertrophic cardiomyopathy. METHODS: Twenty-six patients with hypertrophic obstructive cardiomyopathy and 23 patients with the non-obstructive form of the disease, matched by age, were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony indexes. Data were compared between the different sides in each group, between groups and with conventional Doppler data. RESULTS: In contrast to the non-obstructive forms, patients with intraventricular obstruction showed: Systolic function: similar velocities and integrals, the relations between the different sides of the annulus usually being preserved; longer isovolumic contraction time, time to peak s and PEP/LVET. Diastolic function: similar rapid filling and e/a velocities and integrals, lower atrial contraction velocity and integral, similar number of sides with e/a higher than or equal to 1 on the lateral and inferior side of the annulus; similar diastolic time intervals, except diastolic time. CONCLUSIONS: This study shows that the presence of dynamic intraventricular obstruction and the loading conditions of obstructive forms of hypertrophic cardiomyopathy do not significantly influence most annular tissue Doppler imaging parameters, showing the relative load independence of the technique. So, in obstructive hypertrophic cardiomyopathy patients: 1--Longitudinal systolic function (velocities) is similar to the non-obstructive forms--longitudinal systolic dysfunction. 2--Longitudinal diastolic function (velocities and time intervals) is similar to the non-obstructive forms--longitudinal diastolic dysfunction. 3--Left atrial dysfunction is more severe than in non-obstructive forms. 4--The inferior and lateral sides of the annulus should be those selected in order to identify pseudonormalization of the transmitral flow.

Aged↗
PubMed2003

Prediction of risk for first age-related cardiovascular events in an elderly population: the incremental value of echocardiography.

OBJECTIVES: We sought to determine if echocardiography enhances prediction of first age-related cardiovascular events. BACKGROUND: Whether echocardiographic assessment improves risk stratification for first cardiovascular events is not well known. METHODS: This retrospective cohort study included randomly selected residents of Olmsted County, Minnesota, age >/=65 years, who had >/=1 transthoracic echocardiograms at the Mayo Clinic between 1990 and 1998, in sinus rhythm, without valvular or congenital heart disease, and followed through medical records for first myocardial infarction (MI), coronary revascularization, atrial fibrillation (AF), congestive heart failure (CHF), transient ischemic attack (TIA), stroke, or cardiovascular death. Patients were excluded if they had any of these events before the baseline echocardiogram. RESULTS: Of 1,160 patients (age 75 +/- 7 years; 746 women) followed for a mean of 3.8 +/- 2.7 years, 333 (29%) first events occurred (70 AF, 67 coronary revascularization procedures, 65 CHF, 48 MI, 38 stroke, 25 TIA, and 20 cardiovascular deaths). In a multivariate model, age (p < 0.001), male gender (p < 0.001), diabetes mellitus (p = 0.005), systemic hypertension (p < 0.001), left atrial volume/body surface area >/=32 ml/m(2) (p = 0.003), left ventricular (LV) mass/height >/=120 g/m (p = 0.014), LV systolic dysfunction (p < 0.001), and LV diastolic dysfunction (p = 0.029) were independent predictors. A risk-scoring algorithm was developed and validated for the prediction of first events. The five-year event-free survival was 90%, 74%, and 50% for low-, medium-, and high-risk groups, respectively. CONCLUSIONS: Echocardiography enhanced prediction of first cardiovascular events in this referral-based elderly cohort. Its role in risk stratification for primary prevention of these events in the community warrants further investigations.

Age Factors↗
PubMed2002

Left ventricular hypertrophy in hypertension as a predictor of coronary events: relation to geometry.

The present review examines epidemiological evidence for a relation of left ventricular hypertrophy with coronary heart disease, and mechanisms that may represent pathophysiological links between left ventricular hypertrophy and coronary events. Left ventricular hypertrophy has been demonstrated to be a powerful predictor of coronary heart disease, and when geometry is concentric the relation is even stronger. In addition to its association with risk factors for atherosclerosis and mechanisms that precipitate acute heart attacks, left ventricular hypertrophy also directly predisposes to and aggravates clinical presentation of coronary heart disease through a number of biological mechanisms. These include the following: increase in oxygen requirement related to left ventricular geometry; coronary hypertension, with endothelial dysfunction and reduced coronary reserve; diastolic dysfunction; and structural remodelling of myocardium and vascular bed. Some of these alterations are also worsened by underlying coronary heart disease, and can potentially be maintained by loop mechanisms. A recognizable stage of abnormal coronary haemodynamics in the context of left ventricular hypertrophy is probably that at which coronary reserve is impaired in the absence of any other sign of heart disease; in many circumstances, this may occur early in the disease process.

Coronary Disease↗
PubMedDate not supplied

Assessment of left atrial appendage flow velocity and its relation to spontaneous echocardiographic contrast in 89 cats with myocardial disease.

The hypotheses of this prospective study were that (1) left atrial appendage (LAA) blood flow velocities can be recorded in cats with myocardial disease by transthoracic Doppler echocardiography, (2) LA enlargement, LA mechanical dysfunction, and left ventricular (LV) diastolic abnormalities are associated with decreased LAA flow velocities, and (3) low LAA flow velocities predict the appearance of spontaneous echocardiographic contrast in cats with cardiomyopathy. Transthoracic 2-dimensional, M-mode, and Doppler echocardiographic studies were performed in 89 cats with hypertrophic, restrictive, dilated, or unclassified cardiomyopathy or with hyperthyroid heart disease. Maximal LAA flow velocity (LAAmax) was decreased (P < .001) in cats with cardiomyopathy (median, 0.28 m/s; range, 0.08-1.35) compared to normal cats. Associated with decreased LAA flow velocities were increased LA size, decreased LA function, increased severity of LV diastolic dysfunction, and the presence of congestive heart failure. Multivariate logistic regression analysis detected an LAAmax <0.20 m/s as the only independent variable to predict LA spontaneous echocardiographic contrast (odds ratio, 30.1; 95% confidence interval [CI], 4.1 222.3; P < .001). Receiver operating characteristic analysis performed to predict spontaneous echocardiographic contrast indicated an area under the curve of 0.88 (95% CI, 0.80-0.95; P < .001) with sensitivities of 100 and 74% and specificities of 69 and 83% for LAAmax <0.25 and <0.20 m/s, respectively. Thus, low LAA flow velocities identified a subgroup of patients at increased risk of spontaneous echocardiographic contrast and possible thromboembolism. These findings may have important clinical implications for anticoagulation therapy and prognostication in cats with cardiomyopathy.

Animals↗
PubMed2005

Proinflammatory cytokines, soluble Fas receptor, nitric oxide and angiotensin converting enzyme in congestive heart failure.

We measured serum interleukin-2 receptor (sIL-2R), tumor necrosis factor-a (TNF-a), Fas receptor (sFas), nitric oxide (NO), and angiotensin converting enzyme (ACE) activity in 45 patients with congestive heart failure (CHF) of different etiologies. The relatioship between these bioindices and the severity of heart failure was analysed. Patients were classified according to the etiology of heart failure into: 15 patients with rheumatic valvular heart disease (RHD), 17 with ischemic heart disease (IHD) and 13 with idiopathic dilated cardiomyopathy (DCM). Patients were further classified according to severity of CHF following the New York Heart Association classification (NYHA) into: NYHA class II (n= 7), NYHA class III (n=20) and NYHA class IV (n=18). Eighteen healthy subjects were included as controls. Serum sIL-2R, TNF-alpha and sFas levels were determined by ELISA while serum NO and ACE levels were measured by colorimetric methods. Doppler Echocardiography was performed for all participants. Levels of sIL-2R, TNF-alpha, sFas, NO, and ACE were significantly higher in CHF patients than controls. Levels of the bioindices varied according to the CHF etiology. TNF-a level was the only one that had significant differences among different subgroups (RHD, IHD and DCM). The levels of sIL-2R, TNF-alpha, NO and sFas in patients with NYHA class IV were significantly higher than class II or III. Moreover, sIL-2R, TNF-alpha and NO levels were significantly higher in patients with diastolic dysfunction than patients with normal diastolic function. A significant positive correlations were found between sFas and both TNF-alpha and sIL-2R and between TNF-alpha and both NO and diastolic function. In addition, significant positive correlations were found between TNF-alpha and sIL-2R in both IHD and RHD patients and between sIL-2R and both ACE in IHD patients and diastolic function in DCM patients. It is concluded that a relationship exists between immune system activation, apoptosis and renin- angiotensin system in CHF and this may play a significant role in the pathophysiology and prognosis of the disease.

Adult↗
PubMed1993

[The remote noninvasive assessment of left ventricular diastolic pressure by pulsed Doppler echography--the importance of the time of mitral protodiastolic deceleration].

UNLABELLED: To find a possible correlation between the transmitral diastolic flow, obtained by pulsed Doppler echocardiography, and left ventricular end-diastolic pressure (LVedP), we studied 95 patients (p) (58 +/- 9 years), with coronary artery disease (76 p) and dilated cardiomyopathy (19 p). P with atrial fibrillation, heart rate > 100 b/m or mitral regurgitation > 2+/4+ were excluded. We analyzed E and A wave peak velocities (v), time-velocity integrals (i) and diastolic filling intervals. Restriction to filling pattern was considered in the presence of an E wave deceleration time (DecT) < or = 120 ms (Group B- 22 p); the other 73 p (group A) ranged from abnormal relaxation to normal diastolic patterns, with DecT > 120 ms. RESULTS: -LVedP ranged from 3 to 38 mmHg in group A and from 16 to 39 mmHg in group B. In group A, the Ai/Ei ratio showed a significant linear correlation with the LVedP (r = 0.83, y = 14 chi + 2); Ai/El ratio > 1.0 identified pts with LVedP > 18 mmHg with a sensitivity of 85% and a specificity of 98%. In group B, there was a correlation between LVedP and the inverse ratio of integrals (Ei/Ai) (r = 0.72), as well as Ev/Av ratio (r = 0.69). CONCLUSIONS: In myocardial active relaxation abnormalities, Ai/Ei ratio increases proportionally to LVedP. A short DecT (< or = 120 ms) identifies a subgroup of p with predominant impairment of LV compliance and high filling pressures, in which the atrial contribution decreases as LVedP rises. Thus, whatever the prevailing mechanism of diastolic dysfunction, echo-Doppler transmitral diastolic flow can provide a noninvasive assessment of LVedP.

Adolescent↗
PubMed2003

[Effects of diazepam on intracardiac hemodynamics in patients with chronic cardiac failure].

Diazepam effects on intracardiac hemodynamics were studied in 45 patients with ischemic heart disease. The patients were divided into 3 groups: a control group (n = 13), a group with a systolic dysfunction (EF < 45%, n = 16) and a group with a diastolic dysfunction (E/A < 1.0, n = 16). Echocardiography was made before and after intravenous injection of 10 mg diazepam (relanium, "Polfa). The above diazepam injection improved heart rate and diastolic blood pressure in patients with left ventricular systolic dysfunction, cardiac pump function improved in patients with initial diastolic or systolic dysfunction. In the controls these parameters worsened. Diastolic function was not influenced much in all the three groups. Thus, combination of a sedative effect, a moderate positive action on cardiac pump function and no negative impact on diastolic filling characterizes diazepam as a stress-limiting medicine in patients with chronic cardiac failure.

Anticonvulsants↗
PubMedDate not supplied

[Effects of korinfar-retard on parameters for the left ventricular diastolic function in patients with hypertensive disease].

Enrolled in the study were 52 patients with stage II-III disordered relaxation type diastolic dysfunction of the left ventricle and that of the restrictive type. All patients underwent echocardiography and doppleroechocardiography before and after having been placed on corinfarretard, 10 to 20 mg daily. The duration of the course of treatment was in the average 19.4 +/- 1.51 days. There was an improvement in patients on the above treatment on parameters associated with the temporal patterns of the diastole, those patients with disturbed relaxation type dysfunction having derived the greatest benefit from it. In patients with restrictive type diastolic dysfunction of the left ventricle, no significant changes were revealed in the diastole related to the drug in question.

Anti-Arrhythmia Agents↗
PubMed2000

Diastolic heart failure in the community.

Although it is now widely recognized that isolated diastolic dysfunction can lead to the classic signs and symptoms of congestive heart failure (CHF), this disease process is poorly understood and remains of great interest and concern to cardiovascular disease specialists, as well as to primary care physicians. Recent epidemiologic data have suggested that diastolic heart failure is predominantly a disease of the elderly, the fastest growing segment of our population. Diagnosis is often difficult in this subgroup of patients due to the presence of confounding comorbidities. However, early identification in community-based practices and timely intervention is important due to the significant disability and death that results from this progressive disease process. The poor prognosis of CHF patients with systolic dysfunction is shared by those with isolated diastolic heart failure and preserved systolic function. Further studies of the prevalence, clinical characteristics, and natural history of patients with diastolic dysfunction are needed. This review focuses on the emerging data regarding the prevalence and natural history of diastolic heart failure in the community.

Diastole↗
PubMed2001

Congestive heart failure. Correlation between functional class and systolic and diastolic functions assessed by Doppler echocardiography.

OBJECTIVE: To evaluate the influence of systolic or diastolic dysfunction, or both on congestive heart failure functional class. METHODS: Thirty-six consecutive patients with a clinical diagnosis of congestive heart failure with sinus rhythm, who were seen between September and November of 1998 answered an adapted questionnaire about tolerance to physical activity for the determination of NYHA functional class. The patients were studied with transthoracic Doppler echocardiography. Two groups were compared: group 1 (19 patients in functional classes I and II) and group 2 (17 patients in functional classes III and IV). RESULTS: The average ejection fraction was significantly higher in group 1 (44.84 % +/- 8.04 % vs. 32.59 % +/- 11.48 % with p = 0.0007). The mean ratio of the initial/final maximum diastolic filling velocity (E/A) of the left ventricle was significantly smaller in group 1 (1.07 +/- 0.72 vs. 1.98 +/- 1.49 with p = 0.03). The average maximum systolic pulmonary venous velocity (S) was significantly higher in group 1 (53.53 cm/s +/- 12.02 cm/s vs. 43.41 cm/s +/- 13.55 cm/s with p = 0.02). The mean ratio of maximum systolic/diastolic pulmonary venous velocity was significantly higher in group 1 (1.52 +/- 0.48 vs. 1.08 +/- 0.48 with p = 0.01). A predominance of pseudo-normal and restrictive diastolic patterns existed in group 2 (58.83 % in group 2 vs. 21.06 % in group 1 with p = 0.03). CONCLUSION: Both the systolic dysfunction index and the patterns of diastolic dysfunction evaluated by Doppler echocardiography worsened with the evolution of congestive heart failure.

Diastole↗
PubMed1998

Doxorubicin cardiotoxicity: diastolic cardiac myocyte dysfunction as a result of impaired calcium handling in isolated cardiac myocytes.

We examined intracellular calcium transients of isolated single cardiac myocytes from rats with doxorubicin (DOX)-induced cardiomyopathy with simultaneous measurement of cell motion. DOX was administered i.p. to Sprague-Dawley rats at 2.5 mg/kg once a week for 10 weeks. Field-stimulated calcium transients and simultaneous cell motion in single myocytes were measured in the presence or absence of isoproterenol using fura-2/AM. Histopathologic examination revealed slight changes. The time courses of both calcium transients and cell motion were significantly prolonged by DOX. There was a slight but not significant reduction in parameters of contractility in both calcium transients and cell motion. The beta-adrenoceptor responsiveness of both calcium transients and cell motion was not significantly impaired compared with the controls. Our data indicated that, despite the slight histologic changes in the heart in DOX-induced cardiomyopathy, impaired sequestration of intracellular free calcium ions in individual myocytes may be one factor leading to diastolic dysfunction. Monitoring of diastolic function is important to detect early cardiotoxicity caused by DOX.

Animals↗
PubMed2001

Left ventricular diastolic function in systemic sclerosis.

OBJECTIVE: To assess left ventricular diastolic function in patients with systemic sclerosis (SSc) and to verify if a "primary" diastolic dysfunction might exist. METHODS: In total 124 patients and 41 healthy subjects underwent complete echocardiographic examination. The following pulsed wave Doppler variables were evaluated: peak velocity during early filling (E), peak velocity during late atrial filling (A), E/A ratio, and early filling deceleration time. RESULTS: Seventy-seven patients (62.1%) had conditions potentially affecting left ventricular diastolic function (Group A) and 47 patients (37.9%) formed a homogeneous group without cardiac involvement or other causes of abnormal diastolic function (i.e., systemic and/or pulmonary hypertension, ventricular hypertrophy, pericardial disease, systolic dysfunction, valvular heart disease, coronary artery disease) (Group B). The entire SSc population and Group A showed significant differences in the Doppler variables of diastolic function compared to the control group. No significant differences were found between Group B and controls. CONCLUSION: In patients with SSc, left ventricular diastolic dysfunction was found only in patients with conditions potentially affecting left ventricular diastolic function. In patients without conditions potentially affecting left ventricular diastolic function no differences were seen in comparison with controls. SSc does not seem to cause "primary" diastolic abnormalities.

Adult↗
PubMed1992

Contributors of characteristic mitral flow velocity pattern in congestive heart failure--from clinical observations back to experimental validations.

Mitral flow velocity pattern in patients with left ventricular (LV) diastolic dysfunction usually includes decreased peak early diastolic filling velocity (E), slowed deceleration of the early diastolic filling wave and increased peak filling velocity at atrial contraction (A). However, the abnormal mitral flow velocity pattern can be normalized in the presence of concomitant congestive heart failure. In such cases E can be equal to or even higher than normal, its deceleration is normal or faster than normal value, and A can be normal or lower than normal value. Clinical observations in patients with severe heart failure showed that the mitral flow velocity pattern changes with vasodilating therapy, reflecting the changes in the left atrial (LA) to LV pressure difference rather than those in the absolute LA pressure or LV pressure alone. This was validated in the canine study in which levels of LV dysfunction were made by the injection of microspheres into the left coronary artery to study the interrelation among the mitral flow velocity pattern and LA and LV pressures. In this experiment, the changes in the mitral flow velocity pattern could not be explained by the changes in LA or LV pressure alone but was better explained by the changes in the LA to LV pressure difference. Not only LA-LV crossover pressure but also LA compliance seem to be important as determinants of LA pressure level in diastole. In addition to LV relaxation rate, incompleteness of relaxation, elastic recoil and LV passive elastic properties, extracardiac constraint is also considered to be an important determinant of the level of the LV diastolic pressure and hence of the mitral flow velocity pattern at least in the presence of congestive heart failure. Thus, mitral flow velocity pattern is determined by the interaction of LA and LV pressures, both of which are affected by chamber properties as well as loading conditions.

Animals↗
PubMed2001

Medical management of mild-to-moderate heart failure before the advent of beta blockers.

Clinical trials of beta blockers in heart failure have generally required that patients be receiving optimal drug therapy before randomization to the study medication. Therefore, because beta blockers are used in addition to conventional drug therapy, review of the standard drug therapy of mild-to-moderate heart failure before the advent of beta blockade is essential to understanding the role of beta blockers in the treatment of heart failure. The conventional medical management of systolic heart failure includes angiotensin-converting enzyme (ACE) inhibitors, which should be used as first-line therapy; diuretics, for the management of body fluid-volume excess; digoxin; and some other vasodilators. These therapies have been evaluated in large-scale, randomized, controlled trials. ACE inhibitors have been shown to significantly attenuate disease progression and improve outcome (ie, morbidity and mortality) in patients with mild-to-moderate systolic heart failure. Controversial or unproven therapies include nonglycoside inotropic agents, angiotensin II receptor antagonists, antiarrhythmic agents, anticoagulants, and calcium channel blockers. The pharmacologic management of diastolic heart failure is largely empirical and is directed at reducing symptoms. Symptoms caused by increased ventricular filling pressures may be treated with diuretics and long-acting nitrates. Some calcium channel blockers and most beta blockers prolong diastolic filling time by slowing heart rate, thereby potentially improving the symptoms of diastolic heart failure. Calcium antagonists, beta blockers, diuretics, and ACE inhibitors may also promote regression of left ventricular hypertrophy and thus improve ventricular compliance, possibly preventing the development of diastolic dysfunction. Because randomized controlled trials of diastolic heart failure are lacking, this review focuses on the conventional management of mild-to-moderate systolic heart failure before the advent of beta blockade.

Angiotensin II↗