[New concepts on the physiopathology of cardiac insufficiency: diastolic and systolic dysfunction].
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Blood Pressure↗
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Heart failure: management of patients with left ventricular systolic dysfunction. Agency for Health Care Policy and Research.
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Heart Failure↗
Blockade of the renin-angiotensin system. Effect on mortality in patients with left ventricular systolic dysfunction.
Blockade of the renin-angiotensin-aldosterone system (RAAS) has been shown to be effective in reducing morbidity and mortality in patients with symptomatic left ventricular dysfunction. Angiotensin converting enzyme inhibitors (ACE-I) should be administered to all patients with symptomatic left ventricular dysfunction unless contraindicated or not tolerated. Although ACE-Is are effective, there is reason to believe that further blockade of the RAAS by aldosterone antagonists and/or alternative means of blocking the RAAS by use of renin inhibitors or angiotensin II receptor blocking agents may have an important role in the future. The finding in the SOLVD and SAVE trials that ACE-Is are effective in reducing recurrent ischemic events in patients with left ventricular dysfunction also holds great promise for the future, not only for patients with left ventricular dysfunction but also as a possible secondary prevention of ischemic heart disease in patients without left ventricular dysfunction.
Angiotensin-Converting Enzyme Inhibitors↗
[Is the treatment of left ventricular systolic dysfunction different according to the etiology?].
Cardiac failure is the terminal stage of evolution, the finality of many valvular, vascular, myocardial, general, congenital or acquired conditions. The therapeutic decisions should be based on the search for a curable cause of a predisposing factor and the evaluation of the severity of the cardiac failure. At advanced stages of ventricular dysfunction when the myocardial lesions are constituted, when cardiac and vascular remodelling has occurred, the aetiological treatment, which is the constant objective, is unfortunately too late. The treatment is the same, whatever the aetiology, in order to improve functional problems. At early stages, and, if possible, preventively, surgery, revascularisation techniques, the correction of an arrhythmia, the suppression of a cardiotoxic factor, are essential. The different therapeutic classes used could have different efficacies depending on the aetiology, but, finally, this point is negligible: the medications are based on the results of large scale, controlled, therapeutic trials.
Cardiovascular Surgical Procedures↗
Obesity and the heart.
Obesity can result in alterations in cardiac structure and function even in the absence of systemic hypertension and underlying organic heart disease. Increased total blood volume creates a high cardiac output state that may cause ventricular dilatation and ultimately eccentric hypertrophy of the left (and possibly the right) ventricle. Eccentric left ventricular (LV) hypertrophy produces diastolic dysfunction. Systolic dysfunction may ensue due to excessive wall stress if wall thickening fails to keep pace with dilatation. This disorder is referred to as obesity cardiomyopathy. The presence of systemic hypertension in obese individuals facilitates development of LV dilatation and hypertrophy. Congestive heart failure may occur in such individuals, and may be attributable to LV diastolic dysfunction or to combined LV diastolic and systolic dysfunction. The sleep apnea/obesity hypoventilation syndrome occurs in 5% of morbidly obese individuals and is potentially life-threatening. Treatment of obesity cardiomyopathy consists of weight loss, salt restriction, and diuretics. Digitalis and vasodilators may be useful in selected cases. Central obesity is probably a risk factor for the development of coronary heart disease. Alterations in lipid and insulin metabolism may facilitate development of coronary heart disease in obese patients.
Heart Diseases↗
Role of mechanical and hormonal factors in cardiac remodeling and the biologic limits of myocardial adaptation.
Patients with chronic congestive heart failure manifest > or = 1 of the following abnormalities: diastolic dysfunction, systolic dysfunction, and arrhythmias. Diastolic dysfunction, one of the first symptoms to occur during hypertensive cardiopathy, depends on both active relaxation of the cardiac muscle and passive ventricular compliance. The ability of the ventricles to relax depends on normal calcium metabolism and adenosine triphosphate concentration. Ability to extrude intracellular calcium is depressed in the hypertrophied, overloaded heart as compared with the normal myocardium. Myocardial fibrosis is the major cause of increased diastolic ventricular stiffness. Left ventricular (LV) hypertrophy and myocardial fibrosis also greatly increase the likelihood of ventricular arrhythmias, in particular by prolonging the QRS interval and facilitating the occurrence of reentry arrhythmias. Findings in animal studies have indicated that such fibrosis, which involves excessive collagen deposition, is independent of LV hypertrophy and that LV hypertrophy does not necessarily result in myocardial fibrosis. Instead, the development of myocardial fibrosis is sensitive to circulating levels of both angiotensin II and aldosterone, and the fibrotic response to each of these substances is independent. The aldosterone antagonist spironolactone prevents myocardial fibrosis in several animal models, thus confirming the importance of aldosterone in the genesis of excessive collagen deposition.
Adaptation, Physiological↗
Effects of lisinopril on congestive heart failure in normotensive patients with diastolic dysfunction but intact systolic function.
This study examined the effects of lisinopril on diastolic function in 12 normotensive patients (mean age 72 years) with symptomatic congestive heart failure, intact left ventricular systolic function and abnormal diastolic function secondary to ischaemic heart disease in a placebo-controlled double blind crossover study, with each treatment dosed orally for 5 continuous weeks. Compared to placebo, lisinopril significantly decreased blood pressure, increased plasma renin activity without altering heart rate or plasma norepinephrine. There was no statistically significant improvement with lisinopril in radionuclide derived peak filling rate and time to peak filling rate, in Doppler echocardiographic measurements of the ratio of peak flow velocity in early diastole to the peak flow velocity of atrial contraction (E:A ratio) and in visual analogue scales of symptoms. Thus, although angiotension converting enzyme inhibitors may have an established role in the treatment of heart failure secondary to left ventricular systolic dysfunction, its use in patients with isolated diastolic dysfunction remains unclear.
Aged↗
Which left ventricular function is impaired earlier in the evolution of diabetic cardiomyopathy? An echocardiographic study of young type I diabetic patients.
OBJECTIVE: To determine whether diastolic dysfunction preceded systolic dysfunction in the evolution of diabetic cardiopathy. RESEARCH DESIGN AND METHODS: A total of 157 young (mean age 26.6 years) cardiac asymptomatic type I diabetic patients and 54 age- and sex-matched healthy (nondiabetic) subjects were studied. The severity of diabetic complications (retinopathy, nephropathy, and cardiac autonomic neuropathy) was evaluated by the diabetic complication index (DCI), a sum of individual scores for each complication. Left ventricular (LV) function was studied by M-mode echocardiography. Impaired systolic and diastolic functions were presumed if at least two echocardiographic variables for systolic function (fractional shortening [FS], mean velocity of circumference fiber shortening, and stroke index) and for diastolic function (slope of anterior mitral leaflet in early diastole, isovolumic relaxation time [IRT], and left atrium emptying index) were out of the control range (mean +/- 2 SD). RESULTS: Diastolic dysfunction was twice as common as systolic dysfunction (27% and 12%, respectively, P < 0.001). Of diabetic patients with systolic dysfunction, 83% had impaired diastolic function, whereas only 30% of diabetic patients with diastolic dysfunction had systolic damage (P < 0.001). On the other hand, only 3 of 157 diabetic patients (1.9%) had systolic dysfunction with preserved diastolic function (P > 0.05). Diastolic dysfunction, represented by the interval from minimal LV dimension to mitral valve opening, was seen in diabetic patients approximately 8 years after onset of diabetes and systolic dysfunction represented by FS after approximately 18 years. Diastolic dysfunction, represented by IRT, was found in the presence of mild complications (DCI = 2), and systolic dysfunction, represented by FS, was found in the presence of more severe complications (DCI = 4). CONCLUSIONS: Our findings indicate that myocardial damage in patients with diabetes affects diastolic function before systolic function. The intentional assessment of diastolic function is advisable for early detection of LV dysfunction before clinical symptoms appear, with follow-up to detect further deterioration of cardiac status.
Adult↗
Systolic time intervals in the evaluation of thyroid dysfunction.
Systolic time intervals, the pre-ejection period (PEP), left ventricular ejection time (LVET) and PEP/LVET ratio were studied in ten thyrotoxic and ten hypothyroid patients. LVET and PEP intervals were corrected for heart rate (LVETc and PEPc). The measurements were repeated after 1-28 months when the patients were euthyroid following appropriate therapy. Compared with the euthyroid values, the PEPc intervals and PEP/LVET ratios were significantly decreased (p less than 0.01) in the thyrotoxic and increased (p less than 0.001) in the hypothyroid patients. In both groups the LVETc intervals were significantly prolonged (p less than 0.001). In four of the hypothyroid patients the PEP/LVET ratios were markedly increased (above 0.60, mean 0.66), and above 0.41 in the euthyroid state (reference value 0.35 +/- 0.05). In the other hypothyroid patients and in thyrotoxic patients the euthyroid PEP/LVET ratios were within the reference values. The systolic time intervals were not influenced by propranolol therapy in the thyrotoxic patients. Our results suggest increased myocardial contractility unaffected by adrenergic blockade in thyrotoxicosis, and reduced contractility in hypothyroidism.
Adult↗
Systolic function, readmission rates, and survival among consecutively hospitalized patients with congestive heart failure.
We sought to describe the relation between left ventricular systolic function and rates of hospital readmission and survival among consecutively hospitalized patients with congestive heart failure. Medical records were reviewed for these patients at an academic medical center between Jan. 1, 1992, and Dec. 31, 1993. Left ventricular systolic function assessments performed within 6 months before discharge were used to classify left ventricular systolic function. Hospital readmission rates and survival through Dec. 31, 1994, were compared between patients with systolic dysfunction and those with preserved systolic function. Among 412 patients hospitalized with a primary diagnosis of congestive heart failure, 224 had undergone a left ventricular function assessment during the 6 months before hospital discharge. In-hospital mortality and readmission rates were higher among patients without a recent assessment of left ventricular systolic function. Of patients with systolic dysfunction, 55% versus 41% of patients with preserved systolic function were either readmitted or had an emergency room visit within 6 months after discharge (p = 0.06). At 27 months' follow-up, cumulative survival probabilities were 65% for patients with preserved systolic function, 65% for patients with systolic dysfunction, and 60% for patients without a left ventricular systolic function assessment (p = 0.24). Patients without a recent left ventricular systolic function assessment have significantly higher hospital readmission rates than patients with a recent systolic function assessment. Among hospitalized patients, mortality rates are comparable between patients with systolic dysfunction and those with preserved systolic function. However, patients with heart failure with systolic dysfunction may have higher readmission rates.
Aged↗
Evaluation of the effect of haemodialysis on cardiac dysfunction in patients of chronic renal failure.
Thirty-eight patients with end stage renal disease who were on haemodialysis and had recurrent congestive cardiac failure were analysed. Echocardiographic findings were evaluated at start of haemodialysis and after 6 dialysis sessions. Seventeen cases (48%) had diastolic dysfunction, 11 (29%) systolic dysfunction 8 (18%) had normal echocardiogram and 2 (5%) had dilated left ventricle with normal ejection fraction. In the systolic dysfunction group the end diastolic diameter decreased after 6 dialysis sessions. In the diastolic dysfunction group the end diastolic diameter and ejection fraction decreased minimally. In the systolic dysfunction group 8 patients (42%) expired within 18 months with a mean survival of 5 months and in the diastolic dysfunction group 5 patients (28%) died within 18 months with a mean survival of 12 months.
Evaluation Studies as Topic↗
Diastolic dysfunction of the left ventricle: importance to the clinician.
Diastolic dysfunction is a relatively common problem that may be mild and asymptomatic or may present with severe disabling symptoms. It is frequently due to coronary artery disease and/or LV hypertrophy and it is especially common in the older population. Patients with diastolic dysfunction and normal systolic function are best treated with calcium channel blocking agents or beta-blocking agents (drugs that are generally avoided in patients with significant systolic dysfunction). These drugs are used in the same dosage as is used in patients with angina or hypertension. Most treatment is based on symptomatic relief, and therefore periods of cautious trial and error are the rule. When diastolic dysfunction is associated with systolic dysfunction, it may be necessary to treat both conditions, but in general, positive inotropic agents and arterial vasodilators are not useful in patients with diastolic dysfunction.
Cardiomegaly↗
Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function: clinical characteristics and drug therapy.
PURPOSE: To compare clinical characteristics of and pharmacologic therapy for hospitalized patients with congestive heart failure (CHF) and left ventricular systolic dysfunction or normal left ventricular systolic function. PATIENTS AND METHODS: Medical records were reviewed for all patients discharged with a principal diagnosis of CHF from a university hospital and a community hospital between September 1, 1991 and August 31, 1992. Pertinent medical history items and prescribed drug therapies at discharge were recorded for each patient's first calendar year admission. Patients were categorized as having either normal left ventricular systolic function or systolic dysfunction based on the results of echocardiography and radionuclide angiography or contrast ventriculogram. RESULTS: Of 298 patients with CHF, 92 (31%) had normal left ventricular systolic function. Patients with normal systolic function were older, were more often women, were less likely to have a history of coronary artery disease, and were more likely to have a history of hypothyroidism than patients with systolic dysfunction. However, the prevalence of clinical characteristics overlapped considerably between the two groups. Among patients with systolic dysfunction, 79% were discharged on a therapeutic regimen of digoxin, 65% on an angiotensin-converting enzyme inhibitor, and 26% on either a beta-blocker or a calcium channel blocker. Among patients with normal systolic function, 50% were discharged on a regimen of a beta-blocker or a calcium channel blocker and 38% were discharged on digoxin. Twenty-six percent of patients with normal systolic function and without a history of atrial fibrillation were discharged on a digoxin regimen. CONCLUSION: Hospitalized CHF patients with normal left ventricular systolic function and those with diminished left ventricular systolic function share many clinical features. Since recommended drug therapy and prognosis differ, our data underscore the importance of diagnostic testing to assess left ventricular systolic function. Drug therapy for CHF patients provides a major challenge for quality-of-care improvement.
Aged↗
Prevalence of unsuspected mitral regurgitation and left ventricular diastolic dysfunction in patients with coronary artery disease and acute pulmonary edema associated with normal or depressed left ventricular systolic function.
To define the prevalence and role of left ventricular (LV) systolic dysfunction, LV diastolic dysfunction and mitral regurgitation (MR) in patients with acute pulmonary edema, 40 patients with coronary artery disease and acute pulmonary edema were prospectively evaluated within 36 hours of presentation. LV ejection fraction and 3 parameters of LV diastolic function were measured with radionuclide ventriculography, whereas MR was assessed with Doppler echocardiography. LV ejection fraction was normal in 11 (27%) and depressed in 29 (73%) patients. Moderate or severe MR without LV diastolic dysfunction was common and equally prevalent in patients with and without LV systolic dysfunction (33 vs 38%; difference not significant). Diastolic dysfunction without MR was less frequent but equally prevalent in patients with and without systolic dysfunction (17 vs 27%; difference not significant). Two (18%) of 11 patients without and 12 (33%) of 36 patients with LV systolic dysfunction had both MR and LV diastolic dysfunction. Furthermore, MR was clinically silent and unsuspected in two-thirds of all patients with MR, regardless of a normal or depressed systolic function. These data show that there is a high prevalence of unrecognized moderate to severe MR in patients with acute pulmonary edema, regardless of the presence or absence of LV systolic dysfunction. Furthermore, the prevalence of LV diastolic dysfunction without MR is relatively low even in patients with normal LV systolic function and pulmonary edema. Thus, unrecognized MR may be an important contributor to the syndrome of acute pulmonary edema in patients with normal or depressed LV systolic function.
Aged↗
Insights into the contemporary epidemiology and outpatient management of congestive heart failure.
OBJECTIVES: To evaluate the epidemiology, prognosis, and patterns of practice in patients with chronic congestive heart failure (CHF) treated and followed at a specialized clinic. METHODS: Prospective cohort study of consecutive patients referred to and followed up in a specialized heart failure clinic between September 1989 and March 1996. RESULTS: Of the 628 patients referred, 566 were confirmed to have CHF. Mean duration of follow-up was 518 +/- 490 days (range 1 to 2192 days). Vital status was available for 99.3% of patients. Mean age at enrollment was 66 years, 68% were men, 67% had an ischemic cause of heart disease, and 78% had systolic dysfunction. Patients with preserved systolic function were older, more often female, had higher mean systolic blood pressures, and a lower prevalence of ischemic heart disease, ventricular arrhythmias, or impaired renal function when compared with those with systolic dysfunction (all P </=.001). Although there was a significant negative trend in survival with decreasing ejection fraction (P =. 03), the survival experience of those with CHF and preserved systolic function did not significantly differ from those with systolic failure (P =.25). Multiple logistic regression analysis showed increased mortality risk was associated with increasing age, New York Heart Association class IV, ischemic cause of disease, elevated serum creatinine level, use of diuretics, and systolic dysfunction, whereas use of beta-blockers was associated with reduced risk. CONCLUSIONS: Our data suggest that a specialized outpatient clinic can improve practice patterns in patients with CHF. The high mortality risk in CHF with preserved systolic function suggests the need to find efficacious (and effective) therapies for this condition.
Aged↗
Congestive heart failure: systolic and diastolic function.
There is increasing recognition that disorders of both left ventricular systolic and diastolic function can result in congestive heart failure. As such, consideration of both the filling and emptying characteristics of the left heart is needed to evaluate the hemodynamic abnormalities present in this syndrome. Considerations of the systolic (emptying) and diastolic (filling) pumping characteristics of the left heart also provides a conceptual basis to classify and understand the pathophysiology of congestive heart failure. In this context, systolic dysfunction can be defined as impaired emptying of the LV, apparent as a decreased (< 50%) effective ejection fraction (forward stroke volume divided by end-diastolic volume). Systolic dysfunction may result from impaired myocardial contractile function, increased left ventricular afterload, and/or structural abnormalities of the left heart. Diastolic dysfunction can be defined as a condition in which filling of the LV sufficient to produce an adequate cardiac output requires an elevated pulmonary venous pressure. Thus, diastolic dysfunction is clinically manifested as pulmonary congestion. Defined in this manner, the most common cause of diastolic dysfunction is systolic dysfunction. In fact, the most common symptom of patients with systolic dysfunction is dyspnea from the resulting diastolic dysfunction. Diastolic dysfunction in the setting of normal systolic function may be due to obstruction of left ventricular filling, impaired left ventricular distensibility, or extensive external compression of the LV. Treatment of diastolic dysfunction can be accomplished by relieving myocardial ischemia, improving systolic function, lowering arterial systolic pressure, and decreasing cardiac distention.
Cardiac Output↗
[Diuretics in the treatment of heart failure: current pathophysiological aspects].
From a pathophysiologic point of view heart failure can be divided into systolic and diastolic dysfunction. Systolic dysfunction is characterized by a decreased ejection fraction and increased chamber volume which can be typically found in young people with congestive cardiomyopathy. Diastolic dysfunction is associated with an enhanced filling pressure but with a normal systolic pump function. This disorder can be typically found in elderly patients with myocardial hypertrophy. Treatment of congestive heart failure includes. 1.) reduction of central blood volume (preload reduction) 2.) decrease of peripheral resistance afterload reduction) 3.) regression of myocardial hypertrophy (improving myocardial stiffness) 4.) maintenance of atrial contraction (atrial kick) 5.) decrease of heart rate (prolongation of diastolic filling time and increase in contractility) 6.) improvement of LV relaxation (positive lusitropic effect) and 7.) prevention of myocardial ischemia (improvement in contractility and relaxation). The primary goal of medical therapy is symptomatic improvement. Reduction in morbidity and mortality is only a secondary consideration. To achieve this goal ACE-inhibitors and in certain cases betablockers (cave: neg. inotropic action) are suited best. Additionally, digitalis-especially in the presence of atrial fibrillation- and vasodilators can be used to further improve quality of life. In the case of severe heart failure with or without atrial fibrillation oral anticoagulation is indicated to prevent systemic embolication. Diuretics are often used for symptomatic improvement but have no effect on long-term survival. Aldosterone antagonists (e.g, spironolactone) have a beneficial effect on LV remodeling and probably also on mortality. The role of endothelin antagonists and atriopeptidase inhibitors in the treatment of heart failure are not yet clear.
Adult↗
[The role of hypertrophy and left ventricular function on the occurrence of ventricular arrhythmias in arterial hypertension].
PURPOSE: To evaluate the role of left ventricular hypertrophy (LVH), left ventricular systolic function an other clinical parameters on prevalence and complexity of ventricular arrhythmias in hypertension. METHODS: Ventricular arrhythmias were studied in 39 hypertensives by 24 hours ambulatory electrocardiographic monitoring. Frequency and complexity of ventricular arrhythmias were compared among 3 groups: A and B, respectively without and with LVH, both with normal left ventricular function; and C with LVH and systolic dysfunction. LVH and systolic dysfunction were established echocardiographically. Linear regression analysis was performed in order to identify an independent correlation between clinical parameters and presence of arrhythmias. RESULTS: Group C patients were older and had significantly higher systolic and diastolic blood pressures, greater mass index, diastolic posterior wall thickness and end-systolic stress and increased prevalence of electrocardiographic strain. Left ventricular diastolic diameter in C group patients was increased only when compared to A group. Frequencies of cases with more than 10 ectopic ventricular beats/hour, pairs and nonsustained ventricular tachycardia episodes were all significantly increased in C when compared to B and to A. However, only left ventricular mass index or diastolic posterior wall thickness identified independently patients with ventricular arrhythmias. CONCLUSION: Left ventricular hypertrophy is the main predictor of potential high risk rhythm disturbances in hypertension.
Adult↗