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PubMed1999

[Congestive heart failure in the aged. Therapeutic management].

TOWARDS OPTIMAL CARE: It is essential to distinguish between systolic and diastolic dysfunction to achieve optimal management of patients with congestive heart failure. Data is lacking in the literature for validation of the guidelines usually applied in the elderly population. A specific analysis of therapeutic management of diastolic heart failure has never been performed. Altered response to drugs and associated disease states argue for an assessment of therapeutic options. The therapeutic objectives to test are different in the elderly population where quality of life and morbidity are more important than mortality criteria. In clinical practice, the empirical approach still predominates over evidence based medicine. THERAPEUTIC GOALS: At the acute phase, volume overload requires rapid action diuretics and a treatment of the triggering cause. For chronic situations, diet and lifestyle play a major role (reduced salt intake, regular exercise). Drug therapy, particularly converting enzyme inhibitors have been found to be quite effective. Rehabilitation and secondary preventive measures are the only validated methods proven to improve quality of life.

Aged↗
PubMed2004

Assesment of LV diastolic filling using color M-mode Doppler echocardiography: validation in new hydoraulic model.

The effect of LV properties on v(p) and the E/v(p) ratio remains a matter of debate. Therefore,the objective of this study is to explore - in a new hydraulic model - the individual contributions of LV relaxation, filling pressure and compliance in changes of E, v(p) and E/v(p) for different stages of diastolic function. A new hydraulic model, consisting of an open cylindrical LA connected to an ellipsoidal LV, is designed. E and v(p) are measured for varying values of tau (45-60-90 ms), LV compliance (0.45-1.35 ml/mmHg) and filling pressure (3-10-30 mmHg). The results are used for predicting the evolution of E, v(p) and E/v(p) during different stages of diastolic function. An increase in compliance decreases E, whereas it augments v(p). v(p) is less load-dependent than E. E decreases with delayed relaxation, increases for the case of pseudonormalisation, and becomes higher than the reference values during restrictive filling. The v(p) value is lower for the case of delayed relaxation than for the reference situation. During pseudonormalisation, the value of v(p) remains lower than the reference value but higher than the value for delayed relaxation. v(p) further decreases during restrictive filling. In conclusion, the effect of simultaneous changes in compliance and loading counterbalance changes in v(p). Therefore, under normal physiologic conditions where load and compliance are coupled, v(p) is apparently load-intensive and E/v(p) increases as filling pressure increases. Moreover, in the different stages of diastolic dysfunction, due to the interference of the co-varying relaxation, the increase in E/v(p) is more pronounced.

Biomechanical Phenomena↗
PubMed2002

Doppler characterization of left ventricular diastolic function in beta-thalassaemia major. Evidence for an early stage of impaired relaxation.

AIMS: Doppler echocardiographic studies of left ventricular diastolic function in patients with thalassaemia major have shown conflicting findings. This study was undertaken to compare Doppler echocardiographic parameters of diastolic function among a group of patients with thalassaemia major, a group with thalassaemia intermedia and a group of normal individuals. METHODS AND RESULTS: 50 patients with thalassaemia major, 38 patients with thalassaemia intermedia and 29 normal subjects were studied. All had normal systolic function. The thalassaemia intermedia patients had larger body surface area and left ventricular mass index than the thalassaemia major patients but less than the controls. The ratios between peak early and late mitral diastolic flow (E/A ratio) were comparable between the three groups. The haematocrit levels were comparable in the two study groups, but the ferritin levels were significantly higher in the thalassaemia major group (P<0.001). Using multiple regression analysis to correct for the influence of heart rate, age and body surface area, we found a prolonged isovolumic relaxation time (P<0.03) and a lower E wave (P<0.001) in the thalassaemia major group as compared to the thalassaemia intermedia group. The isovolumic relaxation time also differed significantly between the thalassaemia groups and the control (P<0.001), suggesting a state of impaired relaxation most notable in thalassaemia major that is probably due to iron overload. CONCLUSION: In patients with thalassaemia major and normal systolic function who have iron overload, the earliest sign of diastolic dysfunction is an impairment in left ventricular relaxation manifested as a prolonged isovolumic relaxation time.

Adolescent↗
PubMed2006

Impaired left ventricular filling in patients with essential hyperhidrosis: an echo-Doppler study.

Essential hyperhidrosis is a well recognized dermatologic and neurologic disorder, characterized by excessive sweating of the eccrine sweat glands. It is also associated with cardiac autonomic dysfunction because sympathetic fibers to eccrine glands of palms of the hand arise from stellate and upper thoracic ganglia, which also innervate the heart. In this study, we investigated cardiac function in patients with essential hyperhidrosis by conventional and tissue Doppler imaging methods. Eighteen subjects with essential hyperhidrosis and eighteen control subjects were included in this study. Pulsed-wave Doppler parameters of the left and right ventricles, which represent diastolic filling abnormalities, were obtained by conventional Doppler and tissue Doppler imaging. Isovolumetric relaxation time, isovolumetric contraction time, ejection time and myocardial performance index were also calculated. Mitral inflow peak early (E(M)) and late (A(M)) velocities and E(M)/A(M) ratio, which represent diastolic filling of left ventricle, were significantly lower in hyperhidrotic subjects than in controls. Also, mitral lateral annulus early and late velocities and early/late velocity ratio, reflecting diastolic filling of left ventricle, were significantly lower in hyperhidrotic subjects than those of controls. However, there were no differences between hyperhidrotic subjects and control subjects with regard to the other echocardiographic indices of left and right ventricle diastolic functions. In conclusion, decreased mitral inflow suggests left ventricle diastolic dysfunction in patients with essential hyperhidrosis. This indicates that hyperactivity of sympathetic nervous system in patient with hyperhidrosis may alter cardiac function in long term.

Adult↗
PubMed1983

Abnormal diastolic left ventricular posterior wall motion in left ventricular hypertrophy.

The left ventricular pressure-volume relationship is abnormal in left ventricular hypertrophy (LVH). As a result, the left atrium empties more slowly than normal during the rapid filling phase of diastole, producing a characteristic abnormality of diastolic aortic root motion. In order to determine whether this altered LV filling is accompanied by a derangement of diastolic LV wall motion which might be useful in identifying the presence of altered chamber compliance, the M-mode echocardiograms of 60 patients with LVH secondary to aortic stenosis, hypertrophic subaortic stenosis, or hypertension, and those of 36 normal individuals were evaluated. Patients with LVH demonstrated abnormal LV posterior wall motion manifested by prolonged phases of rapid ventricular filling and atrial contraction (p less than 0.01 and p less than 0.05, respectively). The early diastolic wall motion abnormality can be readily detected by visual inspection of the echocardiogram. These findings support the concept of diastolic dysfunction in LVH and represent another echocardiographic feature of that condition.

Adult↗
PubMed1996

Early diastolic regional function of the hypertrophied left ventricle.

We analyzed cardiac catheterization data from 7 patients with aortic stenosis and 10 patients with nonobstructive hypertrophic cardiomyopathy to compare left ventricular regional diastolic function. Left ventriculogram in the right anterior oblique projection was analyzed by the area method, and regional wall stress and regional area were computed for 4 regions in the mid-portion of the left ventricle. For each region, we assessed the percent area changes (normalized by end-diastolic regional area) and time constant for regional wall stress decrease during the isovolumic relaxation period. Regional non-uniformity during the isovolumic relaxation period was then evaluated by standard deviations for the percent area changes and for regional time constants of the 4 ventricular regions. In patients with hypertrophic cardiomyopathy, both the standard deviations for the percent area changes and the regional time constants were greater (P < 0.05) than those in patients with aortic stenosis, suggesting the presence of pronounced non-uniformity of regional relaxation in hypertrophic cardiomyopathy. The time constant of left ventricular pressure decrease during early relaxation phase was significantly greater (P < 0.01), and the early diastolic peak filling rate of the global left ventricle was significantly smaller (P < 0.05) in patients with hypertrophic cardiomyopathy. Thus, early diastolic left ventricular regional non-uniformity was more pronounced in hypertrophic cardiomyopathy than in aortic stenosis, which was associated with the impairment of relaxation and early filling of the global left ventricle. These findings suggest that different mechanisms are responsible for diastolic dysfunction in primary versus secondary myocardial hypertrophy.

Adult↗
PubMed1993

Left ventricular diastolic filling properties in diabetic patients during isometric exercise.

Left ventricular diastolic filling properties during isometric handgrip exercise were measured by pulsed Doppler echocardiography in 33 noninsulin-dependent diabetic patients with a normal ejection fraction and 15 control subjects. Diabetic patients were subdivided into two groups according to their resting left ventricular filling pattern (A/E): 18 patients were in group DM-1 (A/E < or = 1.1) and 15 patients were in group DM-2 (A/E > 1.1). At rest, A/E ratio and A wave were higher, and deceleration half-time was longer in group DM-2 than in normal subjects and group DM-1, but there was no significant difference between normal subjects and group DM-1. The A/E ratio increased significantly in all three groups during isometric handgrip exercise. However, the change in A/E from rest to peak exercise in group DM-1 (0.29 +/- 0.20) was significantly greater than in normal subjects (0.09 +/- 0.07). These results suggest that diabetes mellitus patients with normal resting left ventricular (LV) filling pattern (group DM-1) had LV diastolic filling abnormalities with isometric handgrip exercise. Doppler echocardiography with isometric handgrip exercise is useful in identifying underlying left ventricular diastolic dysfunction in diabetic patients.

Diabetes Mellitus, Type 2↗
PubMed2001

[Effects of perstarium on the systolic and diastolic functions of the myocardium in patients with chronic cardiac failure].

The aim of the study was to assess prestarium effects on systolic and diastolic cardiac functions in 38 patients with ischemic heart disease and chronic cardiac failure (NYHA functional class II-IV) by biventricular balanced radioventriculography. Both left and right ventricular diastolic dysfunction was found. A course of prestarium treatment caused different alterations in ventricular contractility. 64.2% patients of those who had right ventricular ejection fraction < 40% achieved an increase in right and left ventricular ejection fraction. Improved diastolic function of the myocardium was registered in 71% patients.

Adult↗
PubMed1996

[Myocardiopathies (XI). Restrictive myocardiopathy: concept, classification, and clinical approach].

Currently, cardiomyopathies are defined as "heart muscle diseases of unknown etiology". Restrictive cardiomyopathy is the rarest type of this disease, and the only one with no uniformly accepted diagnostic criteria. Its importance lies primarily in properly distinguishing it from constrictive pericarditis because of the direct consequences of mistakenly treating a case of constrictive pericarditis as if it were inoperable. Restrictive cardiomyopathy must be considered within the broader spectrum of diastolic dysfunction. Diagnostic criteria used show a general consensus for the diagnosis of restrictive cardiomyopathy in patients with clinical signs of heart failure in the presence of a nondilated, nonhypertrophic left ventricle with preserved contractility but abnormal diastolic function. Characteristically, right and left ventricular filling pressures are elevated and a dip and plateau diastolic pressure pattern appears. Restrictive cardiomyopathy may be either idiopathic and thus be a true cardiomyopathy in the strict sense of the term or secondary to an infiltrative disease of the myocardium. In this article we review the clinical and hemodynamic features of this disease and the different imaging techniques used in patients to help differentiate restrictive cardiomyopathy from constrictive pericarditis. Finally we study some types of restrictive cardiomyopathies.

Cardiac Catheterization↗
PubMed1998

Doppler tissue imaging quantitates regional wall motion during myocardial ischemia and reperfusion.

BACKGROUND: Quantification of regional myocardial function is a major unresolved issue in cardiology. We evaluated the accuracy of pulsed Doppler tissue imaging (DTI), a new echocardiographic technique, to quantify regional myocardial dysfunction induced by acute ischemia and reperfusion. METHODS AND RESULTS: In nine open-chest anesthetized pigs, various degrees of regional wall motion abnormalities were induced by graded reduction of left anterior descending coronary artery (LAD) blood flow. Pulsed Doppler tissue imaging was performed from an epicardial apical four-chamber view with the sample placed within the middle part of the septal wall. Peak septal velocities were calculated during systole, isovolumic relaxation, and early and late diastole. Regional myocardial blood flow and systolic and diastolic dysfunctions were assessed by radioactive microspheres and ultrasonic crystals, respectively. Ischemia resulted in a significant rapid reduction of systolic velocities and an early decrease in the ratio of early to late diastolic velocities. Both changes were detected by pulsed DTI within 5 seconds of coronary artery occlusion. The decrease in systolic velocity significantly correlated with both systolic shortening (r=.90, P<.0001) and regional myocardial blood flow (r=.96, P<.0001) during reduction of LAD blood flow. CONCLUSIONS: These results suggest that DTI may be a promising new tool for the quantification of ischemia-induced regional myocardial dysfunction.

Animals↗
PubMed2001

Diastolic function in hypertension.

Diastolic dysfunction in patients with hypertension may present as asymptomatic findings on noninvasive testing, or as fulminant pulmonary edema, despite normal left ventricular systolic function. Up to 40% of hypertensive patients presenting with clinical signs of congestive heart failure have normal systolic left ventricular function. In this article we review the pathophysiologic factors affecting diastolic function in individuals with diastolic function, current and emerging tools for measuring diastolic function, and current concepts regarding the treatment of patients with diastolic congestive heart failure.

Blood Pressure↗
PubMedDate not supplied

Late constrictive involvement of the pericardium in a case of previous myocarditis.

Constrictive pericarditis (CP) is a highly relevant disease clinically because pericardiectomy represents the only curative therapeutic approach. Previous cardiac surgery or mediastinal radiation may cause CP, however, infectious agents account for a substantial portion of CP. In this report, we present a patient with previous biopsy-proven myocarditis and positive seroconversion against coxsackievirus B3 without clinical evidence of acute pericardial involvement who developed CP after a prolonged period of time. This suggests that infectious particles primarily infecting the myocardium may lead to chronic inflammatory responses of the pericardium, thus causing CP even at late clinical stages. This case emphasizes the important fact that primary myocarditis may not only cause systolic ventricular impairment but may also induce diastolic dysfunction of the heart, either as restrictive cardiomyopathy or, as in this case, through inflammatory involvement of the pericardium, leading to CP.

Antibodies, Viral↗
PubMed2005

[Function of the left atrium in Chagas' cardiomyopathy].

OBJECTIVE: To study the function of the left atrium in carriers of dilated cardiomyopathy of chagasic etiology and relate it to the diastolic function and to the functional class. METHODS: We studied 75 chagasic with cardiomyopathy patients from July to 1999 to May to 2001, submitted to clinical exams, electrocardiogram and transesophageal echocardiogram. The left atrium function was assessed by means of the velocities in the left atrial appendix and the atrial reverse in the pulmonary vein. The control group consisted of 20 normal patients. RESULTS: The age was 48 +/- 13 years old and 69% were men. Most of patients (88%) were in functional classes I and II, under a conventional treatment for cardiac insufficiency. The fraction of ejection of the left ventricle was 39 +/- 13%. The indicators of diastolic function associate to those of systolic function and the functional class. Patients with pseudonormal or restrictive pattern of diastolic dysfunction presented a larger diameter of the left atrium, lower flow velocities in the left atrial appendix and a longer duration of the atrial reverse. There was no difference among the patients with normal pattern and abnormal diastolic relaxation in relation to the control group. CONCLUSION: The left atrial function is an important parameter in the assessment of patients with chagasic myocardiopathy and it is related to the systolic and diastolic functions of the left ventricle.

Adult↗
PubMedDate not supplied

Sensitivity and specificity of diastolic indexes for rejection surveillance: temporal correlation with endomyocardial biopsy.

Although acute diastolic dysfunction is an early sequela of the rejecting heart, reported sensitivities and specificities have varied widely when Doppler echocardiography is used for rejection surveillance. This study examines the temporal relationship between changes in Doppler echocardiographic indexes of diastolic function and sequential endomyocardial biopsies to identify possible factors accounting for false-positive and false-negative results. A total of 114 Doppler echocardiographic studies and biopsies were performed weekly in 39 patients aged 14 to 59 years during the initial 3 months after heart transplantation. All Doppler examinations were within 24 hours of biopsy and were analyzed in a blinded fashion. Onset of restrictive physiology, defined as a 15% decrease in either isovolumic relaxation time or pressure half-time, was determined by analysis of the Doppler mitral flow velocity curve.

Adolescent↗
PubMed1990

[Effects of nitrendipine on diastolic left ventricular function and hypertrophy in patients with hypertension].

To assess the effects of antihypertensive therapy on the heart, left ventricular mass and performance indices (determined by M-mode and pulsed Doppler echocardiography) were compared before and after 4-5 months of nitrendipine therapy in 19 primary hypertensive patients (stage I and II). MAP was reduced from 17.1 +/- 1.7 to 14.5 +/- 1.7 kPa (128.5 +/- 12.7 to 109.0 +/- 13.1 mm Hg), P less than 0.001. The heart rate increased from 68 +/- 8 to 70 +/- 8 beats/min (P greater than 0.05). None of the indices for systolic function (SV, SI, CO, CI, EF, FS) changed significantly (P greater than 0.05). But the indices for diastolic function (RFF, RFR, VLef, IRP, EFv, A/E) improved remarkably (P less than 0.001 or 0.05). Furthermore, a positive correlation between the increasing rate of VLef and decreasing rate of MAP (r = 0.58, P less than 0.005) was noticed. Therefore, the decreasing in arterial pressure is considered as a major relative factor in the improvement of diastolic dysfunction. The patients were divided into two groups according to LVMI: group A, 11 patients with LVMI greater than or equal to 125 g/m2; while group B, 8 patients with LVMI less than 125 g/m2. The LV diastolic relaxation index IRP improved to a greater degree in group B (P less than 0.05), although the reduction of MAP was more markable in group A (P less than 0.05). This means that factors other than arterial pressure may influence the LV diastolic relaxation. In group A, the LVMI decreased from 155.1 +/- 29.9 to 144.4 +/- 33.0 g/m2 (a reduction of 7.0 +/- 9.0%). It suggests that LV hypertrophy can be "reversed" following nitrendipine therapy in some of the hypertensive patients.

Adult↗
PubMed2003

Ventricular dysfunction in early diabetic heart disease: detection, mechanisms and significance.

The detection of preclinical heart disease is a new direction in diabetes care. This comment describes the study by Vinereanu and co-workers in this issue of Clinical Science in which tissue Doppler echocardiography has been employed to demonstrate subtle systolic and diastolic dysfunction in Type II diabetic patients who had normal global systolic function and were free of coronary artery disease. The aetiology of early ventricular dysfunction in diabetes relates to complex intramyocardial and extramyocardial mechanisms. The initiating event may be due to insulin resistance, and involves abnormal myocardial substrate utilization and uncoupling of mitochondrial oxidative phosphorylation. Dysglycaemia plays an important role via the effects of oxidative stress, protein kinase C activation and advanced glycosylation end-products on inflammatory signalling, collagen metabolism and fibrosis. Extramyocardial mechanisms involve peripheral endothelial dysfunction, arterial stiffening and autonomic neuropathy. The clinical significance of the ventricular abnormalities described is unknown. Confirmation of their prognostic importance for cardiac disease in diabetes would justify routine screening for presymptomatic ventricular dysfunction, as well as clinical trials of novel agents for correcting causal mechanisms. These considerations could also have implications for patients with obesity and the metabolic syndrome.

Coronary Disease↗
PubMed1998

Left atrial systolic and diastolic function accompanying chronic rapid pacing-induced atrial failure.

The objective of this study was to examine the hypothesis that long-term, rapid atrial pacing produces a model of atrial systolic and diastolic dysfunction but does not alter ventricular function. Eight dogs were atrially paced at 400 beats/min (3:1-5:1 ventricular response) for 6 wk and subsequently instrumented with left atrial (LA) and left ventricular (LV) sonomicrometers and micromanometers. Data were compared with those from six sham-operated controls at matched heart rates and mean LA pressures of 10 mmHg. Dogs with rapid pacing had slightly greater LA volume (10.3 +/- 4.0 vs. 7.9 +/- 4.4 ml) and reduced ejection fraction (2.2 +/- 1.4 vs. 13.0 +/- 4.0, P < 0.05), systolic ejection rate (0.3 +/- 0.1 vs. 2.8 +/- 1.2 vol/s, P < 0.05), and reservoir fraction (0.07 +/- 0.04 vs. 0.35 +/- 0.06, P < 0.05) compared with controls. LA diastolic chamber stiffness was greater after rapid atrial pacing than before (stiffness constant kc, 5.7 +/- 2.3 vs. 3.4 +/- 0.6, P < 0.05), and the ratio of transesophageal echo-determined pulmonary venous systolic to diastolic integrated flow (a measure of relative reservoir to conduit function of the LA) was less in rapidly paced dogs compared with control dogs (0.41 +/- 0.19 vs. 0.68 +/- 0.23, P < 0.05). In contrast, rapid atrial pacing did not influence LV systolic performance or lusitropy, because the LV pressure time derivative and the time constant of LV relaxation were similar in both groups. In this model of isolated atrial myopathy, increased atrial stiffness and enhanced conduit function compensate for impaired atrial booster pump and reservoir functions.

Animals↗
PubMed1998

[Left ventricular wall motion dynamics of asymmetric septal hypertrophy: assessment by intramyocardial pulsed Doppler echocardiography].

Apical pulsed Doppler tissue imaging can be used to assess the function of regional myocardium. We hypothesized that septal dysfunction might be clarified in the hypertrophic cardiomyopathy (asymmetric septal hypertrophy) by this method. Twenty-one patients with asymmetric septal hypertrophy (mean age 54.8 +/- 11 years) and age-matched 24 normal subjects (52.4 +/- 8 years) were studied. The E/A ratio measured by mitral inflow Doppler was not different between the groups (1.1 vs 1.2). E wave velocities of the septum were significantly decreased in the hypertrophy group compared to the control group (4.0 +/- 1.5 vs 8.1 +/- 2.2 cm/sec), and A wave velocities were increased in the hypertrophic septum, resulting in a significantly lower E/A ratio (0.5 +/- 0.3) compared to the E/A ratio (0.9 +/- 0.3) of the normal septum. Deceleration time of the E wave and isovolumic relaxation time were significantly prolonged in the thick septum compared to the normal septum (136 +/- 51 vs 107 +/- 28 msec, 91 +/- 36 vs 63 +/- 19 msec, respectively). In conclusion, asymmetric septal hypertrophy was characterized by diastolic dysfunction of the thickened septum. Intramyocardial pulsed Doppler echocardiography can detect regional myocardial dysfunction earlier than the mitral inflow Doppler method.

Cardiomyopathy, Hypertrophic↗