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Diastolic Heart Diastolic Heart FailureFailure
“ “The very essence of The very essence of cardiovascular medicine is cardiovascular medicine is recognition of early heart recognition of early heart failure.” Sir Thomas Lewis failure.” Sir Thomas Lewis 19331933
Carmen B. Gomez MD Carmen B. Gomez MD
Eugene Yevstratov MDEugene Yevstratov MD
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Introduction
Diastolic heart failure has emerged over the Diastolic heart failure has emerged over the last 10 years as a separate clinical entity. last 10 years as a separate clinical entity. Diastolic heart failure accounts for Diastolic heart failure accounts for approximately one third of all heart failure approximately one third of all heart failure cases, especially in an elderly population, cases, especially in an elderly population, and its natural history, with an annual and its natural history, with an annual mortality rate of 8%, is more benign than mortality rate of 8%, is more benign than other forms of heart failure with an annual other forms of heart failure with an annual mortality of 19%. A need has therefore mortality of 19%. A need has therefore grown to establish precise criteria for the grown to establish precise criteria for the iagnosis of diastolic heart failure.iagnosis of diastolic heart failure.
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Requirments for Diagnostic of the DHF
Presence of sighs or symptoms of Presence of sighs or symptoms of congestive heart failurecongestive heart failure
Presence of normal or only midly Presence of normal or only midly abnormal left ventricular systolic abnormal left ventricular systolic functionfunction
Evidence of abnormal left ventricular Evidence of abnormal left ventricular relaxation(filling,diastolic relaxation(filling,diastolic distensibility or diastolic stiffness)distensibility or diastolic stiffness)
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Pathophysiology
Impaired relaxationImpaired relaxationIncrease passive stiffnessIncrease passive stiffnessEndocardial and pericardial Endocardial and pericardial
disorderswdisorderswMicrovascular flow.Myocardial Microvascular flow.Myocardial
turgorturgorNeurohormonal regulationNeurohormonal regulation
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Epicardial or microvascular Epicardial or microvascular ischemiaischemia
Myocite hypertrophyMyocite hypertrophyCardiomyopathiesCardiomyopathiesAgingAgingHypothyroidismHypothyroidism
PathophysiologyImpaired Relaxation
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Diffuse fibrosisDiffuse fibrosis Post-infarct scarringPost-infarct scarring Myocyte hypertrophyMyocyte hypertrophy Infiltrative (amyloidosis, Infiltrative (amyloidosis,
hemochromatosis, Fabry´s disease)hemochromatosis, Fabry´s disease)
PathophysiologyIncrease Passive Stiffness
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FibroelastosisFibroelastosis Mitral or tricuspid stenosisMitral or tricuspid stenosis Pericardial constrictionPericardial constriction Pericardial tamponadePericardial tamponade
PathophysiologyEndocadial, Pericardial Disorders
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PathophysiologyEndocadial, Pericardial Disorders
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Capillary compressionCapillary compression Venouse engorgementVenouse engorgement
PathophysiologyMicrovascular Flow,Myocardial Turgor
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PathophysiologyMicrovascular Flow,Myocardial Turgor
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Upregulated renin-angiotensin Upregulated renin-angiotensin systemsystem
Volume overload of the Volume overload of the contralatetal ventriclecontralatetal ventricle
Extrinsic compression by tumorExtrinsic compression by tumor
PathophysiologyNeurohormonal Regulation, Other
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Diagnosis
Increased ventricular filling pressure with Increased ventricular filling pressure with normal systolic function.normal systolic function.
Incresed ventricular pressure with Incresed ventricular pressure with preserved systolic function and normal preserved systolic function and normal ventricular volumes.ventricular volumes.
Increased left atrial and pulmonary Increased left atrial and pulmonary capillary wedge pressure.capillary wedge pressure.
Clinical symptoms and signs.Clinical symptoms and signs.
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Clinical Signs and Symptoms
Evidence of raised left atrial pressureEvidence of raised left atrial pressure Exertional dyspnoeaExertional dyspnoea OrthopnoeaOrthopnoea Gallop soundsGallop sounds Lung crepitationsLung crepitations Pulmonary oedemaPulmonary oedema Exercise intoleranceExercise intolerance
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Pathology
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Evidence of Abnormal left Ventricular Relaxation
LVdP/dtLVdP/dt min<1100 mmHg min<1100 mmHg IVRT<30y>92 ms, IVRT30–50y>100 IVRT<30y>92 ms, IVRT30–50y>100
ms, IVRT>50y>105 msms, IVRT>50y>105 ms and/or and/or ÙÙ>48 ms>48 ms
LVEDP>16 mmHg or mean LVEDP>16 mmHg or mean PCW>12 mmHgPCW>12 mmHg
PV A Flow >35 cm . sPV A Flow >35 cm . s""11 b>0·27b>0·27 and/or band/or b**>16>16
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Reduce symptomsReduce symptoms Control hypertensionControl hypertension Prevent myocardial ischemiaPrevent myocardial ischemia
There is no specific There is no specific therapy for DHFtherapy for DHF
Management of DHF
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Diuretics – Diuretics – provide the most symptoms relief if provide the most symptoms relief if fluid retentionn is a futurefluid retentionn is a future
ACE inhibitors and β Blockers – ACE inhibitors and β Blockers – complement diuretics wellcomplement diuretics well
Central sympatholytics –Central sympatholytics – hypertensive hypertensive episodesepisodes
Nitrates – Nitrates – preventing ischemiapreventing ischemia
Trimetazidine – Trimetazidine – as a metabolic supportas a metabolic support
Management of DHF
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Conclusion
Until further evidence isUntil further evidence is available from randomized available from randomized therapeutictherapeutic trials, clinicians trials, clinicians should focus on a fewshould focus on a few general general principles in the treatment ofprinciples in the treatment of DHF:DHF:
RReduce volume overload educe volume overload
SlowSlow the heart ratethe heart rate
CControl hypertension,ontrol hypertension,
RRelieve myocardial ischemia.elieve myocardial ischemia.
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Eugene Eugene Yevstratov MDYevstratov MD
FUNDACION FAVALOROFUNDACION FAVALOROINSTITUTO DE CARDIOLOGIA Y CIRUGIA INSTITUTO DE CARDIOLOGIA Y CIRUGIA
CARDIOVASCULARCARDIOVASCULAR
Carmen B. Gomez Carmen B. Gomez MDMD
http://myprofile.cos.com/eugenefox