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DI STOLIC DYSFUNCTION

AGING OR DISEASE


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Intro

CHF afflicts over 3 million Americans

400,000 new cases &800,000

hospitalizations annually

CHF : primarily a disorder of the elderly

Among the elderly, it is the most frequent

hospital discharge

consumes over 10 billion health care

dollars


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Intro

Nearly half o f HF patients have normal LV

systolic function : diastolic dysfunction

Diastolic dysfunction is a major contributorto hospital admissions

CV conditions associated with diastolic

dysfunction: particularly high prevalencein the elderly

associated with high morbidity


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Intro

Major change in demographics in North

America

mean age of population increasingsignificantly: fastest growth in 65 yrs and

older

In the US, 40% of non-interest federalmoney spending goes to this population

population of the elderly will increase x4 by

2030


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Intro

CV disease is the commonest cause of

morbidity &mortality in this group, yet few

studies elderly were systematically excluded from

the trials

Thus, CV specialists are least prepared todeal with an age group that includes most

pts with CV disease, and that is growing


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Age Related Changes


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Aging & CV Finction

Increased systemic blood pressure &

systemic vascular resistance : diastolic

dysfunction Increased LV stiffness

Change in diastolic LV filling pattern:

reduced early diastolic filling & increasedlate atrial filling


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Altered Diastolic Filling

Confounding influences:

1. Wide variety of CV disorders are

accompanied by altered diastolic filling;most are common in the elderly

2. Doppler parameters could be altered by

changes in HR, preload, afterload, &contractility (frequently seen with aging)

3. Practically all CV meds alter Doppler

diastolic filling


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Aging or Disease

Data showing that altered diastolic filling

pattern is, independent of confounding

factors, likely a primary, biologic agingeffect

E/A 1.2 in the young

no overlap


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Population Doppler Filling Data

Aging alone is one of the most potent

factors ( perhaps the most potent factor),

affecting the E/A ratio Aging or Disease?

CHS data : examining diastolic filling in

5000 community-dwelling elderly

Figure 3


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CHS Data

E/A average 1.0 in the elderly subgroup of

subjects 65-100, with range of 0.65-1.50

Also, substantial overlap between thishealthy subgroup & subgroups with

manifest CV disease, including HTN, HF,

ischemic heart disease Figure 4


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Aging or Disease

Aside from normative reference ranges

(Figure 3 & 4), three additional factors can

aid in determining abnormal from normal: 1. Filling patterns

2. Early deceleration time

3. Pulmonary vein flow


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LV Diastolic Filling Pattern


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Normal Pattern

Seen in healthy young & middle-aged

persons

In sinus rhythm, there are 2 peaks indoppler diastolic filling profile

Peaks occur in response to the pressure

gradient between the LA & LV:

1. Early in diastole following mitral valve

opening when LV pressure falls below LA

pressure;


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Normal Pattern

2. Late in diastole when atrial contraction

increases LA pressure above LV pressure

Predominant rapid filling early in diastolewith modest additional filling during atrial

contraction

Quantified by measuring the peak earlydiastolic flow velocity (E) & peak flow

velocity during atrial contraction (A), E/A>1


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Etdec

Time required for deceleration of the early

diastolic flow (Etdec) & the rate of

deceleration are additional elements thathelp characterize LV filling pattern

In normal young & middle-aged subjects,

Etdec>190 msec Etdec most helpful

Etdec increases slightly with age


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Altered LV Filling Pattern

Delayed Relaxation Reduced peak rate & amount of early filling

Relative importance of atrial filling is

enhanced resulting in reversed E/A

Decreased peak rate of early filling owing

to a decreased early diastolic LA to LV

pressure gradient, caused by a slowed rateof LV relaxation

Etdec is either similar or slightly prolonged


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Delayed Relaxation

Can be seen in pts with LVH, arterial HTN,

CAD

Most are asymptomatic, & vigorous atrialcontraction compensates for the reduced

early filling caused by impaired LV

relaxation This pattern is normally seen in healthy

older persons

NOT ABNORMAL


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Pseudo-Normalization

Abnormal

E/A >1 as seen in young normals (only the

young pattern can be normal!!!)

Pattern seen in patients with more severe

impairment of diastolic function

results from an increase in LA pressure thatcompensates for the slowed rate of LV

relaxation


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Pseudo-normalization

Restores early diastolic LV pressure

gradient to the baseline level seen in

younger persons shortened early deceleration time (Etdec)

owing to increased LV stiffness

Animal studies have shown that there is afixed relationship between Etdec & LV

chamber stiffness(shortened Etdec)


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Pseudo-Normalization

Relatively uncommon

false-positive pattern seen with

significant MR, which is more common inthe elderly

In false -positive pseudo-normalization

Etdec is normal


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Restrictive pattern

Early filling is increased abnormally, even

above that seen in young normals,

exceeding the filling velocity seen duringatrial contraction

E/A increased abnormally, often greater

than two increased early filling results from an

increase in LA pressure that more than

offsets delayed LV relaxation


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Restrictive pattern

The deceleration rate of early flow is rapid

because of increased LV stiffness

short Etdec

This pattern is seen in pts with severe

diastolic dysfunction, pulmonary

congestion, end-stage DCM imparts substantially increased mortality

its prognostic power persists regardless of

age


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Pattern Summary

Each abnormal pattern results from a

variable combination of delayed early

relaxation, increased LA pressure, andincreased LV chamber stiffness

a continuum from normal to severe

diastolic dysfunction Unifying themes: increasing LV chamber

stiffness & decreasing Etdec


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Diastolic Heart Failure

HF is the commonest hospital discharge

diagnosis in the elderly

HF in the elderly is the major cause of death& disability in US: fatality up to 25%; 90-day

hospital readmission up to 50%

DHF is a clinical syndrome manifested by HFsymptoms & normal or even small LV cavity

size with thickened walls & nl LV EF


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DHF

First descibed by Luchi et al in 1982

Luchi suggested this syndrome could

account for 1/3 to 1/2 of cases of CHF

It has also been found that compared with

those with reduced EF, those with a normal

EF were much more likely to be women Population-based databases (CHS) suggest

that over 50% of the elderly with CHF have

nl EF


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DHF pathophysiology

Pts with this syndrome have an inability to

increase stroke volume by Frank-Starling

mechanism despite severely increased LVfilling pressure, indicative of diastolic

dysfunction

Severe exercise intolerance due to areduction in exercise cardiac output and

early lactate formation


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DHF

Primary symptom, similar to systolic

dysfunction, is exercise intolerance,

manifested as exertional dyspnea & fatigue increased prevalence of systemic

hypertension in diastolic HF

Severe HTN is frequently present during theearly phases of acute episodes of CHF in

such pts


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DHF

Systemic HTN increases afterload

LV diastolic relaxation is sensitive to

increased afterload

Neurohormonal activation: atrial

natriuretic peptide & barin natriuretic

peptide have been found to besubstantially elevated, similar to systolic

dysfunction


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DHF Summary

Hallmarks of the syndrome: older age,

female preponderance, a history of

hypertension, nl or small LV cavity size withsignificant hypertrophy, normal or

supernormal contractility, increased LV

filling pressure, and increasedneurohormonal activation


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DHF Summary

Therapeutic goals should include: mild

reduction in LV filling pressure, controlling

systemic arterial pressure, LVH regression,improving LV diastolic distensibility, and

mitigating the effect of neuroendocrine

activation.

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