Contribution of left ventricular diastolic dysfunction to heart failure regardless of ejection fraction

doi:10.1016/j.amjcard.2004.11.006

The American Journal of Cardiology

Volume 95, Issue 5, 1 March 2005, Pages 603-606

https://doi.org/10.1016/j.amjcard.2004.11.006 Get rights and content

Heart failure (HF) has been classified as systolic and diastolic based on the left ventricular ejection fraction. We hypothesized that left ventricular diastolic dysfunction is an important element of HF regardless of ejection fraction. Two hundred six patients who had clinical HF were compared with 72 age-matched controls. Diastolic dysfunction, as assessed by the mitral filling pattern and tissue Doppler imaging, was present in >90% of patients who had HF regardless of ejection fraction and was more frequent and severe than in age-matched controls (p <0.001). In patients who had HF, B-type natriuretic peptide correlated with diastolic dysfunction (r = 0.62, p <0.001) but not with ejection fraction or end-diastolic volume index (EDVI). The degree of diastolic dysfunction influenced survival rate (risk ratio 1.64, p <0.05), whereas ejection fraction and EDVI did not. Systolic function measured by systolic mitral annular velocity was decreased in patients who had HF and an ejection fraction ≤0.40 (4.8 ± 1.1 cm/s) and, to a lesser extent, an ejection fraction ≥0.50 (6.6 ± 1.8 cm/s) compared with control subjects (8.0 ± 2.1 cm/s, p <0.01). Patients who had HF and an ejection fraction ≥0.50 had an increased ratio of ventricular mass to EDVI. Patients who had HF and an ejection fraction ≤0.40 had increased left ventricular EDVI. Thus, regardless of ejection fraction, patients who have HF also have diastolic dysfunction. Diastolic dysfunction is a better predictor of B-type natriuretic peptide levels and mortality than ejection fraction or left ventricular EDVI. In addition to diastolic dysfunction, HF with an ejection fraction ≥0.50 is associated with mild systolic dysfunction and an increased ratio of left ventricular mass to EDVI. In HF with an ejection fraction ≤0.40, systolic dysfunction and left ventricular dilation accompany diastolic dysfunction.

Section snippets

Methods

The study protocol was approved by the institutional review board of Wake Forest University School of Medicine (Winston-Salem, North Carolina). We studied 206 consecutive patients who were found to have clinical evidence of HF (New York Heart Association class ≥II) when evaluated by a faculty cardiologist at Wake Forest University School of Medicine according to previously published criteria.² Each patient had a contemporaneous (0.7 ± 1.9 days) serum B-type natriuretic peptide (BNP)

Patient characteristics

Characteristics of patients are presented in Table 2. The etiology of HF, was considered to be coronary artery disease or hypertension in 90% of patients. Hypertension and coronary artery disease were common regardless of ejection fraction.

Diastolic dysfunction

Diastolic dysfunction assessed by left ventricular filling pattern (Table 3) or diastolic mitral annular velocity (Figure 1) was present in patients who had HF regardless of ejection fraction.

Systolic function

Systolic function assessed by peak systolic mitral annular velocity

Discussion

We found that left ventricular diastolic dysfunction as assessed by left ventricular filling pattern and early diastolic mitral annular velocity is abnormal in patients who have HF, regardless of ejection fraction. Although mild diastolic dysfunction may be present in elderly patients who do not have HF, diastolic dysfunction is more common and more severe in patients who have HF than in age-matched controls. Further, serum BNP levels and subsequent mortality in patients who have HF are related

Acknowledgment

We gratefully acknowledge the secretarial assistance of Amanda Burnette, BS.

References (20)

S. Brucks et al.
Relation of anemia to diastolic heart failure and effect on outcome
Am J Cardiol
(2004)
M.J. Garcia et al.
New Doppler echocardiographic applications for the study of diastolic function
J Am Coll Cardiol
(1998)
C.P. Appleton et al.
The echo-Doppler evaluation of left ventricular diastolic function: a current perspective
Cardiol Clin
(2000)
R.W. Troughton et al.
Plasma B-type natriuretic peptide levels in systolic heart failure: importance of left ventricular diastolic function and right ventricular systolic function
J Am Coll Cardiol
(2004)
J.M. Brophy et al.
A multivariate model for predicting mortality in patients with heart failure and systolic dysfunction
Am J Med
(2004)
W.C. Little et al.
Clinical evaluation of left ventricular diastolic performance
Prog Cardiovasc Dis
(1990)
H. Hasegawa et al.
Diastolic mitral annular velocity during the development of heart failure
J Am Coll Cardiol
(2003)
D.W. Kitzman et al.
Importance of heart failure with preserved systolic function in patients ≥65 years of ageCardiovascular Health Study Research Group Cardiovascular Health Study
Am J Cardiol
(2001)
M.M. Redfield
Understanding “diastolic” heart failure
N Engl J Med
(2004)
D.W. Kitzman et al.
Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure
JAMA
(2002)

There are more references available in the full text version of this article.

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: This study was supported in part by research grant AG18915 from the National Institute on Aging, Bethesda, Maryland.

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Heart failureContribution of left ventricular diastolic dysfunction to heart failure regardless of ejection fraction

Section snippets

Methods

Patient characteristics

Diastolic dysfunction

Systolic function

Discussion

Acknowledgment

Am J Cardiol

J Am Coll Cardiol

Cardiol Clin

J Am Coll Cardiol

Am J Med

Prog Cardiovasc Dis

J Am Coll Cardiol

Am J Cardiol

Understanding “diastolic” heart failure

N Engl J Med

Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure

JAMA

Heart failure
Contribution of left ventricular diastolic dysfunction to heart failure regardless of ejection fraction