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Diastolic heart failure: Can we afford to be in diastole?
Heart, Lung and Circulation 2003; 12: 119–122
Editorial Diastolic Heart Failure: Can We Afford to be in Diastole? Dominic Y. Leung, MB BS, FRCP (Edin), FRACP, FACC, PhD Senior Staff Cardiologist, Liverpool Hospital and Conjoint Associate Professor, University of New South Wales, New South Wales, Australia
C
ongestive heart failure, the leading cause of hospital admission in Australia and around the world, is a modern epidemic. It presents a major public health problem with its rapidly increasing prevalence, high morbidity, poor prognosis, frequent hospital admissions and the resultant heavy demand on health resources. Although left ventricular systolic dysfunction has been the most studied underlying mechanism for congestive heart failure, a proportion of these patients are found to have ‘preserved’ systolic function. When systolic dysfunction cannot be blamed as the cause of heart failure, the blame is shifted onto diastolic function. Therefore, the diagnosis of diastolic heart failure has largely been a diagnosis by exclusion. Diastolic heart failure is a loosely defined syndrome without standardised and universally accepted diagnostic criteria and is reported to account for up to 50% of patients with congestive heart failure.1–4 Although there have been a number of pathophysiological definitions of diastolic heart failure,5,6 the definition offered by the European Study Group on diastolic heart failure is more clinically applicable. Diastolic heart failure is considered to be present when there are signs and symptoms of congestive heart failure in the presence of preserved left ventricular systolic function and abnormal diastolic function.7 Inherent in the diagnosis of diastolic heart failure are the documentation of ‘preserved’ systolic function and the assessment of diastolic function. Preserved systolic function has been variably defined as normal or near normal systolic function with variable cut-offs of the time-honoured (but imperfect for obvious reasons) left ventricular ejection fraction.3,8 A patient with a normal ejection fraction with resting wall motion abnormalities, in fact, cannot be considered to have normal systolic function. The timing of the assessment of left ventricular
function is important, because left ventricular systolic dysfunction as a result of coronary ischaemia and hypertensive heart disease, leading to heart failure, may be transient. Paroxysmal tachyarrhythmia may escape detection and valvular function (mainly regurgitant lesions) may be dependent on loading condition. Furthermore, assessment of left ventricular function is traditionally carried out at rest and a normal resting function does not necessarily mean normal function during exercise. Our limited ability to reliably and easily assess diastolic function has been the main obstacle in the positive diagnosis of diastolic heart failure. Doppler echocardiography is the most extensively used technique to evaluate both systolic and diastolic function. According to the patterns of left ventricular inflow by pulsed wave Doppler, diastolic dysfunction has traditionally been classified (erroneously I think) into stages of normal diastolic function, abnormal or delayed relaxation, pseudonormal pattern and restrictive pattern, as diastolic function worsens.9 Furthermore, pulmonary venous flow patterns have also been used to help characterise the pseudonormal pattern.10,11 However, Doppler patterns of ventricular inflow are not only loading condition dependent,12,13 but their appearances also vary according to age.14,15 Rigid application of these Doppler patterns without considerations being given to the prevailing loading conditions and the age of the patients in the assessment of diastolic function may give erroneous diagnosis of diastolic dysfunction. Using these imperfect techniques, Redfield et al. estimated that up to 28% of the general population suffered from diastolic dysfunction and 6% suffered from systolic dysfunction.16 The age-dependency of these left ventricular inflow Doppler patterns has been recognised by the European Study Group on diastolic heart failure, which has introduced an age-adjusted
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diagnostic criteria of diastolic dysfunction.7 Furthermore, a distinction has been made between the presence of diastolic abnormalities and diastolic dysfunction. The latter is considered to be present in patients treated with diuretics or with left atrial enlargement. With these refined criteria, Fischer et al. found a much lower prevalence of diastolic abnormalities in the general population.8 Recent advances in echocardiography have allowed more precise assessment of left ventricular diastolic properties by measuring myocardial relaxation velocities with tissue Doppler imaging.17 Tissue Doppler imaging allows interrogation by Doppler ultrasound of the low velocity (typically in the range of 10 cm/s), high amplitude motion of the myocardial walls during the cardiac cycle. These myocardial velocities reflect the left ventricular motion in the longitudinal axis during the cardiac cycle and allow quantitative measures of velocities of both the apical displacement of the heart during systole (systolic function) and basal displacement during diastole (diastolic function). Although tissue Doppler velocities of the mitral annulus in diastole have also been found to be age-dependent, and age-adjusted diagnostic criteria have not been developed, they have shown great promise in allowing a loading condition-independent assessment of diastolic function.18,19 Is documentation of diastolic abnormalities necessary for the diagnosis of diastolic heart failure? To overcome the difficulties in assessing diastolic function, there have been suggestions that documentation of diastolic dysfunction is not necessary for the diagnosis of diastolic heart failure.20,21 Diastolic heart failure is considered to be definite if all three diagnostic criteria proposed by the European Study Group are met and assessment of left ventricular systolic function is carried out within 72 h of the acute event. The diagnosis is probable if the assessment is carried out more than 72 h after the event and the diagnosis is possible if signs and symptoms of congestive heart failure are present in the presence of preserved systolic function without documentation of diastolic dysfunction. Zile et al. documented (using traditional Doppler techniques and measurement of left ventricular end-diastolic pressures) that one or more of the indices of diastolic function was abnormal in all patients with heart failure and normal systolic function.20 Obviously, without assessment of diastolic function and positively diagnosing diastolic heart failure, diastolic heart failure remains a diagnosis by exclusion. Does diastolic heart failure really exist? Studies have suggested that it does.8,16,22,23 Diastolic heart failure has been found to be a disease predominantly of the elderly, with hypertension, diabetes mellitus, coronary artery disease and obesity being the consistent ‘risk factors’ with a female preponderance.3,22,24 The study published
Heart, Lung and Circulation 2003; 12
in this issue of Heart, Lung and Circulation by Mottram et al. is unique in that the nature and the spectrum of diastolic dysfunction in their patients were characterised and an attempt was made to actively diagnose diastolic heart failure.25 Incorporation of pulmonary venous Doppler pattern in the study further refined characterisation of left ventricular inflow pattern: specifically, it allowed differentiation of pseudonormal from normal inflow pattern. Furthermore, patients with a history or clinical evidence of coronary artery disease and patients with resting wall motion abnormalities (despite an overall normal function) were excluded. These exclusions, I believe, are the major strengths of this study and have allowed assessment of the true prevalence of pure diastolic heart failure in their population of patients referred for assessment of left ventricular function by echocardiography. However, newer Doppler techniques like tissue Doppler imaging and velocity of intraventricular flow propagation were not used in the study, and age-adjusted diagnostic criteria for diastolic dysfunction were not used either.26 Diastolic heart failure was found in 53 patients (5.7%) and diastolic dysfunction was confirmed by Doppler echocardiography in 38 of these 53 patients, making an overall prevalence of diastolic heart failure and diastolic dysfunction of 4.1%. Examination of the clinical characteristics of these patients showed the ‘usual suspects’: elderly, diabetes mellitus and hypertension, although there was no gender preponderance. Therefore, the authors concluded that carefully defined, isolated diastolic heart failure is uncommon and that most of the patients identified as having the disease demonstrated echocardiographic evidence of diastolic dysfunction. These findings of a low prevalence of diastolic heart failure contrast sharply with some studies, but are in keeping with others.3,16,8 Why is there such disparity in the estimation of the prevalence of diastolic dysfunction and heart failure? Can the lack of standardised diagnostic criteria explain all the variations? I believe not. A distinction needs to be made between diastolic abnormalities, diastolic dysfunction and diastolic heart failure.27 Diastolic abnormalities mean the presence of abnormalities on assessment of diastolic function. Diastolic dysfunction refers to an abnormal left ventricular mechanical function during diastole and may lead to left atrial enlargement.8 Diastolic dysfunction can occur with or without symptoms of heart failure. When symptoms and signs of heart failure are accompanied by predominant or isolated diastolic dysfunction, the clinical syndrome is called diastolic heart failure. Redfield et al. in a cross-sectional survey of 2042 randomly selected subjects, found that less than half of the patients with moderate or severe diastolic dysfunction had recognised congestive heart
Heart, Lung and Circulation 2003; 12
failure.16 The selection bias in the study by Mottram et al. may have led to an underestimation of the true prevalence of diastolic heart failure. The patients in their study were drawn from those referred to the echocardiography laboratory for assessment of left ventricular function. After patients with systolic dysfunction or regional wall motion abnormalities were excluded, patients with clinically defined diastolic heart failure were then sought and their diastolic function was assessed. Furthermore, patients with regional wall motion abnormalities were not actively excluded in other studies of the prevalence of isolated or predominant diastolic heart failure.3,16,23 Can we afford to be in diastole in the evaluation of diastolic dysfunction and heart failure? Diastolic heart failure has been considered a disease with low mortality. The lack of any proven effective treatment for diastolic dysfunction has further dampened enthusiasm for largescale clinical trials. However, recent studies have demonstrated that diastolic dysfunction is not so benign.1,16,24 The presence of even mild dysfunction was found to be predictive of all cause mortality with a hazard ratio of 8.3.16 Treatment for diastolic heart failure has been empirical as there has been no properly conducted randomised controlled trial in the treatment of patients with diastolic heart failure. As patients with isolated diastolic heart failure were found to have similar pathophysiological alterations when compared with patients with systolic dysfunction, treatments involving diuretics, betablockers, calcium antagonists (which are not useful in systolic heart failure) and angiotensin converting enzyme inhibitors are potentially useful and disease modifying in diastolic heart failure.28 Given the substantial morbidity and mortality from diastolic dysfunction and heart failure, the lack of common consensus on the diagnosis and randomised trials of treatment, we certainly cannot afford to be in diastole about diastolic heart failure. We welcome studies by Mottram et al. and await the results of randomised trials of candesartan and perindopril in the treatment of diastolic heart failure with interest.
References 1. Senni M, Tribouilloy CM, Rodeheffer RJ et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation 1998; 98: 2282–9. 2. Yamada H, Goh PP, Sun JP et al. Prevalence of left ventricular diastolic dysfunction by Doppler echocardiography: clinical application of the Canadian consensus guidelines. J. Am. Soc. Echocardiogr. 2002; 15: 1238–44. 3. Devereux RB, Roman MJ, Liu JE et al. Congestive heart failure despite normal left ventricular systolic function in a populationbased sample: the Strong Heart Study. Am. J. Cardiol. 2000; 86: 1090–96.
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4. Vasan RS, Benjamin EJ. Diastolic heart failure – no time to relax. New Engl. J. Med. 2001; 344: 56–9. 5. Brutsaert DL, Sys SU. Diastolic dysfunction in heart failure. J Card. Fail. 1997; 3: 225–42. 6. Gaasch WH. Diastolic dysfunction of the left ventricle: importance to the clinician. Adv. Intern. Med. 1990; 35: 311–40. 7. European Study Group on Diastolic Heart Failure. How to diagnose diastolic heart failure. Eur. Heart J. 1998; 19: 990–1003. 8. Fischer M, Baessler A, Hense HW et al. Prevalence of left ventricular diastolic dysfunction in the community: Results from a Doppler echocardiographic-based survey of a population sample. Eur. Heart J. 2003; 24: 320–28. 9. Rakowski H, Appleton C, Chan KL et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus on Diastolic Dysfunction by Echocardiography. J Am. Soc. Echocardiogr. 1996; 9: 736–60. 10. Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J. Am. Coll. Cardiol. 1993; 21: 1687–96. 11. Klein AL, Tajik AJ. Doppler assessment of pulmonary venous flow in healthy subjects and in patients with heart disease. J. Am. Soc. Echocardiogr. 1991; 4: 379–92. 12. Choong CY, Herrmann HC, Weyman AE, Fifer MA. Preload dependence of Doppler-derived indexes of left ventricular diastolic function in humans. J. Am. Coll. Cardiol. 1987; 10: 800–8. 13. Nishimura RA, Abel MD, Hatle LK et al. Significance of Doppler indices of diastolic filling of the left ventricle: comparison with invasive hemodynamics in a canine model. Am. Heart J. 1989; 118: 1248–58. 14. Klein AL, Burstow DJ, Tajik AJ, Zachariah PK, Bailey KR, Seward JB. Effects of age on left ventricular dimensions and filling dynamics in 117 normal persons. Mayo Clin. Proc. 1994; 69: 212–24. 15. Klein AL, Leung DY, Murray RD, Urban LH, Bailey KR, Tajik AJ. Effects of age and physiologic variables on right ventricular filling dynamics in normal subjects. Am. J. Cardiol. 1999; 84: 440–48. 16. Redfield MM, Jacobsen SJ, Burnett JC, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003; 289: 194–202. 17. Garcia MJ, Thomas JD. Tissue Doppler to assess diastolic left ventricular function. Echocardiography 1999; 16: 501–8. 18. Thomas L, Levett K, Boyd A, Leung DYC, Schiller NB, Ross DL. Compensatory changes in atrial volumes with normal aging: is atrial enlargement inevitable? J. Am. Coll. Cardiol. 2002; 40: 1630–35. 19. Sohn DW, Chai IH, Lee DJ et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J. Am. Coll. Cardiol. 1997; 30: 474–80. 20. Zile MR, Gaasch WH, Carroll JD et al. Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure? Circulation 2001; 104: 779–82. 21. Vasan RS, Levy D. Defining diastolic heart failure: a call for standardized diagnostic criteria. Circulation 2000; 101: 2118–21. 22. Masoudi FA, Havranek EP, Smith G et al. Gender, age, and heart failure with preserved left ventricular systolic function. J Am. Coll. Cardiol. 2003; 41: 217–23.
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23. Gandhi SK, Powers JC, Nomeir AM et al. The pathogenesis of acute pulmonary edema associated with hypertension. New Engl. J. Med. 2001; 344: 17–22. 24. Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J. Am. Coll. Cardiol. 1999; 33: 1948–55. 25. Mottram PM, Short L, Baglin T, Marwick TH. Is ‘diastolic heart failure’ a diagnosis of exclusion? Echocardiographic parameters of diastolic dysfunction in patients with heart failure and normal systolic function. Heart Lung and Circ. 2003; 12: 127–134.
Heart, Lung and Circulation 2003; 12
26. Greenberg NL, Vandervoort PM, Firstenberg MS, Garcia MJ, Thomas JD. Estimation of diastolic intraventricular pressure gradients by Doppler M-mode echocardiography. Am. J. Physiol. Heart Circ. Physiol. 2001; 280: H2507. 27. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure. Part I. Diagnosis, prognosis, and measurements of diastolic function. Circulation 2002; 105: 1387–93. 28. Kitzman DW, Little WC, Brubaker PH et al. Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure. JAMA 2002; 288: 2144–50.
Editorial Diastolic Heart Failure: Can We Afford to be in Diastole? Dominic Y. Leung, MB BS, FRCP (Edin), FRACP, FACC, PhD Senior Staff Cardiologist, Liverpool Hospital and Conjoint Associate Professor, University of New South Wales, New South Wales, Australia
C
ongestive heart failure, the leading cause of hospital admission in Australia and around the world, is a modern epidemic. It presents a major public health problem with its rapidly increasing prevalence, high morbidity, poor prognosis, frequent hospital admissions and the resultant heavy demand on health resources. Although left ventricular systolic dysfunction has been the most studied underlying mechanism for congestive heart failure, a proportion of these patients are found to have ‘preserved’ systolic function. When systolic dysfunction cannot be blamed as the cause of heart failure, the blame is shifted onto diastolic function. Therefore, the diagnosis of diastolic heart failure has largely been a diagnosis by exclusion. Diastolic heart failure is a loosely defined syndrome without standardised and universally accepted diagnostic criteria and is reported to account for up to 50% of patients with congestive heart failure.1–4 Although there have been a number of pathophysiological definitions of diastolic heart failure,5,6 the definition offered by the European Study Group on diastolic heart failure is more clinically applicable. Diastolic heart failure is considered to be present when there are signs and symptoms of congestive heart failure in the presence of preserved left ventricular systolic function and abnormal diastolic function.7 Inherent in the diagnosis of diastolic heart failure are the documentation of ‘preserved’ systolic function and the assessment of diastolic function. Preserved systolic function has been variably defined as normal or near normal systolic function with variable cut-offs of the time-honoured (but imperfect for obvious reasons) left ventricular ejection fraction.3,8 A patient with a normal ejection fraction with resting wall motion abnormalities, in fact, cannot be considered to have normal systolic function. The timing of the assessment of left ventricular
function is important, because left ventricular systolic dysfunction as a result of coronary ischaemia and hypertensive heart disease, leading to heart failure, may be transient. Paroxysmal tachyarrhythmia may escape detection and valvular function (mainly regurgitant lesions) may be dependent on loading condition. Furthermore, assessment of left ventricular function is traditionally carried out at rest and a normal resting function does not necessarily mean normal function during exercise. Our limited ability to reliably and easily assess diastolic function has been the main obstacle in the positive diagnosis of diastolic heart failure. Doppler echocardiography is the most extensively used technique to evaluate both systolic and diastolic function. According to the patterns of left ventricular inflow by pulsed wave Doppler, diastolic dysfunction has traditionally been classified (erroneously I think) into stages of normal diastolic function, abnormal or delayed relaxation, pseudonormal pattern and restrictive pattern, as diastolic function worsens.9 Furthermore, pulmonary venous flow patterns have also been used to help characterise the pseudonormal pattern.10,11 However, Doppler patterns of ventricular inflow are not only loading condition dependent,12,13 but their appearances also vary according to age.14,15 Rigid application of these Doppler patterns without considerations being given to the prevailing loading conditions and the age of the patients in the assessment of diastolic function may give erroneous diagnosis of diastolic dysfunction. Using these imperfect techniques, Redfield et al. estimated that up to 28% of the general population suffered from diastolic dysfunction and 6% suffered from systolic dysfunction.16 The age-dependency of these left ventricular inflow Doppler patterns has been recognised by the European Study Group on diastolic heart failure, which has introduced an age-adjusted
120
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diagnostic criteria of diastolic dysfunction.7 Furthermore, a distinction has been made between the presence of diastolic abnormalities and diastolic dysfunction. The latter is considered to be present in patients treated with diuretics or with left atrial enlargement. With these refined criteria, Fischer et al. found a much lower prevalence of diastolic abnormalities in the general population.8 Recent advances in echocardiography have allowed more precise assessment of left ventricular diastolic properties by measuring myocardial relaxation velocities with tissue Doppler imaging.17 Tissue Doppler imaging allows interrogation by Doppler ultrasound of the low velocity (typically in the range of 10 cm/s), high amplitude motion of the myocardial walls during the cardiac cycle. These myocardial velocities reflect the left ventricular motion in the longitudinal axis during the cardiac cycle and allow quantitative measures of velocities of both the apical displacement of the heart during systole (systolic function) and basal displacement during diastole (diastolic function). Although tissue Doppler velocities of the mitral annulus in diastole have also been found to be age-dependent, and age-adjusted diagnostic criteria have not been developed, they have shown great promise in allowing a loading condition-independent assessment of diastolic function.18,19 Is documentation of diastolic abnormalities necessary for the diagnosis of diastolic heart failure? To overcome the difficulties in assessing diastolic function, there have been suggestions that documentation of diastolic dysfunction is not necessary for the diagnosis of diastolic heart failure.20,21 Diastolic heart failure is considered to be definite if all three diagnostic criteria proposed by the European Study Group are met and assessment of left ventricular systolic function is carried out within 72 h of the acute event. The diagnosis is probable if the assessment is carried out more than 72 h after the event and the diagnosis is possible if signs and symptoms of congestive heart failure are present in the presence of preserved systolic function without documentation of diastolic dysfunction. Zile et al. documented (using traditional Doppler techniques and measurement of left ventricular end-diastolic pressures) that one or more of the indices of diastolic function was abnormal in all patients with heart failure and normal systolic function.20 Obviously, without assessment of diastolic function and positively diagnosing diastolic heart failure, diastolic heart failure remains a diagnosis by exclusion. Does diastolic heart failure really exist? Studies have suggested that it does.8,16,22,23 Diastolic heart failure has been found to be a disease predominantly of the elderly, with hypertension, diabetes mellitus, coronary artery disease and obesity being the consistent ‘risk factors’ with a female preponderance.3,22,24 The study published
Heart, Lung and Circulation 2003; 12
in this issue of Heart, Lung and Circulation by Mottram et al. is unique in that the nature and the spectrum of diastolic dysfunction in their patients were characterised and an attempt was made to actively diagnose diastolic heart failure.25 Incorporation of pulmonary venous Doppler pattern in the study further refined characterisation of left ventricular inflow pattern: specifically, it allowed differentiation of pseudonormal from normal inflow pattern. Furthermore, patients with a history or clinical evidence of coronary artery disease and patients with resting wall motion abnormalities (despite an overall normal function) were excluded. These exclusions, I believe, are the major strengths of this study and have allowed assessment of the true prevalence of pure diastolic heart failure in their population of patients referred for assessment of left ventricular function by echocardiography. However, newer Doppler techniques like tissue Doppler imaging and velocity of intraventricular flow propagation were not used in the study, and age-adjusted diagnostic criteria for diastolic dysfunction were not used either.26 Diastolic heart failure was found in 53 patients (5.7%) and diastolic dysfunction was confirmed by Doppler echocardiography in 38 of these 53 patients, making an overall prevalence of diastolic heart failure and diastolic dysfunction of 4.1%. Examination of the clinical characteristics of these patients showed the ‘usual suspects’: elderly, diabetes mellitus and hypertension, although there was no gender preponderance. Therefore, the authors concluded that carefully defined, isolated diastolic heart failure is uncommon and that most of the patients identified as having the disease demonstrated echocardiographic evidence of diastolic dysfunction. These findings of a low prevalence of diastolic heart failure contrast sharply with some studies, but are in keeping with others.3,16,8 Why is there such disparity in the estimation of the prevalence of diastolic dysfunction and heart failure? Can the lack of standardised diagnostic criteria explain all the variations? I believe not. A distinction needs to be made between diastolic abnormalities, diastolic dysfunction and diastolic heart failure.27 Diastolic abnormalities mean the presence of abnormalities on assessment of diastolic function. Diastolic dysfunction refers to an abnormal left ventricular mechanical function during diastole and may lead to left atrial enlargement.8 Diastolic dysfunction can occur with or without symptoms of heart failure. When symptoms and signs of heart failure are accompanied by predominant or isolated diastolic dysfunction, the clinical syndrome is called diastolic heart failure. Redfield et al. in a cross-sectional survey of 2042 randomly selected subjects, found that less than half of the patients with moderate or severe diastolic dysfunction had recognised congestive heart
Heart, Lung and Circulation 2003; 12
failure.16 The selection bias in the study by Mottram et al. may have led to an underestimation of the true prevalence of diastolic heart failure. The patients in their study were drawn from those referred to the echocardiography laboratory for assessment of left ventricular function. After patients with systolic dysfunction or regional wall motion abnormalities were excluded, patients with clinically defined diastolic heart failure were then sought and their diastolic function was assessed. Furthermore, patients with regional wall motion abnormalities were not actively excluded in other studies of the prevalence of isolated or predominant diastolic heart failure.3,16,23 Can we afford to be in diastole in the evaluation of diastolic dysfunction and heart failure? Diastolic heart failure has been considered a disease with low mortality. The lack of any proven effective treatment for diastolic dysfunction has further dampened enthusiasm for largescale clinical trials. However, recent studies have demonstrated that diastolic dysfunction is not so benign.1,16,24 The presence of even mild dysfunction was found to be predictive of all cause mortality with a hazard ratio of 8.3.16 Treatment for diastolic heart failure has been empirical as there has been no properly conducted randomised controlled trial in the treatment of patients with diastolic heart failure. As patients with isolated diastolic heart failure were found to have similar pathophysiological alterations when compared with patients with systolic dysfunction, treatments involving diuretics, betablockers, calcium antagonists (which are not useful in systolic heart failure) and angiotensin converting enzyme inhibitors are potentially useful and disease modifying in diastolic heart failure.28 Given the substantial morbidity and mortality from diastolic dysfunction and heart failure, the lack of common consensus on the diagnosis and randomised trials of treatment, we certainly cannot afford to be in diastole about diastolic heart failure. We welcome studies by Mottram et al. and await the results of randomised trials of candesartan and perindopril in the treatment of diastolic heart failure with interest.
References 1. Senni M, Tribouilloy CM, Rodeheffer RJ et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation 1998; 98: 2282–9. 2. Yamada H, Goh PP, Sun JP et al. Prevalence of left ventricular diastolic dysfunction by Doppler echocardiography: clinical application of the Canadian consensus guidelines. J. Am. Soc. Echocardiogr. 2002; 15: 1238–44. 3. Devereux RB, Roman MJ, Liu JE et al. Congestive heart failure despite normal left ventricular systolic function in a populationbased sample: the Strong Heart Study. Am. J. Cardiol. 2000; 86: 1090–96.
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4. Vasan RS, Benjamin EJ. Diastolic heart failure – no time to relax. New Engl. J. Med. 2001; 344: 56–9. 5. Brutsaert DL, Sys SU. Diastolic dysfunction in heart failure. J Card. Fail. 1997; 3: 225–42. 6. Gaasch WH. Diastolic dysfunction of the left ventricle: importance to the clinician. Adv. Intern. Med. 1990; 35: 311–40. 7. European Study Group on Diastolic Heart Failure. How to diagnose diastolic heart failure. Eur. Heart J. 1998; 19: 990–1003. 8. Fischer M, Baessler A, Hense HW et al. Prevalence of left ventricular diastolic dysfunction in the community: Results from a Doppler echocardiographic-based survey of a population sample. Eur. Heart J. 2003; 24: 320–28. 9. Rakowski H, Appleton C, Chan KL et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus on Diastolic Dysfunction by Echocardiography. J Am. Soc. Echocardiogr. 1996; 9: 736–60. 10. Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J. Am. Coll. Cardiol. 1993; 21: 1687–96. 11. Klein AL, Tajik AJ. Doppler assessment of pulmonary venous flow in healthy subjects and in patients with heart disease. J. Am. Soc. Echocardiogr. 1991; 4: 379–92. 12. Choong CY, Herrmann HC, Weyman AE, Fifer MA. Preload dependence of Doppler-derived indexes of left ventricular diastolic function in humans. J. Am. Coll. Cardiol. 1987; 10: 800–8. 13. Nishimura RA, Abel MD, Hatle LK et al. Significance of Doppler indices of diastolic filling of the left ventricle: comparison with invasive hemodynamics in a canine model. Am. Heart J. 1989; 118: 1248–58. 14. Klein AL, Burstow DJ, Tajik AJ, Zachariah PK, Bailey KR, Seward JB. Effects of age on left ventricular dimensions and filling dynamics in 117 normal persons. Mayo Clin. Proc. 1994; 69: 212–24. 15. Klein AL, Leung DY, Murray RD, Urban LH, Bailey KR, Tajik AJ. Effects of age and physiologic variables on right ventricular filling dynamics in normal subjects. Am. J. Cardiol. 1999; 84: 440–48. 16. Redfield MM, Jacobsen SJ, Burnett JC, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003; 289: 194–202. 17. Garcia MJ, Thomas JD. Tissue Doppler to assess diastolic left ventricular function. Echocardiography 1999; 16: 501–8. 18. Thomas L, Levett K, Boyd A, Leung DYC, Schiller NB, Ross DL. Compensatory changes in atrial volumes with normal aging: is atrial enlargement inevitable? J. Am. Coll. Cardiol. 2002; 40: 1630–35. 19. Sohn DW, Chai IH, Lee DJ et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J. Am. Coll. Cardiol. 1997; 30: 474–80. 20. Zile MR, Gaasch WH, Carroll JD et al. Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure? Circulation 2001; 104: 779–82. 21. Vasan RS, Levy D. Defining diastolic heart failure: a call for standardized diagnostic criteria. Circulation 2000; 101: 2118–21. 22. Masoudi FA, Havranek EP, Smith G et al. Gender, age, and heart failure with preserved left ventricular systolic function. J Am. Coll. Cardiol. 2003; 41: 217–23.
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23. Gandhi SK, Powers JC, Nomeir AM et al. The pathogenesis of acute pulmonary edema associated with hypertension. New Engl. J. Med. 2001; 344: 17–22. 24. Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J. Am. Coll. Cardiol. 1999; 33: 1948–55. 25. Mottram PM, Short L, Baglin T, Marwick TH. Is ‘diastolic heart failure’ a diagnosis of exclusion? Echocardiographic parameters of diastolic dysfunction in patients with heart failure and normal systolic function. Heart Lung and Circ. 2003; 12: 127–134.
Heart, Lung and Circulation 2003; 12
26. Greenberg NL, Vandervoort PM, Firstenberg MS, Garcia MJ, Thomas JD. Estimation of diastolic intraventricular pressure gradients by Doppler M-mode echocardiography. Am. J. Physiol. Heart Circ. Physiol. 2001; 280: H2507. 27. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure. Part I. Diagnosis, prognosis, and measurements of diastolic function. Circulation 2002; 105: 1387–93. 28. Kitzman DW, Little WC, Brubaker PH et al. Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure. JAMA 2002; 288: 2144–50.