Pulmonary Hypertension and Right Heart Dysfunction in Chronic Lung Disease
Everything To Know About Diastolic Heart Failure
Diastolic heart failure causes a stiff left ventricle that prevents the heart from relaxing between beats. Common symptoms include coughing, tiredness, and shortness of breath.
Systolic and diastolic heart failure involve the left side of the heart. Both types can eventually lead to right-ventricle heart failure over time. During diastolic heart failure, the heart cannot pump an adequate amount of blood throughout the body or has to pump with increased pressure.
However, there are important differences between the two. For example, with systolic heart failure, the left ventricle becomes weak, while with diastolic heart failure, it bulks.
There are many symptoms, causes, and treatments for this high mortality condition. Read on to learn more about diastolic heart failure.
Diastolic heart failure happens when the heart does not relax properly between beats. This means it is unable to pump blood throughout the body as it should. As a result, it has to function at a higher pressure, which can cause symptoms.
If the heart pumps less blood, less oxygen goes to vital organs and tissues.
Heart contractions and diastolic heart failure
When the heart muscles contract, known as the systolic phase, the heart twists and closes slightly — like a wringing motion.
Then, in the diastolic phase, the muscle fibers relax, unwind, and stretch.
Each of these motions is essential for allowing the heart to expand and draw blood into the ventricles.
With diastolic heart failure, the second phase of a heartbeat is challenged by its inability to relax. This means the heart must work overtime to do its job.
Diastolic vs. Systolic heart failure
Systolic and diastolic heart failure both occur in the left ventricle of the heart but can also include the right ventricle.
Systolic heart failure happens when the pumps of the heart are not strong enough to move blood around the body effectively.
Diastolic heart failure means the heart does not relax correctly between beats.
In both cases, the heart is not pumping blood as efficiently as it should.
A person can experience systolic and diastolic heart failure at the same time.
Ejection fraction
Diastolic heart failure is also known as heart failure with preserved ejection fraction (HFpEF).
Ejection fraction is how doctors measure the proportion of blood that leaves the heart each time it contracts.
A healthy heart should pump blood at an ejection fraction of 55% to 70%.
If the ejection fraction is lower than this, it can mean there is damage or heart failure involving the left ventricle, and systolic dysfunction is present.
Several factors may lead to a person being more likely to develop diastolic heart failure.
Who is most likely to have heart failure?
Heart failure is most common among older adults. Statistics show that heart failure affects around 1 in every 100 people over 50 years old and that this number doubles every decade that a person lives.
Underlying conditions
Diastolic heart failure may arise from any number of pre-existing conditions, such as:
Is it hereditary?
Diastolic heart failure may also be hereditary.
People may be more prone to the condition if they have a family history of conditions that can cause it, such as high blood pressure.
Additionally, certain types of genetic conditions link to diastolic heart failure, such as hypertrophic cardiomyopathy, an inherited heart muscle abnormality. It causes the left ventricle walls to thicken and stiffen, which could lead to diastolic heart failure.
The first is the New York Heart Association (NYHA) Functional Classification. This method examines a person's physical ability and has the following stages:
The American College of Cardiology (ACC) and AHA stages of heart failure guidelines provide an objective assessment of cardiovascular disease:
A doctor may use both of these methods to classify a person's stage of heart failure.
For example, if a person is experiencing no symptoms but their ejection fraction is 45%, they have NYHA Class I, ACC/AHA Stage B heart failure.
There is currently no cure for any kind of heart failure.
However, a person can improve their symptoms and outlook with the right treatment.
Behavioral changes
A person can take up heart-healthy habits to help treat and manage diastolic heart failure. Where necessary, these can include:
Medications
A person may require medicines that can help treat symptoms of diastolic heart failure, including:
A person can live many years after a diagnosis of diastolic heart failure, but they might need to follow a long-term treatment plan to help them manage the condition. The survival rate also strongly depends on age at diagnosis.
In 2019, researchers published a study that looked at data for 55,959 people who received a diagnosis of diastolic heart failure in the United Kingdom from 2000 to 2017.
The results suggest that, after receiving a diagnosis of diastolic heart failure, the overall chances of survival are as follows:
People who did not have to spend time in the hospital at their initial diagnosis were more likely to survive longer than those who did.
Here are some questions people often ask about diastolic heart failure.
How long can you live with diastolic heart failure?
Some 2019 research suggests that over 75% of people who receive a diagnosis of diastolic heart failure will live at least 1 more year, and over 12% will live 15 years longer or more.
Is diastolic heart failure serious?
Diastolic heart failure can be serious, but treatment can often manage it effectively, particularly with an early diagnosis. People who are in the hospital for diastolic heart failure when they receive their diagnosis are more likely to have severe symptoms, which can affect their outlook.
Which heart failure is worse, diastolic or systolic?
There is conflicting research about which condition is more serious out of diastolic and systolic heart failure.
A person's outlook depends on many factors, such as:
It is essential for people to seek medical help and follow the treatment plan to avoid potentially severe complications.
What To Know About Congestive Heart Failure
Congestive heart failure (CHF) is when the heart does not pump blood around the body efficiently. This can cause symptoms such as lung congestion and swelling due to fluid retention.
According to the Centers for Disease Control and Prevention (CDC), over 6 million adults in the United States live with heart failure.
The body relies on the heart's pumping action to deliver nutrient and oxygen-rich blood to each of its cells. In congestive heart failure (CHF), the heart cannot pump blood effectively, and the cells do not receive adequate nourishment. As a result, the body cannot function properly.
If the heart becomes weakened and cannot supply the cells with sufficient blood, it can lead to fatigue, breathlessness, and swelling due to fluid retention. Everyday activities that used to be easy may become challenging.
Heart failure can lead to severe complications, such as heart attack and cardiac arrest.
CHF can be systolic or diastolic, depending on whether it affects the heart's ability to contract or relax. This article focuses mainly on systolic CHF and its causes, symptoms, types, and treatment.
Congestion in the lungs
Fluid builds up in the lungs and causes shortness of breath, even when a person is resting, particularly when they are lying down. It can also cause a dry, hacking cough.
Fluid retention
Less blood reaches the kidneys, which can result in water retention and can cause swelling of the ankles, legs, and abdomen. It can also cause weight gain.
Fatigue and dizziness
A reduction in the amount of blood reaching the brain and other organs can cause weakness, dizziness, and confusion.
Irregular and rapid heartbeats
The heart may pump more quickly to counteract the lower volume of blood it pumps out with each contraction. It may also activate stress receptors in the body, increasing the release of stress hormones. Heart failure can increase the risk of arrhythmias that can cause these symptoms.
Many other conditions can cause similar symptoms, so it is important to see a doctor. People with a CHF diagnosis should monitor their symptoms carefully and report any sudden changes to their doctor immediately.
The stages of heart failure are:
Any condition that damages the heart muscle can cause systolic heart failure. These conditions include:
Risk factors for CHF include:
Damage to the heart's pumping action is not always reversible. Nevertheless, treatments can significantly improve a person's quality of life by keeping heart failure under control and helping to relieve many of its symptoms. Treatment can also prevent CHF from progressing.
CHF treatments include medications and surgery.
Medications for heart failure
Many medications can treat the symptoms of CHF. They include:
Controlling blood pressure and cholesterol are also important considerations for treating heart failure, and a doctor may prescribe separate medications for this.
Surgery for heart failure
Not everyone with heart failure responds to drug treatments. In some cases, a doctor may recommend surgery to address the underlying cause and help manage symptoms. Surgical procedures include:
A doctor, who may be a cardiologist, will recommend lifestyle modifications alongside medical treatment to address the underlying cause of a person's heart failure. They include:
In addition, people with heart failure should keep up to date with vaccinations, including the yearly flu shot.
If a doctor suspects heart failure, they will recommend further tests, which may include:
The doctor may also do additional tests, such as:
CHF can be life threatening, but a person's outlook will depend on the type of heart failure, the cause, the stage of the disease, and how effective treatment is.
When heart failure results from cardiomyopathy or coronary artery disease, a person typically has a less positive outlook than someone with heart failure in its earliest stage.
Complications can also affect a person's life expectancy and quality of life. They include:
This will depend on the type of CHF, the severity of the condition, and individual factors, such as overall health and age. Overall, around half of people with a diagnosis of heart failure are likely to live another 5 years or longer. For those with advanced heart failure, 10% to 20% will live 1 year or longer after diagnosis.
This will depend on the type of CHF, the severity of the condition, and individual factors, such as overall health and age. Overall, around half of people with a diagnosis of heart failure are likely to live another 5 years or longer. For those with advanced heart failure, 10% to 20% will live 1 year or longer after diagnosis.
Is congestive heart failure serious?Doctors consider CHF a serious condition, and it can be life threatening. However, this will depend on the stage and other factors. With treatment, many people continue to function and enjoy a good quality of life.
Doctors consider CHF a serious condition, and it can be life threatening. However, this will depend on the stage and other factors. With treatment, many people continue to function and enjoy a good quality of life.
What are the signs of congestive heart failure?A person with CHF may have:
A person with CHF may have:
CHF affects millions of people in the U.S. Doctors cannot always reverse the damage involved, but treatments can provide symptom relief and improve quality of life.
Anyone who experiences symptoms of heart failure should see a doctor for a diagnosis.
Chronic Heart Failure - Heart Failure With Preserved Ejection Fraction Topic Review
IntroductionChronic heart failure occurs when either the left ventricle, the right ventricle, or both require elevated filling pressures to maintain cardiac output. Heart failure is a syndrome, not a specific disease, and occurs as a final common pathway in multiple disease states.
Heart failure (HF) can be due to the following:
The section presents a review of diastolic congestive heart failure, commonly called HFpEF. Reviews of systolic congestive HF, or HFrEF, valvular heart disease, pulmonary hypertension and right HF, and high output HF are discussed elsewhere.
Pathophysiology –HFpEFLeft ventricular diastolic dysfunction is manifest when increased filling pressure (ie, left atrial, pulmonary capillary wedge and pulmonary artery diastolic pressures) is required in order to maintain cardiac output. HFpEF connotes diastolic dysfunction despite a normal ejection fraction. Diastolic dysfunction also occurs frequently in patients with HFrEF. [Hurst's The Heart Section 11:13a,14a-b,15a]
Although the renin-angiotensin-aldosterone system is activated in HFpEF, it is not as prominent as with systolic HF, and cardiac remodelling is less marked.
The figure below shows a schematic of the negative neurohormonal feedback mechanisms that become active in worsening HF:
Etiology –HFpEFSome of the underlying causes of HFpEF are listed below:
Hypertension may cause left ventricular hypertrophy (LVH) and impaired relaxation. Over time, this condition progresses, resulting in higher degrees of diastolic dysfunction, low cardiac output and symptoms of congestive HF.
Restrictive cardiomyopathies frequently involve myocardial infiltration — amyloid deposition, for instance. This results in diastolic relaxation abnormalities and, eventually, the syndrome of HFpEF.
Obstruction to LV outflow leads to left ventricular hypertrophy and diastolic dysfunction. Sustained tachycardia, such as unrecognized and uncontrolled atrial fibrillation with a rapid ventricular response, may occasionally result in HFpEF symptoms. However, more commonly, tachycardia-induced cardiomyopathy results in reduced ejection fraction.
The aging process of the heart is not well understood, but fibrotic changes in the myocardium typically occur with advanced age. This results in relaxation abnormalities that are often present by the age of 60. This can progress in the elderly, causing significant diastolic impairment and HFpEF.
Symptoms –HFpEFThe symptoms of HF include fatigue, exercise intolerance, dyspnea and eventually edema. The symptoms are similar regardless of the etiology of the heart disease, and reflect either impaired cardiac output or fluid retention. Symptoms are important in differentiating left ventricular failure from right ventricular failure.
Early in the course of left ventricular failure, the compensated right heart generates elevated pulmonary artery and wedge pressures that may result in dyspnea, pulmonary congestion or pulmonary edema.
As HF progresses, chronic elevation of pulmonary pressures lead to the development of right ventricular failure. The negative feedback mechanisms outline above result in fluid retention and systemic venous congestion.
Right HF symptoms include lower extremity-dependent edema. When the legs are elevated at night, reabsorption of extracellular fluid increases right heart preload, the fluid redistributes centrally and may cause pulmonary congestion with orthopnea (dyspnea while laying flat) or paroxysmal nocturnal dyspnea (PND). Systemic venous congestion may also lead to hepatic congestion with right upper quadrant abdominal pain.
Symptoms related to low cardiac output include fatigue, exercise intolerance and weakness. In extreme cases, cardiac cachexia can occur.
Clinical Classification –HFpEFTwo HF classification systems are widely used: the New York Heart Association (NYHA) functional classification and the American College of Cardiology and American Heart Association (ACC/AHA) staging system. [Heidenreich 2022;10a(e905)]
The NYHA system categorizes patients into one of four classes based on a health care professional's subjective assessment of the patient's symptoms:
Class I: No symptoms of HFClass II: Symptoms of HF with moderate exertion, such as walking two blocks or climbing two flights of stairsClass III: Symptoms of HF with minimal exertion such as walking one block or one flight of stairs, but no symptoms at restClass IV: Symptoms of HF at rest
The ACC/AHA staging categorizes patients into one of four stages on the basis of risk factors, cardiac structural abnormalities associated with HF and the presence of symptoms of HF: [Heidenreich 2022:10a]
Stage A: At high risk for HF but without symptoms, structural heart disease or cardiac biomarkers of stretch or injuryStage B: Pre-HF, defined as no signs or symptoms of HF but evidence of one of the following: structural heart disease, evidence of increased filling pressures or risk factors plus increased levels of BNPs or persistently elevated cardiac troponinStage C: Structural heart disease with prior or current symptoms of HFStage D: Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy (GDMT)
In addition to focusing on different classificatory parameters, the NYHA functional classification differs from the ACC/AHA heart failure staging in that NYHA allows movement from any one class to another while the ACC/AHA system only allows unidirectional progression of stages (A→B→C→D). [Heidenreich 2022:10a]
Diagnosis –HFpEFIn general, diagnosis of HF is initially based on clinical findings on history and physical examination. However, in recent years, 2D and Doppler echocardiography has become the standard laboratory method to confirm the clinical diagnosis and assess cardiac structure and function. [Metra 2017:3d]
There are four grades of echocardiographic diastolic dysfunction, as described below. Clinical manifestations of congestive HF may occur once grade II diastolic dysfunction is present, but not in the presence of grade I diastolic dysfunction (impaired relaxation).
Grade I (impaired relaxation): The E-wave velocity is reduced, resulting in E/A reversal (ratio < 1). The left atrial pressures are normal. The deceleration time of the E wave is prolonged, measuring greater than 200 milliseconds. The e/e' ratio measured by tissue Doppler is normal.
Grade II (pseudonormal): This is pathological finding characterized by elevated left atrial pressures. The E/A ratio is normal (0.8-1.5), and the deceleration time is normal (160-200 ms), but the e/e' ratio is elevated. The E/A ratio will be less than 1 with Valsalva. A major clue to the presence of grade II diastolic dysfunction vs. Normal diastolic function is the presence of structural heart disease such as left atrial enlargement, left ventricular hypertrophy or systolic dysfunction. If significant structural heart disease is present, and the E/A ratio as well as the deceleration time appear normal, suspect a pseudonormal pattern. Valsalva distinguishes pseudonormal from normal as well as the e/e' ratio. Diuresis can frequently reduce the left atrial pressure, relieving symptoms of HF and returning the hemodynamics to those of grade I diastolic dysfunction.
Grade III (reversible restrictive): This pathological finding is characterized by significantly elevated left atrial pressures. Also known as a "restrictive filling pattern," the E/A ratio is greater than 2, the deceleration time is less than 160 ms and the e/e' ratio is elevated. The E/A ratio changes to less than 1 with Valsalva. Diuresis can frequently reduce the left atrial pressure, relieving symptoms of HF and returning the hemodynamics to those of grade I diastolic dysfunction.
Grade IV (fixed restrictive): This finding is characterized by severely elevated left atrial pressures and indicates a poor prognosis. The E/A ratio is greater than 2, the deceleration time is low and the e/e' ratio is elevated. The major difference distinguishing grade III from grade IV diastolic dysfunction is the lack of E/A reversal with the Valsalva maneuver (no effect will be seen with Valsalva). Diuresis will not have a major effect on the left atrial pressures, and clinical HF is likely established. Grade IV diastolic dysfunction is present only in very advanced HF and frequently seen in end-stage restrictive cardiomyopathies such as amyloid cardiomyopathy.
Treatment –HFpEFUntil recently, prospective randomized controlled interventional trials in HFpEF populations did not a firm evidence base for therapy, and therapy was thus aimed at symptom relief and management of comorbidities. However, recent trials showed effectiveness of several agents in the HFpEF population, and based on those, the 2022 ACC/AHA/Heart Failure Society of America guideline for the management of HF makes several recommendations: [Heidenreich 2022:55b]
The guideline states that routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life is ineffective.
The guideline also states that patients with HFpEF and hypertension should have antihypertensive medications titrated to attain guideline-recommended blood pressure targets (Class I, level of evidence C) and that management of atrial fibrillation can be useful to improve symptoms in patients with HFpEF (Class IIa, level of evidence C).
As in patients with HFrEF, in patients with HFpEF, diuretics are recommended to reduce congestion and improve symptoms (Class I, level of evidence B). [Heidenreich 2022:56a]
References:
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