Pulmonary Hypertension in Congenital Heart Disease: A Scientific Statement From the American Heart Association
Impact Of Azelnidipine Treatment On Left Ventricular Diastolic Performance In Patients With Hypertension And Mild Diastolic Dysfunction: Multi-center Study With Echocardiography
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Diastolic Dysfunction
Diastolic congestive heart failure is reviewed here.
Diastolic dysfunction occurs when the left ventricular myocardium is non-compliant and not able to accept blood return in a normal fashion from the left atrium. This can be a normal physiologic change with aging of the heart or result in elevated left atrial pressures leading to the clinical manifestations of diastolic congestive heart failure. There are four grades of diastolic dysfunction as described below. Echocardiography is the gold standard to diagnose diastolic dysfunction.
Grade I (impaired relaxation): This is a normal finding and occurs in nearly 100% of individuals by the age of 60. The E wave velocity is reduced resulting in E/A reversal (ratio < 1.0). The left atrial pressures are normal. The deceleration time of the E wave is prolonged measuring > 200 ms. The e/e' ratio measured by tissue Doppler is normal.
Grade II (pseudonormal): This is pathological and results in elevated left atrial pressures. The E/A ratio is normal (0.8 +- 1.5), the deceleration time is normal (160-200 ms), however the e/e' ratio is elevated. The E/A ratio will be < 1 with Valsalva. A major clue to the presence of grade II diastolic dysfunction as compared to 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 heart failure and returning the hemodynamics to those of grade I diastolic dysfunction.
Grade III (reversible restrictive): This results in significantly elevated left atrial pressures. Also known as a "restrictive filling pattern", the E/A ratio is > 2.0, the deceleration time is < 160 ms, and the e/e' ratio is elevated. The E/A ratio changes to < 1.0 with Valsalva. Diuresis can frequently reduce the left atrial pressure relieving symptoms of heart failure and returning the hemodynamics to those of grade I diastolic dysfunction.
Grade IV (fixed restrictive): This indicates a poor prognosis and very elevated left atrial pressures. The E/A ratio is > 2.0, 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 clinic heart failure is likely permanent. Grade IV diastolic dysfunction is present only in very advanced heart failure and frequently seen in end-stage restrictive cardiomyopathies such as amyloid cardiomyopathy.
SHPT May Predict Left Ventricular Diastolic Dysfunction
A new study correlates higher levels of intact parathyroid hormone (iPTH) with indicators of left ventricular diastolic dysfunction in patients with pre-dialysis chronic kidney disease (CKD).
Il Young Kim, MD, and colleagues from Pusan National University Yangsan Hospital in South Korea, examined imaging results from 332 CKD patients with estimated glomerular filtration rates (eGFR) below 60 mL/min/1.73m2 and not on dialysis. Of these, 198, 84, and 50 patients had CKD stage 3, 4, and 5, respectively.
Diastolic dysfunction severity increased along with CKD stage: Patients displayed lower peak early mitral annular velocity (E') and higher ratios of early mitral inflow velocity (E) to E', according to tissue Doppler imaging results. The team found no significant differences between groups in left ventricular ejection fraction, which was assessed via 2-D echocardiography, however.
Both univariate and multivariate analysis showed that iPTH significantly correlated with E' and E/E' after adjustment. IPTH did not correlate with systolic dysfunction.
These findings suggest that SHPT is an independent predictor of left ventricular diastolic dysfunction, Dr Kim and his colleagues concluded. They advised future studies to determine whether treating SHPT prevents left ventricular diastolic dysfunction.
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ReferenceKim IY, Kwak IS, Park IS, et al. Secondary hyperparathyroidism is independently associated with left ventricular diastolic dysfunction in patients with CKD. Data were presented as a Kidney Week 2017 publication-only abstract: PUB567.
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