2004长城会演讲幻灯舒张期心力衰竭—是真正独立的疾病吗?
Diastolic heart failure-is it a distinct entity?
John E Sanderson
Division of Cardiology
Department of Medicine & Therapeutics
The Chinese University of Hong Kong
Beijing 2004
Diagnosing Heart Failure
in Practice.
Struthers Allan D.
Heart 2000; 84:334-338
What is heart failure?
Definition difficult
Heart failure-early descriptions
Hippocrates: “The flesh is consumed and becomes water…. The shoulders, clavicles, chest and thighs melt away”.
Reports of the benefit of foxglove exist in the roman literature.
Full undestanding of the nature of heart failure could not be made until Harvey described the circulation in 1628.
Heart failure-earliest description?
“When the pulse is irregular and tremulous and the beats occur at intervals, then the impulse of life fades; when the pulse is slender (smaller than feeble, but still perceptible, thin like a silk thread), then the impulse of life is small.”
Huang Ti Nei Ching Su Wen
The Emperor Physician (1696-2598BC)
Heart Failure: Some Definitions
“A condition in which the heart fails to discharge its contents adequately”
- Thomas Lewis, 1903
“A state in which the heart fails to maintain an adequate circulation for the needs of the body despite a satisfactory filling pressure” - Paul Wood, 1950
“A pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues” - Eugene Braunwald, 1980
“ A clinical syndrome caused by an abnormality of the heart and recognized by a characteristic pattern of haemodynamic, renal, neural and hormonal responses” - Philip A Poole-Wilson, 1985
Heart Failure: Some Definitions (contin)
“ . . . Syndrome . . . which arises when the heart is chronically unable to maintain an appropriate blood pressure without support” - Peter Harris, Br Heart J, 1987
“A syndrome in which cardiac dysfunction is associated with reduced exercise tolerance, a high incidence of ventricular arrhythmias and shortened life expectancy” - Jay N. Cohn, 1988
“Abnormal function of the heart causing a limitation of exercise capacity” or “Ventricular dysfunction with symptoms - Anonymous and pragmatic
“Symptoms of heart failure, objective evidence of cardiac dysfunction and response to treatment directed towards heart failure” - Task Force of the ESC, 1995
What is heart failure?
- Systolic dysfunction (reduced LVEF)
=systolic heart failure
- But many patients with symptoms of “heart failure have a “normal LVEF”
= diastolic heart failure
“Diastolic” Heart Failure is common
Community –based epidemiology studies suggest that 30-50% of cases of HF have “preserved” ventricular function.
Framingham study (Vasan et al JACC 1999;33:1948-55)- 51% had preserved systolic function.
Olmsted County Study ( Senni M et al Circ 1998;98:2282-9) – 43% of incident HF had preserved systolic function; both systolic and diastolic HF had a similar prognosis over 4 years
“diastolic heart failure” is common in Asia.
200 consecutive patients admitted into Prince of Wales Hospital in Hong Kong with typical features of heart failure.
12.5% had valvular heart disease
Of remaining 175 patients 132 had a LVEF>45% (i.e.75%).
Overall therefore, 66% had heart failure with a normal LVEF.
? Related to high prevalence of hypertension
(Yip, Ho, Woo, Sanderson Am J Cardiol 1999;84:563-567)
Main causes of heart failure with “normal” LVEF
(Yip, Ho, Woo, Sanderson Am J Cardiol 1999;84:563-567)
Diastolic Heart Failure hospitalisation rates
Rates of recurrent of hospitilisation are similar for those with a label of DHF as those with HF and systolic dysfunction.
McAlister FA et al Am Heart J 1999;138:87-94.
Pernenkil R et al Am J Cardiol 1997;79:216-9.
Diastolic heart failure- what is it?
European Study Group on Diastolic Heart Failure-diagnosis
Signs or symptoms of congestive heart failure
And
Normal or mildly reduced LV systolic function (LVEF>45%)
And
Evidence of abnormal LV relaxation, filling, diastolic distensibility and diastolic stiffness etc..
Eur Heart J 1998;19:990-1003
Criteria for definite Diastolic heart failure
Definite evidence of CHF: Symptoms of heart failure with radiological evidence of pulmonary congestion, and typical clinical response to treatment with diuretics.
And
Ohjective evidence of normal LV systolic function in proximity to the CHF event (LVEF>0.5)
And
Objective evidence of LV diastolic dysfunction: abnormal LV relaxation/filling/distensibility indices on cardiac catheterisation
Vasan RS, Levy D Circulation 2000;101:2118-2121
Diastolic heart failure is a clinical syndrome characterized by the symptoms and signs of heart failure, a preserved ejection fraction (EF), and abnormal diastolic function. From a conceptual perspective, diastolic heart failure occurs when the ventricular chamber is unable to accept an adequate volume of blood during diastole, at normal diastolic pressures and at volumes sufficient to maintain an appropriate stroke volume. These abnormalities are caused by a decrease in ventricular relaxation and/or an increase in ventricular stiffness.
Definition of Diastolic Heart Failure
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: 1387–1393
Definition of Diastolic Heart failure
Unsatisfactory
(Heart 2003;89:1281-1282)
Is the ejection fraction a good measure of systolic function?
Is “preserved” LV function ie a LVEF>0.45 always normal?
Can diastolic function be measured accurately especially non-invasively? No simple measure of diastolic dysfunction exists (Gibson DG & Francis DP Heart 2003;89:231-48)
Do we have the tools to adequately describe diastolic function?
What is the “gold” standard?
Burkhoff D, Maurer MS, Packer M Circulation. 2003;107:656
Can diastolic dysfunction be measured non-invasively accurately?
Usual Doppler derived mitral inflow velocities are preload and afterload dependent.
Marked age-effect- nearly all “normal” elderly will have an abnormal relaxation pattern of mitral inflow velocity.
Age changes (20-84 years) of mitral annular excursion (LAX) and velocity (m) in systole and diastole
Yip GW, Zhang Y, Tan PY, Wang M, Ho PY, Sanderson JE 1999
Diastolic Function in Patients With Heart Failure and a Normal Ejection Fraction
Zile et al Circulation. 2001;104:779
Cumulative cardiac death curves by tertile of Em & Sm
28.37(6.48 – 124.18)
P < 0.0005
12.75(2.91 – 55.81)
p = 0.001
5.78(1.88 – 17.75)
P = 0.002
20.61(6.88 – 61.80)
P < 0.0005
Wang M, Yip G, Wang A et al. JACC 2003;41:820-6
Incremental value of DT <160 s and tissue Doppler imaging variables in predicting cardiac death
Wang M, Yip G, Wang A et al. JACC 2003;41:820-6
Influence of Age on LV long axis changes in velocities (TDI) in normal subjects
Diastolic dysfunction in systolic heart failure
Abnormalities of diastolic filling are virtuall