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[Heart failure with preserved left ventricular function: clinical, echocardiographic, and clinical course features.
Jean-Paul Bounhoure1, Pierre Massabuau, Michel Galinier
1Clinique Pasteur, Université Paul Sabatier-Faculté de Médecine Toulouse-Rangueuil-31403 Toulouse.
Insights
Diastolic heart failure, characterized by impaired left ventricular filling, affects many patients and can be misdiagnosed. A restrictive filling pattern is a key indicator of poor prognosis and increased mortality in these patients.
Area of Science:
- Cardiology
- Internal Medicine
- Heart Failure Research
Background:
- Heart failure is often linked to reduced myocardial contraction and ejection fraction.
- A subset of patients presents with symptomatic heart failure, preserved ejection fraction, and impaired left ventricular filling, termed diastolic heart failure.
- Diastolic heart failure is frequently underdiagnosed or misdiagnosed, necessitating further characterization.
Purpose of the Study:
- To describe the clinical, echocardiographic, and hemodynamic profiles of 64 hospitalized patients with symptomatic heart failure.
- To identify prognostic variables and evaluate the severity of diastolic left ventricular dysfunction.
- To analyze the outcomes and rehospitalization rates in this patient cohort.
Main Methods:
- Comprehensive assessment including physical examination, ECG, laboratory tests, and echocardiography (measuring atrial and ventricular diameters, ejection fraction, and filling patterns).
- Pulsed Doppler evaluation of mitral and pulmonary venous flow to assess diastolic parameters like E/A ratio and isovolumic relaxation time.
- Left heart catheterization and coronary angiography in 45 patients, with a mean follow-up of 18 months.
Main Results:
- The study included 64 patients (mean age 72.5 years, 45.3% women) with a mean ejection fraction of 48.5%.
- Common comorbidities included ischemic cardiomyopathy (65%), hypertension (52%), and diabetes (38%).
- Despite treatment, 34 patients were rehospitalized, with an in-hospital mortality of 6.2% and an 18-month mortality of 18.7%.
Conclusions:
- Heart failure with preserved systolic function is prevalent, particularly in women with hypertensive heart disease.
- A restrictive left ventricular filling pattern is a significant predictor of adverse events and mortality.
- While prognosis may be better than systolic dysfunction, high morbidity and rehospitalization rates persist, underscoring the need for effective management strategies.
Abstract:
Heart failure is clinically associated with inadequate myocardial contraction, a significant reduction of left ventricular systolic function and ejection fraction and a cardiac enlargement. Some studies have reported that patients with symptomatic heart failure may have an impaired left ventricular filling with a normal or preserved left ventricular systolic function and an ejection fraction > 45%. These patients have a "diastolic heart failure" often neglected or misdiagnosed. The aims of our study is to describe clinical, echocardiographic and hemodynamic characteristics of 64 patients hospitalized for symptomatic heart failure, to determine possible variables with prognosis relevance, and for evaluating the severity of this diastolic left ventricular dysfunction. All patients were assessed by physical and radiographic examination, 12 leads electrocardiogram, and usual laboratory tests. The internal diameter of left atrium and left ventricular end diastolic and tele-systolic diameter were measured following the recommendations of the American Society of Echocardiography, Ejection fraction was determined following Simpson's method. Left ventricular filling patterns were evaluated by pulsed Doppler mitral or venous pulmonary flow. The following parameters were assessed: maximum velocity of E and A waves, E/A ratio, E wave deceleration time and isovolumic relaxation time. The patients were studied following Appleton's classification. 45 patients were submitted to left heart catheterization and coronary angiography. All subjects were routinely followed by cardiologic examinations and the mean follow up is 18 +/- 4, 5 months. 29 women (45.3%) and 35 men with a mean age of 72.5 +/- 3.2 years were included in this study. Left ventricular ejection fraction was in mean 48.5 +/- 4.2%. 65% of patients had ischemic cardiomyopathy with severe coronary stenosis > 50%, often associated with hypertension. 52% of patients had hypertensive heart disease and 38% were diabetics. 34 patients were re-hospitalized for recurrent heart failure despite medical treatment with diuretics, ACE inhibitors (90% of patients), beta-blockers, (37%) or nitrates (36%). 24 patients have been treated by coronary angioplasty. In hospital mortality was 6.2% and during the follow up at 18 months the mortality reaches 18.7%. The factors of poor prognosis are age > 75 years, left ventricular restrictive pattern at doppler diastolic trans mitral flow evaluation, (p < 0.001), history of myocardial infarction, and renal insufficiency defined by creatinemia > 150 micromoles (p = 0.002). In conclusion heart failure with preserved left systolic ventricular function is frequent in women with hypertensive heart disease. The prognosis at mean term is better that prognosis of patients with systolic dysfunction but despite medical treatment there is a high morbidity with numerous re hospitalizations. Restrictive left ventricular filling pattern is significantly related to the occurrence of events and mortality.