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Mechanisms, diagnosis, and treatment of diastolic heart failure
D J Lenihan1, M C Gerson, B D Hoit
1Department of Internal Medicine, University of Cincinnati, OH 45267-0542, USA.
Insights
Diastolic heart failure, a common condition affecting one-third of heart failure patients, involves impaired left ventricular (LV) filling due to various pathologies. Understanding its cellular, hemodynamic, and hormonal determinants is key for diagnosis and treatment.
Area of Science:
- Cardiology
- Physiology
- Pathology
Background:
- Diastolic heart failure (DHF), without systolic dysfunction, affects up to one-third of congestive heart failure patients.
- Abnormal left ventricular (LV) filling characterizes DHF, stemming from conditions like hypertrophy, cardiomyopathies, or ischemia.
Purpose of the Study:
- To review the physiological determinants of LV diastolic filling.
- To outline diagnostic approaches and therapeutic strategies for DHF.
Main Methods:
- Review of cellular mechanisms, hemodynamic factors, and hormonal influences on LV filling.
- Summary of diagnostic techniques (invasive and noninvasive).
- Overview of pharmacologic and interventional treatments.
Main Results:
- LV filling is governed by cellular calcium handling, hemodynamic parameters (e.g., loading, relaxation time, compliance), and neurohormonal systems.
- Diagnosis relies on a combination of clinical tests.
- Pharmacotherapy (calcium channel blockers, beta-blockers, diuretics, ACE inhibitors) and interventions are used for treatment.
Conclusions:
- DHF is a complex condition with multifactorial determinants.
- Effective management involves addressing underlying causes and utilizing appropriate pharmacologic or surgical interventions.
- Future research should focus on myocardial relaxation mechanisms and outcome-improving treatments.
Abstract:
Diastolic heart failure, in the absence of LV systolic dysfunction, is a common clinical condition that can be demonstrated in as many as one third of patients with congestive heart failure. Diastolic dysfunction caused by abnormalities in LV filling can be a result of many pathologic conditions, including hypertrophy, infiltrative cardiomyopathies, or myocardial ischemia. The major physiologic determinants of LV filling can be divided into cellular mechanisms, hemodynamic characteristics, and hormonal influences. Cellular mechanisms for impaired LV inactivation are determined by the handling of calcium within the myocyte during excitation-contraction-relaxation coupling. The hemodynamic characteristics of LV diastolic filling are determined by loading conditions, the time constant of isovolumic relaxation, heart rate, ventricular nonuniformity, pericardial restraint, myocardial elasticity, chamber compliance, and coronary blood flow. The sympathetic nervous system and the renin-angiotensin system are important modulators of diastolic filling, directly or indirectly. The diagnosis of heart failure is confirmed by a combination of clinical tests including invasive and noninvasive techniques, each of which has advantages and disadvantages. Treatment of medical conditions in which diastolic heart failure is a prominent component include pharmacotherapy with calcium channel antagonists, beta-adrenergic blocking agents, diuretic agents, and angiotensin-converting-enzyme inhibitors. Certain conditions associated with diastolic filling abnormalities such as pericardial disease or severe ischemic heart disease may be best managed by surgical or percutaneous intervention. Future research will include further delineation of the cellular mechanisms of active myocardial relaxation and clinical investigation into treatment directed at improving outcome.