Diastolic function in various forms of left ventricular hypertrophy: contribution of active Doppler stress echo

It has been known for a long time that healthy athletes can develop left ventricular hypertrophy with typical electrocardiographic and echocardiographic findings which lead to the definition of the athlete's heart, as a separate physiological feature. In some cases it is difficult to distinguish between pathological versus physiological myocardial hypertrophy. Diastolic dysfunction is an early sign in the temporal sequence of ischemic events in coronary heart disease. Similar changes occur in other types of heart disease due to arterial hypertension or inflammation processes. Diastolic function is changed even in idiopathic hypertrophic cardiomyopathies. In contrast to these groups of patients, diastolic function remains unchanged or is improved in healthy athletes depending on the type of training (isotonic or isometric exercise). In cases with borderline changes, examinations during physical stress (exercise testing) which provokes an oxygen demand/supply imbalance and consecutively impairs early diastolic filling could clarify if an underlying heart disease is present. Although the physiology of diastolic function is complex, the factors contributing to diastolic disturbances can be differentiated into intrinsic and extrinsic left ventricular (LV) abnormalities. Intrinsic mechanisms include a) impaired LV relaxation, b) increased overall chamber stiffness, c) increased myocardial stiffness and d) increased LV asynchrony. All these factors are part of pathological LV hypertrophy. Factors extrinsic to the LV causing diastolic disorders include a) increased central blood volume, which will increase left ventricular pressure without altering the LV pressure-volume relation, and b) ventricular interaction mediated by pericardial restraint, which may cause a parallel upward shift of the diastolic LV pressure-volume curve. Improved understanding of LV relaxation and filling helps to differentiate pathological and physiological myocardial hypertrophy. Ongoing heart disease of different types can be diagnosed early by stress Doppler echocardiography in relation to other clinical findings and symptoms of the patient.