Diastolic heart failure: a clinical challenge early recognition & timely intervention is the need of the hour

Abstract

Diastolic Heart failure (DHF) is the major cause of morbidity and mortality all over the world. It is responsible for more than 50% of the heart failure cases. New onset of symptomatic DHF is a lethal disease with a 5-yr mortality of approximately 50%. DHF is also referred to as heart failure (HF) with normal left ventricular ejection fraction (LVEF)-HFNLVEF. The diagnosis of DHF requires the following criteria: (i) signs and symptoms of heart failure (ii) normal or mildly abnormal systolic left ventricular (LV) function (iii) evidence of LV diastolic dysfunction. Diagnostic evidence of LV diastolic dysfunction can be obtained invasively (LV end-diastolic pressure > 16 mmHg or mean pulmonary capillary wedge pressure > 12 mmHg) or non-invasively by tissue Doppler imaging (TDI) (E/E' > 15). If TDI yields an E/E' ratio suggestive of LV diastolic dysfunction (15 > E/E' > 8), then additional echo variables are required for diagnostic evidence of LV diastolic dysfunction, which include Doppler flow profile of mitral valve or pulmonary veins, measurement of LV mass index (LVMi) or left atrium volume index (LAVi), electrocardiographic evidence of atrial fibrillation or high levels of B-natreuretic peptide. Echo-Doppler techniques using LV filling pressures and tissue Doppler imaging of the mitral annulus help in identifying and classifying the degree of LV diastolic dysfunction. However, clinically this is more relevant to advanced overt disease. Therefore early recognition of DHF in relatively asymptomatic or less symptomatic patients with occult LV diastolic dysfunction is a real challenge. Recently it has been shown that reduction in left atrial strain and strain rate and increase in left atrial (LA) stiffness index has a high predictive value for detection of occult LV diastolic dysfunction. Thus early recognition of occult DHF and timely therapeutic intervention may help in prognostic stratification in DHF.