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European Heart Journal Advance Access originally published online on September 21, 2007
European Heart Journal 2007 28(20):2421-2423; doi:10.1093/eurheartj/ehm412
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

How to diagnose diastolic heart failure—a consensus statement

Liv Hatle*

Faculty of Medicine, Norwegian University of Technology and Science, Trondheim 7005, Norway

* Corresponding author. Tel: +34 972 660871. E-mail address: livhatle{at}eresmas.net

This editorial refers to ‘How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology’ by W.J. Paulus et al., on page 2539

Footnotes

The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

With the increasing incidence of heart failure due mainly to diastolic dysfunction, a consensus statement on how to diagnose diastolic heart failure is clearly important. The paper by Paulus and co-authors represents a significant effort.1 It contains a detailed discussion on whether diastolic heart failure represents a separate entity, or whether it is an early stage where systolic function is only mildly impaired, but with later progression to more severe dysfunction. Newer information on possible mechanisms for the diastolic dysfunction is discussed, and there is clearly more to be learned in this area. However, it is not easy to see diastolic heart failure as a separate single entity when several different diseases can result in cardiac involvement with predominantly diastolic dysfunction.

In the paper, the authors have chosen to replace the term diastolic heart failure with the term HFNEF [heart failure with normal left ventricular (LV) ejection fraction (EF)], citing clarity, even if evidence of diastolic dysfunction is included for the diagnosis of HFNEF. However, heart failure with normal EF can also occur in other conditions and without the presence of diastolic dysfunction.2

The flowcharts for diagnosing or excluding diastolic heart failure are useful, presenting simple and easy pathways and clear cut-off levels. While this can be an advantage, it may also raise questions about excluding data that might improve sensitivity and/or specificity. The choice of LV EF > 50% has been customary to equate with normal systolic function—or, as here, normal or mildly reduced systolic function. It is mentioned that longitudinal shortening may be reduced, but compensated for by increased radial shortening. A decrease in longitudinal shortening is an early sign of LV systolic dysfunction in both non-dilated and dilated ventricles.3–6 However, since the majority of studies as well as laboratories and cardiologists still use only EF for assessment of systolic function, it could have been more clearly stated that when longitudinal function is not separately assessed—in addition to EF—it can be possible to miss that systolic function can be more than mildly impaired even in the presence of an EF > 50 or even 60%.

For the diagnosis of diastolic heart failure, the presence of elevated LV diastolic pressure is necessary. However, there is less or no discussion on the type of diastolic dysfunction in patients. For individual patient management it is useful also to know whether abnormal relaxation or decrease in compliance is the main factor. This is something that cannot be achieved just by assessing an indication of elevated pressure from the E/E' ratio, but rather by separately assessing indicators of abnormal relaxation [isovolumic LV relaxation time (IVRT), LV wall motion/velocity, as well as mitral deceleration time (DT)]7–11 and indicators of decreased compliance and abnormal rise in LV end-diastolic pressure (LVEDP; abbreviated mitral A-wave, longer duration of reversal in the pulmonary vein),12,13 or also in LV early diastolic pressure and in left atrial pressure (shortened mitral deceleration time, shorter IVRT, as well as left atrial enlargement).14–16 Such assessment is a useful guide to choice of therapy. In patients where abnormal relaxation is the main problem, heart rate reduction is beneficial or essential, but this is not the case if the main problem is decrease in compliance.

While both abnormal relaxation and decreased compliance can be present in many patients, abnormal relaxation is often the main problem, especially in those with hypertension and left ventricular hypertrophy (LVH), and with no or only minor decrease in compliance, marked diastolic dysfunction can be present but without elevated pressure at rest (and with E/E' ratio < 8). However, they may develop symptoms and marked pressure rise with exercise depending on the degree of increase in heart rate. In such patients, the diagnosis could be missed unless left atrial size exceeded the limits in the chart. At the other end of the spectrum, but less frequent, are patients with a decrease in compliance as the main factor. With less abnormal relaxation and relatively preserved LV systolic function and stroke volume, annular velocities can be less reduced and the E/E' ratio can be low, even < 8, and it may be only the blood flow Doppler and left atrial size that indicate the presence of elevated LV diastolic pressure. In one study of patients with diastolic dysfunction, the 22 patients with a pseudo-normal mitral inflow pattern had an E/E' ratio of only 8.0 ± 2.1.17 The recommendation to no longer use data from blood flow Doppler as a first-line diagnostic approach to LV diastolic dysfunction may, in some patients, therefore result in losing useful information.

The statement about the absence of pseudonormalization on lengthening velocities is too absolute, enforcing early reports suggesting preload independence of annular velocities.18,19 While early diastolic annular or myocardial velocity is related to relaxation, this is not its only determinant. It has been shown to be preload dependent in patients as well as in animal studies.20–22 Following haemodialysis, a decrease in preload results in a decrease also in the annular velocities, even if this is less pronounced than for the mitral flow velocity.20 In patients with mitral regurgitation, an increased stroke volume and increased early diastolic filling result in increased annular velocity in early diastole as well as in systole.21 Changes in preload are more likely to result in changes in annular velocities in patients with relatively preserved LV systolic function. In contrast, in patients with impaired LV systolic function, the presence of significant mitral regurgitation does not result in significant differences in annular velocity and in the E/E' ratio.23

There could have been somewhat less emphasis on the E/E' ratio > 15 as the sole criterion for elevated pressure and diastolic dysfunction since a ratio this high is seen in relatively few patients with normal or near normal LV systolic function. In the study by Ommen et al., all the patients with an E/E' ratio > 15 had a mean LV diastolic pressure > 12 mmHg, but only four of the 22 were patients with EF > 50%.24 Similarly, in the study by Kim et al., only six of the 167 patients with EF > 50% had an E/E' ratio > 15.25 Thus the sensitivity for detecting elevated pressure by this ratio in patients with relatively good systolic function is very low. Even lowering the cut-off level of the E/E' ratio to ≥ 10, the sensitivity was only 69%.25 In a study of patients with hypertrophic cardiomyopathy, only three of 24 patients with a pre-A pressure ≥ 12 mmHg had an E/E' ratio > 15.26

The majority of patients with EF > 50% and elevated diastolic pressure in both studies24,25 were in the group with an E/E' ratio between 8 and 15, indicating the need to use more of the acquired data for adequate assessment. The conclusion in the study by Ommen et al. was that all available information and all Doppler variables must be considered in the analysis of individual patients.24

In earlier studies, the E/E' ratio has been obtained by using the annular velocity recorded from the either the septal19,25 or the lateral annulus,17,18,26 or both20—or from a mean of four sites.23 As the septal E velocities usually are lower than for the lateral wall, this will give different results. In some patients with hypertension, or with LVH or pulmonary hypertension as well as other lesions, this difference can be marked,3,20 giving quite different values depending on which site is used. An option is therefore as recommended in the consensus document to use the mean value of the annular velocities from the septum and the lateral wall, even if this may distract attention from the presence of marked regional differences in function. For the numerical value of the E/E' ratio, it should also be noted that lower values for the annular velocity will be obtained using colour Doppler as compared with pulsed Doppler, resulting in a higher E/E' ratio. Mitral annular calcification is another factor that may reduce the annular velocity.27

The echo and Doppler blood flow data might have been separated into indices indicating abnormal relaxation and those indicating elevated pressure. A prolonged IVRT is not included, but this can be a better indicator of abnormal relaxation than the E/A ratio, the mitral DT, and sometimes even the annular E velocity. Also, while a low E/A ratio and a prolonged mitral DT indicating abnormal relaxation is included in the chart, an abnormally short DT and IVRT indicating elevated LA and early LV diastolic pressure is not.

The consensus statement1 contains a wealth of information related to diastolic heart failure, and the authors are to be commended for their effort to try to make a simple, easy scheme with relatively few measurements for the diagnosis or exclusion of diastolic heart failure (or HFNEF). However, with the variability between patients in various factors influencing parameters of diastolic function (degree of LVH, ischaemia or other myocardial involvement, pulmonary hypertension, as well as the effect of heart rate, blood pressure, and stroke volume), a combined assessment of the information available from the echocardiography examination provides a better basis for diagnosis and patient management. With echo-Doppler as the main diagnostic technique for the non-invasive diagnosis of diastolic heart failure, this requires a comprehensive study by well-trained echocardiographers/cardiologists. This is essential both for the diagnosis of diastolic heart failure and for the diagnosis of diastolic dysfunction prior to the onset of symptoms. This is important for individual patient management, as well as for patient selection and analysis of results in future clinical trials exploring therapies for diastolic heart failure.

Conflict of interest: none declared.

Footnotes

The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

{dagger} doi:10.1093/eurheartj/ehm037 Back

References

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How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology
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