Abnormal diastolic filling patterns in chronic heart failure—relationship to exercise capacity

Abstract

Abnormal patterns of diastolic ventricular filling are well recognized in chronic heart failure, but their relationship to the severity of heart failure is not known. The present study evaluates the relationship of diastolic filling indices to the severity of heart failure and to exercise capacity. In 40 patients with chronic heart failure secondary to ischaemic left ventricular impairment, exercise capacity was measured as peak oxygen consumption (VO2max) by progressive treadmill exercise. Left ventricular function was assessed by M-mode and Doppler echocardiographic indices. Peak aortic velocity correlated weakly with VO2max (R = +0.38, P less than 0.05). VO2max did not correlate with other systolic indices, including mean aortic acceleration, time to peak velocity, or isovolumic contraction time. VO2max correlated with the mitral inflow E/A ratio (R = -0.57, P less than 0.005) and with the Doppler estimate of isovolumic relaxation time (R = -0.48, P less than 0.01). Two distinct patterns of diastolic filling were observed: subjects with mild-to-moderate heart failure (NYHA grade II, VO2max 15-20 ml.kg-1.min-1) had abnormally low E/A ratios and long isovolumic relaxation times, whereas those with severe heart failure (NYHA grade III-IV, VO2max less than 12 ml.kg-1.min-1) had abnormally high E/A ratios and short isovolumic relaxation times. Different patterns of abnormal diastolic filling with different degrees of severity of heart failure may explain some of the previous controversy as to the prevalence of abnormal diastolic function in chronic heart failure. Exercise capacity in chronic heart failure appears more closely related to abnormalities of diastolic filling pattern than to indices of systolic function.

<b>Value of Left Atrial Function in Predicting Exercise Capacity in Heart Failure With Moderate to Severe Left Ventricular Systolic Dysfunction</b>

“…This is consistent with recent studies demonstrating that LV diastolic rather than systolic function has an important role in determining exercise performance in patients with CHF. 3,4,25) Many studies have described the contribution of LA function to LV diastolic filling. The LA acts as a reservoir during left ventricular systole, and maintains passive filling during early diastole and active pumping during late diastole.…”

“…Maximal early "E" and late "A" filling velocities, the E/A ratio, deceleration time of the "E" wave velocity, and IVRT were measured. 4) LA antero-posterior diameters were determined using a parasternal longaxis window. LA systolic diameter (LASd) (maximal LA dimension) was measured at the end of the T wave and LA diastolic diameter (LADd) (minimal LA dimension) was measured at the beginning of the QRS complex on the electrocardiograph.…”

“…2,3) In contrast, recent reports showed that LV diastolic dysfunction was intimately related to functional status. 4,5) Although LV diastolic dysfunction is known to reduce exercise capacity, it is often difficult to predict precise exercise capacity by evaluating diastolic filling because hemodynamic parameters measured at rest are influenced by age, heart rate, loading condition, and the properties of the LV and left atria (LA). LA function is closely related to LV diastolic filling, therefore, indices of LA function may predict exercise capacity in patients with LV dysfunction.…”

Long‐term prognosis in patients with bifascicular block – the predictive value of noninvasive and invasive assessment

“…An important reason for this discrepancy is that the functional class is not only associated with left ventricular systolic function, but also with diastolic function [27]. It has previously been demonstrated that diastolic dysfunction is an important determinant of exercise intolerance as well as a predictor of mortality in patients with CHF [28,29]. In our study four of five patients with a normal left ventricular systolic function but with symptoms of CHF, died during follow-up suggesting that diastolic dysfunction may have been a major cause of CHF in these patients.…”

Congestive heart failure. Correlation between functional class and systolic and diastolic functions assessed by Doppler echocardiography

“…Controversy exists in the literature regarding the main determinants of heart failure functional class. Some studies have shown that the ability to perform physical exercises is related more to the patterns of diastolic filling of the left ventricle than to the indexes of systolic function [2][3][4] , whereas others have established a direct relationship between functional class and indexes of systolic function 5,6 . The more advanced functional classes (III and IV) are related to greater mortality 1,4,[6][7][8][9][10] .…”