CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 4, July/August 2010
212
AFRICA
Review Article
The clinical quandary of left and right ventricular
diastolic dysfunction and diastolic heart failure
ERNST R SCHWARZ, RAJA DASHTI
Summary
Diastolic heart failure is a common clinical entity that is
indistinguishable from systolic heart failure without direct
evaluation of left ventricular function. Diastolic heart failure
is a clinical diagnosis in patients with signs and symptoms of
heart failure but with preserved left ventricular function and
normal ejection fraction, and is often seen in patients with a
long-standing history of hypertension or infiltrative cardiac
diseases. In contrast, diastolic dysfunction represents a
mechanical malfunction of the relaxation of the left ventricu-
lar chamber that is primarily diagnosed by two-dimensional
transthoracic echocardiography and usually does not present
clinically as heart failure. The abnormal relaxation is usually
separated in different degrees, based on the severity of reduc-
tion in passive compliance and active myocardial relaxation.
The question whether diastolic dysfunction ultimately will
lead to diastolic heart failure is critically reviewed, based
on data from the literature. Treatment recommendations
for diastolic heart failure are primarily targeted at risk
reduction and symptom relief. Currently, few data only are
reported on diastolic dysfunction and its progression to systo-
lic heart failure.
Keywords:
diastolic heart failure, diastolic dysfunction, conges-
tive heart failure, cardiomyopathy
Submitted 25/9/09, accepted 10/3/10
Cardiovasc J Afr
2010;
21
: 212–220
Even though often interchangeably used in the clinical setting,
there is a distinction between diastolic dysfunction and diasto-
lic heart failure. A PubMed literature search revealed a total of
1 478 articles using the search terms diastolic heart failure and
review. In contrast, only a few randomised controlled trials are
available on diastolic heart failure alone. Controversy remains
regarding the optimal therapy in patients with either diastolic
dysfunction or diastolic heart failure.
1
An important question is
whether diastolic dysfunction does indeed lead to diastolic heart
failure and how this progression occurs. Moreover, it is unclear
whether diastolic dysfunction results in both diastolic and subse-
quently, systolic heart failure.
In daily routine, heart failure is often separated into systolic
and diastolic failure based on preservation of left ventricular
ejection fraction.
1
The terms ‘heart failure with preserved left
ventricular function’ or ‘heart failure with normal ejection frac-
tion’ are utilised to emphasise that the aetiology of the patho-
physiology for this group of patients may go beyond diastolic
dysfunction alone.
2
Heart failure in general and diastolic heart failure in particular
causes a significant financial burden and increasing consump-
tion of healthcare resources, especially among the elderly popu-
lation (i.e. for patients 65 years of age or older).
3,4
This article
will review the current knowledge of diastolic dysfunction and
its progression to diastolic heart failure.
Diastolic dysfunction
Diastolic dysfunction is a mechanical abnormality brought upon
by a breakdown in the passive (compliance) and active (myocar-
dial relaxation) intrinsic properties of the ventricle during dias-
tole. Myocardial hypertrophy (e.g. left ventricular hypertrophy
secondary to hypertension) and myocardial ischaemia have
been shown to impair the energy-dependant process of myocar-
dial relaxation. The increased afterload in patient with aortic
stenosis or hypertension can also inhibit myocardial relaxation
by reducing the ability of the left ventricle to contract to small
end-systolic volume, and hence limit the ensuing elastic recoil’s
ability to enhance myocardial relaxation. Also, diastolic dysfunc-
tion can be secondary to pathological states that adversely affect
the passive compliance during diastole, such as increases in
myocardial wall thickness observed in concentric hypertrophy as
a result of longstanding hypertension, or in myocardial fibrosis
in patients with infiltrative pathology.
5
The role of echocardiography in the assessment of
diastolic function
Diastolic function can be evaluated non-invasively using two-
dimensional transthoracic echocardiography. The evaluation
of left ventricular diastolic function should be an essential
part of any echocardiography examination.
6
The three phases
of diastole consist of a period of isovolumic relaxation time
(IVRT), followed by an early rapid diastolic filling period (E), a
plateau, and finally a late filling due to the atrial contraction or
atrial kick (A). These can be evaluated by using the pulse wave
(PW) Doppler of the mitral valve and pulmonary veins. The
left ventricular filling pattern obtained will therefore indirectly
reflect the left ventricular filling pressures.
A complete left ventricular diastolic assessment should
Cedars Sinai Heart Institute, Cedars-Sinai Medical Center
and University of California Los Angeles (UCLA), Los
Angeles, California
ERNST R SCHWARZ, MD, PhD, FACC,
RAJA DASHTI, MD, FRCPC, FACC
