Classification of Left Ventricular Diastolic Dysfunction and Heart Failure Diagnosis and Prognosis

Abstract

Echocardiographic evaluation of patients with possible heart failure includes a comprehensive assessment of left ventricular (LV) systolic and diastolic function, pulmonary artery pressures, and valvular morphology and function, among other variables. Early on, several investigators looked at using echocardiography to identify the presence of diastolic dysfunction (DD) and to grade its severity. This research led to a plethora of indices that are dependent on LV relaxation, chamber stiffness, and filling pressures. The availability of several two-dimensional (2D) and Doppler indices is an advantage when used in the correct setting and when the echocardiographer considers the technical and pathophysiologic factors behind a given recording. The American Society of Echocardiography in conjunction with the European Association of Echocardiography released the first set of guidelines to evaluate LV diastolic function in 2009. 1 Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009; 22: 107-133 Abstract Full Text Full Text PDF PubMed Scopus (2491) Google Scholar Consideration of several variables was recommended, and the approach depended on LV ejection fraction (LVEF). For some clinicians and sonographers, interpretation of diastolic function was perceived as challenging given the presence of several algorithms and the consideration of several parameters, including mitral inflow, pulmonary venous flow, left atrial (LA) maximum volume index, tissue Doppler velocities, pulmonary artery systolic and diastolic pressures, and flow propagation velocity. Some have incorrectly interpreted the 2009 guidelines to mean that concordance among all the variables is required before assignment of a given grade. As a result, another working group with members from the American Society of Echocardiography and the European Association of Cardiovascular Imaging provided an update in 2016. 2 Nagueh S.F. Smiseth O.A. Appleton C.P. Byrd III, B.F. Dokainish H. Edvardsen T. et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016; 29: 277-314 Abstract Full Text Full Text PDF PubMed Scopus (2774) Google Scholar The main differences between the 2009 and the 2016 versions include focusing on fewer variables (mitral inflow velocities, tissue Doppler early diastolic velocity [e′], LA maximum volume index, peak tricuspid regurgitation [TR] velocity by continuous-wave Doppler from multiple windows, and pulmonary venous flow, particularly the atrial velocity due to LA contraction). The 2016 guidelines explicitly recommend consideration of clinical findings and 2D measurements before applying the algorithms. There are two general algorithms for patients in sinus rhythm, and there are recommendations for patients with specific diseases such as atrial fibrillation, mitral valve disease, and noncardiac pulmonary hypertension. The accuracy of the 2016 update against the invasive gold-standard measurement of LV filling pressures was tested in several studies that together represent validation in a large number of patients. 3 Andersen O.S. Smiseth O.A. Dokainish H. Abudiab M.M. Schutt R.C. Kumar A. et al. Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol. 2017; 69: 1937-1948 Crossref PubMed Scopus (248) Google Scholar , 4 Lancellotti P. Galderisi M. Edvardsen T. Donal E. Goliasch G. Cardim N. et al. Echo-Doppler estimation of left ventricular filling pressure: results of the multicentre EACVI Euro-Filling study. Eur Heart J Cardiovasc Imaging. 2017; 18: 961-968 Crossref PubMed Scopus (201) Google Scholar , 5 Balaney B. Medvedofsky D. Mediratta A. Singh A. Ciszek B. Kruse E. et al. Invasive validation of the echocardiographic assessment of left ventricular filling pressures using the 2016 diastolic guidelines: head-to-head comparison with the 2009 guidelines. J Am Soc Echocardiogr. 2018; 31: 79-88 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar However, questions remain about the feasibility and ease of application, the impact of the guidelines on the call of indeterminate diastolic function, and most important the prediction of clinical events. Differential Clinical Implications of Current Recommendations for the Evaluation of Left Ventricular Diastolic Function by EchocardiographyJournal of the American Society of EchocardiographyVol. 31Issue 11PreviewClassification of left ventricular diastolic function (LVDF) by echocardiography is controversial. The aim of this study was to evaluate the impact of the last 2016 recommendations for LVDF evaluation on brain natriuretic peptide (BNP) levels, proportion of final heart failure (HF) diagnosis, and cardiovascular outcomes. Full-Text PDF