Polishing the diastolic dysfunction measurement stick

Abstract

Diastolic heart failure currently accounts for more than 50% of all heart failure cases in Western societies.1 Because of normal left ventricular (LV) systolic function, diastolic heart failure is mainly attributed to diastolic LV dysfunction evident from slow LV relaxation and high diastolic LV stiffness.2,3 High diastolic LV stiffness is the most important cause of the repetitive heart failure episodes occurring in these patients,4 while high arterial elastance,5 atrial remodelling,6 and impaired chronotropic7 or vasomotor8 responses are additional contributors. Because of the pathophysiological importance of diastolic LV dysfunction, all previous diagnostic guidelines for diastolic heart failure considered evidence of diastolic LV dysfunction to be essential for the diagnosis.9–11 The recently updated diagnostic guidelines for diastolic heart failure provided by the Echocardiography and Heart Failure Associations of the European Society of Cardiology12 continued to adhere to this principle and required three conditions to be simultaneously satisfied for the diagnosis of diastolic heart failure: (i) signs or symptoms of fluid congestion; (ii) a normal systolic LV function evident from a LV ejection fraction (EF) >50% and a LV end-diastolic volume index <97 mL/m2, and (iii) evidence of diastolic LV dysfunction. The latter can be acquired by cardiac catheterization, by Doppler echocardiography, and by biomarkers such as brain natriuretic peptide (BNP) and NT-proBNP. A pulmonary capillary wedge pressure larger than 12 mmHg, an LV end-diastolic pressure (LVEDP) larger than 16 mmHg, and a ratio of mitral early diastolic flow velocity over tissue Doppler mitral annular lengthening velocity (E/E′) in excess of 15 provide stand-alone evidence of diastolic LV dysfunction. An E/E′ ratio ranging from 8 to 15 (E/E′ 8–15), BNP larger than 200 pg/mL, and NT-proBNP larger than 220 pg/mL require additional investigations to establish presence of diastolic …