舒张期心力衰竭是真正独立的疾病吗ppt课件

Diastolic heart failure-is it a distinct entity?,John E Sanderson Division of Cardiology Department of Medicine & Therapeutics The Chinese University of Hong Kong,Beijing 2004,Diagnosing Heart Failure in Practice.,Struthers Allan D. Heart 2000; 84:334-338,What is heart failure?,Definition difficult,Heart failure-early descriptions,Hippocrates: “The flesh is consumed and becomes water. The shoulders, clavicles, chest and thighs melt away”. Reports of the benefit of foxglove exist in the roman literature. Full undestanding of the nature of heart failure could not be made until Harvey described the circulation in 1628.,Heart failure-earliest description?,“When the pulse is irregular and tremulous and the beats occur at intervals, then the impulse of life fades; when the pulse is slender (smaller than feeble, but still perceptible, thin like a silk thread), then the impulse of life is small.” Huang Ti Nei Ching Su Wen The Emperor Physician (1696-2598BC),Heart Failure: Some Definitions,“A condition in which the heart fails to discharge its contents adequately” - Thomas Lewis, 1903 “A state in which the heart fails to maintain an adequate circulation for the needs of the body despite a satisfactory filling pressure” - Paul Wood, 1950 “A pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues” - Eugene Braunwald, 1980 “ A clinical syndrome caused by an abnormality of the heart and recognized by a characteristic pattern of haemodynamic, renal, neural and hormonal responses” - Philip A Poole-Wilson, 1985,Heart Failure: Some Definitions (contin),“ . . . Syndrome . . . which arises when the heart is chronically unable to maintain an appropriate blood pressure without support” - Peter Harris, Br Heart J, 1987 “A syndrome in which cardiac dysfunction is associated with reduced exercise tolerance, a high incidence of ventricular arrhythmias and shortened life expectancy” - Jay N. Cohn, 1988 “Abnormal function of the heart causing a limitation of exercise capacity” or “Ventricular dysfunction with symptoms - Anonymous and pragmatic “Symptoms of heart failure, objective evidence of cardiac dysfunction and response to treatment directed towards heart failure” - Task Force of the ESC, 1995,What is heart failure?,- Systolic dysfunction (reduced LVEF) =systolic heart failure - But many patients with symptoms of “heart failure have a “normal LVEF” = diastolic heart failure,“Diastolic” Heart Failure is common,Community based epidemiology studies suggest that 30-50% of cases of HF have “preserved” ventricular function. Framingham study (Vasan et al JACC 1999;33:1948-55)- 51% had preserved systolic function. Olmsted County Study ( Senni M et al Circ 1998;98:2282-9) 43% of incident HF had preserved systolic function; both systolic and diastolic HF had a similar prognosis over 4 years,“diastolic heart failure” is common in Asia.,200 consecutive patients admitted into Prince of Wales Hospital in Hong Kong with typical features of heart failure. 12.5% had valvular heart disease Of remaining 175 patients 132 had a LVEF45% (i.e.75%). Overall therefore, 66% had heart failure with a normal LVEF. ? Related to high prevalence of hypertension,(Yip, Ho, Woo, Sanderson Am J Cardiol 1999;84:563-567),Main causes of heart failure with “normal” LVEF,(Yip, Ho, Woo, Sanderson Am J Cardiol 1999;84:563-567),Diastolic Heart Failure hospitalisation rates,Rates of recurrent of hospitilisation are similar for those with a label of DHF as those with HF and systolic dysfunction. McAlister FA et al Am Heart J 1999;138:87-94. Pernenkil R et al Am J Cardiol 1997;79:216-9.,Diastolic heart failure- what is it?,European Study Group on Diastolic Heart Failure-diagnosis,Signs or symptoms of congestive heart failure And Normal or mildly reduced LV systolic function (LVEF45%) And Evidence of abnormal LV relaxation, filling, diastolic distensibility and diastolic stiffness etc Eur Heart J 1998;19:990-1003,Criteria for definite Diastolic heart failure,Definite evidence of CHF: Symptoms of heart failure with radiological evidence of pulmonary congestion, and typical clinical response to treatment with diuretics. And Ohjective evidence of normal LV systolic function in proximity to the CHF event (LVEF0.5) And Objective evidence of LV diastolic dysfunction: abnormal LV relaxation/filling/distensibility indices on cardiac catheterisation,Vasan RS, Levy D Circulation 2000;101:2118-2121,Diastolic heart failure is a clinical syndrome characterized by the symptoms and signs of heart failure, a preserved ejection fraction (EF), and abnormal diastolic function. From a conceptual perspective, diastolic heart failure occurs when the ventricular chamber is unable to accept an adequate volume of blood during diastole, at normal diastolic pressures and at volumes sufficient to maintain an appropriate stroke volume. These abnormalities are caused by a decrease in ventricular relaxation and/or an increase in ventricular stiffness.,Definition of Diastolic Heart Failure,Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I. Diagnosis, prognosis, and measurements of diastolic function. Circulation. 2002; 105: 13871393,Definition of Diastolic Heart failure,Unsatisfactory (Heart 2003;89:1281-1282) Is the ejection fraction a good measure of systolic function? Is “preserved” LV function ie a LVEF0.45 always normal? Can diastolic function be measured accurately especially non-invasively? No simple measure of diastolic dysfunction exists (Gibson DG 89:231-48),Do we have the tools to adequately describe diastolic function?,What is the “gold” standard?,Burkhoff D, Maurer MS, Packer M Circulation. 2003;107:656,Can diastolic dysfunction be measured non-invasively accurately?,Usual Doppler derived mitral inflow velocities are preload and afterload dependent. Marked age-effect- nearly all “normal” elderly will have an abnormal relaxation pattern of mitral inflow velocity.,Age changes (20-84 years) of mitral annular excursion (LAX) and velocity (m) in systole and diastole,Yip GW, Zhang Y, Tan PY, Wang M, Ho PY, Sanderson JE 1999,Diastolic Function in Patients With Heart Failure and a Normal Ejection Fraction,Zile et al Circulation. 2001;104:779,Cumulative cardiac death curves by tertile of Em & Sm,28.37(6.48 124.18) P 0.0005,12.75(2.91 55.81) p = 0.001,5.78(1.88 17.75) P = 0.002,20.61(6.88 61.80) P 0.0005,Wang M, Yip G, Wang A et al. JACC 2003;41:820-6,Incremental value of DT 160 s and tissue Doppler imaging variables in predicting cardiac death,Wang M, Yip G, Wang A et al. JACC 2003;41:820-6,Influence of Age on LV long axis changes in velocities (TDI) in normal subjects,Diastolic dysfunction in systolic heart failure,Abnormalities of diastolic filling are virtually universal in patients with impaired systolic function and affects both right and left ventricles (Yu CM , Sanderson JE, Chan S et al. Circulation 1996; 93:1509-1514). The restrictive filling pattern is associated with higher ANP and BNP levels and worse LV systolic function (Yu CM, Sanderson JE, Shum IOL et al, European Heart Journal 1996; 17:1694-1702) Diastolic dysfunction determines the prognosis (Yu CM 22:504-512,Yu CM 22:504-512,Diastolic dysfunction and prognosis in patients with systolic heart failure,Systolic function in “Diastolic” heart failure.,(Izzat MB, Sanderson JE, St. John Sutton MG. Echocardiography in Adult Cardiac Surgery),Measurement of LV systolic function the ejection fraction.,LV Long Axis,A more sensitive measure of global LV function?,Left Ventricular Fibre Architecture,Diagram showing dissection in a normal left ventricular myocardium with the longitudinal fibres running between the apex and mitral ring and occupying the subendocardial and subepicardial layers. (MY Henein, DG Gibson. Heart 1999; 81:111-113) (Greenbaum RA, Ho SY, Gibson DG, Becker AE, Anderson RH. Br Heart J 1981;45:248-263),Epicardial counter-clockwise oblique spiral,Endocardial clockwise oblique spiral Apex to base,Mechanical consideration of normal LV contraction,Synchronous LV contraction & relaxation depend critically on coordinate activity of longitudinal & circumferential fibers LAX fibers only small proportion of total LV mass but important in maintaining normal LVEF & determining A-V interaction. During systole, apex relatively stationary, LAX fiber shortening draws A-V ring towards it. During diastole, the A-V ring ascends towards atrium. Not only does this contribute to the fall in the LV vol with ejection, but at the same time increases LA capacity. Unlike circumferential fiber shortening, LAX affects atrial and ventricular function.,FUNCTIONAL IMPORTANCE OF THE LONG AXIS DYNAMICS OF THE HUMAN LEFT VENTRICLE,“Relations between long and short axis motion in healthy individuals are characteristic, and their loss is an early index of systolic ventricular disease. These disturbances precede changes in orthodox measures such as fractional shortening or peak velocity of circumferential fibre shortening.” (CJH Jones, L Raposo, DG Gibson. Br Heart J 1990; 63:215-220),Echocardiographic assessment of ventricular long axis by motion of the mitral annulus.,Mitral ring excursion - M-mode mitral ring velocity - Colour Doppler myocardial imaging/ Doppler tissue imaging/tissue velocity imaging. For both, a systolic wave and two diastolic waves can be measured.,Echocardiographic assessment of mitral annular (or ring) motion-early findings.,Good correlation with LVEF and systolic excursion(Simonson and Schiller 1989; Pai et al 1991) and always reduced when LV cavity sized is increased (Alam et al 1990). Systolic excursion reduced in MI patients (Hoglund et al 1989) and in patients with CAD (Alam et al 1992),Although LVEF assess global function, it is relatively crude measurement of LV systolic function. Measurement of mitral annular systolic velocity seems to provide a more sensitive index of LV systolic function. Question: Will some degree of systolic impairment of LAX motion be present even in those with so- called primary diastolic heart failure?,LV long axis in heart failure,METHODOLOGY LV long axis changes in velocities (TDI),Sm Em Am IVRTm,Diastolic heart failure-is systolic function truly normal?,One hundred and one subjects, 29 with DHF (LVEF 0.45), 39 with SHF (LVEF 0.45) patients and 33 age-matched normal subjects were studied by 2D echocardiography and Colour Doppler Myocardial Imaging with measurement of LVEF by 2D Simpsons method, LV short axis, LV long axis changes (mitral annular excursion and velocity) and mitral Doppler inflow velocities.,Yip G, Wang M, Ho P Sanderson JE Heart 2002;87:121-125,Yip G, Wang M, Ho P Sanderson JE Heart 2002;87:121-125,Yip G, Wang M, Ho P Sanderson JE Heart 2002;87:121-125,Yip G, Wang M, Ho P Sanderson JE Heart 2002;87:121-125,Yip G, Wang M, Ho P Sanderson JE Heart 2002;87:121-125,Yip G, Wang M, Ho P Sanderson JE Heart 2002;87:121-125,Systolic Abnormalities in Diastolic Dysfunction and Diastolic Heart Failure,Yu CM et al, Circ 2002,Em : Normal DD DHF = SHF Sm : Normal DD DHF SHF,SM,IVCM,EM,AM,TDI - Normal,TDI - DHF,SM,EM,AM,Summary,In patients with DHF systolic function measured by Sm (TDI) in the LV long axis changes is lower than age-matched normal subjects. The DHF group appears to be intermediate between those with truly normal function and the SHF patients with obviously severely impaired function. Therefore, LV systolic function is not entirely normal or “preserved” in patients labeled to have diastolic heart failure using standard or conventional criteria.,Miho Kawaguchi, Ilan Hay, Barry Fetics, and David A. Kass Circulation 2003 107: 714-720,Systolic function in Heart failure with “preserved” ejection fraction,Systole and Diastole,“So that the coming together depends on the going apart; the systole depends on the diastole; the flow depends on the ebb.” DH Lawrence,Yip G, Zhang Y, Tan P, Wang M, Ho P, Brodin L-A, Sanderson JE Clinical Science 2002;102:515-22,Yip G, Zhang Y, Tan P, Wang M, Ho P, Brodin L-A, Sanderson JE Clinical Science 2002;102:515-22,Em correlates to Sm,Yip G, Zhang Y, Tan P, Wang M, Ho P, Brodin L-A, Sanderson JE Clinical Science 2002;102:515-22,Wang M, Sanderson JE (unpublished,Early LV Filling,Representative dog with intact LV function and rapid apical filling. (Steine et al. Circulation 1999; 99:2048-2054),Early LV Filling,Representative dog with ischemic LV failure. (Same dog) (Steine et al. Circulation 1999; 99:2048-2054),LV “suction”,(Steine K et al. Circulation 1999; 99:2048-2054),Experiment showing early diastolic flow velocity recorded in apical region (1.8 cm from mitral tip) and LV pressure recorded in apical region. During baseline (left), apical flow accelerates while apical pressure is decreasing. During LV failure (right), where apical filling is retarded, flow accelerates while apical pressure is rising.,SEQUENTIAL CONTRACTION OF THE DESCENDENT AND ASCENDENT SEGMENTS PRODUCE “SYSTOLIC VENTRICULAR FILLING” Torrent-Guasp et al Eur J Cardiovasc Surgery 2004;25:376-386,Illustrations from Richard Lowers Tractatus de corde, (1669),Spiral course of myocardial fibers,(HA Snellen. History of Cardiology. 1984),INCOORDINATION: THE MAIN CAUSE OF PROLONGED ISOVOLUMIC RELAXATION,LV filling in hypertrophic cardiomyopathy,Sanderson JE et al. British Heart Journal 1977; 39:661-670,“The present study may have implications for the measurement of ventricular stiffness i