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Article ID: CV14027
expert roundtable »
Evaluation of Diastolic Function: Scan this code with How Practical Is it? your smartphone camera to access this article on-the-go from our website.
Moderated by Philip R. Liebson, MD
Discussants: Rami Doukky, MD; Melissa Tracy, MD
DR. LIEBSON: I am Dr. Philip Liebson
from the Section of Cardiology, The following Expert Roundtable Discussion was held on Dec 06, 2012. Rush University Medical Center, The discussion focused primarily on: (1) The interpretation and importance of echo- Chicago. I am joined today by two cardiogram reports on diastolic function; (2) the difference between diastolic dys- of my colleagues from the Section of function and diastolic heart failure; (3) the role of diastolic dysfunction and diastolic Cardiology and Echocardiography: heart failure in the management of cardiac patients; and (4) recent advances in the Dr. Rami Doukky, Associate Professor evaluation of diastolic function in echocardiography and other noninvasive measure- of Medicine, Radiology and Dr. Melissa ment of diastolic function. (Med Roundtable Cardiovasc. Ed. 2014;3(4):218–225) Tracy, Associate Professor, Cardiology, 2014 FoxP2 Media, LLC both of whom have been very active in the area of echocardiography.
STUDIES DISCUSSED: CHARM-Preserved perindopril trial; I-PRESERVE trial; PEP-CHF study The topic for discussion is "Evaluation of Diastolic Function, How Practi- COMPOUNDS DISCUSSED: cal Is It?" and encompasses an area in angiotensin II receptor blockers; angiotensin-converting enzyme; diuretics; which there has been much research perindopril; sildenafil and, I have to admit, much confusion. From Rush Medical College, Chicago, IL If you have seen the report of an echo- Address for correspondence: Philip R. Liebson, MD, Rush Medical College, cardiogram on one of your patients 1700 West Van Buren, Suite 470, Chicago, IL 60612 • Email: [email protected] with the information on diastolic func- Published online: www.themedicalroundtable.com • Search for ID: CV14027 tion, indicating "impaired relaxation," "pseudo-normal function," or "revers- DR. DOUKKY: Diastolic function additional information regarding the
ible or fixed restrictive dysfunction," assessment sheds light on left ventricu- loading condition of the patient, ie, the you may have wondered what it lar (LV) performance beyond systolic LV filling pressure. It also provides valu- means, especially when accompanied function. Clinicians are often fixated able prognostic information beyond EF.
by a normal left ventricular ejection on the EF, which is certainly impor- fraction (LVEF). We will consider the tant and many of our management DR. LIEBSON: Dr. Tracy, what is the
importance of these findings and the decisions are based on it. However, difference between the terms diastolic role of diastolic dysfunction and dia- cardiac function is not completely dysfunction and diastolic heart failure? stolic heart failure in the management summed up in the EF. A good deal of Is there an important difference? of cardiac patients, especially when sys- information about contractility could tolic performance is considered to be also be assessed by other means such DR. TRACY: I would like to echo a cou-
normal. We will also discuss some of as myocardial strain, but this is not the ple of points that Dr. Doukky stated. the more recent advances in the evalu- subject of our discussion today.
The reason why we need to discuss ation of diastolic function in echo- diastolic function on every echocar- cardiography and other noninvasive Diastolic function assessment, on the diogram is that diastolic dysfunction other hand, provides additional insight, (abnormal filling/relaxation) is pres- particularly in symptomatic patients. ent in virtually all patients with heart Let's start out with the question, It helps us better understand the failure. In addition, 50% of patients what is the importance of diastolic physiology in patients with normal or who are admitted for congestive heart impaired systolic function by providing failure (fluid overload) actually have 218 Open Access Vol. 3 Iss. 4 The Medical Roundtable: Cardiovascular Edition
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Liebson • Evaluation of Diastolic Function: How Practical Is it?
normal LVEF, ie, normal pumping Therefore, what you were alluding to DR. DOUKKY: I would like to
function to their heart, but abnormal in your first statement, Dr. Liebson, is elaborate on Dr. Tracy's remarks. diastolic function coupled with signs that we use these scientific words, but Heart failure is a clinical diagnosis and symptoms of heart failure, ie, dia- we don't really know what they mean. I manifesting with well-known signs stolic heart failure.1 think it is important that the referring and symptoms. This should not be physicians understand that there are 4 confused with diastolic dysfunction, If the echocardiogram comes back different stages of diastolic dysfunc- which is an echocardiographic finding and the referring physicians read tion, and a patient can actually fluc- not necessarily associated with clinical "normal systolic function or normal tuate between stage 1 to stage 3, but heart failure syndrome.
LVEF" with no mention of diastolic stage 4 tends to be irreversible.
function, they may immediately think It is not unusual for some to confuse that this patient does not have any Stage 1 is a mild form of diastolic diastolic dysfunction with diastolic issues regarding the filling/relaxation dysfunction. At this stage, if, for heart failure. When patients with of the heart and/or cardiac etiology example, the patient's blood pressure preserved systolic function present for the heart failure symptoms, which is treated well, he/she may be able with classic symptoms of heart fail- would be incorrect. If we avoid and to prevent the level of diastolic dys- ure, they are usually at more advanced ignore the fact that there are both function from progressing. Stage II, stages of diastolic dysfunction, systolic (pumping) and diastolic (fill- is called pseudonormal and is a mod- manifesting as diastolic dysfunction ing) physiological factors working grade 2, 3, or 4 on echocardiography.
together for hemodynamic stability as well as other parameters such as those I agree with Dr. Liebson that the in a physical exam, chest radiograph, "Diastolic dysfunction is
prevalence of diastolic heart failure is and biomarkers, we may actually not important not only in its
increasing among the elderly, especially treat our patients appropriately. These prevalence, but also as
at the community level. In referral cen- patients will definitely have progres- a prognostic indicator,
ters, we tend to see more patients with sion of disease with admissions/ especially in patients
systolic heart failure. At the community readmissions for heart failure and a with normal systolic
level, nonetheless, diastolic heart failure worse risk of mortality. Recently, an is certainly on the rise, particularly in article2 in the Journal of Cardiovascular Philip R. Liebson, MD the elderly. In our lifetime, diastolic Translational Research identified sev- dysfunction with preserved EF will eral biomarkers in the plasma, which probably be the most common cause of can be measured. These biomarkers erate degree of diastolic dysfunction. heart failure.
included brain natriuretic peptide and Stage III and IV are severe forms markers of collagen homeostasis and of diastolic dysfunction, with stage DR. LIEBSON: In every type of evalua-
fibrosis. Since there are several etiolo- IV typically being irreversible. tion, you need to have a gold standard, gies leading to diastolic dysfunction, Therefore, diastolic dysfunction is a and I would like to ask what we con- it would be a reasonable conclusion big problem, and it is very impor- sider the gold standard to be for the that multiple biomarkers used inde- tant that we have discussions, so that evaluation of diastolic function.
pendently and in combination will when the referring physician gets the need to be followed to better diag- echocardiogram, he/she understands DR. TRACY: The gold standard would
nose, treat, and improve outcomes for the verbiage.
definitely be echocardiography.
patients with diastolic dysfunction.
DR. LIEBSON: I have to emphasize DR. LIEBSON: Can echocardiography
Looking at all of the parameters that diastolic dysfunction and isolated be compared to another standard, of an echocardiogram for diastolic diastolic dysfunction are quite which may be more direct? That really function is important. The difference common, especially in the elderly, is the thrust of my question.
between diastolic dysfunction and and there are population studies3–6 to diastolic heart failure is that the lat- indicate that at least half of the elderly DR. DOUKKY: The "tau", which can
ter presents with signs and symp- with heart failure have LVEFs greater be measured with left-heart catheter- toms consistent with heart failure than 45%, and in some studies,3,7,8 ization, is widely accepted as a stan- in the absence of depressed LVEF. diastolic heart failure is present, apart dard invasive indicator of the rate of There are 4 different levels of diastolic from systolic heart failure, in up to LV relaxation, while catheter-measured 75% of elderly patients.
LV end-diastolic pressure is the gold The Medical Roundtable: Cardiovascular Edition Vol. 3 Iss. 4 Open Access 219
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Evaluation of Diastolic Function: How Practical Is it? • Liebson
standard for assessing the filling dysfunction. I definitely want to normal LVEF with abnormal systolic pressure. Certainly, no one uses these echo what Dr. Doukky has said, that function). We could discuss further invasive tools for the routine assess- diastolic dysfunction is not a diagno- about whether that it is still feasible/ ment of diastolic function. Therefore, sis that you can make at the bedside.
appropriate, but for the purpose of the practical gold standard remains this discussion, if an echocardiogram echocardiography, which can reli- If you have a patient who does not within approximately 12 hours of ably assess the state of diastolic func- have a history of systolic dysfunction admission demonstrates an EF of 50% tion and the filling condition of the or a weak heart muscle and is admitted or greater, one should evaluate dia- patient in the vast majority of the cases. with heart failure, the echocardiogram stolic dysfunction.
Occasionally, conflicting diastolic indi- helps you decide whether the patient ces may limit our ability to evaluate has systolic dysfunction, diastolic To diagnose diastolic dysfunction, diastolic function echocardiographi- dysfunction, or a combination of you definitely have to look at many cally. In such situations, invasive assess- systolic and diastolic dysfunction or different parameters. You have to ment is still an option.
heart failure and whether you need to look at what is called the mitral valve look at possible pulmonary issues.
inflow while looking at the pattern DR. TRACY: In general, a lot of our
and ratio between early (E) and late measurements are based on cardiac So, echocardiography is really (atrial, A) ventricular filling velocities catheterization, but if you look at paramount in being able to diagnose a (E/A ratio), tissue Doppler obtained the last 10 years, the amount and patient's condition correctly.
from the mitral valve annuli, also to reproducibility of data that we can review the E/e prime ratio, and the get from an echocardiogram allow pulmonary vein flow, which I have you to evaluate filling parameters, "Diastolic function
found to be extremely helpful.
valvular dynamics, and pressure gra- might also help you
dients from the noninvasive and identify further people
Pulmonary vein flow is not easy to highly reproducible echocardiogram who have systolic
measure in patients because you need and compare it to the invasive cardiac impairment by providing
the sample volume of the echocardio- additional information
gram at least 1 to 2 cm within the ori- regarding the loading
fice of the pulmonary vein, and I like We refer back to cardiac catheteriza- condition of the patient,
to try to get more than one pulmonary tion, but in the last 10 years, the area ie, the LV [left ventricu-
vein, if possible, as the information of echocardiography has exponentially lar] filling pressure. It
that you can get on pulmonary vein grown to the point that you will have also provides valuable
flow is really helpful.
an invasive cardiologist and/or a sur- prognostic information
geon come to echocardiography labo- beyond EF [ejection
I then look at pulmonary pressures ratory asking the echocardiographer and see if they are elevated. I also to assist him/her with a particular Rami Doukky, MD check the left atrial size and left atrial case based on the findings from the indexed volume. All this should be echocardiogram. This is because, as Dr. obtained on a standard echocardio- Doukky mentioned, the information DR. LIEBSON: I would like to follow- gram for every patient.
does not always fit together perfectly up this discussion with what specifically like a puzzle, so there are many differ- are the echocardiography techniques I then examine these parameters to ent findings on the echocardiogram for best assessment of diastolic function see where one parameter is indicates that should be looked at for classifi- and what echocardiogram abnormali- diastolic dysfunction. So, it's not just cation of a patient's report as normal ties are best to differentiate between one index that you should consider or abnormal. If the echocardiogram diastolic and systolic dysfunction? for diastolic dysfunction. You have to is not normal, then where does the examine these individual parameters patient fit in the paradigm of diastolic DR. TRACY: I think differentiating for each patient to decide where the
between systolic and diastolic dysfunc- patient is fitting. If you consider all tion is relatively easy because you look of these different indices, you will If you only focus on the mitral valve primarily at the EF: if a patient has an have a good way of diagnosing a inflow or the tissue Doppler alone in EF of 50% or more, you most likely patient with either normal diastolic a vacuum, you will have a difficult have ruled out systolic dysfunction dysfunction or the range of diastolic time accurately diagnosing diastolic (for this discussion, we cannot discuss dysfunction.
220 Open Access Vol. 3 Iss. 4 The Medical Roundtable: Cardiovascular Edition
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Liebson • Evaluation of Diastolic Function: How Practical Is it?
DR. LIEBSON: Dr. Doukky, do you echocardiogram can also be difficult with Chronic Heart Failure and Pre-
have any further comments about to interpret in patients who have body served Left-Ventricular Ejection Frac- habitus issues and chronic obstruc- tion (CHARM-Preserved) trial.9 tive pulmonary disease or those with DR. DOUKKY: I agree with Dr. Tracy. tachycardia accompanied by extreme
Another important piece of infor- You have to look at all indices. I also shortness of breath. Thus, both atrial mation is whether the patient has make an effort to not only specify fibrillation, where you have to take an restrictive filling pattern and whether the stage of diastolic dysfunction but average of at least 10 cardiac cycles, it is reversible. Irreversible restrictive also comment on whether the LV and tachycardia, where the E and A filling pattern after diuretic treatment filling pressure is elevated or not, as wave can be fused, make it difficult to or the Valsalva maneuver carry very it may explain the patient's dyspnea, examine and use the echocardiogram poor prognostic implications and such for example. On the clinical level, parameters.
a patient may be considered for a heart knowing whether the patient is volume overloaded or not is most useful for the In order to ensure that our refer- managing physician.
ring physicians do not get frustrated, On the other hand, echocardio- we have to remember that not every graphic findings of preserved systolic DR. LIEBSON: Different patients obvi- patient has beautiful echocardio- function and grade 1 diastolic dysfunc-
ously have different issues other than graphic windows, and we may have to tion without evidence of elevated filling the diastolic pressure, but are there look at other parameters if that patient pressure carries a good prognosis and any situations where it may be difficult has a difficult body habitus and bad may simply represent relaxation abnor- to assess diastolic dysfunction using chronic obstructive pulmonary disease, mality associated with the normal aging or if the patient is technically unable process. However, grade 1 diastolic to withstand an echocardiogram. I just dysfunction in patients younger than DR. DOUKKY: Yes, there are situations want to preface that because we still 60 years of age may represent impaired
where it is relatively difficult to interpret may have technically limited studies.
relaxation most commonly caused by diastolic function. In atrial fibrillation, long-standing hypertension and may for example, the loss of the atrial con- DR. LIEBSON: Suppose we have the be a precursor to more advanced dia-
traction limits our ability to assess E/A results of the echocardiography and stolic impairment. In the latter case, ratio and changes the pulmonary vein they show that there is a diastolic relax- no specific intervention other than flow pattern. In this case, I find the ation abnormality and evidence of dia- addressing the underlying condition, E/e′ ratio to be very useful. A high ratio stolic dysfunction, while the systolic such as hypertension, is needed.
still identifies high LV filling pressure, function is normal. The next question which is most important clinically. that arises is what sort of intervention Occasionally, we encounter what Secondly, the absolute e′ velocity pro- is required. In other words, how does some call grade 1B diastolic dysfunc- vides a useful assessment of LV diastolic the indication that there is diastolic tion, which is when you have a relax- relaxation, independent of the loading dysfunction affect treatment? ation abnormality manifesting as rever- condition of the patient. In addition sal of E/A ratio, but along with that, to atrial fibrillation, sinus tachycardia DR. DOUKKY: I think it comes down to you have evidence for elevated LV filling
represents a similar challenge.
a couple of issues: one is whether there pressure demonstrated by an increased is high LV filling pressure, and second, E/e′ ratio. You can think of this as a DR. LIEBSON: I think it's important whether the patient is symptomatic. transitional phase between diastolic dys-
that the e′, or the filling, based upon the In symptomatic patients, evidence for function grades 1 and 2. This may be mitral annular motion in early diastole, elevated LV filling pressure, often seen associated with heart failure symptoms, is not heart-rate dependent, and the in grade 2 or 3 diastolic dysfunction, which may improve with diuretics.
ratio of E/e′ may be very important in can actually explain the patient's symp- atrial fibrillation, where, if you could toms. In such a case, treatment with DR. LIEBSON: Dr. Tracy, do you
determine the mitral inflow E and the diuretic can relieve the patient's symp- feel that there are certain classes of e′ of the mitral annulus at the same toms. Additional interventions, such pharmacologic agents that might be time, you could obtain some valuable as angiotensin II receptor blockers more helpful in patients with diastolic information about filling pressures.
(ARBs), may improve the associated dysfunction? morbidity and lower hospital DR. TRACY: I would like to readmission rate as has been shown in DR. TRACY: The data at this point
add to Dr. Doukky's point. The the Effects of Candesartan in Patients do not support one specific form of a The Medical Roundtable: Cardiovascular Edition Vol. 3 Iss. 4 Open Access 221
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Evaluation of Diastolic Function: How Practical Is it? • Liebson
medication that is going to be the most diogram may be a marker of diastolic of the atrium independent of blood beneficial. Obviously, angiotensin- dysfunction that is going to develop in pressure.16 converting enzyme (ACE) and ARBs, these patients.
beta-blockers, and diuretics are There have been several clinical trials paramount. The problem with diastolic So, I repeat the echocardiography involving patients with heart failure dysfunction is that we have actually not to see if the earlier findings are just having normal EFs. These include the been able to treat diastolic dysfunction a normal physiologic response to CHARM-Preserved perindopril trial9 as well as we would like to.
pregnancy or an early marker of what's and the Irbesartan in Heart Failure to come. With diastolic dysfunction, as with Preserved Systolic Function Patients diagnosed with diastolic Dr. Doukky said, I also use ACE inhib- (I-PRESERVE) trial.17 All of these heart failure actually portend a poor itors, ARBs, and diuretics. Those have patients supposedly had normal EF, prognosis. One reason may be that we been shown to be our best therapeutic but the actual EFs were ≥40%. Now, do not treat it as aggressively and as interventions for diastolic dysfunction. we know that in echocardiography, we early as we should. It could also be that consider the normal EF to be >50%, we think we have to focus on patients DR. LIEBSON: I would just like to add so some of these patients certainly had
with systolic dysfunction and make an overview on various types of agents. EFs below what we considered normal.
sure that their blood pressure is better With regards to diastolic stiffness, and under control and that their fluid especially involving the LV, the only The diastolic indices in these stud- status is tighter.
ies included the intraventricular relaxation time, the E/A ratio, the But the diastolic dysfunction patient deceleration time, and the left atrial "…50% of patients who
actually portends a worse prognosis. dimension. The problem was that in are admitted for con-
I think it is important that when we all 3 of these studies, there was no gestive heart failure
encounter a patient with grades 1, evidence that diastolic function had (fluid overload) actu-
1A, or 1B diastolic heart failure, the any prognostic significance with the ally have normal LVEF,
referring physician must establish that primary outcome, which in these ie, normal pumping
the patient does not have a previous cases, were deaths or heart failure function to their heart,
history of diastolic dysfunction and hospitalization. However, there is but abnormal diastolic
that they are not currently being treated some evidence in the CHARM-Pre- function coupled with
for blood pressure. For this patient, the served trial that candesartan, an ARB, signs and symptoms of
mild blood pressure must be monitored significantly reduced hospitalization heart failure, ie, dia-
and the physician must check if maybe for congestive heart failure and in the diet, exercise, and losing weight would Perindopril in Elderly People with control the blood pressure better.
Melissa Tracy, MD Chronic Heart Failure (PEP-CHF) study,18 there was some improvement If the condition has taken a toll on in symptoms and exercise capacity the heart muscle and is no longer current therapy with a salutary effect with perindopril administration.
just isolated elevated blood pressure, on vascular and ventricular stiffness but also shows signs of early diastolic that leads to reduced smooth muscle Statins may have a favorable dysfunction, then you need to be growth, reduced growth factor expres- pleiotropic effect on diastolic aggressive with that patient's treatment sion, and regression of myocardial function19; statins and beta-blockers to be able to control the blood pressure. fibrosis consists of the class of ACE in patients with heart failure and pre- inhibitors. There is evidence that ARBs served LVEF may prevent mortality.12 I have had female patients who I have and aldosterone receptor antagonists Statins have been used for heart fail- performed echocardiography for while may also have efficacy in decreasing ure patients using ACE inhibitors, but they were pregnant. I would perform myocardial fibrosis and thus diastolic mostly in patients whose LVEFs have an echocardiography for them for dysfunction. Beta-blockers and certain been low.
tachycardia and for diagnosing grade calcium channel blockers (verapamil 1 diastolic dysfunction. I have actually and diltiazem) may also be helpful by And finally, there are some interesting been performing an echocardiography prolonging diastolic filling time.10–15 studies20,21 showing that sildenafil, on such patients 6  months post- which has a phosphodiesterase-5A– partum because the diastolic dysfunc- ACE inhibitor therapy, as we know, inhibition effect, may suppress tion showing on a baseline echocar- may result in favorable remodeling chamber and myocyte hypertro- 222 Open Access Vol. 3 Iss. 4 The Medical Roundtable: Cardiovascular Edition
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Liebson • Evaluation of Diastolic Function: How Practical Is it?
phy in animal models and clinical important as a general adjunct in the about the use of MRI? Not that it studies. These studies have found that echocardiography laboratory or just as would be an everyday procedure, but endothelium-receptor antagonists, any comments on the benefit, if any? when added to standard therapy, did not improve outcomes.
DR. TRACY: I think that in the next DR. TRACY: MRI is the ideal method
5 years, if the technology across the to quantitate LV mass and volume. Now, I would like to go to the vendors can become reproducible, the However, I don't believe the current next topic, some of the newer strain and strain rate could be very technology by means of MRI can echocardiography evaluators of valuable. To elaborate a little on what surpass what can be assessed by echo- diastole, which I think should be very Dr. Doukky was saying, if you only cardiogram based on scientifically interesting. Dr. Doukky, do you have look at mitral inflow or tissue Doppler, proven measures, reproducibility, time- any comments about this? What is there are absolute limitations.
liness, and cost. Finally, there's still the new in echocardiography for diastole issue of patients who cannot undergo evaluation in terms of evaluation of One is age, because we know that MRI because of prosthetic equipment beyond the age of 65 years, mitral and/or claustrophobia.
valve inflow pattern alone becomes DR. DOUKKY: Myocardial strain less reliable as a tool. We also haven't
The images and the information that assessment does provide additional talked about the fact that if a patient are obtained from a cardiac MRI are information in the assessment of has a prosthetic valve or a signifi- great, but in my opinion, their use will systolic and diastolic function. cant amount of mitral annular cal- be more related to research rather than Strain imaging can uncover systolic cification, tissue Doppler becomes every day clinical practice.
impairment that may not be apparent unreliable.
by simply looking at the EF.
DR. LIEBSON: Nonetheless, there
So, I definitely think that the is valuable information in certain Furthermore, it may also be helpful limitation on strain and strain rate situations where MRI can provide in assessing diastolic function to some indices is due to a few factors. One information on diastolic dysfunction.
extent, since tissue Doppler imag- of the limitations is that the specific ing is limited by a couple of factors. indices are not reproducible by all DR. TRACY: I agree with you com-
First, it has the angle-dependency of the vendors. So, we cannot repro- pletely, Dr. Liebson. Extrapolating problem, which leads to underestima- duce what one vendor is doing with your question of where we think MRI tion of the measured velocities. Sec- another vendor's equipment, and may be going in the next 5 years, I ond, tissue Doppler may be errone- thus, we rely on information that is remember talking about cardiac com- ously normal due to the translational vendor specific. This results in confu- puted tomography (CT) and cardiac motion of the heart. These 2 factors sion and bias.
MRs 20 years ago and thinking that may lead to errors in the tissue Dop- this is a big thing and that echocar- pler assessment of diastolic function.
The other limitation is that there is a diograms were going to become obso- learning curve with new and evolving lete. I couldn't have been further from Strain imaging, on the other technology. In addition, with the the truth. I do believe that the data hand, implements speckle-tracking currently available equipment, a long obtained from cardiac CT and car- technique, rather than Doppler, to time may be required to obtain accurate diac MR will also continue to grow, evaluate the displacement of 2 echo information. In order to implement but you are not going to be able to speckles within the myocardium strain and strain rate into our everyday get around the limitations of pros- relative to each other. Therefore, it is workflow, the sonographers, fellows, thetic devices. There are newer pros- not affected by the angle-dependency and faculty must be adequately trained thetic devices (artificial heart valves problem or the translational motion of and the time necessary to measure these and pacemakers), which will not be the heart. Strain imaging, however, is indices accurately must not be fraught perturbed by the MRI procedure, but not widely used clinically in the assess- with hindrance and limitations.
we will still have many generations ment of diastolic impairment.
of patients with prosthetics that can't DR. LIEBSON: Thank you, Dr. Tracy. safely utilize this advanced cardiac
DR. LIEBSON: Dr. Tracy, about what Just for the sake of completeness, mag- imagery.
Dr. Doukky has said, do you feel that netic resonance imaging (MRI) has in the next 5 years, the evaluation been used for diastolic dysfunction. There are also patients who are of strain and strain rate would be Do either of you have any comments claustrophobic. Finally, the way our The Medical Roundtable: Cardiovascular Edition Vol. 3 Iss. 4 Open Access 223
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Evaluation of Diastolic Function: How Practical Is it? • Liebson
healthcare system is going, these other In addition, it is important to edu- way to determine diastolic function advanced imaging procedures are cate our referring physicians on the or dysfunction.
not portable and are expensive. They meaning and implications of vari- will never take the place of a good ous terms commonly used in the At present, I think the major concern echocardiogram. They will be able to description of diastolic function.
that many clinicians have is that they add data to a patient's clinical scenario. do not understand what the echocar- You may do it to confirm a diagnosis, DR. LIEBSON: Thank you both for diographic findings mean, and it is
but with the speed and accuracy in an excellent discussion. Let me just extremely important for the echocar- which echocardiography is continuing summarize our discussion. There is diographers to educate their clinicians, to advance, I don't believe you're going no question of whether diastolic dys- so that they know how to interpret the to need either of those 2 modalities to function is important not only in its echocardiographic report. Nonetheless, make a diagnosis, specifically, for dia- prevalence, but also as a prognostic there will be some excellent, important, stolic function and valvular pathology. indicator, especially in patients with new findings in echocardiography over normal systolic function. The impor- the next few years. We have touched DR. LIEBSON: Well, I would like tant thing is that clinicians must upon some of them, and I feel echocar-
to thank you both for an excellent know how to interpret the results of diogram will remain an important pro- discussion. Are there any final words echocardiography, which, again, cur- cedure for evaluating cardiac function, either of you have on this topic? rently is the gold standard, the easiest especially in diastole.
DR. TRACY: As new technology and
new areas in echocardiography are developing, it would be important to make sure that we are educating our sonographers and educating our fellows, so that if they do a complete echocardiography with the latest tech- ➤ Distinguishing between diastolic heart failure and sys- nology, we will be able to deliver the tolic heart failure is important because of the differences information to the referring physician.
in treatment and prognosis.
I think that at an academic institu- ➤ In some studies, over 50% of patients who are admitted tion, such as Rush Medical College, we for congestive heart failure actually have normal systolic have a great service offer for our sonog- raphers and fellows to make sure that we're educating them, so that they're ➤ Diastolic dysfunction is an important prognostic able to understand diastolic func- parameter, especially in patients with normal systolic tion and dysfunction and are able to develop the technology.
➤ Atrial fibrillation makes it difficult to diagnose diastolic DR. DOUKKY: I completely agree
with Dr. Tracy, and I would like dysfunction because of the loss of atrial contraction that to stress again that it is important limits the E/A ratio and changes the pulmonary vein for us to report diastolic function, flow profile.
particularly the filling pressure sta- tus, as it is most useful clinically. It is ➤ Angiotensin-converting enzyme inhibitors, angiotensin- important, within every institution, receptor blockers, diuretics, beta-blockers, and non- to have some sort of agreement on dihydropyridine calcium channel blockers are possible what elements of diastolic function to report clinically. The American therapeutic interventions for diastolic dysfunction, Society of Echocardiography (ASE) but other classes of agents such as aldosterone receptor guidelines22 on the evaluation of dia- blockers and phosphodiesterase inhibitors are being stolic function are probably our best resource for that.
224 Open Access Vol. 3 Iss. 4 The Medical Roundtable: Cardiovascular Edition
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Liebson • Evaluation of Diastolic Function: How Practical Is it?
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jects with normal versus reduced left aldosterone antagonists. Drugs Aging. www.TheMedicalRoundtable.com/Discuss ventricular ejection fraction: Preva- The Medical Roundtable: Cardiovascular Edition Vol. 3 Iss. 4 Open Access 225

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