Diastolic cardiac insufficiency exists when signs and symptoms of heart failure are present, but the left ventricular systolic function is still preserved (ejection fraction above 45%). It is important to differentiate the diastolic from the systolic heart failure so that it can be optimally treated.

The incidence of diastolic heart failure increases with age; in about 50 percent of elderly patients with heart failure, there is isolated diastolic dysfunction, write Chhabi Satpathy and colleagues in the American Family Physician. If diastolic dysfunction is diagnosed early and adequately treated, the prognosis is better than for systolic dysfunction.

Diastolic heart failure is clinically and radiologically indistinguishable from systolic heart failure. However, if there is a normal ejection fraction and an abnormal diastolic function with signs and symptoms of heart failure, diastolic heart failure can be diagnosed. Unlike systolic, diastolic heart failure can occur in isolation. Common causes of diastolic dysfunction include cardiac ischemia, hypertension, aging, obesity, and aortic stenosis. Rarely, the disorder is caused by myocardial diseases such as cardiomyopathy, storage diseases, and amyloidosis or sarcoidosis or by a disease of the pericardium.

In isolated diastolic dysfunction, there is a disorder of isovolumic ventricular relaxation and decreased compliance of the left ventricle. The transmission of higher end-diastolic pressures into the pulmonary circulation can cause pulmonary congestion leading to dyspnea and eventually right heart failure.

Diagnostics

Heart failure may be manifested by fatigue, exertional dyspnoea, paroxysmal nocturnal dyspnea, orthopnea, cervical venous stasis, rales, tachycardia, third or fourth heart sounds, hepatomegaly, and edema. Cardiomegaly and congestion of the pulmonary veins often occur in chest radiographs, but these findings are non-specific and can also occur in non-cardiac diseases. It is difficult to distinguish diastolic from systolic heart failure on the basis of physical examination alone.

Two-dimensional Doppler echocardiography is of great importance in the diagnosis of diastolic heart failure. This study not only provides important information about ventricular size, myocardium, heart valves, systolic function, and pericardium but also provides information on diastolic transmitral and pulmonary venous blood flow. In echocardiography, the peak velocity of blood flow through the mitral valve in the early diastolic filling phase corresponds to the e-wave. The atrial contraction corresponds to the A-wave. From these values, the I / O quotient is calculated. Usually, E is greater than A, and the I / O ratio is about 1.5.

In early diastolic dysfunction, relaxation is disturbed and the I / O ratio drops to less than 1.0 with atrial contraction. As the disease progresses, left ventricular compliance decreases, increasing left atrial pressure and early left ventricular filling despite disturbed relaxation. This paradoxical normalization of the I / O quotient is called “pseudo-normalization”. In patients with severe diastolic dysfunction, the left ventricle is filled, especially in early diastole, resulting in an I/O ratio above 2.0. Although cardiac catheterization is preferred in the diagnosis of diastolic dysfunction. However, two-dimensional Doppler echocardiography has proven to be the best noninvasive method in everyday clinical practice. Rarely, radionuclide angiography is performed, especially in patients who find echocardiography technically difficult.

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Treatment

Primary prevention of diastolic heart failure includes nicotine abstinence and the aggressive treatment of high blood pressure, hypercholesterolemia, and coronary heart disease. Lifestyle changes such as weight loss, cessation of smoking, diet change, restriction of alcohol intake and physical activity serve to prevent diastolic and systolic heart failure. Diastolic dysfunction can remain asymptomatic for many years. Early diagnosis and treatment are important to prevent irreversible structural changes and systolic dysfunction. At first glance, it seems that the treatment of diastolic and systolic heart failure is not very different. However, the treatment of diastolic heart failure is limited due to the lack of large randomized controlled trials. In addition, the optimal treatment for systolic heart failure may result in exacerbation of diastolic heart failure.

Improvement of the left ventricular function

For diastolic dysfunction, it is important to control the heart rate and prevent tachycardia to maximize the diastolic filling period. Beta-blockers are particularly useful for this purpose, but they do not directly affect myocardial relaxation. Beta blockers should be used in particular for the treatment of diastolic heart failure, if a high blood pressure, coronary heart disease or arrhythmia.

Optimization of hemodynamics

Hemodynamic optimization is achieved primarily by reducing cardiac preload and afterload. ACE inhibitors and angiotensin receptor blockers

Definition: What is a Coronary Heart Disease (CHD) and how does it arise? CHD is the most common heart disease of the entire world population. It is also referred to as ischemic heart disease. In Germany, approximately 6 million patients are affected. Scientists believe that the incidence of coronary heart disease will increase with increasing life expectancy.

CHD primarily affects people over the age of 50 and is one of the most frequently reported causes of death in all industrialized countries. It is a disease of the heart caused by occlusions and constrictions in the coronary arteries.

These arteries are among the blood vessels that supply the heart with energy-giving nutrients and oxygen-rich blood. Especially with physical stress, the blood transport through the body is reduced and there are typical symptoms of CHD.

How is the calcification of coronary arteries formed?

Calcification of coronary arteries is caused by deposition of arteriosclerotic plaques by :

  • cholesterol
  • saturated fatty acids
  • lime-like particles

In some cases, initial nutritional damage already exists due to :

  • high blood pressure
  • Diabetes mellitus

The human immune system does not recognize the plaques as endogenous. This is followed by inflammatory reactions and the plaques become increasingly unstable since activated immune cells no longer fulfill their task and die in the same. Deposits begin to open by the progressive increase. The contents enter the bloodstream and finally the coronary vessels, where it settles again.

Typical symptoms of CHD

Depending on the stage of development of CHD different symptoms occur. It is distinguished into three different forms of stages of coronary heart disease.

Latent CHD

A latent coronary heart disease is characterized by mild to moderate constrictions of the coronary arteries. There is coronary sclerosis.

Although this phase is asymptomatic, there is already a significant mismatch between oxygen supply and demand. Despite the absence of symptoms, it is possible to detect a reduced perfusion of the heart muscle. In diabetics often no typical symptoms are noticeable.

Stable CHD

At this stage, sufferers notice typical CHD symptoms that occur under certain conditions. In most cases, they return alone or can be treated with medication (stable angina pectoris).

Angina Pectoris is the leading symptom of coronary heart disease. Affected notice a feeling of tightness as well as pain directly behind the breastbone. Primarily, the symptoms occur in cold but also exercise. Other factors, such as mental stress or high-fat meals, can trigger these symptoms as well.

The resulting pain often spreads to the left arm or to other body regions such as upper abdomen, jaw or neck.

Other typical symptoms of CHD are:

  • Shortness of breath (shortness of breath)
  • sweats
  • Arrhythmia

Occasionally affected people feel dread. As soon as the affected person comes to rest or stays warm again, these symptoms of angina pectoris return.

Typical symptoms of angina pectoris vary in their frequency, intensity, and duration. They are closely related to the current progression of the CHD. In patients with renal insufficiency or diabetes mellitus, chest pain persists. This also applies to persons over 75 years and operated on. Here are breathlessness, dizziness, nausea, and radiation of pain in the abdominal area as warning signs.

Unstable CHD and acute coronary syndrome

Similar symptoms of angina pectoris also occur here. However, they are significantly stronger and unpredictable (unstable angina pectoris). This expression can not always be adjusted to the medication.

As a result, coronary heart disease leads to a reduced resilience of sufferers and causes a reduction in performance. Depending on the severity, this affects the quality of life. In individual cases, patients can no longer sufficiently fulfill everyday tasks.

At the same time, the clinical picture may continue to deteriorate and become a life-threatening stage of CHD. The so-called acute coronary syndrome is characterized by three manifestations :

  1. Unstable angina pectoris
  2. is characterized by a lack of elevations of the heart enzymes (creatine kinase MB, troponin) in the blood. ECG results show no changes that indicate a heart attack.
  3. Non-ST-elevation myocardial infarction (NSTEMI, acute myocardial infarction)
  4. shows no changes in the ECG, however, heart enzymes that point to possible heart disease and an infarction, detectable in the blood.
  5. ST-segment elevation myocardial infarction (STEMI, acute myocardial infarction)
  6. manifests itself by typical changes in the ECG and detectable cardiac enzyme levels in the blood

As a consequence of these features occurs :

  • Heart failure due to a heart attack
  • Heart arrhythmia due to a myocardial scar or coronary circulatory disorders
  • Sudden cardiac death

Risk factors for the development of CHD

The training of CHD is favored by numerous risk factors. Women over the age of 55 and men over the age of 45 are at particular risk. The previous lifestyle plays a particularly important role here. Unhealthy, high-fat diet, lack of exercise and smoking increase the risk of diseases such as high blood pressure, high cholesterol, lipid metabolism and glucose tolerance disorders. As a consequence of this, in turn, a CHD can arise.

Not to be ignored is the family disposition. Special caution is advised when cases of CHD to heart attack have already occurred in the family environment if possible risk factors should be largely avoided and a special focus on a healthy, balanced lifestyle should be laid. 

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The diagnosis of CHD

Due to the risk factors for coronary heart disease described above, the diagnosis begins with an intensive discussion. Besides the risks, complaints are also documented. In addition, an assessment of the physical capacity of the patient.

This is followed by a physical check focusing on the legs, lungs, and heart. Possible signs of CHD include :

  • Cardiac malformations such as aortic valve stenosis
  • rattling breathing due to pulmonary congestion
  • heart failure

Weight, heart rate, blood pressure, and vascular status are also determined