Compare and contrast diastolic heart failure (heart failure with preserved ejection fraction) and systolic heart failure (heart failure with reduced ejection fraction).
You must include the following headings in your answer: pathophysiology, echocardiography features, likely etiologies, and management.
College answer
The etiology part of the question was generally answered well, however, the answers to the pathophysiology and management parts lacked detail, especially the rationale for the suggested managements. The echocardiography part of the answer often lacked details of imaging findings, and once again outlined pathophysiology, which had already been answered.
Discussion
This answer would work better as a table:
| Systolic heart failure |
Diastolic heart failure |
| Pathophysiology |
- Impaired LV contractility because of intrinsic myocyte dysfunction or LV muscle tissue loss
- Thus, decreased reactivity to increased demand
|
- Impaired myocardial relaxation, increased myocardial wall stiffness, extrinsic compression (eg. pericardial), acute chamber dilatation or suddenly increased afterload
- Thus, decreased LV elastance and impaired diastolic relaxation
- Thus, raised LV end-diastolic pressure
- Thus, LA dilatation and increased PV pressure, leading to pulmonary oedema
- Worse in the presence of tachycardia (inadequate diastolic filling time) and hypertension (increased end-systolic LV pressure)
|
| Echocardiography features |
- LV dilatation
- Reduced LV ejection fraction
- Reduced LVOT VTI
- Reduced peak systolic strain
- Reduced fractional LV shortening
- Reduced mitral anterior plane systolic excursion
- Tissue Doppler imaging (TDI) and speckle tracking
|
- LV hypertrophy
- LA enlargement
- Mitral E and A
- Increased mitral inflow E/A ratio
- Loss of E/A reversal with the Valsalva maneuver.
- Pulsed-wave TDI-derived mitral annular early diastolic velocity
|
| Likely aetiologies |
- Ischaemia
- Myocarditis (infectious or autoimmune)
- Toxins (eg. negative inotropes)
- Post-bypass stunning
- Hypothermia
- Endocrine causes (eg. hypoadrenalism, hypothyroidism)
- Metabolic causes (eg. acidosis)
|
- Ischaemia
- Hypertrophy 2n to hypertension
- Hypertrophic cardiomyopathy
- Mitral stenosis
- Infiltrative disease:
- Amyloidosis
- Sarcoidosis
- Lymphoma
|
| Management |
- Afterload reduction is essential (arterial vasodilators)
- Preload reduction is helpful (diuretics)
- Contractility augmentation (inotropes, IABP)
-
|
- Preload reduction is essential (diuretics)
- Afterload reduction is helpful (arterial vasodilators)
- Heart rate reduction (beta blockers and calcium channel blockers)
- Maintenance of sinus rhythm (prevention of AF)
|
Echo features were derived from the ASE guidelines for comprehensive TEE in adults and for assessment of diastolic dysfunction.