Question 23

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. 

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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, increased left ventricular elastance (decreased compliance) 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 
    (for grade II-IV dysfunction)
  • 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.

References

Klaeboe, Lars Gunnar, and Thor Edvardsen. "Echocardiographic assessment of left ventricular systolic function." Journal of echocardiography 17 (2019): 10-16.
Zerbib, Yoann, Julien Maizel, and Michel Slama. "Echocardiographic assessment of left ventricular function." (2019): 2019.
Pirracchio, Romain, et al. "Diastolic heart failure in anaesthesia and critical care." British Journal of Anaesthesia98.6 (2007): 707-721.
Gori, Mauro, Attilio Iacovoni, and Michele Senni. "Haemodynamics of heart failure with preserved ejection fraction: a clinical perspective." Cardiac failure review 2.2 (2016): 102.