Understanding diastolic heart failure

Many patients who present with symptoms of heart failure are found to have a normal left ventricular ejection fraction and therefore were labelled as having “diastolic heart failure” implying that the underlying pathophysiology is due to diastolic dysfunction alone. However, using a combination of echocardiographical techniques, a variety of abnormalities were found including reduced longitudinal function, impaired left ventricular twist and torsional dyssynchrony in systole leading to reduced and delayed untwisting, impaired suction and reduced early diastolic left ventricular filling not fully compensated for in late diastole due to left atrial dysfunction. Furthermore in a group of subjects with treated hypertension, the most common risk factor for this form of heart failure, despite a normal resting echocardiogram, there were already substantial abnormalities of both systolic and diastolic function which were only apparent on exercise. Thus these studies have demonstrated that in heart failure with a normal ejection fraction, there are major abnormalities of systolic function especially torsion or twist, which impact on diastolic filling and that the condition is not due to diastolic dysfunction alone. In addition, these findings emphasise the importance of exercise echocardiography for diagnosis and detecting early left ventricular dysfunction before patients progress to developing heart failure