Systolic and Diastolic Left Ventricular Dysfunction: From Risk Factors to Overt Heart Failure

Tatiana Kuznetsova; Lieven Herbots; Yu Jin; Katarzyna Stolarz-Skrzypek; Jan A Staessen

Disclosures

Expert Rev Cardiovasc Ther. 2010;8(2):251-258. 

In This Article

Abstract and Introduction

Abstract

Because life expectancy and the prevalence of risk factors such as hypertension, obesity and diabetes are rising globally, heart failure (HF) is growing into a major health problem. Impairment of left ventricular (LV) diastolic function as well as systolic function appear very early in the course of heart disease. Recent HF guidelines, therefore, place special emphasis on the detection of subclinical LV dysfunction and the timely identification of risk factors for HF. Conventional echocardiography combined with new imaging techniques such as tissue Doppler and tissue tracking are sensitive tools to detect early subclinical deterioration of LV function. Community-based studies revealed a higher prevalence of LV systolic and diastolic dysfunction using the new echocardiographic imaging techniques. Future prospective studies will clarify the hitherto unknown prognosis associated with early symptom-free LV dysfunction.

Introduction

Heart failure (HF) is a major public health problem, currently affecting an estimated 14 million Europeans. Clinically overt HF has a poor prognosis. More than 40% of patients die and approximately 25% are readmitted to the hospital within 1 year following their first hospitalization. Consequently, HF leads to high healthcare costs, currently exceeding those of cancer.

Heart failure can clinically present with predominantly diastolic or systolic dysfunction, or both. Diastolic HF is a progressive disorder characterized by impaired left ventricular (LV) relaxation, increased LV stiffness, increased interstitial deposition of collagen and modified extracellular matrix proteins. Clinically overt diastolic HF, also referred to as HF with normal ejection fraction (EF), currently accounts for 40–50% of all HF cases and has a prognosis as dire as that of systolic HF.[1] There is emerging evidence that risk factors such as systemic arterial hypertension, diabetes and obesity are associated with an increased prevalence of HF with preserved EF. Because life expectancy and the prevalence of risk factors are rising globally, HF is growing into a major health problem.

Heart faliure is usually a progressive condition that begins with risk factors for LV dysfunction (e.g., hypertension), proceeds to asymptomatic changes in cardiac structure (e.g., LV hypertrophy) and function (e.g., impaired relaxation), and then evolves into clinically overt HF, disability and death.[101] Thus, the process of myocardial remodeling starts before the onset of symptoms. Recent HF guidelines, therefore, placed special emphasis on the detection of subclinical LV systolic and diastolic dysfunction and the timely identification of risk factors for HF.[101] Current guidelines distinguish four stages of HF, with stage A representing subjects who are at high risk for HF owing to hypertension, obesity and/or diabetes, but still with normal LV structure and function, and no symptoms of HF. Stage B includes patients with structural and/or functional LV abnormalities without clinical symptoms of HF (asymptomatic HF). Stage C represents patients with structural and/or functional LV abnormalities and symptoms of HF (symptomatic HF). Finally, stage D refers to patients with refractory symptoms of HF, requiring specialized intervention. A recent community-based study provided prevalence estimates for HF staging and underscored the magnitude of the population at risk for progression to overt HF.[2] Overall, 56% of adults 45 years of age or older were classified as being in stage A (risk factors) or B (asymptomatic LV dysfunction).[2] Transition from stage B to stage C is associated with a fivefold increase in mortality risk,[2] which underscores the importance of correctly identifying persons at stage B for early diagnosis and intervention.

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