Systolic and Diastolic Dysfunction
First Things First (assess & treat for the following)
- Is there evidence for isolated systolic dysfunction?
- LV ejection fraction < 50%
- Is there evidence for isolated diastolic dysfunction?
- Ejection fraction >50%, but
- Impaired ventricular filling on echocardiography
- Signs of heart failure/cardiogenic shock? (i.e., low/“inadequate” cardiac output)
- Heart failure is a clinical diagnosis (symptoms and signs).
- Treat reversible causes (tamponade, coronary ischemia, pulmonary embolism, thyrotoxicosis, severe anemia, etc.).
- Optimize cardiac output and treat symptoms.
- Inotropic support (drugs, assist devices, etc.)
- Vasodilator therapy and/or afterload reduction
- Diuresis as tolerated
History and Physical (assess for the following):
- *= best feature in each category
History (precipitating causes)
- *Past history of heart failure
- *Presence of S3 gallop
- *Atrial fibrillation (irregularly irregular: confirm by EKG)
- (Dyspnea on exertion more likely pulmonary disease than heart failure)
- Coronary ischemia/myocardial infarction (±VSD)
- Hypertension (renal or stimulant drug-induced)
- Arrhythmias (e.g., new-onset atrial fibrillation)
- Valvular disease or infective endocarditis
- Myocarditis (viral or drug-induced)
- Thyrotoxicosis, pregnancy, anemia, infection, etc. (high-output failure)
- Pulmonary embolism
- Dietary and environmental factors
- Orthopnea or dyspnea ± wheezing
- Basal/dependent pulmonary rales
- Pleural effusions
- Cheyne-Stokes respiration
- Tachycardia or pulsus alternans
- Apically displaced focal impulse
- Cool/mottled extremities/gangrene of digits if on vasopressors
- Pitting edema (sacral and pedal)
- Jugular venous distention
- Hepatic congestion with abdominojugular reflex
- CXR (PA and lateral)
- *Presence of pulmonary venous congestion
- Pleural effusions
- 12-lead EKG
- Ejection fraction (systolic dysfunction =< 50%)
- Echocardiography (or radionuclide ventriculography)
- Rule out valvular pathology.
- Doppler echocardiography to assess diastolic dysfunction
- Impaired relaxation (mitral inflow E/A wave reversal)
- Pseudonormal (“normal” E/A pattern with blunted systolic PV flow)
- Restrictive (high velocity/short duration E-wave pattern)
- Tissue Doppler echocardiography to assess ventricular dysfunction
- Reduced peak systolic (Sm) and early diastolic (Em) mitral annulus velocities
- Rule out RV dysfunction.
- May lead to LV diastolic dysfunction (interventricular interdependence)
- Left heart catheterization
- Diagnosis of ischemic and/or valvular etiology
- Right heart catheterization findings
- Low cardiac output
- Elevated PA pressures
- Elevated wedge pressure
- Wedge pressure >25 mmHg is consistent with pulmonary edema.
- Elevated central venous pressure
- Myocardial biopsy
- Transplant rejection
- Laboratory tests (nonspecific but important for management)
- ABG: severe uncompensated metabolic acidosis suggests cardiogenic shock
- CBC, hemoglobin A1C, fasting blood glucose, lipid profile
- s-Electrolytes (including calcium and magnesium), BUN and creatinine
- Elevated liver enzymes and INR
- Thyroid-stimulating hormone to rule out thyrotoxicosis
- Elevated BNP
- Not useful as screening for asymptomatic ventricular dysfunction
- Level < 100 pg/ml rules out heart failure
- Level >500 pg/ml is typically present in heart failure
- Metoprolol increases levels unrelated to NYHA class
General Management Principles
- Both systolic and diastolic dysfunction may lead to heart failure.
- Diuretics & ACE inhibitors have emerged as first-line therapy.
- Angiotensin receptor antagonists can be substituted for ACE inhibitors (angioedema risk remains!).
- Low-dose aldosterone antagonists (e.g., spironolactone) should be considered in patients with moderately severe or severe HF symptoms and recent decompensation, or with LV dysfunction early after MI.
- Digitalis can be beneficial in patients with current or prior symptoms of heart failure and reduced LVEF to decrease re-hospitalizations.
- Beta-blockers and ACE inhibitors should be used in all patients with a recent or remote history of MI regardless of EF orpresence of HF.
- Beta-blockers are indicated in all patients (even without a history of MI) who have a reduced LVEF.
- Beta-blockers (using 1 of the 3 proven to reduce mortality [i.e., bisoprolol, carvedilol, and sustained-release metoprolol succinate]) are recommended for all stable patients with current or prior symptoms of HFand reduced LVEF, unless contraindicated
- Arrhythmia management
- Biventricular pacing and/or AICD (based on history and EF)
- Diet control: reduction of salt intake
- Reduction of physical & emotional distress
Isolated diastolic dysfunction
- Usually some of degree of systolic dysfunction is present too.
- Diuretic treatment reduces symptoms.
- No additional symptombenefit from added ACE or ARB treatment
- Inotropic agents are relatively contraindicated unless systolic failure is present.
- Calcium channel blockers to assist in diastolic relaxation, but no clear current recommendations are available.
- Beta-blocker therapy for long-term therapy to modify underlying pathophysiology
- Heart rate reduction as long as diastolic filling is improved – otherwise may lead to worsening failure
- Maintain sinus rhythm (to optimize diastolic filling).
Acute heart failure
- Oxygen by nasal cannula or mask, BiPAP or endotracheal intubation
- Sitting position to increase venous pooling/decrease venous return
- IV morphine (1-2 mg) provides pre- & afterload reduction as well as a reduction in anxiety & sympathetic override.
- Furosemide (10-40 mg IV) provides diuresis and venous & arterial vasodilatation.
- Vasodilator therapy (nitroglycerin, nicardipine, nesiritide or nitroprusside, etc.)
- Pre-existing renal insufficiency is not worsened by nesiritide.
- Inotropic support
- Dobutamine 3-5 mcg/kg/min
- Milrinone (0.1-0.7 mcg/kg/min)
- Epinephrine (0.03-0.1 mcg/kg/min) for those in cardiogenic shock
- Mechanical support (if cardiogenic shock present)
- Intra-aortic balloon pump counterpulsation
- Tandem heart (temporary left heart support)
- Mechanical assist devices (left and/or right)
- Rarely ECMO ± IABP as bridge to mechanical assist device/heart transplant
- Ongoing assessment of cardiac output (PA catheter, etc.)
- Assess and treat for RV dysfunction/failure.
- Pulmonary vasodilators (oxygen, inhaled prostacyclin or i-NO)
- Optimize RV perfusion: consider norepinephrine and/or vasopressin
- Drain effusions, assisted ventilation, etc. to decrease PVR
- Optimize inotropic therapy vs. vasodilator therapy.
- Consider surgical consult (L or R heart assist devices vs. heart transplant).
- Isolated diastolic dysfunction
- Monitored diuresis
- Afterload reduction as tolerated
- Continue to evaluate for ischemia, valve abnormalities & pericardial effusion.
- Treat non-sinus rhythm aggressively.
- Respiratory distress (pulmonary edema)
- Arrhythmias (including atrial fibrillation, V tach, VF, etc.)
- Worsening coronary ischemia (MI, etc.)
- Electrolyte imbalances (hyperkalemia with spironolactone, ACE inhibitor)
- Drug toxicity and side effects (digoxin, amiodarone, milrinone, etc.)
Heart failure with end-organ failure
- Renal failure (prerenal azotemia)
- Respiratory failure
- Hepatic insufficiency
- Pulmonary embolism
- Gangrene of limbs/digits (vasopressors)
- Stroke (embolic from A fib, LV thrombus)
- Written by Mark A. Cannon, MD
- Revised by Charl J. De Wet, MBChB
Systolic and Diastolic Dysfunction is a sample topic found in
To find other Anesthesia Central topics
please login or purchase a subscription.