From the Guidelines
Congestive heart failure does not typically present with a diastolic murmur as a primary or universal finding, but diastolic murmurs can occur in the context of underlying valvular dysfunction that contributes to or results from heart failure. The clinical manifestations of heart failure, as outlined in the acc/aha 2005 guideline update for the diagnosis and management of chronic heart failure in the adult 1, include dyspnea, fatigue, and fluid retention, which may lead to pulmonary congestion and peripheral edema. These symptoms are largely a result of systolic and diastolic dysfunction, which can coexist in most patients, regardless of the ejection fraction.
Key points to consider in the diagnosis and management of heart failure include:
- The term "heart failure" is preferred over "congestive heart failure" because not all patients have volume overload at the time of initial or subsequent evaluation 1.
- Heart failure may be associated with a wide spectrum of left ventricular (LV) functional abnormalities, ranging from patients with normal LV size and preserved ejection fraction to those with severe dilatation and/or markedly reduced ejection fraction 1.
- Valvular heart disease is a common cause of heart failure, and nearly any form of heart disease may ultimately lead to the heart failure syndrome 1.
When diastolic murmurs are present in patients with heart failure, they typically indicate specific underlying cardiac abnormalities, such as valvular dysfunction, which may be causing or complicating the heart failure. For instance, aortic regurgitation or mitral stenosis can produce distinct diastolic murmurs that warrant further cardiac evaluation, including echocardiography, to identify the specific valvular or structural abnormality contributing to the patient's condition. However, the primary focus in managing heart failure remains on addressing the underlying causes of systolic and diastolic dysfunction, rather than solely on the presence or absence of diastolic murmurs.
From the Research
Presentation of Congestive Heart Failure
- Congestive heart failure (CHF) can present with various symptoms and signs, including those related to diastolic dysfunction 2, 3, 4.
- Diastolic heart failure, a type of CHF, is characterized by normal left ventricular volume and ejection fraction, but abnormal diastolic function 2.
- The diagnosis of diastolic heart failure can be made when a patient has both symptoms and signs of CHF, and normal left ventricular volume and ejection fraction 2.
Diastolic Murmur in Congestive Heart Failure
- There is no direct evidence in the provided studies that congestive heart failure presents with a diastolic murmur 2, 3, 4, 5, 6.
- However, diastolic dysfunction, which can lead to diastolic heart failure, may result from physiological abnormalities of myocardial relaxation or anatomical abnormalities that increase resistance to ventricular inflow 3.
- Treatment of diastolic dysfunction can be accomplished by relieving myocardial ischemia, improving systolic function, lowering arterial systolic pressure, and decreasing cardiac distention 4.
Clinical Implications
- Diastolic heart failure is a frequent cause of CHF, with a significant effect on mortality and morbidity 2.
- The challenge to treating diastolic heart failure is due to the paucity of clinical trials with specific therapies, and those that have been completed have yielded relatively neutral results 5.
- Treatment strategies for diastolic heart failure are much less defined than those for heart failure caused by systolic dysfunction 6.