From the Guidelines
Abnormal diastolic filling pattern is associated with Congestive Heart Failure (CHF), particularly in patients with preserved ejection fraction (HFpEF), as it can indicate diastolic dysfunction, which is a hallmark of HFpEF. Diastolic filling pattern refers to how the heart fills with blood during the relaxation phase (diastole) of the cardiac cycle, typically assessed using echocardiography 1. Abnormal diastolic filling patterns can suggest impaired relaxation or increased stiffness of the left ventricle, which are characteristic of diastolic dysfunction.
There are four main types of diastolic filling patterns:
- Normal
- Impaired relaxation
- Pseudonormal
- Restrictive Patterns 2-4 indicate progressively worsening diastolic function, with restrictive filling being the most severe form of diastolic dysfunction 1. While these abnormal patterns are commonly seen in patients with CHF, particularly those with HFpEF, they are not synonymous with CHF itself. Other conditions, such as hypertension, diabetes, and aging, can also lead to abnormal diastolic filling patterns without necessarily causing CHF.
The pathophysiology of HFpEF is complex and involves multiple factors, including abnormal renal sodium handling, arterial stiffness, and myocardial stiffness 1. Diastolic dysfunction is a key component of HFpEF, and its assessment can be useful in diagnosing and managing HFpEF. The European Society of Cardiology guidelines recommend the use of echocardiography to assess diastolic function and diagnose HFpEF 1.
To diagnose CHF, clinicians consider multiple factors, including symptoms (e.g., shortness of breath, fatigue), physical examination findings, laboratory tests (e.g., BNP levels), and imaging studies 1. The diastolic filling pattern is just one piece of information used in this comprehensive assessment. Therefore, abnormal diastolic filling pattern should be considered as a potential indicator of diastolic dysfunction and HFpEF, and further evaluation and management should be guided by a comprehensive assessment of the patient's clinical presentation and diagnostic test results.
From the Research
Association between Abnormal Diastolic Filling Pattern and Congestive Heart Failure (CHF)
- Abnormal diastolic filling patterns have been linked to Congestive Heart Failure (CHF) in various studies 2, 3, 4, 5, 6
- Approximately 40% of patients with CHF have predominantly diastolic left ventricular dysfunction, as reported in a study published in 1999 2
- Diastolic dysfunction is frequently the first detectable abnormality in many cardiac diseases, and its progression can be observed through changes in filling patterns 2
Types of Diastolic Filling Patterns
- There are three different pathologic filling patterns: delayed relaxation, restrictive, and pseudonormal patterns 2
- The restrictive pattern is associated with a high E/A wave ratio and short deceleration time, and is often seen in patients with severe diastolic dysfunction 2, 4
- The pseudonormal pattern is an intermediate stage between delayed relaxation and restrictive filling, and can be unmasked by the Valsalva maneuver 2
Clinical Correlates and Prognostic Significance
- A restrictive diastolic filling pattern is associated with a longer duration of CHF, more angina, and higher rates of symptomatic recurrences of CHF 4
- Both high and low Doppler E/A ratios are predictive of incident CHF, as reported in a study published in 2001 5
- Echocardiographic findings suggestive of subclinical contractile dysfunction and diastolic filling abnormalities are both predictive of subsequent CHF 5
Mechanisms of Diastolic Dysfunction
- Diastolic function is determined by both active and passive processes occurring at the level of the myocyte, extracellular matrix, and left ventricular chamber 6
- Forces extrinsic to the myocardium, such as the influence of right heart filling, pericardial and extracardiac constraints, and cardiac preload and afterload, also contribute to diastolic dysfunction 6