What is Left Ventricular Diastolic Dysfunction (LVDD)?

From the Guidelines

Left ventricular diastolic dysfunction (LVDD) is a condition where the left ventricle of the heart cannot relax properly during diastole, leading to impaired filling and potentially heart failure with preserved ejection fraction.

Definition and Pathophysiology

LVDD occurs when the myocardium loses its ability to generate force and shorten and returns to an unstressed length and force, and diastolic dysfunction occurs when these events are prolonged, slowed, or are incomplete 1. This condition is often associated with increased myocardial stiffness due to factors like hypertension, aging, diabetes, or coronary artery disease, which impair the heart's ability to fill efficiently without raising filling pressures.

Clinical Characteristics and Epidemiology

Heart failure associated with relatively preserved LVEF is most prevalent among elderly women, most of whom have hypertension, diabetes mellitus, or both and often coronary artery disease or atrial fibrillation as well 1. The morbidity and mortality associated with HF and a relatively preserved LVEF may be nearly as profound as that with low LVEF; frequent and repeated hospitalizations characterize the patient with HF and a normal LVEF.

Management and Treatment

Management of LVDD focuses on treating underlying causes and controlling symptoms. First-line treatments include lifestyle modifications such as sodium restriction (less than 2-3g daily), regular exercise, and weight loss if overweight. Medication therapy typically includes diuretics like furosemide (20-80mg daily) or hydrochlorothiazide (12.5-25mg daily) to reduce fluid overload and improve symptoms. Blood pressure control is essential, with ACE inhibitors (such as lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily) often preferred 1. Beta-blockers like metoprolol (25-200mg daily) may help by slowing heart rate and allowing more filling time. For patients with atrial fibrillation, rate control and anticoagulation are important.

Monitoring and Disease Progression

LVDD progresses through grades 1-3, with increasing severity of filling abnormalities. Regular echocardiographic monitoring is recommended to track disease progression. The condition results from increased myocardial stiffness due to factors like hypertension, aging, diabetes, or coronary artery disease, which impair the heart's ability to fill efficiently without raising filling pressures 1.

Some key points to consider in the management of LVDD include:

• Controlling systolic and diastolic hypertension, in accordance with published guidelines 1
• Controlling ventricular rate in patients with atrial fibrillation 1
• Using diuretics to control pulmonary congestion and peripheral edema 1
• Considering coronary revascularization in patients with coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function 1

From the Research

Definition and Characteristics of Left Ventricular Diastolic Dysfunction (LVDD)

• Left Ventricular Diastolic Dysfunction (LVDD) is characterized by alterations in LV diastolic filling, and is a strong predictor of cardiovascular events and heart failure 2.
• LVDD is an important cause of heart failure in hypertensive heart disease, where the left ventricle's ability to relax and fill during diastole is impaired 3.
• Diastolic heart failure, also referred to as HF with preserved left ventricular systolic function, is a condition where the left ventricular systolic function is normal or only slightly impaired, and the typical manifestations of HF result from increased filling pressure caused by impaired relaxation and compliance of the left ventricle 4.

Risk Factors and Associated Conditions

• Hypertension is the most important risk factor for LVDD in the community, promoting LVDD through several mechanisms, including hemodynamic overload and myocardial ischemia 2.
• Other associated factors that contribute to LVDD include age, ethnicity, dietary sodium, obesity, diabetes mellitus, and chronic kidney disease 2.
• Asymptomatic left ventricular diastolic dysfunction (ALVDD) is associated with incident heart failure and decreased survival, and abnormalities of diastolic function might be included in the definition of stage B HF 5.

Management and Treatment

• Treatment of diastolic HF is aimed to stop the progression of the disease, relieve its symptoms, eliminate exacerbations, and reduce mortality 4.
• The management of diastolic HF should include antihypertensive treatment, maintenance of the sinus rhythm, prevention of tachycardia, venous pressure reduction, prevention of myocardial ischemia, and prevention of diabetes mellitus 4.
• Beta blockers can improve left ventricular diastolic and long axis function when a significant heart rate reduction is achieved in patients with mild-to-moderate arterial hypertension 3.
• The "CHEOPS" bundle, an experts' opinion, provides a potentially useful approach for optimizing the management of critically ill patients with LVDD, including chest ultrasound, hemodynamics assessment, optimization of mechanical ventilation and pulmonary circulation, and stabilization 6.