Routine Testing for Miosis in Diastolic Dysfunction Patients is Not Recommended
Routine testing for miosis in patients with diastolic dysfunction is not recommended as there is no evidence in current guidelines supporting this practice. 1
Assessment of Diastolic Dysfunction: Evidence-Based Approach
Recommended Diagnostic Parameters
The American Society of Echocardiography and European Association of Cardiovascular Imaging recommend four specific variables for identifying diastolic dysfunction 1:
- Annular e' velocity (septal e' < 7 cm/sec, lateral e' < 10 cm/sec)
- Average E/e' ratio > 14
- Left atrial volume index > 34 mL/m²
- Peak tricuspid regurgitation velocity > 2.8 m/sec
Diastolic dysfunction is present when more than half of the available parameters meet these cutoff values 1
Grading Diastolic Dysfunction
- Three stages of diastolic dysfunction are recognized based on echocardiographic findings 2:
- Stage I: Reduced LV filling in early diastole with normal pressures
- Stage II: Pseudonormalization pattern with increased left atrial pressures
- Stage III: Severe restrictive filling pattern with markedly decreased LV compliance
Appropriate Testing Strategy
When to Test
- Testing for diastolic dysfunction should be performed in patients presenting with symptoms of dyspnea or heart failure 1
- Routine echocardiographic assessment should include evaluation of LV diastolic function 1
- Conclusions on LV diastolic function should be included in reports when feasible, particularly in patients referred with symptoms of dyspnea or diagnosis of heart failure 1
What Not to Do
- Indiscriminate screening for cardiac dysfunction in asymptomatic patients is not recommended and not cost-effective 1
- Routine testing for miosis (pupillary constriction) has no established connection to diastolic dysfunction in any of the current guidelines 1
Clinical Implications and Management
- Diastolic heart failure is associated with high morbidity despite potentially lower mortality than systolic heart failure 3
- Treatment should target the underlying cause of diastolic dysfunction 3, 4:
- Hypertension: ACE inhibitors, ARBs, calcium channel blockers
- Ischemia: Anti-ischemic therapy
- Volume overload: Diuretics
Pitfalls to Avoid
- Overdiagnosis through excessive testing without clinical indication can lead to unnecessary patient anxiety and healthcare costs 1
- Missing Stage II (pseudonormalization) diastolic dysfunction because the Doppler pattern appears deceptively normal 2
- Failing to recognize that diastolic dysfunction may be reversible in some clinical scenarios 5
Bottom Line for Practice
- Focus testing on the four recommended echocardiographic parameters for diastolic dysfunction 1
- Reserve testing for patients with symptoms or those at high risk 1
- There is no evidence supporting routine testing for miosis in patients with diastolic dysfunction 1
- A targeted approach based on symptoms and risk factors is more appropriate than universal screening 1