What are the implications of Grade II diastolic dysfunction?

From the Guidelines

Grade II diastolic dysfunction should be managed with a focus on treating the underlying cause, controlling blood pressure, and reducing preload and afterload, as it is highly predictive of worse outcomes if not adequately managed, as noted in the 2016 update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging 1.

Diagnosis and Management

Grade II diastolic dysfunction represents a moderate impairment of left ventricular relaxation, and its diagnosis requires comprehensive echocardiographic assessment, including mitral inflow patterns, tissue Doppler imaging, and elevated E/e' ratio.

• Key diagnostic features include:
  • Mitral inflow velocities and pulmonary vein velocities and time intervals providing important prognostic data in patients with LV systolic dysfunction, as reported by 1.
  • Mitral annular velocities, including E/e′ ratio, predicting outcomes in these patient groups, as also noted by 1.
• Management should focus on treating the underlying cause, which commonly includes hypertension, coronary artery disease, or diabetes, with medications such as:
  • ACE inhibitors or ARBs (like lisinopril 10-40mg daily or valsartan 80-320mg daily)
  • Beta-blockers (such as metoprolol 25-200mg daily)
  • Diuretics (furosemide 20-80mg daily) to reduce preload and afterload

Lifestyle Modifications and Follow-Up

Lifestyle modifications are essential and include sodium restriction (<2g/day), regular physical activity, weight management, and strict blood pressure control (target <130/80 mmHg).

• Regular follow-up echocardiography every 6-12 months is recommended to monitor progression, as Grade II dysfunction can advance to more severe forms and eventually lead to heart failure with preserved ejection fraction if not properly managed, a concern highlighted by the guidelines from the American College of Cardiology and the American Heart Association 1.
• The management principles outlined are consistent with the therapeutic approaches recommended for patients with diastolic dysfunction, focusing on control of blood pressure, control of tachycardia, reduction in central blood volume, and alleviation of myocardial ischemia, as discussed in the guidelines 1.

From the Research

Grade II Diastolic Function

• Grade II diastolic dysfunction is a condition where the left ventricle's ability to relax and fill during diastole is impaired, but not to the same extent as in grade III diastolic dysfunction 2.
• The prevalence of diastolic dysfunction, including grade II, increases with age and is often associated with hypertension, which can lead to left ventricular hypertrophy and decreased compliance 3, 4.
• The renin-angiotensin-aldosterone system (RAAS) plays a significant role in the development and progression of diastolic dysfunction, including grade II, by promoting structural and functional changes in the heart, such as increased myocardial fibrosis 3, 5.
• Pharmacological blockade of the RAAS, using agents such as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and aldosterone antagonists, has been proposed as a rational approach for the treatment of diastolic dysfunction, including grade II 3, 5.
• Patient outcomes, including all-cause mortality and cardiovascular, heart failure, or cardiac arrest hospitalizations, are affected by the grade of diastolic dysfunction, with increasing grade associated with increasing risk 2.
• The risk of cardiac arrest in patients with grade II diastolic dysfunction is comparable to that of patients with moderate systolic dysfunction, highlighting the importance of addressing diastolic dysfunction in the management of heart failure 2.