Korean Circ J.  2025 Feb;55(2):67-78. 10.4070/kcj.2025.0005.

Simple and Practical Way of Assessing Diastolic Function: Diastolic Heart Failure Revisited

• Sohn DW

• KMID: 2565423
• DOI: http://doi.org/10.4070/kcj.2025.0005

Abstract

Recently, usage of the term ‘heart failure with preserved ejection fraction (HFpEF)’ has predominated over the term ‘diastolic heart failure (DHF).’ The term ‘preserved ejection fraction’ represents only one aspect of DHF and does not provide insight into the hemodynamic mechanism of heart failure. In heart failure with reduced ejection fraction (HFrEF), depressed ejection fraction is the independent determinant of prognosis regardless of etiology. However, in HFpEF, because the prognosis is predominantly determined by etiologies of HFpEF, results of the drug on the prognosis in the clinical trial cannot be interpreted as it is. Therefore, studies on patients with HFpEF should be restricted to patients with diastolic dysfunction and, effects of drugs should be focused on symptom improvement not survival benefit. One reason for the prevalent use of HFpEF over DHF is the complexity in assessing diastolic function. Current official recommendations for the evaluation of diastolic function are too complex to be widely applied in the patient enrollment in large clinical trials as well as not easily applicable in our daily clinical practice. Therefore, there is a clinical need for a simple and practical way of assessing diastolic function.

Keyword

Diastolic heart failure; HFpEF; Diastolic dysfunction; LV filling pressure

Figure

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  Figure 1 Cardiac function can best be understood by the working of the roller pump. Pumping function is maintained by complete squeezing of the tube (EF*), adequate side of the tube (LV volume*) and spinning rate of the rotor (HR*). For an adequate filling function of the roller pump, the tube should (A) expand rapidly immediately after the squeeze (rapid relaxation*) and (B) be compliant enough to easily increase the volume of fluid in the tube when extra-pressure is applied from the outside (passive stiffness*).*Corresponding element in cardiac function.

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  Figure 2 Every step in the intracellular mechanism of contraction plays a role in relaxation. With a release of Ca from the SR, myosin binding site of actin is exposed as Ca binds to troponin C and myosin head binds to actin when ATP is hydrolyzed. With the release of phosphorous, power stroke occurs. Myosin head is released from actin when ATP is attached to the myosin head. After the end of contraction, Ca is taken up back into SR by SERCA2. When phospholamban is phosphorylated, inhibition of SERCA2 by the phospholamban is disinhibited.SERCA2 = sarcoplasmic reticulum Ca2+ATPase; SR = sarcoplasmic reticulum.

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  Figure 3 Obtaining time constant of relaxation – tau (τ).AO = aorta; AVC = aortic valve closure; AVO = aortic valve opening; LA = left atrium; LV = left ventricle.

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  Figure 4 Mitral inflow and mitral annulus velocity according to types of diastolic dysfunction.

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  Figure 5 Vp in (A) a normal subject and (B) a patient with relaxation abnormality.Vp = propagation velocity.

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  Figure 6 Restrictive physiology turns into relaxation abnormality pattern with preload reduction in reversible restrictive filling pattern, and restrictive physiology persists even after preload reduction in irreversible restrictive filling pattern. When loading condition manipulation cannot be performed, preserved A′ velocity (>0.05 m/sec) is helpful in differentiating between the two.

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  Figure 7 Suggested algorithm for the (A) determining types of diastolic dysfunction and (B) estimating filling pressure, and therapeutic implications according to the types of diastolic dysfunction.HR = heart rate; TR = tricuspid regurgitation.

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  Figure 8 As pulmonary artery diastolic pressure is always higher than pulmonary capillary wedge pressure representing LV filling pressure, we can safely assume that patients with elevated LV filling pressure also show elevated pulmonary artery systolic pressure, which can be estimated by TR velocity.LV = left ventricle; PA = pulmonary artery; PCWP = pulmonary artery capillary wedge pressure; RA = right atrium; RV = right ventricle; TR = tricuspid regurgitation.

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