General Practice
Do patients with suspected heart failure and preserved left ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study
Lynn Caruana Department of
Cardiology, Western Infirmary, Glasgow G11 6NT
Correspondence to: J
McMurray j.mcmurray{at}bio.gla.ac.uk
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Abstract |
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 Top
 Abstract
 Introduction
Methods
Results
Discussion
References
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Objectives:
To characterise the clinical
features of patients with suspected heart failure but preserved left
ventricular systolic function to determine if they have other potential
causes for their symptoms rather than being diagnosed with "diastolic
heart failure."
With the recent wide availability of non-invasive
assessments of left ventricular function it has become apparent that
many patients diagnosed as having heart failure have preserved left ventricular systolic function.
1 2
It has been proposed
that these patients have abnormalities of ventricular filling in
diastole, and the term "diastolic heart failure" has been
coined.1-3 It does, however, seem likely that given the
non-specificity of the symptoms and signs used to diagnose heart
failure at least some of these patients may not have abnormalities of
diastolic ventricular function but other causes of their symptoms
altogether. We studied consecutive patients who were referred with a
diagnosis of suspected heart failure by general practitioners to our
direct access transthoracic echocardiography service and were found to
have preserved left ventricular systolic function. We defined their
clinical characteristics and considered the alternative diagnoses of
obesity, respiratory disease, and ischaemic heart disease.
Patients Medical history, drug history, and symptoms Body mass index Respiratory function Electrocardiography Transthoracic echocardiography Patients
Table 1.
Design:
Prospective descriptive study.
Setting:
Outpatient based direct access
echocardiography service.
Participants:
159 consecutive patients with suspected
heart failure referred by general practitioners.
Main outcome measures:
Symptoms (including shortness
of breath, ankle oedema, and paroxysmal nocturnal dyspnoea) and history
of coronary heart disease and chronic pulmonary disease. Transthoracic
echocardiography, body mass index, pulmonary function tests, and electrocardiography.
Results:
109 of 159 participants had suspected heart failure in the absence of left ventricular systolic dysfunction, valvular heart disease, or atrial fibrillation. Of these 109, 40 were
either obese or very obese, 54 had a reduction in forced expiratory
volume in 1 second to 
70%, and 97 had a peak expiratory flow rate
70% of normal. Thirty one patients had a history of angina, 12 had
had a myocardial infarction, and seven had undergone a coronary artery
bypass graft. Only seven patients lacked a recognised explanation for
their symptoms.
Conclusions:
For most patients with a diagnosis of
heart failure but preserved left ventricular systolic function there is
an alternative explanation for their symptoms
for example, obesity,
lung disease, and myocardial ischaemiaand the diagnosis of diastolic
heart failure is rarely needed. These alternative diagnoses should be
rigorously sought and managed accordingly.
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
We studied patients with preserved left
ventricular systolic function who were referred with suspected heart
failure to an outpatient based direct access cardiography service.
Patients with left ventricular systolic dysfunction (according to
qualitative "eyeball" assessment, see below), valvular heart
disease, and atrial fibrillation were not studied further. The study
was approved by our local committee for medical ethics. Each patient
gave written informed consent.
A full clinical
history was taken. Symptoms of shortness of breath at rest or on
exertion, paroxysmal nocturnal dyspnoea, and ankle swelling were
specifically recorded. A past or current history of angina was also
specifically elicited. The severity of angina was graded according to
the Canadian Cardiovascular Society.4 Current medication
was recorded.
Body mass index was calculated in the usual
way (weight (kg)/height (m)2). Participants with
a body mass index of less than 18.5 were defined as underweight,
18.5-24.9 as normal weight, 25.0-29.9 as overweight, 30.0-39.9 as
obese, and 
40 as extremely obese.5
All patients had peak expiratory flow
rate measured and had spirometry performedthat is, forced expiratory volume in 1 second (FEV1) and forced vital capacity.
A standard, resting 12 lead
electrocardiogram was recorded in each patient. Pathological Q waves
were taken as evidence of previous myocardial infarction. ST/T changes, previous myocardial infarction, or left bundle branch block were considered to be consistent with a diagnosis of coronary heart disease.
Each patient underwent
transthoracic echocardiography with an Acuson 128XP10c, with the
patient recumbent in the left lateral decubitus position. The same
operator (LC) performed all examinations. Qualitative assessment of
left ventricular systolic function was made by the "eyeball"
technique, with two dimensional images.
6 7
Quantitative
assessment was made by measurement of ejection fraction and fractional
shortening by using M mode echocardiography. Ejection fraction was also
measured using the Simpson's biplane method.8 For
diastolic function the E:A ratio was measured as described
previously.
1 9
Left ventricular hypertrophy was assessed
by M mode echocardiography.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
One hundred and fifty
nine patients with suspected heart failure were referred, and 34 had
left ventricular systolic dysfunction (18 out of 61 men (30%; 95%
confidence interval 19% to 41%) and 16 out of 98 women (16%; 9% to
23%)). Ten patients had atrial fibrillation, two patients had valvular
disease, and four patients had both atrial fibrillation and valvular
heart disease. One hundred and nine patients had suspected heart
failure in the absence of left ventricular systolic function, valvular heart disease, or atrial fibrillation. Details of these 109 patients is
shown in table 1. In keeping with findings of epidemiological studies,
the patients were elderly and usually female. Most patients had been
prescribed diuretics. Thirty three patients were non-smokers, 29 were
current smokers, and 47 were former smokers.
Dyspnoea and ankle swellingMost men and women reported
dyspnoea on exertion, and about a quarter reported either dyspnoea at
rest or at night (table 1). Men and women differed in their reporting
of ankle swelling, however, with twice as many women (80%) complaining
of this symptom.
Angina, myocardial infarction, and coronary artery bypass
graftThirty one (28%; 20% to 36%) patients had a history of
angina though only 11 (10%; 4% to 16%) currently had symptoms (seven were classified as grade I, four as grade II). Twelve (11%; 5% to
17%) patients gave a history of myocardial infarction, and seven had
undergone a coronary artery bypass graft. In total, 33 (30%; 21% to
39%) patients either had a history of angina or myocardial infarction
or had undergone a coronary artery bypass graft. Eight patients had
electrocardiographic evidence consistent with coronary heart
disease.
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Body mass indexOf the 109 patients with suspected heart
failure in the absence of left ventricular systolic dysfunction, valvular heart disease, or atrial fibrillation, 108 had their body mass
index calculated. Details are shown in table 2. Thirty five (32%; 23%
to 41%) were obese, and five (5%;1% to 9%) were extremely obese.
Respiratory function testsOf 109 patients, 106 had their
respiratory function measured. Table 2 shows the results of these measurements. Fifty four patients (50%; 41% to 59%) had
FEV1 less than 70% of that predicted, and 97 (92%; 86% to 98%) had a peak expiratory flow rate 70% of normal.
ElectrocardiographySeventy (64%; 55% to 73%) patients
had a normal results on electrocardiography. More men than women had abnormalities. These are shown in table 2. As left bundle branch block,
myocardial infarction, and ST/T changes are typical findings in
coronary heart disease, 24% of men and 16% of women had
electrocardiographic evidence of possible coronary heart disease. Taken
in conjunction with evidence from the clinical history (33 patients),
eight additional patients had either clinical or electrocardiographic
evidence of possible coronary heart diseasethat is, a total of 41 (38%; 29% to 47%) patients had either clinical or
electrocardiographic evidence of possible coronary heart disease.
Transthoracic echocardiographyTable 3 shows measurements
of left ventricular systolic function. By using the E:A ratio, 67%
(74% men and 64% women) had "diastolic dysfunction." Left ventricular hypertrophy was detected in about one quarter of
patients.
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Assessment of the overlap of obesity, respiratory disease, and
cardiac abnormalitiesTables 4 and 5 show the overlap between abnormalities of body mass index (overweight, obesity, or extreme obesity), FEV1 (less than 70% of predicted),
cardiac structure (left ventricular hypertrophy), and evidence of
coronary heart disease (clinical or electrocardiographic). Table 4
compares the overlap of obesity and angina with the presence of
FEV1 less than 70% of predicted and left
ventricular hypertrophy. Table 5 differs from table 4 in using abnormal
body mass index (overweight, obese, and extremely obese) in place of
obesity and coronary heart disease (history of angina (past or
present), myocardial infarction, coronary artery bypass graft, or ECG
changes consistent with coronary heart disease) in place of angina. Of
109 patients for whom complete data were available for all parameters,
106 were included. Only nine (9%; 4% to 14%) patients were of normal
weight and had a FEV1 greater than 70%
predicted. Of these, two had clinical or electrocardiographic evidence
of coronary heart disease. Consequently, only seven patients (7%; 2%
to 12%) had no evidence of abnormalities of body mass index,
respiratory disease, or coronary heart disease.
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Discussion |
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Top
Abstract
Introduction
Methods
Results
Discussion
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Along with others, we have found that many patients
presenting with heart failure have preserved left ventricular systolic function.
1-3 10-15
While these patients may have
"diastolic dysfunction" it is also possible that there are other
explanations for their symptoms. The problem about making a diagnosis
of "diastolic" heart failure non-invasively is that there is no
agreement on how this should be done, and different criteria for
diastolic dysfunction give enormously differing
prevalences.
2 16
One of the most commonly used criterion,
an E:A ratio of <1, showed that most of our patients with heart
failure and preserved left ventricular systolic function could be said
to have diastolic dysfunction. Rather than examine the vexed issue of
how one defines diastolic dysfunction with echocardiography we have
examined an alternativethat is, could there be another explanation
for these patients' symptoms?
The most obvious alternative diagnoses are obesity, respiratory
disease, and myocardial ischaemia. We found that the first two of these
were common. A third of patients were either obese or very obese. Half
of the patients had a considerable reduction in
FEV1 (to 70% or less) and 89% had a peak
expiratory flow rate less than or equal to 70% of normal. Remarkably,
only nine patients were of normal weight and had
FEV1 greater than 70% predicted. Though we
sought to identify myocardial ischaemia only by recording a history of
angina, 31 patients admitted to this symptom, 12 had a history of
myocardial infarction, and seven had undergone coronary artery bypass
surgery. Furthermore, at least 20 patients had electrocardiographic
changes consistent with myocardial ischaemia or infarction. If we had
undertaken exercise stress electrocardiography even more patients with
myocardial ischaemia would probably have been identified. Of the nine
patients with normal weight and FEV1 greater than
70%, a further two had clinical or electrocardiographic evidence of
coronary heart disease. In other words, only seven patients in this
study with a diagnosis of heart failure but preserved left ventricular
systolic function lacked a recognised explanation for their
symptomsthat is, a diagnosis of diastolic heart failure was
inappropriate. The important message for clinicians is that an
echocardiogram suggesting diastolic dysfunction on the basis of an
abnormal E:A ratio is not diagnostic and represents insufficient investigation.
|
What is already known on this topic
Patients with suspected heart failure but preserved left ventricular systolic function are commonly said to have "diastolic heart failure" What this study addsMost of these patients have an alternative explanation for their symptoms, such as obesity, pulmonary disease, and myocardial ischaemia Complete investigation of these patients requires more than an echocardiogram Improved patient care should result from recognition of the true cause of a patient's symptoms as there are appropriate management strategies for these alternative diagnoses; this is preferable to ascribing symptoms to diastolic heart failure for which there is no evidence based treatment |
We clearly need to improve differentiation of breathlessness due to isolated diastolic dysfunction from that with other causes. It would seem that a rigorous search for non-cardiac causes of breathlessness must be pursued, with pulmonary function testing, calculation of body mass index, resting and exercise electrocardiography, and, probably, chest radiography. Even if these other causes are excluded it may still be difficult to be sure that a patient's breathlessness is definitely cardiac in origin. One possibility is that measurement of plasma natriuretic peptide concentrations might further refine the diagnostic process. It might be expected that increased left ventricular mass, wall stress, or filling pressures would increase secretion of atrial or brain natriuretic peptides. This possibility needs to be tested further.
Of course, it is also possible that patients may have more than one cause of their dyspnoea. This real diagnostic dilemma reinforces the need for better means of determining whether or not there really is a non-systolic cardiac contribution in such cases. We believe that improved patient care should result from recognition of the true cause of a patient's breathlessness as appropriate management of the correct alternative diagnoses can improve presenting symptoms.
In summary, we have shown that in most patients with a diagnosis of
heart failure but preserved left ventricular systolic function there
are alternative explanations for their symptomsfor example, obesity,
lung disease, and myocardial ischaemia. For that reason the diagnosis
of diastolic heart failure is probably unnecessary, even though a high
proportion of these patients will have echocardiographic evidence of
diastolic dysfunction.16
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Acknowledgments |
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Contributors: JJVM had the original idea for the study. JJVM, APD, and LC were involved in the study design. LC collected the data and performed the echocardiograms. MCP and JJVM analysed and interpreted the data. The paper was written jointly by JJVM and MCP. JJVM is the study guarantor.
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Footnotes |
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Funding: None.
Competing interests: None declared.
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References |
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Introduction
Methods
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Discussion
References
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(Accepted 25 April 2000)
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[Full text]
Rapid Responses:
Read all Rapid Responses
- Treat the patient
- Yogi Sehgal
bmj.com, 22 Jul 2000 [Full text] - What about a blood count and chest x ray?
- D Blackburn
bmj.com, 25 Jul 2000 [Full text] - Re: Treat the patient
- Rod Lawson
bmj.com, 25 Jul 2000 [Full text] - E/A reversal: Inappropriate parameter in elderly patients
- Elved Roberts
bmj.com, 31 Jul 2000 [Full text] - Criteria for the diagnosis of diastolic dysfunction
- David Leibowitz
bmj.com, 1 Aug 2000 [Full text] - Diastolic heart failure
- Roger H Jay
bmj.com, 2 Aug 2000 [Full text] - Patients might well have had heart failure
- Nicolas Wisniacki
bmj.com, 4 Aug 2000 [Full text] - "Presbycardia"
- Paul James, et al.
bmj.com, 25 Aug 2000 [Full text] - "Diastolic heart failure"
- Helen Rimington
bmj.com, 28 Sep 2000 [Full text] - Clinical Diagnosis of Diastolic Heart Failure: Comparison between Generalists and Cardiologists.
- Ali Ahmed
bmj.com, 5 Oct 2000 [Full text]
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