 |
| About Bioline | All Journals | Testimonials | Membership | News |
|
||||||
|
||||||
Annals of African Medicine, Vol. 4, No. 3, 2005, pp. 96-98 DIASTOLIC HEART FAILURE: ARE THERE SPECIFIC BEDSIDE CLINICAL MARKERS FOR ITS DIAGNOSIS? A. I. Oyati and S. S. Danbauchi Cardiology Unit, Department
of Medicine, AhmaduBelloUniversity Teaching Hospital, Zaria, Nigeria Abstract Background: Congestive
heart failure due to diastolic dysfunction is common and accounts for 30-40 %
of patients with congestive heart failure. Since the prognosis and clinical
management of congestive heart failure differs between systolic and diastolic
heart failure there is need to differentiate between the two. Echocardiography
has been the only available tool for the diagnosis of diastolic heart failure
in our area of clinical practice. In view of the high cost of echocardiographic
examination and its non-availability in most medical centres, this study was
undertaken to find out if bedside clinical markers could serve as an
alternative way of making the diagnosis of diastolic heart failure. Key words: Diastolic heart failure, bedside diagnosis, clinical markers Résumé Fond : L'arrêt du coeur congestif dû au dysfonctionnement diastolique
est commun et compte pour 30-40 % de malades présentant l'arrêt du coeur congestif.
Puisque le pronostic et la gestion clinique de l'arrêt du coeur congestif diffère
de l'arrêt du coeur systolique et diastolique il y a le besoin de différencier
entre les deux. L'échocardiographie a été le seul outil disponible pour le
diagnostic de l'arrêt du coeur diastolique dans notre secteur de la pratique
clinique. En raison du coût élevé d'examen échocardiographique et de sa non-disponibilité à la
plupart des centres médicaux, cette étude a été entreprise pour découvrir si
les marqueurs cliniques de chevet pourraient servir de manière alternative
de faire le diagnostic de l'arrêt du coeur diastolique. Mots clés : l'Arrêt de coeur diastolique, le diagnostic de chevet, les marqueurs cliniques Introduction Congestive heart failure due to diastolic dysfunction is common and accounts for 30-40% of patients with congestive heart failure.1 The commonly used techniques for differentiating between systolic and diastolic heart failure such as radionuclide angiocardiography2 and echocardio-graphy 3, 4 that measure left ventricular systolic and diastolic functions are not readily available in many centres across the country. The aim of this study is to find out if there are clinical markers that can be used to make a distinction between the two forms of heart failure by the bedside. Patients and Methods Ninety one consecutive patients with hypertensive heart failure were studied. The diagnosis of heart failure was made based on the Framingham criteria for definite heart failure.5 A patient whose blood pressure was ≥ 140/90 mm Hg or had a normal blood pressure at the time of evaluation but a definite history of hypertension in addition to some of the signs and symptoms of definite heart failure6 was said to be in hypertensive heart failure. A chest x-ray was also done on each patient to look for radiologic cardiomegaly defined as CTR > 0.55. Left ventricular function (LVF) was assessed using ALOKA SSD 1700 two-dimensional echocardiograph/Doppler and colour flow ultrasound machine. Those patients with E/A ratio of < 1.0 and normal ejection fraction (≥ 50%) were said to be in diastolic heart failure while those whose ejection fraction was < 50% and E/A ratio of ≥ 1.0 were said to have systolic heart failure. 6 The patients whose E/A ratio was <1.0 and EF < 50% were said to have combined diastolic and systolic heart failure. 6 Chi-squared tests were used to determine the statistical significance of the difference between the two groups. Results Ninety-one patients were recruited into the study. Fifty-two had isolated systolic heart failure, 15 had isolated diastolic heart failure while 24 had combined diastolic and systolic heart failure. The 24 patients with combined systolic and diastolic heart failure were excluded. Table 1 shows the relative frequency of each sign and symptom in both systolic and diastolic heart failure group. Ninety-seven percent of those with systolic heart failure had definite radiologic cardiomegaly, CTR > 0.55, and 83% of those with diastolic heart failure. Table 1: The relative frequency of each sign and symptom in both systolic and diastolic heart failure
PND = Paroxysmal nocturnal dyspnoea; * = Statistically significant; NS= Not significant; += Major Framingham criterion; # = Minor Framingham criterion ; NA= Not available statistically Discussion Radionuclide angiography and echocardiography are among the various techniques commonly used to assess left ventricular function. Both systolic and diastolic functions can be assessed using these techniques which are able to differentiate between heart failure due to systolic dysfunction from that due to diastolic dysfunction. These techniques are not widely available in most of the hospitals across the country especially the secondary and primary institutions. Even in tertiary hospitals, where they are available, all year round coverage is not often possible for logistic reasons. Distinguishing between systolic and diastolic heart failure has important prognostic and clinical management benefits. This study was unable to reveal discriminatory “bedside” clinical markers that could differentiate between the two forms of heart failure. Of the 6 major criteria for the diagnosis of definite heart failure in this study only 2, PND & JVP showed statistically significant difference in the two types of heart failure while in the remaining four the differences were not significant (Table 1). Again while exertional dyspnoea which is a minor criterion occurred in 100% of the patients in both types of heart failure, there was no symptom or sign that occurred exclusively in one of the two types of heart failure. These clinical symptoms and signs of heart failure seem to occur with the same relative frequency in both systolic and diastolic heart failure. This is a confirmation of earlier report 7 that the distinction between diastolic and systolic heart failure cannot easily be made at the bedside since the clinical signs and symptoms occur with the same relative frequency in both systolic and diastolic heart failure. Attempts had been made to use a combination of certain aspects of the history and physical examination, with the clinical measurements to differentiate diastolic dysfunction from systolic heart failure. 8 Patients with hypertensive heart disease for example, especially those with severe left ventricular hypertrophy are said to often experience heart failure because of diastolic dysfunction. 8 This is not absolutely correct because some of the patients with hypertensive heart failure may have symptoms and signs due to isolated systolic dysfunction. In this attempt 8also there was no sign or symptom that was shown to have occurred exclusively in one of the two types of heart failure. It follows from these previous reports 7, 8 and our current study that signs and symptoms are not reliable distinguishing markers between systolic and diastolic heart failure. It is concluded from this study that there are no specific “bedside” clinical markers for the diagnosis of diastolic heart failure. The clinical findings in congestive heart failure syndrome in patients with hypertensive heart disease are just as likely to be related to diastolic dysfunction as to systolic ejection dysfunction. Because of the therapeutic benefits to be derived from accurate diagnosis echocardiography services at affordable cost should be provided at all levels of medical care. Studies using larger patient sample should be carried out in this area using subjects with different causes of heart failure. References
Copyright 2005 - Annals of African Medicine
|
| |||||||||
