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One of the first, if not the first, study to use the term “diastolic heart failure” was by Dr. Kessler in 1988 (1). His report was truly innovative and showed remarkable insight into a difficult clinical problem. I enthusiastically agree with Dr. Kessler's point of view and I am grateful to receive his support. In his letter to the editor of the JACC,he raises three important issues: 1) some patients with diastolic heart failure do not have left ventricular (LV) hypertrophy; 2) the diagnosis of diastolic heart failure should exclude patients with noncardiac (such as pulmonary disease) and other cardiac (such as mitral stenosis, regurgitant valve disease) causes of heart failure; and 3) left ventricular (LV) function must be measured in every patient with heart failure.
In the study that Dr. Kessler refers to in his letter (2), only about one-third of the patients had LV hypertrophy defined as LV mass ≥125 g/m2. However, all patients had concentric hypertrophic remodeling characterized by a decreased LV end diastolic volume/mass ratio or LV end diastolic dimension/wall thickness ratio or an increased relative wall thickness. I believe that a majority of patients with diastolic heart failure in fact have either concentric remodeling or some other evidence of myocardial or cardiac structural alterations such as an enlarged left atrium. With or without concentric remodeling, if a patient truly has objective signs and symptoms of heart failure and noncardiac and other cardiac causes have been ruled out, then heart failure with a normal ejection fraction (EF) is caused by diastolic dysfunction and the appellation “diastolic heart failure” should be applied.
Dr. Kessler correctly points out that in patients with primary right heart failure (caused by chronic lung disease, pulmonic stenosis, tricuspid regurgitation) or mitral stenosis or left-sided regurgitant valvular disease, this can result in heart failure with a normal EF. I am grateful that Dr. Kessler emphasized this point because our previous publications (2,3)did not make it explicitly clear that we had in fact excluded patients with noncardiac and other cardiac causes of heart failure in this study patient cohort.
It is critical that LV function, both systolic and diastolic, be measured in every patient with heart failure. The advent of tissue Doppler (and other echo-Doppler techniques) has made it easier and more practical to identify abnormalities in diastolic function. Nonetheless, precise and comprehensive assessment of diastolic function requires the use of invasive catheterization techniques. However, if noncardiac and other cardiac causes of heart failure are excluded, the remaining patients with heart failure and a normal EF all have abnormalities of diastolic function making measurement of diastolic function confirmatory rather than a mandatory component of diagnostic criteria.
Finally, I join Dr. Kessler in his enthusiastic use of the term “diastolic heart failure” and renew my editorial plea: “Stop the discrimination against the term diastolic heart failure.”
- American College of Cardiology Foundation
- Zile M.R.,
- Gaasch W.H.,
- Carroll J.D.,
- et al.
- Zile M.R.