to the development of symptoms Progression of preclinical diastolic dysfunction

Background Preclinical diastolic dysfunction (PDD) has been defined as subjects with normal systolic function, diastolic dysfunction but no symptoms of heart failure (HF). The clinical phenotype and natural history of the syndrome remains poorly defined. This study’s objective was to determine the clinical phenotype and progression to HF in a group of patients with normal systolic function and moderate or severe diastolic dysfunction as determinate by Doppler criteria without any clinical diagnosis of HF according to the Framingham criteria or any symptoms of HF, specifically dyspnoea, oedema or fatigue at the time of echocardiography. Methods The authors used resources of the Mayo Clinic echocardiography database to consecutively select among patients who had an echocardiogram in 2005, a cohort with moderate or severe diastolic dysfunction by Doppler criteria and EF $50%. Patients could not have a diagnosis of HF, or any HF symptomsdspecifically dyspnoea, oedema or fatiguedat the time of echocardiography; nor grade 3 or greater valvular dysfunction (except tricuspid valve). A total of 82 patients had their medical chart reviewed. Primary endpoint was the time to the development of (1) HF according to the Framingham criteria or (2) any symptoms of dyspnoea, oedema or fatigue. Results The mean age of the cohort of PDD subjects was 69610 years with a female (67%) preponderance. Presence of hypertension was 76%, coronary artery disease was 29%, paroxysmal atrial fibrillation was 26%, estimated creatinine clearance <60 ml/min was 51%. The 2-year cumulative probability of development of HF according to the Framingham criteria was 1.9%; however, the 2-year cumulative probability of development of any symptoms was 31.1%. The 2-year cumulative probability for cardiac hospitalisation was 21.2%. Peripheral vascular disease and hypertension were independently associated with increased likelihood for the development of symptoms. Conclusion The study demonstrates that hypertension, hyperlipidaemia, CAD and renal dysfunction are prevalent in patients with PDD. More importantly, although the progression to the development of clinical HF over 2 years was low, there was a moderate degree of progression to development of symptoms and cardiac hospitalisations over 2 years. Based on the finding that only PVD and hypertension were independently associated with the progression to the development of symptoms in subject with PDD, the authors speculate that ventricular-arterial interaction may be important to the progression of diastolic dysfunction to the development of symptoms. INTRODUCTION In the past decade, there has been significant progress in understanding diastolic heart failure or heart failure with preserved systolic function. Multiple studies have determined that diastolic heart failure is common and carries a very similar prognosis to heart failure with decreased systolic function. A recent study by Achong et al reported in a cohort study that diastolic dysfunction determined by echocardiography Doppler assessment is associated with all-cause mortality and that the population whose diastolic function improved over time had a more favourable outcome. In the AHA/ ACC classification of heart failure (HF), stage B is defined as patients with abnormal heart structure/ function without symptoms. This concept of preclinical HF is based on the fact that abnormal heart structure/function can be detected by complementary methods before the development of symptoms. Patients with those abnormalities may progress to heart failure and are at increased risk of adverse cardiac events, including atrial fibrillation. 10 The echocardiographic characterisation of diastolic dysfunction has also evolved and echocardiographic analysis of diastolic dysfunction is reliable and is performed on a routine basis at most centres. Stage B or preclinical diastolic dysfunction (PDD), has been defined as subjects with normal systolic function, diastolic dysfunction but no symptoms of HF. Population-based studies have demonstrated that PDD is prevalent in the community. Specifically, we have previously reported that in Olmsted County, Minnesota, 6.8% of the population above 45 years old and 16.5% of those above 65 years old with hypertension or coronary artery disease had moderate to severe PDD. Importantly, the subjects with PDD had a higher mortality compared to subjects with normal diastolic function. Another population based study in Canberra, Australia, showed a prevalence of 4.9% in an elderly population (60e86 years old). Despite the prevalence of PDD, the clinical phenotype and natural history of the syndrome remain poorly defined. There are limited data about the clinical characteristics of patients with PDD. We aimed to determine the clinical phenotype and progression to the development of HF in a group of patients with normal LV ejection fraction and moderate or severe diastolic dysfunction as determinate by Doppler criteria without a clinical diagnosis of HF according to the Framingham criteria or any symptoms of HF, specifically dyspnoea, oedema or fatigue at the time of echocardiography. The primary endpoint was the time to the development of (1) HF according to the Framingham criteria or (2) any symptoms of dyspnoea, oedema or fatigue which had to be a chief complaint and not explained Department of Internal Medicine, Division of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Internal Medicine, Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota, USA Correspondence to Dr Horng H Chen, Cardiorenal Research Laboratory, Guggenheim 915, Mayo Clinic and Foundation, 200 First St SW, Rochester, MN 55905, USA; chen.horng@mayo.edu Accepted 24 November 2009 528 Heart 2010;96:528e532. doi:10.1136/hrt.2009. 177980 LV dysfunction group.bmj. com on April 11, 2010 Published by heart.bmj. com Downloaded from