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Left ventricular diastolic dysfunction — Clinical Guidelines

Overview

Left ventricular diastolic dysfunction (DD) refers to impaired ventricular relaxation and filling during diastole, often preceding heart failure with preserved ejection fraction (HFpEF). It is characterized by abnormal diastolic indices despite normal systolic function.

Diagnosis

Key Diagnostic Criteria: Elevated E/A ratio, prolonged deceleration time, increased E/e' ratio 1 9.

Recommended Tests:

- Echocardiography for Doppler indices (E/A, E-wave deceleration time, E/e') 1 9. - Speckle-tracking echocardiography for left atrial strain and strain rate 4 6. - Brachial-ankle pulse wave velocity (baPWV) to assess arterial stiffness 1. - 12-lead ECG for fragmented QRS complex (fQRS) 3.

Grading: Typically classified based on echocardiographic parameters and clinical symptoms 1 6.

Management

First-Line Treatments:

- Lifestyle modifications including weight management and exercise 8. - Blood pressure control with ACE inhibitors or ARBs 9.

Adjunctive Treatments:

- Lipid management to reduce triglyceride levels 9. - Management of comorbidities like diabetes and hypertension 9.

Specific Drug Classes:

- ACE inhibitors/ARBs for blood pressure control and potential benefits in diastolic function 9.

Special Populations

Elderly: Increased prevalence of DD; careful monitoring of arterial stiffness (baPWV) and diastolic parameters 1.

Comorbidities: Central obesity and systemic inflammation correlate strongly with DD; CRP levels may guide management 8.

Pregnancy: No specific data provided in abstracts; general management principles apply with close monitoring [].

Pediatrics: Not addressed in provided abstracts [].

Key Recommendations

Assess arterial stiffness using baPWV in patients with suspected DD to predict progression and outcomes (Evidence: Moderate) 1.

Evaluate left atrial function with speckle-tracking echocardiography, as LA strain may be a better marker for DD than LA enlargement (Evidence: Moderate) 4 6.

Consider elevated triglyceride levels as an independent predictor of impaired LV relaxation and incorporate lipid management into DD treatment plans (Evidence: Moderate) 9.

Use fragmented QRS complex on ECG as an additional diagnostic tool to differentiate between DD and HFpEF (Evidence: Moderate) 3.

Lifestyle modifications, including weight management, are crucial in managing DD, particularly in obese adults (Evidence: Expert opinion) 8.

References

1 Lee SH, Choi KH, Cho SW, Choi SH, Park TK, Lee JM et al.. Impact of brachial-ankle pulse wave velocity on progression of diastolic dysfunction: a cohort study. Revista espanola de cardiologia (English ed.) 2026. link 2 Bening C, Sikand A, Conzelmann LO, Stumpf N, Vahl CF. Reduced right atrial contractile force in patients with left ventricular diastolic dysfunction: A study in human atrial fibers-contractile force and diastolic dysfunction. Asian journal of surgery 2017. link 3 Onoue Y, Izumiya Y, Hanatani S, Kimura Y, Araki S, Sakamoto K et al.. Fragmented QRS complex is a diagnostic tool in patients with left ventricular diastolic dysfunction. Heart and vessels 2016. link 4 Morris DA, Takeuchi M, Krisper M, Köhncke C, Bekfani T, Carstensen T et al.. Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study. European heart journal. Cardiovascular Imaging 2015. link 5 Taşolar H, Mete T, Çetin M, Altun B, Ballı M, Bayramoğlu A et al.. Mitral annular plane systolic excursion in the assessment of left ventricular diastolic dysfunction in obese adults. Anatolian journal of cardiology 2015. link 6 Khan UA, de Simone G, Hill J, Tighe DA, Aurigemma GP. Depressed atrial function in diastolic dysfunction: a speckle tracking imaging study. Echocardiography (Mount Kisco, N.Y.) 2013. link 7 Nottin S, Ménétrier A, Rupp T, Boussuges A, Tordi N. Role of left ventricular untwisting in diastolic dysfunction after long duration exercise. European journal of applied physiology 2012. link 8 Wu CK, Yang CY, Lin JW, Hsieh HJ, Chiu FC, Chen JJ et al.. The relationship among central obesity, systemic inflammation, and left ventricular diastolic dysfunction as determined by structural equation modeling. Obesity (Silver Spring, Md.) 2012. link 9 de las Fuentes L, Waggoner AD, Brown AL, Dávila-Román VG. Plasma triglyceride level is an independent predictor of altered left ventricular relaxation. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography 2005. link 10 Gare M, Parail A, Milosavljevic D, Kersten JR, Warltier DC, Pagel PS. Conscious sedation with midazolam or propofol does not alter left ventricular diastolic performance in patients with preexisting diastolic dysfunction: a transmitral and tissue Doppler transthoracic echocardiography study. Anesthesia and analgesia 2001. link

Left ventricular diastolic dysfunction