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April 27, 1994, Vol 271, No. 16 >
ARTICLE | April 27, 1994

Diagnosis and Treatment of Heart Failure Based on Left Ventricular Systolic or Diastolic Dysfunction FREE

William H. Gaasch, MD
[+] Author Affiliations

Reprint requests to 6 Hawthorne Ave, Auburndale, MA 02166 (Dr Gaasch).

Clinical Cardiology section editors: William H. Gaasch, MD, University of Massachusetts Medical School, Worcester; Margaret A. Winker, MD, Senior Editor, JAMA.

This article is one of a series sponsored by the American Heart Association.


JAMA. 1994;271(16):1276-1280. doi:10.1001/jama.1994.03510400062033
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References

Data from large and small clinical trials reflect major differences in the pathophysiology, treatment, and prognosis of left ventricular (LV) systolic and diastolic dysfunction. These studies also indicate that medical therapy can benefit patients with LV dysfunction regardless of whether or not they are symptomatic. Because the descriptive term congestive heart failure does not provide for these important distinctions, a new classification of LV dysfunction has been developed in which patients with LV dysfunction are categorized on the basis of normal or abnormal systolic function. This classification is based on a simple assessment of LV function, it is applicable to patients without symptoms, and it reflects differences in treatment and prognosis. Those with clinically significant LV systolic dysfunction (ie, an LV ejection fraction <40%) benefit from therapy whether or not they have symptoms of heart failure. Those with LV dysfunction and a normal LV ejection fraction (ie, diastolic dysfunction) also benefit from medical therapy. Annual mortality is higher in those with systolic dysfunction than in those with diastolic dysfunction, but within each of these categories mortality is higher in those with symptoms than in those without. This classification can be useful in the diagnosis and treatment of individual patients as well as in epidemiologic surveys designed to assess medical practice patterns.

(JAMA. 1994;271:1276-1280)

REFERENCES

1 +
Parmley WW.  Pathophysiology and current therapy of congestive heart failure. J Am Coll Cardiol . 1989;;13:771-785.
2 +
Stauffer JC, Gaasch WH.  Recognition and treatment of left ventricular diastolic dysfunction. Prog Cardiovasc Dis . 1990;;32:319-332.
3 +
McKee PA, Castelli WP, McNamara PM, Kannel WB.  The natural history of congestive heart failure: the Framingham Study. N Engl J Med . 1971;; 285:1441-1446.
4 +
Harlan WR, Oberman A, Grimm R, Rosati RA.  Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med . 1977;;86: 133-138.
5 +
Carlson KJ, Lee DCS, Goroll AH, Leahy M, Johnson RA.  An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients. J Chronic Dis . 1985;;38:733-739.
6 +
Marantz PR, Tobin JN, Wassertheil-Smoller S, et al.  The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation . 1988;;77:607-612.
7 +
Echeverria HH, Bilisker MS, Myerburg RJ, Kessler KM.  Congestive heart failure: echocardiographic insights. Am J Med . 1983;;75:750-755.
8 +
Ghali JK, Kadakia S, Cooper RS, Liao Y.  Bedside diagnosis of preserved versus impaired left ventricular systolic function in heart failure. Am J Cardiol . 1991;;67:1002-1006.
9 +
Grossman W.  Diastolic dysfunction in congestive heart failure. N Engl J Med . 1991;;325:1557-1564.
10 +
Bonow RO, Udelson JE.  Left ventricular diastolic dysfunction as a cause of congestive heart failure: mechanisms and management. Ann Intern Med . 1992;;117:502-510.
11 +
Gaasch WH, Blaustein AS, LeWinter MM.  Heart failure and clinical disorders of left ventricular diastolic function.  In: Gaasch WH, LeWinter MM, eds. Left Ventricular Diastolic Dysfunction and Heart Failure . Philadelphia, Pa: Lea & Febiger; 1994;.
12 +
Levine HJ, Gaasch WH.  Clinical recognition and treatment of diastolic dysfunction and heart failure.  In: Gaasch WH, LeWinter MM, eds. Left Ventricular Diastolic Dysfunction and Heart Failure . Philadelphia, Pa: Lea & Febiger; 1994;.
13 +
Johnson RA, Palacios I.  Dilated cardiomyopathies of the adult. N Engl J Med . 1982;;307:1051-1058.
14 +
Force TL, Folland ED, Aebischer N, Sharma S, Parisi AF.  Echocardiographic assessment of ventricular function.  In: Marcus ML, Schelbert HR, Skorton DJ, Wolf JL, eds. Cardiac Imaging . Philadelphia, Pa: WB Saunders Co; 1991;.
15 +
Amico AF, Lichtenberg GS, Reisner SA, Stone CK, Schwartz RG, Meltzer RS.  Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction. Am Heart J . 1989;;118:1259-1265.
16 +
Cohn JN, Archibald DG, Ziesche S, et al.  Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration Cooperative Study. N Engl J Med . 1986;; 314:1547-1552.
17 +
Massie BM, Conway M.  Survival of patients with congestive heart failure: past, present and future prospects. Circulation . 1987;;75( (suppl 4) ):11-19.
18 +
The CONSENSUS Trial Study Group.  Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med . 1987;;316:1729-1735.
19 +
The SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;;325:293-302.
20 +
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991;;325:303-310.
21 +
The SOLVD Investigators.  Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med . 1992;;327: 685-691.
22 +
Pfeffer MA, Braunwald E, Moye LA, et al.  Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the survival and ventricular enlargement trial. N Engl J Med . 1992;; 327:669-677.
23 +
Swedberg K, Held P, Kjekshus J, et al.  Effects of the early administration of enalapril on mortality in patients with acute myocardial infarction: results of the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II). N Engl J Med . 1992;;327:678-684.
24 +
Carroll JD, Hess OM, Hirzel HO, et al.  Left ventricular systolic and diastolic function in coronary artery disease: effects of revascularization on exercise-induced ischemia. Circulation . 1985;;72:119-129.
25 +
Cuocolo A, Sax FL, Brush JE, et al.  Left ventricular hypertrophy and impaired diastolic filling in essential hypertension: diastolic mechanisms for systolic dysfunction during exercise. Circulation . 1990;;81:978-986.
26 +
Clyne CA, Arrighi JA, Maron BJ, et al.  Systemic and left ventricular response to exercise stress in asymptomatic patients with valvular aortic stenosis. Am J Cardiol . 1991;;68:1469-1476.
27 +
Kitzman DW, Higginbotham MB, Cobb FR, Sheikh KH, Sullivan MJ.  Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism. J Am Coll Cardiol . 1991;;17:1065-1072.
28 +
Chon JN, Johnson G.  Heart failure with normal ejection fraction: the V-HeFT study. Circulation . 1990;;81:48-53.
29 +
Setaro JF, Soufer R, Remetz MS, Perlmutter RA, Zaret BL.  Long-term outcome in patients with congestive heart failure and intact systolic left ventricular performance. Am J Cardiol . 1992;;69:1212-1216.
30 +
Judge KW, Pawitan Y, Caldwell J, et al.  Congestive heart failure in patients with preserved left ventricular systolic function: analysis of the CASS registry. J Am Coll Cardiol . 1991;;18:377-382.
31 +
Brogan WC, Hillis LD, Flores ED, et al.  The natural history of isolated left ventricular diastolic dysfunction. Am J Med . 1992;;92:627-630.
32 +
Dougherty AH, Naccarelli GV, Grey EL, et al.  Congestive heart failure with normal systolic function. Am J Cardiol . 1984;;54:778-782.
33 +
Soufer R, Wohlgelernter D, Vita NA, et al.  Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol . 1985;;55: 1032-1036.
34 +
Forman DE, Coletta D, Kenny D, et al.  Clinical issues related to discontinuing digoxin therapy in elderly nursing home patients. Arch Intern Med . 1991;;151:2194-2198.
35 +
Topol EJ, Traill TA, Fortuin NJ.  Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med . 1985;;312:277-283.
36 +
Bonow RO, Dilsizian V, Rosing DR, et al.  Verapamil-induced improvement in left ventricular diastolic filling and increased exercise tolerance in patients with hypertrophic cardiomyopathy: short and long-term effects. Circulation . 1985;;75:853-864.
37 +
Setaro JF, Zaret BL, Schulman DS, et al.  Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance. Am J Cardiol . 1990;;66:981-986.
38 +
Given BD, Lee TH, Stone PH, Dzau VJ.  Nifedipine in severely hypertensive patients with congestive heart failure and preserved ventricular systolic function. Arch Intern Med . 1985;;145:281-285.
39 +
Lorell BH, Isoyama S, Grice WN, et al.  Effects of ouabain and isoproterenol on left ventricular diastolic function during low-flow ischemia in isolated, blood perfused rabbit hearts. Circ Res . 1988;; 63:457-467.
40 +
Schunkert H, Dzau VJ, Tang SS, et al.  Increased rat cardiac angiotensin converting emzyme activity and mRNA expression in pressure overload left ventricular hypertrophy: effects on coronary resistance, contractility, and relaxation. J Clin Invest . 1990;;86:1913-1920.
41 +
Koren MJ, Devereux RB, Casale PN, et al.  Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med . 1991;;114:345-352.
42 +
Shimizu G, Hirota Y, Kita Y, et al.  Left ventricular midwall mechanics in systemic arterial hypertension: myocardial function is depressed in pressure-overload hypertrophy. Circulation . 1991;;83: 1676-1684.
43 +
Lorell BH, Grossman W.  Cardiac hypertrophy: the consequences for diastole. J Am Coll Cardiol . 1987;;9:1189-1193.
44 +
Hoit BD, Walsh RA.  Diastolic dysfunction in hypertensive heart disease.  In: Gaasch WH, LeWinter MM, eds. Left Ventricular Diastolic Dysfunction and Heart Failure . Philadelphia, Pa: Lea & Febiger; 1994;.
45 +
Hammond IW, Devereux RB, Alderman MH, et al.  The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension. J Am Coll Cardiol . 1986;;7:639-650.
46 +
Savage DD, Garrison RJ, Kannel WB, et al.  The spectrum of left ventricular hypertrophy in a general population sample: the Framingham Study. Circulation . 1987;;75:26-33.
47 +
Savage DD, Drayer JI, Henry WL, et al.  Echocardiographic assessment of cardiac anatomy and function in hypertensive subjects. Circulation . 1979;;59:623-632.
48 +
Cutler JA, MacMahon SW, Furberg CD.  Controlled clinical trials of drug treatment for hypertension: a review. Hypertension . 1989;;13:1-36.
49 +
Frohlich ED, Apstein CS, Chobanian AV, et al.  The heart in hypertension. N Engl J Med . 1992;; 327:996-1008.
50 +
Dahlof B, Pennert K, Hansson L.  Reversal of left ventricular hypertrophy in hypertensive patients: a meta-analysis of 109 treatment studies. Am J Hypertension . 1992;;5:95-110.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Parmley WW.  Pathophysiology and current therapy of congestive heart failure. J Am Coll Cardiol . 1989;;13:771-785.
2 +
Stauffer JC, Gaasch WH.  Recognition and treatment of left ventricular diastolic dysfunction. Prog Cardiovasc Dis . 1990;;32:319-332.
3 +
McKee PA, Castelli WP, McNamara PM, Kannel WB.  The natural history of congestive heart failure: the Framingham Study. N Engl J Med . 1971;; 285:1441-1446.
4 +
Harlan WR, Oberman A, Grimm R, Rosati RA.  Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med . 1977;;86: 133-138.
5 +
Carlson KJ, Lee DCS, Goroll AH, Leahy M, Johnson RA.  An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients. J Chronic Dis . 1985;;38:733-739.
6 +
Marantz PR, Tobin JN, Wassertheil-Smoller S, et al.  The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation . 1988;;77:607-612.
7 +
Echeverria HH, Bilisker MS, Myerburg RJ, Kessler KM.  Congestive heart failure: echocardiographic insights. Am J Med . 1983;;75:750-755.
8 +
Ghali JK, Kadakia S, Cooper RS, Liao Y.  Bedside diagnosis of preserved versus impaired left ventricular systolic function in heart failure. Am J Cardiol . 1991;;67:1002-1006.
9 +
Grossman W.  Diastolic dysfunction in congestive heart failure. N Engl J Med . 1991;;325:1557-1564.
10 +
Bonow RO, Udelson JE.  Left ventricular diastolic dysfunction as a cause of congestive heart failure: mechanisms and management. Ann Intern Med . 1992;;117:502-510.
11 +
Gaasch WH, Blaustein AS, LeWinter MM.  Heart failure and clinical disorders of left ventricular diastolic function.  In: Gaasch WH, LeWinter MM, eds. Left Ventricular Diastolic Dysfunction and Heart Failure . Philadelphia, Pa: Lea & Febiger; 1994;.
12 +
Levine HJ, Gaasch WH.  Clinical recognition and treatment of diastolic dysfunction and heart failure.  In: Gaasch WH, LeWinter MM, eds. Left Ventricular Diastolic Dysfunction and Heart Failure . Philadelphia, Pa: Lea & Febiger; 1994;.
13 +
Johnson RA, Palacios I.  Dilated cardiomyopathies of the adult. N Engl J Med . 1982;;307:1051-1058.
14 +
Force TL, Folland ED, Aebischer N, Sharma S, Parisi AF.  Echocardiographic assessment of ventricular function.  In: Marcus ML, Schelbert HR, Skorton DJ, Wolf JL, eds. Cardiac Imaging . Philadelphia, Pa: WB Saunders Co; 1991;.
15 +
Amico AF, Lichtenberg GS, Reisner SA, Stone CK, Schwartz RG, Meltzer RS.  Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction. Am Heart J . 1989;;118:1259-1265.
16 +
Cohn JN, Archibald DG, Ziesche S, et al.  Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration Cooperative Study. N Engl J Med . 1986;; 314:1547-1552.
17 +
Massie BM, Conway M.  Survival of patients with congestive heart failure: past, present and future prospects. Circulation . 1987;;75( (suppl 4) ):11-19.
18 +
The CONSENSUS Trial Study Group.  Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med . 1987;;316:1729-1735.
19 +
The SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;;325:293-302.
20 +
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991;;325:303-310.
21 +
The SOLVD Investigators.  Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med . 1992;;327: 685-691.
22 +
Pfeffer MA, Braunwald E, Moye LA, et al.  Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the survival and ventricular enlargement trial. N Engl J Med . 1992;; 327:669-677.
23 +
Swedberg K, Held P, Kjekshus J, et al.  Effects of the early administration of enalapril on mortality in patients with acute myocardial infarction: results of the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II). N Engl J Med . 1992;;327:678-684.
24 +
Carroll JD, Hess OM, Hirzel HO, et al.  Left ventricular systolic and diastolic function in coronary artery disease: effects of revascularization on exercise-induced ischemia. Circulation . 1985;;72:119-129.
25 +
Cuocolo A, Sax FL, Brush JE, et al.  Left ventricular hypertrophy and impaired diastolic filling in essential hypertension: diastolic mechanisms for systolic dysfunction during exercise. Circulation . 1990;;81:978-986.
26 +
Clyne CA, Arrighi JA, Maron BJ, et al.  Systemic and left ventricular response to exercise stress in asymptomatic patients with valvular aortic stenosis. Am J Cardiol . 1991;;68:1469-1476.
27 +
Kitzman DW, Higginbotham MB, Cobb FR, Sheikh KH, Sullivan MJ.  Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism. J Am Coll Cardiol . 1991;;17:1065-1072.
28 +
Chon JN, Johnson G.  Heart failure with normal ejection fraction: the V-HeFT study. Circulation . 1990;;81:48-53.
29 +
Setaro JF, Soufer R, Remetz MS, Perlmutter RA, Zaret BL.  Long-term outcome in patients with congestive heart failure and intact systolic left ventricular performance. Am J Cardiol . 1992;;69:1212-1216.
30 +
Judge KW, Pawitan Y, Caldwell J, et al.  Congestive heart failure in patients with preserved left ventricular systolic function: analysis of the CASS registry. J Am Coll Cardiol . 1991;;18:377-382.
31 +
Brogan WC, Hillis LD, Flores ED, et al.  The natural history of isolated left ventricular diastolic dysfunction. Am J Med . 1992;;92:627-630.
32 +
Dougherty AH, Naccarelli GV, Grey EL, et al.  Congestive heart failure with normal systolic function. Am J Cardiol . 1984;;54:778-782.
33 +
Soufer R, Wohlgelernter D, Vita NA, et al.  Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol . 1985;;55: 1032-1036.
34 +
Forman DE, Coletta D, Kenny D, et al.  Clinical issues related to discontinuing digoxin therapy in elderly nursing home patients. Arch Intern Med . 1991;;151:2194-2198.
35 +
Topol EJ, Traill TA, Fortuin NJ.  Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med . 1985;;312:277-283.
36 +
Bonow RO, Dilsizian V, Rosing DR, et al.  Verapamil-induced improvement in left ventricular diastolic filling and increased exercise tolerance in patients with hypertrophic cardiomyopathy: short and long-term effects. Circulation . 1985;;75:853-864.
37 +
Setaro JF, Zaret BL, Schulman DS, et al.  Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance. Am J Cardiol . 1990;;66:981-986.
38 +
Given BD, Lee TH, Stone PH, Dzau VJ.  Nifedipine in severely hypertensive patients with congestive heart failure and preserved ventricular systolic function. Arch Intern Med . 1985;;145:281-285.
39 +
Lorell BH, Isoyama S, Grice WN, et al.  Effects of ouabain and isoproterenol on left ventricular diastolic function during low-flow ischemia in isolated, blood perfused rabbit hearts. Circ Res . 1988;; 63:457-467.
40 +
Schunkert H, Dzau VJ, Tang SS, et al.  Increased rat cardiac angiotensin converting emzyme activity and mRNA expression in pressure overload left ventricular hypertrophy: effects on coronary resistance, contractility, and relaxation. J Clin Invest . 1990;;86:1913-1920.
41 +
Koren MJ, Devereux RB, Casale PN, et al.  Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med . 1991;;114:345-352.
42 +
Shimizu G, Hirota Y, Kita Y, et al.  Left ventricular midwall mechanics in systemic arterial hypertension: myocardial function is depressed in pressure-overload hypertrophy. Circulation . 1991;;83: 1676-1684.
43 +
Lorell BH, Grossman W.  Cardiac hypertrophy: the consequences for diastole. J Am Coll Cardiol . 1987;;9:1189-1193.
44 +
Hoit BD, Walsh RA.  Diastolic dysfunction in hypertensive heart disease.  In: Gaasch WH, LeWinter MM, eds. Left Ventricular Diastolic Dysfunction and Heart Failure . Philadelphia, Pa: Lea & Febiger; 1994;.
45 +
Hammond IW, Devereux RB, Alderman MH, et al.  The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension. J Am Coll Cardiol . 1986;;7:639-650.
46 +
Savage DD, Garrison RJ, Kannel WB, et al.  The spectrum of left ventricular hypertrophy in a general population sample: the Framingham Study. Circulation . 1987;;75:26-33.
47 +
Savage DD, Drayer JI, Henry WL, et al.  Echocardiographic assessment of cardiac anatomy and function in hypertensive subjects. Circulation . 1979;;59:623-632.
48 +
Cutler JA, MacMahon SW, Furberg CD.  Controlled clinical trials of drug treatment for hypertension: a review. Hypertension . 1989;;13:1-36.
49 +
Frohlich ED, Apstein CS, Chobanian AV, et al.  The heart in hypertension. N Engl J Med . 1992;; 327:996-1008.
50 +
Dahlof B, Pennert K, Hansson L.  Reversal of left ventricular hypertrophy in hypertensive patients: a meta-analysis of 109 treatment studies. Am J Hypertension . 1992;;5:95-110.

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