Progression of left ventricular diastolic dysfunction and risk of heart failure

Abstract

Context: Heart failure incidence increases with advancing age, and approximately half of patients with heart failure have preserved left ventricular ejection fraction. Although diastolic dysfunction plays a role in heart failure with preserved ejection fraction, little is known about age-dependent longitudinal changes in diastolic function in community populations.

Objective: To measure changes in diastolic function over time and to determine the relationship between diastolic dysfunction and the risk of subsequent heart failure.

Design, setting, and participants: Population-based cohort of participants enrolled in the Olmsted County Heart Function Study. Randomly selected participants 45 years or older (N = 2042) underwent clinical evaluation, medical record abstraction, and echocardiography (examination 1 [1997-2000]). Diastolic left ventricular function was graded as normal, mild, moderate, or severe by validated Doppler techniques. After 4 years, participants were invited to return for examination 2 (2001-2004). The cohort of participants returning for examination 2 (n = 1402 of 1960 surviving [72%]) then underwent follow-up for ascertainment of new-onset heart failure (2004-2010).

Main outcome measures: Change in diastolic function grade and incident heart failure.

Results: During the 4 (SD, 0.3) years between examinations 1 and 2, diastolic dysfunction prevalence increased from 23.8% (95% confidence interval [CI], 21.2%-26.4%) to 39.2% (95% CI, 36.3%-42.2%) (P < .001). Diastolic function grade worsened in 23.4% (95% CI, 20.9%-26.0%) of participants, was unchanged in 67.8% (95% CI, 64.8%-70.6%), and improved in 8.8% (95% CI, 7.1%-10.5%). Worsened diastolic dysfunction was associated with age 65 years or older (odds ratio, 2.85 [95% CI, 1.77-4.72]). During 6.3 (SD, 2.3) years of additional follow-up, heart failure occurred in 2.6% (95% CI, 1.4%-3.8%), 7.8% (95% CI, 5.8%-13.0%), and 12.2% (95% CI, 8.5%-18.4%) of persons whose diastolic function normalized or remained normal, remained or progressed to mild dysfunction, or remained or progressed to moderate or severe dysfunction, respectively (P < .001). Diastolic dysfunction was associated with incident heart failure after adjustment for age, hypertension, diabetes, and coronary artery disease (hazard ratio, 1.81 [95% CI, 1.01-3.48]).

Conclusions: In a population-based cohort undergoing 4 years of follow-up, prevalence of diastolic dysfunction increased. Diastolic dysfunction was associated with development of heart failure during 6 years of subsequent follow-up.

Figure 1

Figure 1a – Within-individual changes in diastolic function classification from Exam 1 to Exam 2 in all participants diastolic function could be classified at both Exams in 1058 of 1402 participants. Participants above the diagonal line manifested a worse diastolic function grade at Exam 2, those on the diagonal line no change in diastolic function grade, and those below the line an improvement in diastolic function grade 1b – Within-individual changes in diastolic function classification from Exam 1 to Exam 2 in 423 (of 531) participants without hypertension, diabetes, coronary disease, heart failure, or cardiovascular medications whose diastolic function grade could be classified at both Exams. Participants above the diagonal line manifested a worse diastolic function grade at Exam 2, those on the diagonal line no change in diastolic function grade, and those below the line an improvement in diastolic function grade.

Figure 2

The cumulative incidence of heart failure after Exam 2. The groups represent three grades of severity and change in diastolic dysfunction from Exam 1 and Exam 2. Persons with heart failure at Exam 2 and those in whom diastolic function could not be classified at both Exams 1 and 2 are excluded, leaving 1047 persons at risk after Exam 2.