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1259

CARDIOVASCULAR MEDICINE

Characteristics of left ventricular diastolic dysfunction

in the community: an echocardiographic survey
W P Abhayaratna, T H Marwick, W T Smith, N G Becker
...............................................................................................................................
Heart 2006;92:1259–1264. doi: 10.1136/hrt.2005.080150

Objective: To determine the prevalence and predictors of left ventricular (LV) diastolic dysfunction in older
adults.
Design, setting and participants: A cross-sectional survey of 1275 randomly selected residents of
See end of article for
Canberra, aged 60 to 86 years (mean age 69.4; 50% men), conducted between February 2002 and June
authors’ affiliations 2003.
....................... Main outcome measures: Prevalence of LV diastolic dysfunction as characterised by comprehensive
Correspondence to:
Doppler echocardiography.
Dr Walter P Abhayaratna, Results: The prevalence of any diastolic dysfunction was 34.7% (95% CI 32.1% to 37.4%) and that of
National Centre for moderate to severe diastolic dysfunction was 7.3% (95% CI 5.9% to 8.9%). Of subjects with moderate to
Epidemiology and severe diastolic dysfunction, 77.4% had an LV ejection fraction (EF) . 50% and 76.3% were in a
Population Health,
Australian National preclinical stage of disease. Predictors of diastolic dysfunction were higher age (p , 0.0001), reduced EF
University and Department (p , 0.0001), obesity (p , 0.0001) and a history of hypertension (p , 0.0001), diabetes (p = 0.02)
of Cardiology, The and myocardial infarction (p = 0.003). Moderate to severe diastolic dysfunction with normal EF, although
Canberra Hospital,
Canberra, ACT, Australia; predominantly preclinical, was independently associated with increased LV mass (p , 0.0001), left atrial
abhayaratna.walter@ volume (p , 0.0001), and circulating amino-terminal pro-B-type natriuretic peptide concentrations
mayo.edu (p , 0.0001), and with decreased quality of life (p , 0.005).
Conclusion: Diastolic dysfunction is common in the community and often unaccompanied by overt
Accepted 23 January 2006
Published Online First congestive heart failure. Despite the lack of symptoms, advanced diastolic dysfunction with normal EF is
17 February 2006 associated with reduced quality of life and structural abnormalities that reflect increased cardiovascular
....................... risk.

O
ver the past decade, several important observations on METHODS
the pathophysiological mechanisms underlying heart As part of the Canberra Heart Survey, the Australian Capital
failure in the community have been documented Territory Health and Community Care Committee and
through population-based echocardiographic surveys.1–8 Australian National University Human Research Ethics
Firstly, congestive heart failure (CHF) has been reported in Committee approved this study in January 2002.
the presence of a normal left ventricular (LV) ejection
fraction (EF).7 8 Although controversial, the presumed Study population
pathophysiology for most patients with heart failure and a Simple random sampling from a population register (federal
normal EF is LV diastolic dysfunction.9 10 Secondly, subjects electoral roll, January 2002) was used to select 2000 Canberra
with heart failure and a normal LV EF have been shown to residents, aged 60–85 years, to constitute our study popula-
have a poor prognosis, even though mortality and morbidity tion. The sample size was selected on the basis of the
in this group are not as high as in patients with a reduced precision of estimates to determine a prevalence of advanced
EF.7 11 ‘‘isolated’’ LV diastolic dysfunction of 4% and the assumption
Following these observations, interest in the epidemiology of a 60% participation rate. Subjects were invited to
of diastolic dysfunction has been growing, which has been participate by letter. Institutionalised subjects and those
facilitated by the availability of non-invasive Doppler who had died or had moved away from the Territory were
methods of characterising diastolic function.12 A recent study5 excluded from the study sample. All study participants
showed that subjects with normal EF can have moderate or provided written and informed consent for the study
severe diastolic dysfunction, most often without accompany- investigations and were enrolled between February 2002
ing clinical evidence of heart failure. The validity of findings and June 2003.
from these cross-sectional surveys of diastolic dysfunction
has, however, been compromised by low participation rates5 Assessment of clinical risk factors for heart failure
and the failure to use comprehensive Doppler methods13 to A self-administered questionnaire was used to gather data on
distinguish subjects with normal and pseudonormal mitral a history of myocardial infarction, angina, hypertension or
inflow patterns, which have increased the potential for diabetes. Brachial artery systolic and diastolic blood pressures
selection bias and misclassification of diastolic function. In were measured after 10 min of rest in a seated position; two
addition, there is a paucity of data regarding echocardio- sets were averaged for each participant. Height and weight
graphic and clinical characteristics of subjects with were measured while the subject was wearing light clothing
diastolic dysfunction and normal EF (DD-NEF) and their but not shoes. Body mass index was calculated for each
influence on clinical status. Our objectives in this study were
to determine the prevalence of diastolic dysfunction in older Abbreviations: CHF, congestive heart failure; DD-NEF, diastolic
adults and to describe the clinical spectrum of subjects with dysfunction and normal ejection fraction; EF, ejection fraction; LV, left
DD-NEF. ventricular, N-BNP, amino-terminal B-type natriuretic peptide

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1260 Abhayaratna, Marwick, Smith, et al

Table 1 Doppler assessment of left ventricular diastolic function (LVDD)

Mitral inflow Pulmonary venous inflow TDI MAM

Normal 0.75 , E:A ,1.5 S.D E/e9 ,10

DT .160 ms MV Adur . PV Adur
Mild LVDD E:A ,0.75 S.D E/e9 ,10
DT .240 ms MV Adur . PV Adur
Moderate LVDD 0.75 , E:A ,1.5 S,D E/e9 >10
DT .160 ms MV Adur + 30 ms , PV Adur
Severe LVDD E:A .1.5 S,D E/e9 >10
DT ,160 ms MV Adur + 30 ms , PV Adur

At least two Doppler criteria consistent with moderate to severe left ventricular diastolic function were required to
distinguish from normal diastolic function.
A, peak mitral filling velocity at atrial contraction; D, peak velocity of pulmonary venous forward flow during
diastole; DT, deceleration time of mitral E wave; E, peak early mitral inflow filling velocity; e9, peak velocity of
lateral mitral annulus motion during early diastole; MV Adur, duration of mitral A wave; PV Adur, duration of
pulmonary venous reversal wave at atrial contraction; S, peak velocity of pulmonary venous forward flow during
systole; TDI MAM, tissue Doppler imaging of mitral annular motion.

participant (weight in kilograms divided by the square of classification of functional status17 and Framingham criteria
height measured in metres) and categorised according to the for the clinical diagnosis of CHF.18 Subjects with systolic or
World Health Organization classification scheme (not over- diastolic dysfunction without a history or clinical evidence of
weight or obese , 25 kg/m2, overweight 25.0–29.9 kg/m2, heart failure were considered to be in the preclinical phase of
obese > 30 kg/m2). disease. Serum amino-terminal B-type natriuretic peptide
(N-BNP) concentrations were measured with a fully auto-
Echocardiography mated electrochemiluminescence sandwich immunoassay
One of two experienced sonographers assessed cardiac (proBNP, Roche Diagnostics).
structure and function by using transthoracic echocardio-
graphy (Acuson 128 XP/10, equipped with native tissue Quality of life
harmonic imaging technology) according to a standardised The standardised SF-36 questionnaire was administered to
protocol. Measurements were made online and recorded on assess general health status.
tape with participants’ initials and study number as their
only identification. A cardiologist, blinded to the participant’s Statistical analysis
clinical data, interpreted the echocardiogram after review off Continuous variables are presented as mean (SD).
line. LV EF was quantified by the biplane disc summation Categorical variables are displayed as percentages.
method (Simpson’s rule) on the two-dimensional echocar- Differences between groups were assessed by likelihood ratio
diographic images from the apical four- and two-chamber tests (categorical variables) or Kruskal–Wallis tests and non-
views.14 LV systolic function was categorised according to EF parametric tests for trend (continuous variables), as appro-
(( 40%, 41–50%, . 50%) and the presence of regional LV priate. We calculated the point estimate and 95% CI (by the
wall motion abnormalities. LV diastolic function was graded exact binomial method) for diastolic dysfunction (for any EF
into four categories by Doppler evaluation of the mitral and and for subjects with EF . 50%), stratified for five-year age
pulmonary venous inflow and by tissue Doppler imaging of groups and sex. Ordinal logistic regression was used to assess
the lateral mitral annulus motion (table 1).13 In a stratified the association between the ordinal variable, diastolic
subsample of 50 participants, interobserver reproducibility for function grade and clinical or echocardiographic predictors
grading of systolic and diastolic function was very good in univariable and multivariable analyses, adjusted for age
(ksystolic = 0.88, 95% confidence interval (CI) 0.63 to 1.0 and and sex and relevant covariates. Least squares linear
kdiastolic = 0.89, 95% CI 0.64 to 1.0). Valvular heart disease regression was used to assess the relationship between
was defined as at least moderate stenosis or regurgitation of general health status score and diastolic function grade,
the aortic or mitral valve on colour Doppler and quantitative after adjustment for age, sex and significant covariates. All
Doppler echocardiographic evaluation. LV mass was assessed hypothesis testing was two sided, and significance was
by the area–length method, by using the two-dimensional declared if p , 0.05. The assumptions for regression models
short-axis parasternal view at the papillary muscle level to were checked statistically.
measure LV muscle area and the apical four-chamber view to
measure the LV length.15 The LV mass was indexed for each RESULTS
participant’s body surface area. Maximum left atrial volume Study participants
was quantified by the modified prolate ellipse method16 and Seventy-five per cent (1388 of 1846) of the eligible subjects
indexed for body surface area. agreed to participate in the survey. The only groups with
participation rates , 70% were women aged 75–79 years
Ascertainment of CHF status (68%) and . 80 years (49%). Consequently, compared with
A self-reported history of clinical heart failure was verified by the source population, the sample population had a higher
a review of the subject’s medical records. During a consulta- proportion of men (50.5% v 47.2%, p , 0.012) and were
tion with a cardiologist who was blinded to the echocardio- younger (68.9 years v 69.6 years, p = 0.0005). About 92%
graphic findings and medical history, participants were asked participants (1275 of 1388; mean age 69.4; 50% men)
if they had symptoms of dyspnoea, orthopnoea, paroxysmal completed all the echocardiographic investigations necessary
nocturnal dyspnoea or dependant oedema. They were also for assessment of LV function.
examined for the presence of a tachycardia, raised jugular
venous pressure, displaced apex beat, added heart sounds, Diastolic dysfunction in the community
cardiac murmurs, lung crepitations and peripheral oedema. For 32 subjects, diastolic function grade could not be
Heart failure clinical status was ascertained according to determined (atrial fibrillation with deceleration time of
clinical scores based on the New York Heart Association mitral E wave . 140 ms; mitral stenosis; E:A fusion; and

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Diastolic dysfunction in the community 1261

Table 2 Prevalence of diastolic dysfunction in the cohort (n = 1275) stratified by age group, sex and left ventricular ejection
fraction status
Age groups (years)

60–64 65–69 70–74 75–79 80–86 All

Diastolic dysfunction, any ejection fraction

Mild
Men 30 (15.3%) 39 (23.8%) 36 (31.0%) 29 (32.2%) 36 (51.4%) 170 (26.7%)
Women 31 (16.1%) 37 (24.8%) 45 (30.8%) 43 (41.7%) 23 (47.9%) 179 (28.0%)
All 61 (15.7%) 76 (24.3%) 81 (30.9%) 72 (37.3%) 59 (50.0%) 349 (27.4%)
Moderate or severe
Men 10 (5.1%) 13 (7.9%) 8 (6.9%) 8 (8.9%) 8 (11.4%) 47 (7.4%)
Women 4 (2.1%) 6 (4.0%) 13 (8.9%) 14 (13.6%) 9 (18.8%) 46 (7.2%)
All 14 (3.6%) 19 (6.1%) 21 (8.0%) 22 (11.4%) 17 (14.4%) 93 (7.3%)
Diastolic dysfunction with normal ejection fraction
Mild
Men 28 (14.3%) 33 (20.1%) 29 (25.0%) 21 (23.3%) 23 (32.9%) 134 (21.1%)
Women 31 (16.1%) 35 (23.5%) 43 (29.5%) 37 (35.9%) 19 (39.6%) 165 (25.8%)
All 59 (15.2%) 68 (21.7%) 72 (27.5%) 58 (30.1%) 42 (35.6%) 299 (23.5%)
Moderate or severe
Men 6 (3.1%) 9 (5.5%) 6 (5.2%) 4 (4.4%) 7 (10.0%) 32 (5.0%)
Women 2 (1.0%) 6 (4.0%) 12 (8.2%) 14 (13.6%) 6 (12.5%) 40 (6.3%)
All 8 (2.1%) 15 (4.8%) 18 (6.9%) 18 (9.3%) 13 (11.0%) 72 (5.6%)

only a single criterion suggestive of moderate to severe DD-NEF increased with age (p , 0.0001) but did not differ
diastolic dysfunction). The prevalence of any diastolic between men and women (p = 0.34). Clinical predictors of
dysfunction was 34.7% (95% CI 32.1% to 37.4%) and that DD-NEF were a history of hypertension (p , 0.0001), angina
of moderate to severe diastolic dysfunction was 7.3% (95% CI (p = 0.04), myocardial infarction (p = 0.003), and obesity
5.9% to 8.9%). Table 2 presents the prevalence of diastolic (p , 0.0001). Figure 1 presents the impact of cardiovascular
dysfunction stratified by age group, sex and EF status. risk factors on age-specific rates of DD-NEF. Of subjects aged
Table 3 outlines the univariate associations between clinical , 70 years and without a history of hypertension, ischaemic
characteristics and diastolic function. Higher age was asso- heart disease, diabetes or obesity, advanced DD-NEF was
ciated with any diastolic dysfunction (p , 0.0001) and documented in only one person.
moderate to severe diastolic dysfunction (3.6% in subjects Doppler evidence of moderate or severe DD-NEF was
aged 60–64 years v 14.4% in subjects aged . 80 years, accompanied by echocardiographic and biochemical markers
ptrend , 0.001), but rates of any diastolic dysfunction of impaired LV relaxation and increased LV filling pressure.
(p = 0.68) or moderate to severe diastolic dysfunction did Even after we controlled for age, sex and EF, worsening DD-
not differ significantly between men and women (7.4% v 7.2%, NEF was associated with an increase in indexed left atrial
respectively, p = 0.90). After adjustment for age and sex, a volume (p , 0.0001) and N-BNP concentration
history of hypertension (p = 0.002), diabetes (p = 0.03), (p , 0.0001). Indexed left atrial volume (p = 0.61) and N-
angina (p = 0.048), myocardial infarction (p , 0.0001), BNP concentration (p = 0.10), however, did not differ
overweight (p = 0.01) and obesity (p , 0.0001) were asso- significantly between subjects with normal and those with
ciated with diastolic dysfunction (table 4). mild diastolic dysfunction, even after stratification for age
Rates of diastolic dysfunction increased with decreasing EF and sex.
(p = 0.0001). Indeed, there were no subjects with an EF In subjects with DD-NEF, there was evidence of LV
( 40% with normal LV diastolic function. remodelling and alterations in long-axis systolic function
(table 5). LV mass index increased and mitral annular
Diastolic dysfunction with normal EF systolic velocity decreased with advancing diastolic dysfunc-
The prevalence of moderate to severe diastolic dysfunction tion (p , 0.0001 for both), independent of age and sex.
with an EF . 50% and no regional LV wall motion However, EF did not decrease significantly in subjects with
abnormalities was 5.6% (95% CI 4.4% to 7.1%). Rates of DD-NEF (ptrend = 0.11).

Table 3 Clinical characteristics of participants according to left ventricular diastolic

function status*
Diastolic dysfunction, any ejection fraction

Normal Mild Moderate to

(n = 801) (n = 349) severe (n = 93) p Value

Age (years) 68 (6) 72 (7) 73 (7) ,0.0001

Women 403 (50.3%) 179 (51.3%) 46 (49.5%) 0.94
Systolic blood pressure (mm Hg) 137 (17) 140 (17) 139 (18) 0.001
Hypertension 337 (42.0%) 191 (54.7%) 59 (63.4%) ,0.0001
Angina 75 (9.4%) 53 (15.2%) 22 (23.7%) ,0.0001
Myocardial infarction 37 (4.6%) 33 (9.5%) 21 (22.6%) ,0.0001
Diabetes 73 (9.1%) 37 (10.6%) 18 (19.4%) 0.007
Obesity 223 (27.8%) 98 (28.1%) 39 (41.9%) 0.01
Excessive alcohol intake 30 (3.7%) 18 (5.2%) 6 (6.5%) 0.32

Data are mean (SD) or number (%).

*Excluding 32 participants with indeterminate left ventricular diastolic function.

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1262 Abhayaratna, Marwick, Smith, et al

Table 4 Association between clinical and age. In contrast to the female preponderance documented in
echocardiographic parameters and left ventricular studies of heart failure with normal EF,7 we found that
diastolic dysfunction diastolic dysfunction was equally common in men and
women. Co-morbid cardiovascular conditions such as hyper-
Adjusted OR (95% CI)* p Value tension, ischaemic heart disease, diabetes, obesity and
Men 0.97 (0.76 to 1.23) 0.78
systolic dysfunction were predictors of diastolic dysfunction,
Age group (referent: independent of age and sex. Advanced (moderate or severe)
60–69 years) diastolic dysfunction rarely equated to ‘‘diastolic’’ heart
70–79 years 2.5 (1.9 to 3.2)` ,0.0001 failure. Indeed, 76% of patients with advanced diastolic
80–86 years 5.7 (3.9 to 8.4)` ,0.0001
Hypertension 1.5 (1.2 to 2.0) 0.002 dysfunction did not have overt symptoms or a history of CHF.
Diabetes 1.4 (1.03 to 2.0) 0.029 We observed that advanced DD-NEF was as common as
Myocardial infarction 2.8 (1.8 to 4.4) ,0.0001 systolic dysfunction (EF ( 50%) and more likely to be
Coronary disease 1.8 (1.3 to 2.4) ,0.0001 present in the preclinical phase of disease. Despite the
Body mass index
(referent: ,25 kg/m2) frequent absence of symptoms, subjects with advanced DD-
25–29.9 kg/m2 1.5 (1.1 to 2.0) 0.01 NEF had evidence of structural remodelling, including
>30 kg/m2 1.9 (1.3 to 2.6) ,0.0001 increased left atrial size and LV mass, and raised N-BNP
Ejection fraction (50% 5.4 (3.3 to 8.8) ,0.0001 concentrations compared with subjects with normal or mildly
*Adjusted for age and sex unless specified; adjusted for age; `adjusted
impaired diastolic function. Furthermore, DD-NEF was
for sex. independently associated with a reduction in general health
CI, confidence interval; OR, odds ratio. status.
Several factors enhance the validity of results from this
study compared with previously published surveys. Our
Quality of life, as assessed by general health status estimates of systolic and diastolic dysfunction are less likely
(table 5), progressively deteriorated with increasing severity to be affected by selection bias arising from a low participa-
of DD-NEF, independent of age, sex, overweight or obesity tion rate5 or misclassification error resulting from the failure
status, history of hypertension, diabetes or ischaemic heart to use comprehensive Doppler methods to distinguish
disease, or EF (p , 0.0001).
subjects with normal diastolic function from those with
moderate diastolic dysfunction.6 Nonetheless, the consistency
Relationship between DD-NEF and heart failure status in prevalence and clinical predictors of diastolic dysfunction
Of subjects with a previous diagnosis of heart failure, 47% between our study and the only other study that employed
(95% CI 35% to 59%) had an EF . 50% and no evidence of detailed Doppler methods of estimating LV filling pressure5
regional wall motion abnormalities. Of subjects with moder- provides reassurance as to the generalisability of our findings.
ate to severe DD-NEF, 86% were in the preclinical stage of This study extends previously published observations on
disease as assessed by strict Framingham criteria. Even when the relationship between DD-NEF and CHF status.5 In
clinical status was judged by the New York Heart Association addition to surveillance of medical records, the incorporation
classification, 36% of subjects with moderate to severe DD- of a clinical examination to detect symptoms and signs of
NEF were asymptomatic. Thus, about one in 20 subjects in CHF has provided a more robust classification of clinical
the sample population had preclinical advanced DD-NEF status of subjects with DD-NEF. By using an array of clinical
(4.9%, 95% CI 3.7% to 6.2%). In contrast, preclinical advanced scores that offer varying degrees of sensitivity and specificity,
systolic dysfunction (EF ( 40%) was rare (0.5%, 95% CI 0.2% we have confirmed the existence of a preclinical phase of
to 1.0%). advanced diastolic dysfunction that is detectable by compre-
Markers of progression from preclinical DD-NEF to overt hensive Doppler echocardiography. Indeed, the prevalence of
CHF were decreased EF (66% in preclinical advanced DD- preclinical advanced DD-NEF is 10-fold greater than that of
NEF v 59% in clinical advanced DD-NEF, p = 0.003), advanced systolic dysfunction. There is scant evidence
increased N-BNP concentration (84 pmol/l v 248 pmol/l, regarding the prognostic significance of preclinical diastolic
p = 0.03) and trends towards increased LV end diastolic dysfunction. Despite their lack of symptoms, subjects with
size (2.67 cm/m2 v 2.83 cm/m2, p = 0.13) and indexed left preclinical advanced DD-NEF have biochemical and morpho-
atrial volume (36.3 ml/m2 v 45.1 ml/m2, p = 0.11). logical evidence supporting the presence of current and
chronic rise of LV filling pressures as assessed by N-BNP
DISCUSSION concentration and left atrial size, respectively. Further, as left
In this population-based sample of older adults, diastolic atrial size has been shown to be an independent risk marker
dysfunction was common and increased in frequency with for the development of atrial fibrillation,19 20 stroke,21 incident

70 Figure 1 Influence of age and risk

Mild DD: no risk factors factor status on the prevalence of mild
60 Mild DD: risk factors and moderate to severe diastolic
Prevalence of DD-NEF (%)

Moderate to severe DD: no risk factors dysfunction (DD) in subjects with left
50 Moderate to severe DD: risk factors ventricular ejection fraction .50% and
no regional wall motion abnormalities.
40 Risk factor status was dichotomised
according to history of the risk factors;
30 hypertension, ischaemic heart disease
(angina or myocardial infarction),
20
obesity, and diabetes. NEF, normal
10
ejection fraction.

0
60–64 65–69 70–74 75–79 80–86
Age group (years)

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Diastolic dysfunction in the community 1263

Table 5 Echocardiographic characteristics of participants with normal EF by diastolic

function status
Diastolic dysfunction, normal EF

Normal* Mild Moderate to

(n = 755) (n = 299) severe (n = 72) p Value

Age (years) 68 (6) 71 (7) 73 (6) ,0.0001

Women 394 (52.2%) 165 (55.2%) 38 (54.3%) 0.34
General health status score (/100) 69 (22) 63 (24) 54 (26) ,0.0001
LV EF (%) 68 (5) 67 (5) 66 (7) 0.11
Mitral annular systolic velocity (cm/s) 10.6 (3) 10.8 (3) 8.4 (2) ,0.0001
LVEDD index (cm/m2) 2.67 (0.3) 2.68 (0.4) 2.70 (0.3) 0.31
LV mass index (g/m) 100 (24) 106 (31) 121 (33) ,0.0001
Left atrial volume index (ml/m2) 22.4 (6.6) 23.4 (8.3) 37.5 (14) ,0.0001
Mitral annular diastolic velocity (cm/s) 10.1 (2) 8.6 (2) 8.5 (2.8) ,0.0001
Amino-terminal pro-BNP (pmol/l) 14 (13) 19 (31) 105 (164) ,0.0001

*Ejection fraction (EF) .50%, no regional wall motion abnormalities and normal diastolic function; EF .50% and
no regional wall motion abnormalities.
BNP, B-type natriuretic peptide; LV, left ventricular; LVEDD, left ventricular end diastolic diameter.

CHF22 and cardiovascular death,23 preclinical DD-NEF is likely relationships (and thus causal relationships) between clinical
to be a condition that portends a poor cardiovascular parameters, cardiac remodelling and diastolic function.
prognosis. Our conclusion is supported by longitudinal data
from a study of Olmsted County residents, which has shown Implications
that people with advanced diastolic dysfunction, most of The burden of DD-NEF in the community will probably
whom were in a preclinical stage of disease, had a 10-fold increase with the ageing population and escalating rates of
higher risk of all cause death than subjects with normal obesity and diabetes in the community. Whether this burden
diastolic function after adjustment for age, sex and EF.5 can be reduced by screening efforts remains to be deter-
Despite evidence from convenience samples that patients mined. Our observations suggest that, as preclinical advanced
with heart failure24–26 or DD-NEF have a subtle decrease in LV DD-NEF is relatively common and associated with cardiac
long-axis systolic dysfunction,26 27 subjects with diastolic markers that portend a poor cardiovascular prognosis,
dysfunction with an EF . 50% have recently been classified screening efforts may be warranted. Before community-
as having isolated diastolic dysfunction.5 Our results suggest based screening programmes for LV (systolic and diastolic)
that this term may be an oversimplification. We have dysfunction are adopted, however, more data are required
observed that, in subjects with an EF . 50% and no regional detailing the natural history of the disease, the efficacy of
wall motion abnormalities, advancing diastolic dysfunction treatment for preclinical LV dysfunction, the screening
was associated with a decrease in long-axis systolic function
performance of biomarkers and ultimately the cost effective-
and CHF status was related to a reduction in radial systolic
ness of screening strategies. As DD-NEF is rare in subjects
function, although EF remained within ‘‘normal’’ limits.
without co-morbid cardiovascular conditions, the efficiency
Furthermore, there was a trend towards an increase in LV
of screening programmes could be optimised by targeting
end diastolic size with advancing diastolic dysfunction and in
high-risk groups, defined according to age (. 70 years) or
subjects with symptomatic DD-NEF. Thus, at least some
risk factor status (hypertension, ischaemic heart disease,
subjects with advanced DD-NEF may have cardiac remodel-
diabetes or obesity).
ling as a pathophysiological response to co-morbid cardio-
vascular conditions (hypertension, ischaemic heart disease or
obesity), with increased LV filling pressure related to an Conclusion
increased ventricular capacitance rather than a shift in the Diastolic dysfunction is common in the community and is
end diastolic pressure–volume relationship caused by a pure often unaccompanied by overt symptoms and signs of CHF.
decrease in LV compliance. Although recent studies have Despite the absence of symptoms, subjects with advanced
provided an insight into the mechanisms underlying such a DD-NEF have accompanying structural abnormalities that
response by showing that patients with advanced DD-NEF reflect an increased risk for adverse cardiovascular outcomes
have load-dependent alterations in diastolic function caused and have a reduced quality of life.
by increased LV systolic and arterial stiffness,28 more work is
required to confirm these findings. ACKNOWLEDGEMENTS
This study was supported by a grant from the Canberra Hospital
Salaried Medical Officers’ Private Practice Fund. The authors
Study limitations acknowledge the support and assistance during study conduct from
A low participation rate from women aged . 80 may have Dr Ian Jeffery, Alice Kam and Pearle Taverner (research nurses), Kate
resulted in an underestimation of the true prevalence of LV Abhayaratna (research assistant) and Christine O’Reilly (sonogra-
dysfunction in the source population. Although echocardio- pher), Siemens Ultrasound (Australia) and Roche Diagnostics
graphy is widely accepted as a safe and convenient method (Australia).
for the diagnosis and follow up of patients with diastolic
.....................
dysfunction,12 it is recognised that Doppler echocardiographic
methods reflect integrative properties of diastolic function Authors’ affiliations
W P Abhayaratna, National Centre for Epidemiology and Population
that lack specificity.29 In this study of survey participants, we
Health, Australian National University and Department of Cardiology,
could not justify the use of invasive methods for the The Canberra Hospital, Canberra, ACT, Australia
assessment of active and passive diastolic LV properties. T H Marwick, Department of Medicine, University of Queensland,
Most (97.6%) of our sample was white and our results may Brisbane, Queensland, Australia
not be applicable to non-white populations. As our data are W T Smith, Centre for Clinical Epidemiology and Biostatistics, University
cross sectional, we were unable to determine temporal of Newcastle, Newcastle, New South Wales, Australia

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1264 Abhayaratna, Marwick, Smith, et al

N G Becker, National Centre for Epidemiology and Population Health, radionuclide angiography for estimating left ventricular size and
Australian National University, Canberra, ACT, Australia performance. Circulation 1981;63:1075–84.
15 Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation
Competing interests: None declared. of the left ventricle by two-dimensional echocardiography. American Society
of Echocardiography Committee on Standards, Subcommittee on Quantitation
of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr
1989;2:358–67.
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IMAGE IN CARDIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
doi: 10.1136/hrt.2005.079160
Pneumopericardium following perianal fistula repair and sigmoidoscopy

A
previously well 19-year-old man presented with a four-hour history of pericarditic chest
pain and right sided neck pain within 24 hours of perianal fistula repair and rigid
sigmoidoscopy. The procedure was performed under self-ventilating general anaesthetic
with a laryngeal mask airway.
Examination revealed a loud precordial rub and surgical emphysema across the right side of
the neck. ECG was normal. A chest radiograph showed an extensive pneumopericardium with
pneumoretroperitoneum and pneumoperitoneum (see panel). His echocardiogram did not
show any evidence of a pericardial collection or tamponade.
He was monitored on the coronary care unit, treated empirically with antibiotics because of
an elevated white blood cell count and a presumed bacteraemia following surgery, and
managed conservatively. Repeat chest radiographs after four days showed complete resolution
of the pneumopericardium but persisting pneumoretroperitoneum. He was discharged home
pain-free after six days.
It is important to recognise pneumopericardium as a differential diagnosis in chest pain as it
is a potentially life threatening condition by causing tamponade and haemodynamic
compromise. Ideally this and a coexisting pericardial effusion should be excluded on
echocardiogram. Depending on the source of the air leak, infection is an additional risk. It
would appear most reported cases are traumatic in origin. However, it has been reported
following colonoscopy and even spontaneously.

X Holmwood
S C-Y Tan
C J McKenna
cjmckenna@hotmail.com

www.heartjnl.com
 Downloaded from http://heart.bmj.com/ on May 10, 2015 - Published by group.bmj.com

Characteristics of left ventricular diastolic

dysfunction in the community: an
echocardiographic survey
W P Abhayaratna, T H Marwick, W T Smith and N G Becker

Heart 2006 92: 1259-1264 originally published online February 17, 2006
doi: 10.1136/hrt.2005.080150

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Clinical diagnostic tests (4492)
Echocardiography (1970)
Heart failure (536)
Acute coronary syndromes (2556)
Diabetes (799)

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