Treatment of asymptomatic left ventricular dysfunction


Opinion statement

Patients with abnormalities of left ventricular (LV) systolic or diastolic function may have no symptoms, especially in the early stages. These patients are not uncommon in the community, and the prevalence of this condition increases in the presence of risk factors such as diabetes, hypertension, and coronary artery disease. Patients with asymptomatic LV dysfunction have a significantly increased risk of overt heart failure and mortality. Therefore, it is of prime importance to identify and treat these patients to prevent progression of the disease. Echocardiography is an excellent tool to characterize systolic and diastolic properties of the left ventricle. However, its cost and lack of widespread availability have limited its usefulness in screening the general population. Careful clinical assessment coupled with electrocardiography and natriuretic peptide level assessment can identify higher-risk patients who should be referred for detailed evaluation of LV function. The goal of therapy is to halt and even reverse LV remodeling. Neurohormonal blockade, now the cornerstone of heart failure therapy, has been shown to have salutatory effects in patients with asymptomatic LV systolic dysfunction, both in reversing remodeling and reducing adverse clinical outcomes. Except for risk factor control, there is no evidence to advocate any specific therapy for asymptomatic patients with LV diastolic dysfunction.


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References and Recommended Reading

  1. 1.
    Mann DL: Mechanisms and models in heart failure: a combinatorial approach. Circulation 1999, 100:999–1008.PubMedGoogle Scholar
  2. 2.
    Hunt SA, Abraham WT, Chin MH, et al.: ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005, 112:e154–e235.PubMedCrossRefGoogle Scholar
  3. 3.
    Lester SJ, Tajik AJ, Nishimura RA, et al.: Unlocking the mysteries of diastolic function: deciphering the Rosetta Stone 10 years later. J Am Coll Cardiol 2008, 51:679–689.PubMedCrossRefGoogle Scholar
  4. 4.
    Davie AP, Francis CM, Love MP, et al.: Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction. BMJ 1996, 312:222.PubMedGoogle Scholar
  5. 5.
    Baker DW, Bahler RC, Finkelhor RS, Lauer MS: Screening for left ventricular systolic dysfunction among patients with risk factors for heart failure. Am Heart J 2003, 146:736–740.PubMedCrossRefGoogle Scholar
  6. 6.
    Corteville DC, Bibbins-Domingo K, Wu AH, et al.: N-terminal pro-B-type natriuretic peptide as a diagnostic test for ventricular dysfunction in patients with coronary disease: data from the heart and soul study. Arch Intern Med 2007, 167:483–489.PubMedCrossRefGoogle Scholar
  7. 7.
    Vasan RS, Benjamin EJ, Larson MG, et al.: Plasma natriuretic peptides for community screening for left ventricular hypertrophy and systolic dysfunction: the Framingham heart study. JAMA 2002, 288:1252–1259.PubMedCrossRefGoogle Scholar
  8. 8.
    Costello-Boerrigter LC, Boerrigter G, Redfield MM, et al.: Amino-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide in the general community: determinants and detection of left ventricular dysfunction. J Am Coll Cardiol 2006, 47:345–353.PubMedCrossRefGoogle Scholar
  9. 9.
    Wang TJ, Levy D, Benjamin EJ, Vasan RS: The epidemiology of “asymptomatic” left ventricular systolic dysfunction: implications for screening. Ann Intern Med 2003, 138:907–916.PubMedGoogle Scholar
  10. 10.
    Wang TJ, Evans JC, Benjamin EJ, et al.: Natural history of asymptomatic left ventricular systolic dysfunction in the community. Circulation 2003, 108:977–982.PubMedCrossRefGoogle Scholar
  11. 11.
    Verdecchia P, Angeli F, Gattobigio R, et al.: Asymptomatic left ventricular systolic dysfunction in essential hypertension: prevalence, determinants, and prognostic value. Hypertension 2005, 45:412–418.PubMedCrossRefGoogle Scholar
  12. 12.
    Chareonthaitawee P, Sorajja P, Rajagopalan N, et al.: Prevalence and prognosis of left ventricular systolic dysfunction in asymptomatic diabetic patients without known coronary artery disease referred for stress single-photon emission computed tomography and assessment of left ventricular function. Am Heart J 2007, 154:567–574.PubMedCrossRefGoogle Scholar
  13. 13.
    Redfield MM, Jacobsen SJ, Burnett JC Jr, et al.: Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003, 289:194–202.PubMedCrossRefGoogle Scholar
  14. 14.
    Ren X, Ristow B, Na B, et al.: Prevalence and prognosis of asymptomatic left ventricular diastolic dysfunction in ambulatory patients with coronary heart disease. Am J Cardiol 2007, 99:1643–1647.PubMedCrossRefGoogle Scholar
  15. 15.
    Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med 1992, 327:685–691.Google Scholar
  16. 16.
    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. The SAVE Investigators. N Engl J Med 1992, 327:669–677.PubMedGoogle Scholar
  17. 17.
    Schillaci G, Pasqualini L, Verdecchia P, et al.: Prognostic significance of left ventricular diastolic dysfunction in essential hypertension. J Am Coll Cardiol 2002, 39:2005–2011.PubMedCrossRefGoogle Scholar
  18. 18.
    Abhayaratna W, Abhayaratna K, O’Reilly C, et al.: Asymptomatic left ventricular diastolic dysfunction and risk of death in the community [abstract]. Presented at the 57th American College of Cardiology Annual Scientific Session. Chicago, IL; March 29–April 1, 2008.Google Scholar
  19. 19.
    Schocken DD, Benjamin EJ, Fonarow GC, et al.: Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation 2008, 117:2544–2565.PubMedCrossRefGoogle Scholar
  20. 20.
    Solomon SD, Janardhanan R, Verma A, et al.: Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial. Lancet 2007, 369:2079–2087.PubMedCrossRefGoogle Scholar
  21. 21.
    Jong P, Yusuf S, Rousseau MF, et al.: Effect of enalapril on 12-year survival and life expectancy in patients with left ventricular systolic dysfunction: a follow-up study. Lancet 2003, 361:1843–1848.PubMedCrossRefGoogle Scholar
  22. 22.
    Kober L, Torp-Pedersen C, Carlsen JE, et al.: A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group. N Engl J Med 1995, 333:1670–1676.PubMedCrossRefGoogle Scholar
  23. 23.
    St John Sutton M, Pfeffer MA, Plappert T, et al.: Quantitative two-dimensional echocardiographic measurements are major predictors of adverse cardiovascular events after acute myocardial infarction. The protective effects of captopril. Circulation 1994, 89:68–75.PubMedGoogle Scholar
  24. 24.
    Greenberg B, Quinones MA, Koilpillai C, et al.: Effects of long-term enalapril therapy on cardiac structure and function in patients with left ventricular dysfunction. Results of the SOLVD echocardiography substudy. Circulation 1995, 91:2573–2581.PubMedGoogle Scholar
  25. 25.
    Packer M, Bristow MR, Cohn JN, et al.: The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med 1996, 334:1349–1355.PubMedCrossRefGoogle Scholar
  26. 26.
    Hjalmarson A, Goldstein S, Fagerberg B, et al.: Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group. JAMA 2000, 283:1295–1302.PubMedCrossRefGoogle Scholar
  27. 27.
    Packer M, Fowler MB, Roecker EB, et al.: Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study. Circulation 2002, 106:2194–2199.PubMedCrossRefGoogle Scholar
  28. 28.
    The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999, 353:9–13.Google Scholar
  29. 29.
    Doughty RN, Whalley GA, Walsh HA, et al.: Effects of carvedilol on left ventricular remodeling after acute myocardial infarction: the CAPRICORN Echo Substudy. Circulation 2004, 109:201–206.PubMedCrossRefGoogle Scholar
  30. 30.
    Groenning BA, Nilsson JC, Sondergaard L, et al.: Antiremodeling effects on the left ventricle during betablockade with metoprolol in the treatment of chronic heart failure. J Am Coll Cardiol 2000, 36:2072–2080.PubMedCrossRefGoogle Scholar
  31. 31.
    Dargie HJ: Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet 2001, 357:1385–1390.PubMedCrossRefGoogle Scholar
  32. 32.
    Aronow WS, Ahn C, Kronzon I: Effect of beta blockers alone, of angiotensin-converting enzyme inhibitors alone, and of beta blockers plus angiotensin-converting enzyme inhibitors on new coronary events and on congestive heart failure in older persons with healed myocardial infarcts and asymptomatic left ventricular systolic dysfunction. Am J Cardiol 2001, 88:1298–1300.PubMedCrossRefGoogle Scholar
  33. 33.
    Vantrimpont P, Rouleau JL, Wun CC, et al.: Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. SAVE Investigators. J Am Coll Cardiol 1997, 29:229–236.PubMedCrossRefGoogle Scholar
  34. 34.
    Exner DV, Dries DL, Waclawiw MA, et al.: Beta-adrenergic blocking agent use and mortality in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a post hoc analysis of the Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 1999, 33:916–923.PubMedCrossRefGoogle Scholar
  35. 35.
    Colucci WS, Kolias TJ, Adams KF, et al.: Metoprolol reverses left ventricular remodeling in patients with asymptomatic systolic dysfunction: the REversal of VEntricular Remodeling with Toprol-XL (REVERT) trial. Circulation 2007, 116:49–56.PubMedCrossRefGoogle Scholar
  36. 36.
    Pfeffer MA, McMurray JJ, Velazquez EJ, et al.: Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003, 349:1893–1906.PubMedCrossRefGoogle Scholar
  37. 37.
    Cohn JN, Tognoni G: A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 2001, 345:1667–1675.PubMedCrossRefGoogle Scholar
  38. 38.
    Granger CB, McMurray JJ, Yusuf S, et al.: Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet 2003, 362:772–776.PubMedCrossRefGoogle Scholar
  39. 39.
    Pitt B, Zannad F, Remme WJ, et al.: The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999, 341:709–717.PubMedCrossRefGoogle Scholar
  40. 40.
    Pitt B, Remme W, Zannad F, et al.: Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003, 348:1309–1321.PubMedCrossRefGoogle Scholar
  41. 41.
    The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group. N Engl J Med 1997, 336:525–533.Google Scholar
  42. 42.
    Rathore SS, Wang Y, Krumholz HM: Sex-based differences in the effect of digoxin for the treatment of heart failure. N Engl J Med 2002, 347:1403–1411.PubMedCrossRefGoogle Scholar
  43. 43.
    Nanthakumar K, Epstein AE, Kay GN, et al.: Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction: a pooled analysis of 10 primary prevention trials. J Am Coll Cardiol 2004, 44:2166–2172.PubMedCrossRefGoogle Scholar
  44. 44.
    Moss AJ, Zareba W, Hall WJ, et al.: Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002, 346:877–883.PubMedCrossRefGoogle Scholar
  45. 45.
    Kadish A, Dyer A, Daubert JP, et al.: Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004, 350:2151–2158.PubMedCrossRefGoogle Scholar
  46. 46.
    Bardy GH, Lee KL, Mark DB, et al.: Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005, 352:225–237.PubMedCrossRefGoogle Scholar
  47. 47.
    Bristow MR, Saxon LA, Boehmer J, et al.: Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004, 350:2140–2150.PubMedCrossRefGoogle Scholar
  48. 48.
    Cleland JG, Daubert JC, Erdmann E, et al.: The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005, 352:1539–1549.PubMedCrossRefGoogle Scholar
  49. 49.
    Cleland JG, Daubert JC, Erdmann E, et al.: Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J 2006, 27:1928–1932.PubMedCrossRefGoogle Scholar
  50. 50.
    Linde C, Gold M, Abraham WT, Daubert JC: Rationale and design of a randomized controlled trial to assess the safety and efficacy of cardiac resynchronization therapy in patients with asymptomatic left ventricular dysfunction with previous symptoms or mild heart failure—the REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (REVERSE) study. Am Heart J 2006, 151:288–294.PubMedCrossRefGoogle Scholar
  51. 51.
    Linde C, Gold M, Abraham WT, Daubert JC: Baseline characteristics of patients randomized in The Resynchronization Reverses Remodeling In Systolic Left Ventricular Dysfunction (REVERSE) study. Congest Heart Fail 2008, 14:66–74.PubMedCrossRefGoogle Scholar
  52. 52.
    Zwanziger J, Hall WJ, Dick AW, et al.: The cost effectiveness of implantable cardioverter-defibrillators: results from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II. J Am Coll Cardiol 2006, 47:2310–2318.PubMedCrossRefGoogle Scholar
  53. 53.
    Nussberger J, Wuerzner G, Jensen C, Brunner HR: Angiotensin II suppression in humans by the orally active renin inhibitor Aliskiren (SPP100): comparison with enalapril. Hypertension 2002, 39:E1–E8.PubMedCrossRefGoogle Scholar
  54. 54.
    Gradman AH, Kad R: Renin inhibition in hypertension. J Am Coll Cardiol 2008, 51:519–528.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Cardiovascular DivisionBrigham and Women’s HospitalBostonUSA

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