Clinical manifestations and diagnosis of asymptomatic left ventricular systolic dysfunction
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Asymptomatic left ventricular systolic dysfunction (ALVSD) is defined as depressed LV systolic function in the absence of heart failure (HF). For the discussion in this topic, ALVSD is defined as depressed LV systolic function with a subnormal LV ejection fraction, regional wall motion abnormality, or both. (See 'Definition' below.)
Population-based studies suggest that ALVSD is at least as common as HF with reduced ejection fraction. ALVSD is a risk factor for progression to HF and death. Structural heart disease (including LV systolic dysfunction) without symptoms or signs of HF is defined as "stage B HF" in the American College of Cardiology Foundation/American Heart Association guidelines .
The prevalence, causes, clinical manifestations, and diagnosis of patients with ALVSD will be reviewed here. Management of ALVSD is presented separately. (See "Management and prognosis of asymptomatic left ventricular systolic dysfunction".)
Asymptomatic left ventricular systolic dysfunction (ALVSD) is defined as depressed LV systolic function in the absence of heart failure. Studies of ALVSD have used heterogeneous criteria to identify this condition:
●Patients with depressed LV systolic function may have global dysfunction, regional dysfunction, or both.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62:e147.
- Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440.
- Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1.
- Echouffo-Tcheugui JB, Erqou S, Butler J, et al. Assessing the Risk of Progression From Asymptomatic Left Ventricular Dysfunction to Overt Heart Failure: A Systematic Overview and Meta-Analysis. JACC Heart Fail 2016; 4:237.
- Ojji D, Atherton J, Sliwa K, et al. Left Ventricular Systolic Dysfunction in Asymptomatic Black Hypertensive Subjects. Am J Hypertens 2015; 28:924.
- 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.
- Devereux RB, Roman MJ, Paranicas M, et al. A population-based assessment of left ventricular systolic dysfunction in middle-aged and older adults: the Strong Heart Study. Am Heart J 2001; 141:439.
- Davies M, Hobbs F, Davis R, et al. Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study. Lancet 2001; 358:439.
- 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.
- Ng LL, Loke IW, Davies JE, et al. Community screening for left ventricular systolic dysfunction using plasma and urinary natriuretic peptides. J Am Coll Cardiol 2005; 45:1043.
- McDonagh TA, Morrison CE, Lawrence A, et al. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet 1997; 350:829.
- Galasko GI, Barnes SC, Collinson P, et al. What is the most cost-effective strategy to screen for left ventricular systolic dysfunction: natriuretic peptides, the electrocardiogram, hand-held echocardiography, traditional echocardiography, or their combination? Eur Heart J 2006; 27:193.
- Cicala S, de Simone G, Roman MJ, et al. Prevalence and prognostic significance of wall-motion abnormalities in adults without clinically recognized cardiovascular disease: the Strong Heart Study. Circulation 2007; 116:143.
- Tsao CW, Gona P, Salton C, et al. Subclinical and clinical correlates of left ventricular wall motion abnormalities in the community. Am J Cardiol 2011; 107:949.
- Rouleau JL, Moyé LA, de Champlain J, et al. Activation of neurohumoral systems following acute myocardial infarction. Am J Cardiol 1991; 68:80D.
- Francis GS, Benedict C, Johnstone DE, et al. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation 1990; 82:1724.
- Rouleau JL, Packer M, Moyé L, et al. Prognostic value of neurohumoral activation in patients with an acute myocardial infarction: effect of captopril. J Am Coll Cardiol 1994; 24:583.
- Benedict CR, Shelton B, Johnstone DE, et al. Prognostic significance of plasma norepinephrine in patients with asymptomatic left ventricular dysfunction. SOLVD Investigators. Circulation 1996; 94:690.
- Tsutamoto T, Wada A, Maeda K, et al. Plasma brain natriuretic peptide level as a biochemical marker of morbidity and mortality in patients with asymptomatic or minimally symptomatic left ventricular dysfunction. Comparison with plasma angiotensin II and endothelin-1. Eur Heart J 1999; 20:1799.
- McDonagh TA, Robb SD, Murdoch DR, et al. Biochemical detection of left-ventricular systolic dysfunction. Lancet 1998; 351:9.
- 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.
- Nielsen OW, McDonagh TA, Robb SD, Dargie HJ. Retrospective analysis of the cost-effectiveness of using plasma brain natriuretic peptide in screening for left ventricular systolic dysfunction in the general population. J Am Coll Cardiol 2003; 41:113.
- Redfield MM, Rodeheffer RJ, Jacobsen SJ, et al. Plasma brain natriuretic peptide to detect preclinical ventricular systolic or diastolic dysfunction: a community-based study. Circulation 2004; 109:3176.
- Heidenreich PA, Gubens MA, Fonarow GC, et al. Cost-effectiveness of screening with B-type natriuretic peptide to identify patients with reduced left ventricular ejection fraction. J Am Coll Cardiol 2004; 43:1019.
- Ledwidge M, Gallagher J, Conlon C, et al. Natriuretic peptide-based screening and collaborative care for heart failure: the STOP-HF randomized trial. JAMA 2013; 310:66.
- Galasko GI, Lahiri A, Barnes SC, et al. What is the normal range for N-terminal pro-brain natriuretic peptide? How well does this normal range screen for cardiovascular disease? Eur Heart J 2005; 26:2269.
- Goetze JP, Mogelvang R, Maage L, et al. Plasma pro-B-type natriuretic peptide in the general population: screening for left ventricular hypertrophy and systolic dysfunction. Eur Heart J 2006; 27:3004.
- de Lemos JA, McGuire DK, Khera A, et al. Screening the population for left ventricular hypertrophy and left ventricular systolic dysfunction using natriuretic peptides: results from the Dallas Heart Study. Am Heart J 2009; 157:746.
- McMurray JV, McDonagh TA, Davie AP, et al. Should we screen for asymptomatic left ventricular dysfunction to prevent heart failure? Eur Heart J 1998; 19:842.
- Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557.
- Kannel WB. Need and prospects for prevention of cardiac failure. Eur J Clin Pharmacol 1996; 49 Suppl 1:S3.
- Kannel WB, D'Agostino RB, Silbershatz H, et al. Profile for estimating risk of heart failure. Arch Intern Med 1999; 159:1197.
- Kurt M, Shaikh KA, Peterson L, et al. Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort. J Am Coll Cardiol 2009; 53:802.
- Depressed left ventricular ejection fraction
- Wall motion abnormalities
- CLINICAL MANIFESTATIONS
- Symptoms and signs
- Test findings
- - Electrocardiogram
- - Natriuretic peptide levels
- Comparison of BNP and NT-proBNP
- DIAGNOSIS AND EVALUATION
- When to suspect asymptomatic left ventricular systolic dysfunction
- - Approach to identifying high-risk patients
- - No routine screening
- Approach to diagnosis
- Approach to evaluation
- Cardiac imaging for diagnosis and evaluation
- - Echocardiography
- - Other cardiac imaging
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS