Evaluation and management 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
Left ventricular (LV) systolic dysfunction with symptoms of heart failure (HF) is a common clinical problem. Population-based studies suggest that asymptomatic LV dysfunction is at least as prevalent as symptomatic HF in the general population. Structural heart disease without signs of symptoms of HF is defined as “stage B HF” in the American College of Cardiology Foundation/American Heart Association guidelines .
Patients with asymptomatic LV systolic dysfunction progress to overt HF over time. In the placebo arm of the SOLVD trial, patients with asymptomatic LV dysfunction not treated with an angiotensin converting enzyme inhibitor progressed to symptomatic HF at a rate of 9.7 percent per year . In addition, the mortality rate in patients with asymptomatic LV dysfunction is increased, although to a lesser degree than in symptomatic HF (figure 1). In the placebo arm of the SOLVD trial, the three-year mortality rate was 16 percent . (See 'Chronic LV systolic dysfunction' below.)
The management of patients with asymptomatic LV systolic dysfunction will be reviewed here. Issues related to the prevalence of and possible screening for asymptomatic LV systolic dysfunction and the management of symptomatic HF with reduced ejection fraction are presented separately. (See "Screening for asymptomatic left ventricular dysfunction" and "Overview of the therapy of heart failure with reduced ejection fraction".)
Asymptomatic LV diastolic dysfunction is also common and associated with an adverse prognosis . However, there are no data on the efficacy of treating diastolic dysfunction before the onset of symptoms. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Asymptomatic diastolic dysfunction'.)
By definition, patients with asymptomatic left ventricular (LV) dysfunction have no symptoms. The diagnosis is usually made by echocardiography performed because the patient might have underlying heart disease or cardiomegaly is detected on chest radiograph.
- 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.
- Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigattors. N Engl J Med 1992; 327:685.
- 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.
- Drazner MH, Rame JE, Dries DL. Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction. Am J Med 2003; 114:431.
- 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.
- Mahon NG, Murphy RT, MacRae CA, et al. Echocardiographic evaluation in asymptomatic relatives of patients with dilated cardiomyopathy reveals preclinical disease. Ann Intern Med 2005; 143:108.
- Burkett EL, Hershberger RE. Clinical and genetic issues in familial dilated cardiomyopathy. J Am Coll Cardiol 2005; 45:969.
- Schillaci G, Vaudo G, Pasqualini L, et al. Left ventricular mass and systolic dysfunction in essential hypertension. J Hum Hypertens 2002; 16:117.
- Klingbeil AU, Schneider M, Martus P, et al. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med 2003; 115:41.
- Dahlöf B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359:995.
- Sutton MG, Sharpe N. Left ventricular remodeling after myocardial infarction: pathophysiology and therapy. Circulation 2000; 101:2981.
- Cohn JN, Ferrari R, Sharpe N. Cardiac remodeling--concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling. Behalf of an International Forum on Cardiac Remodeling. J Am Coll Cardiol 2000; 35:569.
- Mitchell GF, Lamas GA, Vaughan DE, Pfeffer MA. Left ventricular remodeling in the year after first anterior myocardial infarction: a quantitative analysis of contractile segment lengths and ventricular shape. J Am Coll Cardiol 1992; 19:1136.
- Lamas GA, Vaughan DE, Parisi AF, Pfeffer MA. Effects of left ventricular shape and captopril therapy on exercise capacity after anterior wall acute myocardial infarction. Am J Cardiol 1989; 63:1167.
- Sharpe N, Smith H, Murphy J, et al. Early prevention of left ventricular dysfunction after myocardial infarction with angiotensin-converting-enzyme inhibition. Lancet 1991; 337:872.
- Doughty RN, Whalley GA, Gamble G, et al. Left ventricular remodeling with carvedilol in patients with congestive heart failure due to ischemic heart disease. Australia-New Zealand Heart Failure Research Collaborative Group. J Am Coll Cardiol 1997; 29:1060.
- Pfeffer MA, Braunwald E, Moyé 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.
- Køber 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.
- Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet 2001; 357:1385.
- 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.
- 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.
- Torp-Pedersen C, Køber L. Effect of ACE inhibitor trandolapril on life expectancy of patients with reduced left-ventricular function after acute myocardial infarction. TRACE Study Group. Trandolapril Cardiac Evaluation. Lancet 1999; 354:9.
- Ambrosioni E, Borghi C, Magnani B. The effect of the angiotensin-converting-enzyme inhibitor zofenopril on mortality and morbidity after anterior myocardial infarction. The Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study Investigators. N Engl J Med 1995; 332:80.
- de Kam PJ, Voors AA, van den Berg MP, et al. Effect of very early angiotensin-converting enzyme inhibition on left ventricular dilation after myocardial infarction in patients receiving thrombolysis: results of a meta-analysis of 845 patients. FAMIS, CAPTIN and CATS Investigators. J Am Coll Cardiol 2000; 36:2047.
- Shlipak MG, Browner WS, Noguchi H, et al. Comparison of the effects of angiotensin converting-enzyme inhibitors and beta blockers on survival in elderly patients with reduced left ventricular function after myocardial infarction. Am J Med 2001; 110:425.
- Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997; 336:525.
- Kjøller-Hansen L, Steffensen R, Grande P. The Angiotensin-converting Enzyme Inhibition Post Revascularization Study (APRES). J Am Coll Cardiol 2000; 35:881.
- Kjøller-Hansen L, Steffensen R, Grande P. Beneficial effects of ramipril on left ventricular end-diastolic and end-systolic volume indexes after uncomplicated invasive revascularization are associated with a reduction in cardiac events in patients with moderately impaired left ventricular function and no clinical heart failure. J Am Coll Cardiol 2001; 37:1214.
- 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.
- Kleber FX, Niemöller L, Doering W. Impact of converting enzyme inhibition on progression of chronic heart failure: results of the Munich Mild Heart Failure Trial. Br Heart J 1992; 67:289.
- 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.
- Shekelle PG, Rich MW, Morton SC, et al. Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials. J Am Coll Cardiol 2003; 41:1529.
- Dries DL, Exner DV, Gersh BJ, et al. Racial differences in the outcome of left ventricular dysfunction. N Engl J Med 1999; 340:609.
- Exner DV, Dries DL, Domanski MJ, Cohn JN. Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl J Med 2001; 344:1351.
- Dries DL, Strong MH, Cooper RS, Drazner MH. Efficacy of angiotensin-converting enzyme inhibition in reducing progression from asymptomatic left ventricular dysfunction to symptomatic heart failure in black and white patients. J Am Coll Cardiol 2002; 40:311.
- Kermani M, Dua A, Gradman AH. Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction. Am J Cardiol 2000; 86:644.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- CLINICAL FEATURES
- Neurohumoral activation
- Familial disease
- - ACE inhibitors
- - Acute anterior MI
- - Beta blockers
- - Elderly
- - Other medications
- Chronic LV systolic dysfunction
- - ACE inhibitors
- - Beta blockers
- Influence of gender
- Influence of race
- ARRHYTHMIA MANAGEMENT
- Threshold for therapy
- Post-MI or revascularization
- - ACE inhibitors
- - Beta blockers
- Chronic LV systolic dysfunction
- Risk factor modification
- Other therapies