Combined Ventricular Systolic and Diastolic Dysfunction
It is not uncommon for chronic heart failure to have a combination of both systolic and diastolic dysfunction. Therefore, the slope of the end-systolic pressure-volume relationship (ESPVR) is decreased and the slope of the passive filling curve (reciprocal of compliance) is increased in the ventricular pressure-volume loop shown to the right. When this occurs, there is a dramatic reduction in stroke volume (width of pressure-volume loop) because end-systolic volume is increased and end-diastolic volume is decreased. Both ejection fraction and stroke work are also decreased.
The changes shown in the figure assume that heart rate and systemic vascular resistance are both unchanged; however, in patients, both parameters will probably be increased because of neurohumoral activation in response to heart failure.
This combination of systolic and diastolic dysfunction, coupled with compensatory volume expansion, can lead to very high left ventricular end-diastolic pressures that can cause pulmonary congestion and edema. This can lead to systemic edema and ascites, particularly when the right ventricle begins to fail.