Therapy for Diastolic Heart Failure

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There is little objective to guide the therapy of patients with diastolic heart failure. Beacuse of the similarities of pathophysiology abnormalities in diastolic and systolic heart failure, it is a reasonable inference to suggest that the proven therapy for systolic heart failure may also be of benefit in patients with diastolic heart failure. Treatment of underlying or exacerbating conditions in diastolic heart failure, such as hypertension, left ventricular hypertrophy, ischemia, diabetes, anemia, obesity and pulmonary disease is an important means of managing diastolic heart failure. Control of systolic blood pressure is effective in improving and preventing the development of diastolic heart failure. Treament of diastolic heart failure is most effective when it is associated with hypertension. Production of systolic arterial pressure acutely reduces pulmonary congestion, ischemia, and chronically may lead to regression of left ventricular hypertrophy. Patients with diastolic heart failure in the absence of hypertension are very difficult to treat.

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Treatment Based on Studies of Heart Failure and Reduced Ejection Fraction

There is a substantial body of evidence to guide therapy of patients with HF and a reduced (<0.40) ejection fraction. These studies clearly demonstrate an improvement in survival and symptomatic status in patients who are treated with ACE inhibitors and in patients who are treated with the β-adrenergic blocking agents, metoprolol, bisoprolol, and carvedilol.6, 8

Because the pathophysiological abnormalities in patients with diastolic and systolic HF are similar,9, 10 it is a reasonable inference

Treatment Strategies

Based on the pathophysiology and causes of diastolic dysfunction, there are several potential treatment strategies that may be effective in treating patients with HF caused by diastolic dysfunction.4

Drugs

The drugs that have been suggested for treating primary diastolic dysfunction include diuretics and nitrates, β-adrenergic blockers, calcium-entry blockers, and ACE inhibitors and ARB and aldosterone antagonists.6 The effects from these drugs can be classified as direct cardiac effects and indirect (noncardiac) effects4 (Table 2).

Improving Exercise Intolerance

Many elderly subjects and patients with hypertension or LV hypertrophy have Doppler echocardiographic evidence of impaired diastolic function but do not have symptoms of HF at rest.49, 50, 51 The ability to increase the cardiac output during exercise without an abnormal elevation in left atrial pressure depends on the capacity of the left ventricle to enhance its diastolic filling.52 Thus, diastolic dysfunction may limit exercise tolerance before resulting in symptoms at rest.9

Elevated systolic

Conclusion

Treatment of diastolic HF is most effective when it is associated with hypertension. Reduction of systolic arterial pressures acutely reduces pulmonary congestion and ischemia and chronically may lead to regression of LV hypertrophy. Patients with diastolic HF in the absence of hypertension are very difficult to treat. They are prone to develop severe hypotension in response to diuretics or nitrates.

References (62)

  • C.H. Chen et al.

    Verapamil acutely reduces ventricular-vascular stiffening and improves aerobic exercise performance in elderly individuals

    J. Am. Coll. Cardiol.

    (1999)
  • J.F. Setaro et al.

    Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance

    Am. J. Cardiol.

    (1990)
  • R.A. Nishimura et al.

    Failure of calcium channel blockers to improve ventricular relaxation in humans

    J. Am. Coll. Cardiol.

    (1993)
  • J.G. Warner et al.

    Losartan improves exercise tolerance in patients with diastolic dysfunction and a hypertensive response to exercise

    J. Am. Coll. Cardiol.

    (1999)
  • S.K. Gandhi et al.

    The pathogenesis of acute pulmonary edema associated with hypertension

    N. Engl. J. Med.

    (2001)
  • W. Grossman

    Defining diastolic dysfunction

    Circulation

    (2000)
  • M.R. Zile et al.

    New concepts in diastolic dysfunction and diastolic heart failure. Part I: Diagnosis, prognosis, and measurement of diastolic function

    Circulation

    (2002)
  • W.C. Little et al.

    Treatment of heart failure due to diastolic dysfunction

    Contemp. Treat. Cardiovas. Dis.

    (1997)
  • W.C. Little

    Hypertensive pulmonary oedema is due to diastolic dysfunction

    Eur. Heart J.

    (2001)
  • The Task Force of the Working Group on Heart Failure: The treatment of heart failure. Task Force of the Working Group on Heart Failure of the European Society of Cardiology

    Eur. Heart J.

    (1997)
  • M. Jessup et al.

    Heart failure

    N. Engl. J. Med.

    (2003)
  • D.W. Kitzman et al.

    Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure

    JAMA

    (2002)
  • B.G. Angeja et al.

    Evaluation and management of diastolic heart failure

    Circulation

    (2003)
  • G. Wells et al.

    Therapy of diastolic dysfunction in hypertension and hypertrophic cardiomyopathy

  • R.S. Vasan et al.

    Diastolic heart failure—no time to relax

    N. Engl. J. Med.

    (2001)
  • M. Kawaguchi et al.

    Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: Implications for systolic and diastolic reserve limitations

    Circulation

    (2003)
  • W.C. Little et al.

    Determination of left ventricular chamber stiffness from the time for deceleration of early left ventricular filling

    Circulation

    (1995)
  • K. Wachtell et al.

    Change in diastolic left ventricular filling after one year of antihypertensive treatment

    Circulation

    (2002)
  • R.B. Devereux et al.

    Effects of once-daily angiotensin-converting enzyme inhibition and calcium channel blockade–based antihypertensive treatment regimens on left ventricular hypertrophy and diastolic filling in hypertension: The Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement (PRESERVE) Trial

    Circulation

    (2001)
  • W.F. Terpstra et al.

    Long-term effects on amlodipine and lisinopril on left ventricular mass and diastolic function in elderly, previously untreated hypertensive patients: The ELVERA trial

    J. Hypertens.

    (2001)
  • J.B. Kostis et al.

    Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group

    JAMA

    (1997)
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