Therapy for Diastolic Heart Failure
Section snippets
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.
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