What is Diastolic Heart Failure?1

The diagnosis of diastolic heart failure is made when a patient presents with heart failure and normal left ventricular contractile performance. It stands in opposition to systolic heart failure, which is diagnosed when a patient presents with heart failure and reduced left ventricular contractile performance. Left ventricular contractile performance is frequently quantified by left ventricular ejection fraction (= ratio of left ventricular stroke volume over left ventricular end-diastolic volume; normal value > 50%). Diastolic heart failure is therefore also often called heart failure with normal ejection fraction (HFNEF) or heart failure with preserved ejection fraction (HFPEF).

 

Who Suffers from Diastolic Heart Failure?2

Patients with diastolic heart failure are usually older than patients with systolic heart failure (average age ± 72 years). At least two thirds of diastolic heart failure patients are women. Frequent comorbidities are overweight or obesity, arterial hypertension with a wide pulse pressure, metabolic syndrome and type 2 diabetes mellitus. In contrast to systolic heart failure, few patients with diastolic heart failure suffer of obstructive coronary artery disease. Diastolic heart failure is currently observed in 50% of heart failure patients and is prevalence relative to systolic heart failure is rising at an alarming rate of 1% annually.

The diagnosis of diastolic heart failure is more cumbersome than the diagnosis of systolic heart failure, which requires presence of symptoms of dyspnea, signs of fluid overload on physical examination and evidence of a reduced left ventricular ejection fraction. The diagnosis of diastolic heart failure requires more conditions to be satisfied: symptoms of dyspnea, signs of fluid overload, evidence of a normal left ventricular ejection fraction and presence of diastolic left ventricular dysfunction. Especially the latter is often difficult as measures of diastolic left ventricular function, such as left ventricular filling pressures during cardiac catheterization, Dopplerechocardiographic mitral flow velocity and mitral annular tissue Doppler relengthening velocity are all highly sensitive to the patient’s fluid status and normalize quickly after administration of diuretics. Natriuretic peptides are also not useful for the diagnosis of diastolic heart failure because of their low positive predictive value.

 

How to Treat Diastolic Heart Failure?3

In large randomised trials, comparable pharmacological agents such as angiotensin converting enzyme inhibitors, angiotensin receptor blockers and betablockers had contrasting efficacy on mortality and morbidity in patients with systolic and diastolic heart failure. Use of all three aforementioned agents had a positive outcome in systolic heart failure but a neutral outcome in diastolic heart failure. Current heart failure treatment guidelines therefore only recommend diuretics and antihypertensives for patients with diastolic heart failure.

 

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