From the Guidelines
Diastolic heart failure treatment should focus on managing symptoms, controlling blood pressure, and addressing underlying causes, with first-line medications including diuretics, ACE inhibitors, and beta-blockers, as recommended by the ACC/AHA guidelines 1. The primary goal of treatment is to improve symptoms, reduce morbidity, and enhance quality of life.
- Controlling systolic and diastolic hypertension is crucial, in accordance with published guidelines, to prevent further cardiac damage and improve diastolic function 1.
- Diuretics, such as furosemide (20-80mg daily) or hydrochlorothiazide (12.5-25mg daily), are used to control pulmonary congestion and peripheral edema, reducing fluid overload and relieving symptoms such as shortness of breath and edema 1.
- ACE inhibitors, like lisinopril (10-40mg daily), or ARBs, like losartan (25-100mg daily), are essential for blood pressure control and to minimize symptoms of heart failure 1.
- Beta-blockers, such as metoprolol (25-200mg daily), help reduce heart rate, allowing more time for ventricular filling, and are particularly important for patients with atrial fibrillation, where rate control is crucial 1.
- Lifestyle modifications, including sodium restriction (<2g daily), regular moderate exercise, weight management, and smoking cessation, are vital to improve overall cardiovascular health and reduce symptoms.
- Treating underlying conditions, such as hypertension, diabetes, and coronary artery disease, is essential to prevent further cardiac damage and improve outcomes. The use of digitalis to minimize symptoms of heart failure is not well established, and its use should be approached with caution 1. Overall, the treatment of diastolic heart failure requires a comprehensive approach, addressing both the underlying causes and the symptoms, to improve quality of life and reduce morbidity and mortality.
From the FDA Drug Label
Lisinopril had similar blood pressure reductions and adverse effects in younger and older (> 65 years) patients. In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention In one of the studies, the combination of lisinopril, digitalis and diuretics reduced orthopnea, presence of third heart sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance.
The treatment for diastolic heart failure may include lisinopril, as it has been shown to reduce signs and symptoms of heart failure, such as edema and rales, when combined with digitalis and diuretics 2.
- Lisinopril can help reduce blood pressure and improve exercise tolerance in patients with heart failure.
- However, the use of lisinopril in diastolic heart failure should be approached with caution, as the evidence is not as strong as it is for systolic heart failure.
- Ivabradine has been shown to reduce the risk of hospitalization for worsening heart failure in patients with systolic heart failure, but its effectiveness in diastolic heart failure is not directly addressed in the provided drug label 3.
From the Research
Diastolic Heart Failure Treatment
- The treatment of diastolic heart failure should be targeted at symptoms, causal clinical disease, and underlying basic mechanisms 4.
- Symptom-targeted therapy includes:
- Decreasing pulmonary venous pressure using diuretics and long-acting nitrates
- Maintaining atrial contraction and atrial ventricular synchrony
- Reducing heart rate using beta-adrenergic blockers and calcium channel blockers
- Increasing exercise tolerance by reducing exercise-induced increases in blood pressure and heart rate using angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and calcium channel blockers 4
- Disease-targeted therapy includes:
- Preventing or treating myocardial ischemia
- Preventing or regressing left ventricular hypertrophy 4
- Mechanism-targeted therapy (future directions) includes:
- Modifying neurohumoral activation using renin, angiotensin, and aldosterone system antagonists (ACE inhibitors, angiotensin II receptor blockade, aldosterone and renin antagonist)
- Using endothelin antagonists, nitric oxide agonists, and atrial natriuretic peptide agonists
- Altering intracellular mechanisms and extracellular matrix structures 4
Management of Diastolic Heart Failure
- The management of diastolic heart failure should include:
- Antihypertensive treatment
- Maintenance of the sinus rhythm
- Prevention of tachycardia
- Venous pressure reduction
- Prevention of myocardial ischemia and prevention of diabetes mellitus 5
- The European Society of Cardiology specifies the type of therapy in diastolic heart failure based on:
- Angiotensin converting enzyme inhibitors
- Angiotensin receptor blockers
- Beta-blockers
- Non-dihydropyridine calcium channel blockers
- Diuretics 5
Pharmacologic Treatment of Diastolic Heart Failure
- The pharmacologic treatment of diastolic heart failure should focus on:
- Normalizing blood pressure
- Promoting regression of left ventricular hypertrophy
- Avoiding tachycardia
- Treating symptoms of congestion
- Maintaining normal atrial contraction when possible 6
- Diuretic therapy is the mainstay of treatment for preventing pulmonary congestion, while beta blockers appear to be useful in preventing tachycardia and thereby prolonging left ventricular diastolic filling time 6
- Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers may be beneficial in patients with diastolic dysfunction, especially those with hypertension 6
Role of Angiotensin II Receptor Antagonists
- Angiotensin II receptor antagonists have haemodynamic effects similar to ACE inhibitors, but differ in their mechanism of action and certain adverse effects 7
- These agents may be useful in patients with heart failure who are intolerant of ACE inhibitors, but their use as first-line therapy is not recommended 7
Current and Future Treatment Options
- Heart failure with preserved ejection fraction (HFpEF), often referred to as diastolic heart failure, remains one of the more challenging forms of heart failure to treat 8
- Current treatments are aimed more towards associated conditions, such as hypertension, rather than the underlying pathophysiology 8
- Ongoing clinical trials may provide new insights into the treatment of diastolic heart failure and improve patient outcomes 8