What are the implications of Grade 2 diastolic dysfunction (diastolic heart failure)?

From the Guidelines

Grade 2 diastolic dysfunction is a moderate stage of left ventricular diastolic dysfunction that requires management of underlying causes and carries increased risk for progression to heart failure with preserved ejection fraction. The management of Grade 2 diastolic dysfunction typically involves controlling systolic and diastolic hypertension, in accordance with published guidelines, as recommended by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines 1.

• Treatment often includes blood pressure control with medications like ACE inhibitors (e.g., lisinopril 10-40 mg daily), ARBs (e.g., losartan 25-100 mg daily), or calcium channel blockers (e.g., amlodipine 5-10 mg daily) to minimize symptoms of heart failure 2.
• Diuretics such as furosemide (20-80 mg daily) may be needed to manage fluid overload and symptoms.
• Lifestyle modifications are essential, including sodium restriction (<2g daily), regular moderate exercise, weight management, and smoking cessation.
• Blood pressure should be maintained below 130/80 mmHg. Grade 2 diastolic dysfunction is diagnosed when the E/A ratio (early to late ventricular filling ratio) appears normal (1-1.5) but other parameters like tissue Doppler and pulmonary vein flow reveal abnormalities, as indicated by echocardiographic abnormalities in patients with heart failure 3. This stage carries increased risk for progression to heart failure with preserved ejection fraction, so regular cardiac follow-up every 3-6 months is recommended to monitor for symptom development or disease progression. The morbidity and mortality associated with heart failure and a relatively preserved left ventricular ejection fraction may be nearly as profound as that with low left ventricular ejection fraction, with frequent and repeated hospitalizations characterizing the patient with heart failure and a normal left ventricular ejection fraction 1, 2.

From the Research

Implications of Grade 2 Diastolic Dysfunction

The implications of Grade 2 diastolic dysfunction, also known as diastolic heart failure, are significant and can lead to increased cardiovascular morbidity and mortality. Some of the key implications include:

• Increased risk of heart failure, with 40% of patients with hypertension developing heart failure 4
• Association with increased cardiovascular morbidity and mortality 5
• Decreased left ventricular compliance and relaxation, leading to abnormal left ventricular diastolic function 6
• Interplay with atrial fibrillation, which can cause, exacerbate, or be a direct result of diastolic dysfunction 7
• Increased risk of hospitalization for heart failure, particularly in patients with hypertension 5

Treatment and Management

The treatment and management of diastolic dysfunction are crucial in preventing the progression to heart failure. Some of the key treatment strategies include:

• Angiotensin converting enzyme inhibitors and angiotensin receptor blockers to improve diastolic function 5
• Beta-blockers, calcium channel blockers, and diuretics to improve indices of diastolic filling 5
• Normalizing blood pressure to prevent tachycardia and promote regression of left ventricular hypertrophy 6
• Addressing comorbidities and providing pharmacological interventions targeting rate and rhythm control 7

Prognosis and Outcome

The prognosis and outcome of diastolic dysfunction are not well understood, and further research is needed to clarify the independent impact of pharmacologic interventions on prognosis and outcome. However, some studies have shown that:

• The Irbesartan in Heart Failure with Preserved Ejection Fraction (I-PRESERVE) study, Candesartan in Heart Failure: Assessment in Reduction of Mortality and Morbidity (CHARM-Preserved) trial, and the Losartan Intervention For End-point Reduction in Hypertension (LIFE) Study failed to show improved morbidity and mortality with these drugs 5
• The Trial Of Preserved Cardiac function heart failure with an Aldosterone anTagonist (TOPCAT) is an ongoing study evaluating the effect of spironolactone on cardiovascular mortality, aborted cardiac arrest, or hospitalization for diastolic heart failure 5