From the Guidelines
Diastolic dysfunction is a significant cardiac condition that indicates the heart's inability to properly relax and fill with blood during the diastolic phase of the cardiac cycle, and its management is crucial to prevent progression to heart failure with preserved ejection fraction (HFpEF) and reduce morbidity and mortality. The significance of diastolic dysfunction lies in its association with increased morbidity, mortality, and progression to HFpEF. Patients with diastolic dysfunction commonly experience symptoms like shortness of breath, exercise intolerance, and fatigue due to increased filling pressures that can lead to pulmonary congestion.
Pathophysiology and Clinical Presentation
The pathophysiology involves impaired ventricular relaxation, increased myocardial stiffness, and abnormal ventricular-arterial coupling, often resulting from conditions that cause ventricular hypertrophy or fibrosis, as noted in the accf/aha 2009 expert consensus document 1.
Management and Treatment
Management typically involves treating underlying causes such as hypertension, diabetes, and coronary artery disease. Medications like angiotensin-converting enzyme inhibitors (e.g., lisinopril 10-40 mg daily), angiotensin receptor blockers (e.g., losartan 25-100 mg daily), and diuretics (e.g., furosemide 20-80 mg daily) are often prescribed to reduce blood pressure, decrease fluid overload, and improve symptoms, as recommended in the acc/aha 2005 guideline update for the diagnosis and management of chronic heart failure in the adult 1.
- Beta-blockers (e.g., metoprolol 25-200 mg daily) may help by allowing more time for ventricular filling.
- Lifestyle modifications including sodium restriction, weight management, regular physical activity, and smoking cessation are essential components of treatment. Early detection and management of diastolic dysfunction are crucial as it represents a significant risk factor for future cardiovascular events and progression to overt heart failure, as highlighted in the acc/aha guidelines for the evaluation and management of chronic heart failure in the adult: executive summary 1.
From the Research
Significance of Diastolic Dysfunction
The significance of diastolic dysfunction can be understood through its impact on heart health and overall mortality. Key points include:
- Diastolic dysfunction is a condition where the heart's ability to relax and fill during diastole is impaired, leading to increased end-diastolic pressure and pulmonary congestion 2, 3.
- It is a major cause of morbidity and mortality, especially in elderly patients with hypertensive heart disease 2, 3.
- The prognosis of diastolic heart failure is usually better than for systolic dysfunction, with a lower annual mortality rate of approximately 8% compared to 19% in heart failure with systolic dysfunction 2, 3.
Clinical Implications
Diastolic dysfunction has significant clinical implications, including:
- Exercise intolerance and symptomatic clinical heart failure, even in the presence of a normal ejection fraction 4.
- A higher risk of mortality, especially in asymptomatic community-based individuals with hypertension, coronary artery disease, and diabetes 4.
- Similar signs and symptoms to those of heart failure with systolic dysfunction, making diagnosis challenging 5.
Diagnosis and Treatment
Diagnosis and treatment of diastolic dysfunction involve:
- Doppler echocardiography as the most useful tool to routinely measure diastolic function 2, 5.
- Pharmacologic treatment focusing on normalizing blood pressure, promoting regression of left ventricular hypertrophy, avoiding tachycardia, and treating symptoms of congestion 5.
- Potential benefits of calcium channel blockers, beta-blockers, ACE-inhibitors, and ARB, as well as nitric oxide donors, although evidence from randomized controlled trials is limited 2, 3, 6, 5.