Combined Systolic and Diastolic Heart Failure
Yes, congestive heart failure (CHF) can be both systolic and diastolic simultaneously, and in fact, most patients with heart failure have evidence of both systolic and diastolic dysfunction. 1
Understanding Systolic and Diastolic Heart Failure
Heart failure is a clinical syndrome characterized by typical symptoms (breathlessness, fatigue, ankle swelling) and signs (tachycardia, pulmonary rales, elevated jugular venous pressure) resulting from cardiac dysfunction.
The relationship between systolic and diastolic dysfunction:
Systolic heart failure: Characterized by reduced left ventricular ejection fraction (LVEF) typically <40%, resulting in impaired contractility and reduced cardiac output.
Diastolic heart failure: Characterized by preserved LVEF (typically >40-50%) but impaired ventricular filling due to abnormal relaxation, increased stiffness, or external compression.
Combined dysfunction: According to European Society of Cardiology guidelines, "Most patients with HF have evidence of both systolic and diastolic dysfunction at rest or on exercise. Diastolic and systolic HFs should not be considered as separate entities." 1
Prevalence and Clinical Significance
The coexistence of systolic and diastolic dysfunction is extremely common:
While heart failure is often categorized as either heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF), this distinction is somewhat arbitrary 1
Even patients with predominantly systolic dysfunction typically have some degree of diastolic impairment 2
Similarly, patients with primarily diastolic dysfunction may develop some systolic impairment, especially during exercise or with disease progression
Diagnostic Considerations
When evaluating for combined systolic and diastolic dysfunction:
Echocardiography is the primary diagnostic tool, assessing both:
- Systolic function: LVEF, stroke volume, wall motion
- Diastolic function: E/A ratio, deceleration time, tissue Doppler imaging
Clinical presentation may include features of both types:
- Reduced exercise capacity and fatigue (common in systolic dysfunction)
- Dyspnea and pulmonary congestion (prominent in diastolic dysfunction)
Treatment Implications
The management approach for combined systolic and diastolic dysfunction requires addressing both components:
For the systolic component:
- ACE inhibitors/ARBs/ARNI
- Beta-blockers
- Mineralocorticoid receptor antagonists
- SGLT2 inhibitors
For the diastolic component:
- Control of blood pressure
- Heart rate management (particularly with beta-blockers)
- Diuretics for volume overload (used cautiously)
- Treatment of underlying causes (hypertension, ischemia)
Common Pitfalls and Caveats
Diagnostic oversimplification: Classifying patients as having purely systolic or purely diastolic heart failure may lead to incomplete treatment approaches.
Therapeutic challenges: Combined dysfunction may require careful balancing of medications that improve systolic function without worsening diastolic properties.
Prognostic implications: Combined systolic and diastolic dysfunction may carry worse outcomes than either alone, requiring more aggressive management.
Age considerations: Combined dysfunction is particularly common in elderly patients, where age-related changes affect both systolic and diastolic properties 1.
In clinical practice, it's important to recognize that the systolic-diastolic dichotomy is an oversimplification, and a comprehensive approach addressing both components of cardiac function will likely yield better outcomes for most heart failure patients.