What is the best medication for diastolic dysfunction?

From the Guidelines

The best approach to managing diastolic dysfunction involves a combination of medications including diuretics, beta-blockers, ACE inhibitors or ARBs, and calcium channel blockers, tailored to the patient's specific symptoms and underlying causes, with a focus on controlling blood pressure, heart rate, and reducing fluid overload. When considering the management of diastolic dysfunction, it's crucial to address the patient's overall clinical picture, including any comorbid conditions such as hypertension, diabetes, or coronary artery disease 1. The use of diuretics like furosemide (20-80mg daily) or hydrochlorothiazide (12.5-25mg daily) can help reduce fluid overload and alleviate symptoms of congestion, which is a common issue in patients with diastolic dysfunction 1. Beta-blockers, such as metoprolol (25-200mg daily) or carvedilol (3.125-25mg twice daily), are beneficial in lowering heart rate, thus allowing more time for ventricular filling, which can improve diastolic function 1. ACE inhibitors like lisinopril (5-40mg daily) or ARBs such as losartan (25-100mg daily) play a role in reducing afterload and may help prevent cardiac remodeling, which is important in the long-term management of diastolic dysfunction 1. Calcium channel blockers, including verapamil (120-360mg daily) or diltiazem (120-540mg daily), can improve ventricular relaxation, directly addressing the pathophysiology of diastolic dysfunction 1. It's also important to note that blood pressure control is crucial, with targets typically below 130/80 mmHg, and medication selection should be guided by the presence of comorbidities, with ACE inhibitors or ARBs preferred for patients with diabetes or kidney disease, and beta-blockers for those with prior heart attacks 1. Given the lack of controlled clinical trials specifically addressing diastolic dysfunction, the management principles outlined above are based on the available evidence and expert consensus, aiming to improve morbidity, mortality, and quality of life for these patients 1.

From the Research

Medications for Diastolic Dysfunction

The following medications have been studied for their effectiveness in treating diastolic dysfunction:

• Angiotensin converting enzyme inhibitors and angiotensin receptor blockers, which have been shown to improve measures of diastolic function 2
• Beta-blockers, calcium channel blockers, and diuretics, which have also shown some efficacy in improving indices of diastolic filling 2
• Aldosterone antagonists, such as spironolactone, which are being studied for their potential to reduce cardiovascular mortality and hospitalization for diastolic heart failure 2

Specific Studies

Several studies have investigated the effectiveness of specific medications for diastolic dysfunction, including:

• The Irbesartan in Heart Failure with Preserved Ejection Fraction (I-PRESERVE) study, which found no improvement in morbidity and mortality with irbesartan 2
• The Candesartan in Heart Failure: Assessment in Reduction of Mortality and Morbidity (CHARM-Preserved) trial, which found no reduction in cardiovascular death with candesartan, but did find a reduction in hospital admissions for heart failure 2, 3
• The Losartan Intervention For End-point Reduction in Hypertension (LIFE) Study, which found reduced heart failure hospitalization in hypertensive patients with normal in-treatment diastolic function 2
• The Trial Of Preserved Cardiac function heart failure with an Aldosterone anTagonist (TOPCAT), which is an ongoing study evaluating the effect of spironolactone on cardiovascular mortality and hospitalization for diastolic heart failure 2
• A study comparing the effect of diuretic or calcium-channel blocker plus angiotensin-receptor blocker on diastolic function in hypertensive patients, which found that both combinations improved left ventricular relaxation 4

Patient Populations

Diastolic dysfunction can occur in various patient populations, including:

• Patients with hypertension, who are at increased risk of developing diastolic dysfunction 2, 4
• Patients with diabetes mellitus, who are at increased risk of developing diastolic dysfunction due to poor glycemic control and other factors 3
• Patients with chronic heart failure, who may benefit from treatment with beta-blockers, such as metoprolol, which has been shown to reduce mortality and improve clinical status in patients with stable mild to moderate heart failure 5