What is the management of diastolic dysfunction?

Management of Diastolic Dysfunction

The management of diastolic dysfunction should focus on controlling underlying conditions, particularly hypertension, while using appropriate medications including ACE inhibitors/ARBs, beta-blockers, and cautious diuretic therapy to improve symptoms and quality of life. 1

Pharmacological Management

First-line Medications

• Antihypertensive Therapy

  • Control of systolic and diastolic hypertension is a Class I recommendation (Level of Evidence: A) 2
  • Target blood pressure should be <140/90 mmHg for most patients, and <130/80 mmHg in patients with diabetes or chronic kidney disease 1
  • Individualized systolic BP targets should aim for 130 mmHg and, if well tolerated, <130 mmHg, but not <120 mmHg 1

• ACE Inhibitors/ARBs

  • Improve relaxation and cardiac distensibility
  • Promote regression of left ventricular hypertrophy
  • First-line agents despite large trials (I-PRESERVE and CHARM-Preserved) failing to show mortality benefits 1

• Beta-blockers

  • Particularly beneficial when tachycardia is present
  • Lower heart rate and increase diastolic filling period
  • Recommended as Class I evidence 1

Additional Medications

• Diuretics

  • Use cautiously with low initial doses for fluid overload
  • Avoid excessive preload reduction which can worsen symptoms
  • Class IIa recommendation 1

• Calcium Channel Blockers

  • Verapamil-type agents may improve relaxation
  • Particularly useful in hypertrophic cardiomyopathy
  • Class IIb recommendation 1

• Aldosterone Antagonists

  • Low-dose spironolactone (12.5-25 mg daily) should be considered in severe diastolic dysfunction
  • Class IIa recommendation 1

Special Considerations

Comorbid Conditions

• Coronary Artery Disease

  • Nitrates and beta-blockers (with diuretics) for angina (Class I, Level B) 2
  • Coronary revascularization for patients with both heart failure and angina (Class I, Level A) 2
  • Consider revascularization when ischemia negatively affects diastolic function (Class IIa) 1

• Atrial Fibrillation

  • Anticoagulation is indicated (Class I recommendation) 2, 1
  • Control ventricular response with beta-blockers or amiodarone if beta-blockers are contraindicated (Class I, Level A) 2
  • Digitalis can be used to control ventricular response (Class IIa, Level A) 2

Medications to Avoid

• Positive inotropic drugs should be avoided in the absence of systolic dysfunction (Class III) 1
• NSAIDs, COX-2 inhibitors
• Class I antiarrhythmic agents
• Short-acting dihydropyridines
• Tricyclic antidepressants
• Corticosteroids 1

Lifestyle Modifications

• Sodium Restriction

  • Moderate sodium restriction, especially in advanced heart failure 1

• Fluid Management

  • Daily weight measurements to monitor fluid status 1

• Physical Activity

  • Regular aerobic exercise should be encouraged, except during periods of acute decompensation
  • Avoid heavy labor or exhaustive sports 1

• Alcohol Intake

  • Moderate alcohol intake is allowed, except in alcoholic cardiomyopathy 1

Monitoring and Follow-up

• Regular evaluation of symptoms and treatment efficacy
• Monitor for medication side effects
• Assessment of volume status to guide diuretic therapy
• Surveillance for progression to systolic dysfunction 1

Clinical Pearls and Pitfalls

• Diastolic dysfunction has a particularly high prevalence in elderly patients, especially women with hypertension 1, 3
• Prognosis is generally better than systolic heart failure (annual mortality 8% vs 19%), but morbidity remains substantial 1
• Pure diastolic dysfunction may be rare, often occurring with some degree of systolic dysfunction 1
• Aggressive diuresis should be avoided as it can decrease stroke volume more in diastolic dysfunction than in systolic dysfunction 4
• Treatment recommendations are largely based on therapeutic principles rather than definitive evidence, due to limited data from controlled trials 1