What are the treatment recommendations for diastolic heart failure?

Treatment Recommendations for Diastolic Heart Failure

For patients with diastolic heart failure, treatment should focus on controlling blood pressure, heart rate, reducing central blood volume, and alleviating myocardial ischemia, as these are the primary mechanisms to improve outcomes. 1

Underlying Causes and General Approach

• Identify and treat underlying causes of diastolic dysfunction, including coronary artery disease, hypertension, and other contributing factors 2
• Correct precipitating factors such as anemia, infections, obesity, and excessive alcohol intake 2
• Target blood pressure control to levels potentially lower than for uncomplicated hypertension (<130/80 mmHg) 1
• Encourage moderate dynamic exercise (walking, recreational biking) while discouraging intense physical exertion and isometric exercises 2

Pharmacological Management

First-Line Therapies

• Beta-blockers to lower heart rate and increase diastolic filling period, allowing more time for ventricular filling 2, 1
• ACE inhibitors to improve relaxation and cardiac distensibility directly, with potential long-term effects through regression of hypertrophy and blood pressure reduction 3, 2
• Diuretics when fluid overload is present, but used cautiously to avoid excessive preload reduction which could compromise cardiac output 3

Second-Line Therapies

• Verapamil-type calcium antagonists may be beneficial to lower heart rate and increase diastolic period, with some studies showing functional improvement in patients with hypertrophic cardiomyopathy 3, 2
• Nitrates to reduce symptoms by lowering elevated filling pressures 2
• Angiotensin receptor blockers (ARBs) may be considered in patients intolerant to ACE inhibitors 3

Management of Common Comorbidities

Atrial Fibrillation

• Control ventricular rate with drugs that suppress AV conduction 2
• Consider anticoagulation in patients with atrial fibrillation or previous systemic/pulmonary embolism 2
• For persistent atrial fibrillation, electrical cardioversion should be considered, though success depends on duration of atrial fibrillation and left atrial size 3
• In permanent atrial fibrillation, rate control is mandatory; in asymptomatic patients, beta-blockade, digitalis glycosides or combination may be used 3

Hypertension

• Optimize dose of ACE inhibitors, beta-blockers, and diuretics 3
• Add spironolactone or ARBs if not already present 3
• If unsuccessful, try second-generation dihydropyridine derivatives 3

Coronary Artery Disease

• Optimize existing therapy, especially beta-blockade 3
• Consider coronary revascularization 3
• Add long-acting nitrates 3
• If unsuccessful, add second-generation dihydropyridine derivatives 3

Special Considerations

• Avoid drugs with positive inotropic effects as systolic function is generally normal or near normal in diastolic dysfunction 2
• Elderly patients require more cautious therapy with reduced dosages due to altered pharmacokinetics 2
• Monitor for hypotension, especially when initiating diuretics, as patients with diastolic dysfunction are prone to develop hypotension 2
• Moderate salt restriction (no more than 5 g/day) is recommended rather than strict reduction 4
• Consider fluid restriction of 1.5-2 L/day only in selected patients 4

Monitoring and Follow-up

• Carefully assess for progression to more advanced grades of diastolic dysfunction, which may require adjustment of therapy 2
• Consider diastolic stress testing when resting echocardiography does not explain symptoms of dyspnea, especially with exertion 2
• Monitor renal function, especially in elderly patients and those on multiple medications 2

Pitfalls to Avoid

• Excessive diuresis can reduce preload excessively and thereby reduce stroke volume and cardiac output 3
• Combining ACE inhibitors with ARBs is not recommended 3
• Avoid tachycardia as it reduces diastolic filling time 1
• Be cautious with vasodilators in patients with severe outflow tract obstruction 5