What is combined diastolic and systolic heart failure?

Combined Diastolic and Systolic Heart Failure

Combined diastolic and systolic heart failure is a clinical syndrome where patients exhibit both impaired left ventricular contractility (reduced ejection fraction) and abnormal ventricular relaxation/compliance (diastolic dysfunction), resulting in elevated filling pressures and reduced cardiac output. 1

Definition and Clinical Recognition

This condition represents the coexistence of both systolic dysfunction (reduced ejection fraction) and diastolic dysfunction (impaired relaxation and reduced compliance) in the same patient. 1

The ACC/AHA formally recognizes this entity with specific ICD-9-CM diagnostic codes:

• 428.40: Unspecified combined systolic and diastolic heart failure 1
• 428.41: Acute combined systolic and diastolic heart failure 1
• 428.42: Chronic combined systolic and diastolic heart failure 1
• 428.43: Acute or chronic combined systolic and diastolic heart failure 1

Pathophysiology

Combined heart failure involves dual mechanisms of cardiac dysfunction:

• Systolic component: Impaired contractility leads to reduced ejection fraction and decreased cardiac output 2
• Diastolic component: Impaired ventricular relaxation and reduced compliance cause elevated filling pressures, leading to pulmonary congestion 1, 3
• The hemodynamic consequences include both reduced forward flow and elevated backward pressures, creating a particularly challenging clinical scenario 1, 4

Diagnostic Approach

Diagnosis requires demonstrating both reduced ejection fraction (typically <40-50%) AND evidence of diastolic dysfunction with elevated filling pressures. 3, 5

Key diagnostic elements include:

• Echocardiography showing reduced LVEF with evidence of diastolic dysfunction (E/E' ratio, transmitral flow patterns) 5
• Clinical signs and symptoms of heart failure (dyspnea, fatigue, pulmonary congestion) 1, 3
• Elevated natriuretic peptides (though these cannot distinguish between systolic and diastolic components) 6

Treatment Strategy

Management of combined heart failure requires addressing both systolic and diastolic dysfunction simultaneously, which creates unique therapeutic challenges. 2

Neurohormonal Blockade (Systolic Component)

• ACE inhibitors or ARBs are first-line therapy to improve survival and can also improve relaxation and cardiac compliance 2, 3
• Beta-blockers are essential for improving survival in systolic dysfunction while also controlling heart rate to optimize diastolic filling time 2, 3
• Aldosterone antagonists improve survival in advanced systolic heart failure and may reduce myocardial fibrosis 2, 6

Diastolic Optimization

• Blood pressure control is paramount, with targets potentially <130/80 mmHg 2, 3
• Heart rate control is critical to prolong diastolic filling time, making beta-blockers particularly valuable 2, 3
• Diuretics must be used judiciously to reduce congestion without causing excessive preload reduction that could compromise cardiac output 2, 3

Critical Pitfalls

The major therapeutic challenge is that aggressive diuresis (needed for diastolic dysfunction) can worsen cardiac output (already compromised by systolic dysfunction). 2, 6

• Avoid excessive volume depletion, as these patients are preload-dependent despite elevated filling pressures 3, 7
• Positive inotropes may worsen diastolic dysfunction despite improving systolic function 2
• Maintain sinus rhythm when possible, as atrial contribution to ventricular filling is crucial 2, 8

Prognosis

Combined systolic and diastolic heart failure typically carries a worse prognosis than isolated diastolic dysfunction, with mortality rates approaching those of pure systolic heart failure. 4, 6

• Annual mortality for diastolic heart failure alone is approximately 8%, compared to 19% for systolic dysfunction 4
• Combined dysfunction likely approaches the higher mortality rates given the dual pathophysiology 4, 6
• Morbidity remains substantial with frequent hospitalizations for clinical stabilization 3, 6

Management of Comorbidities

Aggressive treatment of underlying conditions is essential:

• Coronary artery disease requires revascularization when appropriate 2
• Hypertension must be aggressively controlled 2, 7
• Atrial fibrillation requires rate control and anticoagulation consideration 2
• Diabetes requires tight glycemic control to prevent further cardiac damage 2