Is a decrease in force of heartbeat a normal progression at 73 with a history of diastolic dysfunction and past PE with PAH?

Decreased Force of Heartbeat at Age 73 with Diastolic Dysfunction and Prior PE/PAH

Yes, a diminished "force of heartbeat" sensation is a normal age-related progression at 73, particularly with Grade 1 diastolic dysfunction, and does not necessarily indicate worsening cardiac pathology. 1, 2

Age-Related Cardiac Changes

The cardiovascular system undergoes predictable structural and functional changes with aging that directly explain your patient's perception:

• Aging has a greater impact on diastolic function than on systolic performance, with progressive decreases in the elastic properties of the heart and great vessels leading to increased myocardial stiffness 1, 2
• Ventricular filling decreases with age due to structural changes and a decline in relaxation and compliance, which is exacerbated by decreased beta-adrenergic receptor density and declining peripheral vasodilator capacity 2
• Baroreceptor sensitivity decreases progressively with aging at approximately 1% per year after age 40, affecting autonomic nervous system responsiveness 2

These changes mean that while the heart can still increase rate appropriately with demand, the contractile vigor and sympathetic responsiveness that create the sensation of a "pounding" heartbeat diminish naturally with age.

Grade 1 Diastolic Dysfunction Context

Grade 1 diastolic dysfunction represents an early pattern of impaired relaxation that is frequently seen in the normal elderly population:

• Grade 1 diastolic dysfunction (impaired relaxation pattern) is commonly observed in elderly subjects and hypertensive patients, and is generally associated with normal or low left ventricular filling pressures 1
• This pattern shows decreased peak transmitral E-velocity with compensatory increase in atrial-induced A-velocity, resulting in a decreased E/A ratio 1
• The morbidity and mortality associated with heart failure and preserved ejection fraction may be nearly as profound as that with low ejection fraction, but Grade 1 dysfunction alone does not constitute heart failure 2

Impact of Prior PE/PAH Episode

The 2021 pulmonary embolism with associated right heart changes that subsequently resolved is relevant but reassuring:

• Left-sided diastolic dysfunction is the most prevalent echocardiographic abnormality after PE, affecting 34.2% of symptomatic post-PE patients in follow-up studies 3
• Approximately 65% of PE survivors report functional impairment despite adequate anticoagulation, though persistent pulmonary vascular disease (CTEPH/CTED) occurs in only 7-12% of cases 3
• Since your patient's right ventricular dilation and PAH resolved, the persistent Grade 1 diastolic dysfunction likely represents age-related changes rather than PE sequelae 3

Clinical Reassurance Points

The patient's perception of diminished "force" with preserved ability to increase heart rate is consistent with normal aging rather than progressive heart failure:

• The cardinal manifestations of heart failure are dyspnea and fatigue limiting exercise tolerance, and fluid retention causing congestion—not subjective changes in heartbeat sensation 1, 4
• Heart failure is defined as a clinical syndrome with specific symptoms (dyspnea, fatigue) and signs (edema, rales), not by subjective perceptions of cardiac contractility 1
• Grade 1 diastolic dysfunction with normal ejection fraction and resolved right heart pathology does not meet criteria for heart failure 1, 4

Monitoring Recommendations

While reassurance is appropriate, continued surveillance is warranted:

• Serial echocardiography should monitor for progression from Grade 1 to higher grades of diastolic dysfunction, particularly watching for pseudonormalization patterns or restrictive filling 1
• Blood pressure control is paramount, as hypertension accelerates diastolic dysfunction progression in elderly patients 1, 2
• Symptoms warranting concern include new dyspnea, exercise intolerance, or fluid retention—not subjective changes in heartbeat sensation 1

In summary, your patient's observation reflects normal cardiovascular aging at 73 with Grade 1 diastolic dysfunction, not pathologic progression. The resolved PE/PAH episode from 2021 does not appear to have left significant sequelae given the normalization of right heart parameters. Continue standard management of diastolic dysfunction risk factors (blood pressure control, rate control if applicable) and reassure the patient that this subjective change is expected with aging. 1, 2