What are the guideline medications for chronic diastolic heart failure?

Guideline Medications for Chronic Diastolic Heart Failure

The evidence base for treating diastolic heart failure (HFpEF) remains limited, but current guidelines recommend focusing on symptom management with diuretics, blood pressure control with ACE inhibitors or ARBs, heart rate control with beta-blockers, and consideration of SGLT2 inhibitors based on recent evidence. 1, 2

Critical Context: The Evidence Gap

There is little evidence from clinical trials or observational studies as to how to treat diastolic dysfunction, and the recommendations are largely speculative (level C evidence). 1 Patients with preserved LV systolic function or diastolic dysfunction were excluded from nearly all large controlled trials in heart failure. 1

Primary Therapeutic Approach

1. Treat Underlying Causes First

• Blood pressure control is paramount - hypertension is the most common underlying cause and drives LV hypertrophy and decreased compliance. 3, 4, 5
• Aggressive antihypertensive therapy to promote regression of LV hypertrophy. 6, 5

2. Diuretics for Symptom Relief

• Use diuretics cautiously when fluid overload is present to relieve pulmonary congestion and peripheral edema. 1
• Critical caveat: Avoid excessive diuresis as this can lower preload excessively and thereby reduce stroke volume and cardiac output in diastolic dysfunction. 1

3. ACE Inhibitors or ARBs

• ACE inhibitors may improve relaxation and cardiac distensibility directly, have long-term effects through regression of hypertrophy, and reduce hypertension. 1
• ARBs are an alternative if ACE inhibitors are not tolerated. 6, 4
• These agents work by reducing afterload and promoting favorable LV remodeling. 3, 4

4. Beta-Blockers

• Beta-blockade is recommended to lower heart rate and increase the diastolic filling period, which is particularly important in diastolic dysfunction. 1
• Prevention of tachycardia is essential as shortened diastolic filling time worsens symptoms. 6, 4

5. Calcium Channel Blockers (Non-Dihydropyridine)

• Verapamil-type calcium antagonists may be used to lower heart rate and increase diastolic period. 1
• Verapamil may lead to functional improvement, particularly in hypertrophic cardiomyopathy. 1
• Growing evidence supports calcium channel blockers as beneficial. 3, 4

6. SGLT2 Inhibitors (Emerging Evidence)

• Current ACC/AHA and ESC guidelines recommend SGLT2 inhibitors for heart failure treatment, including those with preserved ejection fraction. 2
• Recent meta-analysis demonstrates SGLT2 inhibitors decrease cardiovascular hospitalization risk in HFpEF patients. 7
• This represents the most significant advancement in HFpEF therapy in recent years. 7

Special Circumstances

If Atrial Fibrillation is Present:

• Rate control is mandatory in permanent atrial fibrillation. 1
• In asymptomatic patients: beta-blockade, digitalis glycosides, or combination may be considered. 1
• In symptomatic patients: digitalis glycosides are first choice (level C). 1
• Electrical cardioversion should be considered for persistent atrial fibrillation, though success depends on duration and left atrial size. 1

If Concomitant Hypertension Persists:

1. Optimize ACE inhibitors, beta-blockers, and diuretics. 1
2. Add spironolactone or ARBs if not already present. 1
3. Consider second-generation dihydropyridine derivatives if unsuccessful. 1

Key Clinical Pitfalls

• Avoid excessive diuresis: Unlike systolic heart failure, diastolic dysfunction is highly preload-dependent. Over-diuresis can precipitate hypotension and reduced cardiac output. 1
• Maintain sinus rhythm when possible: Atrial contribution to ventricular filling is critical in diastolic dysfunction. 1
• Avoid tachycardia: Shortened diastolic filling time significantly worsens symptoms. 6, 4
• No role for positive inotropes: These are contraindicated as systolic function is preserved. 3

Prognosis Considerations

Diastolic heart failure carries a lower annual mortality rate of approximately 8% compared to 19% in systolic dysfunction, but morbidity can be substantial. 3, 4 Early recognition and treatment of underlying causes is essential to prevent progression. 3, 4, 5