What are the symptoms and management of diastolic heart failure?

Symptoms of Diastolic Heart Failure

Diastolic heart failure presents with breathlessness (either at rest or during exertion), fatigue, and ankle swelling—the same cardinal symptoms as systolic heart failure—but occurs in patients with preserved left ventricular ejection fraction (typically >40-50%). 1

Core Clinical Presentation

The symptom profile is indistinguishable from systolic heart failure and includes:

• Breathlessness (dyspnea): Occurs at rest or on exertion, representing the most common presenting symptom due to elevated pulmonary capillary pressures from impaired ventricular relaxation and increased filling pressures 1, 2
• Fatigue and tiredness: Results from inadequate cardiac output and poor tissue perfusion, particularly during physical activity 1
• Ankle swelling (peripheral edema): Reflects systemic venous congestion from elevated right-sided filling pressures 1

Additional Symptoms and Signs

Beyond the classic triad, patients may exhibit:

• Tachycardia and tachypnea: Compensatory responses to maintain cardiac output 1
• Pulmonary rales: Indicating pulmonary congestion from elevated left atrial pressure 1
• Pleural effusion: From chronic elevation of pulmonary venous pressure 1
• Raised jugular venous pressure: Reflecting elevated right atrial pressure 1
• Hepatomegaly: Secondary to hepatic congestion from right heart failure 1

Critical Diagnostic Caveats

These symptoms are notoriously difficult to interpret, particularly in elderly patients, obese individuals, and women—the exact populations most likely to have diastolic heart failure. 1

• Poor correlation exists between symptom severity and the degree of cardiac dysfunction, making clinical assessment alone unreliable 1
• Symptoms alone are insufficient for diagnosis—objective evidence of cardiac dysfunction at rest (preferably by echocardiography) is mandatory 1
• The European Society of Cardiology emphasizes that clinical response to diuretics or nitrates, while supportive, is not sufficient for diagnosis without objective cardiac assessment 1

Epidemiologic Context

Diastolic heart failure has distinct demographic features:

• Predominantly affects elderly women with a history of hypertension 1, 3, 4
• Increases in prevalence with age, becoming relatively uncommon in younger patients but highly prevalent in the elderly 1
• Systolic hypertension and myocardial hypertrophy with fibrosis are the primary contributors to cardiac dysfunction in this population 1

Management Priorities for Symptomatic Patients

The American College of Cardiology recommends ACE inhibitors or ARBs as cornerstone medications, combined with beta-blockers for heart rate control and judicious diuretic therapy when congestion is present. 3

Pharmacologic Approach

• ACE inhibitors or ARBs: Provide blood pressure control while directly improving ventricular relaxation and promoting regression of left ventricular hypertrophy 3, 5
• Beta-blockers: Lower heart rate to increase diastolic filling period, allowing more time for ventricular filling in the setting of impaired relaxation 3, 5, 6
• Diuretics: Used when fluid overload or congestion is present, but titrated carefully to reduce elevated filling pressures without causing excessive preload reduction that compromises cardiac output 3, 6
• Target blood pressure <130/80 mmHg, potentially lower than for uncomplicated hypertension 3

Critical Medication to AVOID

Positive inotropic agents should be avoided in diastolic dysfunction, as systolic function is typically normal or near-normal and these agents may worsen the condition. 3

Common Management Pitfalls

• Excessive diuresis leading to hypotension and reduced cardiac output is the most frequent error 3, 4
• Inadequate blood pressure control allows continued progression of left ventricular hypertrophy and worsening diastolic function 3
• Failure to control heart rate perpetuates inadequate diastolic filling time 3

Prognostic Implications

• Annual mortality rate approximately 8% compared to 19% in systolic heart failure, though morbidity remains substantial 2, 7
• Grade 2 diastolic dysfunction carries substantially increased mortality with survival rates of only 39% in certain populations, making aggressive management essential 3
• Prognosis varies with age, severity of heart failure, and comorbid conditions such as coronary artery disease 4