How to improve diastolic function in a patient with sufficient systole and potential underlying conditions like hypertension, diabetes, or heart failure?

How to Improve Diastolic Function When Systolic Function is Adequate

The primary strategy is aggressive blood pressure control targeting <130/80 mmHg combined with heart rate control using beta-blockers to increase diastolic filling time, while judiciously using diuretics to relieve congestion without dropping preload excessively. 1

Core Therapeutic Targets

Blood Pressure Control (First Priority)

• Target blood pressure <130/80 mmHg to promote regression of left ventricular hypertrophy and improve diastolic compliance 1
• Avoid lowering diastolic pressure below 60 mmHg, particularly in elderly patients or those with coronary artery disease, as this compromises coronary perfusion 2
• ACE inhibitors (such as lisinopril) or ARBs are first-line agents to improve ventricular relaxation and cardiac compliance 3, 1, 4
• These agents directly improve relaxation and have long-term effects through regression of hypertrophy 3

Heart Rate Control (Second Priority)

• Beta-blockers are the preferred agents to control tachycardia and increase diastolic filling time, as diastolic filling is critically time-dependent 3, 1
• Verapamil-type calcium channel blockers can be used as an alternative to lower heart rate and increase the diastolic period 3
• This is particularly critical if atrial fibrillation develops, where aggressive ventricular rate control is essential 1, 5

Volume Management (Third Priority)

• Use diuretics judiciously to reduce elevated filling pressures and relieve pulmonary congestion symptoms 1, 5
• Critical pitfall: Avoid excessive diuresis, as patients with diastolic dysfunction are highly sensitive to preload reduction and will develop hypotension and reduced cardiac output 1, 2
• The goal is symptom relief without significantly reducing cardiac output 5

Address Underlying Causes

Myocardial Ischemia

• Consider coronary revascularization when symptomatic or demonstrable myocardial ischemia adversely affects diastolic function (Class IIa recommendation) 3, 1, 5
• Relief of myocardial ischemia is an important treatment objective 6

Hypertension and Left Ventricular Hypertrophy

• Long-term treatment of hypertension reduces the risk of developing heart failure 3
• Regression of ventricular hypertrophy is a key therapeutic goal 3, 6

Diabetes Management

• Optimize glycemic control, as diabetes contributes to diastolic dysfunction 3
• Avoid thiazolidinediones in patients with NYHA class III-IV symptoms, as they cause fluid retention and can precipitate heart failure 3

What NOT to Do: Critical Contraindications

• Do not use positive inotropic agents (including digoxin) in the absence of systolic dysfunction or atrial fibrillation—they provide no benefit and are contraindicated (Class III recommendation) 1
• Avoid aggressive diuresis that drops filling pressures too low, as this precipitates hypotension and reduces cardiac output 1, 2
• Do not use nonsteroidal anti-inflammatory drugs, as they promote salt and water retention 3
• Avoid hypotonic fluids 3

Clinical Context and Prognosis

• Diastolic heart failure occurs predominantly in elderly women with hypertension 3
• Annual mortality is approximately 8%, with substantial morbidity including frequent hospitalizations, dyspnea, fatigue, and reduced exercise tolerance 1
• The risk of death appears lower than in systolic heart failure, but management still has major socioeconomic implications 3

Monitoring Strategy

• Perform baseline echocardiographic assessment to establish diastolic function parameters 5, 2
• Repeat evaluation within 2-3 months if chronicity is uncertain 2
• Ongoing clinical assessment is necessary to detect symptom onset or worsening 2