Diastolic Blood Pressure in Heart Failure with Preserved Ejection Fraction and Aortic Atherosclerosis
No, diastolic blood pressure would not always be elevated in this clinical scenario—in fact, it is often normal or even reduced despite the presence of left ventricular hypertrophy and aortic atherosclerosis.
Understanding the Blood Pressure Pattern
The clinical picture you describe—LV diastolic thickness >1.2cm with EF 55-65% and aortic atherosclerosis—represents heart failure with preserved ejection fraction (HFpEF) with LV hypertrophy, typically secondary to chronic hypertension 1. However, the blood pressure pattern in this condition does not follow a predictable rule for diastolic elevation.
Why Diastolic BP May NOT Be Elevated
Isolated systolic hypertension is common in patients with aortic atherosclerosis and arterial stiffness, where systolic pressure rises but diastolic pressure remains normal or falls, creating a widened pulse pressure 2
LV hypertrophy develops as a compensatory response to normalize wall stress from chronic hypertension, but once established, the blood pressure pattern can vary significantly 2, 3
Arterial stiffness from atherosclerosis causes increased systolic pressure with normal or reduced diastolic pressure due to decreased arterial compliance and early wave reflection 2
The Pathophysiology of This Clinical Picture
Left Ventricular Changes
LV wall thickness >1.2cm indicates concentric hypertrophy, which decreases LV compliance and impairs diastolic filling, leading to elevated filling pressures even with preserved systolic function 1
Diastolic dysfunction results from delayed relaxation and increased chamber stiffness, causing upward displacement of the diastolic pressure-volume relationship with elevated end-diastolic, left atrial, and pulmonary capillary wedge pressures 3, 4
The EF of 55-65% confirms preserved systolic function, meeting criteria for HFpEF which requires LVEF >50% 5
Hemodynamic Patterns
Elevated LEFT ventricular filling pressures are the hallmark, not necessarily elevated systemic diastolic blood pressure 1
The E/e' ratio >14, LA volume index >34 mL/m², and TR velocity >2.8 m/s are the key echocardiographic markers of elevated LV filling pressures in this population 1
Aortic atherosclerosis increases arterial stiffness, which elevates systolic BP through increased impedance to LV ejection, but diastolic BP depends on peripheral vascular resistance and arterial compliance 2
Clinical Implications
Blood Pressure Targets
Systolic BP should be controlled to approximately 130 mmHg using guideline-directed medical therapy, which will address both the hypertension and the diastolic dysfunction 6
The diastolic BP target is not specifically defined in HFpEF guidelines, as the focus is on systolic control and symptom management 1, 6
Common Pitfalls
Do not assume elevated diastolic BP from LV hypertrophy alone—many patients with severe LV hypertrophy have isolated systolic hypertension with normal or low diastolic pressures 2
Distinguish between elevated LV filling pressures (intracardiac) and systemic diastolic blood pressure (arterial)—these are separate hemodynamic parameters that do not always correlate 1
Avoid aggressive diastolic BP lowering, as excessive reduction can decrease coronary perfusion pressure and worsen myocardial ischemia, particularly in patients with aortic atherosclerosis 6
Management Approach
ACE inhibitors or ARBs are first-line to promote regression of LV hypertrophy, improve LV compliance, and control blood pressure 1, 6, 2
Beta-blockers help by reducing heart rate, prolonging diastolic filling time, and improving coronary perfusion 1, 2
Diuretics should be used cautiously for volume management only, as excessive preload reduction can decrease stroke volume in patients with stiff, non-compliant ventricles 1, 6
Avoid calcium channel blockers of the verapamil/diltiazem class unless specifically indicated, though they may improve diastolic function in some cases 1, 3