In a patient with heart failure and left‑ventricular diastolic dysfunction who has diastolic blood pressure in the 60‑70 mm Hg range, should we attempt to raise diastolic pressure (even if systolic pressure also increases) to improve coronary perfusion and myocardial oxygen delivery?

Diastolic Blood Pressure and Coronary Perfusion in Heart Failure

Your intuition is correct—diastolic blood pressure in the 60s can compromise coronary perfusion, and this directly relates to your heart failure specialist's concern about inadequate myocardial oxygen delivery, but attempting to raise diastolic pressure by increasing systolic pressure is NOT recommended and could worsen your heart failure. 1

Understanding the Problem

Your concern about low diastolic blood pressure affecting coronary perfusion is physiologically sound:

• Coronary arteries fill during diastole, so lower diastolic pressures reduce the driving pressure for coronary blood flow, particularly to the subendocardium 2
• In patients with coronary artery disease at baseline, the Syst-Eur trial showed evidence of harm when diastolic blood pressure dropped below 55-60 mmHg 2
• Your heart failure specialist's statement about inadequate oxygen delivery is consistent with the known physiology that diastolic pressures below 60-70 mmHg can compromise myocardial perfusion, especially in patients with underlying coronary disease or left ventricular hypertrophy 2, 1

Why Raising Blood Pressure Is NOT the Solution

The critical issue is that your low diastolic pressure is likely a consequence of your underlying heart disease, not the primary problem to fix: 2

• Post-hoc analysis from SHEP trial identified that diastolic pressures below 60-70 mmHg marked a high-risk group, but this was possibly due to the severity of underlying disease rather than overtreatment 2
• The Syst-Eur trial found that low diastolic blood pressure was associated with higher non-cardiovascular mortality even in the placebo group (patients not receiving blood pressure treatment), suggesting the low pressure reflects disease severity rather than causing the problem 2
• Attempting to raise diastolic pressure by increasing systolic pressure would worsen your heart failure by increasing afterload (the resistance your heart must pump against), which is particularly harmful in diastolic dysfunction 1, 3

The Correct Management Approach

Instead of trying to raise your blood pressure, management should focus on:

Primary Goals

• Optimize blood pressure control to less than 130/80 mmHg if tolerated, but critically, avoid letting diastolic pressure fall below 60 mmHg, particularly given your heart failure 1
• Address myocardial ischemia directly through coronary revascularization if you have symptomatic or demonstrable ischemia affecting your diastolic function (Class IIa recommendation) 4, 1
• Control heart rate with beta-blockers to increase diastolic filling time and reduce myocardial oxygen demand 1, 3

Specific Interventions

• ACE inhibitors or ARBs as first-line agents to improve ventricular relaxation and promote regression of left ventricular hypertrophy 1, 3
• Beta-blockers to control heart rate and increase the diastolic period when coronary perfusion occurs 3
• Judicious use of diuretics only if volume overload is present, avoiding excessive diuresis which can drop your blood pressure further and reduce cardiac output 1, 3

Critical Pitfall to Avoid

The American Heart Association specifically warns against lowering diastolic blood pressure below 60 mmHg in elderly patients or those with coronary artery disease, as this compromises coronary perfusion. 1 However, the solution is NOT to raise blood pressure with additional medications, but rather to:

• Carefully adjust your current medications to prevent diastolic pressure from dropping too low
• Avoid excessive diuresis which is a common cause of low diastolic pressure in heart failure patients 1, 3
• Address the underlying coronary ischemia if present, rather than trying to compensate with higher blood pressure 4, 1

When to Seek Cardiology Referral

You should have cardiology involvement if: 1

• You have symptomatic or demonstrable myocardial ischemia requiring evaluation for revascularization
• Your symptoms persist despite 3-6 months of optimized medical management
• You develop atrial fibrillation requiring rate control optimization

The key insight is that your low diastolic pressure is a marker of disease severity, not the primary target for intervention. The focus should be on treating the underlying causes—coronary disease, diastolic dysfunction, and heart failure—rather than artificially raising blood pressure, which would likely make your condition worse.