Diastolic Heart Failure

1. See Also
   1. Heart Failure
   2. Systolic Dysfunction
2. Definition
   1. Hypertrophic heart with impaired relaxation
      1. Stiff, less compliant left ventricle
   2. Heart meets metabolic needs
      1. But cost is a higher diastolic pressure
      2. Transmits pressures to lung vasculature
      3. Results in pulmonary congestion
      4. Ultimately leads to right-sided Heart Failure
3. Epidemiology
   1. Incidence increases with age (over 55 years)
   2. More common in elderly women
   3. Responsible for 30-40% of Congestive Heart Failure
   4. More common in black patients
4. Causes
   1. See Heart Failure Causes
   2. Common causes
      1. Hypertension
         1. Causes Left Ventricular Hypertrophy
      2. Coronary Artery Disease
      3. Aortic Stenosis
      4. Obesity
   3. Other causes
      1. Cardiomyopathy (e.g. Amyloidosis, Sarcoidosis)
      2. Hypertrophic Cardiomyopathy
      3. Glycogen Storage Disease
      4. Hypereosinophilic Syndrome
      5. Hemochromatosis
      6. Constrictive Pericarditis or Pericardial Effusion
      7. Valvular disease
5. Exacerbating Factors
   1. Tachycardia
   2. Atrial Fibrillation
   3. Increased ventricular load (volume overload)
   4. Exercise
   5. Increased salt intake
   6. NSAIDs
   7. Hyperthyroidism
   8. Infection or fever
   9. Anemia
6. Symptoms
   1. Dyspnea on exertion
   2. Fatigue
7. Signs
   1. Symptoms and signs overlap with Systolic Dysfunction
   2. Establish Congestive Heart Failure diagnosis clinically
   3. Evaluate for Systolic Dysfunction
   4. Rule out other causes
      1. Significant valvular disease
      2. Pericardial disease
      3. Inducible Myocardial Ischemia
   5. Document elevated left ventricle end diastolic pressure
      1. Often impractical to perform
8. Labs
   1. B-Type Natriuretic Peptide (BNP)
      1. Does not distinguish from Systolic Dysfunction
9. Diagnostic Studies
   1. Echocardiogram
      1. See Echocardiogram in Congestive Heart Failure
      2. Ejection Fraction >50%
      3. E-A Wave Ratio abnormal
         1. E Wave: Peak velocity diastolic mitral valve flow
         2. A Wave: Atrial contraction
         3. Interpretation
            1. Normal E-A Ratio: 1.5
            2. Early Diastolic Dysfunction: E-A Ratio <1
            3. Moderate Diastolic Dysfunction: E-A=1.5
            4. Severe Diastolic Dysfunction: E-A Ratio >2
      4. Measurement of Tau abnormal
   2. Coronary Angiography
      1. Indicated if Angina or ischemia on other testing
10. Management
    1. Aggressively manage Coronary Risk Factors
       1. Hypertension
       2. Hyperlipidemia
       3. Obesity
       4. Tobacco Abuse
       5. Diabetes Mellitus
       6. Encourage regular aerobic Exercise
    2. Reduce exacerbating factors
       1. Control Myocardial Ischemia
       2. Maintain sinus rhythm and prevent Tachycardia
    3. Preferred medications in Diastolic Dysfunction
       1. Beta Blockers
          1. Maximizes diastolic filling
          2. Decreases pulse, Coronary Artery Disease, LVH
       2. ACE Inhibitor (or Angiotensin Receptor Blocker)
          1. Improves myocardial relaxation and compliance
          2. Lowers preload and afterload
       3. Diuretics
          1. Decrease Dyspnea and acute exacerbations
          2. Risk of Hypotension, Prerenal Failure
    4. Meds with uncertain efficacy in Diastolic Dysfunction
       1. Spironolactone
    5. Medications to use with caution
       1. Nondihydropyrimidine Calcium Channel Blockers
          1. Example: Verapamil
          2. Improves diastolic function overall
          3. Avoid in Left Ventricular Dysfunction
          4. No survival benefit in Diastolic Dysfunction
       2. Dihydropyramidine Calcium Channel Blockers
          1. Example: Amlodipine
          2. Indications: Heart Rate control, Angina
          3. No survival benefit in Diastolic Dysfunction
          4. Limit use to when Beta Blocker is contraindicated
       3. Vasodilators (Nitrates, Hydralazine)
          1. Indications: Preload reduction and Angina
          2. No survival benefit in Diastolic Dysfunction
          3. Limit use to when ACE Inhibitor is contraindicated
    6. Medications to avoid
       1. Avoid Digoxin except in Atrial Fibrillation
11. Prevention
    1. Control Cardiac Risk Factors
12. References
    1. Senni (1997) Mayo Clin Proc 72:453-60
    2. (1995) Circulation 92:2764-84
    3. (1999) J Card Fail 5:357-82
    4. Zile (2002) Circulation 105:1387-93
    5. Zile (2002) Circulation 105:1503-8