If you have DD, you have an increased risk of death — even if your systolic function is normal and you have no other problems with how your heart is functioning, according to a study co-authored by Dr. If your systolic function is normal, that means that the left ventricle of your heart can contract completely and properly pump blood through your body. Jaber notes that the isolated DD relaxation problem with the heart even in the setting of normal systolic pumping function carries a significant risk for death.
Research by Dr. Here Dr. If you show symptoms of DD, your doctor will grade it as mild, moderate or severe. It increases with age and is prevalent among older women with systemic hypertension and ventricular hypertrophy.
Diastolic dysfunction is linked to excessive weight, diabetes, age and limited physical activity or a sedentary lifestyle. Quitting smoking, limiting alcohol intake, dietary changes, weight loss and aggressively controlling hypertension, high cholesterol and coronary artery disease are effective measures you can take to prevent DD.
In addition to providing fundamental information on chamber size, wall thickness and motion, systolic function, the valves, and the pericardium, two-dimensional echocardiography with Doppler is used to evaluate the characteristics of diastolic transmitral and pulmonary venous flow pattern. Similarly, atrial contraction corresponds to the A wave. As the disease progresses, left ventricular compliance is reduced, which increases left atrial pressure and, in turn, increases early left ventricular filling despite impaired relaxation.
The E- and A-wave velocities are affected by blood volume, mitral valve anatomy, mitral valve function, and atrial fibrillation, making standard echocardiography less reliable.
In these cases, tissue Doppler imaging is useful for measuring mitral annular motion a measure of transmitral flow that is independent of the aforementioned factors. Cardiac catheterization remains the preferred method for diagnosing diastolic dysfunction. However, in day-to-day clinical practice, two-dimensional echocardiography with Doppler is the best noninvasive tool to confirm the diagnosis.
Rarely, radionuclide angiography is used for patients in whom echocardiography is technically difficult. Primary prevention of diastolic heart failure includes smoking cessation and aggressive control of hypertension, hypercholesterolemia, and coronary artery disease.
Lifestyle modifications such as weight loss, smoking cessation, dietary changes, limiting alcohol intake, and exercise are equally effective in preventing diastolic and systolic heart failure. Diastolic dysfunction may be present for several years before it is clinically evident Figure 1 Early diagnosis and treatment is important in preventing irreversible structural alterations and systolic dysfunction.
However, no single drug has pure lusitropic properties i. Therefore, medical therapies for diastolic dysfunction and diastolic heart failure often are empirical and not as well defined as therapies for systolic heart failure. On the surface, it appears that the pharmacologic treatments of diastolic and systolic heart failure do not differ dramatically; however, the treatment of diastolic heart failure is limited by the lack of large and conclusive randomized control trials.
Most clinical trials to date have focused exclusively on patients with systolic heart failure; only recently have trials addressed the treatment of diastolic heart failure.
Although conclusive data on specific therapies for diastolic heart failure are lacking, the American College of Cardiology and the American Heart Association joint guidelines 22 recommend that physicians address blood pressure control, heart rate control, central blood volume reduction, and alleviation of myocardial ischemia when treating patients with diastolic heart failure. These guidelines target underlying causes and are likely to improve left ventricular function and optimize hemodynamics.
Table 4 lists treatment goals for diastolic heart failure. ACE inhibitors. Regress left ventricular hypertrophy decrease wall thickness and remove excess collagen. Beta blockers preferred. Beta blocker. Control blood pressure. When treating a patient with diastolic dysfunction, it is important to control the heart rate and prevent tachycardia to maximize the diastolic filling period. Beta blockers are particularly useful for this purpose; however, they do not directly affect myocardial relaxation.
In addition to slowing heart rate, beta blockers have proven benefits in reducing blood pressure and myocardial ischemia, promoting regression of left ventricular hypertrophy, and antagonizing the excessive adrenergic stimulation during heart failure. Beta blockers have been independently associated with improved survival in patients with diastolic heart failure. Optimizing hemodynamics primarily is achieved by reducing cardiac preload and afterload. Angiotensin-converting enzyme ACE inhibitors and angiotensin receptor blockers ARBs directly affect myocardial relaxation and compliance by inhibiting production of or blocking angiotensin II receptors, thereby reducing interstitial collagen deposition and fibrosis.
More importantly, there is improvement in exercise capacity and quality of life. However, it reduced the incidence of hospitalization for CHF exacerbation. Diuretics are effective in managing optimal intravascular volume, and they minimize dyspnea and prevent acute heart failure in patients with diastolic dysfunction.
Although diuretics control blood pressure, reverse left ventricular hypertrophy, and reduce left ventricular stiffness, some patients with diastolic heart failure are sensitive to the preload reduction and may develop hypotension or severe prerenal azotemia.
Intravenous diuretics should only be used to relieve acute symptoms. The hormone aldosterone promotes fibrosis in the heart and contributes to diastolic stiffness. The aldosterone antagonist spironolactone Aldactone has been studied in a large clinical trial of systolic heart failure, 29 which showed a reduction in mortality related to heart failure. However, the specific effects of spironolactone on diastolic dysfunction are unclear. Calcium channel blockers have been shown to improve diastolic function directly by decreasing cytoplasmic calcium concentration and causing myocardial relaxation or indirectly by reducing blood pressure, reducing or preventing myocardial ischemia, promoting regression of left ventricular hypertrophy, and by slowing the heart rate.
However, nondihydropyridine calcium channel blockers e. Vasodilators e. The Vasodilator Heart Failure Trial, 31 however, did not show significant survival benefit in patients with diastolic heart failure. Vasodilators should be used cautiously because decreasing preload may worsen cardiac output. Unlike other medications used for diastolic heart failure, vasodilators have no effect on left ventricular regression. The exact role of digoxin for treating patients with diastolic heart failure remains unclear.
Digoxin can be deleterious in older patients with left ventricular hypertrophy and hypertrophic obstructive cardiomyopathy; therefore, digoxin is only appropriate for patients with diastolic heart failure and atrial fibrillation. Already a member or subscriber? Log in. Interested in AAFP membership?
Learn more. He completed a family practice residency at Creighton University Medical Center, including one year as chief resident.
Address correspondence to Hemant K. Satpathy, M. Reprints are not available from the authors. Heart failure: clinical implications of systolic and diastolic dysfunction. Evolving trends in the epidemiologic factors of heart failure: rationale for preventive strategies and comprehensive disease management. Am Heart J. Litwin SE, Grossman W. Diastolic dysfunction as a cause of heart failure. J Am Coll Cardiol. Diastolic dysfunction in heart failure.
J Card Fail. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. Senni M, Redfield MM. Heart failure with preserved systolic function.
A different natural history?. Diastolic failure: pathophysiology and therapeutic implications [published correction appears in J Am Coll Cardiol ;]. Vasan RS, Levy D. Defining diastolic heart failure: a call for standardized diagnostic criteria. Grossman W. Defining diastolic dysfunction. Eur J Heart Fail. Aging is the most common cause of this stiffening of the heart. Diastolic heart dysfunction often creates the same array of symptoms that are found in other types of heart failure and cardiopulmonary diseases, including:.
It's easy to dismiss these symptoms as part of "normal aging. An ultrasound of your heart known as an echocardiogram can confirm a diagnosis of diastolic dysfunction. By collaborating with physicians in other areas of specialty, we can properly diagnose diastolic dysfunction as a cause of pulmonary hypertension and find the right treatments to help improve your quality of life and sustain your independent lifestyle.
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