Article Figures & Data
Figures
- Figure 1.
Diastolic parameters.
- Figure 2.
Normal diastolic function. Doppler recordings of normal transmitral filling velocities. An E/A wave ratio between 0.75 and 1.5 and deceleration time (DT) greater than 140 milliseconds is characteristic of a normal filling pattern.
- Figure 3.
Mild diastolic dysfunction. Doppler recordings of transmitral filling velocities indicating inpaired relaxation. In this pattern, the E/A wave ratio is less than 0.75 and deceleration time (DT) is greater than 230 milliseconds.
- Figure 4.
Restrictive pattern. Doppler recordings of transmitral filling velocities in a restrictive filling pattern. An E/A wave ratio greater than 1.5 and deceleration time (DT) less than 160 milliseconds indicates restrictive filling pattern.
Tables
Goal Therapy Reduction of congestion Salt restriction Less than 2 g daily Diuretics Thiazides and loop diuretics ACEIs Enalapril Lisinopril ARBs Candesartan Losartan Maintenance of rate control β-blockers Atenolol, metoprolol Calcium channel blockers Diltiazem, verapamil Conversion of atrial fibrillation Atrioventricular pacing Optimal management of hypertension Antihypertensive agents β-blockers Calcium channel blockers Diuretics ACEIs ARBs Spironolactone Prevention and treatment of myocardial ischemia β-blockers Atenolol, metoprolol Calcium channel blockers Diltiazem, verapamil Nitrates Isosorbide dinitrate Isosorbide mononitrate Revascularization Percutaneous transluminal coronary angioplasty, coronary artery bypass surgery * This information is based on the authors’ experience and a review of the literature regarding diastolic heart failure (DHF). It should be emphasized that the literature is incomplete. With the exception of the CHARM study, no randomized controlled trial (RCT) has specifically evaluated the efficacy of a specific agent in the treatment of DHF. Most studies were designed to evaluate a drug in the treatment of systolic heart failure (SHF) and were not specifically designed to assess their efficacy in DHF patients. These studies and an understanding of the pathophysiology of DHF form the basis of current discussion of therapy in the cardiology literature.
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; β-blocker, β-adrenergic receptor blocker.
- Table 2.
Similarities and Differences in Agents Used for the Treatment of Diastolic and Systolic Heart Failure
Similarities Differences β-Blockers • Used to treat HTN • Used to modify left ventricular remodeling to prolong survival in SHF • May be used to rate control patients with atrial fibrillation or flutter • Titrated slowly to specific dose in SHF • In DHF, used to decrease heart rate and prolong diastole to reduce symptoms • DHF titrated more rapidly to response than in SHF Calcium channel blockers • May be used to treat HTN • Generally avoided in treating SHF • Shown to improve diastolic parameters and exercise tolerance • Particularly useful in setting of atrial fibrillation Diuretics • Symptom reduction through volume reduction in acute and chronic settings • Patients with SHF more likely to require higher doses and long-term therapy • May be used to treat HTN • Patients with DHF more likely to tolerate weaning • Judicious use in DHF as patients may be preload-dependent Nitrates • Used to treat patients with ischemic heart disease • Contribute to volume reduction ACEIs • May be used to treat HTN • Ample data to support use in SHF although relatively few studies in patients with DHF • Associated with LV regression and experimental data suggest improved myocardial relaxation ARBs • May be used to treat hypertension • Few trials in patients with DHF • Associated with LV regression and experimental data suggest improved myocardial relaxation Spironolactone • Aldosterone, which promotes fluid retention, myocardial, and vascular fibrosis is blocked. May have benefit in both DHF and SHF treatment • Shown to improve symptoms, decrease risk of death, and hospitalization in SHF Digoxin* • Beneficial for rate control in patients with atrial fibrillation or flutter • Used to improve ejection fraction in patients with SHF • May increase intracellular calcium concentration, which may impair diastolic relaxation * Digoxin use is controversial in the treatment of DHF.
β-blocker, β-adrenergic receptor blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; HTN, hypertension; SHF, systolic heart failure; DHF, diastolic heart failure; LV, left ventricle.
