Treating Diastolic Dysfunction and Diastolic Heart Failure

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If you have been told you have diastolic dysfunction or diastolic heart failure, it is important for you and your doctor to work out a treatment plan — both to prevent and control your symptoms, and to reduce your chances of dying from this condition.

Treatment Strategy For Diastolic Dysfunction

The best strategy for treating diastolic dysfunction, of any level of severity, is to attempt to identify any underlying conditions that contribute to it, and then aggressively manage them.

In particular, the following possibilities must be addressed:

Sedentary lifestyle

Many people with diastolic dysfunction lead habitually sedentary lives, and being sedentary is a major contributing factor to diastolic heart problems. A program of aerobic exercise training can improve the diastolic function of the heart and can be very helpful in diastolic dysfunction. In fact, an exercise program is the only treatment that has been demonstrated to improve the quality of life in patients with this condition. You should talk to your doctor about referring you to a cardiac rehabilitation program to get started.

Hypertension.

You should be carefully evaluated for hypertension. Hypertension is often present in people who have diastolic dysfunction, and it can be tricky to diagnose. Worse, hypertension is very often inadequately treated. But if you have diastolic dysfunction, it is extremely important that your doctor take extra care to make sure your blood pressure is in the optimal range.

Coronary artery disease. (CAD)

People with diastolic dysfunction should also be evaluated for the presence of coronary artery disease (CAD); if CAD is diagnosed, it should be treated aggressively. Occult (that is, undiagnosed and asymptomatic) CAD is a common cause of diastolic dysfunction.

Atrial fibrillation.

If you have atrial fibrillation, this cardiac arrhythmia should be adequately treated. In people who have diastolic dysfunction and atrial fibrillation, the rhythm control strategy is generally preferred over the rate control strategy. (Read about rhythm control vs. rate control in atrial fibrillation.) However, if a normal heart rhythm cannot be maintained, it is particularly important to get the heart rate under control This is because the rapid heart rates commonly caused by atrial fibrillation can cause significant deterioration in cardiac function in people with diastolic dysfunction. 

Diabetes and obesity.

Diabetes and obesity are both associated with diastolic dysfunction. Losing weight and keeping diabetes under good control can help to stop the worsening of diastolic dysfunction.

Sleep disordered breathing

Breathing disorders during sleep, especially sleep apnea conditions, can contribute significantly to diastolic dysfunction. People with diastolic dysfunction — especially if they are obese or have symptoms suggestive of sleep disordered breathing — should be evaluated for sleep apnea, and if it is diagnosed they should be treated.

Treatment of Diastolic Heart Failure

Treating diastolic heart failure (which cardiologists now refer to as “heart failure with preserved ejection fraction,”) can be a challenge. In contrast to classic systolic heart failure, in which many studies have revealed specific drug treatment regimens that significantly improve mortality, no such studies are available for diastolic heart failure. Furthermore, because the ventricles in diastolic heart failure are small and stiff (rather than dilated and flaccid), many of the drugs commonly used in classic heart failure have the potential of actually worsening diastolic heart failure.

Drug therapy for diastolic heart failure is often limited to using diuretics such as furosemide (Lasix) to reduce excess sodium and water from the body, and to reduce the symptoms of pulmonary congestion and edema. Drugs for controlling hypertension are also important.

Further, in the TOPCAT trial, treatment with spironolactone (a type of diuretic) seemed to reduce the need of hospitalization in people with diastolic heart failure, but did not reduce the rate of mortality. 

But the most important therapy for diastolic heart failure is to aggressively control the same factors, listed above, that are important in treating diastolic dysfunction. Of these, exercise training (not being sedentary any longer) is the only method that has been shown in clinical studies to significantly improve the quality of life in people with diastolic heart failure. 

What is the Prognosis of Diastolic Dysfunction?

People who have had an episode of diastolic heart failure have a serious, life-threatening cardiac condition. While their overall prognosis may be somewhat better than for patients with classic systolic heart failure, it is still substantially reduced. This is why anyone who has had diastolic heart failure needs to be treated aggressively — by attempting to manage all of the underlying conditions associated with this diagnosis. 

As for people who have been diagnosed with diastolic dysfunction but who have not had symptoms of heart failure, evidence is accumulating that these individuals also have a higher mortality than normal. This finding should not be surprising when you consider the underlying causes of diastolic dysfunction, the propensity of doctors to "undertreat" the two of the most common of these (i.e., hypertension and undiagnosed coronary artery disease), and the difficulty most people have of changing habitually sedentary lifestyles, and losing weight.

Diastolic dysfunction is an important condition that, at the very least, should prompt a careful search for underlying causes, and then aggressive treatment. The adequate treatment of diastolic dysfunction can greatly improve the likelihood of a good outcome.

Sources:

Borlaug BA, Paulus WJ. Heart Failure with Preserved Ejection Fraction: Pathophysiology, Diagnosis, and Treatment. Eur Heart J 2011; 32:670.

Pitt B, Pfeffer MA, Assmann SF, et al. Spironolactone for Heart Failure with Preserved Ejection Fraction. N Engl J Med 2014; 370:1383.

Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: a Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62:e147.

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