Disclosures: Michael R Zile, MD Grant/Research/Clinical Trial Support: Bayer; CVRx; Medtronic; Novartis; NHLBI [Heart failure with preserved ejection fraction]. Consultant/Advisory Boards: Abbott; Alere; AstraZeneca; Bayer; Bristol-Myers Squibb; Capricor; CVRx; Intersection Medical; Medtronic; MicroVide; Novartis; Thermo Fisher Scientific [Heart failure with preserved ejection fraction]. Employment: MUSC [Heart failure with preserved ejection fraction]. William H Gaasch, MD Nothing to disclose. Wilson S Colucci, MD Consultant/Advisory Boards: Merck [Heart failure (Enalapril)]; Novartis [Heart failure (Enalapril)]; Janssen [Heart failure]; Mast [Heart failure]. Equity Ownership/Stock Options: Cardioxyl [Heart failure]. Susan B Yeon, MD, JD, FACC Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — Diastolic heart failure (DHF) is a clinical syndrome in which patients have symptoms and signs of HF, normal or near normal left ventricular (LV) systolic function, normal LV chamber size, and evidence of LV diastolic dysfunction (eg, abnormal LV filling and/or elevated filling pressures) . DHF is a major cause of HF with preserved ejection fraction (table 1).
The treatment and prognosis of patients with DHF will be reviewed here. Issues related to etiology, clinical manifestations, diagnosis, and pathophysiology are discussed separately. (See "Clinical manifestations and diagnosis of diastolic heart failure" and "Pathophysiology of diastolic heart failure" and "Cellular mechanisms of diastolic dysfunction".)
IMPAIRED RESPONSE TO STRESS — Patients with diastolic heart failure have particular difficulty in tolerating certain hemodynamic stresses:
●They tolerate atrial fibrillation poorly, since the loss of atrial contraction can dramatically reduce left atrial emptying, left ventricular (LV) filling, and LV stroke volume. (See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm".)
●They do not tolerate tachycardia well, since the increase in heart rate shortens the duration of diastole and truncates relaxation, pressure decline, recoil, and diastolic filling.
●Elevations in systemic blood pressure, especially the abrupt, severe, or refractory elevations often seen with renovascular hypertension, increase LV wall stress, which can worsen myocardial relaxation. (See "Treatment of hypertension in patients with heart failure", section on 'Treatment of hypertension in patients with diastolic heart failure' and "Evaluation of secondary hypertension".)
●The acute induction or worsening of diastolic dysfunction by ischemia raises left atrial and pulmonary venous pressure. This explains why many patients with coronary heart disease have respiratory symptoms with their anginal pain, including wheezing, an inability to take a deep breath, shortness of breath, and even overt pulmonary edema. These respiratory symptoms can occur in the absence of anginal pain and are often referred to as "anginal equivalents."
Episodes of hemodynamic decompensation may result in pulmonary congestion or edema severe enough to be life-threatening. This phenomenon, called flash pulmonary edema, is discussed in detail separately. (See "Evaluation of acute decompensated heart failure".) Studies using implantable hemodynamic monitors have shown that LV diastolic pressures rise in a progressive fashion prior to the abrupt onset of heart failure [2-8]. While the development of symptoms is rapid, the increases in diastolic pressure occur gradually over a period of days to weeks.
TREATMENT — The treatment of diastolic heart failure (DHF) remains empiric, since trial data are limited.
General principles — Recommendations for treatment of patients with DHF were included in the 2013 American College of Cardiology Foundation/American Heart Association (ACC/AHA) HF guidelines . The following two strong recommendations were included:
●Systolic and diastolic hypertension should be controlled in accordance with published clinical practice guidelines to prevent morbidity.
●Diuretics should be used to relieve symptoms due to volume overload
Similar recommendations were included in the 2012 European Society of Cardiology HF guidelines . A clinical practice review provided specific examples of clinical therapies appropriate to achieving these goals (table 2) .
Pneumococcal vaccination is recommended for all patients with HF [10,11]. Annual influenza vaccination is now recommended for all individuals six months of age and older. (See "Pneumococcal vaccination in adults" and "Seasonal influenza vaccination in adults".)
Choice of medications — The choice of medications in patients with DHF is determined by two factors:
●Treatment of specific underlying processes such as hypertension or symptomatic coronary heart disease (CHD). Combined therapy may be warranted since hypertrophied hearts are more sensitive to the deleterious effects of ischemia on left ventricular (LV) relaxation than nonhypertrophied hearts . (See "Pathophysiology of diastolic heart failure".)
●The possibly beneficial effect of the drug on the pathophysiology of DHF
An important caveat is that the patient who has LV diastolic dysfunction with a small, stiff LV chamber is particularly susceptible to excessive preload reduction, which can lead to underfilling of the LV, a fall in cardiac output, and hypotension. In patients with severe LV hypertrophy (LVH) due to hypertension or hypertrophic cardiomyopathy, excessive preload reduction can also create subaortic outflow obstruction.
For these reasons, diuretics or venodilators such as nitrates and dihydropyridine calcium channel blockers must be administered with caution. Careful attention is required for symptoms of ventricular underfilling such as weakness, dizziness, near syncope, and syncope.
Digoxin is generally not used in patients with DHF because systolic function is intact. The DIG ancillary trial, a parallel study to the DIG trial, evaluated the role of digoxin in patients with HF and a LV ejection fraction (LVEF) >45 percent [13,14]. At a mean follow-up of 37 months, digoxin had no effect on all-cause or cause-specific mortality, or all-cause or cardiovascular hospitalization . (See "Use of digoxin in heart failure due to systolic dysfunction".)
Antihypertensive therapy — Lowering the systemic blood pressure was associated with reduced rate of HF in some large randomized hypertension treatment trials, particularly those including diuretic therapy [15,16]. The choice of a specific antihypertensive agent must be individualized in the presence of coexisting diseases such as diabetes mellitus or chronic obstructive pulmonary disease. (See "Choice of drug therapy in primary (essential) hypertension: Recommendations".)
Regression of LVH is an important therapeutic goal, since it may improve diastolic function . A meta-analysis published in 2003 attempted to evaluate the relative efficacy of different antihypertensive drugs for their ability to reverse LVH in patients with hypertension . Eighty trials that included 146 and 17 active treatment and placebo arms, respectively, were evaluated. After statistical adjustments for length of therapy and degree of blood pressure lowering, the relative reductions in LV mass index were (figure 1):
●Angiotensin II receptor blockers (ARBs) - 13 percent
●Calcium channel blockers - 11 percent
●Angiotensin converting enzyme (ACE) inhibitors - 10 percent
●Diuretics - 8 percent
●Beta blockers - 6 percent
It appears that ARBs, calcium channel blockers, and ACE inhibitors produced more regression than beta blockers. The clinical significance of this difference is uncertain since there is as yet no evidence that more rapid regression of LVH is associated with improved long-term outcomes. The choice of antihypertensive therapy is usually based upon other factors. (See "Choice of drug therapy in primary (essential) hypertension: Recommendations".)
Atrial fibrillation — As suggested in the 2013 ACC/AHA HF guidelines, atrial fibrillation (AF) is managed in patients with DHF according to published clinical practice guidelines to improve symptomatic HF . LV filling in DHF occurs largely in late diastole and is more dependent than normal hearts on atrial contraction. Tachycardia is also deleterious by shortening the time of diastole. (See "Clinical manifestations and diagnosis of diastolic heart failure", section on 'Pathophysiology'.)
For these reasons, restoration and maintenance of sinus rhythm is preferred when AF occurs in patients with DHF. When this cannot be achieved, rate control becomes important. Beta blockers and calcium channel blockers are the usual first-line agents, with digoxin most often being used in patients with systolic HF. (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations" and "Control of ventricular rate in atrial fibrillation: Pharmacologic therapy".)
A combination of these drugs may be required to achieve adequate heart rate control. It is important to measure heart rate during moderate exercise and not to base heart rate control solely on values obtained in the resting state.
An important component of the management of AF, regardless of whether rhythm control or rate control is chosen, is anticoagulation to prevent systemic embolization. (See "Rhythm control versus rate control in atrial fibrillation".)
Antiischemic therapy — Myocardial ischemia often precipitates and/or contributes to DHF. Ischemia can result from CHD and/or LVH with subendocardial ischemia. In such patients, beta blockers and calcium channel blockers are preferred. Nitrates are also effective but, as mentioned above, the reduction in preload can lead to hypotension in some patients. (See "Stable ischemic heart disease: Overview of care".)
Coronary revascularization by percutaneous coronary intervention or coronary artery bypass graft surgery may be required in patients with drug-resistant ischemic DHF . (See "Stable ischemic heart disease: Indications for revascularization".)
Beta blockers — The role of beta blockade in treatment of DHF is uncertain. Direct evidence of clinical benefit is lacking, although beta blockers have a variety of potential beneficial effects in patients with DHF, including slowing the heart rate (which increases the time available for both LV filling and coronary flow, particularly during exercise), reducing myocardial oxygen demand, and, by lowering the blood pressure, causing regression of LVH [19,20]. Slowing the heart rate may be particularly important in the treatment of pulmonary congestion due to ischemic DHF and, as noted above, in patients in AF.
In the small SWEDIC trial, 113 patients with symptoms of HF, normal LVEF, and abnormal diastolic function were randomly assigned to treatment with carvedilol or placebo, with echocardiographic assessment at baseline and six months . Carvedilol therapy resulted in a significant improvement in the E/A ratio, but no significant improvement in deceleration time, isovolumic relaxation time, or pulmonary vein flow velocity.
Beta blockers may also directly improve diastolic function in patients with idiopathic dilated cardiomyopathy and those with an acute myocardial infarction; both are settings in which beta blockers are recommended because they improve survival [22,23]. Slowing of the heart rate may contribute to this effect by providing more time for calcium exit from myocytes, thereby reversing the cellular calcium overload characteristic of diastolic dysfunction. (See "Cellular mechanisms of diastolic dysfunction".)
However, direct evidence of the clinical efficacy of beta blocker therapy in patients with DHF is lacking. While the SENIORS trial suggested that nebivolol (a beta blocker with vasodilating properties) may be beneficial in patients with HF and preserved systolic function, an OPTIMIZE-HF registry study found no clinical benefit of beta blocker therapy in this population.
●In the SENIORS trial, 2128 patients ≥70 years of age with history of HF or known LVEF ≤35 percent were randomly assigned to nebivolol or placebo . Nebivolol therapy resulted in reduction in the primary outcome of all-cause mortality or cardiovascular hospital admission (31 versus 35 percent) at mean 21-month follow-up. While the majority of study patients had LVEF ≤35 percent, there was no significant influence of ejection fraction on the effect of nebivolol on the outcome. The effect of nebivolol on outcomes was similar in those with preserved and impaired LVEF .
●On the other hand, a difference in the clinical efficacy of beta blocker therapy in patients with systolic HF versus patients with DHF was suggested by a retrospective study from the OPTIMIZE-HF registry of 7154 elderly adults hospitalized with HF . Among patients with LV systolic dysfunction, beta blocker therapy was associated with reduced mortality and rehospitalization rates. In contrast, among patients with preserved systolic function, beta blocker therapy was associated with no improvement in mortality or rehospitalization.
Older patients often exhibit chronotropic incompetence and beta blockers can contribute to excessive bradycardia. Failure to augment heart rate during activity can limit cardiac output and contribute to dyspnea and fatigue. For this reason, management of beta blocker therapy requires attention to heart rate at rest as well as during the patient’s usual activity.
Calcium channel blockers — Calcium channel blockers may also be useful in the treatment of DHF, though evidence is limited. These agents have been purported to have a direct "lusitropic" (relaxation-enhancing) effect. However, it is difficult to distinguish this effect from the benefits related to slowing of the heart rate, both at rest and during exercise, and to a reduction in or prevention of ischemic episodes. (See "Calcium channel blockers in the management of stable angina pectoris".)
Small studies in patients with DHF suggest that verapamil may improve symptoms and improve measures of diastolic function [27,28]. In a small randomized, crossover trial of 20 patients with DHF, verapamil, compared to placebo, significantly reduced the signs and symptoms of HF and increased LV diastolic filling rate and treadmill exercise time .
In addition, as discussed separately, in patients with hypertrophic cardiomyopathy, verapamil may improve symptoms and measures of LV diastolic function. (See "Medical therapy in hypertrophic cardiomyopathy".)
ACE inhibitors — There is no evidence from randomized clinical studies that ACE inhibitor therapy directly improves overall morbidity or mortality in patients with DHF. Because patients with DHF frequently have co-morbidities such as renal insufficiency, ACE inhibitors should be used carefully to avoid the risk of renal dysfunction and hypotension. Despite these concerns, ACE inhibitors play an important role in the treatment of the disease processes that underlie the development of DHF, namely, hypertension, CHD, and diabetes.
●ACE inhibitors are beneficial in hypertensive heart disease. The reduction in systemic pressure can lead to regression of LVH and a gradual improvement in diastolic function [18,29]. (See 'Antihypertensive therapy' above.)
●ACE inhibitors are beneficial in patients with mixed systolic and DHF. They are indicated in patients with systolic HF, since they slow the rate of progression of the myocardial disease and improve survival. In such patients, ACE inhibitors may also limit progression of diastolic dysfunction . (See "ACE inhibitors in heart failure due to systolic dysfunction: Therapeutic use".)
The more general efficacy of ACE inhibitors in patients with DHF was assessed in the PEP-CHF trial in which 850 patients ≥70 years of age had diastolic dysfunction: 79 percent had a history of hypertension; patients with substantial LV systolic dysfunction or valve disease were excluded . The patients were randomly assigned to an ACE inhibitor (perindopril) or placebo. At one year, treatment with perindopril was associated with an almost significant trend toward reduction in the primary end point of combined all-cause mortality and unexpected hospitalization for HF (8.0 versus 12.4 percent, hazard ratio 0.69; 95% confidence interval [CI] 0.47-1.01); this effect was entirely due to fewer unexpected hospitalizations for HF. The patients treated with perindopril also had significant improvements in functional class and six minute walk distance.
While benefit from ACE inhibitors may be mediated by its blood pressure effects, it is also possible that there might be a reduction in myocardial angiotensin II production, which can diminish myocardial stiffness. Evidence in support of this hypothesis has been provided by a study of patients with DHF due to aortic stenosis-induced LVH . The intracoronary infusion of enalaprilat, which produced no evidence of systemic ACE inhibition but presumably impaired cardiac angiotensin II production, improved diastolic distensibility and relaxation. Similar benefits may occur in patients with ischemic heart disease  and during experimental low-flow ischemia in hypertrophied hearts with ischemic diastolic dysfunction . (See "Actions of angiotensin II on the heart" and "Angiotensin converting enzyme inhibitors and receptor blockers in heart failure: Mechanisms of action".)
Angiotensin II receptor blockers — There is no evidence from randomized clinical studies that ARB therapy directly improves overall morbidity or mortality in patients with DHF. There is no evidence of improved diastolic function with ARB treatment as compared to other therapies in patients with asymptomatic LV diastolic dysfunction or overt DHF.
ARBs may be beneficial in patients with LV diastolic dysfunction due to hypertension, although the data on impact compared to other agents are limited [17,18,34-37]. In various studies of hypertensive patients with LVH, ARBs caused more regression of LVH than beta blockers [18,35], a change that was associated with an improvement in LV diastolic filling . In other studies, losartan treatment improved exercise tolerance and quality of life (which were not improved by hydrochlorothiazide)  and reduced myocardial fibrosis and stiffness . (See "Clinical implications and treatment of left ventricular hypertrophy in hypertension", section on 'Effect of antihypertensive therapy'.)
However, a large randomized trial in patients with hypertension and diastolic dysfunction demonstrated that improvement in diastolic function with ARB therapy was similar to that with other antihypertensive therapy . The trial included 382 patients who were treated with antihypertensive drugs not related to angiotensin inhibition and then randomly assigned to valsartan or placebo . There were similar improvements in the two groups in blood pressure control and diastolic function, as measured by myocardial relaxation velocity of the lateral mitral annulus (E').
Outcomes of treatment with ARBs in patients with HF and preserved LVEF were investigated in two large trials:
●In the CHARM-Preserved trial, 3023 patients with symptomatic HF (nearly all New York Heart Association [NYHA] class II or III) and an LVEF >40 percent were randomly assigned to either candesartan (mean dose at six months 25 mg) or placebo . The mean LVEF was 54 percent. Additional medications included ACE inhibitor in 19 percent, beta blocker in 56 percent, and calcium channel blocker in 31 percent.
At a median follow-up of 37 months, there was a small and almost significant difference in incidence of the primary end point of cardiovascular death or hospitalization for HF (22 versus 24 percent; adjusted hazard ratio 0.86; 95% CI 0.74-1.00) that was entirely due to a significant reduction in hospitalization for HF with candesartan (16 versus 18 percent). The overall rate of discontinuation of therapy was similar in the two groups (22 versus 18 percent). However, significantly more patients discontinued candesartan because of renal dysfunction, hyperkalemia, or hypotension.
●In the I-PRESERVE trial, 4128 patients with symptomatic HF (nearly all NYHA class II or III) and an LVEF ≥45 percent were randomly assigned to either daily irbesartan 300 mg or placebo . The mean LVEF was 59 percent. Additional medications included ACE inhibitor in 26 percent, beta blocker in 59 percent, and calcium channel blocker in 40 percent.
At a mean follow-up of 49.5 months, there was no significant difference in the primary end point of death from any cause or hospitalization for a cardiovascular cause. There were also no significant differences in secondary outcomes, which included death from HF or hospitalization for HF, death from any cause, hospitalization for a cardiovascular cause, and quality of life.
Aldosterone antagonists — The efficacy of aldosterone antagonist therapy in patients with DHF is uncertain, given the results of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial . The trial randomly assigned 3445 patients with symptomatic HF and LVEF ≥45 percent to receive either spironolactone or placebo. The composite primary outcome consisted of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for HF. The mean follow-up was 3.3 years.
●The primary outcome occurred at similar rates in the spironolactone and placebo groups (18.6 and 20.4 percent, respectively; hazard ratio, 0.89; 95% CI, 0.77 to 1.04).
●Hospitalization for HF was less frequent in the spironolactone group (12.0 percent) compared to the placebo group (14.2 percent; hazard ratio 0.83; 95% CI, 0.69 to 0.99) but other components of the primary outcome occurred at similar rates in the two treatment groups. Total deaths and total hospitalizations were similar in spironolactone and placebo groups.
●The spironolactone group had doubled the rate of hyperkalemia (18.7 versus 9.1 percent) and a higher rate of increased serum creatinine levels but a lower rate of hypokalemia compared to the placebo group.
●Subgroup analysis showed reduction in the primary outcome with spironolactone therapy among patients who were enrolled according to natriuretic peptide (brain natriuretic peptide [BNP] or N-terminal pro-BNP [NT-proBNP]) criteria but not among those enrolled on the basis of hospitalization for HF in the past year.
●Although the test for interaction between region and study group was not significant, a lower rate of primary outcome was seen with spironolactone in the Americas (27.3 versus 31.8 percent with placebo) but not in Russia and Georgia (9.3 versus 8.4 percent with placebo).
In summary, TOPCAT showed no reduction in the composite primary outcome (death from cardiovascular causes, aborted cardiac arrest, or hospitalization for HF) from spironolactone therapy. However, subgroup analyses suggested regional heterogeneity in patient populations and possible benefit from spironolactone therapy in a subset of patients with diagnosis of HF confirmed by elevated BNP or NT-proBNP levels.
Thus, for patients with clear evidence of DHF (including increased BNP) who can be carefully monitored for changes in serum potassium and renal function, we suggest adding spirolactone therapy to their medical regimens. The serum potassium should be <5.0 meq/L and estimated glomerular filtration rate should be ≥30 mL/min per 1.73 m2.
A potential rationale for aldosterone antagonist therapy for DHF comes from animal studies suggesting that aldosterone contributes to cardiac hypertrophy and fibrosis [42,43]. These processes may be preventable or even reversible by aldosterone blockade [44-46].
Phosphodiesterase-5 inhibition — Beneficial hemodynamic response to the phosphodiesterase-5 inhibitor sildenafil (50 mg three times per day) was observed in a randomized placebo-controlled trial of 44 patients with DHF with LVEF ≥50 percent and pulmonary hypertension (pulmonary artery systolic pressure >40 mmHg) . At six months, there was no response to placebo, but sildenafil led to significant improvements in mean pulmonary artery pressure (reduced by 16.7 mmHg), right ventricular function (7.9 mm increase in mean tricuspid annular systolic excursion), and mean right atrial pressure (reduced by 12.4 mm). Quality-of-life measures of breathlessness, fatigue, and emotional function were significantly improved with sildenafil but not placebo. Similar results were observed at 12 months. These findings require confirmation in a larger trial.
Statins — Intensive lipid lowering with statin therapy is recommended for the secondary prevention of cardiovascular disease, independent of the presence of diastolic dysfunction. (See "Intensity of lipid lowering therapy in secondary prevention of cardiovascular disease" and "Treatment of lipids (including hypercholesterolemia) in secondary prevention".)
Initial observational data suggest that statins might be of benefit in patients with DHF. Randomized trials are required to confirm these observations. Statin therapy in patients with HF is discussed in detail separately. (See "Statin therapy in patients with heart failure".)
Exercise conditioning — During exercise in healthy individuals, diastolic function is enhanced so that LV input remains precisely matched to LV output, despite the shortened duration of diastole resulting from the associated tachycardia. This is achieved in the normal LV by a rapid and marked decrease in intraventricular pressure during early diastole, thereby creating a greater LV "suction" effect, which enhances the transmitral pressure gradient without increasing left atrial pressure. This mechanism is lost in patients with diastolic dysfunction; as a result, dyspnea with exertion is often their most common complaint. (See "Pathophysiology of diastolic heart failure", section on 'Normal response to exercise'.)
Long-term exercise training produces physiologic cardiac hypertrophy with enhanced diastolic function. Experimental studies suggest that exercise conditioning has the potential to reverse the diastolic dysfunction of pathologic LVH or aging [48-51].
Small randomized trials suggest that exercise training improves functional capacity in patients with HF with preserved LVEF (which is largely attributed to DHF). This evidence is discussed separately. (See "Cardiac rehabilitation in patients with heart failure", section on 'Effect on functional capacity'.)
Any exercise training program for the potential treatment of DHF should be based upon dynamic isotonic exercise, not static exercise, since the latter causes changes in cardiac geometry similar to those of hypertensive LVH . (See "Cardiac rehabilitation programs".)
Implantable hemodynamic monitor — As discussed separately, a randomized trial found that use of an implantable hemodynamic monitor decreased HF hospitalizations in a population of patients that included patients with DHF . (See "Strategies to reduce hospitalizations in patients with heart failure".) While such devices are not yet available for clinical use, they are currently being evaluated by the United States Food and Drug Administration. The reasons for possible efficacy are unknown, but may include more appropriate titration of medications as well as earlier recognition of problems.
Treatment differences between SHF and DHF — The results of the randomized clinical trials in patients with DHF (or HF with preserved ejection fraction) have demonstrated that while neurohumoral antagonists such as beta blockers, ACE inhibitors, and ARBs are effective in treatment of systolic heart failure (SHF), they do not decrease morbidity and mortality in DHF. These data suggest that there are fundamental differences in the pathophysiology underlying SHF versus DHF. In addition, these data suggest that future studies should target different and novel mechanisms in DHF. When choosing medications for hypertension, co-morbidities should be considered.
PROGNOSIS — Asymptomatic diastolic dysfunction is a predictor of future cardiovascular morbidity, but prognosis differs from that in patients with symptoms of heart failure (ie, diastolic heart failure [DHF]).
Asymptomatic diastolic dysfunction — Moderate to severe diastolic dysfunction without HF is a predictor of mortality, as illustrated by the following studies:
●In the Mayo Clinic cross-sectional community survey of 2042 adults ≥45 years of age, 21 percent had mild diastolic dysfunction, 7 percent had moderate diastolic dysfunction, and 1 percent had severe diastolic dysfunction . At a median follow-up of 3.5 years, 48 subjects died. After controlling for age, sex, and left ventricular ejection fraction (LVEF), all-cause mortality was increased in patients with mild diastolic dysfunction (96 percent without a diagnosis of HF; hazard ratio [HR] 8.3) and in those with moderate to severe diastolic dysfunction (90 percent without a diagnosis of HF; HR 10.2).
●In another report, 3008 Native Americans 45 to 74 years of age were followed for three years following Doppler echocardiography . Sixteen percent of patients had an E/A ratio <0.6 (impaired diastolic relaxation) and 3 percent had an E/A ratio >1.5 (restrictive pattern due to reduced compliance) (waveform 1). After adjustment for covariates, an E/A ratio >1.5, but not an E/A ratio <0.6, was independently associated with all-cause and cardiac mortality (relative risks 1.7 and 2.8, respectively).
●A Cleveland Clinic study followed 36,261 adults (mean age 58) with LVEF ≥55 percent for a mean of 6.2 years . Sixty percent had mild diastolic dysfunction, 4.8 percent had moderate diastolic dysfunction, and 0.4 percent had severe diastolic dysfunction. 5789 deaths occurred during the follow-up period. Moderate and severe (but not mild) diastolic dysfunction were independent risk factors for mortality after adjustment for cardiovascular risk factors and comorbidities (HR 1.58; 95% CI 1.20-1.28 and HR 1.84; 1.29-2.62).
Symptomatic patients (ie, DHF) — The prognosis of patients with symptomatic DHF is less well defined than in that of patients with systolic HF. Data from the Framingham Heart Study, the V-HeFT trials, and several observational series revealed varying results [56-63]. In addition, the data are not clear on whether the long-term prognosis differs between diastolic and systolic HF .
In reports from the community-based Framingham Heart study and the larger Cardiovascular Health Study, prognosis was significantly better in patients with diastolic dysfunction [58,60]. In the latter study of 269 patients at least 65 years of age who had HF, the mortality rates were 87 versus 154 deaths per 1000 person-years with normal and impaired systolic function, respectively (adjusted HR 1.48 and 1.88 compared to persons with no HF and normal left ventricular systolic function) .
In contrast, another community-based study from Olmsted County, Minnesota found that, after adjustment for risk factors, five-year survival was not significantly different in patients with diastolic versus systolic HF (adjusted relative risk 0.80, p = 0.37) .
Among patients hospitalized for HF, the mortality rates are higher but the data are again conflicting as to whether or not the prognosis is different in diastolic and systolic HF:
●Among 6076 patients discharged from a Mayo Clinic Hospitals in Olmsted County, Minnesota with a diagnosis of decompensated HF over a 15-year period (1987 to 2001), 53 percent had a reduced LVEF and 47 percent had a preserved LVEF . One-year mortality was relatively high in both groups, but slightly lower in patients with a preserved LVEF (29 versus 32 percent in patients with reduced LVEF, adjusted HR 0.96, 95% CI 0.92-1.00). Survival improved over time for those with reduced LVEF but not for those with preserved LVEF.
●In a prospective evaluation of 413 patients hospitalized for HF, the relative risk for six-month mortality was lower for diastolic versus systolic HF dysfunction (13 versus 21 percent, adjusted HR 0.51) .
●In a cohort of 2802 patients discharged from 103 hospitals in Ontario with a diagnosis of decompensated HF, one-year mortality was 22 percent in patients with a preserved LVEF versus 26 percent in patients with a reduced LVEF . This difference was not statistically significant.
Independent predictors of mortality in patients with DHF in different studies include older age, male gender, New York Heart Association (NYHA) class, lower LVEF, the extent of coronary artery disease, peripheral artery disease, diabetes, impaired renal function, the degree of diastolic dysfunction as assessed by Doppler echocardiography, and increased red cell distribution width [65-70].
Causes of death — The mode of death was evaluated in patients with symptomatic DHF (NYHA class II to IV HF with LVEF ≥45 percent) enrolled in the I-Preserve trial . The annual mortality rate was 5 percent. Sixty percent of deaths were cardiovascular (26 percent sudden, 14 percent HF, 5 percent myocardial infarction, and 9 percent stroke), 30 percent were noncardiovascular (including cancer and infection/sepsis), and 10 percent were of unknown cause. Irbesartan treatment did not affect the mortality rate or the distribution of mode of death.
Morbidity — Nearly every study that has compared morbidity outcomes in systolic HF and DHF have found equivalent rates [63,72-76]. These include the rate and frequency of hospitalization for HF, symptomatic status as measured by abnormalities in myocardial oxygen consumption, six-minute walk distance, Minnesota Living with Heart Failure questionnaire scores, and other quality-of-life indicators. Therefore, patients with DHF have a morbidity burden equivalent to that in patients with systolic HF.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topics (see "Patient information: Heart failure and atrial fibrillation (The Basics)")
●Beyond the Basics topic (see "Patient information: Heart failure (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●In patients with diastolic heart failure (DHF), certain types of hemodynamic stress including atrial fibrillation; tachycardia; abrupt, severe, or refractory elevations in systemic blood pressure, and myocardial ischemia are associated with worsening of diastolic dysfunction. (See 'Impaired response to stress' above.)
●The treatment of DHF remains empiric since trial data are limited. The general principles for treatment of DHF are control of systolic and diastolic hypertension, control of heart rate, particularly in patients with atrial fibrillation, control of pulmonary congestion and peripheral edema with diuretics, and coronary revascularization in patients with coronary heart disease with ischemia judged to impair diastolic function. (See 'General principles' above.)
●An important caveat is that the patient who has left ventricular (LV) diastolic dysfunction with a small, stiff LV chamber is particularly susceptible to excessive preload reduction, which can lead sequentially to underfilling of the LV, a fall in cardiac output, and hypotension. In patients with severe LV hypertrophy due to hypertension or hypertrophic cardiomyopathy, excessive preload reduction can also create subaortic outflow obstruction. For these reasons, the diuretics or venodilators such as nitrates and dihydropyridine calcium channel blockers must be administered with caution. (See 'Choice of medications' above.)
●Restoration and maintenance of sinus rhythm is preferred when atrial fibrillation occurs in patients with DHF. When this cannot be achieved, rate control becomes important. (See 'Atrial fibrillation' above.)
●Direct evidence to support a specific drug regimen to treat DHF is lacking. (See 'Treatment' above.)
●Asymptomatic LV diastolic dysfunction is a predictor of future cardiovascular morbidity. Symptomatic patients with DHF experience morbidities (eg, hospitalization for HF) at a rate that is virtually the same as that seen in patients with systolic HF. Mortality rates in both DHF and systolic HF are high; published data on differences in mortality rates are conflicting. (See 'Prognosis' above.)
- Aurigemma GP, Gaasch WH. Clinical practice. Diastolic heart failure. N Engl J Med 2004; 351:1097.
- Zile MR, Bennett TD, St John Sutton M, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation 2008; 118:1433.
- Zile MR, Bourge RC, Bennett TD, et al. Application of implantable hemodynamic monitoring in the management of patients with diastolic heart failure: a subgroup analysis of the COMPASS-HF trial. J Card Fail 2008; 14:816.
- Stevenson LW, Zile M, Bennett TD, et al. Chronic ambulatory intracardiac pressures and future heart failure events. Circ Heart Fail 2010; 3:580.
- Zile MR, Adamson PB, Cho YK, et al. Hemodynamic factors associated with acute decompensated heart failure: part 1--insights into pathophysiology. J Card Fail 2011; 17:282.
- Adamson PB, Zile MR, Cho YK, et al. Hemodynamic factors associated with acute decompensated heart failure: part 2--use in automated detection. J Card Fail 2011; 17:366.
- Ritzema J, Troughton R, Melton I, et al. Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure. Circulation 2010; 121:1086.
- Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 2011; 377:658.
- 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.
- Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008; 29:2388.
- . Nonpharmacologic management and health care maintenance in patients with chronic heart failure. J Card Fail 2006; 12:e29.
- Eberli FR, Apstein CS, Ngoy S, Lorell BH. Exacerbation of left ventricular ischemic diastolic dysfunction by pressure-overload hypertrophy. Modification by specific inhibition of cardiac angiotensin converting enzyme. Circ Res 1992; 70:931.
- Ahmed A, Rich MW, Fleg JL, et al. Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation group trial. Circulation 2006; 114:397.
- Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997; 336:525.
- ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.
- Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358:1887.
- Wachtell K, Bella JN, Rokkedal J, et al. Change in diastolic left ventricular filling after one year of antihypertensive treatment: The Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) Study. Circulation 2002; 105:1071.
- Klingbeil AU, Schneider M, Martus P, et al. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med 2003; 115:41.
- Bonow RO, Udelson JE. Left ventricular diastolic dysfunction as a cause of congestive heart failure. Mechanisms and management. Ann Intern Med 1992; 117:502.
- Brutsaert DL, Sys SU, Gillebert TC. Diastolic failure: pathophysiology and therapeutic implications. J Am Coll Cardiol 1993; 22:318.
- Bergström A, Andersson B, Edner M, et al. Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC). Eur J Heart Fail 2004; 6:453.
- Andersson B, Caidahl K, di Lenarda A, et al. Changes in early and late diastolic filling patterns induced by long-term adrenergic beta-blockade in patients with idiopathic dilated cardiomyopathy. Circulation 1996; 94:673.
- Poulsen SH, Jensen SE, Egstrup K. Effects of long-term adrenergic beta-blockade on left ventricular diastolic filling in patients with acute myocardial infarction. Am Heart J 1999; 138:710.
- Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J 2005; 26:215.
- van Veldhuisen DJ, Cohen-Solal A, Böhm M, et al. Beta-blockade with nebivolol in elderly heart failure patients with impaired and preserved left ventricular ejection fraction: Data From SENIORS (Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure). J Am Coll Cardiol 2009; 53:2150.
- Hernandez AF, Hammill BG, O'Connor CM, et al. Clinical effectiveness of beta-blockers in heart failure: findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) Registry. J Am Coll Cardiol 2009; 53:184.
- Setaro JF, Zaret BL, Schulman DS, et al. Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance. Am J Cardiol 1990; 66:981.
- Hung MJ, Cherng WJ, Kuo LT, Wang CH. Effect of verapamil in elderly patients with left ventricular diastolic dysfunction as a cause of congestive heart failure. Int J Clin Pract 2002; 56:57.
- Aronow WS, Kronzon I. Effect of enalapril on congestive heart failure treated with diuretics in elderly patients with prior myocardial infarction and normal left ventricular ejection fraction. Am J Cardiol 1993; 71:602.
- Hayashida W, Van Eyll C, Rousseau MF, Pouleur H. Regional remodeling and nonuniform changes in diastolic function in patients with left ventricular dysfunction: modification by long-term enalapril treatment. The SOLVD Investigators. J Am Coll Cardiol 1993; 22:1403.
- Cleland JG, Tendera M, Adamus J, et al. The perindopril in elderly people with chronic heart failure (PEP-CHF) study. Eur Heart J 2006; 27:2338.
- Friedrich SP, Lorell BH, Rousseau MF, et al. Intracardiac angiotensin-converting enzyme inhibition improves diastolic function in patients with left ventricular hypertrophy due to aortic stenosis. Circulation 1994; 90:2761.
- Rousseau MF, Gurné O, van Eyll C, et al. Effects of benazeprilat on left ventricular systolic and diastolic function and neurohumoral status in patients with ischemic heart disease. Circulation 1990; 81:III123.
- Warner JG Jr, Metzger DC, Kitzman DW, et al. Losartan improves exercise tolerance in patients with diastolic dysfunction and a hypertensive response to exercise. J Am Coll Cardiol 1999; 33:1567.
- Dahlöf B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359:995.
- Little WC, Zile MR, Klein A, et al. Effect of losartan and hydrochlorothiazide on exercise tolerance in exertional hypertension and left ventricular diastolic dysfunction. Am J Cardiol 2006; 98:383.
- Díez J, Querejeta R, López B, et al. Losartan-dependent regression of myocardial fibrosis is associated with reduction of left ventricular chamber stiffness in hypertensive patients. Circulation 2002; 105:2512.
- Solomon SD, Janardhanan R, Verma A, et al. Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial. Lancet 2007; 369:2079.
- Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet 2003; 362:777.
- Massie BM, Carson PE, McMurray JJ, et al. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med 2008; 359:2456.
- Pitt B, Pfeffer MA, Assmann SF, et al. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med 2014; 370:1383.
- Lijnen P, Petrov V. Induction of cardiac fibrosis by aldosterone. J Mol Cell Cardiol 2000; 32:865.
- Fullerton MJ, Funder JW. Aldosterone and cardiac fibrosis: in vitro studies. Cardiovasc Res 1994; 28:1863.
- Weber KT, Brilla CG. Pathological hypertrophy and cardiac interstitium. Fibrosis and renin-angiotensin-aldosterone system. Circulation 1991; 83:1849.
- Lacolley P, Safar ME, Lucet B, et al. Prevention of aortic and cardiac fibrosis by spironolactone in old normotensive rats. J Am Coll Cardiol 2001; 37:662.
- Young M, Funder JW. Eplerenone, but not steroid withdrawal, reverses cardiac fibrosis in deoxycorticosterone/salt-treated rats. Endocrinology 2004; 145:3153.
- Guazzi M, Vicenzi M, Arena R, Guazzi MD. Pulmonary hypertension in heart failure with preserved ejection fraction: a target of phosphodiesterase-5 inhibition in a 1-year study. Circulation 2011; 124:164.
- Scheuer J, Malhotra A, Hirsch C, et al. Physiologic cardiac hypertrophy corrects contractile protein abnormalities associated with pathologic hypertrophy in rats. J Clin Invest 1982; 70:1300.
- Schaible TF, Ciambrone GJ, Capasso JM, Scheuer J. Cardiac conditioning ameliorates cardiac dysfunction associated with renal hypertension in rats. J Clin Invest 1984; 73:1086.
- Buttrick PM, Malhotra A, Scheuer J. Effects of systolic overload and swim training on cardiac mechanics and biochemistry in rats. J Appl Physiol (1985) 1988; 64:1466.
- Brenner DA, Apstein CS, Saupe KW. Exercise training attenuates age-associated diastolic dysfunction in rats. Circulation 2001; 104:221.
- Spirito P, Pelliccia A, Proschan MA, et al. Morphology of the "athlete's heart" assessed by echocardiography in 947 elite athletes representing 27 sports. Am J Cardiol 1994; 74:802.
- Redfield MM, Jacobsen SJ, Burnett JC Jr, et al. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003; 289:194.
- Bella JN, Palmieri V, Roman MJ, et al. Mitral ratio of peak early to late diastolic filling velocity as a predictor of mortality in middle-aged and elderly adults: the Strong Heart Study. Circulation 2002; 105:1928.
- Halley CM, Houghtaling PL, Khalil MK, et al. Mortality rate in patients with diastolic dysfunction and normal systolic function. Arch Intern Med 2011; 171:1082.
- Senni M, Tribouilloy CM, Rodeheffer RJ, et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation 1998; 98:2282.
- Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006; 355:251.
- Vasan RS, Larson MG, Benjamin EJ, et al. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol 1999; 33:1948.
- Cohn JN, Johnson G. Heart failure with normal ejection fraction. The V-HeFT Study. Veterans Administration Cooperative Study Group. Circulation 1990; 81:III48.
- Gottdiener JS, McClelland RL, Marshall R, et al. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. The Cardiovascular Health Study. Ann Intern Med 2002; 137:631.
- MacCarthy PA, Kearney MT, Nolan J, et al. Prognosis in heart failure with preserved left ventricular systolic function: prospective cohort study. BMJ 2003; 327:78.
- Smith GL, Masoudi FA, Vaccarino V, et al. Outcomes in heart failure patients with preserved ejection fraction: mortality, readmission, and functional decline. J Am Coll Cardiol 2003; 41:1510.
- Bhatia RS, Tu JV, Lee DS, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 2006; 355:260.
- Senni M, Redfield MM. Heart failure with preserved systolic function. A different natural history? J Am Coll Cardiol 2001; 38:1277.
- O'Connor CM, Gattis WA, Shaw L, et al. Clinical characteristics and long-term outcomes of patients with heart failure and preserved systolic function. Am J Cardiol 2000; 86:863.
- Jones RC, Francis GS, Lauer MS. Predictors of mortality in patients with heart failure and preserved systolic function in the Digitalis Investigation Group trial. J Am Coll Cardiol 2004; 44:1025.
- Ahmed A, Aronow WS, Fleg JL. Higher New York Heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function. Am Heart J 2006; 151:444.
- Hillege HL, Nitsch D, Pfeffer MA, et al. Renal function as a predictor of outcome in a broad spectrum of patients with heart failure. Circulation 2006; 113:671.
- Persson H, Lonn E, Edner M, et al. Diastolic dysfunction in heart failure with preserved systolic function: need for objective evidence:results from the CHARM Echocardiographic Substudy-CHARMES. J Am Coll Cardiol 2007; 49:687.
- Felker GM, Allen LA, Pocock SJ, et al. Red cell distribution width as a novel prognostic marker in heart failure: data from the CHARM Program and the Duke Databank. J Am Coll Cardiol 2007; 50:40.
- Zile MR, Gaasch WH, Anand IS, et al. Mode of death in patients with heart failure and a preserved ejection fraction: results from the Irbesartan in Heart Failure With Preserved Ejection Fraction Study (I-Preserve) trial. Circulation 2010; 121:1393.
- Yancy CW, Lopatin M, Stevenson LW, et al. Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol 2006; 47:76.
- Cleland JG, Swedberg K, Follath F, et al. The EuroHeart Failure survey programme-- a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 2003; 24:442.
- Owan TE, Redfield MM. Epidemiology of diastolic heart failure. Prog Cardiovasc Dis 2005; 47:320.
- Liao L, Jollis JG, Anstrom KJ, et al. Costs for heart failure with normal vs reduced ejection fraction. Arch Intern Med 2006; 166:112.
- Aurigemma GP. Diastolic heart failure--a common and lethal condition by any name. N Engl J Med 2006; 355:308.