Diastolic Heart Failure

See Also

Definitions

Heart Failure with Preserved Ejection Fraction (HFpEF or Diastolic Heart Failure)
1. Signs and symptoms of Congestive Heart Failure AND
2. Left ventricular ejection fraction >50% (some include EF >40%)

Pathophysiology

Hypertrophic heart with impaired relaxation
1. Stiff, less compliant left ventricle that does not adequately fill
Heart meets metabolic needs
1. But cost is a higher diastolic pressure
2. Transmits pressures to lung vasculature (with reduced Lung Compliance)
3. Results in pulmonary congestion
4. Ultimately leads to right-sided Heart Failure
Mechanisms
1. Abnormal renal Sodium metabolism
2. Decreased compliance of myocardial wall as well as arterial wall
3. Decreased diastolic ventricular filling

Epidemiology

Incidence and Prevalence
1. Prevalence: 5 Million in U.S.
2. Incidence: 650,000 per year in U.S.
3. Responsible for 30-50% of Congestive Heart Failure (increasing by 1% per year)
Age
1. Incidence increases with age (over 55 years)
2. More common in elderly women
Race
1. More common in black patients

Causes

See Heart Failure Causes
Common causes
1. Hypertension
  1. Longstanding Uncontrolled Hypertension is the most common underlying etiology
  2. Causes Left Ventricular Hypertrophy
2. Coronary Artery Disease
3. Aortic Stenosis
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. Other Valvular disease

Risk Factors
Key Factors

Advanced age
Female gender
Obesity
Diabetes Mellitus
Tobacco Abuse

Risk Factors
Exacerbating Factors

Tachycardia
Atrial Fibrillation
Increased ventricular load (volume overload)
Exercise
Increased salt intake
NSAIDs
Hyperthyroidism
Infection or fever
Anemia

Presentations
Typical patient

Elderly women with systolic Hypertension and Left Ventricular Hypertrophy
Comorbid Obesity or Diabetes Mellitus or Metabolic Syndrome

Symptoms

Dyspnea on exertion
Fatigue
Generalized weakness
Orthopnea or paroxysmal nocturnal Dyspnea
Peripheral Edema

Signs

Symptoms and signs overlap with Systolic Dysfunction
1. S3 Gallup Rhythm (LR+ 4.4)
2. Jugular Venous Distention (LR+ 7.4)
3. Displaced apical impulse (LR+ 16)
4. Madhok (2008) BMC Fam Pract 9:56 [PubMed]
Establish Congestive Heart Failure diagnosis clinically
Evaluate for Systolic Dysfunction
Rule out other causes
1. Significant valvular disease
2. Pericardial disease (e.g. pericardial constriction)
3. Inducible Myocardial Ischemia
Document elevated left ventricle end diastolic pressure
1. Often impractical to perform

Labs

See Systolic Dysfunction
B-Type Natriuretic Peptide (BNP)
1. Does not distinguish from Systolic Dysfunction
2. BNP <100 or NT-BNP <300 excludes Acute Heart Failure in the Emergency Department (LR- 0.1)
3. Martindale (2016) Acad Emerg Med 23(3); 223-42 [PubMed]

Diagnosis

See Framingham Heart Failure Diagnostic Criteria
Transthoracic Echocardiogram
1. See Echocardiogram in Congestive Heart Failure
2. Left Ventricular Ejection Fraction >50%
3. E-A Wave Ratio abnormal (evaluates for Diastolic Dysfunction)
  1. Definitions
    1. E Wave: Peak velocity diastolic mitral valve flow
    2. A Wave: Atrial contraction
  2. 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. Other measures
  1. Left ventricular mass
  2. Valvular Disease
  3. Left atrial size
  4. Measurement of Tau abnormal
Coronary Angiography
1. Indicated if Angina or ischemia on other testing

Management
General

See Congestive Heart Failure Exacerbation Management
Goals
1. Increase Exercise capacity and physical functioning
2. Improve diastolic function
Aggressively manage Hypertension
1. Controlling Blood Pressure is single most important factor
Manage other Coronary Risk Factors
1. Hyperlipidemia
2. Obesity
3. Tobacco Abuse
4. Diabetes Mellitus
5. Encourage regular aerobic Exercise (Exercise training is effective)
  1. Fukuta (2016) Eur J Prev Cardiol 23(10: 78-85 [PubMed]
Reduce exacerbating factors
1. Control Myocardial Ischemia
  1. Revascularization as indicated
2. Maintain sinus rhythm and prevent Tachycardia
3. Manage Atrial Fibrillation
  1. Treat causative conditions (e.g. Hyperthyroidism)
  2. Atrial Fibrillation Rate Control
  3. Atrial Fibrillation Anticoagulation
4. Optimize comorbidities (e.g. COPD, Anemia, Obesity)
5. Screen and treat for Sleep Apnea

Management
Medications

Precautions
1. HFpEF patients are sensitive to excessive Preload reduction (e.g. Diuretics, nitrates)
2. Risk of weakness, Dizziness, Syncope
3. Monitor Electrolytes, Renal Function and volume status (esp. when adding or titrating medications)
Preferred medications in Diastolic Dysfunction
1. Beta Blockers
  1. Maximizes diastolic filling
  2. Decreases pulse, Coronary Artery Disease, Left Ventricular Hypertrophy
  3. No difference in mortality or hospitalizations
    1. van Veldhuisen (2009) J Am Coll Cardiol 53(23): 2150-8 [PubMed]
    2. Yamamoto (2013) Eur J Heart Fail 15(1): 110-8 [PubMed]
2. ACE Inhibitor
  1. Improves myocardial relaxation and compliance
  2. Lowers Preload and Afterload
3. Angiotensin Receptor Blockers
  1. Have not reduced mortality or hospitalizations
    1. Heran (2012) Cochrane Database Syst Rev (4):CD003040 [PubMed]
  2. Entresto (Sacubitril/Valsartan)
    1. Has been FDA approved for HFpEF, but evidence is weak
    2. (2021) Presc Lett 28(2): 9
    3. Sible (2016) Cardiol Rev 24(1):41-7 [PubMed]
4. Diuretics
  1. Thiazide Diuretics
    1. Preferred agent for Hypertension
  2. Loop Diuretics
    1. Loop Diuretics are indicated for Fluid Overload
    2. If not Fluid Overloaded, Loop Diuretics may lower Preload and increase symptoms
    3. Diuretics may decrease Dyspnea and acute exacerbations
    4. Risk of Hypotension, Prerenal Failure
  3. Aldosterone Antagonists (e.g. Spironolactone)
    1. Spironolactone has uncertain efficacy, but is likely beneficial and FDA approved for HFpEF
    2. May reduce HFpEF hospitalizations
    3. Kosmas (2018) Ann Transl Med 6(23): 461+PMID:30603649 [PubMed]
Other medications to consider
1. SGLT2 Inhibitors: Jardiance (Empagliflozin) or Farxiga (Dapagliflozin)
  1. Appears effective in reducing hospitalizations even in non-Diabetic patients with HFpEF (NNT 35 in 2 years)
  2. However, best effect is in reduced Ejection Fraction (even mild reduction of 40-50% EF)
  3. Anker (2021) N Engl J Med [PubMed]
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
  4. Associated with decreased Exercise tolerance
    1. Redfield (2015) N Engl J Med 373(24): 2314-24 [PubMed]
Medications to avoid
1. Digoxin
  1. Avoid except in Atrial Fibrillation
  2. No effect on mortality, but may increase hospitalizations
    1. Hashim (2014) Am J Med 127(2): 132-9 [PubMed]

Prevention

Control Cardiac Risk Factors
Consider Cardiac Rehabilitation

Complications

Mortality from Diastolic Heart Failure is equivalent to Systolic Heart Failure mortality

Prognosis

Hospitalizations
1. Mortality at one year after first HFpEF admission: 25%
2. Mortality at five years after first HFpEF admission
  1. Age over 60 years: 24%
  2. Age over 80 years: 54%
Factors associated with worse prognosis
1. Higher NT-BNP levels
2. Advanced age
3. Diabetes Mellitus
4. Prior Myocardial Infarction
5. Chronic Obstructive Pulmonary Disease
6. Chronic Kidney Disease
  1. Creatinine Clearance >60 ml/min/1.73 m2: Survival >80% 4 year
  2. Creatinine Clearance <20 ml/min/1.73 m2: Survival <20% 4 year

References