CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 4, July/August 2010
218
AFRICA
Guidelines and therapy for diastolic heart failure
The difficulties in the diagnosis of diastolic heart failure
have been partly responsible for the limited number of larger
randomised, controlled trials to guide treatment. In 1998, the
European study group published one of the first widely analysed
guidelines for diagnosis of diastolic heart failure, stating the
need for evidence of heart failure with normal systolic function
(LVEF
≥
0.50) as well as evidence of abnormal filling, diastolic
distensibility, LV relaxation or diastolic stiffness.
53
The European Society of Cardiology recently published their
latest guidelines for diagnosis of diastolic heart failure in 2007;
providing specific guidelines on how to diagnose and exclude
heart failure with normal ejection fraction.
54
The guidelines have
three major criteria for diagnosing heart failure with normal
ejection fraction; (1) signs/symptoms of heart failure, (2) normal
or mildly reduced systolic function (EF
>
50% with a left
ventricular end-diastolic volume index less than 97 ml/m
2
) and
(3) evidence of left ventricular diastolic dysfunction.
The diagnostic strategy provided in this set of guidelines
allows for non-invasive methods of assessing for left ventricular
diastolic dysfunction through tissue Doppler parameters (early
mitral valve flow velocity to early tissue Doppler lengthening
velocity (E/E¢
>
15) and routine blood test biomarkers (brain
natriuretic peptide
>
200 pg/ml) to play a role in situations when
invasive haemodynamic measurements (LV end-diastolic pres-
sure
>
16 mmHg or mean pulmonary capillary wedge pressure
>
12 mmHg) are not available.
Current treatment of diastolic heart failure has been aimed
at controlling blood pressure and tachycardia, using diuretics
to control pulmonary congestion and peripheral oedema, and
alleviation of myocardial ischaemia. The ACC/AHA also recom-
mend using beta-adrenergic blocking agents, angiotensin recep-
tor blockers, angiotensin converting enzyme inhibitors, calcium
antagonists in those patients with controlled blood pressure, and
digitalis in order to control heart failure symptoms. In the latest
update of the ACC/AHA practice guidelines for the diagnosis
and management of chronic heart failure in the adult, which
comprises a document of 63 pages, the treatment of diastolic
heart failure is summarised in less than one page.
55
Chinnaiyan
et al
. described the combined use of beta-block-
ers, angiotensin converting enzyme inhibitors, angiotensin II
receptor blockers, calcium channel blockers and spironolactone
as potential disease-modifying therapy.
56
The authors believe
that the effects of these drugs improve diastolic dysfunction and
diastolic heart failure by regression of left ventricular hyper-
trophy and decreased collagen content. They recommend these
drugs to be utilised in both the setting of decompensated diasto-
lic heart failure as well as for the chronic outpatient management
of diastolic heart failure. In the recently published Hong Kong
diastolic heart failure study,
150 patients with heart failure and
preserved ejection fraction were randomised to diuretics, ACE
inhibitors or angiotensin II receptor blocker therapy.
57
Only
diuretic therapy reduced symptoms and improved quality of life
during one-year follow up.
Currently, only a few large randomised clinical trials have
assessed the possible benefit of pharmacotherapy at different
stages of non-invasively diagnosed diastolic dysfunction, such
as the CHARM Preserved trial and I-PRESERVE (see above).
30,32
While hospitalisation rates have been reduced with candesartan
therapy, survival rate mortality has not been improved in either
of these trials.
Some small trials have been carried out in an attempt to
evaluate possible benefits of pharmacotherapy for patients with
left ventricular diastolic dysfunction and decreased exercise
tolerance. Warner
et al.
studied 20 patients with mild diastolic
dysfunction, diagnosed by Doppler echocardiography, with a
marked hypertensive response to exercise.
58
The authors reported
that using the angiotensin II receptor blocker losartan, resting
blood pressure was unchanged but the hypertensive response
to exercise was reduced (from a mean systolic blood pressure
(SBP) of 226 mmHg to a mean SBP of 193 mmHg).
Similar studies confirmed the benefits of angiotensin II
receptor blockers on exercise tolerance by comparing its effects
with calcium channel blockers (verapamil) or diuretics (hydro-
chlorothiazide). In two separate trials, Little
et al
. demonstrated
that angiotensin II receptor blockers, calcium channel blockers
and diuretics all have the ability to blunt an increase in SBP
during exercise in patients with asymptomatic left ventricular
diastolic dysfunction, but only angiotensin II receptor blocker
therapy increased exercise duration and improved quality of life,
as assessed by questionnaires.
59,60
Conclusion
Further research is needed to improve current knowledge of
diastolic dysfunction and diastolic heart failure as well as its
progression over time. The management of diastolic heart failure
is currently aimed at symptomatic management and control of
physiological factors known to affect ventricular relaxation, and
control of risk factors and co-morbidities (such as hypertension
and diabetes mellitus). A timeline for initiation of treatment for
diastolic dysfunction has yet to be defined. It is anticipated but not
proven whether early initiation of pharmacotherapy once diasto-
lic dysfunction has been diagnosed even in the absence of symp-
toms will prevent or delay the onset of symptomatic heart failure.
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