Diastolic heart failure is defined as heart failure with preserved left ventricular ejection fraction. It accounts for 30-50% of heart failure cases. The main causes are cardiac ischemia, hypertension, aging, obesity, and aortic stenosis. Diagnosis requires clinical signs of heart failure, normal left ventricular ejection fraction, and evidence of left ventricular diastolic dysfunction. Treatment focuses on reducing congestion with diuretics, controlling hypertension and ischemia, and improving left ventricular relaxation.

1. Residence Report

2. Diastolic heart Failure

3. Diagnostic Criteria for Diastolic Heart Failure Definitive diastolic heart failure Definitive evidence of congestive heart failure = Clinical symptoms and signs, supporting chest radiography, typical clinical response to diuretics with or without elevated left ventricular filling pressure, or low cardiac index Objective evidence of normal left ventricular systolic function in proximity of event = LVEF 50 percent or more within 72 hours of event. Objective evidence of left ventricular diastolic dysfunction = Abnormal left ventricular relaxation or filling or distensibility indices on catheterization.

4. 30% to 50% of patients with active congestive heart failure (CHF) have adequate LV systolic function

5. Causes of Diastolic Dysfunction and Heart Failure Cardiac ischemia Hypertension Aging Obesity Aortic stenosis Uncommon causes Myocardial disorders (e.g., amyloidosis, sarcoidosis) Pericardial disorders (e.g., Constrictive pericarditis, Pericardial effusion) Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

6. Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

7. Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

8. J ACC 2008;51:18–22 Mechanical Dyssynchrony in Congestive Heart Failure

9. Trans–mitral-valve Doppler in normal patient Am. Family Physician 2004;69:2609-16. Diastolic Heart Failure: Challenges of Diagnosis and Treatment

10. Trans–mitral-valve Doppler in patient of Diastolic heart failure Am. Family Physician 2004;69:2609-16. Diastolic Heart Failure: Challenges of Diagnosis and Treatment

11. NEJM 351;11 september 9, 2004 Diastolic Heart Failure

12. NEJM 351;11 september 9, 2004 Diastolic Heart Failure

13. NEJM 351;11 september 9, 2004 Diastolic Heart Failure

14. Diastolic and systolic NEJM 351;11 september 9, 2004 Diastolic Heart Failure

15. N Engl J Med 2003;348:2007-18

16. Management Principles for Patients with Diastolic Heart Failure Reduce the congestive state Salt restriction Diuretics ACE inhibitors Angiotensin II–receptor blockers NEJM 351;11 september 9, 2004 Diastolic Heart Failure

17. Management Principles for Patients with Diastolic Heart Failure Maintain atrial contraction and prevent tachycardia Cardioversion of atrial fibrillation Sequential atrioventricular pacing Beta-blockers Calcium-channel blockers Radiofrequency ablation modification of atrioventricular node and pacing

18. Management Principles for Patients with Diastolic Heart Failure Treat and prevent myocardial Ischemia Nitrates Beta-blockers Calcium-channel blockers Coronary-artery bypass surgery, percutaneous coronary intervention Control hypertension Antihypertensive agents NEJM 351;11 september 9, 2004 Diastolic Heart Failure

19. Management Principles for Patients with Diastolic Heart Failure Promote regression of hypertrophy and prevent myocardial fibrosis ACE inhibitors Angiotensin-receptor blockers Spironolactone NEJM 351;11 september 9, 2004 Diastolic Heart Failure

20. Goals for Treating Diastolic Heart Failure Treat precipitating factors and underlying disease. Prevent and treat hypertension and ischemic heart disease. Surgically remove diseased pericardium. Improve left ventricular relaxation. ACE inhibitors Calcium channel blockers Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

21. Goals for Treating Diastolic Heart Failure Regress left ventricular hypertrophy (decrease wall thickness and remove excess collagen). ACE inhibitors and ARBs Aldosterone antagonists Beta blockers Calcium channel blockers Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

22. Goals for Treating Diastolic Heart Failure Maintain atrioventricular synchrony by managing tachycardia (tachyarrhythmia) Beta blockers (preferred) Calcium channel blockers (second-line agents) Digoxin (controversial) Atrioventricular node ablation (rare cases) Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

23. Goals for Treating Diastolic Heart Failure Optimize circulating volume (hemodynamics). ACE inhibitors Aldosterone antagonists (theoretical benefit) Salt and water restriction Diuresis, dialysis, or plasmapheresis Improve survival. Beta blockers ACE inhibitors Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure

24. Goals for Treating Diastolic Heart Failure Prevent relapse by intensifying outpatient follow-up. Control blood pressure. Dietary counseling (sodium) Monitoring volume status (daily weights and diuretic adjustment) Institute exercise program. Am. Family Physician Volume 73, Number 5 2006 Diagnosis and Management of Diastolic Dysfunction and Heart Failure