Diastolic dysfunction medical therapy: Difference between revisions

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Latest revision as of 12:10, 30 January 2013

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2]

Overview

The chronic treatment of diastolic dysfunction involves aggressive management of the underlying disorder that is causing the diastolic dysfunction such as diabetes or hypertension. Mild diastolic dysfunction that is well tolerated requires no specific treatment. Rate control is an important part of the acute therapy of the patient with diastolic heart failure. It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy of diastolic dysfunction.

Acute Treatment of Diastolic Heart Failure

Rate Control

It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy diastolic dysfunction. Furthermore, in atrial fibrillation there is a failure of atrial kick to augment the filling of the left ventricle.

Diuresis

Diuresis may reduce acute volume overload.

Relief of Ischemia

Acute myocardial ischemia leads to diastolic dysfunction which increases left atrial pressure and causes pulmonary edema.

Chronic Treatment of Diastolic Heart Failure

Afterload Reduction

There is some evidence that calcium channel blocker drugs may be of benefit in reducing ventricular stiffness in some cases. Likewise, treatment with angiotensin converting enzyme inhibitors such as enalapril, ramipril, and other ACE inhibitors may be of benefit due to their effect on ventricular remodeling.

ACA/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults^[1] (DO NOT EDIT)

Patients With Heart Failure and Normal Left Ventricular Ejection Fraction

Class I
"1. Physicians should control systolic and diastolic hypertension in patients with heart failure and normal left ventricular ejection fraction, in accordance with published guidelines. (Level of Evidence: C)"
"2. Physicians should control ventricular rate in patients with heart failure and normal left ventricular ejection fraction and atrial fibrillation. (Level of Evidence: C)"
"3. Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with heart failure and normal left ventricular ejection fraction. (Level of Evidence: C)"

Class IIa
"1. Coronary revascularization is reasonable in patients with heart failure and normal left ventricular ejection fraction and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function. (Level of Evidence: C)"

Class IIb
"1. Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and heart failure and normal left ventricular ejection fraction might be useful to improve symptoms. (Level of Evidence: C)"
"2. The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with heart failure and normal left ventricular ejection fraction and controlled hypertension might be effective to minimize symptoms of heart failure. (Level of Evidence: C)"
"3. The usefulness of digitalis to minimize symptoms of heart failure in patients with heart failure and normal left ventricular ejection fraction is not well established. (Level of Evidence: C)"

References

↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation". Circulation. 119 (14): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966.

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[pmid19324966-1] Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation". Circulation. 119 (14): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966.

[1]

@@ Line 1: / Line 1: @@
 __NOTOC__
-Please help WikiDoc by adding more content here.  It's easy!  Click  [[Help:How_to_Edit_a_Page|here]]  to learn about editing.
 {{Diastolic dysfunction}}
-{{CMG}}
+{{CMG}}; '''Associate Editor(s)-in-Chief:''' [[User: Shankar Kumar |Shankar Kumar, M.B.B.S.]] [mailto:kumarshankar@wikidoc.org]
 ==Overview==
-==Medical Therapy==
+The chronic treatment of diastolic dysfunction involves aggressive management of the underlying disorder that is causing the diastolic dysfunction such as [[diabetes]] or [[hypertension]].  Mild diastolic dysfunction that is well tolerated requires no specific treatment.  Rate control is an important part of the acute therapy of the patient with diastolic heart failure.  It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy of diastolic dysfunction.
-==ACA/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults: Patients With Heart Failure and Normal Left Ventricular Ejection Fraction<ref name="pmid19324966">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. | journal=Circulation | year= 2009 | volume= 119 | issue= 14 | pages= e391-479 | pmid=19324966 | doi=10.1161/CIRCULATIONAHA.109.192065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19324966  }} </ref> (DO NOT EDIT)==
+==Acute Treatment of Diastolic Heart Failure==
+=== Rate Control===
+It takes a longer period of time for a stiff left ventricle to fill, and therefore rate control is a critical part of the acute therapy diastolic dysfunction.  Furthermore, in [[atrial fibrillation]] there is a failure of [[atrial kick]] to augment the filling of the [[left ventricle]].
+=== Diuresis===
+Diuresis may reduce acute volume overload.
+=== Relief of Ischemia===
+Acute [[myocardial ischemia]] leads to diastolic dysfunction which increases left atrial pressure and causes [[pulmonary edema]].
+== Chronic Treatment of Diastolic Heart Failure==
+=== Afterload Reduction===
+There is some evidence that [[calcium channel blocker]] drugs may be of benefit in reducing ventricular stiffness in some cases.  Likewise, treatment with [[angiotensin converting enzyme inhibitors]] such as [[enalapril]], [[ramipril]], and other ACE inhibitors may be of benefit due to their effect on [[ventricular remodeling]].
+==ACA/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults<ref name="pmid19324966">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. | journal=Circulation | year= 2009 | volume= 119 | issue= 14 | pages= e391-479 | pmid=19324966 | doi=10.1161/CIRCULATIONAHA.109.192065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19324966  }} </ref> (DO NOT EDIT)==
+===Patients With Heart Failure and Normal Left Ventricular Ejection Fraction===
 {|class="wikitable"
@@ Line 42: / Line 59: @@
 <nowiki>"</nowiki>'''3.''' The usefulness of [[digitalis]] to minimize symptoms of heart failure in patients with heart failure and normal left ventricular ejection fraction is not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |}
-By and large, diastolic dysfunction is chronic process (except during acute [[ischemia]]). When this chronic condition is well tolerated by an individual, no specific treatment may be indicated. Rather, therapy should be directed at the root cause of the stiff left ventricle with things like [[high blood pressure]] and [[diabetes]] treated appropriately. Conversely, and as noted above, diastolic dysfunction tends to be better tolerated if the [[atrium]] is able to pump [[blood]] into the [[ventricles]] in a coordinated fashion. This does not occur in [[atrial fibrillation]] where there is no coordinated atrial activity. Hence, [[atrial fibrillation]] should be treated aggressively in people with diastolic dysfunction. In the same light, and also as noted above, if the atrial fibrillation persists and is leading to a rapid heart rate, treatment must be given to slow down that rate.
-The role of specific treatments for diastolic dysfunction ''per se'' is unclear. There is some evidence that [[calcium channel blocker]] drugs may be of benefit in reducing ventricular stiffness in some cases. Likewise, treatment with [[angiotensin converting enzyme inhibitors]] such as [[enalapril]], [[ramipril]], and many others, may be of benefit due to their effect on [[ventricular remodeling]].
-A major treatment consideration in people with diastolic dysfunction is when [[pulmonary edema]] develops. Unlike treatment of pulmonary edema occurring the setting of [[systolic]] dysfunction (where the primary problem is poor ventricular pumping as opposed to poor filling), the treatment of [[pulmonary edema]] complicating diastolic dysfunction emphasizes [[heart rate]] control (i.e. lowering it). [[Diuretics]] are often given as well. The role of [[afterload]] reduction in this setting is unknown.
 ==References==
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 [[Category:Cardiomyopathy]]
 [[Category:Disease]]
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+[[Category:Up-To-Date cardiology]]
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