Diastolic dysfunction medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
==Medical Therapy== | ==Medical Therapy== | ||
==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)== | |||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
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<nowiki>"</nowiki>'''1.''' Physicians should control systolic and diastolic [[hypertension]] in patients with [[heart failure]] and normal left ventricular [[ejection fraction]], in accordance with published guidelines. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
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<nowiki>"</nowiki>'''2.''' Physicians should control ventricular rate in patients with heart failure and normal left ventricular ejection fraction and [[atrial fibrillation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
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<nowiki>"</nowiki>'''3.''' Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with heart failure and normal left ventricular ejection fraction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
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<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
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<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
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<nowiki>"</nowiki>'''2.''' The use of [[beta-adrenergic]] blocking agents, [[ACEI]]s, 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
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<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> | |||
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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. | 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. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
ACA/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults: Patients With Heart Failure and Normal Left Ventricular Ejection Fraction[1] (DO NOT EDIT)
| 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)" |
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
- ↑ 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.