Diastolic dysfunction medical therapy
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Diastolic dysfunction Microchapters |
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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 dysfunction. 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
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
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 |
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"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)" |
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"2. Physicians should control ventricular rate in patients with heart failure and normal left ventricular ejection fraction and atrial fibrillation. (Level of Evidence: C)" |
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"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 |
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"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 |
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"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)" |
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"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)" |
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"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)" |
In diastolic dysfunction, the heart has poor response to stress-
- Tachycardia, increased heart rate would hamper proper and complete filling of left ventricle.
- Hypertension, especially if it is acute in onset or refractory to treatment increases the stress on the walls of the ventricle, which in turn leads to hypertrophy and impaired filling.
By and large, diastolic dysfunction is chronic process (except during acute ischemia).
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.