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The overall incidence of heart failure increases with age, affecting up to 10% of people >65 years of age. Diastolic heart failure is also age-dependent, increasing from <15% in middle-aged patients to >40% in patients > or =70 years of age. Elderly patients usually have other co-morbid conditions such as hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation that can adversely affect the diastolic properties of the heart. The clinical manifestations of diastolic heart failure are similar to those of systolic heart failure. In practice, the diagnosis is generally based on the finding of typical symptoms and signs of heart failure with preserved left ventricular ejection fraction and no valvular abnormalities on echocardiography. Altered ventricular relaxation and abnormal ventricular filling are the hallmarks of diastolic heart failure. Cardiac fibrosis and cellular disarray lead to the alterations in the diastolic properties of the heart. Diffuse foci of fibrosis in the myocardium have been reported with advancing age. Aldosterone has been shown to play a crucial role in the development of cardiac fibrosis via a direct effect on the mineralocorticoid receptors within the myocardium. Unlike the situation with treatment of systolic heart failure, few clinical trials are available to guide the management of patients with diastolic heart failure. In the absence of controlled clinical trials, patient management is based on control of the physiological factors (blood pressure, heart rate, blood volume and myocardial ischaemia) that are known to exert important effects on ventricular relaxation. Aldosterone antagonists inhibit the deposition of collagen matrix in the myocardium, thereby targeting the basic pathophysiological mechanism of diastolic dysfunction. Thus, they appear to represent a promising therapeutic approach for this condition. Currently, only small clinical trials supporting this therapy are available and large clinical trials evaluating long-term outcomes in diastolic dysfunction are therefore needed.
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PMID:Diastolic heart failure in the elderly and the potential role of aldosterone antagonists. 1673 89

Diastolic heart failure with hypoxemia is a dangerous condition in pregnancy for both the mother and the fetus. Continuous positive airway pressure may help to decrease afterload and reduce venous return and ventricular filling, but its use in diastolic dysfunction has not yet been established. The authors report a case of a patient with pregnancy-induced hypertension and oligohydramnios who developed acute decompensated diastolic heart failure. The addition of continuous positive airway pressure, diuretics, and neurohormonal-blocking agents lead to a dramatic clinical and physiologic improvement. The authors recommend consideration of the use of positive pressure ventilation in these patients.
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PMID:Application of continuous positive airway pressure in hypoxemic acute respiratory failure associated with diastolic dysfunction in pregnancy. 1676 Jul 5

Diastolic heart failure (i.e., heart failure with preserved systolic function) accounts for 30%-50% of all cases of heart failure. Prognosis is almost as poor as with systolic heart failure. Currently, the only requirements for diagnosis are that strict clinical criteria for heart failure are satisfied and that the left ventricular ejection fraction is preserved (i.e., greater than 40%-50%), although in the future measurement of brain natriuretic peptides could be useful. Because of a lack of evidence from large clinical trials, with the exception of the CHARM study which showed that candesartan slightly reduced the hospital readmission rate, therapy is based on the identification and treatment of the causal condition (e.g., hypertension or coronary heart disease), heart rate control, and relief of congestion. Thus, combination treatment with low-dose diuretics, bradycardiac antihypertensives (e.g., beta-blockers or calcium antagonists), and angiotensin antagonists currently seems to be the best therapeutic approach.
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PMID:[Medical treatment of heart failure with preserved left ventricular ejection fraction]. 1714 77

In cardiovascular diseases e.g. heart failure and coronary artery disease gender differences are evident in etiology, pathophysiology, clinical presentation, prognosis and response to treatment. Diabetes and hypertension are the major risk factors in women. Mechanisms leading to apparent diabetes or its clinical pre-stage are different in women and men and according to this result in different therapeutic implications. Diastolic heart failure is more frequent in women and effects and side effects of important groups of active pharmaceutical substances are, at least to some extent, different. Atrial fibrillation and ventricular arrhythmia differ in frequency of occurrence; drug induced tachycardia with QT interval prolongation is particularly frequent in women. Underlying pathomechanisms responsible for gender differences in pharmacotherapy are on the one hand differences in pharmacokinetic mechanisms. Particularly drugs which are metabolised via cytochrome P 450 CYP 3A pathway show different kinetics in women and men. In addition, important differences are evident in pharmocodynamics caused by effects of sex steroid hormones or products of X-chromosomal genes. The evidence of estrogen and testosterone receptors in cardiomyocytes and the vascular system, interaction of sex steroid hormones with cellular pathways and the role of X-chromosomal genes are the focus of basic research. Interactions of sex steroid hormone receptors with other nuclear receptors e.g. PPARs ("peroxisome proliferator-activated receptors") are another important underlying mechanism. The knowledge of different pharmacokinetic mechanisms has to be taken into consideration in pharmacotherapy of cardiovascular diseases, for example by adjustment of drug dosages in women, necessary in different groups of pharmaceutical substances or in the long run, gender differences in effects and side effects of drugs. In drug development both aspects have to be considered. There is more than one good reason to intensify basic and clinical research and research on health care on gender differences in cardiovascular diseases.
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PMID:[Implications of gender-specific aspects in the therapy of cardiovascular diseases]. 1787 7

Diastolic heart failure (DHF) is now firmly established as a significant contributor to the heart failure syndrome. However, compared to the better studied systolic dysfunction heart failure relatively little is known about this form of the syndrome. Epidemiological data have demonstrated that it is particularly important in the elderly likely reflecting the combination of several changes occurring in the myocardium occurring with advancing years, including progressive fibrosis and stiffening of the myocardium, the impact of hypertension over the years and the increased likelihood of ischaemic heart disease. This review will focus on the relevant aetiological factors in DHF, possible pathophysiological mechanisms and outline new and evolving therapeutic strategies for this problem.
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PMID:Diastolic heart failure in the elderly: underlying mechanisms and clinical relevance. 1816 Jan 54

Diastolic heart failure is characterized by the symptoms and signs of heart failure, a preserved ejection fraction and abnormal left ventricular (LV) diastolic function caused by a decreased LV compliance and relaxation. The signs and symptoms of diastolic heart failure are indistinguishable from those of heart failure related to systolic dysfunction; therefore, the diagnosis of diastolic heart failure is often one of exclusion. The majority of patients with heart failure and preserved ejection fraction have a history of hypertension. Hypertension induces a compensatory thickening of the ventricular wall in an attempt to normalize wall stress, which results in LV concentric hypertrophy, which in turn decreases LV compliance and LV diastolic filling. There is an abnormal accumulation of fibrillar collagen accompanying the hypertension-induced LV hypertrophy, which is also associated with decreased compliance and LV diastolic dysfunction. There are no specific guidelines for treating diastolic heart failure, but pharmacological treatment should be directed at normalizing blood pressure, promoting regression of LV hypertrophy, preventing tachycardia and treating symptoms of congestion. Preventive strategies directed toward an early and aggressive blood pressure control are likely to offer the greatest promise for reducing the incidence of diastolic heart failure.
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PMID:Diastolic dysfunction: a link between hypertension and heart failure. 1880 1

Diastolic heart failure (DHF) has different underlying pathophysiologic mechanisms. We sought to compare hemodynamic characteristics in DHF patients with or without hypertension. A conductance catheter with microtip-manometer was used to measure left ventricular (LV) function and hemodynamics in 28 DHF patients. After baseline measurements, nitroglycerin was infused to alter the loading condition and the measurements were repeated. At baseline, end-systolic pressure was higher and the time constant of LV relaxation (tau) was longer in hypertensive DHF patients. Patients in hypertensive DHF had lower LV-arterial coupling ratio than those in non-hypertensive DHF. The peak of loading sequence was in early systole in non-hypertensive DHF patients and in late systole in hypertensive DHF patients. Nitroglycerin decreased LV end-systolic pressure and end-diastolic volume in both groups. In non-hypertensive DHF, nitroglycerin significantly reduced stroke volume and shortened tau (59+/-11 vs. 54+/-10 ms, p<0.05) without any changes in the time to peak LV force, effective arterial elastance (E(a)), or LV-arterial coupling ratio. In contrast, in hypertensive DHF patients, nitroglycerin significantly reduced E(a) and shortened the time to peak LV force, resulting in an improved LV-arterial coupling ratio, preserved stroke volume and shortened tau (75+/-14 vs. 62+/-13 ms, p<0.05). In conclusion, LV relaxation was more prolonged in hypertensive DHF patients than non-hypertensive DHF patients, partly because of the different loading sequence. Changing the loading condition by nitroglycerin improved LV systolic and diastolic function in hypertensive DHF patients.
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PMID:Hemodynamic characteristics of patients with diastolic heart failure and hypertension. 1897 51

Diastolic heart failure (DHF) is estimated to occur in 40% to 50% of patients with heart failure. Evidence suggests that DHF is primarily a cardiogeriatric syndrome that increases from approximately 1% at age 50 years to 10% or more at 80 years. DHF is also more likely to occur in older women who are hypertensive or diabetic. Although survival is better in patients with DHF compared with systolic heart failure, mortality rates for patients with DHF are four times higher than those for healthy, community-dwelling older adults. The increase in DHF is anticipated to continue during the next several decades largely because of the aging of the population; increase in risk factors associated with hypertension, diabetes, and obesity; and ongoing technologic advances in the treatment of cardiovascular disease. Few clinical trials have evaluated therapy in this population, so evidence about the effectiveness of treatment strategies for DHF is limited. Future research should target novel interventions that specifically target patients with DHF who are typically older and female, and experience exertional intolerance and have a considerably reduced quality of life.
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PMID:Diastolic heart failure. 1899 23

Diastolic heart failure is a frequent diagnosis, but now it is more acurate to call this heart failure with preserved ejection fraction. The diagnosis can be made non invasively by the echocardiography and measuring BNP (brain natriuretic peptide). Consensus about treatment are less evidence-based than for heart failure with diminished ejection fraction. It is however certain that control of hypertension and heart rate are important. Fluid overload must also be treated with diuretics.
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PMID:[Diastolic heart failure: myth or fact?]. 1902 72

Data from 519 patients older than 65 years with congestive heart failure (CHF) were analyzed after 5 years of clinical follow-up. Two groups were included in the analysis: 321 patients with ejection fractions > or =50% (group with diastolic heart failure) and 198 patients with reduced ejection fraction <50% (group with systolic heart failure). Hypertension (81%) was the strongest predictor of congestive heart failure, followed by diabetes (46%) and coronary disease (33%). Diastolic heart failure was more predominant in elderly female (P=.007), hypertensive (P=.0001), and hypertrophic (P=.001) patients. Length of hospital stay, readmission rate, all-cause morbidity, and cumulative mortality were not statistically significant between both groups (P=.09).
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PMID:The prevalence, clinical characteristics, and prognosis of diastolic heart failure: a clinical study in elderly Saudi patients with up to 5 years follow-up. 1952 60


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