Elsevier

Heart & Lung

Volume 37, Issue 6, November–December 2008, Pages 405-416
Heart & Lung

Issues in cardiovascular nursing
Diastolic heart failure

https://doi.org/10.1016/j.hrtlng.2007.12.002Get rights and content

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.

Section snippets

Epidemiology

The Cardiovascular Health Study (CHS)9, 10 was the first large epidemiologic study (N = 4842) to examine cardiovascular disease risk in the elderly. HF was present in 425 subjects (8.8%) of the sample, whose mean age was 77 ± 5 years. This was most notable among women, in whom HF increased from 6.6% at age 65 to 69 years to 14% at age greater than 85 years. More than half (55%) of the women in the CHS exhibited a normal LVEF, and LVEF was only mildly reduced in 80% of the women.10 DHF was more

Prognosis and Hospitalizations

Among community samples, the mortality rates for patients with SHF are 10% to 15% annually, higher than the 4% to 8% observed in patients with DHF.2, 10 However, the death rate among patients with DHF is approximately four to five times higher compared with adults with normal diastolic function, indicating its serious impact.10 Short-term survival and hospital readmission rates are more favorable in younger patients with DHF (<65 years) than patients with SHF but are similar at age 75 years or

Pathophysiology of Diastolic Heart Failure

Although much less is known about DHF than SHF, the pathogenesis in most cases seems to be associated with LV diastolic impairment and is the focus of this review. However, conditions such as right-sided HF, lung disease, and pericardial and valvular heart diseases are also acknowledged to contribute to the pathologic changes associated with DHF.17, 18, 19, 20

Diastolic dysfunction is associated with delayed LV relaxation, reduced distensibility (increased diastolic pressure with no change in

Clinical Evaluation

Initially, clinical evaluation of DHF includes a medical history, physical examination, chest radiograph, serum BNP, and electrocardiogram. Symptom similarity with other medical conditions, such as asthma and chronic obstructive pulmonary disease, has increased serum BNP use in clinical settings. A detailed review of cardiac symptoms including ischemic heart disease, such as chest pain, history of angina, myocardial infarction, arrhythmias, especially tachyarrhythmias, or valvular disease,

Treatment Strategies

Although there is substantial evidence to guide therapy for patients with SHF, few trials have been conducted with patients with DHF; therefore, little is known about optimal treatment strategies for this population. The management of DHF has two major objectives: to reverse the consequences of diastolic dysfunction (eg, venous congestion and exercise intolerance) and to eliminate or reduce factors (eg, hypertension) responsible for the diastolic dysfunction.5, 8, 14, 66, 67, 68 Other important

Symptom Management

Initially, patients with DHF often have symptoms related to pulmonary congestion. Pulmonary congestion can be decreased by reducing LV volume, maintaining normal sinus rhythm (arteriovenous synchrony), and prolonging diastole (thereby decreasing heart rate and increasing coronary artery filling time). One of the most common interventions to reduce LV volume is reducing intravascular volume, either by diuretics or nonpharmacologic approaches such as fluid or sodium restriction. Other

Pharmacologic Treatment of Diastolic Heart Failure

Neurohormonal activation contributes to reduced cardiac output and exertional intolerance in patients with DHF.71 Specific therapeutic targets include reducing blood pressure; controlling hypertension, ischemia, and tachycardia; and maintaining a sinus rhythm. Beta-adrenergic receptor blockers decrease blood pressure and reduce ventricular remodeling by lowering the harmful neurohormonal and cytokine cascade. Reducing heart rate is also essential using beta-blockade to improve diastolic filling

Nonpharmacologic Management

DHF and aging both lead to a reduced exercise capacity, in part because of the loss of muscle mass (sarcopenia) and alterations in skeletal muscle blood flow and metabolism. Exercise training can in part reverse the peripheral alteration, improve functional capacity, and improve the symptoms associated with DHF and is now recommended by the American Heart Association/American College of Cardiology guidelines73, 79 and Heart Failure Society of America69 in stable patients with NYHA class I to

Multidisciplinary Management

The complex syndrome of DHF is often complicated by multiple comorbidities, advancing age, lack of resources, sensory deficits, mobility limitations, depression, nutritional concerns, social isolation, and end-of-life decisions. These factors contribute to poor outcomes, nonadherence to medical regimens, increased hospitalizations, and institutionalization. The complexity of issues surrounding many patients with DHF requires a multidisciplinary approach to ensure these issues are addressed to

Conclusions

Although there are few clinical trials to provide strong support for treatment options in DHF, the number of studies is increasing and evidence has steadily grown during the past decade, providing enthusiasm that future therapies will emerge. The most effective management is the prevention of DHF, which includes strategies aimed at aggressively treating the established risk factors, such as hypertension, diabetes, and obesity. In the meantime, nurses have an important role to play in educating

References (96)

  • Y. Iwanaga et al.

    B-type natriuretic peptide strongly reflects diastolic wall stress in patients with chronic heart failure: comparison between systolic and diastolic heart failure

    J Am Coll Cardiol

    (2006)
  • R.B. Devereux et al.

    Congestive heart failure despite normal left ventricular systolic function in a population based sample: The Strong Heart Study

    Am J Cardiol

    (2000)
  • P.A. McCullough et al.

    Confirmation of a heart failure epidemic: findings from the Resource Utilization Among Congestive Heart Failure (REACH) Study

    J Am Coll Cardiol

    (2002)
  • S. Yusuf et al.

    Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial

    Lancet

    (2003)
  • C.B. Granger et al.

    Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial

    Lancet

    (2003)
  • J.J. McMurray et al.

    Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial

    Lancet

    (2003)
  • P. Carson et al.

    The Irbesartan in heart failure with preserved systolic function (I-PRESERVE) trial: rationale and design

    J Card Fail

    (2005)
  • A. Ahmed et al.

    Higher New York Heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function

    Am Heart J

    (2006)
  • A. Ahmed et al.

    Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure

    Am Heart J

    (2002)
  • W.S. Aronow et al.

    Prognosis of congestive heart failure in elderly patients with normal versus abnormal left ventricular systolic function associated with coronary artery disease

    Am J Cardiol

    (1990)
  • M.A. East et al.

    Racial differences in the outcomes of patients with diastolic heart failure

    Am Heart J

    (2004)
  • A.H. Gradman et al.

    Lack of correlation between clinic and 24 hour ambulatory blood pressure in subjects participating in a therapeutic drug trial

    J Clin Epidemiol

    (1989)
  • A.H. Gradman et al.

    From left ventricular hypertrophy to congestive heart failure: management of hypertensive heart disease

    Prog Cardiovasc Dis

    (2006)
  • J. Sadoshima et al.

    Autocrine release of angiotensin II mediates stretch-induced hypertrophy of cardiac myocytes in vitro

    Cell

    (1993)
  • L.R. Peterson et al.

    Alterations in left ventricular structure and function in young healthy obese women: assessment by echocardiography and tissue Doppler imaging

    J Am Coll Cardiol

    (2004)
  • W.B. Kannel et al.

    Role of diabetes in congestive heart failure: the Framingham study

    Am J Cardiol

    (1974)
  • M. Zabalgoitia et al.

    Prevalence of diastolic dysfunction in normotensive, asymptomatic patients with well-controlled type 2 diabetes mellitus

    Am J Cardiol

    (2001)
  • J.E. Liu et al.

    Association of albuminuria with systolic and diastolic left ventricular dysfunction in type 2 diabetes: the Strong Heart Study

    J Am Coll Cardiol

    (2003)
  • J.B. Braunstein et al.

    Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure

    J Am Coll Cardiol

    (2003)
  • S. Paul

    Diastolic dysfunction

    Crit Care Nurs Clin N Am

    (2003)
  • D.W. Kitzman

    Exercise intolerance

    Prog Cardiovas Dis

    (2005)
  • M.A. Quinones

    Assessment of diastolic dysfunction

    Prog Cardiovasc Dis

    (2005)
  • K. Hogg et al.

    Neurohormonal pathways in heart failure with preserved systolic function

    Prog Cardiovasc Dis

    (2005)
  • S.A. Hunt et al.

    ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure)

    J Am Coll Cardiol

    (2001)
  • J.G. Warner et al.

    Losartan improves exercise tolerance in patients with diastolic dysfunction and a hypertensive response to exercise

    J Am Coll Cardiol

    (1999)
  • W.C. Little et al.

    Effect of losartan and hydrochlorothiazide on exercise tolerance in exertional hypertension and left ventricular diastolic dysfunction

    Am J Cardiol

    (2006)
  • R.C. Jones et al.

    Predictors of mortality in patients with heart failure and preserved systolic function in the Digitalis Investigation Group trial

    J Am Coll Cardiol

    (2004)
  • R.A. Gary et al.

    Home-based exercise improves functional performance and quality of life in women with diastolic heart failure

    Heart Lung

    (2004)
  • N. Smart et al.

    Predictors of a sustained response to exercise training in patients with chronic heart failure: a telemonitoring study

    Am Heart J

    (2005)
  • N.T. Artinian et al.

    What do patients know about their heart failure?

    Appl Nurs Res

    (2002)
  • B. Carlson et al.

    Self-care abilities of patients with heart failure

    Heart Lung

    (2001)
  • K.E. Joynt et al.

    Why is depression bad for the failing heart?A review of the mechanistic relationship between depression and heart failure

    J Card Fail

    (2004)
  • V. Konstam et al.

    Depression and anxiety in heart failure

    J Card Fail

    (2005)
  • D.W. Kitzman

    Diastolic heart failure in the elderly

    Heart Fail Rev

    (2002)
  • A. Ahmed

    Association of diastolic dysfunction and outcomes in ambulatory older adults with chronic heart failure

    J Am Geriatr Soc

    (2005)
  • M.D. Thomas et al.

    The epidemiology enigma of heart failure with preserved systolic function

    Eur J Heart Fail

    (2004)
  • W.S. Aronow

    Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure

    Cardiol Rev

    (2006)
  • M.M. Redfield et al.

    Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic

    JAMA

    (2003)
  • Cited by (27)

    • Galectin-3 and myocardial fibrosis in nonischemic dilated cardiomyopathy

      2015, International Journal of Cardiology
      Citation Excerpt :

      Neurohormonal activation and myocardial vulnerability concur to the development of cardiac fibrosis, which represents a key mechanism in the progression of adverse cardiac remodeling in patients with dilated cardiomyopathy [1,2]. Moreover, cardiac fibrosis is associated with worsening of left ventricular (LV) systolic and diastolic function [3,4], and with a poor outcome, regardless of etiology. Late gadolinium enhancement (LGE) at cardiac magnetic resonance imaging (MRI) has recently emerged as a powerful, noninvasive tool for the estimation of the extent of cardiac fibrosis in HF patients.

    • Diastolic Heart Failure in Women: Expanding Knowledge About Self-Care Practices

      2012, Nursing for Women's Health
      Citation Excerpt :

      To date there has been little evidence to guide clinicians concerning the diagnosis, treatment and maintenance of one type of heart failure in women—diastolic heart failure (DHF). Among individuals with heart failure, women (67 percent) more than men (42 percent) suffer from DHF (Gary & Davis, 2008; Roger et al., 2011). As compared to a healthy heart (which has an ejection fraction ranging from 55 percent to 70 percent), heart failure is classified as either systolic (ejection fraction < 40 percent) or diastolic (ejection fraction > 45 percent) or both and is characterized as a chronic and progressive condition (American Heart Association [AHA], 2012).

    • Cost-effectiveness of aldosterone antagonists for the treatment of post-myocardial infarction heart failure

      2012, Value in Health
      Citation Excerpt :

      The value depends crucially on the number of future patients who could benefit from further research and the time horizon over which the information would be useful. Post-MI HF accounts for approximately 20% of all HF cases [42]. The British Heart Foundation estimates that the prevalence of HF in the United Kingdom is 707,000 (393,000 men, 314,000 women) and the annual incidence of HF is estimated to be 68,000 cases (38,000 men, 30,000 women) [4].

    • Antifibrotic Effects of ω-3 Fatty Acids in the Heart: One Possible Treatment for Diastolic Heart Failure

      2011, Trends in Cardiovascular Medicine
      Citation Excerpt :

      By 2040, this number is anticipated to increase to 1.5 million, largely because of the aging population. HF is the leading cause for hospital admissions and death among older adults, and it is the most expensive Medicare expenditure, with costs estimated to be between $30 and $40 billion annually (Aronow 2006, Gary and Davis 2008). Diastolic HF is defined as HF with preserved ejection fraction and reduced diastolic function.

    View all citing articles on Scopus
    View full text