Evaluation and Management of Diastolic Heart Failure

Case presentation: A 73-year-old female smoker with a his-tory of hypertension presents to the emergency room with dyspnea on exertion for 2 weeks, now progress-ing to shortness of breath at rest for 1 day. She has no angina, but has 2-pillow orthopnea and possible par-oxysmal nocturnal dyspnea. On exam-ination, blood pressure is 180/ 96 mm Hg, heart rate is 95 beats per minute and regular, and she is afebrile. Jugular venous pressure is 11 cm, and there are rales in the lower third of both lung fields. On cardiac ausculta-tion there is an S4, but no S3 or murmur. On chest radiography, em-physematous changes are present, and there are patchy bilateral infiltrates consistent with pulmonary edema or pneumonia. Heart size is mildly in-creased. Is she suffering from conges-tive heart failure, and if so, why? What are the best management options acutely and after hospital discharge? Overview Congestive heart failure (CHF) is one of the most common reasons for hos-pital admission in the United States. The syndrome usually evokes images of an enlarged heart with reduced sys-tolic function. However, perhaps 50% of patients with CHF have normal or only minimally impaired systolic dys-function and are diagnosed with dia-stolic heart failure (D-CHF) by exclu-sion.1–4 Rather than define D-CHF by what it is not (that is, CHF without systolic dysfunction), we regard D-CHF as CHF due to increased resis-tance to diastolic filling of part or all of the heart. Causes of D-CHF so defined are listed in Table 1; this review will focus on the myocardial causes.5,6 Depending on the cohort studied and the exact definition, the prevalence of D-CHF increases with age and is higher in women than men. Hyperten-sion and left ventricular hypertrophy (LVH) are common. Compared with classic systolic CHF (S-CHF), the prognosis is unclear, but long-term mortality may be similar, especially in older patients.7,8