Diastolic heart failure treatment

Aronow WS Drug treatment of systolic and diastolic heart failure in elderly persons. J Gerontol A Biol Med Sci 2005 60 1597. [PMID 16424295]... 

Gutierrez C, Blanchard DG. Diastolic heart failure challenges of diagnosis and treatment. Am Fam Physician. 2004 69 2609-2616. 

Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure Part II causal mechanisms and treatment. Circulation 2002 105 1503-1508. 

Treatment should be targeted at symptom reduction, causal clinical disease, and underlying basic mechanisms. Patients with diastolic heart failure may be treated differently than those with systolic dysfunction. 

Heart failure (HP) may becausedbya primary abnormality in systolic function, diastolic function, or both. Making the distinction is important because the prevalence, prognosis, and treatment of HP may be quite different depending on whether the predominant mechanism causing the symptoms is systolic or diastolic dysfunction. Some clinical studies have reported that as many as 30% to 50% of patients with congestive heart failure have preserved left ventricular (LV) function, making diastolic heart failure (DHP) very common. In addition, abnormalities in diastolic function also can play an important role in the development of symptoms in patients with cardiomyopathy and systolic heart failure (SHP). 

TABLE 18—2. General Approach to Treatment of Diastolic Heart Failure... 

FIGURE 18-3. Treatment of chronic diastolic heart failure. 

Zile MR Diastolic heart failure Diagnosis, prognosis, treatment. Minerva Cardiol 2003 51 131-142. 

The most difficult patient population to address is that which includes patients with diastolic heart failure and PEFHF with secondary pulmonary venous hypertension, given the lack of effective treatment... 

The combined use of ACE inhibitors and ARBs in the treatment of heart failure offers the intriguing possibility of additive therapeutic benefit by virtue of distinctive modes of angiotensin antagonism. Some experts suggest that the addition of an AT blocker to a heart failure regimen that includes an ACE inhibitor can be considered in an effort to reduce hospitalizations. ATj antagonists also appear to reduce hospitalization in patients with diastolic heart failure. 

There are no definitive trials to guide therapy in patients with diastolic heart failure, and one is therefore unable to initiate treatment in anticipation of attenuating disease progression or reducing mortality. It is, however, possible to make some general comments regarding mechanistic considerations in selecting treatment. 

Patients with diastolic heart failure are typically dependent upon preload to maintain adequate cardiac output. While patients with symptomatic volume overload will benefit from careful modulation of intravascular volume, volume reduction should be accomplished gradually and treatment goals reassessed frequently. In addition to cautious volume management, it is important to maintain synchronous atrial contraction in such patients, which maintains adequate left ventricular filling during the latter phase of diastole. Cardiac function is often severely impaired if patients with diastolic heart failure develop atrial fibrillation, particularly in the context of sub-optimal ventricular rate control. Meticulous control of the ventricular rate with drugs that slow AV conduction is mandatory (see Chapter 34) and restoration of sinus rhythm should be considered. It is also important to evaluate and treat conditions that are associated with dynamic abnormalities of diastolic function, such as myocardial ischemia and poorly controlled systemic hypertension. 

Cardiostimulation. By stimulating Pi-receptors, hence activation of ade-nylatcyclase (Ad-cyclase) and cAMP production, catecholamines augment all heart functions, including systolic force (positive inotropism), velocity of shortening (p. clinotropism), sinoatrial rate (p. chronotropism), conduction velocity (p. dromotropism), and excitability (p. bathmotropism). In pacemaker fibers, diastolic depolarization is hastened, so that the firing threshold for the action potential is reached sooner (positive chronotropic effect, B). The cardiostim-ulant effect of p-sympathomimetics such as epinephrine is exploited in the treatment of cardiac arrest Use of p-sympathomimetics in heart failure carries the risk of cardiac arrhythmias. 

Myocardial ischemia and infarction cause abnorma myocardial metabolism, decreased left ventricular (LV) systolic function, diastolic dysfunction, congestive heart failure, and decreased survival. Consequently, revascularization techniques, either surgical or catheter based, have become integral to treatment of severe ischemic heart disease. 

Heart failure is a progressive syndrome, and optimal pharmacologic management is based on a detailed diagnosis, determination of the etiology, characterization of the clinical syndrome (systolic vs. diastolic) and careful monitoring of the response to pharmacologic therapy. There is a need to modify treatment in accordance with the patient s response to therapy. 

Thiazide diuretics or -blockers have been compared with either ACE inhibitors or CCBs in elderly patients with either systolic or diastolic hypertension or both. In a Swedish trial, no significant differences were seen between conventional drugs and either ACE inhibitors or CCBs. However, there were significantly fewer myocardial infarctions and cases of heart failure in the ACE inhibitor group compared with the CCB group. These data suggest that overall treatment may be more important than specific antihypertensive agents in this population. 

DITPA treatment improved left ventricular performance in rat and rabbit post-M I models of heart failure. In a double-blind, placebo controlled, pilot phase II clinical study in 19 patients with NYHA class II or III CHF in 2003, DITPA demonstrated a significant increase in cardiac index, as well as improvements in diastolic function, systemic vascular resistance, and cholesterol and triglyceride levels. In this study, DITPA was well tolerated, with no significant increase in heart rate or significant adverse events. Subsequently, a larger trial was initiated which, however, was discontinued in October 2006, based on a business decision by Titan. 

It enhances the force of myocardial contraction and in the case of heart failure this dominating inotropic ect results in a much modified cardiac output with regard to more complete emptying of the ventricle at systole, an apparent decrease in the elevated end-diastolic ventricular pressure, and above all a positive reduction in the size of the dilated heart It is used in the treatment of congestive heartfailure. 

The adverse effects of carbenoxolone include an increase in blood pressure (both systolic and diastolic), fluid retention and reduced serum potassium levels. The incidence of these adverse effects is said in some reports to be as high as 50% others quote lower figures. Hypertension and fluid retention occur early in carbenoxolone treatment, whereas the hypokalae-mia develops later and may occur in the absence of the other two adverse effects. " Carbenoxolone is therefore unsuitable for patients with congestive heart failure, or those taking digitalis glycosides, unless measures to avoid hypokalaemia are taken. 

---