What is Diastolic Heart Failure and How Should I Treat It? William H. Gaasch Lahey Clinic, Burlington, Vermont, USA Although dozens of large-scale clinical trials have been conducted evaluating treatment of patients with heart failure due to impaired left ventricular systolic function, none has evaluated treatment of heart failure due to left ventricular diastolic dysfunction. Many patients develop heart failure due to left ventricular diastolic dysfunction, and it is important for physicians to understand the phenomenon and to learn how to diagnose and treat patients who develop the condition. Dr. Gaasch showed a very dramatic slide: On the left side were listed the names of about twenty large-scale, randomized, double-blind studies of treatments for patients with heart failure due to left ventricular systolic dysfunction. On the right side, the column was labeled "Diastolic Dysfunction" but there was only blank space beneath the label. In fact, relatively little attention is given to this problem in the medical literature and among clinicians. Dr. Gaasch reviewed the European Cardiology Societyﾕs definition of heart failure due to diastolic dysfunction. The definition requires the presence of all three of the following: (1) signs and symptoms of congestive heart failure, (2) normal or only mildly abnormal ejection fraction, and (3) evidence of diastolic abnormality. Dr. Gaasch described a study he and his colleagues had conducted at his institution, the Lahey Clinic. They performed an echocardiography and cardiac catheterization correlation study, performing both studies in 63 patients who had congestive heart failure, normal left ventricular volumes and ejection fractions, and evidence of increased left ventricular wall thickness -- that is, left ventricular hypertrophy. The researchers found abnormal diastolic filling pressures and prolonged relaxation times, including prolonged isovolumic relaxation time and prolonged deceleration time, in these patients. Overall, all of the patients had abnormal diastolic function and 94% had at least one pressure and one echocardiographic abnormality. Dr. Gaasch concluded: "In congestive heart failure with left ventricular hypertrophy and a normal left ventricular ejection fraction, the diagnosis of diastolic heart failure can be made via demonstration of diastolic abnormalities on echocardiography, without cardiac catheterization." Dr. Gaasch then described two very small studies of treatment of heart failure secondary to diastolic dysfunction, each involving approximately 20 patients. One used verapamil as the study drug, and the other used losartan. The results of the studies demonstrated improvements in exercise capacity and Quality of Life and decreases in congestive heart failure score. Two treatment studies are currently underway, one investigating candesartan and the other perindopril. Dr. Gaasch concluded: "In these patients, treat the hypertension, because in these patients, hypertensive left ventricular hypertrophy is apparently the primary underlying cause of the failure. However, if a patient presents with symptoms of heart failure, first treat those symptoms -- donﾕt think about the etiology. Then, if the patient has coronary artery disease, he should undergo revascularization. If he has hypertensive heart disease, treat the hypertension." Reporter: Andre Weinberger, MD Copyright 2000-2013 by HESCO International, Ltd. All rights reserved.