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Novel strategies in diastolic heart failure
Walter J Paulus Heart 2010 96: 1147-1153

doi: 10.1136/hrt.2009.169052

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Education in Heart

HEART FAILURE

Novel strategies in diastolic heart failure
Walter J Paulus
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published online only. To view these files pleasevisit the journal online (http://heart.bmj. com). Correspondence to Professor Dr Walter J Paulus, Department of Physiology, VU University Medical Center Amsterdam, Van der Boechorststraat 7 1081 BT Amsterdam, The Netherlands; wj.paulus@vumc.nl

The diagnosis of diastolic heart failure (DHF) is based on the presence of a triad consisting of signs or symptoms of congestive heart failure, a normalleft ventricular (LV) systolic function, and evidence of diastolic LV dysfunction.1 As diastolic LV dysfunction is not unique to DHF but also occurs in patients with heart failure and reduced LV systolic function (ie, systolic heart failure), DHF is often referred to as heart failure with normal LV ejection fraction (EF) (HFNEF)w1 or heart failure with preserved LVEF (HFPEF).w2 DHF currentlyaccounts for more than 50% of all heart failure cases in western societies.2 Although prognosis of patients with DHF was initially perceived as superior to patients with systolic heart failure (SHF), recent evidence shows prognosis to be equally poor in both conditions.2 Furthermore, whereas the prognosis of patients with SHF has improved over the last two decades as a result of modern heart failuretreatment, the prognosis of patients with DHF has not improved notably over the same time period.2 This review will focus on current diagnostic and therapeutic strategies for DHF.

diagnosis of DHF, apart from signs or symptoms of fluid overload and a normal LV systolic function.1 Recently, the Heart Failure and Echocardiography Associations of the European Society of Cardiology jointly published anupdated set of criteria for the diagnosis of DHF, which makes use of LVEF, LV end-diastolic volume (LVEDV), LV diastolic function indices, LV hypertrophy, LA size, and natriuretic peptides.1 This update of a previous European consensus document on the diagnosis of DHF4 had become necessary because of the widespread clinical use of tissue Doppler and natriuretic peptides. In accordance with thisupdated set of criteria, three conditions need to be satisfied for the diagnosis of DHF (figure 1): (1) signs or symptoms of congestive heart failure; (2) normal LV systolic function, and (3) diastolic LV dysfunction.

Signs or symptoms of congestive heart failure
Since many patients with DHF present with dyspnoea and no detectable signs of fluid overload, symptoms are considered sufficient clinicalevidence to suggest the presence of congestive heart failure. Objective evidence of reduced exercise performance is optional and can be provided by exercise testing with measurements of peak exercise oxygen consumption (pronounced limitation: VO2max 50% and LVEDVI < 97 ml/m2

Evidence of abnormal LV relaxation, filling, diastolic distensibility and diastolic stiffness

Invasive haemodynamic...