Insuficiencia

The

new england journal

of

medicine

clinical practice

Diastolic Heart Failure
Gerard P. Aurigemma, M.D., and William H. Gaasch, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’clinical recommendations.

A 78-year-old woman with a history of hypertension is admitted to the hospital with congestive heart failure. Physical examination reveals a blood pressure of 180/90 mm Hg, increased jugular venous pressure, peripheral edema, and pulmonary rales. A chest radiograph shows pulmonary edema and mild cardiomegaly. An echocardiogram (Fig. 1) shows increased thickness of the leftventricular wall, a left ventricular cavity of normal size, left atrial enlargement, and a left ventricular ejection fraction of 70 percent. The left ventricular Doppler filling pattern is abnormal and consistent with an elevated pulmonary-capillary wedge pressure. How should this patient be treated?

the clinical problem
Diastolic dysfunction refers to an abnormality of diastolic distensibility,filling, or relaxation of the left ventricle — regardless of whether the ejection fraction is normal or abnormal and whether the patient is symptomatic or asymptomatic.1 Thus, an asymptomatic patient with hypertensive left ventricular hypertrophy and an echocardiogram showing a normal ejection fraction and abnormal left ventricular filling can be said to have diastolic dysfunction. If effortintolerance and dyspnea developed in such a patient, especially in combination with venous congestion and pulmonary edema, it would be appropriate to use the term “diastolic heart failure.”1-4 Cross-sectional and population-based studies indicate that at least one third of all patients with congestive heart failure have a normal or near-normal ejection fraction.1-12 The prevalence of diastolic heartfailure is highest in patients over the age of 75 years.1,5-7 The mortality rate among patients with diastolic heart failure ranges from 5 to 8 percent annually, as compared with 10 to 15 percent among patients with systolic heart failure.12-17 As is the case with systolic heart failure, the mortality rate is directly related to age and the presence or absence of coronary disease.3,11-17 Themorbidity associated with diastolic heart failure (including the rate of hospitalization) is similar to that associated with systolic heart failure.11-17 There are fewer published data concerning the incidence of heart failure among patients with diastolic dysfunction, as demonstrated by Doppler echocardiography. In one population-based study, heart failure developed within five years in 11 to 15percent of persons older than 65 years of age who had no clinical evidence of heart disease but had Doppler evidence of left ventricular diastolic dysfunction.10 The factors that promote fluid retention and precipitate overt heart failure are similar in patients with systolic heart failure and those with diastolic heart failure.18 These factors include uncontrolled hypertension, atrial fibrillation,noncompliance with or inappropriate discontinuation of medications for heart failure, myocardial ischemia, anemia, renal insufficiency, use of nonsteroidal antiinflammatory drugs or thiazolidinediones,19 and overindulgence in salty foods.
From the Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester (G.P.A.); and the Department of CardiovascularMedicine, Lahey Clinic, Burlington, Mass. (W.H.G.). Address reprint requests to Dr. Aurigemma at the University of Massachusetts Medical School, 55 Lake Ave. N., Worcester, MA 01655, or at aurigemg@ ummhc.org. N Engl J Med 2004;351:1097-105.
Copyright © 2004 Massachusetts Medical Society.

n engl j med 351;11

www.nejm.org

september 9, 2004

1097

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