Heart failure with normal ejection fraction

Opinion statement Heart failure with normal ejection fraction, also known as diastolic heart failure, is a major problem for patients and health-care providers and is a substantial expense to society. The main pathophysiologic processes involved are increased left ventricular stiffness and abnormal relaxation, with resulting impaired left ventricular filling. These processes typically displace the pressure-volume relationship in an upward direction, resulting in increased left ventricular end-diastolic, left atrial, and pulmonary capillary wedge pressures, leading to symptoms of pulmonary congestion. The most common clinical disorders leading to diastolic heart failure are 1) hypertension with concentric left ventricular hypertrophy, 2) coronary artery disease with decreased left ventricular compliance, 3) hypertrophic cardiomyopathy, and 4) aortic stenosis with concentric left ventricular hypertrophy. Echocardiography and cardiac catheterization with magnetic resonance imaging hold promise as future diagnostic tools. The approach to the treatment of diastolic heart failure is focused on four treatment goals: 1) persistent control of elevated blood pressure, with regression of left ventricular hypertrophy, 2) careful reduction of central blood volume (diuretics), 3) maintenance of atrial contraction and control of heart rate (beta-blockers, digoxin, atrioventricular pacing); and 4) improvement of left ventricular relaxation. There is currently no drug treatment specific for abnormal relaxation, although efforts are being made to develop such compounds. A promising future therapy includes agents that lyse advanced glycation end-products as an approach to relieving increased ventricular stiffness. In addition to pharmacotherapy, maintaining ideal body weight and a regular exercise program are also helpful in the treatment of diastolic heart failure. Although the overall prognosis of patients with diastolic dysfunction is more favorable than that of patients with systolic dysfunction, the frequency of treatment failure and recurrent symptoms underscores the need for further improvement in treatment of this condition.