Heart failure is a leading cause of hospital admissions in North America. Approximately half of patients with symptoms of
heart failure have normal or minimally impaired systolic function and are therefore diagnosed, by exclusion, with diastolic dysfunction. The
therapy of diastolic dysfunction to date is largely unsatisfactory. There have been few outcome-based clinical trials to guide clinicians, and most treatments have been empirically derived from the data from
systolic heart failure studies. In general, acute management consists of central volume reduction with
loop diuretics and long-acting
nitrates. In some cases improvement in left ventricular filling can be achieved by reducing heart rate, usually with either beta blockers or
calcium channel blockers. The role of
digoxin is unclear and it should be used with caution. Theoretically, it has the capacity to further impair ventricular function, but one of the few trials in
diastolic heart failure suggested that it improves symptoms and reduces hospitalization. Renin-angiotensin system blockade is a very attractive therapeutic avenue;
angiotensin-converting enzyme inhibitors and
angiotensin receptor blockers effectively reduce afterload, induce regression of
left ventricular hypertrophy in excess of their blood pressure-lowering effect, and confer survival benefits to patients at high risk for cardiovascular death. Although the results of a recent trial using an
angiotensin receptor blocker in patients with primarily
diastolic heart failure were unimpressive, renin-angiotensin system blockade should still be considered because of its aforementioned benefits. The long-term management of these patients includes a careful assessment for and treatment of
myocardial ischemia, treatment of
hypertension, and reduction in
left ventricular hypertrophy. For the treatment of
ischemia, long-acting
nitrates and
calcium channel blockers may be particularly useful. The results of new trials in this area are expected soon, and hopefully
therapy that directly targets the pathophysiologic pathways of this important disease is on the horizon.