Heart Failure Evaluation and Management

Diagnosis and Prognosis

• Diastolic dysfunction is categorized into three grades according to the American Society of Echocardiography and the European Association of Cardiovascular Imaging, which carries different prognostic implications 1
• Heart failure is defined as systolic heart failure with left ventricular ejection fraction (LVEF) <40% and diastolic heart failure with LVEF ≥40-50% and evidence of abnormal diastolic function, according to the European Society of Cardiology 2
• The evaluation of diastolic function should include an assessment of diastolic dysfunction grade, which is essential for proper management and risk stratification of patients with heart failure, particularly those with preserved ejection fraction 1
• Initial assessment includes evaluating symptoms and signs of heart failure, performing ECG, ordering chest X-ray, and measuring BNP/NT-proBNP levels, as suggested by the European Heart Journal 3
• Definitive diagnosis is made by performing echocardiography with Doppler studies, which measures LVEF, assesses chamber size and wall thickness, and evaluates diastolic function parameters, as stated by the European Heart Journal 2
• Diastolic dysfunction classification is based on mitral inflow patterns, with the following characteristics:

Treatment and Management

• The American College of Cardiology recommends using ACE inhibitors/ARBs as first-line therapy to improve relaxation, reduce hypertrophy, and decrease blood pressure in patients with diastolic dysfunction 4, 5, 6
• Beta-blockers are recommended to lower heart rate and increase diastolic filling period in patients with diastolic dysfunction 4, 5
• Verapamil-type calcium channel blockers may improve relaxation and functional capacity, especially in hypertrophic cardiomyopathy, in patients with diastolic dysfunction 4, 5
• Diuretics should be used cautiously for fluid overload to avoid excessive preload reduction in patients with diastolic dysfunction 4, 5
• Lifestyle modifications, including sodium restriction (<2g/day), weight loss if overweight/obese, regular and appropriate exercise, treatment of sleep apnea if present, and limiting alcohol consumption, are recommended to manage grade II diastolic dysfunction 1, 5

Follow-up and Prognosis

• Echocardiographic follow-up every 1-2 years is recommended to monitor progression of diastolic dysfunction, left atrial size, development of pulmonary hypertension, and LV systolic function 7, 8, 9, 10
• Patients with Grade II diastolic dysfunction have a worse prognosis than Grade I or normal function, and increases the risk of hospitalization for heart failure, emphasizing the need for proper management 11, 1
• Neglecting the prognostic significance of grade II diastolic dysfunction, which warrants more aggressive risk factor modification, is a significant concern, with a significantly lower 5-year survival rate (39% vs 79% vs 95%) 11, 1