Diastolic Heart Failure

Definition and Characteristics

• The American College of Cardiology defines diastolic heart failure as the presence of symptoms and signs of heart failure in patients with preserved left ventricular systolic function, typically with a left ventricular ejection fraction of >40-50% 1, 2
• Approximately 20-60% of patients with heart failure have preserved systolic function, according to the American College of Cardiology 3, 4
• The primary mechanism is an alteration in ventricular relaxation and/or a decrease in left ventricular compliance, leading to elevated filling pressures, as stated by the American College of Cardiology 1, 5

Diagnosis

• Diagnosis is based on finding typical symptoms and signs of heart failure in a patient with a normal ejection fraction and no significant valvular abnormalities on echocardiography, as recommended by the American College of Cardiology 1, 5
• It is essential to note that heart failure with preserved systolic function and diastolic dysfunction are not synonymous; the diagnosis of pure diastolic heart failure requires evidence of abnormal diastolic function, according to the European Heart Journal 2, 6

Epidemiology and Risk Factors

• Diastolic heart failure is more prevalent in older individuals, particularly women, as reported by the American College of Cardiology 1, 3
• Aging-related cardiovascular changes have a greater impact on diastolic function than on systolic function, according to the American College of Cardiology 1, 4

Treatment

• The American College of Cardiology recommends controlling systolic and diastolic hypertension to manage diastolic heart failure 1, 5
• Beta-blockers can reduce heart rate and increase diastolic period, as suggested by the European Heart Journal 2, 6
• Calcium channel blockers, such as verapamil, may be useful for the same reason, according to the European Heart Journal 2, 7
• ACE inhibitors can improve relaxation and cardiac compliance, as reported by the European Heart Journal 2, 6
• Diuretics can be used for volume overload episodes, but with caution to avoid excessive preload reduction, as recommended by the European Heart Journal 2, 7

Prognosis

• Although the risk of death may be lower than in patients with heart failure and impaired systolic function, these patients suffer significantly from dyspnea and fatigue, as stated by the American College of Cardiology 1
• They are frequently hospitalized for clinical stabilization, which has significant socioeconomic implications, according to the American College of Cardiology 1

Pulse Pressure and Cardiovascular Risk in Grade 1 Diastolic Dysfunction

Interpretation of Pulse Pressure

• A pulse pressure (PP) of ≈ 60 mm Hg falls within the normal‑to‑favorable range, indicating relatively preserved arterial elasticity and arguing against significant cardiovascular pathology. 8
• A wide PP (generally > 60–80 mm Hg) is the concerning pattern; it reflects arterial stiffness, increases left‑ventricular afterload, and reduces coronary perfusion during diastole. 8

Mortality Associations in Dialysis Populations (Evidence from Observational Cohort)

• In patients receiving dialysis, lower PP (≤ 59 mm Hg) is associated with the lowest observed mortality, whereas progressively higher PP categories correspond to higher mortality rates. 8

Arterial Stiffness, Aging, and HFpEF

• Aging diminishes the elastic properties of the heart and large arteries, leading to higher systolic pressure, increased myocardial stiffness, and a predisposition to heart‑failure with preserved ejection fraction (HFpEF). [9][10]
• A normal PP supports the absence of the arterial stiffness and elevated afterload that are typical pathophysiologic contributors in symptomatic HFpEF patients. [9][10]

Blood‑Pressure and Risk‑Factor Management

• Strict control of both systolic and diastolic blood pressure is the cornerstone strategy for preventing progression of diastolic dysfunction and for mitigating arterial stiffening. [9][10]
• An example of well‑controlled blood pressure (≈ 124/65 mm Hg) is considered favorable and aligns with recommendations to maintain target pressures in this population. [9][10]
• Ongoing management of modifiable comorbidities—such as hypertension, diabetes, and coronary artery disease—remains essential for limiting the evolution of diastolic impairment. [9][10]

All statements are based on peer‑reviewed evidence (observational cohort and mechanistic studies) as cited above.