Management of Diastolic Heart Failure
The lack of large randomised controlled trials to guide therapy in diastolic heart failure causes some difficulties for evidence-based medicine practising clinicians. Traditionally, treatments for systolic heart failure have been highjacked for diastolic heart failure without much proof of benefit. However, recent studies have began to provide some evidence base for our practice. Betablockers and angiotensin receptor antagonists have recently been shown to reduce hospitalisation in large randomised controlled trials. Diuretic based antihypertensive regimes have been shown to reduce heart failure by 50%. Left ventricular hypertrophy regression is likely to be a good surrogate endpoint for diastolic heart failure, although definitive proof for this is not yet available. Angiotensin receptor antagonists, ACEI, calcium channel blockers, diuretics and aldosterone blockers have all been shown to cause left ventricular hypertrophy regression.
We recommend these drugs to achieve strict blood pressure control together with dietary and lifestyle modification for the treatment of diastolic heart failure. We emphasise the importance of rate control, as diastolic heart-failure patients tolerate tachycardia poorly. We further argue that the pathophysiology of diastolic heart failure is part of systolic heart failure and the two should not be thought of as separate entities. Therefore, our traditional practice of using systolic heart failure treatments for diastolic heart failure is theoretically sound and should not cause us undue anxiety.
In the current age of evidence-based medicine, randomised controlled trials with hard endpoints have become the required standard for assessing therapy. Unfortunately, the design of large-scale randomised controlled trials are often driven by economic and publication pressures. Consequently, treatment for some common diseases have very little evidence-based validation. For example, although systolic heart failure is the gold medal champion of evidence-based medicine, yet diastolic heart failure has failed to even enter the qualifying rounds. As companies lose interest in older drugs, there will no longer be the economic support for large randomised controlled trials to assess their value in diastolic heart failure. It is therefore unlikely that current therapies for the treatment of diastolic heart failure would ever gain as solid an evidence base as the therapies for systolic heart failure has. How then does the clinician treat diastolic heart failure in this evidence-based vacuum? The aim of this article was to review the pathophysiological basis and the evidence available for diastolic heart-failure therapies in order to make treatment recommendations.
Summary
The lack of large randomised controlled trials to guide therapy in diastolic heart failure causes some difficulties for evidence-based medicine practising clinicians. Traditionally, treatments for systolic heart failure have been highjacked for diastolic heart failure without much proof of benefit. However, recent studies have began to provide some evidence base for our practice. Betablockers and angiotensin receptor antagonists have recently been shown to reduce hospitalisation in large randomised controlled trials. Diuretic based antihypertensive regimes have been shown to reduce heart failure by 50%. Left ventricular hypertrophy regression is likely to be a good surrogate endpoint for diastolic heart failure, although definitive proof for this is not yet available. Angiotensin receptor antagonists, ACEI, calcium channel blockers, diuretics and aldosterone blockers have all been shown to cause left ventricular hypertrophy regression.
We recommend these drugs to achieve strict blood pressure control together with dietary and lifestyle modification for the treatment of diastolic heart failure. We emphasise the importance of rate control, as diastolic heart-failure patients tolerate tachycardia poorly. We further argue that the pathophysiology of diastolic heart failure is part of systolic heart failure and the two should not be thought of as separate entities. Therefore, our traditional practice of using systolic heart failure treatments for diastolic heart failure is theoretically sound and should not cause us undue anxiety.
Introduction
In the current age of evidence-based medicine, randomised controlled trials with hard endpoints have become the required standard for assessing therapy. Unfortunately, the design of large-scale randomised controlled trials are often driven by economic and publication pressures. Consequently, treatment for some common diseases have very little evidence-based validation. For example, although systolic heart failure is the gold medal champion of evidence-based medicine, yet diastolic heart failure has failed to even enter the qualifying rounds. As companies lose interest in older drugs, there will no longer be the economic support for large randomised controlled trials to assess their value in diastolic heart failure. It is therefore unlikely that current therapies for the treatment of diastolic heart failure would ever gain as solid an evidence base as the therapies for systolic heart failure has. How then does the clinician treat diastolic heart failure in this evidence-based vacuum? The aim of this article was to review the pathophysiological basis and the evidence available for diastolic heart-failure therapies in order to make treatment recommendations.
SHARE
