I have been debating writing this post for weeks and have successfully deferred it in favor of other posts. This morning, following a conversation with Dr. Mustafa Ahmed, I decided to tackle the subject. My hesitance was borne from the magnitude of the subject. For now, the approach will be for a general overview of diastolic heart failure and we can get more specific in future posts should the need arise.
Before we go to far, there are two definitions that we should address.
Heart failure – This is the clinical syndrome where your body is unable to distribute enough blood flow to meet your body’s needs, or at least it cannot meet those within normal parameters and pressures. Heart failure is often called congestive heart failure or CHF for short.
Ejection fraction – This is the percentage of blood that your heart pumps with each heart beat. A normal heart usually evacuates a little more than half of its volume with each heartbeat. This means that the ejection fraction will be greater than 50%. Most of the time when your physician is speaking of ejection fraction, he/she is referring to the left ventricle.
Diastolic heart failure, is when you have heart failure* with a near normal (preserved) ejection fraction**. This type of heart failure is related more to the heart’s inability to relax than to its inability to squeeze. Diastole is the period of the cardiac cycle when the heart relaxes and blood enters the heart before being ejected. It is somewhat like loading a cannon. Each time the cannon is fired it has to be reloaded. The internal combustion engine of your car may be a more apt analogy but I will need to think about it further. Regardless, what would happen if you had trouble reloading your cannon? You would have all kinds of trouble wouldn’t you?
A heart with diastolic dysfunction is extra-stiff much like the brand new balloon that my kids want me to inflate. I have to huff and puff extra hard to get air into it. The brand new balloon requires a higher than normal pressure to appropriately fill it just like an extra stiff heart. The stiff heart requires more time to fill with blood and sometimes requires higher intracardiac pressures (pressures within the heart). Faster or irregular heart rates (such as atrial fibrillation) can negatively affect your heart’s ability to function at peak efficiency.
There are two main characteristics in diastolic heart failure: 1) you have to have heart failure. 2) you have a near normal ejection fraction in the setting of a stiff heart.
The diagnosis of heart failure is primarily clinical and is characterized by the following:
- Shortness of breath
- Difficulty lying flat because of shortness of breath
- Waking in the middle of the night gasping for breath. Often times you may want to sit up in bed.
- Persistent cough or wheezing
- Edema or fluid build-up
- Weakness or easy fatigue
- Poor appetite or nausea
- Abnormally fast heart rate.
- Enlarged neck veins suggestive of elevated pressure within your heart
- An enlarged heart or signs of fluid on a chest x-ray.
If your doctor is unsure about the diagnosis, then additional testing such as plasma BNP or NT pro-BNP, and cardiopulmonary exercise testing may be in order.
The second requirement is confirmation of a normal or near normal ejection fraction. There are a number of methods to evaluate the ejection fraction including echocardiography, nuclear testing, ventriculography at the time of catheterization, cardiac MRI and cardiac CT. Findings such as thickened heart walls, an enlarged left atrium and stiff heart muscle support the diagnosis. Other causes of heart failure not directly related to the muscle must be excluded. Echocardiography is the most utilized tool because of its accessibility, ability to evaluate the aforementioned supportive findings and lack of radiation.
Treatment of Diastolic Heart Failure
If you have been diagnosed with diastolic heart failure there are four main objectives for treatment:
- Excellent control of your blood pressure
- If you have atrial fibrillation or an abnormally fast heart rate, your heart rate should be controlled.
- Treat your symptoms of heart failure
- If you have significant coronary artery disease then blockages should that are contributing to your symptoms should be addressed.
Blood pressure control
Your heart is like a muscular engine built around a connective tissue chassis. It is powerful and has almost unimaginable endurance. It responds to work and stress by getting stronger. High blood pressure is like lifting weights for your heart. On the surface, that seems like it should be a good thing. Unfortunately your heart doesn’t like lifting weights is prefers yoga. Lifting the heavy load of blood pressure does the same thing to your heart that it does to your biceps. The muscle gets bulky (left ventricular hypertrophy or LVH) and inflexible (impaired relaxation). If you recall from part 1 of this post, stiffening of the heart is what gets you into trouble. As a matter of fact, high blood pressure of hypertension is one of the, if not the leading cause of diastolic dysfunction.
The good thing is that all is not lost. There is solid evidence that improving ones blood pressure can lead to regression of LVH. Some medicines such as angiotensin II receptor blockers (ARBs), calcium channel blockers and angiotensin converting enzyme (ACE) inhibitors seem to lead to regression faster than other classes. Other classes such as diuretics and beta-blockers are also effective but to a lesser degree. There is no strong evidence that faster regression leads to improved outcomes.
The most important thing for you is to get your blood pressure under control. The Joint National Committee regularly updates their recommendations on how to best control blood pressure. There are extensive guidelines as to what medicines are most helpful in certain medical conditions such as diabetes and coronary artery disease. For those of you with diastolic heart failure, your medication regimen will be based largely on any other co-existing medical conditions. When it comes to diastolic heart failure, the journey is probably less important than the destination.
Heart rate control
We have already learned that the heart fills with blood during diastole. When the heart becomes stiff, it needs more time to fill. Diastole is indirectly related to heart rate so faster heart rates mean shorter filling times. This is why tachycardia, or an abnormally fast heart rate, is not well tolerated in this condition. This is magnified in conditions such as atrial fibrillation or atrial flutter. Usually, the atria and ventricles work in concert. The atria are essentially reservoirs that sit above the ventricles (the heart’s main pumping chambers). They intermittently pump blood into the ventricles to help the ventricles fill with as much blood as possible. This results in a more efficient diastole and happier ventricles. These conditions often result in tachycardia and more importantly; the coordinated squeeze is also lost. In the setting of diastolic heart failure, since ventricular filling is already compromised, this can have a profound effect. It becomes doubly important to have a reasonably slow heart rate to allow for optimal filling. The medicines used most commonly to slow your heart rate fall under the categories of beta-blocker and calcium channel blocker. Sometimes in atrial fibrillation or flutter we have to go a step further and take actions to return you to a normal heart rhythm.
Treat your symptoms of heart failure
Treatment for diastolic heart failure is primarily directed at treating the “congestion” of congestive heart failure. These symptoms are related to higher than normal pressures within your heart and lead to the classical symptoms including shortness of breath, edema and fatigue. Management of these symptoms relies heavily on diuretic use to help your body eliminate excess fluid. Limiting salt intake is of critical importance (please review Dr. Guichard’s discussion on salt in heart failure). Lowering an abnormally high blood pressure and treated other correctable causes such as aortic stenosis are also beneficial. Long-term exercise has been shown to improve diastolic function and improves the functional capacity of persons with abnormal diastolic function
Ischemia is bad
Coronary artery disease where a heart blockage causes significantly decreased blood flow can lead to varying levels of ischemia in the myocardium. Ischemia is a shortage of blood flow that results in insufficient oxygen and nutrient transport to maintain normal metabolism. Relaxation of the myocardium is an energy driven process, meaning that it requires work to relax (kind of oxymoronic). Coronary blockages can thereby affect the heart ability to relax and should be aggressively treated.
Diastolic heart failure is a complex entity that is not always intuitive. A good low salt diet, blood pressure control and regular exercise will go a long way to controlling many of your symptoms. Your doctor will be able to help you determine what the likely cause of your diastolic disease and devise a treatment plan to combat it.
I am confused about my condition. My doctor says I have a stiff heart. But my symptoms don’t agree with those I see on the web. I am perfectly normal when sitting. when I walk for more than a block or two, I must walk slow (my muscles have gotten weak), sometimes I experience angina and sometimes I gasp. I rest for a few minutes and I’m OK. I have no problem sleeping of anything else. No excess sleeping; I am absolutely normal except if I do mild exercise. I have a pacemaker and have Afib. Can I improve my condition? Where do I start?
My wife’s doctor said she has acute diastolic cardiac disease
But no treatment? What. Do I do. Where do I go???
Dr. Jason L. Guichard, MD, PhD says
Diastolic heart failure or heart failure with preserved ejection fraction (HFpEF) is the clinical syndrome of heart failure in the setting of normal left ventricular ejection fraction (LVEF). Even though HFpEF is treated like systolic heart failure or heart failure with reduced ejection fraction (HFrEF), there are no proven therapies for HFpEF only extrapolation from studies in systolic heart failure. Current evidence shows that there is a lack of significant benefit (mortality or quality of life) with neurohormonal antagonism in HFpEF. Current treatment of HFpEF remains empirical and centered around the control of blood pressure (including diagnostic work-up for resistant hypertension when indicated), diabetes, dyslipidemia, OSA (with CPAP or BiPAP), COPD, and volume status (with the use of diuretics). Along with life style changes (weight loss, regular exercise, smoking cessation, and salt restriction), all of these interventions can potentially improve the clinical syndrome. Of note, exercise training in patients with HFpEF appears to be safe and is associated with an improvement in cardiorespiratory fitness and quality of life but without significant changes in left ventricular systolic or diastolic function.
Jacky Glen says
I have diastolic dysfunction and heart failure. I’ve always had low blood pressure. I’m not diabetic. My veins etc are apparently that of a young girl. Until recently I’ve been going to gym 3 to 4 times a week so I don’t understand why I still got this problem and have been doing everything they say would improve it already.
Dr. Jason L. Guichard, MD, PhD says
I would recommend an evaluation by a heart failure cardiologist to see if there are any diagnostic and therapeutic options in your case.
The Dr said my echo showed a little stiffness in the heart muscle. Normal ejection rate. Said not to worry. Limit fluid intake, cont eff ol bp and loose extra weight. This is cardiologist. But my primary and rheumatologist put on my chart and say I have congested heart failure. I also show it on internet its diastolic congested heart failure. Why do the doctors sau different things. Im worried . Dont wanna have that but am worried do I . If I do will have to deal with it. What do you think.
Mary B. Stearns says
Thank you for this excellent explanation of Diastolic Heart Failure. The hospitalist did not explain this diagnosis at all, until I demanded it, and then it was a couple of sentences, so I decided I’d look it up at home. This is so much better than simplistic WebMD, Mayo Clinic online, etc. and less complicated than professional articles. I am an RN, but worked in surgery for my career, so my knowledge of cardiology is lacking. I have bookmarked this site for further reference.
I appreciate the education you have me in regards to Dostolic Heart Failure. If doctors give you this really with no information, it can be scary.
Renee Michel says
My daughter has a blood pressure of 117/29 and recently went to see her doctor because she had pain in the left arm, she recently began to feel very tired, had difficulty sleeping because she said her heart feels tired. The doctor just gave her Tylenol and sent her home! She is 25 years old, recently had a change in her medications for depression, what is going on?
I would definitely get another opinion. Diastolic pressure of 29 is way too low . I notice this was over 7 months ago, hope she’s okay.
Lance Cary says
No, it’s way to high. It should be below 18. I speak from experience with diastolic heart failure.
Thank you so much for your explantion of my condition. My doctor diagnosed me with DHF and out me on cardizem to slow my heart. I haven’t had any further testing to make sure blockages aren’t there except for the Nuclear Stress Test and ultra sound. I really feel like I was diagnosed and given meds then sent on my way to cope. I don’t have follow ups to monitor my potassium levels done put on 40mg lasix. I was previously on Lisinopril HCTZ 20/25 that I took religiously every day since I was 20 yrs old. The doctor kept me on HCTZ with my lasix. I’m only 48 years old and can’t hardly walk without shortness of breath. Should I suggest anything else be done to confirm my specific diagnosis? Should I consider another doctor? I can’t even exercise without loosing breath and getting really weak. I’m really discouraged.
Kenda fischer says
I’m only 47 yrs old. Close to ur age as well. I’m also a nurse. Afraid I’m not ever going to b able to go back to work cuz of my shortness of breath with this DHF. So scary. I’m on lasix. Potassium. And recently added metoprolol for high heart rate. I have not been told how often to get potassium checked as well. I will b asking dr soon. Good luck.
talk about being in easy i am 53 just got told i have this and i am lost. they did not give me any meds just shot of steroids and told me they may put me on something. talk about worried 🙁
I have been diagnosed with diastolic heart failure…hfnef. Everything I read tributes high blood pressure as a cause. I have never had high blood pressure over my lifetime…it has always been very low. So what is that about?
Chris Adrian says
There is more than one cause of Diastolic Heart Failure (DHF). I have DHF and was told by Cardiologist that the cause was weight/obesity and the related causes; poor diet and not enough exercise. Other causes can be hypertension, abnormal heart rhythm, coronary artery disease (CAD), diabetes, aging, and others. My treatment includes daily aspirin, beta-blocker to control heart rate, statin for cholesterol, and lifestyle changes.
Lots of questions came up after the diagnosis and I researched online from good websites like WebMD, National Institutes of Heath, American Heart Association, drugs.com. Any questions were taken to my cardiologist.
I am a RN and in today’s world, the patient has to be the “pilot” of his/her heath care. If you have questions, ask. Do not be afraid, we pay the doctors, so they work for us.
My heart doctor told me I have diastolic dysfunction after 3 and 1/2 hours of testing. She told me it was not serious and if I felt tired to sit and rest. My blood pressure is great. I have googled about this diastolic dysfunction and got so upset. I do not have any of the symptoms as listed on google. Should I be worried?
I was diagnosed with Right side stage 2 diastolic dysfunction back in May. I went to the cardiologist because of shortness of breath. My arteries are as clear as a bell so I know that isn’t the problem. I also have POTS which causes my heart rate to be really high. My cardiologist isn’t concerned about the dysfunction. He believes my shortness of breath is due to pulmonary issues. I know the difference between trouble breathing because of lungs and this. This is an entirely different feeling. I am going to the Pulmonologist to rule lung issues out so the cardiologist might look at my heart as being the cause of the shortness of breath. What else can I do to make my doctor look at this more?
Dr. Mustafa Ahmed says
See what the pulmonologist says and go from there.
I too have been diagnosed with hfpef, & I also have Hyperadrenergic postural orthostatic tachycardia syndrome. I have a pots specialist, a pulmonary specialist and a cardiologist. I was experiencing shortness of breath and weakness and low pulse oxygen levels. I was getting palpitations and angina and a feeling of bronchitis and bloody taste in my mouth. Cchf did several cardiopulmonary stress tests, echos, and finally a right sided heart catheterization procedure. The heart cath revealed the hfpef. I was told it was due to my obesity and if I lost enough weight I could stop the progression of this disease. I however found that as a Hyperadrenergic pots person the elevated adrenal hormones can contribute a great deal to the development of hfpef. I am on metoprolol, potassium, magnesium, hydrochlorothiazide for my condition but I am having a lot of palps and weakness. I am so scared I don’t want to die I’m only 38. Anyone have anything that says I can live longer than 5yrs?
Susan Difronzo says
Yes, it is scary. And adds to the condition in that the not knowing layers on more stress!
A pots and a pulmonary?? I only have a cardiologist.
Why can’t we find out more about our conditions? So aggravating!
A. MacDonald says
These questions are all good. The article was fine as far as it went, but, as so many others here, I’ve been out of breath if I do anything, and fatigued, with swollen ankles, feet and legs. I was immediately given 5 days of Lasix for the water retention. I’m a healthy 63 year old. Which may sound old to the doctors, but not to me! Yes, I was given an ecogardiogram and diagnosed with “Grade 1 Diastolic Dysfunction” which both an internest and pulmonologist says is not the cause of my problems. Internest has gone from blood clot, to bronchitis, to walking puemonia, to Lyme disease! I tested negative for Lyme disease and had no blood clot, and a CT of my lungs is clear. Pulmonologist says I have asthma and sleep apnea, which is why I can’t breath and am tired! I am going to a cardiologist anyway to learn more that “eat a healthy low sodium diet and exercise” to help my diastolic dysfunction. How “low” is low for sodium? What kind of exercise should I do? When? I can’t walk far without getting out of breath, do I start exercise now? And since I’m swelling again (three weeks later), what does that mean and what do I do? Doctors have been making this seem so minor, nothing special or harmful until I’m WAy older they say! I got the speal about the cannon from the pulmonologist. No doctor has given me enough information about this condition. It’s very negligent I think.
I have shortness of breath, wake up in the middle of the night gasping for air, have to sleep with two + pillows, can’t walk very far anymore without losing my breath. In the past, I was a consistent walker (5 miles/day). My cardiologist just told me the results of my echo show that I have diastolic dysfunction. He said to continue exercising and try to lose weight. I haven’t been able to lose weight since being diagnosed with lupus 10 years ago. (I am not taking prednisone, so it isn’t the cause of the weight gain.) When you say that, “ischemia is a shortage of blood flow that results in insufficient oxygen and nutrient transport to maintain normal metabolism” does that mean that it has affected my metabolism/ability to lose weight? Also, would lupus be a cause for this heart muscle stiffness?
I am 44yrs old and have lupus was diagnosed in 2015. All other labs thru the yrs have came up with fibro until 2015. Presently have been feeling palpitations and went to my Pcp and he requested an Echo and EKg.. EKG was fine nothing abnormal and Echo came back with stage 3 diagnostic disfunction.. My Pcp just referred me to a cardiologist ,but my rheumatologist nurse practitioner thinks i should be writting out my last Will and testimate. I am so stressed and scared to even live life do to this condition.. I don’t know if it’s from prednisone,Lupus or being over weight.I am 44 not 70.. I dont even know if my condition could be fixed.. hopefully i can get in earlier to see the cardiologist.. .
Mary Young says
I have been diagnosed with left ventricular diastolic dysfunction grade 1. I also have mild pulmonary hypertension. I have well-controlled high blood pressure it is always been controlled. I also have obstructive sleep apnea. They are having trouble treating my moderate obstructive sleep apnea because the machine causes me to have Central apneas. I am morbidly obese at over 300 lb I am in my 50s and a female. Is there anything I can do to live? I want to raise my youngest son he is only 12. Please please answer thank you
Joy Thomas says
I survived SCD due to V Tach 03/20/2013. Life support for 3 day’s. ICD/PM placed, I was 49 yoa & in good health other than I had been extremely fatigued beginning to swell chest pains they told me it was due to stress Etc. They did not anticipate me to survive however I did. The cardiologist at the time told me to anticipate 3 1/2 to 5 years. I am now approaching five years and my latest Echo now shows I still suffer low blood pressure, with a high heart rate and my ICD shows I still suffer the tachycardia. They State now I have pulmonary hypertension, left ventricular hypertrophy, diastolic failure. There are no meds that they give me based on the tachycardia and the low blood pressure and high heart rate. What exactly does this mean no one wants to tell me. Lately my fatigue has become exasperated as well as nausea loss of appetite and weight loss I’m not overweight never have been I’ve always been your typical gym rat up until this happened to me. Now I find myself short of breath just walking to the mailbox and around my house just trying to do things such as make my bed. Any info would be appreciated.
Kelly S Hoffman says
I have a question. I was just diagnosied with DHF and also said my ekg showed an A1 what does this mean
This article was very helpful. Thank you. My mom was recently diagnosed with DHF. Her ankles and abdomen are swollen quite a bit. So what sort of exercise would be effective and doable for someone so swollen up and with shortness of breath?
the most helpful would be walking a short distance then gradually increasing daily.
Denise Briley says
I am 44 and was just told I have severe hypokinesis if the left ventrical with AA reduced ejection fraction of 15% . No high blood pressure no swollen feet or ankles. Dr’s ( I’ve seen three) can’t give me a consistent answer!! I feel fine for the most part please help me understand!!
What do you do to correct low blood pressure.
I have grade II dystaloic.
Pamela Alston says
I have been diagnosed with diastolic heart disease. My cardiologist added diuretics to my medicine and I will continue to take valsartan. I am also working with an endocrinologist because it is believed that my high blood pressure is caused by an overactive thyroid. Does all of this make sense to you?
Robin Lenka says
I have been diagnosed with Grade III diastolic dysfunction – have extreme swelling in my feet and ankles. My primary referred me for an echocardiogram where this dysfunction was diagnosed. Referred to a cardiologist who said my heart is just fine and ordered a lexiscan and everything is fine. I’m not sure how to interpret it…is this serious or not? Cardiologist thought I was wasting his time even though my primary was concerned, otherwise she wouldn’t have referred me.
Leslie Burns says
I would visit a different cardiologist, or two.
I also was diagnosed with diastolic dysfunction.call me
Leslie Burns says
My V.A. primary care insisted anxiety was reason I was easily fatigued. I failed treadmill stress test horribly, and had ct scan. All he could say is ,”no blockage, no blockage”. I informed him that there are many other possible problems. He angrily, at my insistence referred me to cardiologist. One echocardiogram later; stage II diastolic dysfunction. You have to fight for your own good.
Joyce Hopkins says
I have had pulmonary sarcoidosis for 20 years and obstructive sleep apnea for 17 years that evolved into complex apnea 4 years ago. The sarcoid flared up 5years ago after a 10 year break. I had SVT 3 years ago that has been treated with metoprolol. About 2 years ago sarcoid flared up even more in my heart with cardiomyopathy and diastolic heart failure stage 2. The SVT is mostly controlled, but I’m not so sure about the rest.
My lungs have been doing well since starting humira injections 2 years ago but my legs began to swell occasionally, shortness of breath, cough and tiredness increased last winter. furosemide helps the swelling. I started using 2 liters O2 in January, which helps some. I also, am battling with sleep apnea. The OSA is controlled but the central apnea that developed 4 years ago is not.
I don’t know whether I stay tired from the apnea or the heart failure. The doctors can’t seem to help. Where do I go for help before all this does me in.
Indrajit Biswas says
Hello Dr, I am from India, aged 51 M, smoker.. diagnosed with LVH + DD Grade1.. of sudden I had a black out today for about few seconds.. is it a curtain call sign… appreciate to suggest.
Dr. Jason L. Guichard, MD, PhD says
I would recommend an evaluation by a cardiologist.