Update on diastolic heart failure or heart failure with preserved ejection fraction in the older adults

Figures & data

Figure 1. Mechanisms of DHF. All abbreviations are explained in the text of the manuscript.

Table I. Predisposing and precipitating factors for DHF.

Predisposing factors:	Precipitating factors:
Advanced age	Recurrent ischemia
Female sex	Atrial fibrillation
Obesity	Renal failure
Hypertension	Sepsis
Diabetes
Coronary artery disease

Table II. Prevalence of specific symptoms and signs in systolic versus diastolic HF.

Clinical features	SHF or heart failure with reduced ejection fraction	DHF or heart failure with preserved or normal ejection fraction
Symptoms and signs
Orthopnea	73%	60%
Paroxysmal nocturnal dyspnea	50%	55%
Jugular venous distension	96%	85%
Edema in the legs	46%	35%
Hepatomegaly	40%	30%
Displaced apical impulse	60%	50%
S3	65%	45%
S4	65%	45%
Rales or crepitations	70%	72%
Chest radiography
Pulmonary venous hypertension	80%	75%
Cardiomegaly	96%	90%

Adapted from Zile et al. Circulation. 2002;105:1387–93 (28).

Figure 2. Diagnostic approach for DHF. (All abbreviations are explained in the text of the manuscript.)

Table III. Drug trials in DHF/HFPEF.

Type of medication/study/ref	Patients (n)	Mean age	Duration of study	Outcomes
Diuretics versus ACE inhibitor versus ARB/Hong Kong Diastolic Heart Failure Study (RCT)/Yip 2008 (87)	150	65 y	52 weeks	Improved symptoms and QOL. Little further benefit on symptoms and QOL with the addition of ramipril or irbesartan, but marginally improved LV systolic and diastolic longitudinal function and decreased NT-proBNF levels (P <0.05)
Spironolactone/(RCT)/Roongsritong 2005 (88)	30	71 y	4 months	Decreased left ventricular mitral flow, improved left ventricular diastolic dysfunction. Improved mitral E/A ratio—0.71±0.08 versus 0.84±0.19, P =0.025, improved deceleration time 285.5±73.1 versus 230±54.7, P =0.035)
ACE inhibitors + diuretics versus diuretics/Prospective randomized study/Aronow 1993 (92)	21	80 y	3 months	Decreased LV mass (230±46 g versus 313±43 g, P <0.0001). Increased peak mitral E/A ratio (0.7±0.1 versus 0.6±0.1, P <0.001) and increased exercise tolerance 270+44 versus 224+27, P <0.001)
Indapamide ± perindopril/HYVET (RCT)/Beckett 2008 (89)	3845	80 y	24 months	HF risk reduction –64%, P =0.001
Candesartan/CHARM – PRESERVED (RCT)/Yusuf 2003 (94)	3023	67 y	37 months	Mortality: HR 0.95 (95% CI 0.76–1.18), P =0.635. Hospitalization: HR 0.84 (95% CI 0.70–1.0), P =0.047
Perindopril/PEP-CHF (RCT)/Cleland 2006 (95)	850	70 y	27 months	Mortality: HR 0.92 (95% CI 0.70–1.21), P =0.55. Hospitalization: HR 0.63 (95% CI 0.41–0.97), P =0.033
Irbesartan/I-PRESERVE (RCT)/Massie 2008 (96)	4128	72 y	50 months	Mortality: HR 1.00 (0.88–1.14), P =0.98. Hospitalization: HR 0.95 (0.85–1.08), P =0.44
Propanolol + diuretic + ACE versus diuretic + ACE/Prospective randomized study/Aronow 1997 (97)	158	81 y	32 months	Reduction in mortality plus non-fatal myocardial infarction (RR 0.630 (95% CI 0.430–0.924))
Nebivolol/SENIORS study (RCT)/Ghio 2006 (98)	752	76 y	21 months	Mortality: HR 0.86 (95% CI 0.74–0.97), P =0.039
Statin/(RCT)/Tehrani 2010 (108)	270	79 y	5 y	Mortality: RR 0.646 (95% CI 0.438–0.953), P =0.0277
Combined statin, ACE-inhibitor, beta-blocker/(observational study)/Shah 2008 (107)	13553	>60 y	3 y	Improved survival: RR 0.73 (95% CI 0.68–0.79)
Digoxin/DIG-PEP (RCT)/Ahmed 2006 (104)	988	67 y	37 months	Combined end-point of heart failure hospitalization or mortality: HR 0.82 (95% CI 0.63–1.07), P =0.136

All abbreviations are explained in the text of the manuscript.