Diastolic cardiac failure: Therapeutic modalities

The management of cardiac failure due to diastolic dysfunction is not well codified and is often empirical. It has three objectives : improving the ph ysiopathological components of ventricular filling, treating the associated aggravating pathological conditions, and treating the basic cause of the d ysfunction. Symptomatic treatment aims to reduce venous congestion (by diuretics or nit rate derivatives), to prolong the diastolic period by slowing the heart rat e (by betablockers, bradycardising calcium antagonists or digitalis in case s of irreducible atrial fibrillation), to improve passive ventricular diste nsibility by an effect on remodelling (by angiotensin converting enzyme inh ibitors or anti-aldosterone diuretics). The treatment of associated pathological conditions is particularly importa nt. It is essential to maintain or reestablish an effective atrial systole by cardioversion and anti-arrhythmic drugs in atrial fibrillation, by dual chamber pacing in cases of atrio-ventricular asynchrony due to atrioventric ular block. Treatment of the underlying cause aims to induce regression of ventricular hypertrophy of hypertensive origin by using antihypertensive drugs with thi s property. In coronary artery disease, the choice is determined by the cli nical context because nearly all anti-anginal or interventional treatments may improve ischaemic diastolic dysfunction. The same applies in hypertroph ic cardiomyopathy because most types of treatment (betablockers, verapamil, cardiac pacing, surgery) may improve diastolic function. Finally, in valvu lar aortic stenosis, aortic valve replacement restores normal diastolic fun ction.