```html

Diastolic Heart Failure: A Comprehensive Patient Guide

Overview

Diastolic heart failure—also called heart failure with preserved ejection fraction (HFpEF)—occurs when the left ventricle becomes stiff and cannot relax normally during diastole (the heart’s filling phase). The heart’s pumping ability (systolic function) is usually normal, but because the chamber does not fill properly, less blood reaches the body, leading to the classic signs of heart failure.

Who it affects: HFpEF is most common in older adults, especially women. According to the American Heart Association, approximately 50 % of all heart‑failure diagnoses are diastolic (HFpEF), and its prevalence rises sharply after age 65.

Prevalence: In the United States, an estimated 3–6 million people live with HFpEF, a number that is projected to increase as the population ages and obesity rates rise. Worldwide, the condition accounts for roughly 1.3 % of all adults, with higher rates in high‑income countries where hypertension and diabetes are common.

Symptoms

Symptoms develop gradually and may be mistaken for normal aging or other conditions. Knowing the full list helps you recognize when to seek care.

Cardinal symptoms

• Shortness of breath (dyspnea) – especially with exertion or when lying flat (orthopnea).
• Fatigue & reduced exercise tolerance – feeling unusually tired after everyday activities.
• Swelling (edema) – usually in the ankles, feet, or lower legs; may progress to the abdomen (ascites).
• Rapid or irregular heartbeat (palpitations) – can be a sign of atrial fibrillation, a common companion.

Associated symptoms

• Persistent cough, sometimes with frothy sputum.
• Chest discomfort or a sense of “tightness” (not typical angina).
• Weight gain of several pounds over a few days due to fluid accumulation.
• Nighttime waking with shortness of breath (paroxysmal nocturnal dyspnea).
• Reduced appetite or nausea from abdominal congestion.

Causes and Risk Factors

HFpEF is usually the result of conditions that make the ventricular wall stiff or thick.

Primary causes

• **Hypertension** – long‑standing high blood pressure forces the heart to work harder, leading to concentric hypertrophy (thickening) of the left ventricle.
• **Ischemic heart disease** – prior heart attacks can scar tissue, impairing relaxation.
• **Aortic stenosis** – narrowed aortic valve increases after‑load, promoting ventricular stiffening.
• **Infiltrative diseases** – amyloidosis, sarcoidosis, or hemochromatosis deposit abnormal proteins or iron in the heart muscle.
• **Obesity** – excess adipose tissue raises circulating volume and inflammatory mediators that stiffen the myocardium.
• **Diabetes mellitus** – chronic hyperglycemia causes microvascular damage and promotes fibrosis.
• **Chronic kidney disease** – fluid overload and uremic toxins contribute to ventricular remodeling.

Risk factors

• Age > 65 years.
• Female sex (especially post‑menopausal).
• Uncontrolled hypertension.
• Obesity (BMI ≥30 kg/m²).
• Type 2 diabetes.
• Sleep apnea.
• Family history of heart failure or cardiomyopathy.
• Sedentary lifestyle.

Diagnosis

Because HFpEF can mimic other conditions, a systematic approach is essential.

Clinical evaluation

• Detailed medical history (symptoms, comorbidities, medication use).
• Physical exam – auscultation for lung crackles, checking for peripheral edema, assessing jugular venous pressure.

Key diagnostic tests

Echocardiography

The cornerstone test. It measures:

• Ejection fraction (EF) ≥ 50 % (preserved systolic function).
• Left‑ventricular filling pressures via E/e’ ratio.
• Left‑atrial size (often enlarged in HFpEF).
• Wall thickness and signs of concentric hypertrophy.

Blood tests

• Brain natriuretic peptide (BNP) or N‑terminal pro‑BNP – elevated levels support a heart‑failure diagnosis.
• Complete metabolic panel, CBC, thyroid function, HbA1c – to identify reversible contributors.

Electrocardiogram (ECG)

Detects atrial fibrillation, left‑ventricular hypertrophy, or prior infarction.

Advanced imaging (when needed)

• Cardiac MRI – excellent for tissue characterization (e.g., amyloid, fibrosis).
• Stress testing or coronary CT angiography – to rule out ischemia.

Invasive hemodynamic testing

Right‑heart catheterization with measurement of left‑ventricular end‑diastolic pressure is considered when non‑invasive data are inconclusive.

Diagnostic criteria

Guidelines from the European Society of Cardiology (2021) require all of the following:

1. Symptoms/signs of heart failure.
2. Left‑ventricular ejection fraction ≥ 50 %.
3. Evidence of diastolic dysfunction (e.g., E/e’ > 14, LA volume index > 34 mL/m², or LV mass index ↑).
4. Elevated natriuretic peptides (BNP > 35 pg/mL or NT‑proBNP > 125 pg/mL).

Treatment Options

Treatment aims to relieve symptoms, prevent hospitalizations, and address underlying comorbidities.

Medications

• Diuretics (loop or thiazide) – first‑line for volume overload; adjust dose to maintain euvolemia.
• Mineralocorticoid receptor antagonists (MRAs) – spironolactone or eplerenone can improve outcomes in selected patients (based on EMPEROR‑Preserved trial).
• SGLT2 inhibitors – dapagliflozin and empagliflozin have shown benefit in HFpEF irrespective of diabetes status (DELIVER trial, 2022).
• Blood‑pressure control – ACE inhibitors, ARBs, or ARNI (sacubitril/valsartan) help reduce ventricular stiffness.
• Beta‑blockers – useful when atrial fibrillation or hypertension is present; not all patients need them.
• Rate‑control for atrial fibrillation – using beta‑blockers, diltiazem, or digoxin.

Procedural & device therapies

• Cardiac rehabilitation – supervised exercise improves functional capacity.
• Implantable cardioverter‑defibrillator (ICD) – considered only if there is a concurrent reduced‑EF or documented ventricular arrhythmia.
• Transcatheter mitral‑valve repair (MitraClip) – may help in patients with significant mitral regurgitation contributing to HFpEF.
• Ablation for atrial fibrillation – restores sinus rhythm and may improve symptoms.

Lifestyle and self‑care

• Low‑sodium diet (≤ 2 g/day) to limit fluid retention.
• Fluid restriction (often 1.5–2 L/day) if advised by your clinician.
• Weight monitoring – a gain of > 2 lb (≈ 0.9 kg) in 24 h warrants diuretic adjustment.
• Regular aerobic activity (e.g., walking, stationary cycling) 30‑45 minutes most days.
• Alcohol moderation (≤ 1 drink/day for women, ≤ 2 for men) and smoking cessation.

Living with Diastolic Heart Failure

Managing HFpEF is a daily partnership between you and your healthcare team.

Medication adherence

• Use a pill organizer or mobile app for reminders.
• Keep a written list of all medicines, including over‑the‑counter drugs.

Monitoring

• Weigh yourself each morning; record the weight and note any sudden rise.
• Track blood pressure at home; aim for 130/80 mmHg or as directed.
• Recognize early signs of fluid overload (e.g., tighter shoes, swelling).

Physical activity

• Start slow; a 5‑minute warm‑up followed by 20‑30 minutes of moderate walking, 5 days/week.
• Include light resistance training (e.g., bands) twice weekly to preserve muscle mass.
• Consider cardiac rehab programs; they provide supervised exercise and education.

Nutrition

• Emphasize fruits, vegetables, whole grains, lean protein, and healthy fats (Mediterranean‑style).
• Read labels; aim for ≤ 2 g sodium per day.
• Limit processed foods, canned soups, and salty snacks.

Psychosocial health

• Depression and anxiety are common; seek counseling or support groups if mood changes occur.
• Stay socially active—regular contact with friends/family improves adherence and quality of life.

Regular follow‑up

Schedule appointments every 3–6 months, or sooner if symptoms change. Labs (electrolytes, renal function, BNP) are typically checked at each visit to guide diuretic dosing.

Prevention

While you cannot change age or genetics, many modifiable factors can lower the risk of developing HFpEF.

• Control blood pressure – maintain <130/80 mmHg or lower; use lifestyle changes and medication.
• Manage weight – aim for a BMI < 25 kg/m²; even modest weight loss (5–10 %) improves cardiac function.
• Treat diabetes aggressively – keep HbA1c < 7 % (or target set by your doctor).
• Exercise regularly – at least 150 minutes of moderate aerobic activity per week.
• Quit smoking – seek nicotine‑replacement therapy or counseling.
• Screen for sleep apnea – CPAP therapy reduces hypertension and fluid retention.
• Limit alcohol – excessive intake worsens hypertension and cardiomyopathy.

Complications

If HFpEF progresses without adequate treatment, several serious complications may arise:

• Acute decompensated heart failure – sudden worsening of symptoms requiring hospitalization.
• Atrial fibrillation – prevalence exceeds 30 % in HFpEF; increases stroke risk.
• Pulmonary hypertension – raised pressures in lung vessels can lead to right‑heart failure.
• Kidney dysfunction – chronic congestion reduces renal perfusion, accelerating chronic kidney disease.
• Thromboembolism – blood clots can form in a dilated left atrium and cause stroke.
• Reduced quality of life & functional decline – limited exercise capacity can lead to frailty.

When to Seek Emergency Care

References

• Mayo Clinic. “Heart failure with preserved ejection fraction (HFpEF).” mayoclinic.org
• American Heart Association. “2022 Heart Disease and Stroke Statistics Update.” ahajournals.org
• European Society of Cardiology. “Guidelines for the diagnosis and treatment of acute and chronic heart failure.” 2021.
• EMPEROR‑Preserved Trial, NEJM 2021; 385: 1082‑1094.
• DELIVER Trial, Lancet 2022; 400: 1110‑1120.
• CDC. “High blood pressure statistics.” cdc.gov
• NIH National Heart, Lung, and Blood Institute. “Heart Failure.” nhlbi.nih.gov

```