Half of Heart Failure Is Diastolic, Not Systolic


SAN FRANCISCO — A majority of patients presenting to emergency departments with pulmonary edema have diastolic heart failure, also known as heart failure with preserved ejection fraction, Dr. William Grossman said.

A recent analysis of data from more than 100,000 hospitalizations in the Acute Decompensated Heart Failure Registry (ADHERE) showed that 51% of patients with heart failure had preserved ejection fractions, and 49% had depressed ejection fractions, also called systolic heart failure (J. Am. Coll. Cardiol. 2006;47:76–84). In-hospital mortality rates were 3% with diastolic heart failure and 4% with systolic heart failure, he said at a meeting sponsored by the California chapter of the American College of Cardiology.

That finding may surprise many people who attribute death from heart failure mainly to systolic dysfunction, said Dr. Grossman, chief of cardiology at the University of California, San Francisco. Many patients have both types of heart failure.

Compared with the systolic heart failure group, patients who had diastolic heart failure were more likely to be women and less likely to have a prior MI or to be taking ACE inhibitors or angiotensin receptor blockers (ARBs).

In a separate recent study, investigators from the Mayo Clinic, Rochester, Minn., followed 556 patients with heart failure in the community for 6 months. The mortality rate was 16% both in the 55% of patients with diastolic heart failure and in the rest of the cohort, who had systolic heart failure, Dr. Grossman noted.

“The prognosis is really not much better than for classic systolic heart failure,” he said at the meeting, also sponsored by the university.

In the Mayo Clinic study, diastolic dysfunction and the patient's ejection fraction independently predicted elevation of brain natriuretic peptide (BNP).

“When patients come to the emergency ward with acute shortness of breath, many of us look to the BNP to tell us, is this pneumonia? Is this asthma? Is this hypertension? BNP is elevated in heart failure whether it's systolic or diastolic,” an important fact to recognize, he said.

If diastolic heart failure is so widespread, what's causing it? It's not all caused by amyloidosis, and is unlikely to be due to untreated hypertension in so many cases, Dr. Grossman believes.

German investigators performed cardiac biopsies and other tests on 70 patients hospitalized with diastolic heart failure and found that 84% were infected with parvovirus B19. Presence of the virus was strongly associated with coronary endothelial dysfunction (Circulation 2005;111:879–86).

“I'm not saying this is what's going on in our emergency wards, but it's certainly something that I would never have thought to look for. We should pay attention. There may be increased information about this in the future,” Dr. Grossman commented.

There are few data from randomized trials to guide treatment of diastolic heart failure. Dr. Grossman approaches management much as he would for patients with systolic heart failure.

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