1. Management of Diastolic Heart Failure:
What is the Recent Results in Clinical Trial
報告學生：陳秋縈
指導老師：李貽恆醫師
報告日期：2012/11/13
CASE REPORT

2. 2
Patient profile
Name 吳○○ Admission date 2012/10/18
Age 79 Allergy history NKDA
Gender female Social history Smoking: (-)
Drinking: (-)
Betel nut: (-)
Drug abuse: (-)
HT/BW 168cm/62.3kg
BMI 22
Past history Regular medication
• Hypertension
• Persistent atrial fibrillation
• Hyperuricemia
• Impaired glucose tolerance
• Amlodipine 5mg PO QD
• Furosemide 20mg PO QOD
• Aspirin EM 100mg PO QD
• Benzbromarone 50mg PO QD
Chief complaint
• Productive cough and shortness of breath for 2 weeks
• Mild fever up to 37.3°C in recent days

3. 3
History of present illness
• Intermittent exertional dyspnea for several years
• Long term follow up in local clinic
4/12 • Visit NCKUH CV OPD
• Arrange further examination
4/23 • CXR: Cardiomegaly, atherosclerosis of the aorta
• ECG: AF, VPC
• Echocardiography:
Dilated RA, LA and LVH
Adequate global LV systolic performance
Mild MR and TR with mild pulmonary HTN
10/18 • Suffered from productive cough and intermittent low grade fever
for 2 weeks
• Dyspnea, transferred to ER from OPD
OPD PRESCRIPTION
• Amlodipine 5mg PO QD
• Furosemide 20mg PO QOD
• Aspirin EM 100mg PO QDAC
• Benzbromarone 50mg PO QD
LOCAL CLINIC PRESCRIPTION
• Olmesartan /Amodipine
20mg/5mg PO QD
• Bumetanide 0.5mg QD
• Digoxin 0.125mg PO QD
• Aspirin EM 100mg PO QDAC
• Benzbromarone 50mg PO QD

4. 4
Physical examination
• VITAL SIGN
TPR: 37.7/85/20 BP: 141/78 mmHg SpO2: 92%
• NECK: JVE(+)
• CHEST: crackles over right lower lung
• HEART: irregular heart beats, grade III/IV pansystolic murmur over apex
• EXT: bilateral legs pitting edema 3+
ECG
• Af with RVR
CXR
• Cardiomegaly
• Patchy consolidatoin and infiltrations over both lungs
 Suspect pneumonia or lung edema

5. 5
Lab data
Impression
• HF with AE, favor infection induced
• Af with RVR
• HTN
Normal
range
10/18
ALBUMIN 3.5-5 4.1 g/dL
CREA 0.6-1.2 1.16 mg/dL
eGFR 45
ALT 0-54 15 U/L
CK 30-135 154 U/L
NA 135-148 145 mmol/L
K 3.5-5 4.8 mmol/L
GLU.P.C. 80-140 144 mg/dL
CK-MB <2.9 3.62 ng/mL
hsTnT 0.025 ng/mL
NTproBNP <125 12956 pg/mL
Normal
range
10/18
WBC 3.2-9.2 9.8 10^3/μL
Hb 11.6-14.8 10.8 g/dL
Plt 151-366 183 10^3/μL
Blast 0 %
Pro 0 %
Myelo 0.5 %
Meta 0 %
Band 1 %
Seg 43-64 79.5 %
Eos 0-6 0 %
Baso 0-1 0 %
Mono 3-9 8 %
Lymph 27-47 11 %
Aty-lym 0 %
NRBC 0 /Count WBCs

6. 6
Hospital course
Date Event Management
10/18
16:00
at ER
• BT: 37.7, cough, dyspnea
• CXR : patchy consolidatoins and infiltrations
• WBC: 9.8 (103/μL), Seg: 79.5%, band:1%
Suspect CAP
• Legionella & pneumococcus Ag (urine): (-)
• PCT: (-)
• SOB, orthopnea
• BP: 141/78 mmHg, SpO2: 92%
• IRHB, JVE(+), crackles over right lower lung,
lower leg pitting edema
• CXR: cardiomegaly
• ECG: Af with RVR
• NTproBNP: 12956 pg/mL
Suspect HF with AE
• S/C & gram stain, B/C x 2 sets
• Acetaminophen 500mg
Q6HPRN if BT>38.3
• Ceftriaxone inj 1g IVD Q12H
• Levofloxacin 500mg PO
QDAC
• O2: 3L/min
• Furosemide 40mg IVP STAT
• Digoxin 0.25mg in NS 50ml
IVD 30min STAT

7. 7
Date Event Management
10/18
18:00
after
admission
HF with AE, favor infection related
HTN previous under amlodipine
• Scr: 1.31 mg/dL, K:4.8 mmol/L
Persistent Af
Gout history
• Diet: 限鹽 5g/day, 限水1500ml/day
• Shift amlodipine to
Valsartan 80mg PO QD
• Furosemide 40mg PO BID
• Isosorbide DN 5mg PO TIDAC
• Digoxin 0.125mg PO QD
• Aspirin EM 100mg QD
• Benzbromarone 50mg PO QD
10/20 • Echocardiography report
 HF with Preserved Ejection
Fraction (HFPEF)
• SOB improved, BW↓, I/O↑
• Furosemide 40mg PO QD
Hospital course
Echocardiography report
Dilated LA, LV, RA
Adequate LV systolic performance
Moderately-severe posterior-eccentric MR (3+)
Moderately-severe TR (3+)
Normal LV filling pressure, mean E/E'=7.7 (<8)
Af with occasional VPCs
LVEF: 61.1%
10/18 10/19 10/20
BW (kg) 62.3 61.25 60.8
I/O (ml) -390 -650 +40
LVEF: left ventricular ejection fraction

8. 8
Date Event Management
10/21 • Keep Valsartan use
10/22 • SOB improved, no orthopnea,
less cough, less edema
• F/U lab no leukocytosis
WBC: 4.5 (103/μL), Seg:61.8%
• CXR: complete resolution of
consolidation
• Valsartan 160mg PO QD
• Furosemide 20mg PO QD
• DC Ceftriaxone
10/23 • TPR: 36.8/60/20
• BP:113/85 mmHg
• Stable condition
• Discharged and OPD F/U
Hospital course
10/18 10/21
Scr (mg/dL) 1.16 0.82
K (mmol/L) 4.8 3.6
10/18 10/22
Discharge Order
• Valsartan 160mg PO QD
• Furosemide 20mg PO QD
• Isosorbide DN 5mg PO TIDAC
• Digoxin 0.125mg PO QD
• Aspirin EM 100mg PO QDAC
• Benzbromarone 50mg PO QD
• Levofloxacin 500mg PO QDAC x 4days

9. 9
Summary of our patient
Drug 10/18 10/19 10/20 10/21 10/22 10/23
discharge
order
CAP
Ceftriaxone 100mg IVD q12h
Levofloxacin 500mg qdAC
Acetaminophen 500mg q6h prn
HF
Isosorbide DN 5mg tidAC
Valsartan 80mg qd 160mg QD
Furosemide 40mg bid 40mg QD 20mg QD
Af
Digoxin 0.125mg qd
Aspirin EM 100mg qd
Hyperu-
ricemia Benzbromarone 50mg qd
BW(kg) 62.3 61.25 60.8 60.5 60.4 59.7
I/O (ml) -390 -650 +40 +450
Scr 1.16 mg/dL
K 4.8 mmol/L
Scr 0.82 mg/dL
K 3.6 mmol/L

10. 10
Outline
 Diastolic heart failure (DHF)
 Definition and diagnosis criteria
 Epidemiology
 Pathophysiology
 Clinical Manifestations
 Management
 Recent results in clinical trials
 Case discussion
 Take home message

11. 11
Heart failure
 A complex clinical syndrome that can result from any
structural or functional cardiac disorder that impairs the
ability of the ventricle to fill with or eject blood.
 Systolic heart failure
 Diastolic heart failure
ACC/AHA Practice Guidelines

12. Diastolic Heart Failure (DHF)
Also called:
• Diastolic dysfunction
• Heart failure with preserved ejection fraction (HFPEF)
• Heart failure with normal ejection fraction (HFNEF)

13. 13
Definition
 Vary with no global consensus
 A clinical syndrome
 Signs or symptoms of heart failure
 Congestion, low perfusion
 Normal or near normal left ventricular systolic function
 Variably defined as an LVEF >40%, >45%, or >50%
 Evidence of diastolic dysfunction
 Abnormal left ventricular relaxation, impaired filling , myocardium
stiffness
1. Galderisi M. Cardiovasc Ultrasound. 2005 Apr 4;3:9.
2. Aurigemma GP, Gaasch WH. N Engl J Med. 2004;351(11):1097.
LVEF: left ventricular ejection fraction

14. 14
Diagnostic Criteria
Adapted from Yturralde FR. Prog Cardiovasc Dis 2005;47:314-19
2009 Focused Update: ACCF/AHA Heart FailureGuidelines
Clinical evidence of HF:
Clear clinical presentation of HF
or Framingham or Boston criteria
If uncertain:
Plasma BNP or NT-proBNP
or chest x-ray
or cardiopulmonary exercise testing
LVEF < 50% LVEF ≥ 50%
Supportive evidence:
• Eccentric LVH or remodeling
Supportive evidence:
• Concentric LVH or remodeling
• Left atrial enlargement in absence of AF
• Echo Doppler or catheter evidence of
diastolic dysfunction
Exclusions:
• Non-myocardial disease Exclusions:
• Non-myocardial disease
Diastolic HFSystolic HF

15. 15
Epidemiology
 50% of patients with HF has normal LVEF
 Increasing prevalence
Secular Trends in the Prevalence of HF-PEF
Owan T, et al. NEJM. 2006;355:251-9
DHF SHF

16. 16
Mortality: SHF vs. DHF
 Varies with cohort studied
 Differences in definition used to diagnose, co-morbidities
present, composition of the populations studied
Bhatia RS. NEJM. 2006;355:260-9
Owan T, et al. NEJM. 2006;355:251-9
HR 1.13; 95%CI 0.94-1.36; P=0.18
No significant difference

17. 17
Patient Characteristics: SHF vs. DHF
Owan T, et al. NEJM. 2006;355:251-9
older
female





lower
SHF DHF

18. 18
Etiology
Major causes
 Hypertension
 Coronary heart disease
 Diabetes
 Cardiomyopathy
Precipitating factors
 Excess salt intake
 Exercise
 Anemia
 Infection
 Tachycardia
 Arrhythmia

19. 19
Pathophysiology
Mandinov L, Eberli FR, Seiler C, Hess OM. Cardiovasc Res. 2000 Mar;45(4):813-25.
Abnormalities of active relaxation
Passive stiffness of myocardium
Impaired Left ventricular filling capacity
Risk factors
HTN, CAD, DM, Cardiomyopathy, Obesity, Aging

20. 20
Clinical Manifestations
Extravascular water ↑
 Dyspnea
 Elevated jugular venous
pressure
 Pulmonary rales
 Edema
Tissue perfusion ↓
 Cool arms and legs
 Sleepy, obtunded
 Hypotension
 Worsening renal function

21. 21
Management
 Limited evidence, no standard treatment regimen
Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. Circulation. 2009;119:e391-e479
ACC/AHA HF PRACTICE GUIDELINE RECOMMENDATIONS Class Level
• Control systolic and diastolic hypertension in accordance with published guidelines I A
• Use diuretics to control pulmonary congestion and peripheral edema I C
• Coronary revascularization in patients with CAD in whom ischemia is judged to be
having adverse effect on cardiac function
IIA C
• In patients with atrial fibrillation
− Control ventricular rate
− Restoration and maintenance of sinus rhythm might improve symptoms
I
IIB
C
C
• Use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients
controlled hypertension might be effective to minimize symptoms of HF
IIB C
• Usefulness of digitalis to minimize symptoms is not well established IIB C
Level of Evidence C:
Only consensus opinion of experts, case studies, or standard of care.

22. 22
Goal
• Control hypertension
• Reduce the congestive state
• Treat and prevent myocardial ischemia
• Maintain atrial contraction and prevent tachycardia
• Promote regression of hypertrophy and fibrosis*
Management Principle
Target on
• Symptom reduction
• Causes and risk factors
• Possibly beneficial effect on pathophysiology
1. Koprowski A, Gruchala M, Rynkiewicz A. Curr Opin Cardiol. 2009 Mar;24(2):161-6.
2. Aurigemma GP, Gaasch WH. N Engl J Med. 2004 Sep 9;351(11):1097-105.
*thioretical benefit
Pharmacotherapy
• ACEI/ARB
• Aldosterone antagonist
• Beta blocker
• CCB
• Diuretic
• Other: Digoxin, Statin, Vasodilator
Nonpharmacologic therapy
• Lifestyle modification

23. 23
SHF vs. DHF
Systolic heart failure Diastolic heart failure
Pathophysiology
Impaired myocardial contractility
Dilated heart
Impaired relaxation and filling
Hypertrophied heart
Ejection Fraction Reduced Normal
Signs and Symptoms Similar
Mortality and Morbidity No significant difference
BNP/NT-proBNP Levels More elevated Less elevated
Patient Characteristics Prior myocardial infarction
Older
Woman
Obesity
Hypertensive
Atrial fibrillation
Evidence
Supported Treatment
Well Poor

24. What is the recent results in
clinical trial

25. 25
Completed trials for HF with preserved EF
Trial Drug Patient Follow-up
PEP-CHF
2006
Perindopril
•n=850
•EF ≥ 40%
26.2 mo
VALIDD
2007
Valsartan
•n=384
•EF>50%
38 wk
I-PRESERVE
2008
Irbesartan
•n=4128
•EF ≥ 45% 49.5 mo
CHARM-Preserved
2003
Candesartan
•n = 3023
•EF > 40%
36.6 mo
Cochrane Syst Rev
2012
ARB
•LVEF>40%, n=7151
•LVEF≤40% , n=3766
Meta analysis
OPTIMIZE – HF
2009
β-blockers
•n = 7154
•EF > 40%
•Naïve to β-blockers
Retrospective
cohort
DIG trial (ancillary group)
2006
Digoxin
•N= 988
•EF > 45%
37 mo
1. Eur Heart J. 2006 Oct;27(19):2338-45
2. Lancet 2007; 369:2079.
3. N Engl J Med. 2008 Dec 4;359(23):2456-67
1. Lancet. 2003 Sep 6;362(9386):777-81
2. Cochrane Database Syst Rev.2012 Apr 18;(4)
3. J Am Coll Cardiol. 2009;53(2):184
4. Lancet. 2003 Sep 6;362(9386):777-81

26. 26
PEP-CHF: Perindopril
Perindopril in Elderly People with Chronic Heart Failure
Eur Heart J. 2006 Oct;27(19):2338-45
Patient
N=850, age≥ 70y (median age 75 y)
with diastolic dysfunction, exclude LVEF < 40%
hospitalized for a cardiovascular cause within previous 6mo
Intervention Perindopril titrate to 4mg QD vs. Placebo
Outcome
Primary:
All-cause mortality or hospitalization for HF
Follow-up mean 26.2 mo (range 12-30)
Cleland JG, Tendera M, Adamus J, et al. Eur Heart J. 2006 Oct;27(19):2338-45.
ACEI

27. 27
PEP-CHF: Perindopril
Cleland JG, Tendera M, Adamus J, et al. Eur Heart J. 2006 Oct;27(19):2338-45.
Results
Perindopril vs. Placebo
•Reduce unplanned heart failure related
hospitalization at 1 year
8% vs. 12.4% (p = 0.033, NNT 23)
•All-cause mortality or hospitalization for HF
23.6% vs. 25.1%
(HR 0.92; 95% CI 0.70 to 1.21; p = 0.545)

28. 28
VALIDD (Valsartan in Diastolic Dysfunction)
Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic
function in patients with hypertension and diastolic dysfunction: a randomised trial.
Lancet. 2007 Jun 23;369(9579):2079-87
Patient
n = 384, History of stage 1 or 2 essential HTN, LVEF>50%
Give antihypertensive agents not inhibit RAA system (diuretic, βb, ccb, α blocker)
BP target under 135/80mmHg
Intervention Valsartan titrate to 320mg/day vs. Placebo
Outcome
Change in diastolic relaxation velocity
Change in BP
Follow-up 38 wk
Results
Valsartan vs. Placebo
•Reduce BP and increase diastolic relaxation velocity
not significant between groups
significantly from baseline(p<0.0001)
 Valsartan may not improve diastolic function beyond antihypertensive effect
Lowering BP improves diastolic function irrespective of the type of
antihypertensive agent used
Solomon SD, Janardhanan R, Verma A, et al. Lancet. 2007 Jun 23;369(9579):2079-87
ARB

29. 29
I-PRESERVE: Irbesartan
Irbesartan in patients with heart failure and preserved ejection fraction
N Engl J Med. 2008 Dec 4;359(23):2456-67
Patient
n = 4128, mean age 72 y
EF ≥ 45%
NYHA class II-IV symptoms
Hospitalized for HF during last 6 mo or persist class III or IV symptoms
Intervention
Irbesartan titrate to 300mg/day vs. Placebo
Mean dose 275mg/day
Outcome
Primary:
All-cause death or hospitalization for a cardiovascular cause
Follow-up mean 49.5 mo
Results
Irbesartan vs. Placebo
•36% vs. 37% (HR 0.95; 95% CI 0.86 to 1.05; p = 0.35)
No significant differences between groups
 Irbesartan does not reduce mortality or hospitalization in HFPEF
Massie BM, Carson PE, McMurray JJ, et al. N Engl J Med. 2008 Dec 4;359(23):2456-67
ARB

30. 30
CHARM-Preserved: Candesartan
Effects of candesartan in patients with chronic heart failure and preserved left-
ventricular ejection fraction: the CHARM-Preserved Trial
Lancet. 2003 Sep 6;362(9386):777-81
Patient
n = 3023, mean age 67 y
EF > 40%
NYHA class II-IV for at least 4 wks
hospital admission for cardiovascular causes
Intervention
Candesartan titrate to 32mg/day vs. Placebo
Mean dose at 6 mo: 25mg/day
Outcome
Primary:
cardiovascular death or hospital admission for HF
Follow-up mean 36.6 mo
Yusuf S, Pfeffer MA, Swedberg K, et al. Lancet. 2003 Sep 6;362(9386):777-81.
ARB

31. 31
Results
Candesartan vs. Placebo
•Reduce hospital admission for HF
15.9% vs. 18.3% (p=0.047, NNT 42)
•Cardiovascular death or hospital admission for HF
22% vs. 24%
(adjusted HR 0.86; 95% CI 0.74 to 1.00; p = 0.051)
CHARM-Preserved: Candesartan
Yusuf S, Pfeffer MA, Swedberg K, et al. Lancet. 2003 Sep 6;362(9386):777-81
ARB

32. 32
Angiotensin receptor blockers for heart failure
Cochrane Database Syst Rev. 2012 Apr 18;4:CD003040.
 Study design: Systemic review of RCTs
 Objective:
Compare ARBs with ACEIs or placebo on mortality, morbidity and
withdrawals due to adverse effects in patients with symptomatic
HF (NYHA Class II to IV) (subgroup: LVEF>40%, LVEF≤40% )
 Results:
11 trials with 11,794 patients compared ARBs vs. placebo
2 trials in 7,151 patients with LVEF > 40% included
 Candesartan (CHARM-preserved trial)
 Irbesartan (I-PRESERVE trial)
ARB

33. 33
Total Mortality
Total Hospitalizations
ARBs vs. placebo in LEVF > 40%
No significant differences
No significant differences
Cochrane Database Syst Rev.2012 Apr 18;(4)
ARB

34. 34
Hospitalisations for Heart Failure
ARBs vs. placebo in LEVF > 40%
Cochrane Database Syst Rev.2012 Apr 18;(4)
ARB might reduce hospitalization for heart failure
but not total hospitalizations or mortality in patients
with symptomatic HF and EF > 40%
ARB

35. 35
Clinical effectiveness of beta-blockers in heart failure:
findings from the OPTIMIZE-HF Registry.
Am Coll Cardiol. 2009;53(2):184
Study design A retrospective cohort study
Objective Examine associations between initiation of β-blocker therapy and outcomes
Data source
OPTIMIZE-HF(Organized Program to Initiate Lifesaving Treatment in
Hospitalized Patients With Heart Failure)
Centers for Medicare and Medicaid Services (CMS)
Patient
N= 7154 (LVSD: 3001; preserved systolic function: 4153), age>65y
hospitalized with HF
Naïve to β-blockers
Intervention newly initiated β-blocker vs. no β-blocker
Outcome Mortality, rehospitalization, and a combined mortality–rehospitalization
OPTIMIZE – HF: β-blockers
Hernandez AF, Hammill BG, O'Connor CM et al. J Am Coll Cardiol. 2009;53(2):184.
β-blockers

36. 36
OPTIMIZE – HF: β-blockers
Hernandez AF, Hammill BG, O'Connor CM et al. J Am Coll Cardiol. 2009;53(2):184.
Reduced mortality and rehospitalization rates
No improvement in mortality or rehospitalization
β-blockers
SHF
DHF

37. 37
DIG trial (ancillary group): digoxin
Effects of digoxin on morbidity and mortality in diastolic heart failure:
the ancillary digitalis investigation group trial.
Circulation. 2006;114(5):397
Patient
n = 988, mean age 67 y
EF > 45%
NYHA class I-IV
Normal sinus rhythm
Most patient were taking ACEI and diuretics
Intervention
Digoxin 0.125, 0.25, 0.375, or 0.5 mg/day vs. Placebo (n= 496)
Mean dose: 0.25mg/day
Outcome HF hospitalization or HF mortality
Follow-up mean 37 mo
Results
Digoxin vs. Placebo
•HF hospitalization or HF mortality
21% vs. 24% (HR 0.82; 95% CI 0.63 to 1.07; p = 0.136)
Yusuf S, Pfeffer MA, Swedberg K, et al. Lancet. 2003 Sep 6;362(9386):777-81.
Digoxin

38. 38
DIG trial (ancillary group): digoxin
Digoxin does not reduce morbidity or mortality in patients with
DHF and normal sinus rhythm receiving ACEI and diuretics
Digoxin

39. 39
Ongoing trials
 Trial of Aldosterone Antagonist Therapy in Adults With
Preserved Ejection Fraction Congestive Heart Failure (TOPCAT)
Start Date: August 2006
Estimated Completion Date: July 2013
N = 4500
 Study design: Randomised Double blind clinical trial
 Compare: Spironolactone vs. placebo
 Primary outcome: hospitalization for the management of heart
failure and Aborted cardiac arrest
ClinicalTrials.gov: NCT00094302
Spironolactone

40. Case discussion

41. 41
Back to our patient
 HF with Preserved Ejection Fraction
 Af
 HTN

42. 42
Treatment strategy in our patient
• Reduce the congestive state
• Control HTN
• Control Af
Current medication
• Furosemide 20mg PO QD
• Isosorbide DN 5mg PO TIDAC
• Valsartan 160mg PO QD
• Aspirin EM 100mg PO QDAC
• Digoxin 0.125mg PO QD
Target on
• Symptom reduction
• Causes and risk factors
• Possibly beneficial effect on pathophysiology

43. 43
Diastolic HF with chronic Af
Af Tachycardia
Shorten
diastolic
filling period
Deteriorate
HF
Rate control in DHF with Af is important!
 LV filling in DHF
 Occurs largely in late diastole
 More dependent on atrial contraction

44. 44
Control Atrial Fibrillation
Current medication: Digoxin 0.125mg PO QD
Rate
control
Recommendation:
Consider beta blocker after the patient is stable
Start at low dose then titrate as tolerated
Drug of choice mg/tab Initial dose Max dose
Bisoprolol 5 1.25 mg QD 10 mg QD
Metoprolol SR 100 12.5-25 mg QD 200 mg QD
Carvedilol
6.25
25
3.125 mg BID 25 mg BID
Potential beneficial effect
• Heart rate
• Myocardial oxygen demand 
• Blood pressure 
-promote regression of LVH

45. 45
Control Atrial Fibrillation
Current medication: Digoxin 0.125mg PO QD
Rate
control
Risk of
thrombosis
Recommendation:
Consider beta blocker after the patient is stable
Start at low dose then titrate as tolerated
Recommendation:
CHADS2= 3
Suggest warfarin use
Current medication: Aspirin EM 100mg PO QD
Score
C CHF 1
H HTN 1
A Age ≥75 yrs 1
D DM 1
S2 Stroke or TIA 2

46. 46
 New or worse symptoms of heart failure
 Life style modification
 Low salt diet
 Medication
Breathing Weight Swelling Activity
Patient education

47. 47
Take home message
Treatment strategy
• Symptom reduction
• Causes and risk factors
• Possibly beneficial effect on pathophysiology
 Control : BP, HR, congestive state, myocardial ischemia
Diastolic heart failure
• Signs or symptoms of heart failure
 Similar with SHF
• Normal or near normal left ventricular systolic function
 LVEF ≥ 50%
• Evidence of diastolic dysfunction
 Abnormal relaxation, myocardium stiffness, impaired filling

48. THANKS