Diastolic heart failure in the elderly: Underlying mechanisms and clinical relevance

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Abstract

Diastolic heart failure (DHF) is now firmly established as a significant contributor to the heart failure syndrome. However, compared to the better studied systolic dysfunction heart failure relatively little is known about this form of the syndrome. Epidemiological data have demonstrated that it is particularly important in the elderly likely reflecting the combination of several changes occurring in the myocardium occurring with advancing years, including progressive fibrosis and stiffening of the myocardium, the impact of hypertension over the years and the increased likelihood of ischaemic heart disease. This review will focus on the relevant aetiological factors in DHF, possible pathophysiological mechanisms and outline new and evolving therapeutic strategies for this problem.

Introduction

Heart failure is a prevalent syndrome which predominantly affects the elderly [1], [2]. The syndrome has a marked deleterious effect on quality of life with an impact greater than many other chronic diseases [3]. In addition, it remains one of the commonest reasons for hospital admission in the elderly, with approximately one fifth of heart failure patients requiring admission to hospital at least once per year [4]. This hospital dependence explains the major economic impact of the syndrome with 2% of health care budgets required to cover direct costs, 70% of which relates to hospital utilisation [5], [6].

Over the last two decades there have been significant advances in the management of heart failure. These have almost exclusively focused on that segment of the population who have reduced systolic function as the underlining pathophysiological basis of the presentation [7]. This form of heart failure accounts for somewhere between 50 and 75% of the total patient population and has become increasingly well understood with effective therapies directed predominantly at well described neurohumoral abnormalities. However, it is becoming increasingly clear that a significant minority of heart failure patients do not have this form of the syndrome and present with apparently normal systolic function [8], [9]. This type of heart failure predominantly involves the elderly and depending on the age profile and the predominant background cardiovascular diseases in the community it may affect up to 50% of a heart failure population. This group of patients have historically been omitted from heart failure trials and therefore there is a major deficiency in basic understanding of the pathophysiological abnormalities in this group. One often suggested abnormality to explain heart failure within this population is diastolic dysfunction which occurs as a result of abnormalities of active relaxation and compliance in the left ventricle [10], [11], [12]. The result of these abnormalities is a shift in the pressure–volume relationship of the left ventricle which may result in the symptoms and signs of heart failure.

Section snippets

Nomenclature

The syndrome of heart failure in the presence of normal systolic function of the left ventricle has gone through a turbulent period, as it initially struggled through heated debate about its very existence to discussion on the central pathophysiological mechanisms. It is not surprising therefore that the actual name of this form of heart failure remains contentious, with some referring to this condition as heart failure with preserved systolic function (HF-PSF), others use the term heart

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