Background Patients with preserved left ventricular ejection fraction and signs and symptoms of heart failure are defined as having diastolic heart failure (DHF). Evidence-based therapies for this disorder are not clearly defined. We present three cases, which derived significant benefit from different medical regimens tailored to the individual patient.
Case 1 A 66-year-old, hypertensive male referred for assessment of his progressive shortness of breath (SOB). SOB had worsened over the past 6 months to the point of being unable to walk half a block without symptoms. Echocardiogram revealed a preserved ejection fraction with reversal of the E:A ratio. Lung/heart ratio on dipyridamole thallium scan was elevated at 0.67. His DHF was treated by starting ramipril and increasing his metoprolol. After treatment, he noted that he was able to use his stationary bike for 15 to 20 minutes without dyspnea.
Case 2 A 49-year-old hypertensive obese female presented with retrosternal chest discomfort associated with worsening SOB after walking only 10 feet. Cardiac catheterization revealed an elevated end-diastolic pressure of 40 mm Hg but no evidence of coronary artery disease. Echocardiogram showed moderate left ventricular hypertrophy with a preserved ejection fraction. She was initially started on benazepril and metoprolol, with spironolactone added later. Her distance walked had increased to one block since beginning treatment.
Case 3 A 54-year-old female presented to the emergency department complaining of exhaustion and SOB after walking only one-tenth of a mile for the past 3 weeks. Cardiac catheterization showed nonobstructive coronaries with an LVEDP of 38mmHg. Echocardiogram showed a preserved ejection fraction with a right ventricular systolic pressure of 53 mm Hg and impaired relaxation. She was initially treated with losartan, spironolactone, Isordil, Lasix, and hydrochlorothiazide. Verapamil was added later in a follow-up visit, with further improvement in symptoms. Later, verapamil was stopped and Toprol XL was added. However, as her symptoms of SOB worsened, verapamil was reinstated. SOB improved by restarting the verapamil. She is now able to walk 450 feet with relative ease, whereas prior to hospitalization, she could only walk 50 feet before becoming tired and SOB.
Conclusions We presented three patients with DHF who responded to individually tailored medical regimens, resulting in a 100 to 1,000% increase in exercise tolerance. Medical therapy for DHF can produce striking improvement in quality of life. Precise medical therapy and hierarchy of its implementation remain to be defined.
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