DeCure for Diastolic heart failure

Up to half of heart failure patients have preserved systolic function, but treatment of diastolic heart failure remains largely empiric because no large-scale randomised trials have evaluated specific pharmacological agents. A 2009 review states that many drugs used for diastolic dysfunction are similar to those for systolic failure, though the rationale and dosing may differ entirely. The review notes that nonpharmacologic, pharmacologic and surgical approaches exist but their efficacy has not been proven. Treatment should target the underlying condition — hypertension, coronary artery disease, hypertrophic obstructive cardiomyopathy, or constrictive pericarditis — with goals such as lowering blood pressure, regressing hypertrophy and fibrosis, treating ischaemia, or removing the constricting pericardium. Short-term goals include manipulating loading conditions and controlling heart rate.

Spironolactone, an aldosterone antagonist, has been studied in post-myocardial infarction patients. A prospective study of 528 patients (262 in the treatment group, 266 controls) found that adding low-dose spironolactone (20 mg/day) to conventional treatment significantly improved echocardiographic indicators — LVESD, LVEDD, LVEF, LAD-ML and LAD-SI — at one year compared with controls (P<0.05). In the treatment group, these measures improved more at one year than at one month (P<0.05; P=0.007 for LVEF). In the control group only LVEF improved significantly at one year (P=0.0277). No significant differences in serum potassium or creatinine were seen between groups. The authors concluded that early spironolactone could inhibit late cardiac remodelling and prevent heart failure. However, a 2004 review of 163 heart failure patients in four teaching hospitals found that three years after the Randomized Aldactone Evaluation Study, only 14% of ideal candidates (8 of 57) were prescribed spironolactone, indicating it was underutilised.

Sunitinib, a tyrosine kinase inhibitor, can cause severe cardiac toxicity. Three case reports describe life-threatening complications: one patient developed heart failure with left ventricular dilation and decreased ejection fraction after one cycle, requiring ACE inhibitors, loop diuretics and dobutamine; another developed coronary artery stenosis after one cycle and died of multi-organ failure despite normal follow-up angiography after six further cycles; a third with pre-existing chronic renal failure required haemodialysis for acute-on-chronic renal failure after starting sunitinib.

A 2012 review states that evidence-based management of chronic heart failure with systolic dysfunction includes ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and device therapy (CRT, ICD, VAD). A 2016 talk notes that diastolic dysfunction has different underlying mechanisms depending on the pathology, and describes both surgical and pharmacological treatments. A 2003 review emphasises that hypertension is a major cause of diastolic dysfunction and that advances in diagnosis and treatment may improve outcomes, but the condition remains poorly understood. What is still missing are large-scale randomised trials specifically for diastolic heart failure, clear patient stratification by underlying mechanism, and consistent implementation of existing evidence in clinical practice.