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What's The Difference Between Systolic And Diastolic Heart Failure?
In systolic heart failure, the heart cannot effectively contract with each heartbeat. In diastolic heart failure, your heart cannot relax between heartbeats. Both types can lead to right-sided heart failure.
Doctors can diagnose left-ventricular heart failure as systolic, which means the heart is unable to contract well during heartbeats, or diastolic, which means the heart is unable to relax between heartbeats.
Both types of heart failure have treatment options, ranging from medication and adopting a heart-healthy lifestyle to implanted devices, surgery, and transplantation.
Systolic heart failure happens when the left ventricle of your heart cannot contract completely. That means your heart will not pump forcefully enough to move your blood throughout your body in an efficient way.
It's also called heart failure with reduced ejection fraction (HFrEF).
Ejection fraction (EF) is a measurement of how much blood leaves a heart ventricle every time it pumps.
Symptoms of systolic heart failure include:
Doctors determine your EF as a percentage with an imaging test such as an echocardiogram. The typical range is between 50% and 70% EF, according to the American Heart Association (AHA). But it's still possible to have other types of heart failure, even if your EF is within that range.
If your EF is under 40%, you may have reduced ejection fraction or systolic heart failure.
Diastolic heart failure occurs when your left ventricle can no longer relax between heartbeats because the tissues have become stiff. When your heart can't fully relax, it won't fill up again with blood before the next beat.
This type is also called heart failure with preserved ejection fraction (HFpEF).
The symptoms of diastolic heart failure are the same as for systolic heart failure. A doctor must conduct tests to determine which type of left-sided heart failure you are experiencing.
For this type, your doctor may order an imaging test on your heart and determine that your EF looks fine.
Your doctor will then consider whether you have other symptoms of heart failure and whether there's evidence from other tests that your heart is not functioning properly. If those criteria are met, you may be diagnosed with diastolic heart failure.
This type of heart failure most often affects older people and also affects more females than males. It typically occurs alongside other types of heart disease and other non-heart-related conditions such as cancer and lung disease.
Having high blood pressure, also called hypertension, is one of the most important risk factors. Another important risk factor is untreated sleep apnea.
In systolic heart failure, the muscles of the heart become weak, and the left ventricle can't contract normally.
In diastolic heart failure, the muscles of the heart become stiff, and the left ventricle can't relax normally.
Systolic and diastolic heart failure are different types of left-sided heart failure. The left side is in charge of pumping oxygen-rich blood into your body, while the right side collects blood that's low in oxygen from your veins and sends it to your lungs to collect oxygen, after which it returns to the left side.
If you have left-sided heart failure, it means your heart is not pumping enough blood out to your body. Your heart may pump less efficiently when you're doing physical activity or feeling stressed.
Two types of heart failure can affect the left side of the heart: systolic and diastolic. The diagnosis depends on how well your heart can pump blood.
If you have systolic heart failure, it means your heart doesn't contract effectively with each heartbeat. If you have diastolic heart failure, it means your heart isn't able to relax normally between beats.
Both types of left-sided heart failure can lead to right-sided heart failure. Right-sided heart failure happens when the right ventricle functions poorly due to poor contraction or high pressure in the right side of the heart.
When it comes to diagnosing and managing these two types of heart failure, there are some similarities and some differences. Read on to find out what you need to know about systolic and diastolic heart failure.
Diagnosis of left-sided heart failureDoctors diagnose heart failure clinically at a patient's bedside. The diagnosis is confirmed based on the results from imaging tests, symptoms, and other lab tests, such as blood tests.
If doctors suspect you have heart failure, they may perform tests that can include:
A primary care doctor provides overall healthcare and is your main point of contact for health concerns. They can refer you to a cardiologist, who specializes in heart disease.
A cardiologist may order tests to monitor your condition and recommend medication, certain procedures, surgery, or lifestyle changes. Both doctors often work with nurses and physician assistants.
A cardiac surgeon may perform coronary bypass surgery, heart valve repair, or other operations to treat underlying causes of heart failure. They may implant a device to help your heart work. Rarely, they may do a heart transplant. Their team may include nurses and physician assistants.
Cardiac rehabilitation includes lifestyle education, physical exercises, and psychosocial support. It can help strengthen your heart, improve your well-being, and reduce your risk of future heart problems. Your team may include nurses, occupational therapists, and physical therapists.
A balanced diet protects your heart and may help you lose weight. A registered dietitian can help you develop a sustainable, heart-healthy diet. You may need to adjust your intake of calories, saturated fat, sodium, or fluids.
Medications for systolic heart failureThere are different medications available to treat systolic heart failure. These can include:
Standard treatment can involve a combination of these medications, since each class of medication targets a different mechanism of heart failure.
A typical treatment regimen can include ARNI, ARB, or ACE I, along with a beta-blocker and an MRA. Diuretics may also be used for people who continue to have problems with fluid retention despite other medical treatments and while following a low salt diet.
There is new evidence that SGLT2, originally a diabetes medication, can reduce the likelihood of death and re-hospitalization. It's now a standard part of heart failure treatment.
A review published in 2017 looked at 57 previous trials involving combination treatments. It found that people who took a combination of ACE inhibitors, BBs, and MRAs had a 56% reduced risk of death from systolic heart failure compared with people who took a placebo.
People who took a combination of ARN inhibitors, BBs, and MRAs had a 63% reduced death rate compared with those who took a placebo.
Medications for diastolic heart failureDoctors may treat diastolic heart failure using many of the same medications that are options for systolic heart failure.
In general, the main approaches to treating diastolic heart failure with medication include:
Doctors may also recommend adopting a heart-healthy lifestyle as part of a cardiac rehabilitation program.
Recommendations can include:
For some people with left-sided heart failure, a device that is surgically implanted improves heart function. Types of devices can include:
In some cases, surgery may be recommended to treat left-sided heart failure. The two main types of surgery can include:
Tobacco, alcohol, and other drugs can damage your heart and blood vessels. A smoking cessation or substance use counselor can help you stop using these substances if you find it hard to quit. They may prescribe medication and counseling.
Heart disease raises the risk of anxiety, depression, and post-traumatic stress disorder (PTSD), which can affect heart health.
A psychologist, clinical social worker, or licensed counselor may help treat mental health conditions with psychotherapy. A psychiatrist can prescribe medication if needed. Social workers can connect you with support services and assist with legal, financial, and insurance concerns.
Palliative carePalliative care doctors and nurses provide care to ease heart failure symptoms and treatment side effects, such as fatigue and nausea. A palliative care social worker helps you and your family plan for the future. Palliative care may improve quality of life at any stage of heart failure.
Systolic and diastolic heart failure both affect the left side of the heart.
In systolic heart failure, the left ventricle can't squeeze or contract normally, keeping blood from circulating properly. In diastolic heart failure, the left ventricle can't relax, preventing blood from filling the heart between beats and causing the blood flow to back up.
The left side of the heart is in charge of pumping oxygen-rich blood to the body. Having left-ventriclular heart failure means that your heart is not able to efficiently pump all the blood that your body needs.
This can cause symptoms such as shortness of breath, fatigue, and weakness.
It's common to have questions about medications, especially when they're first prescribed to you. Your pharmacist can help explain medication dosing and timing as well as check for interactions with other prescription drugs, foods, or supplements.
Heart Failure Undertreated In Duchenne Muscular Dystrophy
With improved survival becoming more common among individuals who have Duchenne muscular dystrophy (DMD), cardiomyopathy is also increasing in prevalence among this population.
New data from a 20-year observational study show that among individuals who have Duchenne muscular dystrophy (DMD), cardiomyopathy with systolic heart failure (HF) is the leading cause of death, leading investigators to emphasize the importance of HF drug therapy in this unique population.
"In this vulnerable population with a rare, inherited disease, conducting randomized controlled intervention trials is challenging," they write, "and despite the risk of various sources of bias, cohort studies are needed to understand the effect of interventions and to generate hypotheses that can be tested in controlled trials."
Cardiologist doctor examine patient heart functions and blood vessel on virtual interface.Image Credit: ckybe - stock.Adobe.Com
With their findings also showing that lower left ventricular ejection fraction (LVEF) is independently linked to death at a younger age in the setting of DMD—older age showed only a weak association with LVEF reduction—they underscore that future research needs to focus on identifying and ameliorating predictors of LVEF decline.
This retrospective observational research appeared in a recent issue of European Respiratory Journal Open Research. Primary end points were time to cardiac or noncardiac death and association between LVEF and survival. The 67 patients with DMD received treatment at the Department of Pulmonology at the University Hospital Zurich, and to be included, they had to have echocardiographies (EKG) from 3 age groups taken as part of their outpatient DMD disease management (ie, an EKG from an emergency department admission was not allowed).
There were 430 EKGs from the 67 patients, and the baseline study visit was considered the first visit when transitioning to adult care. The mean (SD) patient age at first visit was 19.1 (3.9) years, and at last visit, 27.8 (6.6) years. Mean LVEF at first visit was 47.1% (10.2%) compared with 37.5% (12.4%) at the last visit.
For the study duration, nocturnal home mechanical ventilation (HMV) and angiotensin-converting enzyme (ACE) inhibitors were the most common HF treatments, increasing from 50.7% and 49.3% to 88.1% and 836.6%, respectively; beta-blockers had the next highest jump, from 14.9% to 53.7% of the study population by the final visit. Patients started ventilation at a mean age of 20.0 (4.8) years and had a percutaneous endoscopic gastrostomy (feeding tube insertion) by age 32 (47.8) years.
Twenty-eight of the 67 patients were deceased when this study started, and of the 60.7% for whom case of death was known, a cardiac-related cause of death was seen in 53%; the mean age at death was 29.2 (6.4) years vs an overall median (IQR) survival of 33 (25-40) years. Of those who had a cardiac-related death, their LVEF was 11 (95% CI, –21.1 to –0.9; P = .035) percentage points lower at time of death (24.2% [11.55] vs 35.2% [8.2%]) and at least 71% were taking ACE inhibitors (71.4%) or beta-blockers (76.4%) or were on HMV (89.3%).
For predictors of change in LVEF, the investigators saw from the EKG data that older aged had a weak association with lower LVEF (P = .065), but that forced vital capacity, measures of respiratory failure (arterial partial pressure of carbon dioxide, bicarbonate concentration, and nocturnal transcutaneous partial pressure of carbon dioxide), and type of dystrophin mutation had no association with LVEF. ACE inhibitors and beta-blockers (both P = .002) were shown to be independent negative predictors of change in LVEF.
"Annual echocardiography from the age of 10 years is recommended in DMD and the use of ACE inhibitors and beta-blockers as soon as abnormalities are detected," the study authors wrote. "However, there is little evidence to guide the management of heart failure in DMD."
They add that due to the increased survival of patients living with DMD, the aging of patients necessitates more extensive follow-up of comorbidities.
"Close collaboration between neuromuscular centers treating DMD patients and cardiologists is important," they concluded, "and international studies of HF therapy in DMD are needed to determine specific recommendations."
Potential limitations on their findings include its small size and retrospective observational nature, and their inability to model a potential association between type of ACE inhibitor and LVEF.
Reference
Lechner A, Herzig JJ, Kientsch JG, et al. Cardiomyopathy as cause of death in Duchenne muscular dystrophy: a longitudinal observational study. ERJ Open Res. 2023;9(5):00176-2023. Doi:10.1183/23120541.00176-2023
Video: SGLT2 Inhibitors In Heart Failure With Preserved Ejection Fraction
Published: November 15, 2023
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