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In his excellent Editorial Comment, Dr. Zile states that “heart failure with a preserved ejection fraction” and “diastolic heart failure” are synonymous (1). Respectfully, I must disagree. Not all patients with diastolic heart failure have left ventricular hypertrophy. Therefore, the general applicability of the study cited supporting the equivalency of the two terms might be limited because all patients in that study had echocardiographic evidence for left ventricular hypertrophy, and diastolic dysfunction is generally accepted to precede hypertrophy. In our early experience about one-third of patients with heart failure with a preserved ejection fraction had explanations for the signs and symptoms of failure other than diastolic dysfunction, predominately right heart failure due to pulmonary disease and regurgitant valvular heart disease (2). The nonspecific nature of the symptoms of heart failure and iatrogenic volume overload were also noted. It is unclear to what extent stricter diagnostic criteria for heart failure would affect these findings, and I believe that our initial criteria would still lead most clinicians to the diagnosis of heart failure. Furthermore, a patient with heart failure due to chronic, severe mitral regurgitation with an ejection fraction of 40% or even 50% has predominately systolic, not diastolic, heart failure. Therefore, I believe it is best to conclude that patients with “diastolic heart failure” form a subgroup of patients with “heart failure with a preserved ejection fraction.”
Until a uniformly accepted and therapeutically meaningful measure of diastolic dysfunction is defined, diastolic heart failure is in many ways a diagnosis of exclusion. The value of initially using the term “heart failure with preserved, or normal, ejection fraction” underscores the need to define left ventricular function in virtually all patients with heart failure (3)as well as the need to carefully eliminate other cardiac and noncardiac possibilities from the patient's signs and symptoms. After eliminating other possibilities, I agree that the term “diastolic heart failure” seems most appropriate, and I hope, as Dr. Zile does, that accepting the term promotes the investigative efforts that are long overdue for these patients.
- American College of Cardiology Foundation
- Zile M.R.
- Hunt S.A.,
- Baker D.W.,
- Chin M.H.,
- et al.