Diastolic heart failure ======================= * Jonathan R. Dalzell * Colette E. Jackson Katina Tzanetos and colleagues comprehensively reviewed the literature on the phenomenon that has become known as diastolic heart failure. 1 It is becoming recognized that the binary categorization of heart failure as either systolic or diastolic heart failure on the basis of an arbitrary cut-off for left ventricular ejection fraction is oversimplified and misguided. 2 Recent studies have shown that significant numbers of patients diagnosed with diastolic heart failure have demonstrable systolic dysfunction when detailed echocardiographic investigations are conducted. 3,4 Moreover, in a large population-based study, Bursi and colleagues reported that advanced objective echocardiographic parameters of diastolic dysfunction were present in 83% of patients with heart failure who had a low left ventricular ejection fraction (i.e., patients with systolic heart failure) and that this dysfunction was more severe than in patients with diastolic heart failure. 5 Similarly, Brucks and colleagues demonstrated in patients with systolic heart failure that objective parameters of diastolic dysfunction were not only highly prevalent but also more predictive of mortality than left ventricular ejection fraction itself. 6 Systole and diastole need to be recognized as active and complementary components of the cardiac cycle, both contributing to overall myocardial performance. They are not separate entities, and one of them can only be as effective as the other allows. Thus, in reality, systolic and diastolic dysfunction coexist to varying degrees. 2 The continuing disagreement in major international guidelines over diagnostic criteria 7,8 casts doubt on the accuracy of the patient selection process for studies to date and, therefore, the validity of these studies’ results. A universally accepted definition and criteria for diagnosis would allow cases of heart failure in which left ventricular diastolic dysfunction predominates to be correctly identified and subsequently characterized. ## Footnotes * **Competing interests:** None declared. ## REFERENCES 1. 1. Tzanetos K, Leong D, Wu RC. Office management of patients with diastolic heart failure. CMAJ 2009; 180:520–7. [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODAvNS81MjAiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTgwLzkvOTUyLjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 2. 2. Task Force for Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of European Society of Cardiology, Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Eur Heart J 2008;29:2388–442. [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiZWhqIjtzOjU6InJlc2lkIjtzOjEwOiIyOS8xOS8yMzg4IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE4MC85Lzk1Mi4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 3. 3. Petrie MC, Caruana L, Berry C, et al. “Diastolic heart failure” or heart failure caused by subtle left ventricular systolic dysfunction?Heart 2002;87:29–31. [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiaGVhcnRqbmwiO3M6NToicmVzaWQiO3M6NzoiODcvMS8yOSI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xODAvOS85NTIuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 4. 4. Yip G, Wang M, Zhang Y, et al. Left ventricular long axis function in diastolic heart failure is reduced in both diastole and systole: Time for a redefinition?Heart 2002;87:121–5. [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiaGVhcnRqbmwiO3M6NToicmVzaWQiO3M6ODoiODcvMi8xMjEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTgwLzkvOTUyLjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 5. 5. Bursi F, Weston SA, Redfield MM, et al. Systolic and diastolic heart failure in the community. JAMA 2006;296:2209–16. [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.296.18.2209&link_type=DOI) [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=17090767&link_type=MED&atom=%2Fcmaj%2F180%2F9%2F952.1.atom) [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000241827700021&link_type=ISI) 6. 6. Brucks S, Little WC, Chao T, et al. Contribution of left ventricular diastolic dysfunction to heart failure regardless of ejection fraction. Am J Cardiol 2005; 95:603–6. [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/j.amjcard.2004.11.006&link_type=DOI) [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=15721099&link_type=MED&atom=%2Fcmaj%2F180%2F9%2F952.1.atom) [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000227156400010&link_type=ISI) 7. 7. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice. Circulation 2005;112:e154–235. [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImNpcmN1bGF0aW9uYWhhIjtzOjU6InJlc2lkIjtzOjExOiIxMTIvMTIvZTE1NCI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xODAvOS85NTIuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 8. 8. Paulus WJ, Tschöpe C, Sanderson JE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the heart failure and echocardiography associations of the European Society of Cardiology. Eur Heart J 2007;28:2539–50. [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiZWhqIjtzOjU6InJlc2lkIjtzOjEwOiIyOC8yMC8yNTM5IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE4MC85Lzk1Mi4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)