Class IIb recommendations
Coronary revascularization in patients who have HF and coronary artery disease but no angina. (Level of Evidence: B)
Restoration of sinus rhythm by electrical cardioversion in patients with HF and atrial fibrillation. (Level of Evidence: C)
Amiodarone to prevent sudden death in patients with HF and asymptomatic ventricular arrhythmias. (Level of Evidence: B)
Anticoagulation in patients with HF who do not have atrial fibrillation or a previous thromboembolic event. (Level of Evidence: B or C)
PATIENTS WITH HF AND NORMAL LEFT VENTRICULAR EJECTION FRACTION (DIASTOLIC DYSFUNCTION)
Approximately 20% to 40% of patients with HF have preserved left ventricular systolic function and (in the absence of valvular disease) are believed to have an impairment of ventricular relaxation as the primary mechanism leading to symptoms. Several r e c o g n i z e d m y o c a r d i a l d i s o r d e r s a r e a s s o c i a t e d w i t h d i a s t o l i c d y s f u n c t i o n , i n c l u d i n g hypertrophic restrictive cardiomyopathy, obstructive and non-obstructive
cardiomyopathy, and infiltrative cardiomyopathies. However, the vast majority of patients who present with HF and normal systolic function do not have a defined myocardial disease but nevertheless have a clinically significant impairment of diastolic function. Many of the changes that occur in the cardiovascular system as a result of aging have a greater impact on diastolic function than on systolic performance. HF associated with preserved systolic function is primarily a disease of elderly women, most of whom have hypertension94. These patients suffer considerably from dyspnea and fatigue, which can limit their exercise tolerance and quality of life, and they are hospitalized frequently for clinical stabilization. Although the risk of death in these patients appears to be lower than in patients with HF and poor systolic function, the management of these patients still has major socioeconomic implications.
It is difficult to be precise about the diagnosis of diastolic dysfunction. Non-invasive methods, especially those that rely on Doppler echocardiography, have been developed to assist in such diagnosis. In practice, however, the diagnosis of diastolic HF is generally based on the finding of typical symptoms and signs of HF in a patient who is shown to have a normal left ventricular ejection fraction and no valvular abnormalities on echocardiography.
94 Davie AP, Francis CM, Caruana L, Sutherland GR, McMurray JJ. The prevalence of left ventricular diastolic filling abnormalities in patients with suspected heart failure. Eur Heart J 1997;18:981– 4.