[Diastolic cardiac failure: therapeutic modalities]

The management of cardiac failure due to diastolic dysfunction is not well codified and is often empirical. It has three objectives: improving the physiopathological components of ventricular filling, treating the associated aggravating pathological conditions, and treating the basic cause of the dysfunction. Symptomatic treatment aims to reduce venous congestion (by diuretics or nitrate derivatives), to prolong the diastolic period by slowing the heart rate (by betablockers, bradycardising calcium antagonists or digitalis in cases of irreducible atrial fibrillation), to improve passive ventricular distensibility by an effect on remodelling (by angiotensin converting enzyme inhibitors or anti-aldosterone diuretics). The treatment of associated pathological conditions is particularly important. It is essential to maintain or reestablish an effective atrial systole by cardioversion and anti-arrhythmic drugs in atrial fibrillation, by dual chamber pacing in cases of atrioventricular asynchrony due to atrioventricular block. Treatment of the underlying cause aims to induce regression of ventricular hypertrophy of hypertensive origin by using antihypertensive drugs with this property. In coronary artery disease, the choice is determined by the clinical context because nearly all anti-anginal or interventional treatments may improve ischaemic diastolic dysfunction. The same applies in hypertrophic cardiomyopathy because most types of treatment (betablockers, verapamil, cardiac pacing, surgery) may improve diastolic function. Finally, in valvular aortic stenosis, aortic valve replacement restores normal diastolic function.