Diastolic heart failure in elderly: The prognostic factors and interventions regarding heart failure with preserved ejection fraction Sadik Acikel ⁎ , Ramazan Akdemir, Harun Kilic, Asuman Bicer Yesilay, Mehmet Dogan, Goksel Cagirci Ministry of Health Dışkapı Yıldırım Beyazıt Educational and Research Hospital, Department of Cardiology, Ankara, Turkey Received 9 April 2008; accepted 28 June 2008 Available online 9 October 2008 Abstract Heart failure with a preserved ejection fraction is more common in elderly. Common comorbidities may have an impact on management of heart failure with preserved ejection fraction. The prognosis in more recent studies has been shown to be essentially similar to heart failure with reduced ejection fraction. Unlike heart failure with reduced ejection fraction for which many medications have been demonstrated to improve morbidity and mortality, no treatment has yet been shown to reduce morbidity and mortality in heart failure with preserved ejection fraction. Therefore, current treatment recommendations are aimed at symptomatic management as well as management of concomitant comorbidities. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Diastolic heart failure; Elderly; Prognosis ⁎ Corresponding author. Ministry of Health Diskapi Yildirim Beyazit Education and Research Hospital, Department of Cardiology, 06110 Ankara, Turkey. Tel.: +90 312 5962400; fax: +90 312 3186690. E-mail address: sadik.acikel@tkd.org.tr (S. Acikel). In their recently published article [1], Pérez de Isla and co- workers investigated the incidence and predictors of in-hospital mortality, long term mortality and morbidity in elderly patients after a first admission due to diastolic heart failure. They found the in-hospital mortality of 4.9% and the history of dilated cardiomyopathy was the only independent predictor of in- hospital mortality in multivariate analysis. On long term follow-up, one-year likelihood of death was reported 25.4% in that study. One year likelihood of readmission was 43%. The independent predictors of long term mortality were age and pulmonary systolic pressure in the multivariate analysis. The independent predictor of composite outcome of death or readmission was age with relative risk of 1.05 (95% confidence interval [CI], 1.004 to1.104, p =0.03) in that study [1]. Heart failure (HF) is a prevalent syndrome which predominantly affects the elderly. Depending on the population studied, the proportion of HF patients admitted to hospital with HF and preserved systolic function can range from 13% to 74% [2]. Clinical observations and knowledge regarding the effect of aging on diastolic left ventricular function suggest that the elderly may be particularly predisposed to the syndrome of congestive heart failure (CHF) with preserved systolic function [3]. Patients with HF and preserved systolic function are associated with female gender, race and a history of chronic systemic hypertension [3,4]. Coronary artery disease, hyper- tension, atrial fibrillation and diabetes are all conditions that are known to be associated with or to exacerbate diastolic HF and are also more common in the elderly [5]. However, prognostic factors and interventions regarding HF with preserved ejection fraction in elderly are still not well described. It is unclear whether HF patients with preserved ejection fraction have prognosis similar to patients with depressed ejection fraction. Observational studies are often considered evidence that the prognosis for patients with preserved ejection fraction is more benign [6–9], although some recent studies have reported similar prognosis between diastolic HF and HF with reduced ejection fraction [10–12]. The results of these studies about morbidity and mortality have varied widely depending on many factors including age, ejection fraction, atrial fibrillation underlying disease process causing diastolic HF and presence of coexistent pathology [5]. In prospective study evaluating the impact of atrial fibrillation in HF with normal ejection fraction, Fung and co-workers demonstrated that patients with HF with normal ejection fraction and atrial fibrillation were associated with higher incidence of death or recurrent HF hospitalization than in sinus rhythm (28.6% vs. 10.6%; p b 0.01) [13]. Both atrial fibrillation and restrictive diastolic dysfunction were inde- pendent predictors of HF hospitalization or death in HF with normal ejection fraction. Parkash and co-workers also demonstrated that patients with atrial fibrillation, HF and preserved left ventricular ejection fraction (N 50%) have a similarly high mortality as compared with those with depressed left ventricular ejection fraction at 5 years (50% vs 48%, p = 0.74) [14]. Yancy and co-workers demonstrated 311 Letters to the Editor