VOLUME 11 NUMBER 2 • JUNE 2014
73
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Correspondence to: Sur Genel
University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj-Napoca, and Emer-
gency Clinical Hospital for Children, Cluj-Napoca, Romania
Tel: 0724504964
e-mail:
Floca Emanuela, Sur M Lucia, Sur G Daniel, Radulescu Dan
University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj-Napoca, Romania
Radulescu Dan
Department of Cardiology, Municipal Hospital Cluj Napoca, Romania
Originally published in
Diabetes Metab
2014;
5
(3): e113
S Afr J Diabetes Vasc Dis
2014;
11
: 73–74
Treatment of diastolic heart failure in hypertensive diabetic
patients: between illusion and achievements
SUR GENEL, FLOCA EMANUELA, SUR M LUCIA, SUR G DANIEL, RADULESCU DAN
Abstract
Hypertension is the most prevalent cardiovascular disease
in the world. Because of associated morbidity and mortality,
it is in one of the most important public health problems.
Hypertension is the most important cause of heart failure
with low or preserved ejection fraction. If hypertension
develops concomitantly with diabetes mellitus, treatment
of the two diseases becomes more complex. It is known
that beta-blockers may induce type 2 diabetes, but new
generation drugs such as nebivolol do not have this effect.
There are many drugs with proven efficacy in lowering
blood pressure, but the optimal treatment to prevent
progression to heart failure is uncertain. Beta-blockers are a
class of drugs with benefits for both hypertension and heart
failure. Drugs in this class have different pharmacological
properties in terms haemodynamic and cardiovascular
effects.
Nebivolol is a beta-blocker that causes vasodilatation
mediated by nitric oxide release. This medicine lowers blood
pressure, prevents endothelial dysfunction and improves
coronary flow reserve and diastolic function independent
of ventricular geometry changes. The action of nebivolol
is superior to classic beta-blockers due to reversibility of
subclinical changes in the left ventricle before the onset of
heart failure.
In the early stages of heart failure with preserved ejection
fraction management is not yet established. Therefore it is
important to know that in these situations nebivolol has
beneficial effects.
Keywords:
diastolic, heart failure, nebivolol, diabetes, hypertension
Introduction
There is a high prevalence of hypertension worldwide. Prevalence is
higher for males than females up to the age of 50 years. There is an
increasing prevalence of this pathology with age. Hypertension and
diabetes are the main causes of heart failure, with the preservation
or decrease of the ejection fraction thus representing an important
public health problem.
1
Diastolic heart failure
In patients with hypertension, structural changes, both cardiac and
vascular, occur as a consequence of increasing blood pressure. At
the same time, these structural changes develop in an attempt
to normalise wall stress. Cardiac remodelling has functional
consequences by which cardiovascular risk is increased. These
consequences are related to individual aspects such as age, 24-hour
blood pressure, the rigidity of blood pressure, plasma volume,
neuro-hormonal status, and genetic aspects.
2,3
Ventricular hypertrophy involves both myocytes and interstitial
tissue. Interstitial tissue can lead to fibrosis, a phenomenon that
contributes to cardiac dysfunction in hypertension. The neuro-
endocrine changes that occur with aging, such as decreased
β
-adrenergic receptor density, decreased
β
-adrenergic inotropic
response, and increased angiotensin receptors and angiotensinogen
and angiotensin-converting enzyme concentrations contribute to
myocyte hypertrophy. Hypertrophy and fibrosis of the left ventricle
reduce ventricular compliance, finally leading to diastolic heart
failure.
4-6
There are numerous studies showing that arterial stiffness
is increased in hypertension. Vascular stiffness influences the
propagation velocity of the pressure wave generated by cardiac
contraction. The pressure wave is transmitted through the vessels
back to the heart in a short time, resulting in increased pressure of
the anterograde wave and decreased blood flow. Aortic compliance
is low.4,6 Wave reflection can be accelerated, increasing left
ventricular ejection resistance. This mechanism contributes to left
ventricular hypertrophy, which is associated with impaired diastolic
function. Arterial stiffness contributes to myocardial ischaemia by
altering ventriculo-arterial coupling. In patients with hypertension,
microvascular ischaemia and interstitial fibrosis determine
subendocardial dysfunction.
7,8
Regarding myocardial architecture, some studies have shown
that shortening in the fibres of the longitudinal axis is followed
by shortening in the circumferential axis. Longitudinal shortening
plays a role in the contractile function of the heart being involved
in ventricular ejection.6 Diabetes contributes to the development of
heart failureby excessivemyocardial fibrosis, interstitial accumulation
of glycoproteins, and an altered release from dysfunctional coronary
endothelium of mediators such as nitric oxide, which has a vascular
relaxation effect.
9,10
How to diagnose diastolic heart failure
A diagnosis of diastolic heart failure requires the mandatory
presence of three criteria: (1) presence of signs or symptoms of
congestive heart failure; (2) presence of normal or mildly reduced
left ventricular systolic function; (3) evidence of abnormal left
