Diastolic dysfunction has a major impact on symptom status, functional capacity, medical treatment, and prognosis in both systolic and diastolic heart failure (HF), irrespective of the cause.^{w1 w2} When systolic dysfunction is clearly present, the central clinical question concerns the presence or absence of elevated filling pressure; a restrictive filling pattern is highly specific for elevated pulmonary wedge pressure in this setting.^1w3 The transmitral flow pattern is also predictive of outcome; non-reversibility of restrictive filling with treatment portends a very poor prognosis.² Thus, diastolic evaluation is an important component of the evaluation of the patient with systolic left ventricular (LV) impairment.

IS ASSESSMENT OF DIASTOLIC FUNCTION NECESSARY?

Paradoxically, the role of diastolic function assessment is more difficult to define in patients with diastolic HF. Diastolic dysfunction is the predominant cardiac abnormality in this syndrome, which is associated with increased risk of hospitalisation and death.³ However, the American College of Cardiology/American Heart Association guidelines for the evaluation and management of HF^w4 support a diagnosis of exclusion—that is, clinical evidence of HF with preserved systolic function. Indeed, such a definition of diastolic HF has been adopted by the majority of previous reports,^w5 and is supported by the results of recent studies which indicate that the presence of diastolic dysfunction may be assumed in patients presenting with HF and normal LV ejection fraction (LVEF).^{4w6 w7} Zile and colleagues demonstrated that at least one abnormal index of diastolic function was present in patients with HF and normal systolic function. These data suggest that a diagnosis of diastolic HF may accurately be made as a diagnosis of exclusion,⁴ albeit in a highly selected population of relatively young, predominantly male patients who were scheduled to undergo cardiac catheterisation (contrasting with the large clinical population of elderly, hypertensive, predominantly female patients with HF …