Clinical suspicion of diastolic heart failure should rely on more than symptoms of dyspnoea

EDITOR—Caruana et al's study focuses on the well established difficulties in the diagnosis of diastolic heart failure in the community.1 I question the authors' conclusions that most patients in the community with a diagnosis of diastolic heart failure have unrelated conditions.

Proposed criteria for the diagnosis of diastolic heart failure require definitive evidence of congestive heart failure by clinical criteria, physical examination, chest radiography, response to diuretics, etc as a starting point. 2 3 The authors do not provide the indications that led the primary physicians to refer the patients for echocardiography; the clinical suspicion of diastolic heart failure should rely on more than symptoms of dyspnoea at rest or on exertion, for which the differential diagnosis is broad.

The authors consider a history of coronary artery disease or electrocardiographic changes consistent with coronary disease to be an alternative explanation for the patients' symptoms. In patients with normal systolic function and without acute ischaemia, physiological stress testing would be mandatory to support this claim; however, no such evaluation was performed.

Lastly, in an elderly population (mean age 71) an E:A ratio of <1.0 is a normal finding and should not be construed as indicating diastolic dysfunction.4 The use of mitral filling variables in …