Exercise Hemodynamics Enhance Diagnosis of Early Heart Failure with Preserved Ejection Fraction

By Barry A. Borlaug, Rick A. Nishimura, P. Sorajja, C. Lam, M. Redfield. Circulation: Heart Failure, 2010

1,014 citations recorded by the source corpus.

Background—When advanced, heart failure with preserved ejection fraction (HFpEF) is readily apparent. However, diagnosis of earlier disease may be challenging because exertional dyspnea is not specific for heart failure, and biomarkers and hemodynamic indicators of volume overload may be absent at rest. Methods and Results—Patients with exertional dyspnea and ejection fraction >50% were referred for hemodynamic catheterization. Those with no significant coronary disease, normal brain natriuretic peptide assay, and normal resting hemodynamics (mean pulmonary artery pressure <25 mm Hg and pulmonary capillary wedge pressure [PCWP] <15 mm Hg) (n=55) underwent exercise study. The exercise PCWP was used to classify patients as having HFpEF (PCWP ≥25 mm Hg) (n=32) or noncardiac dyspnea (PCWP <25 mm Hg) (n=23). At rest, patients with HFpEF had higher resting pulmonary artery pressure and PCWP, although all values fell within normal limits. Exercise-induced elevation in PCWP in HFpEF was confirmed by greater increases in left ventricular end-diastolic pressure and was associated with blunted increases in heart rate, systemic vasodilation, and cardiac output. Exercise-induced pulmonary hypertension was present in 88% of patients with HFpEF and was related principally to elevated PCWP, as pulmonary vascular resistances dropped similarly in both groups. Exercise PCWP and pulmonary artery systolic pressure were highly correlated. An exercise pulmonary artery systolic pressure ≥45 mm Hg identified HFpEF with 96% sensitivity and 95% specificity. Conclusions—Euvolemic patients with exertional dyspnea, normal brain natriuretic peptide, and normal cardiac filling pressures at rest may have markedly abnormal hemodynamic responses during exercise, suggesting that chronic symptoms are related to heart failure. Earlier and more accurate diagnosis using exercise hemodynamics may allow better targeting of interventions to treat and prevent HFpEF progression.

Subfields: Cardiology and Cardiovascular Medicine, Pulmonary and Respiratory Medicine

View Paper: https://www.semanticscholar.org/paper/162c64a62baee8805089ee7b2e173420480b7d7c

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In Cardiology and Cardiovascular Medicine

In Pulmonary and Respiratory Medicine

Citations in the corpus

Definitions and diagnosis of pulmonary hypertension. (2013, background): “(24) studied the effects of exercise on hemodynamics in patients with exertional dyspnea and presumed HFpEF but normal resting PAWP levels.”
Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. (2011, methodology): “These figures were created based upon previously published data in Borlaug et al.(28,33) Heart failure with preserved ejection fraction 675”
A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure with Preserved Ejection Fraction (2018, positive): “Patients with HFpEF were identified by elevated pulmonary capillary wedge pressure at rest (≥15 mm Hg) or during exercise (≥25 mm Hg).(7,8) Noncardiac dyspnea was defined as no evidence of a cardiac cause for dyspnea after exhaustive clinical evaluation, including normal rest and exercise hemodynami”
How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). (2019, background): “detected only during exercise or when the patient deteriorates.(28,179,230,256,257) Also, volume depletion or intensified diuretic treatment may shift the diastolic pressure–volume relationship to the left, without changing LV compliance (dV/dP; the inverse of LV stiffness(252)) If resting filling p”
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (2016, positive): “vasive haemodynamics at rest with assessment of filling pressures [pulmonary capillary wedge pressure (PCWP) ≥15 mmHg or left ventricular end diastolic pressure (LVEDP) ≥16 mmHg] followed by exercise haemodynamics if below these thresholds, with assessment of changes in filling pressures, pulmonary ”
Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations (2012, neutral): “Unique to CPX for this indication, a hypertensive response to exercise that coincides with exertional dyspnoea and exercise intolerance may be an early indicator of HF-PEF.”