Bedside Assessment of Cardiac Hemodynamics: The Impact of Noninvasive Testing and Examiner Experience

From, Aaron M.; Lam, Carolyn S.P.; Pitta, Sridevi R.; Kumar, Prasanna Venkatesh; Balbissi, Kais Al; Booker, Jeffrey D.; Singh, Inder; Sorajja, Paul; Reeder, Guy S.; Borlaug, Barry A.

doi:10.1016/j.amjmed.2011.05.034

Cited by 38 publications

(22 citation statements)

References 34 publications

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“…8 This scheme works well for patients with a high likelihood of disease based upon clinical indicators of congestion such as jugular distention, gallop sounds, or edema. 9 To address the patients without overt congestion, more recent guidelines statements from the ESC and ASE/ EACVI require objective evidence of high LV filling pressures, such as elevations in plasma natriuretic peptide (NP) levels and the ratio of transmitral E to mitral annular e’ velocities (E/e’). 2–4 While this approach is supported by some studies, others have raised serious questions regarding their accuracy.…”

Section: Introductionmentioning

confidence: 99%

Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction

et al. 2017

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Background Diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) is challenging and relies largely on demonstration of elevated cardiac filling pressures (pulmonary capillary wedge pressure, PCWP). Current guidelines recommend use of natriuretic peptides (NT-proBNP) and rest/exercise echocardiography (E/e’ ratio) to make this determination. Data to support this practice is conflicting. Methods Simultaneous echocardiographic-catheterization studies were prospectively conducted at rest and during exercise in subjects with invasively-proven HFpEF (n=50) and participants with dyspnea but no identifiable cardiac pathology (n=24). Results NT-proBNP levels were below the level considered to exclude disease (≤125 pg/ml) in 18% of subjects with HFpEF. E/e’ ratio was correlated with directly measured PCWP at rest (r=0.63, p<0.0001) and during exercise (r=0.57, p<0.0001). While specific, current guidelines were poorly sensitive, identifying only 34–60% of subjects with invasively-proven HFpEF based upon resting echocardiographic data alone. Addition of exercise echocardiographic data (E/e’ ratio>14) improved sensitivity (to 90%) and thus negative predictive value, but decreased specificity (71%). Conclusions Currently proposed HFpEF diagnostic guidelines based upon resting data are poorly sensitive. Adding exercise E/e’ data improves sensitivity and negative predictive value but compromises specificity, suggesting that exercise echocardiography may help rule out HFpEF. These results question the accuracy of current approaches to exclude HFpEF based upon resting data alone and reinforce the value of exercise testing using invasive and noninvasive hemodynamic assessments to definitively confirm or refute the diagnosis of HFpEF. Clinical trial registration NCT01418248 https://clinicaltrials.gov/ct2/results?term=NCT01418248&Search=Search

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Section: Introductionmentioning

confidence: 99%

Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction

et al. 2017

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“…However, these noninvasive tests have limited sensitivity, particularly for the presence of high filling pressures. [2][3][4][5]14,15 Diagnosis is further complicated by patients with compensated HFpEF, who frequently display normal hemodynamics at rest, with elevations in PCWP and PA pressures that develop only during stress. 1,3,16 Exercise is the most commonly encountered stress in everyday life and represents the ultimate test of diastolic reserve.…”

Section: Pathophysiologic Implicationsmentioning

confidence: 99%

“…Diagnosis can be challenging in patients with normal ejection fraction (EF) because of the difficulties in noninvasively assessing left ventricular (LV) filling pressures and pulmonary artery (PA) pressures. [1][2][3][4][5][6] Patients with early stage heart failure and preserved EF (HFpEF) or pulmonary hypertension may display normal hemodynamics rest, with abnormalities developing only when the cardiovascular system is stressed. 1,3,7 Invasive hemodynamic exercise testing has been shown to greatly enhance diagnosis of HFpEF and pulmonary hypertension.…”

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Differential Hemodynamic Effects of Exercise and Volume Expansion in People With and Without Heart Failure

Andersen

Olson

Melenovský

et al. 2015

Circ: Heart Failure

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Background-Invasive hemodynamic exercise testing is commonly used in the evaluation of patients with suspected heart failure with preserved ejection fraction (HFpEF) or pulmonary hypertension. Saline loading has been suggested as an alternative provocative maneuver, but the hemodynamic changes induced by the 2 stresses have not been compared. Methods and Results-Twenty-six subjects (aged, 67±10 years; n=14 HFpEF; n=12 control) underwent right heart catheterization at rest, during supine exercise, and with acute saline loading in a prospective study. Exercise and saline each increased cardiac output and pressures in the right atrium, pulmonary artery, and pulmonary capillary wedge positions. Changes in heart rate, blood pressure, rate-pressure product, and cardiac output were greater with exercise compared with saline. In controls subjects, right atrial pressure, pulmonary arterial pressure, and pulmonary capillary wedge pressure increased similarly with saline and exercise, whereas in HFpEF subjects, exercise led to ≈2-fold greater increases in right atrial pressure (10±4 versus 6±3 mm Hg; P=0.02), pulmonary arterial pressure (22±8 versus 11±4 mm Hg; P=0.0001), and pulmonary capillary wedge pressure (18±5 versus 10±4 mm Hg; P<0.0001) compared with saline. Systolic reserve assessed by stroke work and cardiac power output was lower in HFpEF subjects with both exercise and saline. Systemic and pulmonary arterial compliances were enhanced with saline but reduced with exercise. Conclusions-Exercise elicits greater pulmonary capillary wedge pressure elevation compared with saline in HFpEF but not controls, suggesting that hemodynamic stresses beyond passive stiffness and increased venous return explain the development of pulmonary venous hypertension in HFpEF. Exercise testing is more sensitive than saline loading to detect hemodynamic derangements indicative of HFpEF. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01418248.(Circ Heart Fail. 2015;8:41-48.

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“…1,2 Accurate noninvasive assessment of PCWP is difficult, 4 but if there is a low ejection fraction (EF) or significant left-sided valve disease, the diagnosis of group 2 PH is generally rendered with confidence. 1,2 The more difficult distinction is between group 1 PH and PH caused by HF with preserved EF (HFpEF).…”

Section: Article See P 116mentioning

confidence: 99%

Invasive Assessment of Pulmonary Hypertension

Borlaug

2014

Circ: Heart Failure

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Bedside Assessment of Cardiac Hemodynamics: The Impact of Noninvasive Testing and Examiner Experience

Cited by 38 publications

References 34 publications

Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction

Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction

Differential Hemodynamic Effects of Exercise and Volume Expansion in People With and Without Heart Failure

Invasive Assessment of Pulmonary Hypertension

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