Exercise haemodynamics in heart failure with preserved ejection fraction: a systematic review and meta‐analysis

Abstract

Aims Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current haemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise haemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects. Methods and resultsWe performed a systematic literature review until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all haemodynamic variables were evaluated, stratified according to body position (supine/upright exercise). The PAWP/cardiac output (CO) slope during exercise was extrapolated. Twenty-seven studies were identified, providing data for 2180 HFpEF patients and 682 controls. At peak exercise, patients with HFpEF achieved higher PAWP (30 [29-31] vs. 16 [15-17] mmHg, P < 0.001) and mean right atrial pressure (P < 0.001) than controls. These differences persisted after adjustment for age, sex, body mass index, and body position. However, peak PAWP values were highly heterogeneous among the cohorts (I 2 = 93%), with a relative overlap with controls. PAWP/CO slope was steeper in HFpEF than in controls (3.75 [3.20-4.28] vs. 0.95 [0.30-1.59] mmHg/L/min, P value < 0.0001), even after adjustment for covariates (P = 0.007). Conclusions Despite methodological heterogeneity, as well as heterogeneity of pooled haemodynamic estimates, the exercise haemodynamic profile of HFpEF patients is consistent across studies and characterized by a steep PAWP rise during exercise. More standardization of exercise haemodynamics may be advisable for a wider application in clinical practice.

Understanding mechanisms of Fontan failure: exercise haemodynamics to unmask diastolic dysfunction, again!

“…Diagnostic thresholds, as highlighted in the work by Miranda et al ., might need to be adapted to underlying patient's condition (or even to body position in which exercise is performed). Based on available evidence, it seems today reasonable to accept, as indicative of relevant diastolic dysfunction with prognostic implications, an end‐expiratory mean PAWP at peak ≥25 mmHg during supine exercise (which would roughly correspond to a respiratory‐averaged mean PAWP >20 mmHg, 15 as well as to an end‐expiratory mean PAWP >20 mmHg during upright exercise). A PAWP/CO slope >2 mmHg/L/min may help reinforce the diagnosis 15 irrespectively of body position, 14 carries prognostic indications, and might enhance our ability to detect diastolic dysfunction in preload‐limited conditions, such as post‐Fontan patients, over‐diuresed HFpEF patients, or patients with HFpEF buried below a pulmonary vascular barrage (when pulmonary arterial hypertension and HFpEF coexist in the same patient).…”

“…Diagnostic thresholds, as highlighted in the work by Miranda et al, might need to be adapted to underlying patient's condition (or even to body position in which exercise is performed). Based on available evidence, it seems today reasonable to accept, as indicative of relevant diastolic dysfunction with prognostic implications, an end-expiratory mean PAWP at peak ≥25 mmHg during supine exercise (which would roughly correspond to a respiratory-averaged mean PAWP >20 mmHg, 15 as well as to an end-expiratory mean PAWP >20 mmHg during upright exercise). A PAWP/CO slope >2 mmHg/L/min may help reinforce the diagnosis 15 .…”

“…Based on available evidence, it seems today reasonable to accept, as indicative of relevant diastolic dysfunction with prognostic implications, an end-expiratory mean PAWP at peak ≥25 mmHg during supine exercise (which would roughly correspond to a respiratory-averaged mean PAWP >20 mmHg, 15 as well as to an end-expiratory mean PAWP >20 mmHg during upright exercise). A PAWP/CO slope >2 mmHg/L/min may help reinforce the diagnosis 15 . The interpretation of exercise haemodynamics is thus becoming more and more complex and at the same time more informative.…”

Pulmonary artery wedge pressure and left ventricular end-diastolic pressure during exercise in patients with dyspnoea

“…From rest to peak exercise, end-expiratory PAWP M passed in median from 14 [9][10][11][12][13][14][15][16][17][18] to 33 [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] mmHg, PAWP ED from 14 [9][10][11][12][13][14][15][16][17] to 31 [25][26][27][28][29][30][31][32][33][34][35][36][37][38] mmHg, LVEDP from 15 [10][11][12][13][14][15][16]…”

Invasive exercise haemodynamics: an oracle in heart failure with preserved ejection fraction diagnosis and prognostication

“…At the 2008 4th World symposium on pulmonary hypertension held in Dana Point, the established mean PAP value in excess of 30 mmHg as a solitary cut‐point for defining pulmonary hypertension was abandoned. More recent meta‐analyses and consensus statements emphasize indexing PAWP and PAP to CO to account for the amount of blood flow and the ‘dose’ of exercise 3,13,14 . Hence, application of solitary cut‐points may pertain to instances where exercise is limited due to body position/mechanical constraints.…”