Exercise haemodynamics may unmask the diagnosis of diastolic dysfunction among patients with pulmonary hypertension

Abstract

Between 2004 and 2012, 200 symptomatic patients with exertional dyspnoea, preserved left ventricular systolic function and suspected pulmonary hypertension, underwent right heart catheterization. Included in the study were 63 patients with resting pulmonary arterial wedge pressure (PAWP) ≤15 mmHg. Patients were divided to three tertiles based on their peak exercise PAWP. Mean age was 60 ± 20 years and 29% were males. Mean pulmonary arterial pressure was 31 ± 14 mmHg at rest and 42 ± 18 mmHg upon exercise. Mean change in PAWP between rest and exercise was 0.0 ± 4.3, 4.6 ± 2.4, and 16.6 ± 7.1 mmHg in the lower, middle, and upper tertiles, respectively (P < 0.001). Higher exercise PAWP tertiles were associated with reduced pulmonary vascular resistance (8.3 ± 6.7, 2.9 ± 2.7, and 5.8 ± 4.6 Woods units, respectively; P = 0.004). A multivariate linear regression model demonstrated that each 5 kg/m 2 increase in body mass index was associated with 2.5 ± 1.0 mmHg increase in exercise PAWP (P = 0.017). A multivariate binary logistic model showed that subjects with borderline PAWP at rest (12-15 mmHg) were 4.5 times more likely to be in the upper tertile of exercise PAWP (P = 0.011).

From comorbidities to heart failure with preserved ejection fraction: a story of oxidative stress

“…When treated with sildenafil, pulmonary vascular resistance and right heart pressures decreased in patients with HFrEF having secondary PHT and long-term treatment improved functional status, exercise tolerance, LV diastolic function and cardiac geometry 73–75. Many patients with HFpEF develop PHT due to elevated left-sided filling pressures76 and, vice versa, patients with unexplained PHT appear to have HFpEF 77. In a small clinical study in patients with HFpEF having PHT, treatment with sildenafil for 12 months improved LV diastolic function and reduced hypertrophy and pulmonary pressures 78.…”

Normal resting pulmonary artery wedge pressure: a diagnostic trap for heart failure with preserved ejection fraction

“…The presence of this wide ‘grey zone’ is considered to be a major methodological shortcoming of Doppler echocardiographic imaging for the diagnosis of diastolic LV dysfunction. The study by Maor et al in this issue sheds further light on this ‘grey zone’ as it suggests a similar ‘grey zone’ for a normal resting PAWP, which ranges from 12 to 15 mmHg . In their study, 62% of patients, who had a substantial rise in exercise PAWP, had a resting PAWP in the range of 12–15 mmHg, and a resting PAWP within this range made it 4.5 times more likely to be in the highest tertile of exercise PAWP.…”

“…Failure to establish the diagnosis of HFPEF correctly can be related to omission of evidence of diastolic LV dysfunction, to exclusive reliance on elevated natriuretic peptides, which are only modestly raised in HFPEF, and to the fortuitous presence of a hypovolaemic status at the time of diagnostic evaluation, which necessitates a repeat assessment during exercise or saline infusion . The latter was convincingly demonstrated in the current issue of the journal by the study of Maor et al , who performed a limited upper body exercise stress test mimicking daily living activities during right heart catheterization in patients with pulmonary hypertension (PHT) [mean pulmonary artery pressure (mPAP) >25 mmHg] and normal resting pulmonary artery wedge pressure (PAWP <15 mmHg) . Despite attaining a rise in heart rate of 10%, which was only 62% of the age‐predicted maximal heart rate, one‐third of the patients had a substantial rise of PAWP from 11.4 ± 3.3 to 28.0 ± 6.5 mmHg.…”

“…7 The latter was convincingly demonstrated in the current issue of the journal by the study of Maor et al, who performed a limited upper body exercise stress test mimicking daily living activities during right heart catheterization in patients with pulmonary hypertension (PHT) [mean pulmonary artery pressure (mPAP) >25 mmHg] and normal resting pulmonary artery wedge pressure (PAWP <15 mmHg). 8 Despite attaining a rise in heart rate of 10%, which was only 62% of the age-predicted maximal heart rate, one-third of the patients had a substantial rise of PAWP from 11.4 ± 3.3 to 28.0 ± 6.5 mmHg. Without exercise stress testing, their HFPEF-induced post-capillary (group 2) PHT would have remained unnoticed and these patients would have been erroneously classified as pre-capillary (group 1) PHT in accordance with the Dana Point PHT criteria.…”

“…In the study by Maor et al , the PHT patients erroneously classified as group 1 PHT based on the Dana Point criteria and reclassified as HFPEF‐induced group 2 PHT following exercise stress testing presented with interesting clinical, echocardiographic, and haemodynamic features . Specific clinical features were high BMI ( P = 0.023) and obesity ( P = 0.035).…”