Relative Impairments in Hemodynamic Exercise Reserve Parameters in Heart Failure With Preserved Ejection Fraction

Pandey, Ambarish; Khera, Rohan; Park, Bryan; Haykowsky, Mark J.; Borlaug, Barry A.; Lewis, Gregory D.; Kitzman, Dalane W.; Butler, Javed; Berry, Jarett D.

doi:10.1016/j.jchf.2017.10.014

Cited by 62 publications

(65 citation statements)

References 47 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…A high resting mPCWP and a pathological increase in mPCWP during exercise predict poor outcomes from HFpEF 168 , 249 , 263 . Patients with a normal mPCWP at rest (<12 mmHg) but a steep increase during exercise (to ≥25 mmHg) have a two‐fold increase in mortality 263 .…”

Section: Calculating and Interpreting The Hfa–peff Scorementioning

confidence: 99%

“…In a meta-analysis, exercise capacity in HFpEF was related to chronotropic incompetence, high mPCWP, blunted augmentation of arteriovenous oxygen-content difference (implying inadequate perfusion of exercising skeletal muscles), reduced stroke volume reserve, and pulmonary hypertension. 168 Changes in pulmonary artery pressure (PAP) on exercise are determined by the interplay between CO, pulmonary artery compliance, pulmonary vascular resistance, and mPCWP. The increase in PAP is flow-dependent so it is best reported in relation to the increase in CO; the upper limit of normal is +3 mmHg/L/min.…”

Section: Defining Aetiology and Pathophysiologymentioning

confidence: 99%

“…Heart failure with preserved ejection fraction is a clinical syndrome with multiple contributing factors, aetiologies, and pathophysiological expressions. 168,275 It is a limitation that we suggest an algorithm that reduces it to a single clinical diagnosis. Future studies should evaluate and refine the recommended diagnostic algorithm and classify HFpEF patients into specific subgroups.…”

Section: Limitations Gaps In Evidence and Unanswered Questionsmentioning

confidence: 99%

See 2 more Smart Citations

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)

Pieske

Tschöpe

Boer

et al. 2020

European J of Heart Fail

415

643

View full text Add to dashboard Cite

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the ‘HFA–PEFF diagnostic algorithm’. Step 1 (P=Pre‐test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non‐cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e′), LV filling pressure estimated using E/e′, left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2–4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

show abstract

Section: Calculating and Interpreting The Hfa–peff Scorementioning

confidence: 99%

Section: Defining Aetiology and Pathophysiologymentioning

confidence: 99%

Section: Limitations Gaps In Evidence and Unanswered Questionsmentioning

confidence: 99%

See 1 more Smart Citation

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)

Pieske

Tschöpe

Boer

et al. 2020

European J of Heart Fail

415

643

View full text Add to dashboard Cite

show abstract

“…11 Similar to HFrEF, peak Q̇c and impaired peripheral oxidative capacity limit peak exercise performance in HFpEF patients. 7 9-17 While peak Q̇c is blunted due to chronotropic incompetence and impaired stroke volume reserve during maximal exercise, 12 it is unclear to what extent HFpEF patients experience impaired haemodynamic and metabolic function during submaximal exercise, similar to activities of daily living. In contrast to HFrEF, HFpEF patients consistently demonstrate normal augmentation of Q̇c during low-intensity submaximal exercise.…”

Section: Original Research Articlementioning

confidence: 99%

“…A recent meta-analysis indicates that HFpEF patients have normal or slightly smaller changes in a-vO 2 difference at peak exercise in the supine position, whereas during exercise in the upright posture (the position of most activities of daily living), a-vO 2 difference at peak exercise is consistently lower. 12 In regards to Q̇c, all studies to date have found that HFpEF patients display a preserved or exaggerated Q̇c response during submaximal exercise. 9 10 14 18 Specifically, the majority of these studies indicate that the rise in Q̇c in response to a change in VȮ 2 (Q̇c/VȮ 2 relationship) is preserved in HFpEF patients compared with healthy controls.…”

Section: Potential Mechanisms For Reduced Kinetics In Hfpefmentioning

confidence: 99%

Impaired oxygen uptake kinetics in heart failure with preserved ejection fraction

Hearon

Sarma

Dias

et al. 2019

Heart

View full text Add to dashboard Cite

Background The amount of time needed to increase oxygen utilization to sufficiently meet metabolic demand (V̇O2 kinetics) is impaired in heart failure (HF) with reduced ejection fraction, and is an independent predictor of HF mortality. However, it is not known if V̇O2 kinetics are slowed in heart HF patients with preserved ejection fraction (HFpEF). We tested the hypothesis that V̇O2 kinetics are slowed during submaximal exercise (equivalent to activities of daily living) in HFpEF patients, and that slower V̇O2 kinetics are related to impaired peripheral oxygen extraction. Methods Eighteen healthy controls (69±6 years, 10 females) and eighteen HFpEF patients (68±7 years, 10 females) were studied during submaximal (~30% predicted max) and peak treadmill exercise. Cardiac output (Qc, acetylene rebreathing), pulmonary oxygen uptake (V̇O2, Douglas bags), and arterial‐venous oxygen difference (a‐v O2 diff) were measured during exercise. Breath‐by‐breath V̇O2 uptake was measured continuously at the onset and throughout submaximal exercise, and V̇O2 kinetics quantified as the time needed to for V̇O2 to rise to ~63% of steady state V̇O2 (mean response time, MRT). Results During submaximal exercise, absolute oxygen demand was similar between groups (V̇O2: Control: 0.81±0.1, HFpEF: 0.85±0.2 L/min; P=0.54) however, HFpEF patients had substantially slowed V̇O2 kinetics (MRT: Control: 40.1±14.2, HFpEF: 65.4±27.7 s; P=0.002), and >50% greater accumulated oxygen deficit compared to controls (Control: 400±173, HFpEF: 693±392 mL; P=0.007). At peak exercise, HFpEF patients had lower relative V̇O2 (Control: 22.2±4.0, HFpEF: 14.6±3.1 mL/kg/min; P<0.001), preserved peak Qc (Control: 13.4±4.0, HFpEF: 13.9±3.5 L/min; P=0.68), and reduced peripheral oxygen extraction (a‐v O2 diff: Control: 12.7±2.9, HFpEF: 10.4±2.1 mL/dL; P=0.01). When stratified by MRT, HFpEF patients with a MRT >60s demonstrated impaired peripheral oxygen extraction that was apparent during submaximal exercise compared to HFpEF patients with a MRT <60s (submaximal a‐v O2 diff: MRT<60s: 9.7±2.1, MRT>60s: 7.9±1.1 mL/dL; P=0.03). Conclusions HFpEF patients have slowed V̇O2 kinetics during exercise that are due in part to impaired peripheral oxygen utilization. This finding supports growing evidence that peripheral oxidative capacity is a primary contributor to exercise intolerance in HFpEF leading to substantial oxygen deficit even during activities of daily living. Further, MRT can lend important insight into the pathophysiology of exercise intolerance in individual HFpEF patients, and identify patients with severe peripheral limitations to exercise capacity. Support or Funding Information NIH: AG017479, F32‐HL137285 This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

show abstract

Effect of Neladenoson Bialanate on Exercise Capacity Among Patients With Heart Failure With Preserved Ejection Fraction

Shah

Voors

McMurray

et al. 2019

JAMA

Self Cite

View full text Add to dashboard Cite

with preserved ejection fraction (HFpEF) lacks effective treatments. Based on preclinical studies, neladenoson bialanate, a first-in-class partial adenosine A 1 receptor agonist, has the potential to improve several heart failure-related cardiac and noncardiac abnormalities but has not been evaluated to treat HFpEF. OBJECTIVES To determine whether neladenoson improves exercise capacity, physical activity, cardiac biomarkers, and quality of life in patients with HFpEF and to find the optimal dose.

show abstract

Relative Impairments in Hemodynamic Exercise Reserve Parameters in Heart Failure With Preserved Ejection Fraction

Cited by 62 publications

References 47 publications

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)

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)

Impaired oxygen uptake kinetics in heart failure with preserved ejection fraction

Effect of Neladenoson Bialanate on Exercise Capacity Among Patients With Heart Failure With Preserved Ejection Fraction

Contact Info

Product

Resources

About