The combined exercise stress echocardiography and cardiopulmonary exercise test for identification of masked heart failure with preserved ejection fraction in patients with hypertension

Abstract

Background: Heart failure with preserved ejection fraction (HFpEF) is commonly associated with hypertension (HTN). However, resting echocardiography (ECHO) can underestimate the severity of disease. Exercise stress echocardiography (ESE) and the cardiopulmonary exercise testing (CPX) appeared to be useful tests in dynamic assessment of HFpEF. The value of combined exercise stress echocardiography cardiopulmonary testing (ESE-CPX) in the identification of masked HFpEF is still undetermined. Objective: The purpose of this study was to analyse the value of the combined ESE-CPX in the identification of masked HFpEF in patients with HTN, dyspnoea and normal resting left ventricular (LV) systolic and diastolic function. Methodology: We studied 87 patients with HTN, exertional dyspnoea and normal resting LV function. They all underwent ESE-CPX testing (supine bicycle, ramp protocol, 15 W/min). ECHO measurements were performed at rest, and at peak load. Achievement of peak E/e' ratio>15 was a marker for masked HFpEF. Results: Increase of E/e'>15 occurred in 8/87 patients (9.2%) during ESE-CPX. Those patients had the lower peak VO2 (p ¼ 0.012), the lower VO2 at anaerobic threshold (p ¼ 0.025), the lower workload (p ¼ 0.026), the lower peak partial pressure end tidal carbon dioxide (PetCO2) (p < 0.0001), and the higher VE/VCO2 slope (p < 0.0001) which was an independent multivariate predictor of HFpEF (p ¼ 0.021), with the cut-off value of 32.95 according to the receiveroperator characteristic (ROC) curve (sensitivity (Sn) 100%, specificity (Sp) 90%). Conclusion: The combined ESE-CPX test is feasible and reliable test that can unmask HFpEF and may become an important aid in the early diagnosis of HFpEF, excluding the other causes of exertional dyspnoea.

Clinical and Hemodynamic Correlates and Prognostic Value of VE/VCO 2 Slope in Patients With Heart Failure With Preserved Ejection Fraction and Pulmonary Hypertension

“…They concluded that the VE/ VCO2 slope could be a reliable test to diagnose HFpEF in an early stage, but they did not investigate the possible association between VE/VCO2 and mortality. 22 Hemodynamic measurements in our study showed that increased VE/VCO2 slope was associated with increased mPAP and PVR. Of note, no association was observed between VE/ VCO2 slope and PWCP.…”

“…A few others studied the value of CPX in patients with HFpEF. [20][21][22] Guazzi et al compared CPX parameters with multiple variables between an HFrEF and an HFpEF population. 20 Although that study showed that the VE/VCO2 slope represents HFpEF severity, no relationship between the VE/VCO2 slope and mortality was studied.…”

2016 Focused Update: Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations

“…Numerous variables from both CPX and Doppler echocardiography at peak exercise (eg, E/e´, peak V slope) were significantly different between subjects with and without HF with preserved EF. 105 These findings demonstrate the potential utility of CPX and exercise Doppler echocardiography in identifying HF with preserved EF at an earlier time point, prompting more aggressive medical management and improving clinical outcome. 106 We recognize the combined CPX-Doppler echocardiographic assessments do not hold broad applicability at this time.…”

The Amount of Weight Loss Six Months after Bariatric Surgery: It Makes a Difference

“…Obesity can lead to structural and functional worsening of the cardiovascular and pulmonary system [17, 18], as well as a reduction of the oxidative capacity of skeletal muscles [19]. Cardiopulmonary functional capacity provides diagnostic and prognostic information in a wide variety of clinical settings [20, 21]. …”