Value of combined cardiopulmonary and echocardiography stress test to characterize the haemodynamic and metabolic responses of patients with heart failure and mid-range ejection fraction

Pugliese, Nicola Riccardo; Fabiani, Iacopo; Santini, Claudia; Rovai, Ilaria; Pedrinelli, Roberto; Natali, Andrea; Dini, Frank Lloyd

doi:10.1093/ehjci/jez014

Cited by 65 publications

(72 citation statements)

References 30 publications

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“…1 Our findings suggest that AVO 2 diff might be used as a novel early marker of HT-related effort intolerance. Prior non-invasive 8,9,24,25 and invasive 26 studies found that a peripheral limitation was the most important cause of reduced peak VO 2 in HFpEF, whereas impaired CO had less impact. However, HFpEF is a heterogeneous syndrome, and exercise capacity is strongly influenced by co-morbid defects.…”

Section: Central and Peripheral Components Of Oxygen Consumptionmentioning

confidence: 97%

“…Cardiopulmonary exercise test (CPET) combined with exercise stress echocardiography (ESE) offers a feasible, non‐invasive evaluation of different cardiac conditions . In particular, CPET‐ESE allows the simultaneous analysis of the peripheral and central components of oxygen consumption (VO 2 ), suggesting that an impaired peripheral oxygen extraction significantly accounts for the effort intolerance in patients with HFpEF . As the history of the disease remains unclear, we analysed HT subjects with and without HFpEF using CPET‐ESE to identify early haemodynamic and metabolic alterations that might explain the increased susceptibility of HT patients to develop HFpEF.…”

Section: Introductionmentioning

confidence: 99%

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Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test

Pugliese

Mazzola

Fabiani

et al. 2020

European J of Heart Fail

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Aim We combined cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE) to identify early haemodynamic and metabolic alterations in patients with hypertension (HT) with and without heart failure with preserved ejection fraction (HFpEF). Methods and results Fifty stable HFpEF‐HT outpatients (mean age 68 ± 14 years) on optimal medical therapy, 63 well‐controlled HT subjects (mean age 63 ± 11 years) and 32 age and sex‐matched healthy controls (mean age 59 ± 15 years) underwent a symptom‐limited graded ramp bicycle CPET‐ESE. The acquisition protocol included left ventricular cardiac output, global longitudinal strain, E/e′, peak oxygen consumption (VO2), non‐invasive arterial–venous oxygen content difference (AVO2diff) and lung ultrasound B‐lines. There was a decline in peak VO2 from controls (24.4 ± 3 mL/min/kg) to HFpEF‐HT (15.2 ± 2 mL/min/kg), passing through HT (18.7 ± 2 mL/min/kg; P < 0.0001). HFpEF‐HT displayed a lower peak cardiac output (9.8 ± 0.9 L/min) compared to HT (12.6 ± 1.0 L/min; P = 0.02) and controls (13.3 ± 1.0 L/min; P = 0.01). Peak AVO2diff was reduced in HFpEF‐HT and HT (13.3 ± 2 and 13.5 ± 2 mL/dL vs. controls: 16.9 ± 2 mL/dL; P < 0.0001). A different left ventricular contractility was observed among groups, expressed as low‐load global longitudinal strain (−16.8 ± 5% in HFpEF‐HT, −18.2 ± 3% in HT, and 20.9 ± 3% in controls; P < 0.0001), and distribution of E/e′ and B‐lines [HFpEF‐HT: 13.7 ± 3 and 16, interquartile range (IQR) 10–22; HT: 9.5 ± 2 and 8, IQR 4–10; controls: 6.2 ± 2 and 0, IQR 0–2; P < 0.0001]. Conclusions Reduced peak VO2 values in HT with and without HFpEF may be the result of decreased AVO2diff. CPET‐ESE can also identify mild signs of left ventricular systo‐diastolic dysfunction and pulmonary congestion, promoting advances in personalized therapy.

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Section: Central and Peripheral Components Of Oxygen Consumptionmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test

Pugliese

Mazzola

Fabiani

et al. 2020

European J of Heart Fail

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“…Our findings concur with the results of previous studies on exercise intolerance which described heart rate, stroke volume and skeletal-muscle function as the main contributors to exercise intolerance. 13,14,17,18,[33][34][35] The contribution of each of these factors to EC varies depending on the individual patient's disease profile but were not investigated in patients treated for AMI. Results of CPET-SE examination of patients with heart failure have demonstrated exercise intolerance among patients with mid-range and preserved LV EF, to be predominantly influenced by peripheral factors (such as A-VO2Diff), but among patients with reduced LV EF, by decreased stroke volume.…”

Section: Contributors Of Exercise Intolerancementioning

confidence: 99%

“…It is an emerging diagnostic method with considerable potential in cardiology, especially in evaluation of the predictors of exercise intolerance. [13][14][15][16][17][18] However, this strategy has been predominantly used in studies of patients with heart failure. 13,14,17,18 Parameters that play crucial role in EC in patients after AMI, have not been sufficiently studied.…”

Section: Introductionmentioning

confidence: 99%

“…[13][14][15][16][17][18] However, this strategy has been predominantly used in studies of patients with heart failure. 13,14,17,18 Parameters that play crucial role in EC in patients after AMI, have not been sufficiently studied. The present study aims to assess the determinants of EC using CPET-SE in patients treated for AMI with normal or mildly reduced LV EF at least 4 weeks after AMI.…”

Section: Introductionmentioning

confidence: 99%

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Combined Use of Stress Echocardiography and Cardiopulmonary Exercise Testing to Assess Exercise Intolerance after Acute Myocardial Infarction

Smarż¹,

Jaxa-Chamiec²,

Zaborska³

et al. 2020

Preprint

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Background: Exercise capacity (EC) after acute myocardial infarction (AMI) influences prognosis, but the causes of its reduction are complex and not sufficiently studied. Methods: We prospectively enrolled consecutive patients who underwent percutaneous coronary intervention for their first AMI with left ventricular ejection fraction (LV EF) >40% at least 4 weeks after AMI. We performed combined stress echocardiography and cardiopulmonary exercise testing (CPET-SE) using a semi-supine cycle ergometer to determine predictors of EC (peak oxygen uptake [VO2]). Results: Among 81 patients (70% male, mean age 58 ± 11 years), 40% had AMI with ST-segment elevation, and 60% non ST-segment elevation, LV EF was 57 ± 7%; wall motion score index, 1.18 (IQR 1.06 - 1.31); peak VO2, 19.5 ± 5.4 mL/kg/min. Multivariate analysis revealed that parameters at peak exercise: heart rate (β = 0.17, p < 0.001), stroke volume (β = 0.09, p < 0.001), and arteriovenous oxygen difference (A-VO2Diff, β = 93.51, p < 0.001) were independently positively correlated with peak VO2, with A-VO2Diff being its strongest contributor. Conclusions: In patients treated for AMI with normal/mildly reduced LV EF, EC is associated with peak peripheral oxygen extraction as well as peak heart rate and peak stroke volume. CPET-SE is a useful tool to evaluate decreased fitness in this group.

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Left atrial function and maximal exercise capacity in heart failure with preserved and mid‐range ejection fraction

et al. 2020

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Aims Exercise intolerance is the leading manifestation of heart failure with preserved or mid-range ejection fraction (HFpEF or HFmrEF), and left atrial (LA) function might contribute to modulating left ventricular filling and pulmonary venous pressures. We aim to assess the association between LA function and maximal exercise capacity in patients with HFpEF or HFmrEF. Methods and results Sixty-five patients, prospectively enrolled in the German HFpEF Registry, were analysed. Inclusion criteria were New York Heart Association functional class ≥ II, left ventricular ejection fraction > 40%, structural heart disease or diastolic dysfunction, and elevated levels of N terminal pro brain natriuretic peptide (NT-proBNP). LA function was evaluated through speckle-tracking echocardiography by central reading in the Charité Academic Echocardiography core lab. All patients underwent maximal cardiopulmonary exercise test and were classified according to a peak VO 2 cutoff of prognostic value (14 mL/kg/min). NT-pro-BNP was measured. Twenty-nine patients (45%) reached a peak VO 2 < 14 mL/kg/min (mean value 12.4 ± 1.5) and 36 patients (55%) peak VO 2 ≥ 14 mL/kg/min (mean value 19.4 ± 3.9). There was no significant difference in left ventricular ejection fraction (60 ± 9 vs. 59 ± 8%), left ventricular mass (109 ± 23 vs. 112 ± 32 g/m 2), LA volume index (45 ± 17 vs. 47 ± 22 mL/m 2), or E/e´(13.1 ± 4.7 vs. 13.0 ± 6.0) between these groups. In contrast, all LA strain measures were impaired in patients with lower peak VO 2 (reservoir strain 14 ± 5 vs. 21 ± 9%, P = 0.002; conduit strain 9 ± 2 vs. 13 ± 4%, P = 0.001; contractile strain 7 ± 4 vs. 11 ± 6%, P = 0.02; reported lower limits of normality for LA reservoir, conduit and contractile strains: 26.1%, 12.0%, and 7.7%). In linear regression analysis, lower values of LA reservoir strain were associated with impaired peak VO 2 after adjustment for age, sex, body mass index, heart rhythm (sinus/AFib), and log-NTproBNP [β 0.29, 95% confidence interval (CI) 0.02-0.30, P = 0.02], with an odds ratio 1.22 (95% CI 1.05-1.42, P = 0.01) for peak VO 2 < 14 mL/kg/min for LA reservoir strain decrease after adjustment for these five covariates. Adding left ventricular ejection fraction, it did not influence the results. On the other hand, the addition of LA strain to the adjustment parameters alone described above provided a significant increase of the predictive value for lower peak VO 2 values (R 2 0.50 vs. 0.45, P = 0.02). With receiver operating characteristic curve analysis, we identified LA reservoir strain < 22% to have 93% sensitivity and 49% specificity in predicting peak VO 2 < 14 mL/kg/min. Using this cutoff , LA reservoir strain < 22% was associated with peak VO 2 < 14 mL/kg/min in logistic regression analysis after comprehensive adjustment for age, sex, body mass index, heart rhythm, and log-NTproBNP [odds ratio 95% CI 10.4 (1.4-74), P = 0.02]. Conclusions In this HFpEF and HFmrEF cohort, a reduction in LA reservoir strain was a sensible marker of decreased peak exercise capacity. T...

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Value of combined cardiopulmonary and echocardiography stress test to characterize the haemodynamic and metabolic responses of patients with heart failure and mid-range ejection fraction

Cited by 65 publications

References 30 publications

Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test

Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test

Combined Use of Stress Echocardiography and Cardiopulmonary Exercise Testing to Assess Exercise Intolerance after Acute Myocardial Infarction

Left atrial function and maximal exercise capacity in heart failure with preserved and mid‐range ejection fraction

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