A systematic review of diastolic stress tests in heart failure with preserved ejection fraction, with proposals from the EU‐FP7 MEDIA study group

Abstract

Aims Cardiac function should be assessed during stress in patients with suspected heart failure with preserved ejection fraction (HFPEF), but it is unclear how to define impaired diastolic reserve. Methods and results We conducted a systematic review to identify which pathophysiological changes serve as appropriate targets for diagnostic imaging. We identified 38 studies of 1111 patients with HFPEF (mean age 65 years), 744 control patients without HFPEF, and 458 healthy subjects. Qualifying EF was >45–55%; diastolic dysfunction at rest was a required criterion in 45% of studies. The initial workload during bicycle exercise (25 studies) varied from 12.5 to 30 W (mean 23.1 ± 4.6), with increments of 10–25 W (mean 19.9 ± 6) and stage duration 1–5 min (mean 2.5 ± 1); targets were submaximal (n = 8) or maximal (n = 17). Other protocols used treadmill exercise, handgrip, dobutamine, lower body negative pressure, nitroprusside, fluid challenge, leg raising, or atrial pacing. Reproducibility of echocardiographic variables during stress and validation against independent reference criteria were assessed in few studies. Change in E/e' was the most frequent measurement, but there is insufficient evidence to establish this or other tests for routine use when evaluating patients with HFPEF. Conclusions To meet the clinical requirements of performing stress testing in elderly subjects, we propose a ramped exercise protocol on a semi‐supine bicycle, starting at 15 W, with increments of 5 W/min to a submaximal target (heart rate 100–110 b.p.m., or symptoms). Measurements during submaximal and recovery stages should include changes from baseline in LV long‐axis function and indirect echocardiographic indices of LV diastolic pressure.

Low level exercise echocardiography helps diagnose early stage heart failure with preserved ejection fraction: a study of echocardiography versus catheterization

“…Moreover, the uncommon rate of complete E and A merging at low level exercise facilitates Doppler analysis. [19,26] Exercise septal E/e' appears to be superior to lateral and E/ average e' ratio. Finally, E/e' appears to be reliable only in patients with apparent CD and should not be used for the assessment of exercise LVFP in patients with normal LV morphology and no history of coronary artery disease.…”

“…Relatively low levels of exercise were chosen because obviously all the patients can reach this threshold, [25] and invasive LV pressure tracings, as well as echocardiographic image quality, are well maintained at this workload. [19,26] Moreover, most of the changes in LVFP occur during this low level of exercise.…”

“…[14][15][16] Thus the clinical integration of exercise E/e' in daily clinical practice is debated. [17][18][19] The aim of this study was to assess the E/e' ratio for the estimation of low level exercise LVFP using a direct invasive measurement as the reference method in patients at high risk of HFpEF.…”

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“…Поряд із функціональним кла-сом (ФК) ХСН, іншим найважливішим предиктором перспективи зберегти життя хворого є скоротливість міокарда та її показник -фракція викиду лівого шлу-ночка (ФВ ЛШ). Традиційно вважають, що ФВ ЛШ -універсальний показник, який не тільки самостійно характеризує важкість декомпенсації та ефективність лікування, але й впливає на проґноз хворих із ХСН [5, 10,12].Одним із головних компонентів формування ХСН, незалежно від її етіолоґії, є ремоделювання серця [2, 6, 7]. Тобто за ушкодженням міокарда на початку, що призводить до втрати певної кількості кардіоміоцитів, які функціонують нормально, наростає важкість ХСН через ремоделювання [7].…”

“…Поряд із функціональним кла-сом (ФК) ХСН, іншим найважливішим предиктором перспективи зберегти життя хворого є скоротливість міокарда та її показник -фракція викиду лівого шлу-ночка (ФВ ЛШ). Традиційно вважають, що ФВ ЛШ -універсальний показник, який не тільки самостійно характеризує важкість декомпенсації та ефективність лікування, але й впливає на проґноз хворих із ХСН [5, 10,12].…”