Diagnostic, prognostic and differential-diagnostic relevance of pulmonary haemodynamic parameters during exercise: a systematic review

Abstract

The cardiopulmonary hemodynamic profile observed during exercise may identify patients with early stage pulmonary vascular and primary cardiac diseases, and is used clinically to inform prognosis. However, a standardised approach to interpreting hemodynamics is lacking.We performed a systematic literature search according to PRISMA guidelines to identify parameters that may be diagnostic for an abnormal hemodynamic response to exercise and offer optimal prognostic and differential-diagnostic value. We performed random-effects-meta-analyses of the normal values and reported effect sizes as weighted means and standard deviations (sd). Results of diagnostic and prognostic studies are reported descriptively.We identified n=45 eligible studies with n=5598 subjects. The mean pulmonary arterial pressure (mPAP)/cardiac output (CO) slope, pulmonary arterial wedge pressure (PAWP)/CO slope and peak cardiac index (or CO) provided the most consistent prognostic hemodynamic parameters during exercise. The best cut-offs for survival and cardiovascular events were mPAP/CO slope>3 Wood units (WU) and PAWP/CO slope>2 WU. A PAWP/CO slope cut-off>2 WU best differentiated pre- from post-capillary causes of PAP elevation during exercise. Upper limits of normal (defined as mean+2 sd) for the mPAP/CO and PAWP/CO slopes were strongly age-dependent and ranged in 30-to 70-year old healthy subjects from 1.6 to 3.3 WU and 0.6 to 1.8 WU, respectively.Increased mPAP/CO slope during exercise is associated with impaired survival and an independent, prognostically relevant cut-off>3 WU has been validated. A PAWP/CO slope>2 WU may be suitable for the differentiation between pre- and post-capillary causes of PAP increase during exercise.

2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension

“…Exercise PH, defined by an mPAP/cardiac output (CO) slope >3 mmHg/L/min between rest and exercise [17], has been re-introduced. The mPAP/CO slope is strongly age dependent and its upper limit of normal ranges from 1.6-3.3 mmHg/L/min in the supine position [17].…”

“…Exercise PH, defined by an mPAP/cardiac output (CO) slope >3 mmHg/L/min between rest and exercise [17], has been re-introduced. The mPAP/CO slope is strongly age dependent and its upper limit of normal ranges from 1.6-3.3 mmHg/L/min in the supine position [17]. An mPAP/CO slope >3 mmHg/L/min is not physiological in subjects aged <60 years and may rarely be present in healthy subjects aged >60 years [17].…”

“…The mPAP/CO slope is strongly age dependent and its upper limit of normal ranges from 1.6-3.3 mmHg/L/min in the supine position [17]. An mPAP/CO slope >3 mmHg/L/min is not physiological in subjects aged <60 years and may rarely be present in healthy subjects aged >60 years [17]. A pathological increase in pulmonary pressure during exercise is associated with impaired prognosis in patients with exercise dyspnoea [18] and in several cardiovascular conditions [19][20][21][22].…”

Abnormal pulmonary hemodynamics during exercise is associated with exercise capacity in COPD

“…In recent years, our understanding of pulmonary hemodynamics during exercise improved and prognostically relevant variables have been identi ed. Out of these, the mPAP/CO-slope may be considered as most robust parameter to characterize abnormal pulmonary hemodynamics during exercise [11][12][13]. However, there are still very limited data available on the characteristic changes in pulmonary hemodynamics during exercise in COPD and on the clinical relevance of these changes In this study, we aimed to investigate pulmonary hemodynamics and right ventricular function during exercise in COPD patients with normal or minimally elevated mean pulmonary arterial pressure (mPAP) at rest and to compare them to age-and sex-matched controls.…”

The Paradox of Pulmonary Vascular Resistance: Restoration of Pulmonary Capillary Recruitment as a Sine Qua Non for True Therapeutic Success in Pulmonary Arterial Hypertension

“…Exercise testing with concurrent hemodynamic measurement has provided insights into pulmonary circulatory and cardiac dysfunction in pulmonary hypertension [ 33 , 34 , 35 , 36 , 37 , 38 ]. A variety of ventilatory parameters, including ventilatory dead space indicative of ventilation/perfusion matching, are abnormal, and the pulmonary artery pressure/blood flow slope is abnormally steep.…”