Diastolic relaxation and compliance reserve during dynamic exercise in heart failure with preserved ejection fraction

Abstract

Background Recent studies have examined hemodynamic changes with stressors such as isometric handgrip and rapid atrial pacing in heart failure with preserved ejection fraction (HFpEF), but little is known regarding left ventricular (LV) pressure-volume responses during dynamic exercise. Objective Assess LV hemodynamic responses to dynamic exercise in patients with HFpEF. Methods and Results Twenty subjects with normal EF and exertional dyspnea underwent invasive hemodynamic assessment during dynamic exercise to evaluate for suspected HFpEF. LV end-diastolic pressure (LVEDP) was elevated at rest (>15mmHg, n=18) or with exercise (≥20mmHg, n=20) in all, consistent with HFpEF. Heart rate, blood pressure, arterial elastance and cardiac output increased with exercise (all p<0.001). Minimal and mean LV diastolic pressures increased by 43–56% with exercise (both p<0.0001), despite a trend toward reduction in LV end-diastolic volume (p=0.08). Diastolic filling time was abbreviated with increases in heart rate, and the proportion of diastole that elapsed prior to estimated complete relaxation increased (p<0.0001), suggesting inadequate relaxation reserve relative to the shortening of diastole. LV diastolic chamber elastance acutely increased 50% during exercise (p=0.0003). Exercise increases in LV filling pressures correlated with changes in diastolic relaxation rates, chamber stiffness and arterial afterload but were not related to alterations in preload volume, heart rate, or cardiac output. Conclusion In patients with newly-diagnosed HFpEF, LV filling pressures increase during dynamic exercise in association with inadequate enhancement of relaxation and acute increases in LV chamber stiffness. Therapies that enhance diastolic reserve function may improve symptoms of exertional intolerance in patients with hypertensive heart disease and early HFpEF.

Impaired myocardial relaxation with exercise determines peak aerobic exercise capacity in heart failure with preserved ejection fraction

“…Impaired diastolic reserve, measured as an inadequate increase in myocardial relaxation, is considered a hallmark of HFpEF and is associated with a progressive decline in exercise capacity 1, 5, 8. However, measuring diastolic parameters only at rest may not reveal the severity of limitation in patients suffering from this syndrome.…”

Cardiac Diastolic Function Is Impaired at Rest and Worsens With Exercise in Otherwise Healthy Individuals With Insulin Resistance

“…22) On the other hand, in the two studies performed in patients with heart failure with preserved ejection fraction (HFPEF), the E/e' ratio was significantly higher with exercise in the patient group when compared to the controls and this increase was correlated with exertional dyspnea. 20,23) In a stress echocardiography study conducted by Podolec, et al in patients with ischemic heart failure, an increase of the E/e' ratio with exercise was the most important determinant of reduced exercise capacity in this patient population. 24) Briefly, an exercise induced increase in the E/e' ratio seems to be a good predictor of reduced ventricular compliance and decreased exercise capacity.…”

“…This phenomenon is called "diastolic relaxation reserve" and is the primary determinant of exercise capacity in patients with impaired augmentation of heart rate, vasodilation, and contractility with exercise (elderly, patients with hypertension, etc.). 19,20) Stress echocardiography is a very useful method for the assessment of coronary artery disease, myocardial viability, and myocardial contractility. Evaluating tissue Doppler recordings in conjunction with the standard protocol increases its feasibility and accuracy.…”

Echocardiographic Predictors of Chronotropic Incompetence to Exercise in Patients with Heart Failure with Preserved Ejection Fraction

“…exercise capacity being worse in patients with marked diastolic dysfunction. [12,13,31] In order to define the role of CI in exercise capacity limitation we performed multiple stepwise regression analysis (Table 4), but parameters represented CI did not appear as independent predictors of lower exercise capacity, whilst echocardiographic parameters that represent extensive diastolic dysfunction, higher LV filling pressure and symptoms mostly of dyspnoea or fatigue during exercise appeared strongly associated with exercise capacity limita-tion. Although CI did not appear strongly associated with exercise capacity limitation, it does exist more frequently in patients with more pronounced diastolic dysfunction.…”

“…exercise capacity being worse in patients with marked diastolic dysfunction. [12,13] Understanding the pleiotropic nature of exercise capacity limitation in patients with HFpEF, we intended to examine whether there are predictive echocardiographic parameters of diastolic dysfunction for impaired chronotropic response to exercise, which would result in more tailored therapy for individual patients.…”