Diastolic stress test echocardiography in patients with suspected heart failure with preserved ejection fraction: a pilot study

Abstract

AimsThe purpose of this pilot study was to assess the potential usefulness of diastolic stress test (DST) echocardiography in patients with suspected heart failure with preserved ejection fraction (HFpEF).Methods and resultsPatients with suspected HFpEF (left ventricular ejection fraction ≥ 50%, exertional dyspnoea, septal E/e′ at rest 9–14, and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) at rest < 220 pg/mL; n = 13) and a control group constituted from asymptomatic patients with arterial hypertension (n = 19) and healthy subjects (n = 18) were included. All patients were analysed by two‐dimensional and Doppler echocardiography at rest and during exercise (DST) and underwent cardiopulmonary exercise testing and NT‐proBNP analysis during exercise. HFpEF during exercise was defined as exertional dyspnoea and peak VO2 ≤ 20.0 mL/min/kg. In patients with suspected HFpEF at rest, 84.6% of these patients developed HFpEF during exercise, whereas in the group of asymptomatic patients with hypertension and healthy subjects, the rate of developed HFpEF during exercise was 0%. Regarding the diagnostic performance of DST to detect HFpEF during exercise, an E/e′ ratio >15 during exercise was the most accurate parameter to detect HFpEF (accuracy 86%), albeit a low sensitivity (45.5%). Nonetheless, combining E/e′ with tricuspid regurgitation (TR) velocity > 2.8 m/s during exercise provided a significant increase in the sensitivity to detect patients with HFpEF during exercise (sensitivity 72.7%, specificity 79.5%, and accuracy 78%). Consistent with these findings, an increase of E/e′ was significantly linked to worse peak VO2, and the combination of an increase of both E/e′ and TR velocity was associated with elevated NT‐proBNP values during exercise.ConclusionsThe findings of this pilot study suggest that DST using E/e′ ratio and TR velocity could be of potential usefulness to diagnose HFpEF during exercise in patients with suspected HFpEF at rest.

Sex and Heart Failure with Preserved Ejection Fraction: From Pathophysiology to Clinical Studies

“…This study agrees with our findings that showed usefulness of diastolic stress echocardiography in discovering HFpEF patients in the individuals with dyspnea on exertion in simple clinical settings [48], without the use of right heart catheterization and comprehensive blood gas analysis.…”

“…However, only a small portion have been devoted to sex-related changes [7,47]. Our study group has recently published data regarding the diagnosis of HFpEF using diastolic stress echocardiography testing, which also partly illuminates the hemodynamic changes typical of HFpEF [48].…”

How to diagnose heart failure with preserved ejection fraction: the HFA–PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

“…The parameters that have been studied most often, during or immediately after exercise, are the mitral E/e ′ ratio and the TR peak velocity, which indicate increases in mPCWP and PASP, respectively. 28,41,[244][245][246][247][248]250 Ideally a semi-supine bicycle test with imaging during exercise, or else a treadmill or upright bicycle exercise protocol with imaging at or immediately after peak stress, is recommended 41,244 but there are no universally adopted protocols. The European Association of Cardiovascular Imaging and the American Society of Echocardiography recommend a stepped protocol, starting at 25 W at 60 r.p.m.…”

“…Acquiring echocardiographic data during exercise can unmask LV diastolic and systolic dysfunction. The parameters that have been studied most often, during or immediately after exercise, are the mitral E / e ′ ratio and the TR peak velocity, which indicate increases in mPCWP and PASP, respectively 28 , 41 , 244–248 , 250 …”

Prognostic significance of exercise‐induced diastolic dysfunction: A systematic review

“…3,4 Studies have demonstrated the diagnostic utility of diastolic stress testing in identifying patients with cardiac dyspnea and HFpEF. 5 Prior studies have also shown that impaired exercise hemodynamics are associated with adverse cardiovascular outcomes. [6][7][8] However, current guidelines cite lack of sufficient evidence to determine the prognostic value of DD uncovered during stress testing.…”