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

Abstract

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.

Type 2 diabetes and reduced exercise tolerance: a review of the literature through an integrated physiology approach

“…In the diabetic population, a high prevalence of HF with preserved ejection fraction (HFpEF) is observed [58]; since a reduced Δ(a − v)O 2 using imaging-CPET has been previously demonstrated in patients with HFpEF in comparison to either controls or HF with reduced ejection fraction [59], one can hypothesize that it might play a role in T2DM alike. Indeed, only two studies have addressed this question reaching different conclusions [19,49].…”

Hypertension and heart failure: insights from exercise stress testing

“…6,11,12 Exercise stress echocardiography and CPET can be a valued asset in clinical care and scientific investigation, and this modality has substantially advanced our understandings of heart failure. 15,16 The data by Pugliese et al 7 support the utility of CPET testing and add to the growing body of literature demonstrating the potential added value of lung ultrasonography 9 and exercise E/e' 17 in evaluating HFpEF among hypertension patients at risk. However, given the discrepancies and potential error in estimating CO during exercise with ESE (and all variables calculated from CO), we need to remember to maintain a healthy degree of skepticism.…”

“…2,3 Thus, while patients usually develop HFpEF in the background of hypertension, the clinical factors associated with this progression from hypertension to HFpEF remain only partially understood. [4][5][6] In this issue of the Journal, Pugliese et al 7 report the results of a prospective study using non-invasive exercise stress echocardiography (ESE) with cardiopulmonary exercise testing (CPET) to explore these questions. The authors recruited 63 asymptomatic hypertensives, 50 patients with hypertension and HFpEF, and 32 healthy controls.…”

March 2020 at a glance: heart failure with preserved ejection fraction, left atrial myopathy, atrial fibrillation and cardiac amyloidosis

“…Cardiopulmonary exercise test (CPET) is useful for the risk stratification of HFpEF patients. 9,10 Pugliese et al 11 evaluated patients with hypertension with and without HFpEF by CPET and exercise stress echocardiography. Reduced peak oxygen consumption, low cardiac output, high E/e' and B-lines were found more frequently in patients with HFpEF and hypertension compared to the others.…”