Oakland HT, Joseph P, Elassal A, Cullinan M, Heerdt PM, Singh I. Diagnostic utility of sub-maximum cardiopulmonary exercise testing in the ambulatory setting for heart failure with preserved ejection fraction.
Pulm Circ 2020;
10:2045894020972273. [PMID:
33282205 PMCID:
PMC7691918 DOI:
10.1177/2045894020972273]
[Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/17/2020] [Indexed: 12/04/2022] Open
Abstract
Pulmonary hypertension is commonly associated with heart failure with preserved
ejection fraction. In heart failure with preserved ejection fraction, the
elevated left-sided filling pressures result in isolated post-capillary
pulmonary hypertension or combined pre- and post-capillary pulmonary
hypertension. Although right heart catheterization is the gold standard for
diagnosis, it is an invasive test with associated risks. The ability of
sub-maximum cardiopulmonary exercise test as an adjunct diagnostic tool in
pulmonary hypertension-associated heart failure with preserved ejection fraction
is not known. Forty-six patients with heart failure with preserved ejection
fraction and pulmonary hypertension (27 patients with combined pre- and
post-capillary pulmonary hypertension and 19 patients with isolated
post-capillary pulmonary hypertension) underwent sub-maximum cardiopulmonary
exercise test followed by right heart catheterization. The study also included
18 age- and gender-matched control subjects. Several sub-maximum gas exchange
parameters were examined to determine the ability of sub-maximum cardiopulmonary
exercise test to distinguish between isolated post-capillary pulmonary
hypertension and combined pre- and post-capillary pulmonary hypertension.
Conventional echocardiogram measures did not distinguish between isolated
post-capillary pulmonary hypertension and combined pre- and post-capillary
pulmonary hypertension. Compared to isolated post-capillary pulmonary
hypertension, combined pre- and post-capillary pulmonary hypertension had
greater ventilatory equivalent for carbon dioxide (VE/VCO2) slope,
reduced delta end-tidal CO2 change during exercise, reduced oxygen
uptake efficiency slope, and reduced gas exchange determined pulmonary vascular
capacitance. The latter was significantly associated with right heart
catheterization determined pulmonary artery compliance
(r = 0.5; p = 0.0004). On univariate analysis,
sub-maximum VE/VCO2, delta end-tidal carbon dioxide, and gas exchange
determined pulmonary vascular capacitance emerged as independent predictors of
the extrapolated maximum oxygen uptake (%predicted) (β-coefficient values of
–7.32, 95% CI: –13.3 – (–1.32), p = 0.01; 8.01, 95% CI:
1.96–14.05, p = 0.01; 8.78, 95% CI: 2.26–15.29,
p = 0.01, respectively). Sub-maximum gas exchange
parameters obtained during cardiopulmonary exercise test in an ambulatory
setting allows for discrimination between isolated post-capillary pulmonary
hypertension and combined pre- and post-capillary pulmonary hypertension.
Additionally, sub-maximum cardiopulmonary exercise test derived
VE/VCO2, delta end-tidal carbon dioxide, and gas exchange
determined pulmonary vascular capacitance influences aerobic capacity in heart
failure with preserved ejection fraction.
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