Performance and Interpretation of Invasive Hemodynamic Exercise Testing.

Published on Nov 1, 2020in Chest8.308
· DOI :10.1016/J.CHEST.2020.05.552
C. Charles Jain4
Estimated H-index: 4
(Mayo Clinic),
Barry A. Borlaug76
Estimated H-index: 76
(Mayo Clinic)
Sources
Abstract
Abstract Exertional dyspnea is a common complaint for patients seen in pulmonary, cardiac and general medicine clinics, and elucidating the cause is often challenging, particularly when physical examination, echocardiography, radiography and pulmonary function test results are inconclusive. Invasive cardiopulmonary exercise testing (CPET) has emerged as the gold standard test to define causes of dyspnea and exertional limitation in this population. In this review, we describe the methods for performing and interpreting invasive CPET, with particular attention to the hemodynamic and blood sampling data as they apply to patients being evaluated for heart failure and pulmonary hypertension.
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Heart failure with preserved ejection fraction (HFpEF) has grown to become the dominant form of heart failure worldwide, in tandem with ageing of the general population and the increasing prevalences of obesity, diabetes mellitus and hypertension. The clinical syndrome of HFpEF is heterogeneous and must be distinguished from heart failure with reduced ejection fraction as well as other aetiologies that have different treatment strategies. The diagnosis of HFpEF is challenging and ultimately rela...
30 CitationsSource
#1Masaru Obokata (Mayo Clinic)H-Index: 22
#2Garvan C. Kane (Mayo Clinic)H-Index: 50
Last. Barry A. Borlaug (Mayo Clinic)H-Index: 76
view all 8 authors...
Introduction Identification of elevated pulmonary artery (PA) pressures during exercise has important diagnostic, prognostic, and therapeutic implications. Stress echocardiography is frequently used to estimate PA pressures during exercise testing, but data supporting this practice are limited. This study examined the accuracy of Doppler echocardiography for the estimation of PA pressures at rest and during exercise. Methods Simultaneous cardiac catheterisation-echocardiographic studies were per...
8 CitationsSource
#1Ambarish Pandey (UTSW: University of Texas Southwestern Medical Center)H-Index: 40
#2William E. Kraus (Duke University)H-Index: 100
Last. Dalane W. Kitzman (Wake Forest University)H-Index: 103
view all 4 authors...
Abstract Objectives The aim of this study was to evaluate the association between age and invasive cardiovascular hemodynamics during upright exercise among healthy adults. Background The marked age-related decline in maximal exercise oxygen uptake (peak VO2) may contribute to the high burden of heart failure among older individuals and their greater severity of exertional symptoms. However, the mechanisms underlying this decline are not well understood. Methods A total of 104 healthy community-...
6 CitationsSource
#1Jennifer E. HoH-Index: 50
#2Emily K. Zern (Harvard University)H-Index: 4
Last. Gregory D. LewisH-Index: 53
view all 17 authors...
Abstract Background Abnormal pulmonary arterial pressure (PAP) responses to exercise have been described in select individuals; however, clinical and prognostic implications of exercise pulmonary hypertension (exPH) among broader samples remains unclear. Objectives This study sought to investigate the association of exPH with clinical determinants and outcomes. Methods The authors studied individuals with chronic exertional dyspnea and preserved ejection fraction who underwent cardiopulmonary ex...
22 CitationsSource
#1Yogesh N.V. Reddy (Mayo Clinic)H-Index: 26
#2Masaru Obokata (Mayo Clinic)H-Index: 22
Last. Barry A. Borlaug (Mayo Clinic)H-Index: 76
view all 9 authors...
AIMS : Increases in extravascular lung water (EVLW) during exercise contribute to symptoms, morbidity, and mortality in patients with heart failure and preserved ejection fraction (HFpEF), but the mechanisms leading to pulmonary congestion during exercise are not well-understood. METHODS AND RESULTS : Compensated, ambulatory patients with HFpEF (n = 61) underwent invasive haemodynamic exercise testing using high-fidelity micromanometers with simultaneous lung ultrasound, echocardiography, and ex...
48 CitationsSource
#1Burkert PieskeH-Index: 92
#2Carsten Tschöpe (Charité)H-Index: 80
Last. Gerasimos Filippatos (UCY: University of Cyprus)H-Index: 129
view all 24 authors...
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiogra...
209 CitationsSource
#1Kathryn H. Melamed (UCLA: University of California, Los Angeles)H-Index: 2
#2Mário Santos (Brigham and Women's Hospital)H-Index: 16
Last. David M. Systrom (Brigham and Women's Hospital)H-Index: 35
view all 8 authors...
Purpose The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE).
7 CitationsSource
#1Yogesh N.V. Reddy (Mayo Clinic)H-Index: 26
#2Masaru Obokata (Mayo Clinic)H-Index: 22
Last. Barry A. Borlaug (Mayo Clinic)H-Index: 76
view all 8 authors...
AIMS: Left atrial (LA) function is impaired in heart failure with preserved ejection fraction (HFpEF) and predicts disease severity and risk of adverse outcome. We sought to evaluate whether LA strain could enhance diagnosis of HFpEF. METHODS AND RESULTS: Consecutive patients with unexplained exertional dyspnoea and image quality suitable for measuring LA strain underwent invasive cardiopulmonary exercise testing to ascertain the presence of HFpEF or non-cardiac causes of dyspnoea (NCD). LA rese...
51 CitationsSource
#1Barry A. Borlaug (Mayo Clinic)H-Index: 76
#2Yogesh N.V. Reddy (Mayo Clinic)H-Index: 26
Abstract The elastic pericardium exerts a compressive contact force on the surface of the myocardium that becomes more substantial when heart volume increases, as in patients with various forms of heart failure (HF). Pericardial restraint plays an important role in determining hemodynamics and ventricular function in both health and disease. This review discusses the physiology of pericardial restraint in HF and explores the question of whether it can be targeted indirectly through medical inter...
29 CitationsSource
#1Sam Esfandiari (UHN: University Health Network)H-Index: 8
#2Emil WolskH-Index: 11
Last. Susanna Mak (U of T: University of Toronto)H-Index: 20
view all 7 authors...
ABSTRACT Background The pulmonary arterial wedge pressure (PAWP) response to exercise may unmask latent heart failure with preserved ejection fraction. There remains a lack of consensus over threshold values for PAWP during exercise. A systematic review of studies examining PAWP by means of right heart catheterization at rest and during exercise in healthy individuals was performed. Methods and Results Relevant data derived from healthy volunteers were stratified by age (older than 40 years vs 4...
11 CitationsSource
Cited By1
Newest
#1Andrea SalzanoH-Index: 17
#2Mariarosaria De Luca (University of Naples Federico II)H-Index: 1
Last. Alberto M. Marra (University of Naples Federico II)H-Index: 20
view all 16 authors...
Exercise intolerance represents a typical feature of heart failure with preserved ejection fraction (HFpEF), and is associated with a poor quality of life, frequent hospitalizations, and increased all-cause mortality. The cardiopulmonary exercise test is the best method to quantify exercise intolerance, and allows detection of the main mechanism responsible for the exercise limitation, influencing treatment and prognosis. Exercise training programs improve exercise tolerance in HFpEF. However, s...
Source
Heart failure with preserved ejection fraction (HFpEF) is a major global public health problem. Diagnosis of HFpEF is still challenging and built based on the comprehensive echocardiographic analysis. Currently, there are no universally accepted therapies that alter the clinical course of HFpEF. This review attempts to summarize the current advances in the diagnosis of HFpEF and provide future directions of the patients´ management with this very widespread, heterogeneous clinical syndrome.
1 CitationsSource