Elsevier

Journal of Cardiac Failure

Volume 18, Issue 9, September 2012, Pages 702-710
Journal of Cardiac Failure

Clinical Investigation
Hemodynamic Determinants of the Abnormal Cardiopulmonary Exercise Response in Heart Failure With Preserved Left Ventricular Ejection Fraction

https://doi.org/10.1016/j.cardfail.2012.06.530Get rights and content

Abstract

Background

The cardiopulmonary exercise testing (CPET) response in heart failure with preserved left ventricular ejection fraction (HFPEF) is incompletely understood. We aimed to describe the CPET response in HFPEF and to assess its invasive hemodynamic determinants.

Methods and Results

Ten patients with HFPEF and 8 asymptomatic controls underwent resting and exercise right heart catheterization and maximal symptom-limited CPET. The slope of the minute ventilation/carbon dioxide production relationship (VE/VCO2 slope; 34.3 ± 5.4 vs. 28.4 ± 3.4; P = .02) was steeper, peak oxygen consumption (peak VO2; 15.1 ± 4.9 vs. 26.6 ± 12.5 mL∗kg-1∗min-1; P = .02) was lower, and heart rate recovery 1 minute after exercise termination (HRR-1; 10 ± 5 vs. 27 ± 10 beats/min; P < .001) was slower in HFPEF compared to controls. A steeper VE/VCO2 slope (r = 0.67, P = .002), lower peak VO2 (r = −0.48, P = .04), and slower HRR-1 (r = −0.58, P = .02) were significantly related to a higher ratio of the change in pulmonary capillary wedge pressure per change in work rate as a measure of the left ventricular pressure volume relationship.

Conclusions

In HFPEF patients, fundamental alterations in the CPET profile occur and these may, in part, result from the rapid rise in left ventricular filling pressures which accompanies exercise in these patients.

Section snippets

Patients and Protocol

We studied 10 patients with HFPEF and 8 control subjects who all underwent transthoracic echocardiography at rest and during exercise, assessment of resting and exercise right heart catheterization, and maximal symptom-limited CPET. This is a subanalysis of study that has been published previously.6 The following criteria for the definition of HFPEF were used: patients with HFPEF had to have exercise intolerance corresponding to a New York Heart Association Class II or III, a nondilated left

Study Population

As detailed in our previous report,6 we studied a HFPEF population with demographic features similar to those described in recent mechanistic studies5, 11, 20 and controls of similar age (69 ± 10 vs. 61 ± 12 years; P = .12) and gender (9 males/1 female vs. 5/3; P = .41). Patients with HFPEF had higher body mass index (31.3 ± 4.2 vs. 25.0 ± 5.1 kg/m2; P = .01) and by definition were more symptomatic (New York Heart Association Class II/III: 6/4 vs. 0/0) than controls. Patients with HFPEF were on

Discussion

In this study, we present a detailed evaluation of the hemodynamic determinants of the CPET response in HFPEF. Consistent with features of HFPEF, our study cohort was characterized by evidence consistent with a steep diastolic pressure volume relationship.21 In accordance with previous research we found a significantly reduced peak VO2,4 a steep VE/VCO2 slope,4 and impaired heart rate recovery5 in HFPEF patients. For the first time, we demonstrated the relationship between these CPET parameters

Conclusions

Key features of the CPET response in patients with HFPEF reflect the underlying fundamental hemodynamic abnormalities. Sequential CPET testing focussing on parameters beyond peak VO2 may provide additional information in the evaluation of prognosis and the response to therapy in HFPEF patients.

Acknowledgment

The excellent technical assistance by Donna Vizi, Jenny Starr, Liz Dewar, Sofie Karapanagiotidis, Faizel Hartley, Matthew Ellis, and Brigitte Borg is greatly appreciated.

Disclosures

None.

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    This study was supported by a Program Grant (to D.M.K.) from the National Health and Medical Research Council of Australia (Canberra, Australia) and the Swiss National Science Foundation (Grant number PBZHB-121007 to M.T.M.; Berne, Switzerland).

    See page 709 for disclosure information.

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