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Exercise Pulmonary Hypertension and Dyspnea on Effort
Study Questions:
What is the association of exercise pulmonary hypertension (exPH) with clinical determinants and outcomes in patients with dyspnea on effort?
Methods:
The investigators studied individuals with chronic exertional dyspnea and preserved ejection fraction who underwent cardiopulmonary exercise testing with invasive hemodynamic monitoring. Exercise pulmonary hypertension was ascertained using minute-by-minute pulmonary arterial pressure (PAP) and cardiac output (CO) measurements to calculate a PAP/CO slope, and exPH defined as a PAP/CO slope >3 mm Hg/L/min. The primary outcome was cardiovascular (CV) hospitalization or all-cause mortality. Kaplan-Meier survival estimates were used for the primary outcome of cardiovascular event-free survival among patients with normal versus abnormal pulmonary vascular responses to exercise and Cox models utilized to estimate age- and sex-adjusted risk of clinical outcomes by PAP/CO slope.
Results:
Among 714 individuals (age 57 years, 59% women), 296 (41%) had abnormal PAP/CO slopes. Over a mean follow-up of 3.7 ± 2.9 years, there were 208 CV or death events. Individuals with abnormal PAP/CO slope had a twofold increased hazard of future CV or death event (multivariable-adjusted hazard ratio, 2.03; 95% confidence interval, 1.48-2.78; p < 0.001). The association of abnormal PAP/CO slope with outcomes remained significant after excluding rest PH (n = 146, hazard ratio, 1.75; 95% confidence interval, 1.21-2.54; p = 0.003). Both pre- and post-capillary contributions to exPH independently predicted adverse events (p < 0.001 for both).
Conclusions:
The authors concluded that exPH is independently and inversely associated with CV event-free survival among individuals undergoing evaluation of chronic dyspnea.
Perspective:
This study reports that exPH is associated with worse functional capacity and abnormal right ventricular contractile reserve, and the presence of exPH predicts worse CV event-free survival. Furthermore, adverse prognosis remains associated with exercise PH even in the absence of resting PH or known CV disease. These findings suggest incremental value of exercise hemodynamic assessment in identifying the burden of subclinical PH in individuals with dyspnea. Additional studies are indicated to assess the prognostic and therapeutic implications of an abnormal pulmonary hemodynamic response to exercise and to assess how specific interventions may influence the pre-capillary and post-capillary components of exPH and ameliorate the abnormal pulmonary vascular responses.
Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Acute Heart Failure, Pulmonary Hypertension, Exercise, Hypertension
Keywords: Arterial Pressure, Disease-Free Survival, Dyspnea, Exercise, Exercise Test, Heart Failure, Hemodynamics, Hypertension, Pulmonary, Primary Prevention, Stroke Volume
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