Physiologic Differences in Patients With HFpEF and PH

Study Questions:

How does the presence of pulmonary vascular disease (PVD) in heart failure with preserved ejection fraction (HFpEF) affect the physiologic response to exercise?

Methods:

Patients who had undergone invasive hemodynamic exercise testing at the Mayo Clinic were identified (n = 161), and HFpEF patients were divided into pulmonary hypertension (PH) subgroups: non-PH (mean pulmonary artery pressure [mPAP] <25 mm Hg), PH with no PVD (isolated precapillary PH, mean PAP ≥25 mm Hg with PV resistance [PVR] ≤3 Wood units and diastolic pressure gradient [DPG] <7 mm Hg), and PH with PVD (combined post- and precapillary PH; mPAP ≥25 mm Hg with PVR >3.0 and/or DPG ≥7 mm Hg). Invasive resting and exercise hemodynamics and echo parameters were compared between the three groups.

Results:

Of all HFpEF, 87% of patients had PH. Of those, 68% had isolated PH and 32% had combined PH. Although resting left ventricular (LV) dimensions, mass, and EF were similar in all groups, those with PH had greater E/e’. Patients with combined PH had more right ventricular (RV) dysfunction, more tricuspid regurgitation, lower PA compliance, reduced stroke volume and cardiac index, and greater ventricular interdependence at rest. During exercise, both PH groups achieved a lower workload and had decreased pVO2. Those with combined PH had a significantly lower increase in cardiac output/venous return, greater increase in PA elastance and PVR, and paradoxical decrease in LV transmural pressure (LVTMP) compared to the other groups. This was coupled with decreased aerobic capacity. Both PH groups had greater increases in right atrial pressure (RAP) during exercise compared to the non-PH HFpEF group; however, the increase was more dramatic in the combined PH group. In patients with combined PH, lower PA compliance was associated with greater increase in RAP, and as exercise PVR and DPG increased, there was a greater reduction in LVTMP.

Conclusions:

Patients with HFpEF and PVD (combined PH) have unique exercise hemodynamics, which may contribute to increased RV dysfunction, decreased stroke volume, underfilling of the LV, inability to augment cardiac output, and decreased aerobic capacity.

Perspective:

PVD in the setting of HFpEF is associated with unique alterations in exercise hemodynamics that create significant limitations in exercise capacity. Consideration should be given to performing exercise hemodynamics in HFpEF patients for better characterization of physiology, and targeted interventions should be investigated.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Acute Heart Failure, Pulmonary Hypertension, Echocardiography/Ultrasound, Exercise

Keywords: Blood Pressure, Echocardiography, Exercise, Exercise Test, Heart Failure, Hypertension, Pulmonary, Stroke Volume, Tricuspid Valve Insufficiency, Vascular Diseases, Ventricular Dysfunction, Right


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