The H2FPEF and HFA-PEFF algorithms for predicting exercise intolerance and abnormal hemodynamics in heart failure with preserved ejection fraction

AbstractExercise intolerance is a primary manifestation in patients with heart failure with preserved ejection fraction (HFpEF) and is associated with abnormal hemodynamics and a poor quality of life. Two multiparametric scoring systems have been proposed to diagnose HFpEF. This study sought to determine the performance of the H2FPEF and HFA-PEFF scores for predicting exercise capacity and echocardiographic findings of intracardiac pressures during exercise in subjects with dyspnea on exertion referred for bicycle stress echocardiography. In a subset, simultaneous expired gas analysis was performed to measure the peak oxygen consumption (VO2). Patients with HFpEF (n = 83) and controls without HF (n = 104) were enrolled. The H2FPEF score was obtainable for all patients while the HFA-PEFF score could not be calculated for 23 patients (feasibility 88%). Both H2FPEF and HFA-PEFF scores correlated with a higher E/e′ ratio (r = 0.49 and r = 0.46), lower systolic tricuspid annular velocity (r = − 0.44 and = − 0.24), and lower cardiac output (r = − 0.28 and r = − 0.24) during peak exercise. Peak VO2 and exercise duration decreased with an increase in H2FPEF scores (r = − 0.40 and r = − 0.32). The H2FPEF score predicted a reduced aerobic capacity (AUC 0.71, p = 0.0005), but the HFA-PEFF score did not (p = 0.07). These data provide insights into the role of the H2FPEF and HFA-PEFF scores for predicting exercise intolerance and abnormal hemodynamics in patients presenting with exertional dyspnea.

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The H2FPEF and HFA-PEFF Algorithms for Predicting Exercise Intolerance and Abnormal Hemodynamics in Heart Failure with Preserved Ejection Fraction

10.21203/rs.3.rs-919359/v1 ◽

2021 ◽

Author(s):

Shiro Amanai ◽

Tomonari Harada ◽

Kazuki Kagami ◽

Kuniko Yoshida ◽

Toshimitsu Kato ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Scoring Systems ◽

Exercise Duration ◽

Poor Quality ◽

Gas Analysis ◽

Exercise Intolerance ◽

Peak Oxygen Consumption ◽

Peak Exercise ◽

Preserved Ejection Fraction

Abstract Exercise intolerance is a primary manifestation of patients with heart failure with preserved ejection fraction (HFpEF) and is associated with abnormal hemodynamics and poor quality of life. Two multiparametric scoring systems have been proposed to diagnose HFpEF. This study sought to determine the performance of the H2FPEF and HFA-PEFF scores for predicting exercise capacity and echocardiographic measures of intracardiac pressures during exercise. Patients with HFpEF (n = 83) and control subjects without HF (n = 104) underwent bicycle exercise echocardiography. In a subset, simultaneous expired gas analysis was performed to measure peak oxygen consumption (VO2). The H2FPEF score was obtainable in all patients while the HFA-PEFF score could not be calculated in 23 patients (feasibility 88%). Both H2FPEF and HFA-PEFF scores were correlated with higher E/e’ ratio (r = 0.49 and r = 0.46), lower systolic tricuspid annular velocity (r=-0.44 and =-0.24), and lower cardiac output (r=-0.28 and r=-0.24) during peak exercise. Peak VO2 and exercise duration decreased with increasing the H2FPEF score (r=-0.40 and r=-0.32), and the H2FPEF score predicted reduced aerobic capacity (AUC 0.71, p = 0.0005), but the HFA-PEFF score did not (p = 0.07). These data provide new insights into the role of the H2FPEF and HFA-PEFF scores for predicting exercise intolerance and abnormal hemodynamics in patients HFpEF.

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Clinical Considerations and Exercise Responses of Patients with Heart Failure and Preserved Ejection Fraction: What Have We Learned in 20 Years?

Journal of Clinical Exercise Physiology ◽

10.31189/2165-6193-9.1.17 ◽

2020 ◽

Vol 9 (1) ◽

pp. 17-28

Author(s):

Peter H. Brubaker ◽

Wesley J. Tucker ◽

Mark J. Haykowsky

Keyword(s):

Quality Of Life ◽

Heart Failure ◽

Exercise Training ◽

Ejection Fraction ◽

The United States ◽

Exercise Intolerance ◽

Peak Exercise ◽

Preserved Ejection Fraction ◽

Rehabilitation Programs

ABSTRACT Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of all heart failure (HF) cases and is the fastest growing form of HF in the United States. The cornerstone symptom of clinically stable HFpEF is severe exercise intolerance (defined as reduced peak exercise oxygen uptake, VO2peak) secondary to central and peripheral abnormalities that result in reduced oxygen delivery to and/or use by exercising skeletal muscle. To date, pharmacotherapy has not been shown to improve VO2peak, quality of life, and survival in patients with HFpEF. In contrast, exercise training is currently the only efficacious treatment strategy to improve VO2peak, aerobic endurance, and quality of life in patients with HFpEF. In this updated review, we discuss the specific central and peripheral mechanisms that are responsible for the impaired exercise responses as well as the role of exercise training to improve VO2peak in clinically stable patients with HFpEF. We also discuss the central and peripheral adaptations that contribute to the exercise training-mediated improvement in VO2peak in HFpEF. Finally, we provide clinical exercise physiologists with evidence-based exercise prescription guidelines to assist with the safe implementation of exercise-based cardiac rehabilitation programs in clinically stable patients with HFpEF.

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Haemodynamics, dyspnoea, and pulmonary reserve in heart failure with preserved ejection fraction

European Heart Journal ◽

10.1093/eurheartj/ehy268 ◽

2018 ◽

Vol 39 (30) ◽

pp. 2810-2821 ◽

Cited By ~ 59

Author(s):

Masaru Obokata ◽

Thomas P Olson ◽

Yogesh N V Reddy ◽

Vojtech Melenovsky ◽

Garvan C Kane ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Pulmonary Ventilation ◽

Left Ventricular ◽

Functional Class ◽

Gas Analysis ◽

Peak Exercise ◽

Preserved Ejection Fraction ◽

Ventilatory Drive ◽

Pulmonary Abnormalities

Abstract Aims Increases in left ventricular filling pressure are a fundamental haemodynamic abnormality in heart failure with preserved ejection fraction (HFpEF). However, very little is known regarding how elevated filling pressures cause pulmonary abnormalities or symptoms of dyspnoea. We sought to determine the relationships between simultaneously measured central haemodynamics, symptoms, and lung ventilatory and gas exchange abnormalities during exercise in HFpEF. Methods and results Subjects with invasively-proven HFpEF (n = 50) and non-cardiac causes of dyspnoea (controls, n = 24) underwent cardiac catheterization at rest and during exercise with simultaneous expired gas analysis. During submaximal (20 W) exercise, subjects with HFpEF displayed higher pulmonary capillary wedge pressures (PCWP) and pulmonary artery pressures, higher Borg perceived dyspnoea scores, and increased ventilatory drive and respiratory rate. At peak exercise, ventilation reserve was reduced in HFpEF compared with controls, with greater dead space ventilation (higher VD/VT). Increasing exercise PCWP was directly correlated with higher perceived dyspnoea scores, lower peak exercise capacity, greater ventilatory drive, worse New York Heart Association (NYHA) functional class, and impaired pulmonary ventilation reserve. Conclusion This study provides the first evidence linking altered exercise haemodynamics to pulmonary abnormalities and symptoms of dyspnoea in patients with HFpEF. Further study is required to identify the mechanisms by which haemodynamic derangements affect lung function and symptoms and to test novel therapies targeting exercise haemodynamics in HFpEF.

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Left Ventricular Diastolic Dysfunction and Exercise Intolerance in Obese Heart Failure with Preserved Ejection Fraction

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00610.2020 ◽

2021 ◽

Author(s):

T. Jake Samuel ◽

Dalane W. Kitzman ◽

Mark J. Haykowsky ◽

Bharathi Upadhya ◽

Peter Brubaker ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Strain Rate ◽

Left Ventricular ◽

Exercise Intolerance ◽

Peak Exercise ◽

Strain Rates ◽

Preserved Ejection Fraction ◽

Diastolic Strain Rate ◽

Strain And Strain Rate

This study tested the hypothesis that early left ventricular (LV) relaxation is impaired in older obese heart failure with preserved ejection fraction (HFpEF) patients, and related to decreased peak exercise oxygen uptake (peak VO2). LV strain and strain rate were measured by feature tracking of magentic resonance cine images in 79 older obese HFpEF patients (mean age: 66 years; mean BMI: 38 kg/m2) and 54 healthy control participants. LV diastolic strain rates were indexed to cardiac preload as estimated by echocardiography derived diastolic filling pressures (E/e'), and correlated to peak VO2. LV circumferential early diastolic strain rate was impaired in HFpEF compared to controls (0.93±0.05 s-1 vs 1.20±0.07 s-1, p=0.014); however, we observed no group differences in early LV radial or longitudinal diastolic strain rates. Isolating myocardial relaxation by indexing all three early LV diastolic strain rates (i.e. circumferential, radial, and longitudinal) to E/e' amplified the group difference in early LV diastolic circumferential strain rate (0.08±0.03 vs 0.13±0.05, p<0.0001), and unmasked differences in early radial and longitudinal diastolic strain rate. Moreover, when indexing to E/e', early LV diastolic strain rates from all three principal strains, were modestly related with peak VO2 (R=0.36, -0.27, 0.35, respectively, all p<0.01); this response, however, was almost entirely driven by E/e' itself, (R=-0.52, P<0.001). Taken together, we found that while LV relaxation is impaired in older obese HFpEF patients, and modestly correlates with their severely reduced peak exercise VO2, LV filling pressures appear to play a much more important role in determining exercise intolerance.

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