Highlights
- •This study showed the incremental prognostic value of CPET for HFA-PEFF in patients with unexplained dyspnea with preserved EF.
- •Even the HFA-PEFF ≥5 group, which should be diagnosed as HFpEF, had considerable proportions of normal and indeterminate diastolic function in this study.
- •Moreover, CPET parameters, such as peak VO2 and VE/CO2, were significantly different between groups. Patients with unexplained dyspnea should be approached with a comprehensive diagnostic evaluation including HFA-PEFF score and CPET as well as diastolic function grading.
Abstract
Background
HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic
tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate
the incremental prognostic value of CPET for the HFA-PEFF score among patients with
unexplained dyspnea with preserved ejection fraction (EF).
Methods
Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET
and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography
in the left ventricle, left atrium and right ventricle. The primary outcome was defined
as a composite cardiovascular event including cardiovascular-related mortality, acute
recurrent heart failure hospitalization, urgent repeat revascularization/myocardial
infarction or any hospitalization due to cardiovascular events.
Results
The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study
population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2–4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO2 slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure
were independently associated with composite cardiovascular events. Furthermore, the
addition of VE/VCO2 and HFA-PEFF to the base model showed incremental prognostic value for predicting
composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement
0.129, p = 0.032; net reclassification improvement 1.043, p ≤ 0.001).
Conclusions
CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic
value and diagnosis among patients with unexplained dyspnea with preserved EF.
Keywords
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References
- Epidemiology of left ventricular systolic dysfunction and heart failure in the Framingham study: an echocardiographic study over 3 decades.JACC Cardiovasc. Imaging. 2018; 11: 1-11https://doi.org/10.1016/j.jcmg.2017.08.007
- Persistent high burden of heart failure across the ejection fraction Spectrum in a Nationwide setting.J. Am. Heart Assoc. 2022; 11e026708https://doi.org/10.1161/jaha.122.026708
- Heart failure with preserved ejection fraction: insights into diagnosis and pathophysiology.Cardiovasc. Res. 2021; 117: 999-1014https://doi.org/10.1093/cvr/cvaa228
- ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)developed with the special contribution of the heart failure association (HFA) of the ESC.Eur. Heart J. 2016; 37: 2129-2200https://doi.org/10.1093/eurheartj/ehw128
- Evidence-based approach to help guide diagnosis of heart failure with preserved ejection fraction.Circulation. 2018; 138: 861-870https://doi.org/10.1161/circulationaha.118.034646
- How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the heart failure association (HFA) of the European Society of Cardiology (ESC).Eur. Heart J. 2019; 40: 3297-3317https://doi.org/10.1093/eurheartj/ehz641
- Epidemiological and clinical boundaries of heart failure with preserved ejection fraction.Eur. J. Prev. Cardiol. 2022; 29: 1233-1243https://doi.org/10.1093/eurjpc/zwab077
- The H(2)FPEF and HFA-PEFF algorithms for predicting exercise intolerance and abnormal hemodynamics in heart failure with preserved ejection fraction.Sci. Rep. 2022; 12: 13https://doi.org/10.1038/s41598-021-03974-6
- Predictive value of HFA-PEFF score in patients with heart failure with preserved ejection fraction.Front. Cardiovasc. Med. 2021; 8656536https://doi.org/10.3389/fcvm.2021.656536
- Prognostic significance of the HFA-PEFF score in patients with heart failure with preserved ejection fraction.ESC Heart Fail. 2021; 8: 2154-2164https://doi.org/10.1002/ehf2.13302
- Hemodynamic correlates and diagnostic role of cardiopulmonary exercise testing in heart failure with preserved ejection fraction.JACC Heart Fail. 2018; 6: 665-675https://doi.org/10.1016/j.jchf.2018.03.003
- Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J. Am. Soc. Echocardiogr. 2015; 28: 1-39.e14https://doi.org/10.1016/j.echo.2014.10.003
- EACPR/AHA scientific statement. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations.Circulation. 2012; 126: 2261-2274https://doi.org/10.1161/CIR.0b013e31826fb946
- Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation.Stat. Med. 2004; 23: 2109-2123https://doi.org/10.1002/sim.1802
- Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers.Stat. Med. 2011; 30: 11-21https://doi.org/10.1002/sim.4085
- Advances in measuring the effect of individual predictors of cardiovascular risk: the role of reclassification measures.Ann. Intern. Med. 2009; 150: 795-802https://doi.org/10.7326/0003-4819-150-11-200906020-00007
- Ventilatory power: a novel index that enhances prognostic assessment of patients with heart failure.Circ. Heart Fail. 2012; 5: 621-626https://doi.org/10.1161/circheartfailure.112.968529
- Cardiopulmonary exercise testing with echocardiography to identify mechanisms of unexplained dyspnea.J. Cardiovasc. Transl. Res. 2022; 15: 116-130https://doi.org/10.1007/s12265-021-10142-8
- Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur. Heart J. Cardiovasc. Imaging. 2016; 17: 1321-1360https://doi.org/10.1093/ehjci/jew082
- Impact of the 2016 ASE/EACVI recommendations on the prevalence of diastolic dysfunction in the general population.Eur. Heart J. Cardiovasc. Imaging. 2018; 19: 380-386https://doi.org/10.1093/ehjci/jex252
- Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J. Am. Soc. Echocardiogr. 2016; 29: 277-314https://doi.org/10.1016/j.echo.2016.01.011
- Impaired ventilatory efficiency in chronic heart failure: possible role of pulmonary vasoconstriction.Am. Heart J. 1998; 136: 778-785https://doi.org/10.1016/s0002-8703(98)70121-8
- Cardiopulmonary exercise testing in the clinical and prognostic assessment of diastolic heart failure.J. Am. Coll. Cardiol. 2005; 46: 1883-1890https://doi.org/10.1016/j.jacc.2005.07.051
- Clinical and hemodynamic associations and prognostic implications of Ventilatory efficiency in patients with preserved left ventricular systolic function.Circ. Heart Fail. 2020; 13e006729https://doi.org/10.1161/circheartfailure.119.006729
- Usefulness of ventilatory inefficiency in predicting prognosis across the heart failure spectrum.ESC Heart Fail. 2022; 9: 293-302https://doi.org/10.1002/ehf2.13761
- Chemoreflex and Baroreflex sensitivity hold a strong prognostic value in chronic heart failure.JACC Heart Fail. 2022; 10: 662-676https://doi.org/10.1016/j.jchf.2022.02.006
- Exercise oscillatory breathing in heart failure with reduced ejection fraction: clinical implication, Eur.J. Prev. Cardiol. 2022; 29: 1692-1698https://doi.org/10.1093/eurjpc/zwac116
- Clinician’s guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association.Circulation. 2010; 122: 191-225https://doi.org/10.1161/CIR.0b013e3181e52e69
Article info
Publication history
Published online: May 23, 2023
Accepted:
May 21,
2023
Received in revised form:
May 10,
2023
Received:
January 10,
2023
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Elsevier B.V. All rights reserved.
