Comprehensive diastolic exercise stress echocardiography in heart failure with preserved ejection fraction

Background In heart failure with preserved ejection fraction (HFpEF), diastolic exercise stress echocardiography (ESE) is currently recommended with E/e' and systolic pulmonary artery pressure (SPAP) from tricuspid regurgitant jet velocity (TRV). Purpose To evaluate conventional and advanced ESE parameters in patients with HFpEF. Methods We prospectively screened 124 patients with suspected HFpEF (dyspnea, resting EF >50%, increased natriuretic peptide levels) and HFA-PEFF score ≥1. Of these 124, 10 patients were excluded for history of coronary artery disease, 3 for severe mitral regurgitation (MR), 12 for inducible ischemia. The final study population consisted of 99 patients (mean age 63±7 yrs, 57 females). All underwent ESE, with semi-supine bike (n=35), upright bike (n=20) or treadmill (n=44 patients) in 11 accredited labs from 9 countries (Argentina, Brazil, Bulgaria, Hungary, Italy, Lithuania, Mexico, Russia and Spain). In addition to E/e' average (abnormal stress response ≥15 units) and TRV (abnormal stress response >3.4 m/s), we measured 8 additional criteria: B-lines (4-site simplified scan, abnormal stress value ≥2); cardiac index (CI) reserve (increase from rest to stress, abnormal 6.8 ml/m2); MR (abnormal, stress value more than mild). Results Technical success rate during stress ranged from 100% for B-lines to 75% for GLS: see Table. At individual criteria analysis, positivity rate in interpretable studies ranged from 67% of HRR to 10% of peak MR: see table. At individual patient analysis, an abnormal response in 1 ESE criterion occurred in 4 pts (4%), of 2 to 4 criteria in 71 pts (72%) and of ≥5 criteria in 24 (24%). Conclusion In suspected HFpEF, ESE is helpful in the screening phase to identify extra-diastolic causes of dyspnea such as myocardial ischemia or severe MR. In the diagnostic phase, a comprehensive ESE captures the functional heterogeneity of HFpEF, with variable association of multiple phenotypes, the most frequent represented by reduced chronotropic, cardiac or contractile reserve and pulmonary congestion. Funding Acknowledgement Type of funding sources: None.