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Investigate RV loading conditions in HFpEF and their effect on afterload and contractility during exercise.

November 10, 2025ESC Heart Failure0 citationsOpen Access

Exercise‐induced out‐of‐proportion increase in afterload and impaired right ventricular contractile reserve in HFpEF

JWJan Sebastian Wolter ASAlexander Schulz TLTorben Lange

Key Points

Investigate RV loading conditions in HFpEF and their effect on afterload and contractility during exercise.
Patients with exertional dyspnoea and diastolic dysfunction underwent rest and exercise-stress echocardiography.
Right heart catheterization and cardiovascular magnetic resonance (CMR) were performed to assess RV haemodynamics.
HFpEF was diagnosed based on pulmonary capillary wedge pressure measurements.
HFpEF patients displayed higher afterload and contractility values at rest and during exercise compared to non-cardiac dyspnoea individuals.
A smaller increase in contractility from rest to exertion was noted in overt HFpEF patients.
Elevated resting afterload led to inadequate increases in cardiac index in HFpEF patients, potentially affecting functional capacity.

Abstract

Abstract Aims The pathophysiology of heart failure with preserved ejection fraction (HFpEF) includes pulmonary vascular remodelling and right ventricular (RV) involvement. We sought to investigate the significance of non‐invasive cardiovascular magnetic resonance (CMR)‐derived RV loading conditions. Methods Patients with exertional dyspnoea and diastolic dysfunction E/e′ > 8, left ventricular ejection fraction (LVEF) >50% underwent rest and exercise‐stress echocardiography, right heart catheterization and CMR. HFpEF was defined by pulmonary capillary wedge pressure rest ≥15 mmHg (overt) or stress ≥25 mmHg (masked); otherwise, patients were classified as non‐cardiac dyspnoea (NCD). CMR‐derived RV haemodynamic indices were defined as follows: afterload Ea = end‐systolic pressure (ESP)/stroke volume (SV), contractility Ees = ESP/left ventricular end‐systolic volume and RV/pulmonary artery coupling as Ea/Ees. Results HFpEF ( n = 34; female 73.5%; median age 69 years) patients showed increased afterload and contractility at rest (Ea 1.20 vs. 0.85, P = 0.001, Ees 0.61 vs. 0.37, P < 0.001) and during exercise (Ea 2.48 vs. 1.53, Ees 1.00 vs. 0.74, P < 0.001) compared with NCD ( n = 34; female 55.9%; median age 66 years). The relative increase of contractility from rest to stress was smallest in overt HFpEF (overt 1.40 vs. masked 1.86, P = 0.001) and highest in NCD (HFpEF 1.56 vs. NCD 1.97, P = 0.022). The out‐of‐proportion increase in afterload over contractility in HFpEF was reflected in a statistical trend towards increased Ea/Ees from rest to stress in HFpEF ( P = 0.078) while Ea/Ees decreased in NCD ( P = 0.002). Patients with resting Ea or Ees above the median showed lower exercise‐induced increases in cardiac index (Ea: below: 2.8 vs. above: 2.2, P = 0.031; Ees: below: 2.9, above: 2.1, P < 0.001). Conclusions Resting RV afterload elevation in HFpEF results in a compensatory increase in contractility. Out‐of‐proportion increase of afterload paralleled by inadequate increase in contractility results in failure to increase the cardiac index in HFpEF, potentially associated with exertional functional failure.

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