Role of peak septal systolic annular velocity in the evaluation of heart failure with preserved ejection fraction: a simultaneous invasive-echocardiographic study

Background Diagnosing heart failure with preserved ejection fraction (HFpEF) remains challenging in patients with unexplained exertional dyspnea. Current non-invasive diagnostic tools, including natriuretic peptides, HFpEF scores, and the diastolic stress test (DST), lack sensitivity. We investigated whether longitudinal systolic function assessed during exercise provides incremental diagnostic value beyond the diastolic stress test (DST). Methods Patients with unexplained dyspnea who underwent simultaneous semi-supine invasive cardiopulmonary exercise testing (iCPET) and exercise echocardiography between 2018 and 2024 were included in a prospective clinical cohort. The longitudinal systolic function was assessed using peak septal systolic annular velocity (exS′), measured by pulsed-wave Tissue Doppler Imaging, and mitral annular plane systolic excursion (MAPSE), measured using M-mode imaging. The relationship between these parameters and invasively obtained left-sided filling pressures was examined. The diagnostic value of longitudinal systolic function during stress was evaluated by receiver operating characteristic (ROC) curve analysis, with invasively confirmed HFpEF as the reference standard. Differences in the area under the curve (AUC) were assessed by DeLong’s test. Results Among 58 included patients, 40 (69%) fulfilled invasive criteria for HFpEF. ExS’ correlated with directly measured pulmonary capillary wedge pressure during exercise (r= - 0.58, P<0.001). An exS′ threshold of ≤11 cm/s demonstrated optimal diagnostic accuracy (AUC: 0.82, 95%CI: 0.70-0.93), with 75% sensitivity and 78% specificity for diagnosing HFpEF. Accuracy of MAPSE was significantly lower (AUC: 0.67, 95%CI: 0.52-0.82, p=0.017). Patients with reduced exS′ had higher PCWP, lower cardiac output, worse diastolic and longitudinal systolic function, and a more adverse clinical profile (Tables 1 and 2). ExS′ predicted an HFpEF diagnosis, independent of HFpEF probability resting scores (HFA-PEFF and H2FPEF), DST, and peak tricuspid regurgitation velocity (>3.4 m/s). The addition of exS′ (≤11 cm/s) improved sensitivity for the HFA-PEFF score (including DST) from 35.0% to 77.5%, and for the H2FPEF score from 12.5% to 77.5%, while also reducing the number of indeterminate cases. Conclusions The use of peak septal systolic annular velocity during exercise (exS′) in exercise echocardiography offers a novel, simple, and non-invasive approach for diagnosing HFpEF. Values below 11 cm/s indicate impaired cardiac output reserve and elevated filling pressures. Incorporating exS′ into current diagnostic algorithms significantly improves non-invasive diagnostic performance.