Key result
Handgrip exercise elevates LVEDP similarly in patients with normal coronaries regardless of resting diastolic dysfunction.
Why the study?
Patients with unexplained exertional symptoms may lack heart failure symptoms or diastolic dysfunction at rest, prompting invasive assessment of left ventricular filling pressures during exercise.
Does a 3-minute manual handgrip exercise unmask elevated left ventricular end diastolic pressures in symptomatic patients with normal coronaries and normal resting echocardiographic diastolic function?
Observational (n=30)
No
Does a 3-minute manual handgrip exercise unmask elevated left ventricular end diastolic pressures in symptomatic patients with normal coronaries and normal resting echocardiographic diastolic function?
Absolute Event Rate: 4.222% vs 3.556%
p-value: p=0.432
Manual handgrip exercise during cardiac catheterization can unmask elevated left ventricular filling pressures in symptomatic patients with normal coronaries and normal resting echocardiograms, aiding in the diagnosis of diastolic dysfunction.
Handgrip exercise may unmask elevated LVEDP despite normal resting diastolic function; hypothesis-generating and should not yet change practice.
Background Diastolic dysfunction is the cause in nearly half of cases of heart failure, the hemodynamic equivalent of which is elevated cardiac filling pressures. However, owing to its ubiquity, it is often diagnosed as an incidental finding, but an association with symptoms is not established in many of the patients. Most patients with hypertension or left ventricular (LV) hypertrophy have evidence of impaired diastolic function as a finding on Doppler echocardiography, but do not have any symptoms of heart failure at rest. However, these patients do have symptoms related to diastolic dysfunction only during exercise. In this study, we have contemplated to assess invasively, left ventricular filling pressures in patients with unexplained shortness of breath with normal systolic and diastolic function on echocardiography, on exercise and compare the level of rise in patients with established diastolic dysfunction. Methods This is an observational prospective study, done over a span of 3 months, wherein patients with typical symptoms such as chest pain and shortness of breath, after ruling out systemic causes, and were subjected to coronary angiogram. If no coronary lesion identified, patients were subjected to invasive cardiac catheterization during coronary angiogram. Patients were divided into two groups, one without diastolic dysfunction and the other with established diastolic dysfunction. Simultaneous left ventricular end diastolic pressures (LVEDP) were measured at rest and after 3-minute manual handgrip exercise and readings were noted. Results The mean age of the population ( n = 30) was 55.8 ± 7.538 and 20 were males. The mean value of LVEDP in patients with no diastolic dysfunction at resting was 4.4 ± 3.169 and after exercise was 8.40 ± 4.169. The mean value of LVEDP in patients with established diastolic dysfunction at resting was 5.30 ± 3.948 and after exercise was 8.75 ± 4.506. Paired t -test among two groups revealed a significant p -value of 0.001 after exercise among both groups, suggesting a significant increase in LVEDP in patients with exercise. Unpaired t -test comparing both groups revealed that the elevation of LVEDP in no diastolic dysfunction group was comparable with patients with diastolic dysfunction ( p = 0.432). Conclusion The increase in LVEDP with exercise is a well-established fact in patients with diastolic dysfunction. Our study adds to the fact that patients with unexplained shortness of breath can have raised LVEDP after exercise, thereby unmasking the underlying diastolic dysfunction. Our study stresses the importance of inclusion of exercise as a provocative test for the assessment of diastolic function, either invasively or non-invasively, in patients presenting with exertional dyspnea.
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Reddy et al. (2022) conducted an observational in Unexplained shortness of breath with normal coronaries or mild coronary artery disease (n=30). Manual handgrip exercise vs. Patients with established diastolic dysfunction was evaluated on Elevation of left ventricular end diastolic pressure (LVEDP) after exercise (p=0.432). Manual handgrip exercise significantly increased LVEDP in symptomatic patients with normal coronaries, and the elevation in patients without resting diastolic dysfunction was comparable to those with established diastolic dysfunction (p=0.432).
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