Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Suspected heart failure with normal LVEF (n=85). Intervention: Passive leg-lifting (PLL) vs. Normal NT-proBNP (nBNP) patients. Primary outcome: Pulmonary capillary wedge pressure (PCWP) during passive leg-lifting (median mmHg) (p=<0.001).

Erik Tossavainen; Gerhard Wikström; M. Henein; M. Lundqvist; Urban Wiklund; Per Lindqvist

doi:10.1007/s00392-019-01531-w

July 31, 2019Clinical Research in CardiologyOpen Access

Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures

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Key result

In patients with suspected heart failure and elevated NT-proBNP, a pulmonary capillary wedge pressure > 15 mmHg during passive leg-lifting predicted an exercise-induced rise > 25 mmHg with 91% sensitivity and 92% specificity.

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Why the study?

The study aimed to assess PCWP with passive leg-lifting and exercise in patients with normal LVEF and either elevated or normal NT-proBNP plasma concentrations.

Does passive leg-lifting predict exercise-induced rise in left ventricular filling pressures in patients with suspected heart failure and normal LVEF?

Study Design

Type

Observational (n=85)

Multicenter

No

Structured PICO

Does passive leg-lifting predict exercise-induced rise in left ventricular filling pressures in patients with suspected heart failure and normal LVEF?

P

Population

85 patients with suspected heart failure and normal LVEF (>50%), comprising 51 patients with elevated NT-proBNP (≥125 ng/l) and 34 patients with normal NT-proBNP (<125 ng/l). Excluded: advanced valvular disease, heart transplantation, LVEF <50%, and PAH criteria.

I

Intervention

Right heart catheterization (RHC) with passive leg-lifting (PLL) for up to 3 minutes, followed by 6-minute steady state supine bicycle exercise (20-70 Watts).

C

Comparator

Patients with normal NT-proBNP (<125 ng/l) undergoing the same RHC, PLL, and exercise protocol.

O

Outcome

Prediction of exercise-induced elevated pulmonary capillary wedge pressure (PCWP > 25 mmHg) using PCWP during passive leg-lifting (PCWP > 15 mmHg).surrogate

Main Result

Absolute Event Rate: 15% vs 10.5%

p-value: p=<0.001

Passive leg-lifting during right heart catheterization accurately predicts exercise-induced elevations in left ventricular filling pressures in patients with suspected heart failure and preserved ejection fraction.

Limitations

Retrospective, non-randomised, single-center study
Differences in baseline medications and age between the eBNP and nBNP groups
Lack of detailed echocardiographic results prior to right heart catheterization
Patients only performed submaximal exercise
Both patient groups were taking medications, more commonly in the eBNP group
nBNP patients were younger than eBNP patients
nBNP group cannot be considered a healthy population
Cutoff values for abnormality can be argued

Implication

Supports passive leg-lifting to predict exercise PCWP rise during catheterization; hypothesis-generating for HFpEF evaluation pending validation.

Abstract

AIM: The aim of this study was to assess PCWP with passive leg-lifting (PLL) and exercise, in two groups of patients presenting with normal left ventricular ejection fraction (LVEF); one group with elevated NT-proBNP (eBNP), and one with normal NT-proBNP (nBNP) plasma concentration. METHODS AND RESULTS: Fifty-one patients with eBNP (NT-proBNP ≥ 125 ng/l) and LVEF > 50%, were investigated and compared with 34 patients with nBNP (NT-proBNP < 125 ng/l) and LVEF > 50%. Both groups underwent right heart catheterization (RHC) at rest, PLL and exercise. From RHC, mean pulmonary arterial pressure (mPAP), cardiac output (CO), and PCWP were measured. All nBNP patients had PCWP < 15 mmHg at rest, and a PCWP of < 25 mmHg with PLL and during exercise. Patients with eBNP had higher (p < 0.01) resting mPAP, PCWP, and mPAP/CO. These values increased with exercise; however, CO increased less in comparison with nBNP patients (p = 0.001). 20% of patients with eBNP had a PCWP > 15 mmHg at rest, this percentage increased to 47% with PLL and 41% had a PCWP > 25 mmHg during exercise. Of those with PCWP > 25 mmHg during exercise, 91% had a PCWP > 15 mmHg with PLL. A PCWP > 15 mmHg on PLL had a 91% sensitivity and 92% specificity in predicting exercise-induced PCWP of > 25 mmHg. CONCLUSION: In patients presenting with eBNP, PLL can predict which patients will develop elevated PCWP with exercise. These findings highlight the role of stress assessment.

Discussion

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Cite This Study

Tossavainen et al. (2019) conducted an observational in Suspected heart failure with normal LVEF (n=85). Passive leg-lifting (PLL) vs. Normal NT-proBNP (nBNP) patients was evaluated on Pulmonary capillary wedge pressure (PCWP) during passive leg-lifting (median mmHg) (p=<0.001). In patients with suspected heart failure and elevated NT-proBNP, a pulmonary capillary wedge pressure > 15 mmHg during passive leg-lifting predicted an exercise-induced rise > 25 mmHg with 91% sensitivity and 92% specificity.

synapsesocial.com/papers/6a166a4a497e763bc37c085d https://doi.org/10.1007/s00392-019-01531-w

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Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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