Why the study?
It was hypothesized that PAWP increases would differ across diastolic stress tests and that the diagnostic margin of PAWP ≥25 mmHg would only be reliably achieved through ergometry.
Do different diastolic stress test modalities yield different increases in pulmonary capillary wedge pressure in patients with intermediate risk for HFpEF?
RCT (n=19)
Randomized order
Do different diastolic stress test modalities yield different increases in pulmonary capillary wedge pressure in patients with intermediate risk for HFpEF?
Bicycle ergometry produces a distinct and significantly higher increase in PAWP compared to passive leg raise, fluid challenge, and handgrip, confirming its necessity for reliable detection of occult HFpEF.
May inform diastolic stress test selection in suspected HFpEF; hypothesis-generating and requires prospective validation before practice change.
AIMS: Pulmonary capillary wedge pressure (PAWP) ≥25 mmHg during bicycle ergometry is recommended to uncover occult heart failure with preserved ejection fraction. We hypothesized that PAWP increase would differ in available diastolic stress tests and that the margin of PAWP ≥25 mmHg would only be reliably achieved through ergometry. METHODS AND RESULTS: We conducted a prospective, single-arm study in patients with an intermediate risk for heart failure with preserved ejection fraction according to the ESC HFA-PEFF score. A total of 19 patients underwent four stress test modalities in randomized order: leg raise, fluid challenge, handgrip, and bicycle ergometry. The primary outcome was the difference (Δ) between resting and exercise PAWP in each modality. Secondary outcomes were differences (Δ) in mean pulmonary artery pressure (mPAP), cardiac output (CO), as well as the ratios between mPAP and PAWP to CO. Compared to resting values, passive leg raise (Δ7.7 ± 8.0 mmHg, p = 0.030), fluid challenge (Δ9.2 ± 6.4 mmHg, p = 0.003), dynamic handgrip (Δ9.6 ± 7.5 mmHg, p = 0.002), and bicycle ergometry (Δ22.3 ± 5.0 mmHg, p < 0.001) uncovered increased PAWP during exercise. Amongst these, bicycle ergometry also demonstrated the highest ΔmPAP (27.2 ± 7.1 mmHg, p < 0.001), ΔCO (3.3 ± 2.6 L/min, p < 0.001), ΔmPAP/CO ratio (2.3 ± 2.0 mmHg/L/min, p < 0.001), and ΔPAWP/CO ratio (2.2 ± 1.4 mmHg/L/min, p < 0.001) compared to other modalities. PAWP ≥25 mmHg was only reliably achieved in bicycle ergometry (31.1 ± 3.9 mmHg). In all other modalities only 10.5% of patients achieved PAWP ≥25 mmHg (handgrip 18.4 ± 6.6 mmHg, fluid 18.1 ± 5.6 mmHg, leg raise 16.5 ± 7.0 mmHg). CONCLUSIONS: We demonstrate that bicycle ergometry exhibits a distinct haemodynamic response with higher increase of PAWP compared to other modalities. This finding needs to be considered for valid detection of exercise PAWP ≥25 mmHg when non-bicycle tests remain inconclusive.
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Wernhart et al. (2023) conducted an RCT in Intermediate risk for heart failure with preserved ejection fraction (n=19). Bicycle ergometry vs. Passive leg raise, fluid challenge, and dynamic handgrip was evaluated on Difference (Δ) between resting and exercise pulmonary capillary wedge pressure (PAWP) in each modality (Δ22.3 mmHg, p=<0.001).
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