The Fallacy of Resting Echocardiographic Parameters of Cardiac Function in Heart Failure with Preserved Ejection Fraction

We read with interest the editorial comment by Dragos Vinereanu and Andrei Margulescu entitled ‘The fallacy of resting echocardiographic parameters of cardiac function in heart failure with preserved ejection fraction: add global longitudinal strain to the list’.1 Referring to previous work on global longitudinal strain (GLS), they conclude that despite encouraging early studies GLS falls in the same category of other resting echocardiographic indices, being normal in approximately one-third of patients with heart failure and preserved ejection fraction (HFpEF). Although it is now well-established from multiple studies that systolic function, especially longitudinal function, is not normal in the majority of patients with HFpEF, it is apparent that resting measurements do not reflect the severity of ventricular and atrial dysfunction which can occur on exercise. In our studies, we found that exercise in HFpEF revealed marked abnormalities of ventricular function affecting long-axis motion, rotation, untwisting, early mitral recoil and suction.2, 3 Indeed patients with hypertension and completely normal resting echocardiograms developed quite marked abnormalities of ventricular function on exercise.4 However, strain is difficult to measure on exercise and can only be measured reliably at low levels of exercise and moderate increases in heart rate despite dedicated interpolation software.2, 4 Standard tissue Doppler measurements such as s' and e' are more reliable. But another even simpler and overlooked measurement is the mitral annular plane systolic excursion (MAPSE) by M-mode, which is much easier to measure on exercise, and which fails to rise normally in HFpEF patients on mild exercise.2, 3 Perhaps, owing to its simplicity and a relative old age, it has been overlooked but we found that a reduced increase in MAPSE on exercise compared to normals was a remarkably robust and accurate method for diagnosing HFpEF.5 MAPSE is interesting, because of the helical structure of the heart fibres the motion of the mitral annulus is effectively integrating longitudinal, oblique, and radial motions. Larger scale studies using MAPSE with exercise echocardiography would be of value?