Natriuretic peptide responses to exercise in HFpEF diagnosis: a pilot study

Figures

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  Figure 1. Graphical abstract. We hypothesised that exercise-induced ‘overshoot’ in left ventricular filling pressures in those with HFpEF would result in a more than average increase in myocardial wall stress with exercise, leading to a substantial elevation of natriuretic peptide plasma levels. This steep rise in comparison to stage B heart failure patients would then provide discriminatory value beyond rest NT-proBNP values for diagnosing HFpEF. HFpEF, heart failure with preserved ejection fraction; NT-proBNP, N-terminal pro-brain natriuretic peptide.

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  Figure 2. HFA-PEFF diagnostic algorithm The HFA-PEFF algorithm is a method to establish HFpEF diagnosis in patients suspected of HFpEF. The score is based on a combination of rest echocardiography functional and morphological criteria (0, 1 or 2 points per category), and a natriuretic peptide-based biomarker score (0, 1 or 2 points depending on the level). A total score ≥5 is diagnostic for HFpEF. If the findings are inconclusive (2–4 points), and then exercise testing is recommended. HFpEF, heart failure with preserved ejection fraction; LAVI, left atrial volume indexed to body surface area; LV, left ventricular; NT-proBNP, N-terminal pro-brain natriuretic peptide; TR, tricuspid regurgitation.

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  Figure 3. Area under the curve for rest NT-proBNP, post-exercise NT-proBNP and delta (∆) NT-proBNP Area under the curve of continuous values of Δ NT-proBNP (red curve), NT-proBNP at rest (green curve) and NT-proBNP after exercise (pg/mL) (blue curve). AUC, area under the curve; aHFpEF, heart failure with preserved ejection fraction; NT-proBNP, N-terminal pro-brain natriuretic peptide.

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  Figure 4. Correlation between Δ NT-proBNP and NT-proBNP after exercise with peak exercise echocardiography measurements indicative of increased filling pressures Association of (A) after exercise NT-proBNP and peak E/e’ ratio, (B) after exercise NT-proBNP and peak TR velocity, (C) delta in NT-proBNP and peak E/e’ ratio and (D) delta in NT-proBNP and peak TR velocity. No significant associations were observed. NT-proBNP, N-terminal pro-brain natriuretic peptide; TR, tricuspid regurgitation.