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      The Role of Diastolic Stress Testing in the Evaluation for HFpEF: A Simultaneous Invasive-Echocardiographic Study

      research-article
      , MD, PhD, , MD, PhD, , MD, , PhD, , MD, PhD, , MD
      Circulation
      diagnosis, diastolic stress test, exercise, heart failure

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          Abstract

          Background

          Diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) is challenging and relies largely on demonstration of elevated cardiac filling pressures (pulmonary capillary wedge pressure, PCWP). Current guidelines recommend use of natriuretic peptides (NT-proBNP) and rest/exercise echocardiography (E/e’ ratio) to make this determination. Data to support this practice is conflicting.

          Methods

          Simultaneous echocardiographic-catheterization studies were prospectively conducted at rest and during exercise in subjects with invasively-proven HFpEF (n=50) and participants with dyspnea but no identifiable cardiac pathology (n=24).

          Results

          NT-proBNP levels were below the level considered to exclude disease (≤125 pg/ml) in 18% of subjects with HFpEF. E/e’ ratio was correlated with directly measured PCWP at rest (r=0.63, p<0.0001) and during exercise (r=0.57, p<0.0001). While specific, current guidelines were poorly sensitive, identifying only 34–60% of subjects with invasively-proven HFpEF based upon resting echocardiographic data alone. Addition of exercise echocardiographic data (E/e’ ratio>14) improved sensitivity (to 90%) and thus negative predictive value, but decreased specificity (71%).

          Conclusions

          Currently proposed HFpEF diagnostic guidelines based upon resting data are poorly sensitive. Adding exercise E/e’ data improves sensitivity and negative predictive value but compromises specificity, suggesting that exercise echocardiography may help rule out HFpEF. These results question the accuracy of current approaches to exclude HFpEF based upon resting data alone and reinforce the value of exercise testing using invasive and noninvasive hemodynamic assessments to definitively confirm or refute the diagnosis of HFpEF.

          Clinical trial registration NCT01418248 https://clinicaltrials.gov/ct2/results?term=NCT01418248&Search=Search

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          Author and article information

          Journal
          0147763
          2979
          Circulation
          Circulation
          Circulation
          0009-7322
          1524-4539
          5 January 2017
          30 December 2016
          28 February 2017
          28 February 2018
          : 135
          : 9
          : 825-838
          Affiliations
          The Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN 55906
          Author notes
          Address for correspondence: Barry A. Borlaug, MD, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, Phone: 507-284-4442, Fax: 507-266-0228, borlaug.barry@ 123456mayo.edu
          Article
          PMC5330848 PMC5330848 5330848 nihpa840194
          10.1161/CIRCULATIONAHA.116.024822
          5330848
          28039229
          4209f7ec-9770-4250-949c-c0630532c7dc
          History
          Categories
          Article

          heart failure,diagnosis,diastolic stress test,exercise
          heart failure, diagnosis, diastolic stress test, exercise

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