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Exercise hemodynamics in heart failure patients with preserved and mid-range ejection fraction: key role of the right heart

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Abstract

Objective

We sought to explore whether classification of patients with heart failure and mid-range (HFmrEF) or preserved ejection fraction (HFpEF) according to their left ventricular ejection fraction (LVEF) identifies differences in their exercise hemodynamic profile, and whether classification according to an index of right ventricular (RV) function improves differentiation.

Background

Patients with HFmrEF and HFpEF have hemodynamic compromise on exertion. The classification according to LVEF implies a key role of the left ventricle. However, RV involvement in exercise limitation is increasingly recognized. The tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/PASP) ratio is an index of RV and pulmonary vascular function. Whether exercise hemodynamics differ more between HFmrEF and HFpEF than between TAPSE/PASP tertiles is unknown.

Methods

We analyzed 166 patients with HFpEF (LVEF ≥ 50%) or HFmrEF (LVEF 40–49%) who underwent basic diagnostics (laboratory testing, echocardiography at rest, and cardiopulmonary exercise testing [CPET]) and exercise with right heart catheterization. Hemodynamics were compared according to echocardiographic left ventricular or RV function.

Results

Exercise hemodynamics (e.g. pulmonary arterial wedge pressure/cardiac output [CO] slope, CO increase during exercise, and maximum total pulmonary resistance) showed no difference between HFpEF and HFmrEF, but significantly differed across TAPSE/PASP tertiles and were associated with CPET results. N-terminal pro-brain natriuretic peptide concentration also differed significantly across TAPSE/PASP tertiles but not between HFpEF and HFmrEF.

Conclusion

In patients with HFpEF or HFmrEF, TAPSE/PASP emerged as a more appropriate stratification parameter than LVEF to predict clinically relevant impairment of exercise hemodynamics.

Graphic abstract

Stratification of exercise hemodynamics in patients with HFpEF or HFmrEF according to LVEF or TAPSE/PASP, showing significant distinctions only with the RV-based strategy. All data are shown as median [upper limit of interquartile range] and were calculated using the independent-samples Mann–Whitney U test or Kruskal–Wallis test. PVR pulmonary vascular resistance; max maximum level during exercise.

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Acknowledgements

Funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)—Project Number 268555672–SFB 1213, Project B08. We thank Claire Mulligan, Ph.D. (Beacon Medical Communications Ltd, Brighton, UK), for editorial support funded by the University of Giessen.

Funding

Funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)—Project Number 268555672–SFB 1213, Project B08.

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Author notes

  1. Andreas J. Rieth and Manuel J. Richter have contributed equally to this work.

Authors and Affiliations

  1. Department of Cardiology, Kerckhoff-Klinik GmbH, Benekestr 2-8, 61231, Bad Nauheim, Germany

    Andreas J. Rieth, Steffen D. Kriechbaum, Veselin Mitrovic & Christian W. Hamm

  2. Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany

    Manuel J. Richter & Hossein A. Ghofrani

  3. Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany

    Manuel J. Richter, Khodr Tello, Henning Gall, Hossein A. Ghofrani & Werner Seeger

  4. Department of Medicine, Imperial College London, London, UK

    Hossein A. Ghofrani

  5. Department of Thoracic Surgery, Kerckhoff-Klinik, Bad Nauheim, Germany

    Stefan Guth & Christoph B. Wiedenroth

  6. Department of Cardiology, University Hospital Jena, Jena, Germany

    P. Christian Schulze

  7. Department of Cardiology, Justus Liebig University Giessen, Universities of Giessen and Marburg, Giessen, Germany

    Christian W. Hamm

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  1. Andreas J. Rieth
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Contributions

Each author has contributed significantly to this work: AJR, MJR, KT: conception and design, analysis and interpretation of data; drafting of the manuscript; final approval of the manuscript submitted. HG, HAG, SG, CBW, WS, SDK, VM, PCS, CWH: analysis and interpretation of data; revising the manuscript critically for important intellectual content; final approval of the manuscript submitted.

Corresponding author

Correspondence to Andreas J. Rieth.

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Conflict of interest

All authors report that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Ethical approval

The investigation conforms with the principles outlined in the Declaration of Helsinki. All patients enrolled into the registries gave written informed consent, and data collection and analyses were approved by the ethics committee of the Faculty of Medicine at the University of Giessen (Approval No. 186/16, 266/11, 117/16).

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All patients enrolled into the registries gave written informed consent.

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All patients enrolled into the registries gave written informed consent.

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Rieth, A.J., Richter, M.J., Tello, K. et al. Exercise hemodynamics in heart failure patients with preserved and mid-range ejection fraction: key role of the right heart. Clin Res Cardiol 111, 393–405 (2022). https://doi.org/10.1007/s00392-021-01884-1

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