Performance and Interpretation of Invasive Hemodynamic Exercise Testing

doi:10.1016/j.chest.2020.05.552

Chest

Volume 158, Issue 5, November 2020, Pages 2119-2129

https://doi.org/10.1016/j.chest.2020.05.552 Get rights and content

Exertional dyspnea is a common complaint for patients seen in pulmonary, cardiac, and general medicine clinics, and elucidating the cause is often challenging, particularly when physical examination, echocardiography, radiography, and pulmonary function test results are inconclusive. Invasive cardiopulmonary exercise testing has emerged as the gold standard test to define causes of dyspnea and exertional limitation in this population. In this review, we describe the methods for performing and interpreting invasive cardiopulmonary exercise testing, with particular attention to the hemodynamic and blood sampling data as they apply to patients being evaluated for heart failure and pulmonary hypertension.

Section snippets

Indications for Invasive CPET

Invasive CPET has multiple advantages over noninvasive assessment and is considered the gold standard assessment for dyspnea and exertional limitation.1, 2, 3, 4, 5, 6 Current indications for invasive CPET include the evaluation of patients with dyspnea not clearly defined by noninvasive methods, including HF with preserved ejection fraction (HFpEF), resting or exercise-induced pulmonary hypertension (PH), and other causes of dyspnea, including valvular heart disease, intracardiac shunts,

Case

A 72-year-old woman presented for evaluation of dyspnea on exertion. She had a history of hypertension, diabetes, sleep apnea, and obesity. Over the past 2 years, her dyspnea progressed to the point that she could no longer walk more than one block on level ground without stopping because of dyspnea. Low-dose loop diuretics were initiated empirically, with no improvement in symptoms.

Examination revealed a mildly obese woman in no acute distress. BP was 142/78 mm Hg, with a heart rate of 72

Interpretation

Proper interpretation of results from invasive CPET requires careful and integrated evaluation of pressure waveforms, blood gas and lactate data, expired gas analyses, and assessment of cardiac output and AVO₂diff reserve (Table 2). Not all centers use the same exercise protocols, and methods for interpretation also may vary. Although it is feasible to perform CPET on supplemental oxygen in research settings, we require that patients exercise on room air if expired gas analysis will be

Conclusion

Invasive CPET combines the expired gas analysis capabilities of CPET with the definitive assessments of pressure, flow, and resistance from cardiac catheterization, providing the most robust evaluation of exertional intolerance available in clinical practice. This review summarizes the performance and proper interpretation of invasive CPET, which relies on careful integration of pressure waveforms, blood gas data, expired gas analysis, and assessments of oxygen transport. Given the

Acknowledgments

Financial/nonfinancial disclosures: None declared.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

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How to interpret a cardiorespiratory fitness assessment – Key measures that provide the best picture of health, disease status and prognosis
2024, Progress in Cardiovascular Diseases
Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.
Comprehensive diagnostic workup in patients with suspected heart failure and preserved ejection fraction
2024, Hellenic Journal of Cardiology
Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging and it could require different tests, some of which are affected by limited availability. Nowadays, considering that new therapies are available for HFpEF and related conditions, a prompt and correct diagnosis is relevant. However, the diagnostic role of biomarker level, imaging tools, score-based algorithms and invasive evaluation, should be based on the strengths and weaknesses of each test. The aim of this review is to help the clinician in diagnosing HFpEF, overcoming the diagnostic uncertainty and disentangling among the different underlying causes, in order to properly treat this kind of patient.
Liver Fibrosis Scores Are Associated With Resting and Exercise Fontan and Pulmonary Artery Wedge Pressures: Insights Into FALD
2023, Canadian Journal of Cardiology
Alterations in liver perfusion and venous hypertension have been implicated in the pathophysiology of Fontan-associated liver disease (FALD). However, the correlation between exercise hemodynamics and markers of FALD have not been studied.
We performed a retrospective review of 32 consecutive adults undergoing exercise catheterisation at the Mayo Clinic, Minnesota. Invasive hemodynamics were correlated with aspartate transaminase to platelet ratio index (APRI) and the Fibrosis-4 (Fib-4) score, well validated surrogates of liver fibrosis.
The mean age was 30.9 ± 7 years. The mean APRI was 0.5 ± 0.2 and the mean Fib-4 score 1.3 ± 0.8. Fib-4 scores correlated with spleen size on abdominal imaging (r = 0.40; P = 0.03). Resting Fontan pressure was 13.9 ± 3.9 mm Hg and pulmonary artery wedge pressure (PAWP) 10.0 ± 3.5 mm Hg. At peak exercise (69.4 ± 23.2 W), Fontan pressures increased to 26.5 ± 6.2 mm Hg and PAWP to 22.4 ± 7.1 mm Hg. APRI and Fib-4 score were directly related to Fontan pressure and PAWP at rest and during exercise, and inversely related to exercise arterial O₂ saturation. Fib-4 inversely correlated with O₂ delivery indices. Similarly, when categorising patients according to high APRI (> 0.5 vs ≤ 0.5) or Fib-4 score (≥ 1.45 vs < 1.45) according to previously proposed cutoffs for diagnosis of liver fibrosis, those with elevated scores had higher resting and exercise Fontan and PAWP pressure with lower O₂ arterial saturation.
APRI and Fib-4 score correlated with resting and exercise Fontan pressure and PAWP. In addition, Fib-4 scores were inversely related to O₂ delivery indices. These findings support a role played by hepatic venous hypertension and reduced O₂ supply in patients with FALD.
Les altérations de l’irrigation du foie et l’hypertension veineuse ont été mises en cause dans la physiopathologie de la maladie du foie associée à l’intervention de Fontan (FALD, pour Fontan-associated liver disease). Cependant, la corrélation entre l’hémodynamique à l’effort et les marqueurs de la FALD n’a pas été étudiée.
Nous avons réalisé une analyse rétrospective des cas de 32 adultes consécutivement soumis à un cathétérisme d’effort à la clinique Mayo, au Minnesota. Les résultats d’une surveillance hémodynamique invasive étaient corrélés à l’indice du rapport aspartate aminotransférase/plaquettes (APRI, pour aspartate transaminase to platelet ratio index) et au score Fibrosis-4 (FIB-4), deux indicateurs validés de la fibrose hépatique.
L’âge moyen était de 30,9 ± 7 ans. L’APRI moyen était de 0,5 ± 0,2 et le score FIB-4 moyen, de 1,3 ± 0,8. Les scores FIB-4 étaient corrélés à la taille de la rate évaluée par imagerie abdominale (r = 0,40; p = 0,03). La pression au repos dans le circuit de Fontan était de 13,9 ± 3,9 mmHg et la pression capillaire pulmonaire bloquée (PCPB), de 10,0 ± 3,5 mmHg. À l’effort maximal (69,4 ± 23,2 W), la pression dans le circuit de Fontan a augmenté à 26,5 ± 6,2 mmHg et la PCPB, à 22,4 ± 7,1 mmHg. L’APRI et le score FIB-4 étaient directement proportionnels à la pression dans le circuit de Fontan et à la PCPB au repos comme à l’effort, et inversement proportionnels à la saturation artérielle en O₂ à l’effort. Il y avait une corrélation inverse entre les scores FIB-4 et les indices de l’apport en O₂. De même, la catégorisation des patients en fonction de l’APRI (> 0,5 vs ≤ 0,5) ou du score FIB-4 (≥ 1,45 vs < 1,45), selon les valeurs seuils antérieurement proposées pour le diagnostic de la fibrose hépatique, a permis de constater que chez les patients dont les scores étaient élevés, la pression dans le circuit de Fontan et la PCPB, tant au repos qu’à l’effort, étaient plus élevées et que la saturation artérielle en O₂ était plus faible.
L’APRI et le score FIB-4 étaient corrélés avec la pression dans le circuit de Fontan et la PCPB, tant au repos qu’à l’effort. De plus, les scores FIB-4 étaient inversement proportionnels aux indices d’apport en O₂. Ces observations étayent le rôle de l’hypertension veineuse et de l’apport réduit en O₂ chez les patients présentant une FALD.
Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism
2023, Interventional Cardiology Clinics
Exercise Capacity, NT-proBNP, and Exercise Hemodynamics in Adults Post-Fontan
2023, Journal of the American College of Cardiology
Cardiopulmonary exercise testing (CPET) and N-terminal pro–B-type natriuretic peptide (NT-proBNP) measurement are frequently performed in adults post-Fontan, but their correlations with exercise invasive hemodynamics are poorly understood. Moreover, whether exercise cardiac catheterization provides incremental prognostic information is unknown.
The authors sought to correlate resting and exercise Fontan pressures (FP) and pulmonary artery wedge pressure (PAWP) with peak oxygen consumption (VO₂) on CPET, NT-proBNP, and clinical outcomes.
This was a retrospective cohort of 50 adults (age ≥18 years) post-Fontan undergoing supine exercise venous catheterization between 2018 and 2022.
Median age was 31.5 years (IQR: 23.7-36.5 years). Ventricular ejection fraction was 48.5% ± 13.0%. Exercise FP and PAWP were related to peak VO₂ and ln NT-proBNP levels. Patients with peak VO₂ <50% predicted had higher exercise FP (30.0 ± 6.8 mm Hg vs 19 mm Hg [IQR: 16-24 mm Hg]; P < 0.001) and PAWP (25.9 ± 6.3 mm Hg vs 15.1 ± 7.0 mm Hg; P <0.001) compared with those with more preserved exercise capacity. Exercise FP (30.0 ± 7.1 mm Hg vs 23.2 ± 7.2 mm Hg; P = 0.003) and PAWP (25.1 ± 6.7 mm Hg vs 18.8 ± 7.9 mm Hg; P = 0.006) were higher in those with NT-proBNP levels ≥300 pg/mL. During a follow-up of 0.9 years (IQR: 0.6-2.9 years), exercise FP and PAWP remained independently associated with a composite of death, cardiac transplantation, or hospitalization due to heart failure/refractory arrhythmias after adjusting for confounders.
In adults post-Fontan, resting and exercise FP and PAWP were inversely related to exercise capacity on noninvasive CPET, and exercise hemodynamics were directly related to NT-proBNP levels. Exercise FP and PAWP were independently associated with clinical outcomes and might be more sensitive than resting values to predict clinical outcomes.
Right Heart Catheterization (RHC): A Comprehensive Review of Provocation Tests and Hepatic Hemodynamics in Patients With Pulmonary Hypertension (PH)
2022, Current Problems in Cardiology
The classic definition of pulmonary arterial hypertension (PAH) is a mean pulmonary artery pressure (mPAP) of 20 mmHg. The gold standard for assessing pulmonary hemodynamics is right heart catheterization (RHC), which is necessary to confirm the diagnosis of PH. In some instances, RHC evaluates the degree of hemodynamic dysfunction and performs vasoreactivity tests. Measurement of the hepatic venous pressure gradient remains the gold standard diagnostic for identifying portal hypertension. This review aims to describe the procedure of RHC and the hemodynamic measurement in patients with PAH and Portopulmonary hypertension (PoPH). The RHC remains the gold standard for diagnosing PAH and PoPH.

View all citing articles on Scopus

: FUNDING/SUPPORT: Dr Borlaug is supported by RO1 HL128526 and U10 HL110262.

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Chest

Pulmonary and Cardiovascular: How I Do ItPerformance and Interpretation of Invasive Hemodynamic Exercise Testing

Section snippets

Indications for Invasive CPET

Case

Interpretation

Conclusion

Acknowledgments

J Am Coll Cardiol

JACC Heart Fail

JACC Heart Fail

Am J Cardiol

J Card Fail

Am J Cardiol

JACC Heart Fail

JACC Heart Fail

J Am Coll Cardiol

JACC Heart Fail

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Diagnosis and treatment of heart failure with preserved ejection fraction

Nat Rev Cardiol

Exercise hemodynamics enhance diagnosis of early heart failure with preserved ejection fraction

Circ Heart Fail

Role of diastolic stress testing in the evaluation for heart failure with preserved ejection fraction: a simultaneous invasive-echocardiographic study

Circulation

The invasive cardiopulmonary exercise test

Circulation

Invasive cardiopulmonary exercise testing in the evaluation of unexplained dyspnea: insights from a multidisciplinary dyspnea center

Eur J Prev Cardiol

An official European Respiratory Society statement: pulmonary haemodynamics during exercise

Eur Respir J

Pulmonary vascular hemodynamic response to exercise in cardiopulmonary diseases

Circulation

Unexplained exertional dyspnea caused by low ventricular filling pressures: results from clinical invasive cardiopulmonary exercise testing

Pulm Circ

The spectrum of exercise tolerance in mitochondrial myopathies: a study of 40 patients

Brain

Pulmonary capillary wedge pressure patterns during exercise predict exercise capacity and incident heart failure

Circ Heart Fail

Criteria for diagnosis of exercise pulmonary hypertension

Eur Respir J

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Eur Heart J

Pulmonary and Cardiovascular: How I Do It
Performance and Interpretation of Invasive Hemodynamic Exercise Testing