Obokata Masaru, Kane Garvan C, Reddy Yogesh N V, Olson Thomas P, Melenovsky Vojtech, Borlaug Barry A
From Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN (M.O., G.C.K., Y.N.V.R., T.P.O., B.A.B.); and IKEM - Institute for Clinical and Experimental Medicine, Department of Cardiology, Prague, Czech Republic (V.M.).
Circulation. 2017 Feb 28;135(9):825-838. doi: 10.1161/CIRCULATIONAHA.116.024822. Epub 2016 Dec 30.
Diagnosis of heart failure with preserved ejection fraction (HFpEF) is challenging and relies largely on demonstration of elevated cardiac filling pressures (pulmonary capillary wedge pressure). Current guidelines recommend use of natriuretic peptides (N-terminal pro-B type natriuretic peptide) and rest/exercise echocardiography (E/e' ratio) to make this determination. Data to support this practice are conflicting.
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).
N-Terminal pro-B type natriuretic peptide 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 pulmonary capillary wedge pressure at rest (=0.63, <0.0001) and during exercise (=0.57, <0.0001). Although specific, current guidelines were poorly sensitive, identifying only 34% to 60% of subjects with invasively proven HFpEF on the basis of 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%).
Currently proposed HFpEF diagnostic guidelines on the basis of 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 on the basis of 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.
URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01418248.
射血分数保留的心力衰竭（HFpEF）的诊断具有挑战性，很大程度上依赖于证实心脏充盈压升高（肺毛细血管楔压）。当前指南推荐使用利钠肽（N末端B型利钠肽原）和静息/运动超声心动图（E/e'比值）来做出这一判定。支持这种做法的数据相互矛盾。
对经有创检查证实为HFpEF的受试者（n = 50）和有呼吸困难但未发现心脏病变的参与者（n = 24），前瞻性地进行静息和运动时的同步超声心动图-心导管检查研究。
在18%的HFpEF受试者中，N末端B型利钠肽原水平低于被认为可排除疾病的水平（≤125 pg/mL）。E/e'比值与静息时直接测量的肺毛细血管楔压相关（r = 0.63，P < 0.0001），运动时也相关（r = 0.57，P < 0.0001）。尽管具有特异性，但当前指南的敏感性较差，仅根据静息超声心动图数据只能识别出34%至60%经有创检查证实为HFpEF的受试者。加入运动超声心动图数据（E/e'比值>14）可提高敏感性（至90%），从而提高阴性预测值，但降低了特异性（71%）。
目前基于静息数据提出的HFpEF诊断指南敏感性较差。加入运动E/e'数据可提高敏感性和阴性预测值，但会损害特异性，这表明运动超声心动图可能有助于排除HFpEF。这些结果质疑了仅基于静息数据排除HFpEF的当前方法的准确性，并强化了使用有创和无创血流动力学评估进行运动测试以明确证实或反驳HFpEF诊断的价值。
