Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
JACC Heart Fail. 2018 Aug;6(8):665-675. doi: 10.1016/j.jchf.2018.03.003. Epub 2018 May 23.
This study sought to define the invasive hemodynamic correlates of peak oxygen consumption (Vo) in both supine and upright exercise in heart failure with preserved ejection fraction (HFpEF) and evaluate its diagnostic role as a method to discriminate HFpEF from noncardiac etiologies of dyspnea (NCD).
Peak Vo is depressed in patients with HFpEF. The hemodynamic correlates of reduced peak Vo and its role in the clinical evaluation of HFpEF are unclear.
Consecutive patients with dyspnea and normal EF (N = 206) undergoing both noninvasive upright and invasive supine cardiopulmonary exercise testing were examined. Patients with invasively verified HFpEF were compared with those with NCD.
Compared with NCD (n = 72), HFpEF patients (n = 134) displayed lower peak Vo during upright and supine exercise. Left heart filling pressures during exercise were inversely correlated with peak Vo in HFpEF, even after accounting for known determinants of O transport according to the Fick principle. Very low upright peak Vo (<14 ml/kg/min) discriminated HFpEF from NCD with excellent specificity (91%) but poor sensitivity (50%). Preserved peak Vo (>20 ml/kg/min) excluded HFpEF with high sensitivity (90%) but had poor specificity (49%). Intermediate peak Vo cutoff points were associated with substantial overlap between cases and NCD.
Elevated cardiac filling pressure during exercise is independently correlated with reduced exercise capacity in HFpEF, irrespective of body position, emphasizing its importance as a novel therapeutic target. Noninvasive cardiopulmonary testing discriminates HFpEF and NCD at high and low values, but additional testing is required for patients with intermediate peak Vo.
本研究旨在确定射血分数保留心力衰竭（HFpEF）患者在仰卧位和直立位运动时峰值摄氧量（Vo）的侵袭性血流动力学相关性，并评估其作为鉴别 HFpEF 与非心源性呼吸困难（NCD）病因的诊断作用。
HFpEF 患者的峰值 Vo 降低。降低的峰值 Vo 的血流动力学相关性及其在 HFpEF 临床评估中的作用尚不清楚。
连续纳入因呼吸困难且 EF 值正常（N=206）而接受非侵入性直立和侵入性仰卧心肺运动测试的患者进行检查。将患有经证实的 HFpEF 的患者与患有 NCD 的患者进行比较。
与 NCD（n=72）相比，HFpEF 患者（n=134）在直立和仰卧运动时的峰值 Vo 较低。HFpEF 患者在运动时的左心充盈压与峰值 Vo 呈负相关，即使根据 Fick 原理考虑到 O 转运的已知决定因素也是如此。非常低的直立峰值 Vo（<14ml/kg/min）对 HFpEF 的特异性（91%）很好，但敏感性（50%）较差。保留的峰值 Vo（>20ml/kg/min）排除 HFpEF 的敏感性（90%）较高，但特异性（49%）较差。中间峰值 Vo 切点与病例和 NCD 之间存在大量重叠。
运动时升高的心脏充盈压与 HFpEF 运动能力降低独立相关，与体位无关，强调其作为一种新的治疗靶点的重要性。心肺非侵入性测试可在高值和低值时鉴别 HFpEF 和 NCD，但对于峰值 Vo 中等的患者需要进一步测试。
