- •
Rest and exercise hemodynamics are useful in prognostic and therapeutic decision making across the spectrum of heart failure.
- •
Several hemodynamic measures may appear normal at rest and require dynamic challenge, such as exercise, to provoke symptoms and reveal abnormal physiology.
- •
Invasive cardiac catheterization remains the gold standard but may be limited by practicality; consequently, several echocardiographic and MRI parameters are becoming of increasing interest, particularly in regard to
Resting and Exercise Doppler Hemodynamics: How and Why?
Section snippets
Key points
Exercise Testing
Conventional exercise testing, performed on a treadmill or upright cycle, has the disadvantage of limiting access to peak imaging, so most studies are performed immediately postexercise. This has the disadvantage of potentially missing signals that rapidly dissipate. Supine exercise is more amenable to imaging, but the position changes preload, and therefore subjects begin at different points on the diastolic pressure-volume curve. Left ventricular (LV) volumes and stroke volume are larger when
Parameters
Several hemodynamic parameters are relevant to the failing heart (Table 1). Fundamentally, dyspnea occurs most commonly due to an elevation of LVFP, and accurate noninvasive estimation at rest and at peak exercise has remained the holy grail. Elevation of LVFP is primarily a compensatory response to preserve cardiac output in heart failure, with the magnitude of elevation indexed to workload proving highly prognostic.13 Beyond accurate LVFP measurement, invasive catheterization allows for
Diseases
Patients with heart failure, regardless of ejection fraction (EF), display varying levels of pulmonary vascular remodeling, left atrial dysfunction, dynamic mitral regurgitation, and peripheral oxygen extraction abnormalities. Consequently, the physiologic response to exercise is variable, and accurate and deep phenotypic identification allows for precise targeted therapy.
Cardiac Catheterization
Invasive hemodynamic testing, particularly with exercise, remains the gold standard for the accurate quantification of FP in all forms of heart failure.
Summary
Rest and exercise hemodynamics are useful in prognostic and therapeutic decision making across the spectrum of heart failure. Although invasive measurement remains the gold standard, noninvasive parameters are becoming increasingly useful, particularly in regard to quantifying ventriculo-vascular interactions. Currently, significant heterogeneity exists around exercise protocols, and there is a distinct need to develop consensus methodology and to validate these noninvasive measures in all
References (40)
- et al.
Causes of exercise intolerance in heart failure with preserved ejection fraction: searching for consensus
J Card Fail
(2014) - et al.
Hemodynamic basis of exercise limitation in patients with heart failure and normal ejection fraction
J Am Coll Cardiol
(2010) - et al.
Hemodynamics at rest and during supine and sitting bicycle exercise in normal subjects
Am J Cardiol
(1978) Ventricular–arterial coupling: invasive and non-invasive assessment
Artery Res
(2013)- et al.
Hemodynamic phenotyping based on exercise catheterization predicts outcome in patients with heart failure and reduced ejection fraction
J Heart Lung Transplant
(2017) - et al.
Heart failure with preserved ejection fraction expert panel report
JACC Heart Fail
(2018) - et al.
Hemodynamics in pulmonary arterial hypertension: current and future perspectives
Am J Cardiol
(2012) - et al.
Echocardiography of right ventriculoarterial coupling combined with cardiopulmonary exercise testing to predict outcome in heart failure
Chest
(2015) - et al.
Hemodynamic effects of exercise in patients with aortic stenosis
Am J Med
(1969) - et al.
Clinical significance of exercise pulmonary hypertension in secondary mitral regurgitation
Am J Cardiol
(2015)
Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
J Am Soc Echocardiogr
Accuracy of echocardiography to evaluate pulmonary vascular and RV function during exercise
JACC Cardiovasc Imaging
Diastolic stress echocardiography: hemodynamic validation and clinical significance of estimation of ventricular filling pressure with exercise
J Am Coll Cardiol
Left atrial function dynamics during exercise in heart failure: pathophysiological implications on the right heart and exercise ventilation inefficiency
JACC Cardiovasc Imaging
Diffuse myocardial fibrosis evaluated by post-contrast T1 mapping correlates with left ventricular stiffness
J Am Coll Cardiol
Cardiovascular magnetic resonance phase contrast imaging
J Cardiovasc Magn Reson
CMR imaging for diastolic hemodynamic assessment: fantasy or reality?
JACC Cardiovasc Imaging
4D flow cardiovascular magnetic resonance consensus statement
J Cardiovasc Magn Reson
Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations
Circulation
Position as a variable for cardiovascular responses during exercise
Clin Cardiol
Cited by (0)
Disclosure Statement: The authors have nothing to disclose.
Funding: S. Nanayakkara is supported by a scholarship from the National Heart Foundation of Australia and the Baker Bright Sparks program. D.M. Kaye is supported by a Fellowship from the National Health and Medical Research Council of Australia. The Baker Heart and Diabetes Institute is supported in part by the Victorian Government’s Operational Infrastructure Support Program.