Exercise-induced changes in pulmonary artery wedge pressure: insights from heart failure with preserved ejection fraction

The accurate assessment of pulmonary artery wedge pressure (PAWP) is essential to differentiate between pulmonary vascular disease and heart failure with preserved ejection fraction (HFpEF). At exercise, there is a debate on whether it should be averaged (avg) throughout the respiratory cycle or based on end-expiratory (exp) measures. We evaluated the relevance of respiratory pressure swings during exercise and compared the concordance of the 3 proposed approaches to diagnose HFpEF based on exercise hemodynamics: total pulmonary resistance (TPR)avg at peak>3 WU + PAWPavg>20 mmHg; PAWPexp at peak≥25 mmHg; PAWPexp/cardiac output slope>2 mmHg/L/min. 57 patients (age 70±9, 71% females) with dyspnea and suspicion of HFpEF underwent cardiac catheterization at rest and during exercise. Pulmonary artery pressure (PAP), TPR and PAWP exp values were higher than avg (p<0.01). This results in a higher prevalence of abnormal PAWP responses when considering exp than avg values (p<0.01). The proportion of patients meeting the 3 HFpEF definitions is shown in figure. Discordant results were present in 30% of cases (light+dark grey). In conclusion, exp and avg values during exercise differ, and the proposed hemodynamic definitions for HFpEF provide discordant results in a relevant proportion of patients. More standardization is needed for univocal interpretation of exercise hemodynamics in clinical practice.