Many patients with heart failure and preserved ejection fraction (HFpEF) present at an early stage with complaints of exercise intolerance or exertional dyspnea. But resting examinations, including echocardiography and resting right heart catheterization, may be completely normal at this stage.(1) Hence the importance of "stressing" a dyspneic patient using exercise, this may unmask a pathological diastolic reserve as well as other abnormalities of exercise physiology associated with HFpEF.(2,3)
Exercise hemodynamics are the gold standard to diagnose HFpEF at an early stage, but this examination is not universally available, requires a high level of expertise, and is invasive with risk of complications. Echocardiography has reasonable "rule in" capacity especially when combined with cardiopulmonary exercise testing (CPETEcho).(4) The authors of this paper in the Journal revisited all exercise echos performed, and assessed outcomes according to the Heart Failure Association PEFF score (HFA-PEFF).(5) The HFA-PEFF score is subdivided in a "resting" score (maximum of 6 points) based on natriuretic peptide levels and echocardiography parameters.(6) Patients with exertional dyspnea or exercise intolerance scoring 0-1 points have <25% risk of HFpEF, those scoring ≥5 points have a >90% risk of HFpEF, and the remaining patients have an intermediate probability.(7) In these latter patients, exercise echocardiography is recommended, and high exercise E/e' or pulmonary artery pressures can add 2-3 points to the score.(6)
The authors found that, among patients with exertional dyspnea, those who received a diagnosis of early HFpEF had worse outcomes (mortality or heart failure event) compared to those with non-cardiac dyspnea. Moreover, those who had HFA PEFF score <5 at rest, but added points during exercise stress, had similar outcomes to the other HFpEF patients.
But there is hope for those with early HFpEF: patients who received early intervention had better outcomes! Of note, intervention was mainly diuretics or sodium-glucose cotransporter 2 inhibition in this study, but in general exercise training and weight loss therapy should be part of a HFpEF therapeutic strategy.
Taking into account some limitations, such as the retrospective design and referral bias, this study provides a ground for further research to diagnose HFpEF earlier using exercise echocardiography, possibly improving outcomes in these patients.