Exercise Echocardiography for Risk Stratification in Unexplained Dyspnea: The Incremental Value of the Mean Pulmonary Artery Pressure/Slope - 01/10/25
Abstract |
Background |
Patients with unexplained dyspnea and an elevated mean pulmonary artery pressure (mPAP)/cardiac output (CO) slope on invasive hemodynamic assessment during exercise have worse clinical outcomes. The aim of this study was to evaluate the incremental prognostic value of the noninvasive mPAP/CO slope in addition to heart failure with preserved ejection fraction (HFpEF) probability scores and diastolic stress testing in patients with unexplained dyspnea.
Methods |
In a multicenter cohort study involving six Belgian dyspnea clinics, patients with unexplained dyspnea underwent exercise echocardiography for mPAP/CO slope assessment. Positive HFpEF scores were defined as HFA-PEFF (Heart Failure Association pretest probability echocardiography, functional testing, final diagnosis) score ≥ 5 and H2FPEF (heavy, hypertensive, atrial fibrillation, pulmonary hypertension, elder, filling pressure) score ≥ 6. The outcome evaluated was a composite of all-cause mortality or heart failure hospitalization.
Results |
Among 2,452 patients (mean age, 63 ± 15 years; 53% women), mPAP/CO slope > 3.5 mm Hg · L−1 · min−1 best predicted adverse outcomes. The prognostic value of the mPAP/CO slope was greater in patients with negative HFpEF scores than in those with positive scores (interaction P = .02). The mPAP/CO slope remained independently prognostic after adjustment for N-terminal pro–B-type natriuretic peptide (hazard ratio [HR], 2.26; 95% CI, 1.33-3.82) and for HFpEF scores and diastolic stress testing (HR, 1.99; 95% CI, 1.37-2.88), whereas exercise tricuspid regurgitant velocity did not. Both HFpEF score–negative patients with slope > 3.5 mm Hg · L−1 · min−1 (HR, 2.99; 95% CI, 1.81-4.95) and HFpEF score–positive patients (HR, 6.29; 95% CI, 4.25-9.31) showed significantly higher risk compared with HFpEF score–negative patients with slope ≤ 3.5 mm Hg · L−1 · min−1.
Conclusions |
The mPAP/CO slope, unlike exercise tricuspid regurgitant velocity, adds prognostic value beyond natriuretic peptides, HFpEF scores, and diastolic stress testing, identifying high-risk patients with exercise-induced hemodynamic abnormalities who may benefit from invasive confirmation and closer follow-up.
El texto completo de este artículo está disponible en PDF.Central Illustration |
Kaplan-Meier curves demonstrating time to the composite outcome (all-cause mortality or heart failure hospitalization). Consecutive patients with unexplained dyspnea were assessed using the HFpEF scores and exercised echocardiography at six dyspnea clinics in Belgium. Patients were categorized into three groups: (1) HFpEF score positive (HFA-PEFF score ≥ 5 or H2FPEF score ≥ 6; red), (2) HFpEF score negative with elevated mPAP/CO slope (>3.5 mm Hg · L−1 · min−1; blue), and (3) HFpEF score negative with normal mPAP/CO slope (≤3.5 mm Hg · L−1 · min−1; green; reference group).
Kaplan-Meier curves demonstrating time to the composite outcome (all-cause mortality or heart failure hospitalization). Consecutive patients with unexplained dyspnea were assessed using the HFpEF scores and exercised echocardiography at six dyspnea clinics in Belgium. Patients were categorized into three groups: (1) HFpEF score positive (HFA-PEFF score ≥ 5 or H2FPEF score ≥ 6; red), (2) HFpEF score negative with elevated mPAP/CO slope (>3.5 mm Hg · L−1 · min−1; blue), and (3) HFpEF score negative with normal mPAP/CO slope (≤3.5 mm Hg · L−1 · min−1; green; reference group).
Central IllustrationKaplan-Meier curves demonstrating time to the composite outcome (all-cause mortality or heart failure hospitalization). Consecutive patients with unexplained dyspnea were assessed using the HFpEF scores and exercised echocardiography at six dyspnea clinics in Belgium. Patients were categorized into three groups: (1) HFpEF score positive (HFA-PEFF score ≥ 5 or H2FPEF score ≥ 6; red), (2) HFpEF score negative with elevated mPAP/CO slope (>3.5 mm Hg · L−1 · min−1; blue), and (3) HFpEF score negative with normal mPAP/CO slope (≤3.5 mm Hg · L−1 · min−1; green; reference group).El texto completo de este artículo está disponible en PDF.
Highlights |
• | mPAP/CO slope > 3.5 predicts 3-4 times higher risk for death or HF hospitalization. |
• | Adds prognostic value beyond NT-proBNP, HFpEF scores, and DSTs. |
• | Flags high-risk early HFpEF group missed by scores; invasive confirmation warranted. |
• | Two-thirds of patients had low scores and mPAP/CO slopes and low event rates. |
• | The results support exercise echo in dyspnea clinics for better risk stratification. |
Keywords : mPAP/CO slope, Heart failure with preserved ejection fraction, Dyspnea, Echocardiography, Exercise testing
Abbreviations : CO, COPD, CPET, CPETecho, DST, exE/e′, exTRV, FEV1, H2FPEF, HFA-PEFF, HFpEF, HR, ICC, IQR, mPAP, NT-proBNP, RAP, RER, SpO2, TR, TRG, TRV, V̇co2, V̇e, V̇o2
Esquema
| Drs. Falter and Bekhuis have received funding through the Flanders Research Foundation FWO (file number 1SE1222N and T004420N, respectively). Dr Gevaert is supported by the Belgian Heart Foundation (Dumont Prize) and the University of Antwerp (BOF DOCPRO4 51265). Dr. Dhont is supported by Research Foundation Flanders (Strategic Basic Research 1SH5O24N). |
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| Drs. Falter and Bekhuis contributed equally to this work as joint first authors. |
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| Drs. Claessen and Verwerft contributed equally to this work as joint senior authors. |
Vol 38 - N° 10
P. 875-889 - octobre 2025 Regresar al número
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