Journal Article

Exercise‐induced out‐of‐proportion increase in afterload and impaired right ventricular contractile reserve in HFpEF

Hasenfuß, Gerd, Wolter, Jan Sebastian, Schuster, Andreas, Kowallick, Johannes T., Treiber, Julia M., Lange, Torben, Kriechbaum, Steffen D., Rolf, Andreas, Backhaus, Sören J., Sossalla, Samuel, Schulz, Alexander, Kutty, Shelby

2025

Overview

Aims The pathophysiology of heart failure with preserved ejection fraction (HFpEF) includes pulmonary vascular remodelling and right ventricular (RV) involvement. We sought to investigate the significance of non‐invasive cardiovascular magnetic resonance (CMR)‐derived RV loading conditions. Methods Patients with exertional dyspnoea and diastolic dysfunction [E/e′ > 8, left ventricular ejection fraction (LVEF) >50%] underwent rest and exercise‐stress echocardiography, right heart catheterization and CMR. HFpEF was defined by pulmonary capillary wedge pressure [rest ≥15 mmHg (overt) or stress ≥25 mmHg (masked)]; otherwise, patients were classified as non‐cardiac dyspnoea (NCD). CMR‐derived RV haemodynamic indices were defined as follows: afterload Ea = end‐systolic pressure (ESP)/stroke volume (SV), contractility Ees = ESP/left ventricular end‐systolic volume and RV/pulmonary artery coupling as Ea/Ees. Results HFpEF (n = 34; female 73.5%; median age 69 years) patients showed increased afterload and contractility at rest (Ea 1.20 vs. 0.85, P = 0.001, Ees 0.61 vs. 0.37, P < 0.001) and during exercise (Ea 2.48 vs. 1.53, Ees 1.00 vs. 0.74, P < 0.001) compared with NCD (n = 34; female 55.9%; median age 66 years). The relative increase of contractility from rest to stress was smallest in overt HFpEF (overt 1.40 vs. masked 1.86, P = 0.001) and highest in NCD (HFpEF 1.56 vs. NCD 1.97, P = 0.022). The out‐of‐proportion increase in afterload over contractility in HFpEF was reflected in a statistical trend towards increased Ea/Ees from rest to stress in HFpEF (P = 0.078) while Ea/Ees decreased in NCD (P = 0.002). Patients with resting Ea or Ees above the median showed lower exercise‐induced increases in cardiac index (Ea: below: 2.8 vs. above: 2.2, P = 0.031; Ees: below: 2.9, above: 2.1, P < 0.001). Conclusions Resting RV afterload elevation in HFpEF results in a compensatory increase in contractility. Out‐of‐proportion increase of afterload paralleled by inadequate increase in contractility results in failure to increase the cardiac index in HFpEF, potentially associated with exertional functional failure. Non‐cardiac dyspnoea (n = 34, NCD) and heart failure with preserved ejection fraction (n = 34, HFpEF) patients were classified according to right heart catheterisation. Cardiovascular magnetic resonance derived right ventricular (RV) haemodynamic indices for afterload (Ea), contractility (Ees) and RV/pulmonary artery coupling (Ea/Ees) were evaluated. At rest, RV afterload elevation in HFpEF results in a compensatory increase in contractility. During exercise‐stress an out‐of‐proportion increase of afterload paralleled by inadequate increase in contractility results in failure to increase the cardiac index in HFpEF but not in NCD.

• Publisher: Oxford University Press,Wiley
• Subject: afterload / Aged / Blood pressure / Cardiac arrhythmia / Cardiac Catheterization / contractility / Dyspnea / Echocardiography, Stress / Ejection fraction / Exercise - physiology / Exercise Test / exercise‐stress / Female / Follow-Up Studies / Heart / Heart Failure - diagnosis / Heart Failure - physiopathology / Heart Ventricles - diagnostic imaging / Heart Ventricles - physiopathology / Hemodynamics / HFpEF / Humans / Hypertension / Magnetic Resonance Imaging, Cine - methods / Male / Middle Aged / Myocardial Contraction - physiology / Pulmonary arteries / Pulmonary Wedge Pressure - physiology / right ventricle / Stroke Volume - physiology / Ventricular Dysfunction, Right - physiopathology / Ventricular Function, Left - physiology / Ventricular Function, Right - physiology