A streamlined protocol for exercise right heart catheterisation for the diagnosis of heart failure with preserved ejection fraction

Abstract Background Heart failure with preserved ejection fraction (HFpEF) can be a challenging diagnosis. The gold standard diagnostic test is exercise right heart catheterisation (eRHC), with HFpEF confirmed if pulmonary capillary wedge pressure (PCWP) >15mmHg at rest or ≥25mmHg with exercise. However, many centres do not perform eRHC and the current, well-established, nine-minute eRHC protocol can be time consuming and costly. Purpose We sought to determine whether an abbreviated 3-minute eRHC protocol is sufficient for accurate diagnosis of HFpEF, thus allowing simplification, reduced patient risk and costs, and broader uptake of eRHC across centres. Methods Patients undergoing eRHC between 09/09/2008 and 18/07/2023 at a tertiary hospital in Australia were retrospectively analysed. Haemodynamic measurements at three minutes of exercise were correlated with peak measurements. Results Overall cohort of n=532, with a mean age of 64 ± 12 years, and 60% female. Compared to PCWP ≥25mmHg at peak exercise, measurement of PCWP at 3 minutes yielded an area under the receiver-operating characteristic curve of 0.92±0.01, P<0.0001. PCWP ≥25mmHg at 3 minutes has a high specificity (97%) but moderate sensitivity (65%) for diagnosis of HFpEF; PCWP ≥21 mmHg at 3 minutes has good specificity (83%) and sensitivity (85%) for predicting peak PCWP ≥25mmHg. Using the 3-minute protocol with PCWP cut-off of 21mmHg, 86% of participants were correctly diagnosed (Figure 1). There were strong positive correlations in PCWP (R2=0.6922), cardiac output (R2=0.5543) and pulmonary vascular resistance (R2=0.6516) between 3 minutes and peak exercise (Figure 2). Conclusions Abbreviated 3-minute eRHC protocol has good diagnostic potential in HFpEF, with strong correlations in haemodynamics, when compared to peak exercise. This suggests that simplification of the current HFpEF protocol to 3 minutes exercise could be a valid strategy to enable improved uptake and maximise resource utilisation while maintaining diagnostic accuracy.Figure 1.Sankey plot of PCWP valuesFigure 2.Haemodynamics during eRHC