Abstract 4141328: Exercise right heart catheterization combined with echocardiography in evaluation of subclinical pulmonary hypertension and heart failure with preserved left ventricular ejection fraction

Introduction: Diagnosis of exercise-induced pulmonary hypertension (EIPH) or exercise-induced heart failure with preserved left ventricular ejection fraction (E-HFpEF) is challenging due to a lack of consensus. The 2022 ESC/ERS guidelines define EIPH as mean (m) PAP/CO > 3 mmHg/L/min, and E-HFpEF as PCWP/CO > 2 mmHg/L/min, a revision of the previous criteria of mPAP ≥ 30 mmHg and PCWP ≥ 25 mmHg. Hypothesis: We investigated the role of exercise RHC in identifying EIPH and E-HFpEF in a group of patients with dyspnea and correlated the rest echo findings with the E-RHC results. We hypothesized that the resting echo parameters can help identify patients with EIPH and E-HFpEF using 2022 ESC/ERS definitions. Methods: A cohort of patients with dyspnea and normal LVEF with E-RHC data from 2016-2019 was included. Patients were categorized into Groups (g) A-E (Fig 1-T1) according to the 2018 WSPH definition of PH. Echo, hemodynamic, and clinical data were collected. The ESC/ERS 2022 guidelines were used to identify EIPH and E-HFpEF. Echo parameters were retrospectively analyzed by logistic regression analysis. Results: 200 patients were included. The mPAP and PCWP, but not PVR, significantly increased post-exercise in all groups. Over 50% of patients in each group had evidence of at least grade I LV diastolic dysfunction on rest Echo (Fig 1). PVs/PVd was significantly lower (0.8±0.3) and E/e’ higher (15±7.9) in g-C (Post-Cap) compared to g-A (No-PH), B (Pre-Cap) and E (undifferentiated). In g-A and g-E, 46.8% and 73% demonstrated EIPH, with 87% and 100% showing a mPAP≥30 mmHg respectively. The prevalence of E-HFpEF in g-A, g-B, and g-E was 45%, 50%, and 63% respectively. Only 34%, 42%, and 56% of subjects in g-A, g-B and g-E demonstrated E-PCWP ≥ 25 mmHg. Echo parameters that predicted E-HFpEF included E and E/e’; E/e’ also predicted EIPH (Fig 1). Conclusions: In this study, Echo features of advanced LV diastolic dysfunction including decreased PVs/PVd and increased E/e’ were associated with post-capillary PH. Rest E/e’ and E (LV rapid inflow velocity) may predict E-HFpEF. Exercise RHC may have utility in the evaluation of patients with suspected subclinical PH and HFpEF, but larger prospective designs are warranted