Prognostic benefit of early diagnosis with exercise stress testing in heart failure with preserved ejection fraction
Prognostic benefit of early diagnosis with exercise stress testing in heart failure with preserved ejection fraction
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运动负荷测试早期诊断射血分数保留的心力衰竭的预后益处
DOI：
10.1093/eurjpc/zwad127
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发表时间：
2023
影响因子：
8.3
通讯作者：
Ishii Hideki
中科院分区：
文献类型：
--
作者：
Saito Yuki;Obokata Masaru;Harada Tomonari;Kagami Kazuki;Wada Naoki;Okumura Yasuo;Ishii Hideki
背景射血分数保留性心力衰竭（HF）的延迟诊断可导致不良的临床结局。运动负荷试验，尤其是运动负荷超声心动图，在呼吸困难患者HFpEF的早期检测中起着主要作用，但其预后意义尚不清楚，因为是否启动指南指导的治疗可以改善临床结果，在这样的早期HFpEF.Methods和resultsErgometry运动负荷超声心动图进行了368例劳力性呼吸困难。通过HFA-PEFF算法步骤2（静息评估）和步骤3（运动试验）的总分≥ 5或静息或运动期间肺毛细血管楔压升高诊断射血分数保留的心力衰竭。主要终点包括全因死亡率和HF事件恶化。182例患者诊断为射血分数正常的心力衰竭，186例患者为非心源性呼吸困难（对照组）。诊断为HFpEF的患者发生复合事件的风险是对照组的7倍[风险比（HR）7.52; 95%置信区间（CI），2.24 - 25.2; P = 0.001]。HFA-PEFF第2步<5分但运动负荷试验（第2 - 3步）后HFA-PEFF ≥ 5的患者发生复合事件的风险高于对照组。在指数运动试验后诊断为HFpEF的90例患者中开始指南推荐的治疗。早期治疗的患者复合结局发生率低于未治疗的患者（HR 0.33; 95%CI，0.12 - 0.91; P = 0.03）。此外，指南导向治疗的启动可能与改善早期HFpEF.Lay SummaryDelayed诊断心力衰竭（HF）与保留射血分数（HFpEF）的患者的临床结果可能会导致不良的临床结果。运动负荷试验，尤其是运动负荷超声心动图，在呼吸困难患者HFpEF的早期识别中起主要作用，但其预后意义尚不清楚，指南指导治疗是否可以改善早期HFpEF的临床结局。在目前的研究中，测力运动负荷超声心动图进行了368例劳力性呼吸困难。射血分数保留的心力衰竭通过由步骤2（静息评估）和步骤3（运动超声心动图或运动右心导管插入术）组成的既定算法进行诊断。主要终点包括全因死亡率和HF事件恶化。182例患者诊断为射血分数正常的心力衰竭，186例患者诊断为非心源性呼吸困难（对照组）。新诊断的HFpEF患者发生复合事件的风险是对照组的7倍。在指数运动试验后新诊断为HFpEF的90例患者中开始指南推荐的治疗。早期治疗患者的复合结局发生率低于未接受治疗的患者。总之，通过运动负荷试验识别HFpEF可能有助于对慢性劳力性呼吸困难患者进行风险分层。此外，指南指导治疗的启动可能与早期HFpEF患者的临床结局改善相关。
BackgroundDelayed diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) can lead to poor clinical outcomes. Exercise stress testing, especially exercise stress echocardiography, plays a primary role in the early detection of HFpEF among dyspnoeic patients, but its prognostic significance is unknown, as is whether initiation of guideline-directed therapy could improve clinical outcomes in such early-stage HFpEF.Methods and resultsErgometry exercise stress echocardiography was performed in 368 patients with exertional dyspnoea. Heart failure with preserved ejection fraction was diagnosed by a total score of HFA-PEFF algorithm Step 2 (resting assessments) and Step 3 (exercise testing) ≥ 5 or elevated pulmonary capillary wedge pressure at rest or during exercise. The primary endpoint comprised all-cause mortality and worsening HF events. Heart failure with preserved ejection fraction was diagnosed in 182 patients, while 186 had non-cardiac dyspnoea (controls). Patients diagnosed with HFpEF had a seven-fold increased risk of composite events than that of controls [hazard ratio (HR) 7.52; 95% confidential interval (CI), 2.24–25.2;P= 0.001]. Patients with an HFA-PEFF Step 2 < 5 points but had an HFA-PEFF ≥ 5 after exercise stress testing (Steps 2–3) had a higher risk of composite events than controls. Guideline-recommended therapies were initiated in 90 patients diagnosed with HFpEF after index exercise testing. Patients with early treatment experienced lower rates of composite outcomes than those without (HR 0.33; 95% CI, 0.12–0.91;P= 0.03).ConclusionIdentification of HFpEF by exercise stress testing may allow risk stratification in dyspnoeic patients. Furthermore, initiation of guideline-directed therapy may be associated with improved clinical outcomes in patients with early-stage HFpEF.Lay SummaryDelayed diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) can lead to poor clinical outcomes. Exercise stress testing, especially exercise stress echocardiography, plays a primary role in the early identification of HFpEF among dyspnoeic patients, but its prognostic significance is unknown, as is whether initiation of guideline-directed therapy could improve clinical outcomes in such early-stage HFpEF. In the current study, ergometry exercise stress echocardiography was performed in 368 patients with exertional dyspnoea. Heart failure with preserved ejection fraction was diagnosed by the established algorithm consisting of Step 2 (resting assessments) and Step 3 (exercise echocardiography or exercise right heart catheterization). The primary endpoint comprised all-cause mortality and worsening HF events. Heart failure with preserved ejection fraction was diagnosed in 182 patients and non-cardiac dyspnoea (controls) in 186 patients. Patients newly diagnosed with HFpEF had a seven-fold increased risk of composite events than that of controls. Guideline-recommended therapies were initiated in 90 patients newly diagnosed with HFpEF after index exercise testing. Patients with early treatment experienced lower rates of composite outcomes than those without. In conclusion, identification of HFpEF by exercise stress testing may allow risk stratification in patients with chronic exertional dyspnoea. Furthermore, initiation of guideline-directed therapy may be associated with improved clinical outcomes in patients with early-stage HFpEF.