Korean Circ J.  2016 May;46(3):350-364. 10.4070/kcj.2016.46.3.350.

Two Distinct Responses of Left Ventricular End-Diastolic Pressure to Leg-Raise Exercise in Euvolemic Patients with Exertional Dyspnea

• Choi S
• Shin JH
• Park WC
• Kim SG
• Shin J
• Lim YH
• Lee Y

• KMID: 2344448
• DOI: http://doi.org/10.4070/kcj.2016.46.3.350

Abstract

BACKGROUND AND OBJECTIVES
Few studies have invasively assessed diastolic functional reserve and serial changes in left ventricular hemodynamics in euvolemic patients with exertional dyspnea. In this study, sequential changes in left ventricular end-diastolic pressure (LVEDP) to leg-raise exercise were measured invasively in patients with early heart failure with preserved ejection fraction (HFpEF) to determine the association between these serial changes and echocardiographic results or clinical features.
SUBJECTS AND METHODS
During their hospital stay, 181 patients with early HFpEF underwent left cardiac catheterization, coronary angiography, and transthoracic echocardiography (TTE). Leg-raise exercise was performed in two stages: during cardiac catheterization and again during TTE.
RESULTS
Compared with the initial values, all the invasively measured LVEDP values increased significantly during the leg-raise exercise, whereas the septal e/e' ratio remained unchanged. Active leg-raise led to increased LVEDP, which caused dyspnea. The severity of symptoms correlated with the level and extent of changes in LVEDP. At the end of active leg-raise, LVEDP decreased in 40 patients (22.1%), who were younger and had significantly lower e/e' ratios. On multivariate analysis to predict the response of LVEDP to active leg-raise, age and the septal e/e' ratio remained significant predictors.
CONCLUSION
Despite having similar LVEDP values at rest, patients may respond to exercise with different LVEDP levels and clinical manifestations, depending on their diastolic capacity. The leg-raise exercise in early HFpEF can elucidate individual diastolic profiles, and the LVEDP response to the leg-raise test may serve as a useful criterion in stratifying patients with early HFpEF with respect to functional reserve.

Keyword

Left ventricular function; Exercise; Heart failure, diastolic

MeSH Terms

Cardiac Catheterization
Cardiac Catheters
Coronary Angiography
Dyspnea*
Echocardiography
Heart Failure
Heart Failure, Diastolic
Hemodynamics
Humans
Length of Stay
Multivariate Analysis
Ventricular Function, Left

Figure

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  Fig. 1 Measurement of LVEDP and pre-aLVDP. The pre-aLVDP is measured at the onset of the a-wave, and the measurement of LVEDP is made at the nadir of the atrial contraction wave before the onset of a rapid rise in left ventricular (LV) systolic pressure or at the peak of R-wave on EKG. LVEDP: left ventricular end-diastolic pressure, pre-aLVDP: pre-a left ventricular diastolic pressure, LV: left ventricle, EKG: electrocardiography, P: P wave, QRS: QRS complex, LVSBP: left ventricle systolic blood pressure, LVDBP: left ventricle diastolic blood pressure.

• 

  Fig. 2 Association of the invasively measured LVEDPs between the echocardiographic e/e' ratios during leg-raise. Leg-raise, especially active leg-raise, significantly increases all types of LVEDP parameters. Unlike the invasively measured LVEDP, the septal e/e' ratio is not significantly changed during passive and active leg-raise. "p" indicates passive leg-raise, "a" active leg-raise, and "R" recovery period. For example, p30 is at 30-second passive leg-raise. *p<0.05 vs. baseline at passive stage, †p<0.01 vs. at a0. LVEDP: left ventricular end-diastolic pressure.

• 

  Fig. 3 Time course of the invasively measured LVEDP according to the LVEDP response to leg-raise. In most of the patients (77.9%), LVEDP increased steadily throughout active leg-raise. In contrast, LVEDP in 22.1% of the patients increased moderately during the early stage of active leg-raise and then declined during the late stage, relative to the initial stage. "p" indicates passive leg-raise, "a" active leg-raise, and "R" recovery period. For example, p30 is at 30-second passive leg-raise. *p<0.05 vs. baseline at passive stage, †p%0.01 vs. at a0, ‡p<0.01 vs. ΔLVEDP_frequent>0 mmHg. LVEDP: left ventricular end-diastolic pressure.

• 

  Fig. 4 Time course of septal e/e' ratio according to the LVEDP response to leg-raise. Septal e/e' ratios in the ΔLVEDP_frequent≤0 mmHg group were significantly lower at initial, passive, and active stages, as compared with those in the ΔLVEDP_frequent>0 mmHg group. However, septal e/e' ratio showed no significant change during active leg-raise. "p" indicates passive leg-raise, "a" active leg-raise, and "R" recovery period. For example, p30 is at 30-second passive leg-raise. *p<0.05 vs. baseline at passive stage. †p<0.01 vs. at a0, ‡p<0.05 vs. LVEDP of ΔLVEDP_frequent>0 mmHg, §p<0.05 vs. e/e' ratio of ΔLVEDP_frequent>0 mmHg. LVEDP: left ventricular end-diastolic pressure.

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