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Pulmonary vascular response to exercise in symptomatic heart failure with reduced ejection fraction and pulmonary hypertension
Author(s) -
Verbrugge Frederik H.,
Dupont Matthias,
Bertrand Philippe B.,
Nijst Petra,
Grieten Lars,
Dens Joseph,
Verhaert David,
Janssens Stefan,
Tang W. H. Wilson,
Mullens Wilfried
Publication year - 2015
Publication title -
european journal of heart failure
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 5.149
H-Index - 133
eISSN - 1879-0844
pISSN - 1388-9842
DOI - 10.1002/ejhf.217
Subject(s) - medicine , cardiology , pulmonary wedge pressure , heart failure , vascular resistance , ejection fraction , cardiac index , pulmonary hypertension , pulmonary artery , afterload , hydralazine , blood pressure , cardiac output , sodium nitroprusside , stroke volume , anesthesia , nitric oxide
Aims To study pulmonary vascular response patterns to exercise in heart failure with reduced ejection fraction ( HFrEF ) and pulmonary hypertension ( PH ). Methods and results In this prospective single‐centre cohort study, consecutive symptomatic HFrEF patients ( n = 40) with mean pulmonary arterial pressure ( MPAP ) ≥25 mmHg , pulmonary artery wedge pressure ( PAWP ) >15 mmHg , and cardiac index <2.5 L/min.m 2 , received protocol‐driven titrated sodium nitroprusside ( SNP ) and diuretics to reach mean arterial blood pressure 65–75 mmHg and PAWP ≤15 mmHg . Patients performed symptom‐limited supine bicycle testing under continued SNP administration. Afterwards, SNP was gradually withdrawn, renin–angiotensin system blockers uptitrated, and hydralazine added to maintain haemodynamic targets. Subsequently, bicycle testing was repeated. Patients presented with pulmonary vascular resistance ( PVR ) = 3.8 ± 1.4 Wood Units at rest, decreasing to 2.9 ± 0.9 Wood Units after decongestion, with PH was completely reversed ( MPAP <25 mmHg ) in 22%. From rest to maximal exercise, the cardiac index did not change significantly ( P = 0.334 under SNP ; P‐value = 0.552 under oral therapy). A dynamic exercise‐induced PVR increase >3.5 Wood Units was noted in 19 patients (48%) under oral therapy vs. five (13%) under SNP . Such exercise‐induced PVR increase was associated with a 33% relative decrease in right ventricular stroke work index ( P = 0.037). Conclusions Even after thorough decongestion and under continuous afterload reduction, PH secondary to HFrEF is completely reversible in only a minority of patients. Others demonstrate an exercise‐induced PVR increase, associated with impaired right ventricular stroke work, which might be ameliorated by nitric oxide donor support.