Blood Pressure Assessment During Exercise Testing Aids Risk Stratification of Patients With Heart Failure

In patients who have heart failure with reduced ejection fraction (HFrEF), higher pulsatile blood pressure (BP) at rest is a favorable prognostic feature because it's associated with preserved left ventricular contractility. Pulsatile BP can be evaluated as proportionate pulse pressure (PrPP), an easily calculated clinical index: the ratio of pulse pressure to systolic BP (pulse pressure is systolic BP minus diastolic BP).

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Some studies suggest that in heart failure with preserved ejection fraction (HFpEF), higher BP pulsatility is unfavorable, reflecting increased arterial stiffness and wave reflection. Most of this research has focused on resting measures, and HFpEF is often incompletely characterized by resting measures alone.

Mayooran Namasivayam, MBBS, PhD, clinical and research fellow in the Corrigan Minehan Heart Center at Massachusetts General Hospital, Gregory D. Lewis, MD, Jeffrey and MaryEllen Jay chair and head of the Heart Failure Program and director of the Cardiopulmonary Exercise Testing Laboratory, and colleagues conducted the first study of BP pulsatility, evaluated as PrPP, in patients with HFpEF who were exercising. In JACC Heart Failure, they say the measurements can reveal underlying cardiovascular pathophysiology that increases the risk of adverse outcomes.

Methods

The retrospective analysis included 146 patients who underwent invasive cardiopulmonary exercise testing between 2006 and 2018 and met a strict definition of HFpEF. Arterial stiffness was also characterized in most patients.

PrPP at peak exercise was correlated with a composite cardiovascular outcome (all-cause mortality, implantation of a left ventricular assist device, or heart transplantation). The findings were compared with measures obtained in 57 patients with HFrEF who underwent invasive exercise testing during the same time period.

Key Results

The basis and implications of BP responses to exercise were different in HFpEF and HFrEF:

• In HFpEF, age (β=0.59; P<0.001), stroke volume (β=0.35; P<0.001), and baseline arterial stiffness (β=0.18; P=0.02) were significant predictors of peak PrPP
• In HFpEF, higher PrPP was associated with a greater risk of adverse cardiovascular outcomes (HR, 0.53 for PrPP below median; P=0.043), reflecting greater arterial stiffness
• In HFrEF, higher PrPP was not associated with arterial stiffness but was linked to greater peak stroke volume (P=0.013) and lower risk of adverse cardiovascular events (P=0.004)

Applying the Findings to the Clinic

Exercise testing is simple, safe, and often undertaken in patients with HFpEF and HFrEF. Exercise-induced PrPP can be measured routinely—and noninvasively—and could help clinicians better assess patients with HF. These results show it adds to risk prediction and can help differentiate HFpEF from HFrEF.

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