Diagnostic Performance of Passive Leg-Raise and Low-Workload Exercise to Diagnose Heart Failure With Preserved Ejection Fraction

Background Provocative tests during right heart catheterization (RHC) can unmask occult heart failure with preserved ejection fraction (HFpEF). We sought to explore the performance of pulmonary artery wedge pressure (PAWP) during both passive leg raise (PLR) and supine low-workload exercise (EX1; ie, the first step of a step-incremental exercise) to diagnose or exclude HFpEF. Methods In this 2-center international cohort study, we sought to evaluate the diagnostic performance of PAWPPLR and PAWPEX1 in consecutive patients with unexplained dyspnea and PAWP at rest ≤ 15 mmHg who underwent a symptom-limited exercise supine RHC. Results We included 166 patients; more than 50% had an intermediate HFpEF probability; 75% eventually classified as HFpEF after exercise RHC. The area under the curve was 0.67 (0.58–0.76) for PAWPPLR and 0.85 (0.79-0.92) for PAWPEX1. Only PAWPPLR < 4 mmHg certainly excluded HFpEF, with higher PAWPPLR thresholds (eg, < 11 mmHg) being associated with lower sensitivity (80%) and low negative predictive value (34%). PAWPPLR ≥ 21 and ≥ 19 mmHg identified HFpEF with a specificity of 100% and 98%, and a positive predictive value of 100% and 96%, respectively. During a low-workload exercise, PAWPEX1 < 9 mmHg ruled out HFpEF with 100% sensitivity and negative predictive value. PAWPEX1 > 25 mmHg was 100% specific for HFpEF, while PAWPEX1 values between 21 and 25 showed acceptable specificity (90%–95%) and positive predictive value (95%–96%). Conclusions PLR and low-workload supine exercise may reduce the hemodynamic zone of uncertainty for the diagnosis of HFpEF. Both may be useful for the ruling-in of this syndrome, although they are less efficacious for ruling-out HFpEF.