The role of exercise during hemodynamic assessment to improve pulmonary hypertension diagnosis in older adults

Pulmonary hypertension (PH) is a disorder that complicates multiple cardiac and respiratory diseases. PH is currently classified into two main hemodynamic states, including pre-capillary PH (Pre-cap PH) and PH associated with left heart disease (PH-LHD). However; the current clinical and hemodynamic diagnostic approach does not fully discriminate the 2 conditions for patients suspected of having PH who are older, particularly when cardiovascular risk factors (CVRF) are present. Exercise is a strategy that may improve the ability to distinguish the 2 conditions. We are conducting a single-center prospective cohort study to evaluate the clinical value of the systematic addition of exercise to initial diagnostic right-heart catheterization (RHC) in a population of older adults with suspected PH. In this interim analysis, we present the clinical and hemodynamic characteristics of the cohort, initial hemodynamic diagnosis and the effect of exercise to change the hemodynamic classification. In brief, our inclusion criteria were patients older than 45 years with at least one CVRF. Resting hemodynamic classifications were based on the most current iteration of the guidelines from the ESC/ERS. Cycle ergometry was performed in a semi-upright position as we have previously published. To date, we have recruited 36 patients (50% female; 72±9 years). The table demonstrates the high prevalence of CVRF including hypertension (86%), diabetes mellitus (36%) and obesity (44%). In this cohort, 75% had at least 3 CVRF while 42% had a risk factor for Pre-cap PH. Rest and exercise hemodynamic classifications are demonstrated in the Figure. At rest, 50% were demonstrated to have Pre-cap PH and 31% PH-LHD. With exercise, overall, the vast majority were demonstrated to have some form of PH even if baseline hemodynamics were normal. The systematic addition of exercise to RHC changed hemodynamic classifications in over half the population. Specifically, the proportion of patients with Pre-cap PH decreases from 50% to 31%, while the proportion of PH-LHD increases from 31% to 53%. In a group of older patients with suspected PH without obvious cardiac etiology, exercise added to RHC resulted in a reclassification of the PH diagnosis in over half of the patients. The reclassification included Exercise PH not evident at rest and a shift of the dominant PH diagnosis from Pre-cap PH to PH-LHD. Our next steps include to evaluate if these reclassifications are clinically relevant.View Large Image Figure ViewerDownload Hi-res image Download (PPT)