Passive leg raise may be viable alternative tool to diagnose, rule out HFpEF
WASHINGTON — Pulmonary capillary wedge pressure during a passive leg raise may be a viable method to diagnose or rule out occult HF with preserved ejection fraction.
According to research presented at the American College of Cardiology Scientific Session, pulmonary capillary wedge pressure of less than 11 mm Hg during a passive leg raise may be enough to rule out occult HFpEF, and a pulmonary capillary wedge pressure of 19 mm Hg or more may be used to diagnose occult HFpEF with 100% accuracy.
The study was simultaneously published in Circulation: Heart Failure.
“Stress testing is required to diagnose so-called ‘occult-HFpEF,’ that is, patients with normal left ventricular filling pressures at rest but a pathological rise in filling pressures during exercise, as a consequence of LV diastolic dysfunction. Noninvasive tests (namely natriuretic peptides and exercise echocardiogram) have been proven to have a low sensitivity and/or low specificity to diagnose (occult) HFpEF,” Arno A. van de Bovenkamp, MD, MSc, of the department of cardiology at Amsterdam University Medical Centers and Amsterdam Cardiovascular Sciences, the Netherlands, and colleagues wrote in Circulation: Heart Failure. “In case of intermediate pretest likelihood, it is recommended to perform a right heart catheterization with exercise, the gold standard to diagnose HFpEF. Although right heart catheterization is proven safe in experienced centers, performing exercise during a right heart catheterization presents some technical challenges, requiring special equipment and expertise, and additional procedure time.”
The passive leg raise increases venous return to the heart due to blood from the patient’s lower extremities that returns to central circulation, according to the study.
For the present analysis, researchers evaluated whether a passive leg raise during right heart catheterization could improve accuracy of occult HFpEF diagnosis.
Researchers enrolled all patients at the VU University Medical Center who underwent pulmonary capillary wedge pressure measurement with exercise stress testing and passive leg raise during right heart catheterization from 2014 to 2020.
The analysis included 33 patients with occult HFpEF, 37 with manifest HFpEF and 39 without HFpEF.
Among patients with normal pulmonary capillary wedge pressure, defined as less than 15 mm Hg, the use of a passive leg raise during right heart catheterization improved diagnostic accuracy compared with pulmonary capillary wedge pressure at rest (area under the curve, 0.82 vs. 0.69; P = .03).
Pulmonary capillary wedge pressure of 19 mm Hg or more during a passive leg raise had a specificity of 100% for the diagnosis occult HFpEF, regardless of diuretic use. At 11 mm Hg or more, the passive leg raise had a 100% sensitivity and negative predictive value for diagnosing occult HFpEF, according to the study.
Using an external validation cohort of 18 patients with occult HFpEF and 24 without HFpEF, researchers found that both pulmonary capillary wedge pressure cutoffs ( 19 mm Hg and < 11 mm Hg) retained 100% specificity and 100% sensitivity.
“Measurement of pulmonary capillary wedge pressure during passive leg raise is a simple tool with high incremental diagnostic value in patients suspected for HFpEF,” van de Bovenkamp told Healio. “Low — less than 11 mm Hg — or high — 19 mm Hg or more — pulmonary capillary wedge pressure values can be used to accurately rule out or diagnose occult HFpEF.”
Moreover, the absolute change in pulmonary capillary wedge pressure during passive leg raise and V-wave-derived parameters provided no added value in diagnosing occult HFpEF.
“Based on the current evidence, I think the above described cutoffs allow us for omission of exercise testing in approximately one-third of the patients currently requiring exercise testing during a right heart catheterization,” van de Bovenkamp told Healio. “As diagnostic accuracy of the passive leg raise is less in patients with intermediate filling pressures during the passive leg raise, exercise should be performed in case of pulmonary capillary wedge pressure during passive leg raise of 11 to 18 mm Hg.”
See the full study for a proposed diagnostic pathway for the implementation of passive leg raise during right heart catheterization.
“Passive leg raise is easy to perform and especially valuable in centers where exercise testing during a right heart catheterization is difficult to perform,” van de Bovenkamp said.
Reference:
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van de Bovenkamp AA, et al. Abstract 1004-03. Presented at: American College of Cardiology Scientific Session; April 2-4, 2022; Washington, D.C. (hybrid meeting).