Invasive haemodynamic assessment in heart failure with preserved ejection fraction

Abstract

Despite the increasing prevalence and substantial burden of heart failure with preserved ejection fraction (HFpEF), which constitutes up to 50% of all heart failure cases, significant challenges persist in its diagnostic and therapeutic strategies. These difficulties arise primarily from the heterogeneous nature of the condition, the presence of various comorbidities and a wide range of phenotypic variations. Considering these challenges, current international guidelines endorse the utilization of invasive haemodynamic assessments, including resting and exercise haemodynamics, as the gold standard for enhancing diagnostic accuracy in cases where traditional diagnostic methods yield inconclusive results. These assessments are crucial not only for confirming the diagnosis but also for delineating the complex underlying pathophysiology, enabling the development of personalized treatment strategies, and facilitating the precise classification of HFpEF phenotypes. In this review, we summarize the haemodynamic changes observed in patients with HFpEF, comparing resting and exercise-induced parameters to those of normal subjects. Additionally, we discuss the current role of invasive haemodynamics in HFpEF assessment and highlight its utility beyond diagnosis, such as identifying HFpEF comorbidities, guiding phenotype-based personalized therapies and characterizing prognostication. Finally, we address the challenges associated with utilizing invasive haemodynamics and propose future directions, focusing on integrating these assessments into routine HFpEF care.

Keywords: heart failure with preserve ejection fraction; invasive haemodynamic assessment.

Figure 1

Pathophysiological changes during exercise: comparison between normal versus HFpEF patients. Abbreviations: CO, cardiac output; HFpEF, heart failure with preserved ejection fraction; LV, left ventricle; LVEDP, left ventricular end‐diastolic pressure.

Figure 2

Haemodynamic changes during exertion in HFpEF versus healthy individuals. Abbreviations: HFpEF, heart failure with preserved ejection fraction; LV, Left ventricle; PAWP, pulmonary artery wedge pressure.

Figure 3

Strategic workflow for HFpEF diagnosis: from risk stratification to targeted case selection for invasive haemodynamic assessment. Abbreviations: CO, cardiac output; HFpEF, heart failure with preserved ejection fraction; PAWP, pulmonary artery wedge pressure.

Figure 4

Difference between supine versus upright positioning during exercise RHC. Abbreviations: CO, cardiac output; HFpEF, heart failure with preserved ejection fraction; mPAP, mean pulmonary artery pressure; PAWP, pulmonary artery wedge pressure; RAP, right atrial pressure; RHC, right heart catheterization.

Figure 5

Phenotypic classification in HFpEF for clinical trial participation. RESPONDER‐HF requires patients to have peak exercise PAWP ≥ 25 mmHg and exercise PVR < 1.75 WU, while ALLAY‐HF requires patients to have peak exercise LAP ≥ 25 mmHg and exercise PVR < 1.8 WU. Abbreviations: BMI, body mass index; GDMT, guideline directed medical therapy; HF, heart failure; HFmREF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; LAP, left atrial pressure; mPAP, mean pulmonary artery pressure; PA, pulmonary artery; PAWP, pulmonary artery wedge pressure; PLR, passive leg raising; PVR, pulmonary vascular resistance; RAP, right atrial pressure; WU, Wood unit.