Characterization of hemodynamic and metabolic abnormalities in the heart failure spectrum: the role of combined cardiopulmonary and exercise echocardiography stress test. [Review]

Pugliese NR; DE Biase N; Balletti A; Filidei F; Pieroni A; D’Angelo G;
Armenia S; Mazzola M; Gargani L; Del Punta L; Asomov M; Cerri E; Franzoni F;
Nesti L; Mengozzi A; Paneni F; Masi S

Minerva Cardiology and Angiology. 70(3):370-384, 2022 Jun.

Heart failure (HF) is a complex clinical syndrome characterized by
different etiologies and a broad spectrum of cardiac structural and
functional abnormalities. Current guidelines suggest a classification
based on left ventricular ejection fraction (LVEF), distinguishing HF with
reduced (HFrEF) from preserved (HFpEF) LVEF. HF should also be thought of
as a continuous range of conditions, from asymptomatic stages to
clinically manifest syndrome. The transition from one stage to the next is
associated with a worse prognosis. While the rate of HF-related
hospitalization is similar in HFrEF and HFpEF once clinical manifestations
occur, accurate knowledge of the steps and risk factors leading to HF
progression is still lacking, especially in HFpEF. Precise hemodynamic and
metabolic characterization of patients with or at risk of HF may help
identify different disease trajectories and risk factors, with the
potential to identify specific treatment targets that might offset the
slippery slope towards overt clinical manifestations. Exercise can unravel
early metabolic and hemodynamic alterations that might be silent at rest,
potentially leading to improved risk stratification and more effective
treatment strategies. Cardiopulmonary exercise testing (CPET) offers
valuable aid to investigate functional alterations in subjects with or at
risk of HF, while echocardiography can assess cardiac structure and
function objectively, both at rest and during exercise (exercise stress
echocardiography [ESE]). The purpose of this narrative review was to
summarize the potential advantages of using an integrated CPET-ESE
evaluation in the characterization of both subjects at risk of developing
HF and patients with stable HF.