Exercise Hemodynamics to Evaluate the Breathless Patient: Defining the Normal Pulmonary Arterial Wedge Pressure

The diagnosis of heart failure with preserved ejection fraction (HFpEF) may appear to be straightforward, with the patient frequently having comorbidities, such as longstanding hypertension, symptoms and signs of heart failure, preserved left ventricular ejection fraction, evidence on echocardiography of impaired relaxation, and other structural abnormalities, such as left atrial enlargement and elevated circulating natriuretic peptides. However, in many cases the diagnosis may be less evident. In that situation, a form of stress test has been advocated to establish the diagnosis. 1 Exercise echocardiography can be used to noninvasively assess left ventricular filling pressures, pulmonary artery pressures, longitudinal systolic strain, and stroke volume changes with exercise. Another method that can be performed during exercise testing is right heart catheterization. 2 As an invasive test, it can provide a comprehensive hemodynamic assessment with right atrial, pulmonary, and pulmonary arterial wedge pressures as well as cardiac output.