Response by Obokata and Borlaug to Letter Regarding Article, "Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction: A Simultaneous Invasive-Echocardiographic Study".

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HomeCirculationVol. 136, No. 4Response by Obokata and Borlaug to Letter Regarding Article, “Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction: A Simultaneous Invasive-Echocardiographic Study” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Obokata and Borlaug to Letter Regarding Article, “Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction: A Simultaneous Invasive-Echocardiographic Study” Masaru Obokata, MD, PhD and Barry A. Borlaug, MD Masaru ObokataMasaru Obokata From Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN. Search for more papers by this author and Barry A. BorlaugBarry A. Borlaug From Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN. Search for more papers by this author Originally published25 Jul 2017https://doi.org/10.1161/CIRCULATIONAHA.117.029037Circulation. 2017;136:430–431In Response:We thank Drs Smiseth and Nagueh for their interest in our recent publication testing the role of invasive and noninvasive diastolic stress testing in the evaluation of heart failure with preserved ejection fraction (HFpEF).1 The authors point out how the hemodynamic data collected in our study provides a unique opportunity to understand more about the determinants of exercise capacity in patients with HFpEF. We agree, and in fact we have published a different article from this cohort specifically devoted to that question.2The goal of this article was not to characterize the pathophysiology but to examine the role of exercise testing in the diagnosis of HFpEF.1 As the authors recommended, we have reanalyzed our sample using the algorithm from Figure 8B from the American Society of Echocardiography and the European Association of Cardiovascular Imaging document.3 Like the algorithm from Figure 8A that we tested in our study,1 this scheme displayed poor sensitivity for HFpEF (42%). Even if we restrict the analysis to the 32 subjects with HFpEF in our study with high filling pressures at rest, the algorithm from Figure 8B again displayed poor sensitivity (63%).The authors suggest that scatterplots correlating hemodynamics and echocardiographic indices with exercise performance would have been informative. That was not the purpose of our article.1 However, those questions were examined in our earlier report.2 As we demonstrated in that article, exercise capacity (peak oxygen consumption) was inversely correlated with directly measured filling pressures during exercise (r= −0.44, P<0.001) as well as pulmonary artery pressures (r= −0.45, P<0.001).2 In contrast, resting E/e’ ratio was only modestly correlated with peak aerobic capacity (r= −0.30, P=0.01).Drs Smiseth and Nagueh suggest that invasive diastolic stress testing is not practical and is restricted to a small number of centers. We are aware of ≥30 US medical centers currently performing invasive hemodynamic exercise tests for the evaluation of unexplained dyspnea, and >200 exercise catheterizations are performed each year at our institution alone. The added equipment needed for this purpose is minimal and inexpensive and in past eras was available in most diagnostic catheterization labs. Our study cohort was not highly selected but was drawn from consecutive patients referred to our laboratory with unexplained exertional dyspnea, reflecting what is seen in the community.Last, the necessity of invasive exercise testing for a substantial portion of patients with dyspnea is neither an assumption nor is it premature because this conclusion is supported by empirical data obtained in a prospective trial.1 We agree that further study and validation may be worthwhile, particularly to verify the utility and accuracy of exercise echocardiography because previous studies from other groups have reported less robust findings using noninvasive imaging compared with our data.4,5 Accurate diagnosis in patients presenting with dyspnea can provide a multitude of valuable, patient-centered benefits that positively affect the care we deliver. This often requires careful hemodynamic measurements during exercise in addition to rest, and these tests are too frequently not performed at all, invasively or noninvasively.Masaru Obokata, MD, PhDBarry A. Borlaug, MDDisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.