title: The combined exercise stress echocardiography and cardiopulmonary exercise test for identification of masked heart failure with preserved ejection fraction in patients with hypertension.
abstract: BACKGROUND
  Heart failure with preserved ejection fraction (HFpEF) is commonly associated with hypertension (HTN). However, resting echocardiography (ECHO) can underestimate the severity of disease. Exercise stress echocardiography (ESE) and the cardiopulmonary exercise testing (CPX) appeared to be useful tests in dynamic assessment of HFpEF. The value of combined exercise stress echocardiography cardiopulmonary testing (ESE-CPX) in the identification of masked HFpEF is still undetermined.
  
  
  OBJECTIVE
  The purpose of this study was to analyse the value of the combined ESE-CPX in the identification of masked HFpEF in patients with HTN, dyspnoea and normal resting left ventricular (LV) systolic and diastolic function.
  
  
  METHODS
  We studied 87 patients with HTN, exertional dyspnoea and normal resting LV function. They all underwent ESE-CPX testing (supine bicycle, ramp protocol, 15 W/min). ECHO measurements were performed at rest, and at peak load. Achievement of peak E/e' ratio>15 was a marker for masked HFpEF.
  
  
  RESULTS
  Increase of E/e'>15 occurred in 8/87 patients (9.2%) during ESE-CPX. Those patients had the lower peak VO2 (p = 0.012), the lower VO2 at anaerobic threshold (p = 0.025), the lower workload (p = 0.026), the lower peak partial pressure end tidal carbon dioxide (PetCO2) (p < 0.0001), and the higher VE/VCO2 slope (p < 0.0001) which was an independent multivariate predictor of HFpEF (p = 0.021), with the cut-off value of 32.95 according to the receiver-operator characteristic (ROC) curve (sensitivity (Sn) 100%, specificity (Sp) 90%).
  
  
  CONCLUSIONS
  The combined ESE-CPX test is feasible and reliable test that can unmask HFpEF and may become an important aid in the early diagnosis of HFpEF, excluding the other causes of exertional dyspnoea.
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia ivannanedeljkovic@yahoo.com.
authors.forename: Ivana
authors.initials: I
authors.lastname: Nedeljkovic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Marko
authors.initials: M
authors.lastname: Banovic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Jelena
authors.initials: J
authors.lastname: Stepanovic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Vojislav
authors.initials: V
authors.lastname: Giga
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Ana
authors.initials: A
authors.lastname: Djordjevic-Dikic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Danijela
authors.initials: D
authors.lastname: Trifunovic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Milan
authors.initials: M
authors.lastname: Nedeljkovic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Milan
authors.initials: M
authors.lastname: Petrovic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Milan
authors.initials: M
authors.lastname: Dobric
authors.affiliation: Outpatient Clonoc for Sport Medicine 'Vita Maxima', Belgrade, Serbia.
authors.forename: Nenad
authors.initials: N
authors.lastname: Dikic
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia.
authors.forename: Milan
authors.initials: M
authors.lastname: Zlatar
authors.affiliation: Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia.
authors.forename: Branko
authors.initials: B
authors.lastname: Beleslin
mesh_terms: D000328:Adult; D019540:Area Under Curve; D001642:Bicycling; D004417:Dyspnea / Q000209:etiology / Q000503:physiopathology; D018619:Echocardiography, Doppler, Pulsed; D025401:Echocardiography, Stress / Q000379:methods*; D005080:Exercise Test; D017079:Exercise Tolerance; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D006973:Hypertension / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption; D011237:Predictive Value of Tests; D011379:Prognosis; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D013318:Stroke Volume; D016277:Ventricular Function, Left
keywords: Diastolic function; cardiopulmonary exercise testing; exercise echocardiography; hypertension