- Design
- Diagnostic accuracy study against invasive exercise haemodynamics, with multicentre validation
- Population
- 482 patients with chronic unexplained dyspnoea (386 HFpEF, 96 non-cardiac)
- Primary outcome
- Diagnostic accuracy for HFpEF
- Effect
- Current approach sensitivity 55–60%; two-threshold model 95–99% among classified, invasive tests ~60% → ~30%
A multicentre study in the European Heart Journal (10 September) took 482 patients with chronic unexplained breathlessness and put them through invasive haemodynamic exercise testing with simultaneous echocardiography. 386 had HFpEF on invasive criteria; 96 had a non-cardiac cause.
Using the current scores (H2FPEF, HFA-PEFF, HFpEF-ABA) with exercise echocardiography as currently recommended, sensitivity was only 55–60%. Adding resting left atrial compliance — left atrial reservoir strain divided by E/e' — raised sensitivity to about 85%, but at the cost of 31–43% false positives.
The useful step was using two thresholds instead of one. Exercise E/e' of 13.8 or more, or resting left atrial compliance of 1.6% or less, ruled HFpEF in. Exercise E/e' below 7.2 together with compliance above 4.4% ruled it out. Everyone in between stayed indeterminate and went to invasive testing. Among patients who could be classified, sensitivity reached 95–99%, and the share needing an invasive study fell from about 60% to about 30%. The result held in an international validation cohort.
For most clinics the message is that a normal exercise echo does not exclude HFpEF. Where left atrial strain is available, reporting it adds real diagnostic value; where it is not, an indeterminate patient with a convincing story still needs referral for invasive testing.
- A normal exercise echocardiogram does not rule out HFpEF in a breathless patient.
- Ask the echo lab to report left atrial reservoir strain alongside E/e' where it is available.
- Rule-in thresholds in this study: exercise E/e' ≥13.8 or resting left atrial compliance ≤1.6%.
- Rule-out required both exercise E/e' <7.2 and left atrial compliance >4.4%.
- Refer patients who fall between the thresholds for invasive exercise haemodynamics.
Why it matters
It challenges the assumption that exercise echo can stand in for invasive testing in unexplained breathlessness.
Don't overread it
The thresholds come from specialist centres with invasive testing; how they perform in routine echo labs is untested.
The statistics, in plain English
Sensitivity of 55–60% means that of every ten patients who really had HFpEF, current non-invasive methods found only five or six. The two-threshold approach reached 95–99% only among patients it could classify; about 30% remained indeterminate and still needed an invasive test.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for cardiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free