Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test

Aim We combined cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE) to identify early haemodynamic and metabolic alterations in patients with hypertension (HT) with and without heart failure with preserved ejection fraction (HFpEF). Methods and results Fifty stable HFpEF‐HT outpatients (mean age 68 ± 14 years) on optimal medical therapy, 63 well‐controlled HT subjects (mean age 63 ± 11 years) and 32 age and sex‐matched healthy controls (mean age 59 ± 15 years) underwent a symptom‐limited graded ramp bicycle CPET‐ESE. The acquisition protocol included left ventricular cardiac output, global longitudinal strain, E/e′, peak oxygen consumption (VO2), non‐invasive arterial–venous oxygen content difference (AVO2diff) and lung ultrasound B‐lines. There was a decline in peak VO2 from controls (24.4 ± 3 mL/min/kg) to HFpEF‐HT (15.2 ± 2 mL/min/kg), passing through HT (18.7 ± 2 mL/min/kg; P  < 0.0001). HFpEF‐HT displayed a lower peak cardiac output (9.8 ± 0.9 L/min) compared to HT (12.6 ± 1.0 L/min; P = 0.02) and controls (13.3 ± 1.0 L/min; P = 0.01). Peak AVO2diff was reduced in HFpEF‐HT and HT (13.3 ± 2 and 13.5 ± 2 mL/dL vs. controls: 16.9 ± 2 mL/dL; P < 0.0001). A different left ventricular contractility was observed among groups, expressed as low‐load global longitudinal strain (−16.8 ± 5% in HFpEF‐HT, −18.2 ± 3% in HT, and 20.9 ± 3% in controls; P < 0.0001), and distribution of E/e′ and B‐lines [HFpEF‐HT: 13.7 ± 3 and 16, interquartile range (IQR) 10–22; HT: 9.5 ± 2 and 8, IQR 4–10; controls: 6.2 ± 2 and 0, IQR 0–2; P < 0.0001]. Conclusions Reduced peak VO2 values in HT with and without HFpEF may be the result of decreased AVO2diff. CPET‐ESE can also identify mild signs of left ventricular systo‐diastolic dysfunction and pulmonary congestion, promoting advances in personalized therapy.