#HFpEF pearl of the day. We often need to “perturb the system” in HFpEF pts to make the Dx or to understand underlying pathophys. When exercise testing is not feasible, even a simple passive leg raise (preload⬆️) maneuver can be helpful. Just use a wedge pillow under the legs.
PCWP ⬆️ significantly with passive leg raise alone in HFpEF, and it has high AUROC for diagnosing HFpEF, almost as good as exercise hemodynamics (exercise PCWP >25 mmHg was used as the gold standard to diagnose HFpEF in this study).
Effect of passive leg raise on mitral inflow is also helpful. In the example 👇, A=rest, B=after release of Valsalva maneuver (Valsalva done incorrectly). C=correct Valsalva showing E/A reversal (=DD is grade 2). D=⬆️⬆️E velocity to 100 cm/s with leg raise (from 70 cm/s at rest).
Effect of passive leg raise on LA reservoir strain: also helpful for HFpEF Dx. Normally LA reservoir strain should augment with passive leg raise but in patients with HFpEF it does not, as shown in the example below.
In the example above, in the patient with non-cardiac dyspnea, both booster strain (down arrow) and conduit strain (up arrow) augmented with passive leg raise. Reservoir = booster + conduit, so reservoir strain augmented as well. None of the 3 LA strains augmented in the HFpEF pt
Change in LVOT VTI in response to passive leg raise can also be helpful. Normally LVOT VTI will go up in response to ⬆️preload. If it doesn’t, it may be a sign of a problem with the LA (sign of LA myopathy in HFpEF).
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