Invasive Exercise PCWP for HFpEF — EECC MCQ

Correct answer: B — Exercise-induced elevation of PCWP >25 mmHg confirms HFpEF — this patient has elevated filling pressures unmasked by exercise that are not apparent at rest, representing the pathophysiological hallmark of HFpEF

Invasive exercise haemodynamics is the gold standard for HFpEF diagnosis when resting parameters are indeterminate. The HFA-PEFF algorithm (ESC 2019 consensus) recommends exercise RHC when: (1) resting PCWP is normal (≤15 mmHg) BUT clinical suspicion for HFpEF remains; (2) non-invasive diastolic stress testing is inconclusive. Diagnostic threshold: exercise PCWP >25 mmHg (at low-moderate workload, typically 25-75 watts supine cycling). This unmasking of elevated filling pressures during exercise is the pathophysiological definition of HFpEF — the stiff, non-compliant LV cannot accommodate the increased venous return during exercise without disproportionate pressure elevation. Importantly: healthy individuals increase PCWP to ~15-20 mmHg during exercise (the 25 mmHg threshold accounts for this physiological range). Exercise PCWP testing has diagnostic and prognostic value and is increasingly used at specialist HFpEF centres.

Reference: ESC (2023): HF Guidelines; HFA-PEFF Algorithm