By Michael H. Crawford, MD, Editor
Synopsis: A small observational study of patients with ischemic cardiomyopathy and mitral valve regurgitation referred for exercise testing who underwent isometric handgrip exercise showed that the baseline presence or development of severe mitral regurgitation with exercise was predictive of a composite adverse outcome endpoint at one year.
Source: Spieker M, Sidabras J, Lagarden H, et al. Exercise-induced dynamic mitral regurgitation is associated with outcomes in patients with ischaemic cardiomyopathy. ESC Heart Fail. 2025; Jan 20. doi: 10.1002/ehf2.15195. [Online ahead of print].
Bicycle exercise echocardiography is recommended to unmask severe mitral regurgitation (MR) and increased pulmonary artery pressure (PAP) in patients with ischemic MR, which may explain a patient’s symptoms and suggest the value of a mitral valve (MV) intervention. However, there is a paucity of data on the potential value of isometric handgrip exercise for this purpose. Thus, these investigators from Germany studied patients with left ventricular ejection fraction (LVEF) < 50% as the result of ischemic heart disease (IHD) with at least mild MR who were referred for exercise testing.
Excluded were patients with inadequate echo images, inability to perform handgrip exercise, previous MV procedures, and severe aortic or MV stenosis. The resulting 133 patients recruited from 2018-2021(mean age 75 years, 21% women) performed handgrip exercise at 30% of their maximum effort for three to five minutes while an echocardiogram was recorded. None of their medications were held for the study, including beta-blockers. After the handgrip exercise study, they were followed for one year. The composite primary outcome endpoint was the first occurrence of all-cause mortality, heart failure hospitalization (HFH), MV surgery, MV transcutaneous edge-to-edge repair (TEER), LV assist device (AD) placement, or heart transplantation.
Handgrip exercise increased heart rate (73 bpm to 83 bpm, P < 0.001) and systolic blood pressure (115 mmHg to 129 mmHg, P < 0.001). Estimated PAP also increased (40 mmHg to 47 mmHg, P < 0.001). At rest, nine patients (7%) had severe MR. With handgrip exercise, 25 patients (20%) with mild to moderate MR developed severe MR. Thus, the total number of patients with severe MR increased significantly with exercise (nine to 34, P < 0.001).
The one-year follow-up was accomplished in 96% of the patients. The composite primary endpoint occurred in 56% of the patients (10% died, 26% HFH, 24% TEER, 5% MV surgery, 1% LVAD, 4% transplant). Severe MR at rest was not predictive of the composite endpoint, whereas severe MR with handgrip exercise was (hazard ratio [HR], 2.00; 95% confidence interval [CI], 1.37-2.94; P < 0.001).
The authors concluded that resting evaluation of ischemic MR may underestimate the severity of MR. However, isometric handgrip exercise can identify one in five patients with severe MR. Severe MR with exercise, but not at rest, was predictive of one-year adverse outcomes or MV interventions.
Commentary
Studies of bicycle exercise have reported that 20% to 50% of patients with ischemic cardiomyopathy have dynamic MR. This German study has shown that 20% of such patients have severe MR with isometric handgrip exercise, and compared to their resting results, 37% were reclassified. Isometric handgrip exercise mainly increases afterload, whereas dynamic exercise (e.g., bicycle) increases both afterload and preload. The afterload increase with handgrip exercise in the German study largely was the result of increased blood pressure. Average LV volumes were somewhat higher with exercise, but the changes were not significant. However, the investigators did observe significant changes in the geometry of the MV apparatus that have been associated with MR (tenting height and area). The German authors postulate that handgrip exercise could be especially useful in patients with symptoms but non-severe MR to unmask those who may benefit from an MV intervention.
There are limitations to this study. The principle one is that it is not a randomized trial comparing handgrip to bicycle exercise or comparing handgrip exercise to no exercise testing. Given the encouraging results from this observational study, perhaps a randomized trial will be conducted. Also, the number of patients was small, and no one was blinded to the results of exercise testing. In addition, the population was patients referred for exercise testing, which may not represent all patients with ischemic cardiomyopathy and MR. Finally, the population studied was biased toward those being considered for an intervention.
At this time, bicycle exercise probably is the preferred method of risk stratifying patients with MR and ischemic cardiomyopathy. However, a significant proportion of such patients either are incapable of performing bicycle exercise or cannot achieve enough exercise to assess the competence of the MV adequately. Thus, it seems that handgrip exercise could be a useful alternative. Also, handgrip exercise requires less equipment and technical staff to perform. It also can be done at the bedside using auscultation to detect changes in the intensity and duration of the MR murmur. Although not as sophisticated as echocardiography, this bedside application could be useful in certain circumstances.
Michael H. Crawford, MD, is Professor Emeritus of Medicine and Consulting Cardiologist, UCSF Health, San Francisco.
A small observational study of patients with ischemic cardiomyopathy and mitral valve regurgitation referred for exercise testing who underwent isometric handgrip exercise showed that the baseline presence or development of severe mitral regurgitation with exercise was predictive of a composite adverse outcome endpoint at one year.
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