Top Things to Know: Standardization of Baseline and Provocative Invasive Hemodynamic Protocols for the Evaluation of Heart Failure and Pulmonary Hypertension
Published: January 06, 2026
Prepared by Natalie Tapaskar, MD, Assistant Professor of Medicine, Advanced Heart Failure, LVAD, Heart Transplant, UT Southwestern Medical Center
- This statement provides guidance on the role of static, provocative, and serial assessments of invasive hemodynamics in phenotyping and management of patients with heart failure (HF), HF with preserved ejection fraction (HFpEF), pulmonary hypertension (PH), left ventricular assist support devices (LVAD), and cardiogenic shock (CS). Further research is needed in individualizing care in response to dynamic hemodynamic testing.
- PH is an important predictor of 30-day mortality after heart transplant. Thus, vasoreactivity testing is helpful to assess the reversibility of PH in patients with HF failure via infusion of sodium nitroprusside or a milrinone bolus. Inhaled nitric oxide can also be used if pulmonary artery wedge pressure (PAWP) is not elevated.
- When static hemodynamics do not explain symptoms of dyspnea, provocative maneuvers using fluid bolus challenge and passive leg raise can help unmask occult post-capillary PH.
- Invasive exercise hemodynamic testing helps identify causes of exertional symptoms and assesses cardiac function, preload, and exercise-induced pulmonary hypertension. It is important to consider differences in equipment, protocols, and thresholds between supine and upright testing methods when interpreting results.
- Exercise-induced PH predicts outcomes independently from resting pulmonary hemodynamics and is identified by a steeper flow-normalized mean pulmonary artery pressure increase, however exercise-induced PH remains a physiologic finding and is not yet a distinct target for specific therapeutics.
- Acute vasoreactivity testing (AVT) using inhaled prostacyclin analogs or nitric oxide, which are favored over intravenous agents, is indicated in patients with suspected idiopathic, heritable, and drug-induced pulmonary arterial hypertension. Positive AVT response defined as mPAP ≥ 10 mmHg to an absolute value < 40 mmHg without a decrease in cardiac output predicts long-term clinical response to calcium channel blocker therapy.
- In the current era of magnetically levitated centrifugal-flow LVAD therapy, invasive hemodynamics during ramp and reverse ramp studies are preferred over echocardiogram alone to optimize LVAD pump performance. Achievement of a CVP <12 mmHg, PAWP <18 mmHg, and CI > 2.2 L/min/m2 is associated with reduced hospital admissions and hemocompatibility-related adverse events. Reverse ramp studies at both full and nominal LVAD support are important to assess for myocardial recovery with LVAD therapy.
- Continuous pulmonary artery catheter (PAC) use is helpful in patients with advanced PH and/or RV dysfunction undergoing high-risk procedures or peri-operatively for LVAD implantation, pulmonary endarterectomy, or liver transplant recipients with portopulmonary hypertension, however more data are needed to guide the routine use of early PAC in CS management.
- Serial RHC can track disease evolution and guide therapy escalation in HF-CS patients that are unable to titrate medical therapy, every 3-6 months in patients listed for heart transplant, in patients with LVADs to re-assess pulmonary vascular resistance (if limiting transplant eligibility) or for myocardial recovery, and in those with pulmonary vascular disease at routine intervals to assess treatment changes, or with clinical worsening.
- Remote implanted PA pressure monitoring consistently reduces HF-related hospitalizations, making it a valuable option for high-risk HF patients who can be managed within structured multidisciplinary teams.
Citation
Belkin MN, Fudim M, Baratto C, Grinstein J, Hollis I, Ijioma N, Kataria R, Lewis G, Mak S, Tedford RJ, Thibodeau JT, Yaku H; on behalf of the American Heart Association Fellow-In-Training and Early Career Committee of the Council on Clinical Cardiology. Standardization of baseline and provocative invasive hemodynamic protocols for the evaluation of heart failure and pulmonary hypertension: a scientific statement from the American Heart Association. Circ Heart Fail. 2026;19:e000088. doi: 10.1161/HHF.0000000000000088