Physician Update: AHA Special Edition
Read more articles from our most relevant research presented at the 2025 AHA Scientific Sessions.
Comprehensive Heart and Vascular Center
Noninvasive Diastolic Stress Testing in a Large Observational Cohort Study: Insights from the Dallas Heart Study
By Alvin Chandra, M.D.
Associate Professor of Internal Medicine
Heart failure with preserved ejection fraction (HFpEF) is an increasing public health challenge, especially among older adults, yet diagnosis remains difficult because symptoms often manifest only with exertion. While invasive hemodynamic exercise testing is the gold standard for detecting elevated filling pressures, it is costly and not widely available. Noninvasive diastolic stress echocardiography has shown promise in smaller studies.
For example, the study we presented at #AHA25 (myself and Yimin Yang, M.S., B.S.; Yinun Zeleke, M.S.; Ambarish Pandey, M.D.; James de Lemos, M.D.; Jarett Berry, M.D., M.S.; and Amil Shah, M.D., M.P.H.) evaluated the prevalence and predictors of subclinical HFpEF using noninvasive diastolic stress testing in phase 3 of the Dallas Heart Study. The analysis included 712 adults with preserved LVEF (≥ 50%) and no history of heart failure who underwent semi-recumbent bicycle stress echocardiography with resting imaging and submaximal exercise at 30 watts. An abnormal response was defined as mean E/e′ > 14.
“These findings demonstrate that noninvasive diastolic stress echocardiography is feasible at scale and can uncover subclinical HFpEF that is not apparent at rest.”
Alvin Chandra, M.D.
Participants were on average 59 years old, 56% female, and racially diverse (47% Black, 32% White, 18% Hispanic). Hypertension and diabetes were present in 58% and 23%, respectively, and mean BMI was 31. Mean LV mass index was normal at 81 g/m², and mean LVEF at rest was normal at 62%.
Stress testing increased e′ velocities, TR velocity, and LA volume. At rest, 5% of our participants had abnormal mean E/e’ ratio, while during stress, this increased to 8%. Importantly, 36 participants had normal E/e’ ratio at rest but abnormal during stress – highlighting the value of exercise testing. Multivariable regression identified age and BMI as independent predictors of abnormal stress response.
These findings demonstrate that noninvasive diastolic stress echocardiography is feasible at scale and can uncover subclinical HFpEF that is not apparent at rest. As therapeutic options for HFpEF continue to expand, broader implementation of this approach may enable earlier identification and risk-guided management in at-risk populations.
