Proposed standardised protocol of exercise haemodynamic testing
| 1. Include patients with resting mPAP<25 mmHg |
| 2. Brachial or jugular vein approach. |
| 3. Dynamic exercise in supine position on bicycle. |
| 4. Number of work step and work increment to reach the maximum within 10–15 min. |
| 5. Successive stages: baseline supine, legs on cycle pedal, unloaded pedalling (0 W) and at constant workload increments of 10–30 W depending on estimated exercise capacity (usually 1–3 work load steps). |
| 6. Measurement of mPAP and PAWP averaged over the respiratory cycle and CO in triplicate using thermodilution or direct Fick method. |
| 7. Measure mPAP, PAWP and CO at steady state at each step: i.e. unchanged mPAP and heart rate; usually during the last 2 min of each exercise step. |
| 8. Interpretations |
| If at submaximal workload, mPAP >30 mmHg with CO <10 L·min−1: (TPR >3 WU) you can stop the test: exercise PH. |
| If not, continue the test until maximum tolerable workload: |
| If TPRmax ≤3 WU with mPAP >30 mmHg: no exercise PH |
| If TPRmax ≤3 WU with mPAP ≤30 mmHg: no exercise PH |
| If TPRmax >3 WU with mPAP ≤30 mmHg: no exercise PH |
| If TPRmax >3 WU with mPAP >30 mmHg: exercise PH |
mPAP: mean pulmonary artery pressure; PAWP: pulmonary artery wedge pressure; CO: cardiac output; TPRmax: total pulmonary resistance at maximal exercise.