The Effect of Leg Elevation on Preload Responsiveness in Heart Failure Patients
DOI:
https://doi.org/10.37287/ijghr.v8i1.651Keywords:
fluid responsiveness, heart failure, hemodynamics, passive leg raisingAbstract
Accurate hemodynamic assessment is critical for guiding fluid therapy and avoiding fluid overload in patients with heart failure (HF). Leg elevation maneuvers, including passive leg raising (PLR) and leg lifting (PLL), have emerged as functional diagnostic interventions. Still, their multifaceted roles across different HF phenotypes have not been fully synthesized. This literature review aimed to evaluate the effect of leg elevation on preload responsiveness and its broader clinical applications in adult patients with HF. A comprehensive search of online studies published between 2019 and 2025 was conducted across multiple databases (Sage Journals, Scopus, ScienceDirect, PubMed, Wiley Online Library, and ProQuest). Keywords included “heart failure”, “passive leg raising”, and “hemodynamics.” A total of 1551 articles were identified, and 5 articles were thoroughly reviewed. Five articles that met the inclusion criteria were systematically analyzed to synthesize evidence on the impact of PLR on key hemodynamic parameters. Leg elevation serves distinct, context-dependent roles. PLR/PLL is a provocative test in patients with suspected HF with preserved ejection fraction (HFpEF), confirming latent diastolic dysfunction with a significant PCWP increase. A blunted increase in the stroke volume index (SVi) during PLR/PLL signifies exhausted preload reserve and is an independent predictor of poor clinical outcomes in patients with HF with reduced ejection fraction (HFrEF). A significant decrease in PPV during the maneuver accurately predicts fluid responsiveness, which is particularly crucial for vulnerable patients, such as those with heart failure, as it remains accurate even with low-tidal-volume ventilation. Leg elevation is a versatile and reliable non-invasive maneuver with a multifaceted role in the management of HF. Beyond simply predicting fluid responsiveness, it functions as a crucial diagnostic tool for HFpEF, a prognostic tool for HFrEF, and an accurate predictor of fluid needs in critical care settings. Integrating PLR/PLL into clinical practice allows for precise, physiology-based decision-making, fluid management optimization, and improved patient outcomes.
References
Alvarado-Sánchez, J. I. (2015). The passive leg raising test (PLR). Colombian Journal of Anesthesiology, 43(3), 214–218. https://doi.org/10.1016/j.rcae.2015.03.005
Araos, J., Kenny, J. E. S., Rousseau-Blass, F., & Pang, D. S. (2020). Dynamic prediction of fluid responsiveness during positive pressure ventilation: A review of the physiology underlying heart-lung interactions and a critical interpretation. Veterinary Anaesthesia and Analgesia, 47(1), 3–14. https://doi.org/10.1016/j.vaa.2019.08.004
Barjaktarevic, I., et al. (2018). Ultrasound assessment of the change in carotid corrected flow time in fluid responsiveness in undifferentiated shock. Critical Care Medicine, 46(11), e1040–e1046. https://doi.org/10.1097/CCM.0000000000003356
Berger, D., Moller, P. W., & Bachmann, K. F. (2023). Cardiopulmonary interactions—Which monitoring tools to use? Frontiers in Physiology, 14. https://doi.org/10.3389/fphys.2023.1234915
Bhadade, R., Harde, M., de Souza, R., & Madke, T. (2022). Assessment of fluid responsiveness by changes in end tidal carbon dioxide during passive leg raising test and fluid challenge. Journal of the Association of Physicians of India, 70(5), 70–75.
Chandra, K. A., Herawati, T., & Zahra, A. N. (2025). The effectiveness of breathing exercises in reducing dyspnea in patients with heart failure: A systematic review. Malahayati International Journal of Nursing and Health Science, 8(3), 389–398. https://doi.org/10.33024/minh.v8i3.913
Chen-Scarabelli, C., Saravolatz, L., Hirsh, B., Agrawal, P., & Scarabelli, T. M. (2015). Dilemmas in end-stage heart failure. Journal of Geriatric Cardiology, 12(1), 57–65. https://doi.org/10.11909/j.issn.1671-5411.2015.01.007
Cherpanath, T. G. V., et al. (2016). Predicting fluid responsiveness by passive leg raising: A systematic review and meta-analysis of 23 clinical trials. Critical Care Medicine, 44(5), 981–991. https://doi.org/10.1097/CCM.0000000000001556
Eder, M., et al. (2023). The importance of forward flow and venous congestion in diuretic response in acute heart failure: Insights from the ESCAPE trial. International Journal of Cardiology, 381, 57–61. https://doi.org/10.1016/j.ijcard.2023.04.002
Fudim, M., Khan, M. S., Paracha, A. A., Sunagawa, K., & Burkhoff, D. (2022). Targeting preload in heart failure: Splanchnic nerve blockade and beyond. Circulation: Heart Failure, 15(3), 211–220. https://doi.org/10.1161/CIRCHEARTFAILURE.121.009340
Health Research and Development Agency. (2019). National Riskesdas Report 2018. Jakarta: Health Research and Development Agency Publishing Institute (LPB).
Henein, M. Y., Tossavainen, E., A’roch, R., Söderberg, S., & Lindqvist, P. (2019). Can Doppler echocardiography estimate raised pulmonary capillary wedge pressure provoked by passive leg lifting in suspected heart failure? Clinical Physiology and Functional Imaging, 39(2), 128–134. https://doi.org/10.1111/cpf.12547
Hotz, E., van Gemmern, T., & Kriege, M. (2024). Are we always right? Evaluation of the performance and knowledge of the passive leg raise test in detecting volume responsiveness in critical care patients: A German national survey. Journal of Clinical Medicine, 13(9), 2518. https://doi.org/10.3390/jcm13092518
Jaenputra, J. J., Sigit, R., Harsono, T., & Firdaus, A. A. A. (2024). Heart disease detection from PSAX echocardiography view using ultrasound portable based on machine learning method. In Proceedings of the 2024 International Electronics Symposium: Shaping the Future: Society 5.0 and Beyond (pp. 637–643). IEEE. https://doi.org/10.1109/IES63037.2024.10665785
Jatmiko, W., Ma’Sum, M. A., Isa, S. M., Imah, E. M., Rahmatullah, R., & Wiweko, B. (2016). Developing smart telehealth system in Indonesia: Progress and challenge. 2015 International Conference on Advanced Computer Science and Information Systems (ICACSIS), 29–36. https://doi.org/10.1109/ICACSIS.2015.7415199
Kapur, N. K., et al. (2024). Mechanical preload reduction: Harnessing a cornerstone of heart failure management to improve clinical outcomes. ASAIO Journal, 70(10), 821. https://doi.org/10.1097/MAT.0000000000002240
Kar, A. (2025). What happens to preload and afterload in heart failure? Narayana Health. https://www.narayanahealth.org/blog/what-happens-to-preload-and-afterload-in-heart-failure
Klabunde, R. E. (2025). CV Physiology: Pathophysiology of heart failure. Wolters Kluwer. https://cvphysiology.com/heart-failure/hf003
Kurniyanti, W. S., Herawati, T., & Aryani, D. F. (2023). Effect of physical exercise on heart failure patients. Journal of Telenursing (JOTING), 5(2), 2650–2659. https://doi.org/10.31539/joting.v5i2.5854
Mallat, J., et al. (2022). Passive leg raising-induced changes in pulse pressure variation to assess fluid responsiveness in mechanically ventilated patients: A multicenter prospective observational study. British Journal of Anaesthesia, 129(3), 308–316. https://doi.org/10.1016/j.bja.2022.04.031
Mallat, J., et al. (2025). Changes in pulse pressure variation induced by passive leg raising test to predict preload responsiveness in mechanically ventilated patients with low tidal volume in ICU: A systematic review and meta-analysis. Critical Care, 29(1), 18. https://doi.org/10.1186/s13054-024-05238-x
Matolinets, N., & Yakymenko, I. (2024). Assessment of fluid responsive unity as a component of hemodynamic monitoring in the operating room and intensive care unit. Emergency Medicine (Ukraine), 20(6), 475–481. https://doi.org/10.22141/2224-0586.20.6.2024.1759
Ministry of Health, Republic of Indonesia. (2024). Thematic Report of the 2023 Indonesian Health Survey: Portrait of a Healthy Indonesia. Jakarta: Ministry of Health.
Moher, D., et al. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097
Savarese, G., Becher, P. M., Lund, L. H., Seferovic, P., Rosano, G. M. C., & Coats, A. J. S. (2023). Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovascular Research, 118(17), 3272–3287. https://doi.org/10.1093/cvr/cvac013
Shibata, N., et al. (2021). Easy-to-use preload stress echocardiography by using combined dynamic postural stress can identify high-risk patients with heart failure with reduced ejection fraction. ESC Heart Failure, 8(4), 2765–2775. https://doi.org/10.1002/ehf2.13346
Tabucanon, T., & Tang, W. H. W. (2020). Right heart failure and cardiorenal syndrome. Cardiology Clinics, 38(2), 185–202. https://doi.org/10.1016/j.ccl.2020.01.004
Teboul, J. L., Monnet, X., Chemla, D., & Michard, F. (2019). Arterial pulse pressure variation with mechanical ventilation. American Journal of Respiratory and Critical Care Medicine, 199(1), 22–31. https://doi.org/10.1164/rccm.201801-0088CI
Tossavainen, E., Wikström, G., Henein, M. Y., Lundqvist, M., Wiklund, U., & Lindqvist, P. (2020). Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures. Clinical Research in Cardiology, 109(4), 498–507. https://doi.org/10.1007/s00392-019-01531-
Van De Bovenkamp, A. A., et al. (2022). The value of passive leg raise during right heart catheterization in diagnosing heart failure with preserved ejection fraction. Circulation: Heart Failure, 15(4), e008935. https://doi.org/10.1161/CIRCHEARTFAILURE.121.008935
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