Diagnostic Testing: Exercise Testing Recommendation for Diagnostic Testing: Exercise Testing for Chronic Primary MR Referenced studies that support the recommendation are summarized in Online Data Supplement 28. COR LOE Recommendation In patients with primary MR (Stages B and C) and symptoms that might be attributable to MR, hemodynamic exercise testing using Doppler echocardiography or cardiac catheterization or cardiopulmonary exercise testing is reasonable.1 4 Synopsis In a subset of apparently asymptomatic patients with se- vere primary MR, exercise testing with hemodynamics can provide additional diagnostic and prognostic information. Recommendation-Specific Supportive Text 1. The onset of symptoms represents a key develop- ment in severe MR. However, some patients may not recognize their symptoms, may deny them, or may alter their lifestyle to remain asymptomatic. A formal treadmill exercise test can establish true exercise tolerance and can also form the base- line for future symptom assessment. Additional information about a cardiac or noncardiac limita- tion can be obtained from oxygen consumption measurements during exercise. When patients do complain of symptoms, they usually complain of dyspnea with exertion, yet noninvasive evaluation is usually made at rest. Exercise echocardiography or exercise invasive hemodynamics may add addi- tional prognostic value beyond conventional exer- cise treadmill testing in patients with asymptomatic moderate or severe chronic primary MR.1 4 MR may worsen during exercise, or filling pressures may become markedly abnormal, helping to demon- strate MR as the cause of the patient s dyspnea.1 4 7.2.3. Medical Therapy Recommendations for Medical Therapy for Chronic Primary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 29. 