Cardiopulmonary and Noninvasive Hemodynamic Responses to Exercise Predict Outcomes in Heart Failure (original) (raw)
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A cardiopulmonary exercise testing score for predicting outcomes in patients with heart failure
American Heart Journal, 2008
Objective The aim of this study is to evaluate the predictive accuracy of a cardiopulmonary exercise test (CPX) score. Background Cardiopulmonary exercise test responses, including peak VO 2 , markers of ventilatory inefficiency (eg, the VE/VCO 2 slope and oxygen uptake efficiency slope [OUES]), and hemodynamic responses, such as heart rate recovery (HRR) and chronotropic incompetence (CRI) are strong predictors of outcomes in patients with heart failure (HF). However, there is a need for simplified approaches that integrate the additive prognostic information from CPX.
2010
OBJECTIVES We studied whether direct assessment of the hemodynamic response to exercise could improve the prognostic evaluation of patients with heart failure (HF) and identify those in whom the main cause of the reduced functional capacity is related to extracardiac factors. BACKGROUND Peak exercise oxygen consumption (VO 2) is one of the main prognostic variables in patients with HF, but it is influenced also by many extracardiac factors. METHODS Bicycle cardiopulmonary exercise testing with hemodynamic monitoring was performed, in addition to clinical evaluation and radionuclide ventriculography, in 219 consecutive patients with chronic HF (left ventricular ejection fraction, 22 Ϯ 7%; peak VO 2 , 14.2 Ϯ 4.4 ml/kg/min). RESULTS During a follow-up of 19 Ϯ 25 months, 32 patients died and 6 underwent urgent transplantation with a 71% cumulative major event-free 2-year survival. Peak exercise stroke work index (SWI) was the most powerful prognostic variable selected by Cox multivariate analysis, followed by serum sodium and left ventricular ejection fraction, for one-year survival, and peak VO 2 and serum sodium for two-year survival. Two-year survival was 54% in the patients with peak exercise SWI Յ30 g⅐m/m 2 versus 91% in those with a SWI Ͼ30 g⅐m/m 2 (p Ͻ 0.0001). A significant percentage of patients (41%) had a normal cardiac output response to exercise with an excellent two-year survival (87% vs. 58% in the others) despite a relatively low peak VO 2 (15.1 Ϯ 4.7 ml/kg/min). CONCLUSIONS Direct assessment of exercise hemodynamics in patients with HF provides additive independent prognostic information, compared to traditional noninvasive data.
The lowest VE/VCO2 ratio during exercise as a predictor of outcomes in patients with heart failure
Journal of cardiac …, 2009
Background: The lowest minute ventilation (VE) and carbon dioxide production (VCO 2 ) ratio during exercise has been suggested to be the most stable and reproducible marker of ventilatory efficiency in patients with heart failure (HF). However, the prognostic power of this index is unknown. Methods and Results: A total of 847 HF patients underwent cardiopulmonary exercise testing (CPX) and were followed for 3 years. The associations between the lowest VE/VCO 2 ratio, maximal oxygen uptake (peak VO 2 ), the VE/VCO 2 slope, and major events (death or transplantation) were evaluated using proportional hazards analysis; adequacy of the predictive models was assessed using Akaike information criterion (AIC) weights. There were 147 major adverse events. In multivariate analysis, the lowest VE/ VCO 2 ratio (higher ratio associated with greater risk) was similar to the VE/VCO 2 slope in predicting risk (hazard ratios [HR] per unit increment 2.0, 95% CI 1.1e3.4, and 2.2, 95% CI 1.3e3.7, respectively; P ! .01), followed by peak VO 2 (HR 1.6, 95% CI 1.1e2.4, P 5 .01). Patients exhibiting abnormalities for all 3 responses had an 11.6-fold higher risk. The AIC weight for the 3 variables combined (0.94) was higher than any single response or any combination of 2. The model including all 3 responses remained the most powerful after adjustment for b-blocker use, type of HF, and after applying different cut points for high risk. Conclusions: The lowest VE/VCO 2 ratio adds to the prognostic power of conventional CPX responses in HF. (J Cardiac Fail 2009;15:756e762)
2010
This study was designed to determine the relevance of a proposed classification for advanced heart failure (HF). Profiles based on clinical assessment of congestion and perfusion at the time of hospitalization were compared with subsequent outcomes. BACKGROUND Optimal design of therapy and trials for advanced HF remains limited by the lack of simple clinical profiles to characterize patients. METHODS Prospective analysis was performed for 452 patients admitted to the cardiomyopathy service at the Brigham and Women's Hospital with a diagnosis of HF. Patients were classified by clinical assessment into four profiles: profile A, patients with no evidence of congestion or hypoperfusion (dry-warm, n ϭ 123); profile B, congestion with adequate perfusion (wetwarm, n ϭ 222); profile C, congestion and hypoperfusion (wet-cold, n ϭ 91); and profile L, hypoperfusion without congestion (dry-cold, n ϭ 16). Other standard predictors of outcome were included and patients were followed for the end points of death (n ϭ 117) and death or urgent transplantation (n ϭ 137) at one year. RESULTS Survival analysis showed that clinical profiles predict outcomes in HF. Profiles B and C increase the risk of death plus urgent transplantation by univariate (hazard ratio [HR] 1.83, p ϭ 0.02) and multivariate analyses (HR 2.48, p ϭ 0.003). Moreover, clinical profiles add prognostic information even when limited to patients with New York Heart Association (NYHA) class III/IV symptoms (profile B: HR 2.23, p ϭ 0.026; profile C: HR 2.73, p ϭ 0.009). CONCLUSIONS Simple clinical assessment can be used to define profiles in patients admitted with HF. These profiles predict outcomes and may be used to guide therapy and identify populations for future investigation.
CHEST Journal, 2005
Background: Peak oxygen consumption (V O 2) and minute ventilation (V E)/carbon dioxide production (V CO 2) slope have been widely demonstrated to have strong prognostic value in patients with heart failure (HF). In the present study, we investigated the effect of HF etiology on the prognostic applications of peak V O 2 and V E/V CO 2 slope. Methods: Two hundred sixty-eight subjects underwent symptom-limited cardiopulmonary exercise testing (CPX). The population was divided into ischemic (115 men and 22 women) and nonischemic (108 men and 23 women) subgroups. The occurrence of cardiac-related events over the year following CPX was compared between groups using receiver operating characteristic curve (ROC) analysis Results: Mean age ؎ SD was significantly higher (61.0 ؎ 10.0 years vs 50.3 ؎ 16.2 years) while mean peak V O 2 was significantly lower (15.0 ؎ 5.2 mL/kg/min vs 17.5 ؎ 6.7 mL/kg/min) in the ischemic HF group (p < 0.05). ROC curve analysis demonstrated that both peak V O 2 and V E/V CO 2 slope were significant predictors of cardiac events in both the ischemic group (peak V O 2 , 0.74; V E/V CO 2 slope, 0.76; p < 0.001) and the nonischemic group (peak V O 2 , 0.75; V E/V CO 2 slope, 0.86; p < 0.001). Optimal prognostic threshold values for peak V O 2 were 14.1 mL/kg/min and 14.6 mL/kg/min in the ischemic and nonischemic groups, respectively. Optimal prognostic threshold values for the V E/V CO 2 slope were 34.2 and 34.5 in the ischemic and nonischemic groups, respectively. Conclusions: Baseline and exercise characteristics were different between ischemic and nonischemic patients with HF. However, the prognostic power of the major CPX variables was strikingly similar. Different prognostic classification schemes based on HF etiology may therefore not be necessary when analyzing CPX responses in clinical practice.
2006
Background: Cardiopulmonary exercise testing (CPX) clearly holds prognostic value in the heart failure (HF) population. Studies investigating the prognostic value of CPX in individuals with HF have consistently examined predominantly male groups. The purpose of the present study was to examine the prognostic value of CPX in a female HF group. Methods: Seventy-five female and 337 male subjects diagnosed with HF participated in this study. The ability of peak oxygen consumption (VO 2 ) and the minute ventilation/carbon dioxide production (VE/VCO 2 ) slope to predict cardiac-related events were assessed. Results: In the year following CPX, the female group suffered 26 cardiac-related events (8 deaths/18 hospitalizations), while the male group suffered 89 cardiac-related events (20 deaths/69 hospitalizations). The hazard ratios for peak VO 2 and the VE/VCO 2 slope were 4.0 (95% confidence interval: 2.6 -6.1, p < 0.001) and 4.2 (95% confidence interval: 2.7 -6.6, p < 0.001) in the male group and 3.8 (95% confidence interval: 1.7 -8.5, p < 0.001) and 4.3 (95% confidence interval: 1.8 -9.8, p < 0.001) in the female group. In both the male and female groups, Cox multivariate analysis revealed VE/VCO 2 slope was the strongest predictor of cardiac-related events while peak VO 2 added significant predictive value and was retained in the regression.
Background: Many studies have shown a strong association between numerous variables from a cardiopulmonary exercise (CPX) test and prognosis in patients with heart failure with reduced ejection fraction (HFrEF). However, few studies have compared the prognostic value of a majority of these variables simultaneously, so controversy remains regarding optimal interpretation. Methods and Results: This was a retrospective analysis of patients with HFrEF (n 5 1,201; age 5 55 6 13 y; 33% female) and a CPX test from 1997 to 2010. Thirty variables from a CPX test were considered in separate adjusted Cox regression analyses to describe the strength of the relation of each to a composite end point of all-cause mortality, left ventricular assist device implantation, or heart transplantation. During a median follow-up of 3.8 years, there were 577 (48.0%) events. The majority of variables were highly significant (P ! .001). Among these, percentage of predicted maximum _ VO 2 (ppM _ VO 2 ; Wald 5 203; P ! .001; C-index 5 0.73) was similar to V E -VCO 2 slope (Wald 5 201; P ! .001; C 5 0.72) and peak _ VO 2 (Wald 5 161; P ! .001; C 5 0.72). In addition, there was no significant interaction observed for peak respiratory exchange ratio !1 vs $1. Conclusions: Consistent with prior studies, many CPX test variables were strongly associated with prognosis in patients with HFrEF. The choice of which variable to use is up to the clinician. Renewed attention should be given to ppM _ VO 2 , which appears to be highly predictive of survival in these patients. (J Cardiac Fail 2015;-:1e9)