Elsevier

JACC: Heart Failure

Volume 9, Issue 3, March 2021, Pages 226-236
JACC: Heart Failure

Clinical Research
Predictive Value of Cardiopulmonary Exercise Testing Parameters in Ambulatory Advanced Heart Failure

https://doi.org/10.1016/j.jchf.2020.11.008Get rights and content
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Abstract

Objectives

This study sought to determine cardiopulmonary exercise (CPX) predictors of the combined outcome of durable mechanical circulatory support (MCS), transplantation, or death at 1 year among patients with ambulatory advanced heart failure (HF).

Background

Optimal CPX predictors of outcomes in contemporary ambulatory advanced HF patients are unclear.

Methods

REVIVAL (Registry Evaluation of Vital Information for ventricular assist devices [VADs] in Ambulatory Life) enrolled 400 systolic HF patients, INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles 4-7. CPX was performed by 273 subjects 2 ± 1 months after study enrollment. Discriminative power of maximal (peak oxygen consumption [peak VO2]; VO2 pulse, circulatory power [CP]; peak systolic blood pressure • peak VO2], peak end-tidal pressure CO2 [PEtCO2], and peak Borg scale score) and submaximal CPX parameters (ventilatory efficiency [VE/VCO2 slope]; VO2 at anaerobic threshold [VO2AT]; and oxygen uptake efficiency slope [OUES]) to predict the composite outcome were assessed by univariate and multivariate Cox regression and Harrell’s concordance statistic.

Results

At 1 year, there were 39 events (6 transplants, 15 deaths, 18 MCS implantations). Peak VO2, VO2AT, OUES, peak PEtCO2, and CP were higher in the no-event group (all p < 0.001), whereas VE/VCO2 slope was lower (p < 0.0001); respiratory exchange ratio was not different. CP (hazard ratio [HR]: 0.89; p = 0.001), VE/VCO2 slope (HR: 1.05; p = 0.001), and peak Borg scale score (HR: 1.20; p = 0.005) were significant predictors on multivariate analysis (model C-statistic: 0.80).

Conclusions

Among patients with ambulatory advanced HF, the strongest maximal and submaximal CPX predictor of MCS implantation, transplantation, or death at 1 year were CP and VE/VCO2, respectively. The patient-reported measure of exercise effort (Borg scale score) contributed substantially to the prediction of outcomes, a surprising and novel finding that warrants further investigation. (Registry Evaluation of Vital Information for VADs in Ambulatory Life [REVIVAL]; NCT01369407)

Key Words

ambulatory heart failure
cardiac transplant
cardiopulmonary exercise stress test
mechanical circulatory support
predictors

Abbreviations and Acronyms

%PPVO2
percent of predicted peak VO2
CP
circulatory power
CPX
cardiopulmonary exercise
EOV
oscillatory ventilation
HF
heart failure
HFrEF
heart failure with reduced ejection fraction
MCS
mechanical circulatory support
OUES
oxygen uptake efficiency slope
PEtCO2
end-tidal pressure of CO2
VE/VCO2 slope
slope of minute ventilation to CO2 production
VO2
oxygen consumption
VO2AT
VO2 at the anaerobic threshold

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