Predictive Value of Cardiopulmonary Exercise Testing Parameters in Ambulatory Advanced Heart Failure
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Published on: October 1, 2019
Anuradha Lala1, Keyur B Shah2, David E Lanfear3
1Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Insights
Cardiopulmonary exercise testing (CPX) identifies key predictors for advanced heart failure patients needing mechanical circulatory support (MCS), transplantation, or facing death within a year. Circulatory power and ventilatory efficiency slope are strong indicators, with patient-reported exercise effort also proving significant.
Area of Science:
- Cardiology
- Exercise Physiology
- Heart Failure Management
Background:
- Optimal cardiopulmonary exercise (CPX) predictors for outcomes in ambulatory advanced heart failure (HF) patients are not well-defined.
- Understanding these predictors is crucial for timely clinical decision-making and patient management.
Purpose of the Study:
- To identify cardiopulmonary exercise (CPX) predictors for the combined outcome of durable mechanical circulatory support (MCS), transplantation, or death within one year.
- To evaluate both maximal and submaximal CPX parameters in predicting adverse events in advanced HF patients.
Main Methods:
- The REVIVAL (Registry Evaluation of Vital Information for VADs in Ambulatory Life) study enrolled 400 systolic HF patients (INTERMACS profiles 4-7).
- Cardiopulmonary exercise testing (CPX) was performed on 273 subjects.
- Maximal (peak oxygen consumption, circulatory power) and submaximal (ventilatory efficiency slope) CPX parameters were analyzed using Cox regression and concordance statistics.
Main Results:
- At one year, 39 events (transplantation, death, MCS implantation) occurred.
- Circulatory power (CP) and ventilatory efficiency (VE/VCO2 slope) were significant multivariate predictors of the composite outcome (HR: 0.89, p=0.001 and HR: 1.05, p=0.001, respectively).
- Patient-reported peak Borg scale score also significantly contributed to outcome prediction (HR: 1.20, p=0.005).
Conclusions:
- Circulatory power (CP) and ventilatory efficiency slope (VE/VCO2) are the strongest maximal and submaximal CPX predictors, respectively, for adverse outcomes in ambulatory advanced HF.
- The patient-reported Borg scale score emerged as a novel and significant predictor, highlighting the value of subjective exercise effort assessment.
- These findings offer valuable insights for risk stratification and management strategies in advanced heart failure patients.
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).
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