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Salvioni E, Bonomi A, Magrì D, Merlo M, Pezzuto B, Chiesa M, Mapelli M, Baracchini N, Sinagra G, Piepoli M, Agostoni P. The cardiopulmonary exercise test in the prognostic evaluation of patients with heart failure and cardiomyopathies: the long history of making a one-size-fits-all suit. Eur J Prev Cardiol 2023; 30:ii28-ii33. [PMID: 37819221 DOI: 10.1093/eurjpc/zwad216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 10/13/2023]
Abstract
Cardiopulmonary exercise test (CPET) has become pivotal in the functional evaluation of patients with chronic heart failure (HF), supplying a holistic evaluation both in terms of exercise impairment degree and possible underlying mechanisms. Conversely, there is growing interest in investigating possible multiparametric approaches in order to improve the overall HF risk stratification. In such a context, in 2013, a group of 13 Italian centres skilled in HF management and CPET analysis built the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score, based on the dynamic assessment of HF patients and on some other instrumental and laboratory parameters. Subsequently, the MECKI score, initially developed on a cohort of 2716 HF patients, has been extensively validated as well as challenged with the other multiparametric scores, achieving optimal results. Meanwhile, the MECKI score research group has grown over time, involving up to now a total of 27 centres with an available database accounting for nearly 8000 HF patients. This exciting joint effort from multiple HF Italian centres allowed to investigate different HF research field in order to deepen the mechanisms underlying HF, to improve the ability to identify patients at the highest risk as well as to analyse particular HF categories. Most recently, some of the participants of the MECKI score group started to join the forces in investigating a possible additive role of CPET assessment in the cardiomyopathy setting too. The present study tells the ten-year history of the MECKI score presenting the most important results achieved as well as those projects in the pipeline, this exciting journey being far to be concluded.
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Affiliation(s)
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milano, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Merlo
- Department of Cardiovascular, 'Azienda Sanitaria Universitaria Giuliano-Isontina', Trieste, Italy
| | | | - Mattia Chiesa
- Centro Cardiologico Monzino, IRCCS, Milano, Italy
- Department of Electronics, Information and Biomedical Engineering, Politecnico di Milano, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Nikita Baracchini
- Department of Cardiovascular, 'Azienda Sanitaria Universitaria Giuliano-Isontina', Trieste, Italy
| | - Gianfranco Sinagra
- Department of Cardiovascular, 'Azienda Sanitaria Universitaria Giuliano-Isontina', Trieste, Italy
| | - Massimo Piepoli
- Clinical Cardiology, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
- Department of Preventive Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | - Piergiuseppe Agostoni
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy
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Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Cardiopulmonary Exercise Testing in Patients with Heart Failure: Impact of Gender in Predictive Value for Heart Transplantation Listing. Life (Basel) 2023; 13:1985. [PMID: 37895367 PMCID: PMC10608092 DOI: 10.3390/life13101985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men. METHODS Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx. RESULTS A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percent of predicted pVO2 were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO2 ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO2 slope > 35, and percent of predicted pVO2 ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO2, VE/VCO2 slope and percent of predicted pVO2 cut-offs in each sex group presented a higher prognostic power than the recommended thresholds. CONCLUSION Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.
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Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - António Valentim Gonçalves
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - João Ferreira Reis
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rita Ilhão Moreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Tiago Pereira-da-Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Pedro Rio
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rui M. Soares
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rui Cruz Ferreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
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Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Age Differences in Cardiopulmonary Exercise Testing Parameters in Heart Failure with Reduced Ejection Fraction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1685. [PMID: 37763804 PMCID: PMC10535443 DOI: 10.3390/medicina59091685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Cardiopulmonary exercise testing (CPET) is a cornerstone of risk stratification in heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of evidence on its predictive power in older patients. The aim of this study was to evaluate the prognostic power of current heart transplantation (HTx) listing criteria in HFrEF stratified according to age groups. Materials and Methods: Consecutive patients with HFrEF undergoing CPET between 2009 and 2018 were followed-up for cardiac death and urgent HTx. Results: CPET was performed in 458 patients with HFrEF. The composite endpoint occurred in 16.8% of patients ≤50 years vs. 14.1% of patients ≥50 years in a 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percentage of predicted pVO2 were strong independent predictors of outcomes. The International Society for Heart and Lung Transplantation thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers), VE/VCO2 slope > 35 and percentage of predicted pVO2 ≤ 50% presented a higher overall diagnostic effectiveness in younger patients (≤50 years). Specific thresholds for each age subgroup outperformed the traditional cut-offs. Conclusions: Personalized age-specific thresholds may contribute to an accurate risk stratification in HFrEF. Further studies are needed to address the gap in evidence between younger and older patients.
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Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - António Valentim Gonçalves
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - João Ferreira Reis
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rita Ilhão Moreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Tiago Pereira-da-Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Pedro Rio
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rui M. Soares
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rui Cruz Ferreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
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Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Cardiopulmonary Exercise Testing in the Age of New Heart Failure Therapies: Still a Powerful Tool? Biomedicines 2023; 11:2208. [PMID: 37626705 PMCID: PMC10452308 DOI: 10.3390/biomedicines11082208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). METHODS Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. RESULTS CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO2 (pVO2) and VE/VCO2 slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO2 slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO2 ≤ 10 mL/kg/min and VE/VCO2 slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. CONCLUSION ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.
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Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - António Valentim Gonçalves
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - João Ferreira Reis
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Rita Ilhão Moreira
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Tiago Pereira-da-Silva
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Pedro Rio
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Ana Teresa Timóteo
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Rui M. Soares
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Rui Cruz Ferreira
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
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Forton K, Lamotte M, Gillet A, Chaumont M, van de Borne P, Faoro V. Beta-Adrenergic Receptor Blockade Effects on Cardio-Pulmonary Exercise Testing in Healthy Young Adults: A Randomized, Placebo-Controlled Trial. SPORTS MEDICINE - OPEN 2022; 8:150. [PMID: 36538192 PMCID: PMC9768047 DOI: 10.1186/s40798-022-00537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Beta-blockers are increasingly prescribed while the effects of beta-adrenergic receptor blockade on cardio-pulmonary exercise test (CPET)-derived parameters remain under-studied. METHODS Twenty-one young healthy adults repeated three CPET at the same time with an interval of 7 days between each test. The tests were performed 3 h after a random, double-blind, cross-over single-dose intake of placebo, 2.5 mg or 5.0 mg bisoprolol, a cardio-selective beta1-adrenoreceptor antagonist. Gas exchange, heart rate (HR) and blood pressure (BP) were measured at rest and during cyclo-ergometric incremental CPET. RESULTS Maximal workload and VO2max were unaffected by the treatment, with maximal respiratory exchange ratio > 1.15 in all tests. A beta-blocker dose-dependent effect reduced resting and maximal BP and HR and the chronotropic response to exercise, evaluated by the HR/VO2 slope (placebo: 2.9 ± 0.4 beat/ml/kg; 2.5 mg bisoprolol: 2.4 ± 0.5 beat/ml/kg; 5.0 mg bisoprolol: 2.3 ± 0.4 beat/ml/kg, p < 0.001). Ventilation efficiency measured by the VE/VCO2 slope and the ventilatory equivalent for CO2 at the ventilatory threshold were not affected by beta1-receptor blockade. Post-exercise chronotropic recovery measured after 1 min was enhanced under beta1-blocker (placebo: 26 ± 7 bpm; 2.5 mg bisoprolol: 32 ± 6 bpm; 5.0 mg bisoprolol: 33 ± 6 bpm, p < 0.01). CONCLUSION The present results suggest that a single dose of bisoprolol does not affect metabolism, respiratory response and exercise capacity. However, beta-adrenergic blockade dose dependently reduces exercise hemodynamic response by lowering BP and the chronotropic response.
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Affiliation(s)
- Kevin Forton
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium ,grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Michel Lamotte
- grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexis Gillet
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium ,grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Martin Chaumont
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium ,grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe van de Borne
- grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Vitalie Faoro
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium
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Chaudhry S, DeVore AD, Vidula H, Nassif M, Mudy K, Birati EY, Gong T, Atluri P, Pham D, Sun B, Bansal A, Najjar SS. Left Ventricular Assist Devices: A Primer For the General Cardiologist. J Am Heart Assoc 2022; 11:e027251. [PMID: 36515226 PMCID: PMC9798797 DOI: 10.1161/jaha.122.027251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Durable implantable left ventricular assist devices (LVADs) have been shown to improve survival and quality of life for patients with stage D heart failure. Even though LVADs remain underused overall, the number of patients with heart failure supported with LVADs is steadily increasing. Therefore, general cardiologists will increasingly encounter these patients. In this review, we provide an overview of the field of durable LVADs. We discuss which patients should be referred for consideration of advanced heart failure therapies. We summarize the basic principles of LVAD care, including medical and surgical considerations. We also discuss the common complications associated with LVAD therapy, including bleeding, infections, thrombotic issues, and neurologic events. Our goal is to provide a primer for the general cardiologist in the recognition of patients who could benefit from LVADs and in the principles of managing patients with LVAD. Our hope is to "demystify" LVADs for the general cardiologist.
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Affiliation(s)
- Sunit‐Preet Chaudhry
- Division of CardiologyAscension St. Vincent Heart CenterIndianapolisIN,Ascension St. Vincent Cardiovascular Research InstituteIndianapolisIN
| | - Adam D. DeVore
- Department of Medicine and Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Himabindu Vidula
- Division of Heart Failure and TransplantUniversity of Rochester School of Medicine and DentistryRochesterNY
| | - Michael Nassif
- Division of Heart failure and TransplantSaint Luke’s Mid America Heart InstituteKansas CityMO
| | - Karol Mudy
- Division of Cardiothoracic SurgeryMinneapolis Heart InstituteMinneapolisMN
| | - Edo Y. Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and SurgeryPadeh‐Poriya Medical Center, Bar Ilan UniversityPoriyaIsrael
| | - Timothy Gong
- Center for Advanced Heart and Lung DiseaseBaylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical CenterDallasTX
| | - Pavan Atluri
- Division of Cardiovascular SurgeryUniversity of PennsylvaniaPhiladelphiaPA
| | - Duc Pham
- Center for Advanced Heart FailureBluhm Cardiovascular Institute, Northwestern University, Feinberg School of MedicineChicagoIL
| | - Benjamin Sun
- Division of Cardiothoracic Surgery, Abbott Northwestern HospitalMinneapolisMN
| | - Aditya Bansal
- Division of Cardiothoracic Surgery, Department of SurgeryOchsner Clinic FoundationNew OrleansLA
| | - Samer S. Najjar
- Division of Cardiology, MedStar Heart and Vascular InstituteMedstar Medical GroupBaltimoreMD
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Chen S, Wu P, Wang L, Wei C, Cheng C, Fang H, Fang Y, Chen Y, Huang DK, Lee F, Chen M. Optimizing exercise testing‐based risk stratification to predict poor prognosis after acute heart failure. ESC Heart Fail 2022; 10:895-906. [PMID: 36460605 PMCID: PMC10053263 DOI: 10.1002/ehf2.14240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 09/04/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022] Open
Abstract
AIMS The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO2 ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO2 and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era. METHODS AND RESULTS We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO2 and HFSS in predicting primary outcomes. The median follow-up period was 3.3 years. The primary outcome occurred in 57 participants. Peak VO2 outperformed HFSS when predicting 1 year (0.81 vs. 0.61; P = 0.017) and 2 year (0.78 vs. 0.58; P < 0.001) major outcomes. The cutoff peak VO2 for predicting a 20% risk of a major outcome within 2 years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO2 , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes. CONCLUSIONS Optimizing the cutoff value of peak VO2 is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.
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Affiliation(s)
- Shyh‐Ming Chen
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
| | - Po‐Jui Wu
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
| | - Lin‐Yi Wang
- Department of Physical Medicine and Rehabilitation Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Chin‐Ling Wei
- Department of Nursing, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Cheng‐I Cheng
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
| | - Hsiu‐Yu Fang
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
| | - Yen‐Nan Fang
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
| | - Yung‐Lung Chen
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
| | - David Kwan‐Ru Huang
- Division of Cardiovascular Surgery, Department of Surgery Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Fan‐Yen Lee
- Division of Cardiovascular Surgery, Department of Surgery Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Mien‐Cheng Chen
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
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Cedars A, Joseph S. Don't tell your patients where they are, let them tell you. Eur J Heart Fail 2022; 24:2105-2107. [PMID: 36088541 DOI: 10.1002/ejhf.2682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Ari Cedars
- Divisions of Pediatric and Adult Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Susan Joseph
- Division of Cardiology, University of Maryland, Baltimore, MD, USA
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 601] [Impact Index Per Article: 300.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 687] [Impact Index Per Article: 343.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Gonçalves AV, Pereira-da-Silva T, Galrinho A, Rio P, Soares R, Feliciano J, Moreira RI, Silva S, Alves S, Capilé E, Ferreira RC. Melhora no Consumo Máximo de Oxigênio e na Ventilação após Tratamento com Sacubitril-Valsartana. Arq Bras Cardiol 2020; 115:821-827. [PMID: 33084746 PMCID: PMC8452225 DOI: 10.36660/abc.20190443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/23/2019] [Indexed: 12/11/2022] Open
Abstract
Fundamento O tratamento com sacubitril-valsartana teve seu benefício prognóstico confirmado no ensaio PARADIGM-HF. No entanto, dados sobre alterações no teste de esforço cardiopulmonar (TECP) com o uso de sacubitril-valsartana são escassos. Objetivo O objetivo deste estudo foi comparar os parâmetros do TECP antes e depois do tratamento com sacubitril-valsartana. Métodos Avaliação prospectiva de pacientes com insuficiência cardíaca (IC) crônica e fração de ejeção do ventrículo esquerdo ≤40%, mesmo sob terapia padrão otimizada, que iniciaram tratamento com sacubitril-valsartana, sem expectativa de tratamentos adicionais para a IC. Os dados do TECP foram coletados na semana anterior e 6 meses depois do tratamento com sacubitril-valsartana. Diferenças estatísticas com valor p <0,05 foram consideradas significativas. Resultados De 42 pacientes, 35 (83,3%) completaram o seguimento de 6 meses, uma vez que 2 (4,8%) morreram e 5 (11,9%) interromperam o tratamento devido a eventos adversos. A média de idade foi de 58,6±11,1 anos. A classe NYHA (classificação da New York Heart Association) melhorou em 26 (74,3%) pacientes. O consumo máximo de oxigênio (VO2max) (14,4 vs. 18,3 ml/kg/min, p<0,001), a inclinação VE/VCO2 (36,7 vs. 31,1, p<0,001) e a duração do exercício (487,8 vs. 640,3 s, p<0,001) também melhoraram com o uso de sacubitril-valsartana. O benefício foi mantido mesmo com a dose de 24/26 mg (13,5 vs. 19,2 ml/kg/min, p=0,018) de sacubitril-valsartana, desde que esta tenha sido a maior dose tolerada. Conclusões O tratamento com sacubitril-valsartana está associado a uma melhora acentuada do VO2max, da inclinação VE/VCO2 e da duração do exercício no TECP. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
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12
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Cardiopulmonary exercise testing in chronic heart failure patients treated with beta-blockers: Still a valid prognostic tool. Int J Cardiol 2020; 317:128-132. [DOI: 10.1016/j.ijcard.2020.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
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13
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Cazzoli I, Gunturiz-Beltran C, Guarguagli S, Alonso-Gonzalez R, Babu-Narayan SV, Dimopoulos K, Swan L, Uebing A, Gatzoulis MA, Ernst S. Catheter ablation for patients with end-stage complex congenital heart disease or cardiomyopathy considered for transplantation: Trials and tribulations. Int J Cardiol 2020; 301:127-134. [PMID: 31604655 DOI: 10.1016/j.ijcard.2019.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/27/2019] [Accepted: 09/06/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Arrhythmia contributes significantly to morbidity and mortality of patients with congenital heart disease (CHD) or cardiomyopathy (CMP). It also has the potential to worsen symptoms and is particularly detrimental to patients with advanced heart failure awaiting cardiac transplantation. We report our experience using catheter ablation to treat recurrent arrhythmia in patients with CHD or CMP considered for transplantation. METHODS Five consecutive patients (3 female, mean age 47.8 ± 12.8 years) with complex CHD or CMP (tricuspid atresia, mitral atresia, double inlet left ventricle, arrhythmogenic right ventricular cardiomyopathy, left ventricular non-compaction) presented with either atrial (n = 3) or ventricular (n = 2) arrhythmias. All ablations were guided by three-dimensional (3D) electro-anatomical mapping, plus remote magnetic navigation in 3 patients. RESULTS Patients underwent a median of 2 ablation procedures for a total number of 26 tachycardias. None of the 5 patients experienced further arrhythmia at a median of 939 days (range 4-1375) from their last ablation. During a median follow up of 31 months (range 1-70), three patients underwent successful transplantation at 1375, 1062 and 321 days following their last ablation. One patient with a Fontan circulation died from hepatic cancer and one from end-stage heart failure despite urgent transplant listing. CONCLUSIONS Catheter ablation is feasible in complex cardiac patients considered for heart transplantation and should be offered for rhythm management and patient optimization until a suitable donor is found.
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Affiliation(s)
- Ilaria Cazzoli
- Department of Cardiology, Royal Brompton and Harefield Hospital, Imperial College London, United Kingdom
| | - Clara Gunturiz-Beltran
- Department of Cardiology, Royal Brompton and Harefield Hospital, Imperial College London, United Kingdom; Electrophysiology Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Silvia Guarguagli
- Department of Cardiology, Royal Brompton and Harefield Hospital, Imperial College London, United Kingdom
| | - Rafael Alonso-Gonzalez
- Adult and Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospital, London, United Kingdom
| | - Sonya V Babu-Narayan
- Department of Cardiology, Royal Brompton and Harefield Hospital, Imperial College London, United Kingdom; Cardiovascular Research Center, Royal Brompton and Harefield Hospital, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Konstantinos Dimopoulos
- Adult and Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospital, London, United Kingdom
| | - Lorna Swan
- Adult and Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospital, London, United Kingdom
| | - Anselm Uebing
- Electrophysiology Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Department of Paediatric Cardiology, University of Muenster, Muenster, Germany
| | - Michael A Gatzoulis
- Adult and Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospital, London, United Kingdom
| | - Sabine Ernst
- Department of Cardiology, Royal Brompton and Harefield Hospital, Imperial College London, United Kingdom.
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14
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Menachem JN, Reza N, Mazurek JA, Burstein D, Birati EY, Fox A, Kim YY, Molina M, Partington SL, Tanna M, Tobin L, Wald J, Goldberg LR. Cardiopulmonary Exercise Testing-A Valuable Tool, Not Gatekeeper When Referring Patients With Adult Congenital Heart Disease for Transplant Evaluation. World J Pediatr Congenit Heart Surg 2019; 10:286-291. [PMID: 30832541 DOI: 10.1177/2150135118825263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Treatment of patients with adult congenital heart disease (ACHD) with advanced therapies including heart transplant (HT) is often delayed due to paucity of objective prognostic markers for the severity of heart failure (HF). While the utility of Cardiopulmonary Exercise Testing (CPET) in non-ACHD patients has been well-defined as it relates to prognosis, CPET for this purpose in ACHD is still under investigation. METHODS We performed a retrospective cohort study of 20 consecutive patients with ACHD who underwent HT between March 2010 and February 2016. Only 12 of 20 patients underwent CPET prior to transplantation. Demographics, standard measures of CPET interpretation, and 30-day and 1-year post transplantation outcomes were collected. RESULTS Patient Characteristics. Twenty patients with ACHD were transplanted at a median of 40 years of age (range: 23-57 years). Of the 12 patients who underwent CPET, 4 had undergone Fontan procedures, 4 had tetralogy of Fallot, 3 had d-transposition of the great arteries, and 1 had Ebstein anomaly. Thirty-day and one-year survival was 100%. All tests included in the analysis had a peak respiratory quotient _1.0. The median peak oxygen consumption per unit time (_VO2) for all diagnoses was 18.2 mL/kg/min (46% predicted), ranging from 12.2 to 22.6. CONCLUSION There is a paucity of data to support best practices for patients with ACHD requiring transplantation. While it cannot be proven based on available data, it could be inferred that outcomes would have been worse or perhaps life sustaining options unavailable if providers delayed referral because of the lack of attainment of CPET-specific thresholds.
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Affiliation(s)
- Jonathan N Menachem
- 1 Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nosheen Reza
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Danielle Burstein
- 3 Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edo Y Birati
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Arieh Fox
- 4 Division of Cardiology, Mount Sinai Medical Center, New York, NY, USA
| | - Yuli Y Kim
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Maria Molina
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sara L Partington
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Monique Tanna
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lynda Tobin
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce Wald
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lee R Goldberg
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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15
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Paolillo S, Veglia F, Salvioni E, Corrà U, Piepoli M, Lagioia R, Limongelli G, Sinagra G, Cattadori G, Scardovi AB, Metra M, Senni M, Bonomi A, Scrutinio D, Raimondo R, Emdin M, Magrì D, Parati G, Re F, Cicoira M, Minà C, Correale M, Frigerio M, Bussotti M, Battaia E, Guazzi M, Badagliacca R, Di Lenarda A, Maggioni A, Passino C, Sciomer S, Pacileo G, Mapelli M, Vignati C, Clemenza F, Binno S, Lombardi C, Filardi PP, Agostoni P. Heart failure prognosis over time: how the prognostic role of oxygen consumption and ventilatory efficiency during exercise has changed in the last 20 years. Eur J Heart Fail 2019; 21:208-217. [PMID: 30632680 DOI: 10.1002/ejhf.1364] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 10/15/2018] [Accepted: 10/18/2018] [Indexed: 12/11/2022] Open
Abstract
AIMS Exercise-derived parameters, specifically peak exercise oxygen uptake (peak VO2 ) and minute ventilation/carbon dioxide relationship slope (VE/VCO2 slope), have a pivotal prognostic value in heart failure (HF). It is unknown how the prognostic threshold of peak VO2 and VE/VCO2 slope has changed over the last 20 years in parallel with HF prognosis improvement. METHODS AND RESULTS Data from 6083 HF patients (81% male, age 61 ± 13 years), enrolled in the MECKI score database between 1993 and 2015, were retrospectively analysed. By enrolment year, four groups were generated: group 1 1993-2000 (n = 440), group 2 2001-2005 (n = 1288), group 3 2006-2010 (n = 2368), and group 4 2011-2015 (n = 1987). We compared the 10-year survival of groups and analysed how the overall risk (cardiovascular death, urgent heart transplantation, or left ventricular assist device implantation) changed over time according to peak VO2 and VE/VCO2 slope and to major clinical and therapeutic variables. At 10 years, a progressively higher survival from group 1 to group 3 was observed, with no further improvement afterwards. A 20% risk for peak VO2 15 mL/min/kg (95% confidence interval 16-13), 9 (11-8), 4 (4-2) and 5 (7-4) was observed in group 1, 2, 3, and 4, respectively, while the VE/VCO2 slope value for a 20% risk was 32 (37-29), 47 (51-43), 59 (64-55), and 57 (63-52), respectively. CONCLUSIONS Heart failure prognosis improved over time up to 2010 in a HF population followed by experienced centres. The peak VO2 and VE/VCO2 slope cut-offs identifying a definite risk progressively decreased and increased over time, respectively. The prognostic threshold of peak VO2 and VE/VCO2 slope must be updated whenever HF prognosis improves.
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Affiliation(s)
- Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | | | - Ugo Corrà
- Division of Cardiac Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Veruno, Veruno, Italy
| | - Massimo Piepoli
- Division of Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Rocco Lagioia
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Cassano Murge, Bari, Italy
| | - Giuseppe Limongelli
- Cardiology SUN, Monaldi Hospital (Azienda dei Colli), Second University of Naples, Naples, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Gaia Cattadori
- Division of Cardiac Rehabilitation, Multimedica IRCCS, Milan, Italy
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Michele Senni
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Domenico Scrutinio
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Cassano Murge, Bari, Italy
| | - Rosa Raimondo
- Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Tradate, Tradate, Italy
| | - Michele Emdin
- Gabriele Monasterio Foundation, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Chiara Minà
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT, Palermo, Italy
| | | | - Maria Frigerio
- 'A. De Gasperis' Cardiology Department, Niguarda Hospital, Milan, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Milan, Milan, Italy
| | - Elisa Battaia
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | - Marco Guazzi
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Health Authority 1 and University of Trieste, Trieste, Italy
| | | | - Claudio Passino
- Gabriele Monasterio Foundation, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Susanna Sciomer
- Department of Cardiovascular Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Pacileo
- Cardiology SUN, Monaldi Hospital (Azienda dei Colli), Second University of Naples, Naples, Italy
| | | | | | - Francesco Clemenza
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT, Palermo, Italy
| | - Simone Binno
- Division of Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Mulkareddy V, Racette SB, Coggan AR, Peterson LR. Dietary nitrate's effects on exercise performance in heart failure with reduced ejection fraction (HFrEF). Biochim Biophys Acta Mol Basis Dis 2018; 1865:735-740. [PMID: 30261290 DOI: 10.1016/j.bbadis.2018.09.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 01/09/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a deadly and disabling disease. A key derangement contributing to impaired exercise performance in HFrEF is decreased nitric oxide (NO) bioavailability. Scientists recently discovered the inorganic nitrate pathway for increasing NO. This has advantages over organic nitrates and NO synthase production of NO. Small studies using beetroot juice as a source of inorganic nitrate demonstrate its power to improve exercise performance in HFrEF. A larger-scale trial is now underway to determine if inorganic nitrate may be a new arrow for physicians' quiver of HFrEF treatments.
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Affiliation(s)
- Vinaya Mulkareddy
- The Department of Medicine, 4960 Children's Place, Campus Box 8066, St. Louis, MO 63110, USA.
| | - Susan B Racette
- The Department of Medicine, 4960 Children's Place, Campus Box 8066, St. Louis, MO 63110, USA; Program in Physical Therapy, Washington University School of Medicine, Campus Box 8502, 4444 Forest Park Ave., St. Louis, MO 63108-2212, USA.
| | - Andrew R Coggan
- Department of Kinesiology, Indiana University Purdue University Indianapolis, 901 West New York Street, Indianapolis, IN 46202, USA; Department of Cellular and Integrative Physiology, Indiana University Purdue University Indianapolis, 901 West New York Street, Indianapolis, IN 46202, USA.
| | - Linda R Peterson
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA.
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17
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Abstract
Risk stratification is a mainstay in the care of cardiac and pulmonary disorders, as the identification of adverse outcomes helps provide measures to improve survival and quality of life. The cardiopulmonary exercise test is a useful prognostic tool in the clinical evaluation of several pathological conditions, such as heart diseases, respiratory disorders, and pulmonary hypertension. If not contraindicated, a cardiopulmonary exercise test should always be performed and integrated with clinical, laboratory, and hemodynamic parameters to better stratify patient risk. In heart failure, the cardiopulmonary exercise test is important in all the stages of patient management, from diagnosis to risk assessment. Different exercise variables have been advocated as prognostic indicators in this condition, including peak oxygen uptake, ventilatory efficiency, respiratory patterns, and identification of the anaerobic threshold. The prognostic role of the cardiopulmonary exercise test in heart failure is amplified when included in multiparametric risk stratification methodology, currently considered the best method to assess patient outcome. In respiratory disorders and in pulmonary hypertension, cardiopulmonary exercise test parameters, focusing on ventilatory performance during exercise, may help evaluate the risk of adverse events. Finally, the cardiopulmonary exercise test may help define the presence of coexisting cardiac and respiratory disorders, a combination that leads to increased rates of disability and mortality.
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18
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Ehrman JK, Brawner CA, Shafiq A, Lanfear DE, Saval M, Keteyian SJ. Cardiopulmonary Exercise Measures of Men and Women with HFrEF Differ in Their Relationship to Prognosis: The Henry Ford Hospital Cardiopulmonary Exercise Testing (FIT-CPX) Project. J Card Fail 2018; 24:227-233. [PMID: 29496519 DOI: 10.1016/j.cardfail.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 02/12/2018] [Accepted: 02/15/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND This study evaluated if different prognostic characteristics exist for peak oxygen consumption (VO2), percent predicted peak VO2 (ppVO2), and the slope of the change in minute ventilation to volume of carbon dioxide produced (VE-VCO2) slope between men and women with heart failure and reduced ejection fraction (HFrEF). METHODS Analysis of the Henry Ford Hospital Cardiopulmonary Exercise Testing database (n = 1085; 33% women, 55% black) of individuals with HFrEF who completed a physician-referred cardiopulmonary exercise testing (CPX) between 1997 and 2010. Primary outcome was a composite of all-cause death, left ventricular assist device placement, and orthotopic heart transplant . Logistic and Cox regressions were performed and Kaplan-Meier survival curves were developed to describe relationships of the CPX variables and the composite outcome within and between men and women. RESULTS All patients were followed-up for a minimum of 5 years, during which there were 643 combined events (62%; 499 deaths, 64 left ventricular assist device implants, 80 orthotopic heart transplant). Each CPX variable was significantly related to event-free survival among both men and women. Log-rank assessment of Kaplan-Meier curves noted survival differences for peak VO2 and VE-VCO2 slope (p ≤ .002), but not ppVO2 (P = .32), between men and women. CONCLUSIONS Prognostic values for peak VO2 and the VE-VCO2 slope might be considered separately for men and women, whereas the ppVO2 value corresponding to 1- and 3-year survival rates may not be different between the sexes.
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Affiliation(s)
| | | | - Ali Shafiq
- Aurora Health Care, Milwaukee, Wisconsin
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19
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Abstract
PURPOSE OF REVIEW Heart transplantation is the best option for irreversible and critically advanced heart failure. However, limited donor pool, the risk of rejection, infection, and right ventricular dysfunction in short-term post-transplant period, as well as, the development of coronary allograft vasculopathy and malignancy in the long-term post-transplant period limits the utility of heart transplantation for all comers with advanced heart failure. Therefore, selection of appropriate candidates is very important for the best short and long-term prognosis. In this article, we discuss the principles of selection of candidates and compare to the recently updated International Society for Heart and Lung Transplantation (ISHLT) listing criteria with the goal of updating current clinical practice. RECENT FINDINGS We found that while most of the recommendations in the new listing criteria are continuous with the previous criteria, updated recommendations are made on the risk stratification models in choosing transplantation candidates. Recommendation on hepatic dysfunction is not directly included in the updated ISHLT listing criteria; however, adoption of the Model for End-stage Liver Disease (MELD) score and modified MELD scores in the evaluation of risk are suggested in recent studies. In conclusion, evaluation of patient selection for heart transplantation should be comprehensive and individualized with respect to indications and the risk of comorbidities of candidates. With the advancement of mechanical circulatory support (MCS), the selection of heart transplantation candidate is continuously evolving and widened. MCS as bridge to candidacy should be considered when the candidate has potentially reversible risk factors for transplantation.
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20
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Abstract
Heart failure is a complex clinical syndrome. The natural history of this syndrome is progressive. Advanced heart failure is present when a patient has signs and symptoms of heart failure that are refractory to therapy. Patients with the most advanced disease and worst prognosis can be identified using iterative, integrated clinical assessment of symptom burden, effort intolerance, and cardiac dysfunction. Recognizing the transition to advanced heart failure is necessary for referral to an advanced heart disease program. Advanced heart disease specialists can tailor medical therapies, perform risk stratification, and evaluate candidacy for mechanical support, transplantation, or end-of-life palliative treatment options.
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Affiliation(s)
- Sunit-Preet Chaudhry
- Department of Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Garrick C Stewart
- Department of Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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21
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Comment on “Variables measured during cardiopulmonary exercise testing as predictors of mortality in chronic systolic heart failure”. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abreu A. Comentário a «Variáveis medidas durante prova de esforço cardiorrespiratória como preditoras de mortalidade na insuficiência cardíaca crónica com disfunção sistólica». Rev Port Cardiol 2016. [DOI: 10.1016/j.repc.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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23
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Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee. J Card Fail 2015; 21:519-34. [PMID: 25953697 DOI: 10.1016/j.cardfail.2015.04.013] [Citation(s) in RCA: 242] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/20/2015] [Accepted: 04/23/2015] [Indexed: 12/26/2022]
Abstract
We propose that stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive decline should be primarily driven by the heart failure syndrome. Formally defining advanced heart failure and specifying when medical and device therapies have failed is challenging, but signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models are useful in this process. Identification of patients in stage D is a clinically important task because treatments are inherently limited, morbidity is typically progressive, and survival is often short. Age, frailty, and psychosocial issues affect both outcomes and selection of therapy for stage D patients. Heart transplant and mechanical circulatory support devices are potential treatment options in select patients. In addition to considering indications, contraindications, clinical status, and comorbidities, treatment selection for stage D patients involves incorporating the patient's wishes for survival versus quality of life, and palliative and hospice care should be integrated into care plans. More research is needed to determine optimal strategies for patient selection and medical decision making, with the ultimate goal of improving clinical and patient centered outcomes in patients with stage D heart failure.
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Affiliation(s)
- Taiki Higo
- Cardiovascular Medicine, Kyushu University Hospital
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Bogaev RC, Meyers DE. Medical Treatment of Heart Failure and Coronary Heart Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Despite advances in medical therapy for chronic heart failure (HF), advanced HF carries a dismal prognosis. Options such as transplantation and durable mechanical circulatory support have greatly improved outcomes for these patients, but their introduction has introduced significant complexity to patient management. Although much of this management occurs at specialized heart transplant centers, it is the responsibility of the primary cardiologist of the patient with advanced HF to refer patients at the appropriate time and to help them navigate the difficult decisions related to the pursuit of advanced therapies. We present a unique pathway that incorporates guidelines, recent data, and expert opinion to help general cardiologists determine which patients should be referred for transplantation or durable mechanical circulatory support, and when they should be referred. Decision making on referral to the heart transplant center is also summarized.
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Corrà U, Piepoli MF, Adamopoulos S, Agostoni P, Coats AJ, Conraads V, Lambrinou E, Pieske B, Piotrowicz E, Schmid JP, Seferović PM, Anker SD, Filippatos G, Ponikowski PP. Cardiopulmonary exercise testing in systolic heart failure in 2014: the evolving prognostic role. Eur J Heart Fail 2014; 16:929-41. [DOI: 10.1002/ejhf.156] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 06/23/2014] [Accepted: 06/27/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ugo Corrà
- Cardiology Division, IRCCS Fondazione ‘S. Maugeri’; Centro Medico e di Riabilitazione di Veruno; Veruno Novara Italy
| | - Massimo F. Piepoli
- Heart Failure Unit, Cardiac Department; G Da Saliceto Hospital; Piacenza Italy
| | | | | | - Andrew J.S. Coats
- Monash University, Melbourne, Australia and University of Warwick; Coventry UK
| | - Viviane Conraads
- Department of Cardiology; Antwerp University Hospital; Edegem Antwerpen Belgium
| | | | - Burkert Pieske
- Department of Cardiology Medical University Graz; Austria
| | - Ewa Piotrowicz
- Telecardiology Center; Institute of Cardiology; Warsaw Poland
| | - Jean-Paul Schmid
- Department of Cardiology, Cardiovascular Prevention, Rehabilitation & Sports Medicine; Bern University Hospital and University of Bern; Switzerland
| | - Petar M. Seferović
- Polyclinic of the Clinical Centre of Serbia, and Department of Internal Medicine Belgrade University School of Medicine; Belgrade Serbia
| | - Stefan D. Anker
- Applied Cachexia Research; Department of Cardiology, Charitè, Campus Virchow Klinikum; Berlin Germany
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology; University Hospital Attikon; Athens Greece
| | - Piotr P. Ponikowski
- Department of Heart Diseases, Faculty of Health Sciences; Wroclaw Medical University Military Hospital; Wroclaw Poland
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Giannoni A, Baruah R, Leong T, Rehman MB, Pastormerlo LE, Harrell FE, Coats AJS, Francis DP. Do optimal prognostic thresholds in continuous physiological variables really exist? Analysis of origin of apparent thresholds, with systematic review for peak oxygen consumption, ejection fraction and BNP. PLoS One 2014; 9:e81699. [PMID: 24475020 PMCID: PMC3903471 DOI: 10.1371/journal.pone.0081699] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/15/2013] [Indexed: 11/22/2022] Open
Abstract
Background Clinicians are sometimes advised to make decisions using thresholds in measured variables, derived from prognostic studies. Objectives We studied why there are conflicting apparently-optimal prognostic thresholds, for example in exercise peak oxygen uptake (pVO2), ejection fraction (EF), and Brain Natriuretic Peptide (BNP) in heart failure (HF). Data Sources and Eligibility Criteria Studies testing pVO2, EF or BNP prognostic thresholds in heart failure, published between 1990 and 2010, listed on Pubmed. Methods First, we examined studies testing pVO2, EF or BNP prognostic thresholds. Second, we created repeated simulations of 1500 patients to identify whether an apparently-optimal prognostic threshold indicates step change in risk. Results 33 studies (8946 patients) tested a pVO2 threshold. 18 found it prognostically significant: the actual reported threshold ranged widely (10–18 ml/kg/min) but was overwhelmingly controlled by the individual study population's mean pVO2 (r = 0.86, p<0.00001). In contrast, the 15 negative publications were testing thresholds 199% further from their means (p = 0.0001). Likewise, of 35 EF studies (10220 patients), the thresholds in the 22 positive reports were strongly determined by study means (r = 0.90, p<0.0001). Similarly, in the 19 positives of 20 BNP studies (9725 patients): r = 0.86 (p<0.0001). Second, survival simulations always discovered a “most significant” threshold, even when there was definitely no step change in mortality. With linear increase in risk, the apparently-optimal threshold was always near the sample mean (r = 0.99, p<0.001). Limitations This study cannot report the best threshold for any of these variables; instead it explains how common clinical research procedures routinely produce false thresholds. Key Findings First, shifting (and/or disappearance) of an apparently-optimal prognostic threshold is strongly determined by studies' average pVO2, EF or BNP. Second, apparently-optimal thresholds always appear, even with no step in prognosis. Conclusions Emphatic therapeutic guidance based on thresholds from observational studies may be ill-founded. We should not assume that optimal thresholds, or any thresholds, exist.
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Affiliation(s)
- Alberto Giannoni
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Cardiovascular Medicine, Fondazione Toscana G. Monasterio, Pisa, Italy
- * E-mail:
| | - Resham Baruah
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Tora Leong
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | - Frank E. Harrell
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Andrew J. S. Coats
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Norfolk and Norwich Hospital, University of East Anglia, Norwich, United Kingdom
| | - Darrel P. Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
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Prognostic significance of peak oxygen consumption≤10ml/kg/min in heart failure: Context vs. criteria. Int J Cardiol 2013; 168:3419-23. [DOI: 10.1016/j.ijcard.2013.04.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 04/15/2013] [Accepted: 04/19/2013] [Indexed: 11/18/2022]
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Rogers JG. Defining and Refining Heart Failure Risk Stratification to Optimize Patient Selection for Cardiac Transplantation. Circ Heart Fail 2013; 6:2-3. [DOI: 10.1161/circheartfailure.112.973529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph G. Rogers
- From the Division of Cardiology, Duke University School of Medicine and the Duke Clinical Research Institute, Durham, NC
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Corrà U, Mezzani A, Giordano A, Caruso R, Giannuzzi P. A new cardiopulmonary exercise testing prognosticating algorithm for heart failure patients treated with beta-blockers. Eur J Prev Cardiol 2011; 19:185-91. [DOI: 10.1177/1741826710396625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ugo Corrà
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
| | - Alessandro Mezzani
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
| | - Andrea Giordano
- Bioengineering Department, Salvatore Maugeri Foundation, IRCCS, Via per Revislate 13, 28010 Veruno, Italy
| | - Roberto Caruso
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
| | - Pantaleo Giannuzzi
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
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A cutoff point for peak oxygen consumption in the prognosis of heart failure patients with beta-blocker therapy. Int J Cardiol 2010; 145:75-7. [DOI: 10.1016/j.ijcard.2009.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 05/01/2009] [Indexed: 11/19/2022]
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Sachdeva A, Horwich TB, Fonarow GC. Comparison of usefulness of each of five predictors of mortality and urgent transplantation in patients with advanced heart failure. Am J Cardiol 2010; 106:830-5. [PMID: 20816124 DOI: 10.1016/j.amjcard.2010.04.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 04/26/2010] [Accepted: 04/26/2010] [Indexed: 11/30/2022]
Abstract
B-type natriuretic peptide (BNP), peak oxygen consumption (VO(2)), blood urea nitrogen (BUN), systolic blood pressure (SBP), and pulmonary capillary wedge pressure are all established predictors of mortality or urgent transplantation in patients with advanced heart failure (HF). However, their comparative predictive ability in estimating prognosis has not been well studied. We analyzed 1,215 patients with advanced systolic HF referred to a university center from 1999 to 2009. BUN, BNP, VO(2), SBP, and pulmonary capillary wedge pressure were measured as a part of the initial evaluation. The patients were divided into groups according to the best cutoffs for predicting both 1- and 2-year mortality from the analysis of the receiver operating characteristic curves (BNP > or =579 pg/ml, peak VO(2) <14 ml/kg/min, BUN > or =53 mg/dl, SBP <118 mm Hg, and pulmonary capillary wedge pressure > or =21 mm Hg). During a 2-year follow-up, 234 patients (19%) died, and 208 (17%) required urgent transplantation. BNP (odds ratio 4.3, 95% confidence interval 3.3 to 5.5) and peak VO(2) (odds ratio 4.5, 95% confidence interval 2.6 to 7.8) were the strongest predictors for death or urgent transplantation. On multivariate analyses, BNP and peak VO(2) were the strongest predictors for both death or urgent transplantation and all-cause mortality. The c-statistic was 0.756 for BNP, 0.701 for VO(2), 0.659 for BUN, 0.638 for SBP, and 0.650 for pulmonary capillary wedge pressure. In conclusion, of the 5 established predictors of outcomes in advanced HF, BNP was the most robust discriminator of risk and thus could be useful, along with other more traditional prognostic variables, in patient counseling regarding prognosis and determining the timing for heart transplantation.
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Affiliation(s)
- Amit Sachdeva
- Department of Medicine, University of California, Los Angeles, Medical Center, Los Angeles, California, USA
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Ferreira AM, Tabet JY, Frankenstein L, Metra M, Mendes M, Zugck C, Beauvais F, Cohen-Solal A. Ventilatory Efficiency and the Selection of Patients for Heart Transplantation. Circ Heart Fail 2010; 3:378-86. [DOI: 10.1161/circheartfailure.108.847392] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- António M. Ferreira
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Jean-Yves Tabet
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Lutz Frankenstein
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Marco Metra
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Miguel Mendes
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Christian Zugck
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Florence Beauvais
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
| | - Alain Cohen-Solal
- From the Departments of Cardiology, Santa Cruz Hospital (A.M.F., M. Mendes), Carnaxide, Portugal; Lariboisière Hospital (J.-Y.T., F.B., A.C.-S.), Paris, France; Heidelberg University Hospital (L.F., C.Z.), Heidelberg, Germany; Brescia University (M. Metra), Brescia, Italy; and Université Denis Diderot (A.C.-S.), INSERM U 942, Paris, France
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Elmariah S, Goldberg LR, Allen MT, Kao A. The Effects of Race on Peak Oxygen Consumption and Survival in Patients With Systolic Dysfunction. J Card Fail 2010; 16:332-9. [DOI: 10.1016/j.cardfail.2009.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 12/11/2009] [Accepted: 12/14/2009] [Indexed: 10/19/2022]
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Lizak MK, Zakliczyński M, Jarosz A, Zembala M. Is there a difference between patients with peak oxygen consumption below 10 ml/kg/min versus between 10 and 14 ml/kg/min? Does the "Grey Zone" really exist? Transplant Proc 2009; 41:3190-3. [PMID: 19857707 DOI: 10.1016/j.transproceed.2009.07.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing is an important component of evaluation when orthotopic heart transplantation (OHT) is considered for chronic heart failure (CHF) patients. However there is a question about the accuracy of interpretations of peak oxygen consumption (VO(2)max) used at present. MATERIALS AND METHODS We analyzed 302 CHF patients stratified into 3 groups according to VO(2)max (mL/kg/min): group 1 = <10 (n = 37); group 2 = 10-14 (n = 121) and group 3 = >14 (n = 144). We compared the mortality rate, the OHT rate, time to OHT, time to death and pulmonary function tests (PFT) among the groups using ANOVA Kruskal-Wallis tests for analysis in Statistica 7.1. RESULTS No important differences were observed between groups 1 and 2 (P > .05), but first in comparison with group 3 (P < .05) in terms of mortality (48.6% vs 33.1% vs 21.5%), number of OHT (24.3% vs 32.2% vs 14.6%), time to death (15.4 vs 16.6 vs 34.4 months) or PFT results (forced expiratory volume in the first second forced vital capacity and peak expiratory flow, all as direct or as percent of normal values). In contrast, time to OHT (4.6 vs 6.9 vs 10.9 months) and percent of normal vital capacity (72% vs 81% vs 91%) differed significantly among all groups (P < .05). CONCLUSION Patients with VO(2)max between 10 and 14 or <10 mL/kg/min are at similar risk of death.
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Affiliation(s)
- M K Lizak
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, ul. Szpitalna 2, 41-800 Zabrze, Poland.
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Russell SD, Saval MA, Robbins JL, Ellestad MH, Gottlieb SS, Handberg EM, Zhou Y, Chandler B. New York Heart Association functional class predicts exercise parameters in the current era. Am Heart J 2009; 158:S24-30. [PMID: 19782785 DOI: 10.1016/j.ahj.2009.07.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The New York Heart Association (NYHA) functional class is a subjective estimate of a patient's functional ability based on symptoms that do not always correlate with the objective estimate of functional capacity, peak oxygen consumption (peak V(O2)). In addition, relationships between these 2 measurements have not been examined in the current medical era when patients are using beta-blockers, aldosterone antagonists, and cardiac resynchronization therapy (CRT). Using baseline data from the HF-ACTION (Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing) study, we examined this relationship. METHODS One thousand seven hundred fifty-eight patients underwent a symptom-limited metabolic stress test and stopped exercise due to dyspnea or fatigue. The relationship between NYHA functional class and peak V(O2) was examined. In addition, the effects of beta-blockers, aldosterone antagonists, and CRT therapy on these relationships were compared. RESULTS The NYHA II patients have a significantly higher peak Vo(2) (16.1 +/- 4.6 vs 13.0 +/- 4.2 mL/kg per minute), a lower ventilation (Ve)/V(CO2) slope (32.8 +/- 7.7 vs 36.8 +/- 10.4), and a longer duration of exercise (11.0 +/- 3.9 vs 8.0 +/- 3.4 minutes) than NYHA III/IV patients. Within each functional class, there was no difference in any of the exercise parameters between patients on or off of beta-blockers, aldosterone antagonists, or CRT therapy. Finally, with increasing age, a significant difference in peak Vo(2), Ve/V(CO2) slope, and exercise time was found. CONCLUSION For patients being treated with current medical therapy, there still is a difference in true functional capacity between NYHA functional class II and III/IV patients. However, within each NYHA functional class, the presence or absence or contemporary heart failure therapies does not alter exercise parameters.
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Pascual-Figal DA, Peñafiel P, Nicolas F, de la Morena G, Ansaldo P, Redondo B, Sánchez Mas J, Valdés M. Valor pronóstico del BNP y la prueba de esfuerzo cardiopulmonar en la insuficiencia cardiaca sistólica en tratamiento con bloqueadores beta. Rev Esp Cardiol 2008. [DOI: 10.1157/13116653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Blair JEA, Manuchehry A, Chana A, Rossi J, Schrier RW, Burnett JC, Gheorghiade M. Prognostic markers in heart failure--congestion, neurohormones, and the cardiorenal syndrome. ACTA ACUST UNITED AC 2008; 9:207-13. [PMID: 17891672 DOI: 10.1080/17482940701606913] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
There are several markers of poor prognosis in heart failure (HF). The most established markers of poor prognosis in HF include neurohormonal (NH) imbalance, low ejection fraction (EF), ventricular arrhythmias, intraventricular conduction delays, low functional capacity, low SBP, and renal failure. The relative importance of these factors is unknown, as they have never been studied together. We present a 74-year-old female with nonischemic cardiomyopathy and an EF<20% who over 24 years since diagnosis, never developed clinical or hemodynamic congestion, was never hospitalized for HF, and never required a loop diuretic. She had all of the clinical indicators of poor prognosis in HF except for severe NH imbalance and renal failure, illustrating their importance in HF prognosis. While NH activation in HF is initially an adaptive mechanism, an imbalance of NH effectors causes congestion leading to a vicious cycle of congestion, renal dysfunction, and worsening of HF. The combination of NH activation and renal failure in HF is a vasomotor nephropathy known as the cardiorenal syndrome (CRS) and portends a poor prognosis. Pharmacological disruption of NH pathways early in HF may prevent CRS and, therefore, improve outcomes.
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de Jonge N, Kirkels J, Klöpping C, Lahpor J, Caliskan K, Maat A, Brügemann J, Erasmus M, Klautz R, Verwey H, Oomen A, Peels C, Golüke A, Nicastia D, Koole M, Balk A. Guidelines for heart transplantation. Neth Heart J 2008; 16:79-87. [PMID: 18345330 PMCID: PMC2266869 DOI: 10.1007/bf03086123] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Based on the changes in the field of heart transplantation and the treatment and prognosis of patients with heart failure, these updated guidelines were composed by a committee under the supervision of both the Netherlands Society of Cardiology and the Netherlands Association for Cardiothoracic surgery (NVVC and NVT).THE INDICATION FOR HEART TRANSPLANTATION IS DEFINED AS: 'End-stage heart disease not remediable by more conservative measures'.CONTRAINDICATIONS ARE: irreversible pulmonary hypertension/elevated pulmonary vascular resistance; active systemic infection; active malignancy or history of malignancy with probability of recurrence; inability to comply with complex medical regimen; severe peripheral or cerebrovascular disease and irreversible dysfunction of another organ, including diseases that may limit prognosis after heart transplantation.Considering the difficulties in defining end-stage heart failure, estimating prognosis in the individual patient and the continuing evolution of available therapies, the present criteria are broadly defined. The final acceptance is done by the transplant team which has extensive knowledge of the treatment of patients with advanced heart failure on the one hand and thorough experience with heart transplantation and mechanical circulatory support on the other hand. (Neth Heart J 2008;16:79-87.).
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Affiliation(s)
- N. de Jonge
- University Medical Center Utrecht, Utrecht, the Netherlands
| | - J.H. Kirkels
- University Medical Center Utrecht, Utrecht, the Netherlands
| | - C. Klöpping
- University Medical Center Utrecht, Utrecht, the Netherlands
| | - J.R. Lahpor
- University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - J. Brügemann
- University Medical Center Groningen, Groningen, the Netherlands
| | - M.E. Erasmus
- University Medical Center Groningen, Groningen, the Netherlands
| | - R.J.M. Klautz
- Leiden University Medical Center, Leiden, the Netherlands
| | - H.F. Verwey
- Leiden University Medical Center, Leiden, the Netherlands
| | - A. Oomen
- Antonius Hospital, Sneek, the Netherlands
| | - C.H. Peels
- Catharina Hospital, Eindhoven, the Netherlands
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Jankowska EA, Witkowski T, Ponikowska B, Reczuch K, Borodulin-Nadzieja L, Anker SD, Piepoli MF, Banasiak W, Ponikowski P. Excessive ventilation during early phase of exercise: A new predictor of poor long-term outcome in patients with chronic heart failure. Eur J Heart Fail 2007; 9:1024-31. [PMID: 17702647 DOI: 10.1016/j.ejheart.2007.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 03/27/2007] [Accepted: 07/02/2007] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Studies demonstrating prognostic value of excessive exercise ventilation in chronic heart failure (CHF) have focused on data derived from the whole cardiopulmonary exercise test (CPET). Whether ventilatory response to early phase of exercise is useful for risk stratification in CHF is unknown. METHODS AND RESULTS We evaluated 216 patients with systolic CHF who underwent CPET (age: 60+/-11 years, NYHA class [I/II/III/IV]: 18/104/77/17). Ventilatory response to exercise (slope of regression line relating ventilation to carbon dioxide production) was calculated from the whole exercise test (VE-VCO(2)-all) and from the first 3 min of exercise (early phase - VE-VCO(2)-3 min). During follow-up (mean: 40+/-20 months, >3 years in survivors), 89 (41%) CHF patients died. High VE-VCO(2)-all and VE-VCO(2)-3 min predicted poor outcome in single predictor analyses, and in multivariable models when adjusted for prognosticators (age, NYHA class, ejection fraction, peak VO(2)) (P<0.0001). In receiver operating characteristic curve analysis, areas under curve for 3-year follow-up were similar for VE-VCO(2)-all and VE-VCO(2)-3 min. VE-VCO(2)-3 min maintained its prognostic value in patients taking beta-blockers (P<0.0001) and those unable to perform maximal CPET (P=0.0009). CONCLUSIONS In CHF patients, excessive ventilation assessed over the first 3 min predicts poor outcome. Assessment of ventilatory response to exercise for prognostic stratification may be extended to patients unable to perform maximal CPET.
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Affiliation(s)
- Ewa A Jankowska
- Cardiology Department, Military Hospital, Weigla 5, 50-981 Wroclaw, Poland
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Arena RA, Guazzi M, Myers J, Abella J. The Prognostic Value of Ventilatory Efficiency with Beta-Blocker Therapy in Heart Failure. Med Sci Sports Exerc 2007; 39:213-9. [PMID: 17277583 DOI: 10.1249/01.mss.0000241655.45500.c7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Beta-blockade (BB) has been shown to improve outcomes among patients with heart failure (HF). The impact this pharmacological approach has on the prognostic information gained from cardiopulmonary exercise testing (CPX) is, however, unclear. METHODS Four hundred seventeen subjects diagnosed with HF underwent CPX. The numbers of subjects prescribed and not prescribed a BB agent were 167 and 250, respectively. Subjects were tracked for cardiac-related mortality after CPX. RESULTS Values are reported for the no-BB versus the BB group throughout. Age (57.9 +/- 13.3 vs 55.6 +/- 12.5), peak VO2 (16.2 +/- 5.7 vs 16.5 +/- 5.5 mL x kg(-1) x min(-1)), VE/VCO2 slope (34.2 +/- 9.0 vs 33.2 +/- 7.4), and peak RER (1.07 +/- 0.16 vs 1.05 +/- 0.14) were similar between groups (P > 0.05). Multivariate Cox regression analysis revealed that the VE/VCO2 slope was the superior predictor of death in both groups (chi-square: 71.9, P < 0.001; and 18.4, P < 0.001). The optimal threshold values for VE/VCO2 slope in the no-BB and BB groups were 36.0 and 34.3, respectively. CONCLUSIONS The results of the present study indicate that BB does not alter the prognostic value/characteristics of the VE/VCO2 slope. Findings from previous investigations examining the prognostic significance of CPX predominantly using HF groups not receiving a BB agent may, therefore, still be applicable in modern-day clinical practice.
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Affiliation(s)
- Ross A Arena
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23298-0224, USA. raarena@.vcu.edu
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Guazzi M, Arena R, Myers J. Comparison of the prognostic value of cardiopulmonary exercise testing between male and female patients with heart failure. Int J Cardiol 2006; 113:395-400. [PMID: 16650490 DOI: 10.1016/j.ijcard.2005.11.105] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Revised: 10/06/2005] [Accepted: 11/17/2005] [Indexed: 11/18/2022]
Abstract
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. CONCLUSION The results of the present study indicate that the prognostic value of peak VO(2) and the VE/VCO(2) slope are similar in men and women diagnosed with HF. In both men and women, the prognostic power of the VE/VCO(2) slope is greater than that of peak VO(2).
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Affiliation(s)
- Marco Guazzi
- University of Milano, San Paolo Hospital, Cardiology Division, Italy
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Tabet JY, Metra M, Thabut G, Logeart D, Cohen-Solal A. Prognostic value of cardiopulmonary exercise variables in chronic heart failure patients with or without beta-blocker therapy. Am J Cardiol 2006; 98:500-3. [PMID: 16893705 DOI: 10.1016/j.amjcard.2006.03.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 03/06/2006] [Accepted: 03/06/2006] [Indexed: 10/24/2022]
Abstract
The prognostic value of exercise-derived variables in the prediction of mortality in patients with chronic heart failure treated by beta blockers continues to be debated. A total of 402 patients with chronic heart failure, including 255 treated with beta blockers, were included and followed for 26 +/- 20 months after the exercise test. On univariate analysis, and in contrast to peak exercise oxygen consumption, the prognostic value of the minute ventilation/carbon dioxide production slope was increased in patients receiving beta-blocker therapy. On multivariate analysis, no independent prognostic variable emerged in patients not on beta-blocker therapy. However, the model that included the circulatory power (peak oxygen uptake x systolic blood pressure), in addition to age, New York Heart Association class, and left ventricular ejection fraction, was the best 1 for patients on beta-blocker therapy. In conclusion, in patients with chronic heart failure, the circulatory power is the exercise variable with the greatest independent prognostic value, compared with the peak exercise oxygen consumption and minute ventilation/carbon dioxide production slope.
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Affiliation(s)
- Jean Yves Tabet
- Department of Cardiology, Assistance Publique-Hopitaux de Paris, Hopital Lariboisière, Paris, France
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Arena R, Guazzi M, Myers J. Prognostic value of end-tidal carbon dioxide during exercise testing in heart failure. Int J Cardiol 2006; 117:103-8. [PMID: 16843545 DOI: 10.1016/j.ijcard.2006.04.058] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2006] [Accepted: 04/29/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND The partial pressure of end-tidal carbon dioxide production (P(ET)CO2) at ventilatory threshold (VT) has been shown to be strongly correlated with cardiac output during exercise in patients with heart failure (HF), but few data are available regarding its prognostic utility. AIMS The purpose of this study was to assess the ability of P(ET)CO2 to predict cardiac-related events in a group of subjects with HF. METHODS One hundred and thirty subjects diagnosed with compensated HF underwent cardiopulmonary exercise testing (CPX). Peak oxygen consumption (VO2), the minute ventilation-carbon dioxide production (VE/VCO2) slope and P(ET)CO2 were determined. RESULTS Receiver operating characteristic (ROC) curve analysis revealed that P(ET)CO2 at the ventilatory threshold (VT) was a significant predictor of cardiac-related events (ROC area=0.82, p<0.001). The optimal P(ET)CO2 at a VT threshold value for separating high (< or =) and low (>) risk groups was 36.1 mm Hg (77% sensitivity, 69% specificity). In a multivariate Cox regression analysis, P(ET)CO2 at VT added significant predictive value to the VE/VCO2 slope and peak VO2. CONCLUSION These results indicate that P(ET)CO2 during CPX is a significant predictor of cardiac-related events in patients with HF. Clinical assessment of this variable in patients with HF undergoing CPX may therefore be warranted.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, Box 980224, Virginia Commonwealth University, Health Sciences Campus, Richmond, Virginia 23298-0224, United States.
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Elmariah S, Goldberg LR, Allen MT, Kao A. Effects of Gender on Peak Oxygen Consumption and the Timing of Cardiac Transplantation. J Am Coll Cardiol 2006; 47:2237-42. [PMID: 16750689 DOI: 10.1016/j.jacc.2005.11.089] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 11/21/2005] [Accepted: 11/28/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study examines the gender effects on peak exercise oxygen consumption (VO2) and survival in heart failure (HF) patients and their implications for cardiac transplantation. BACKGROUND The predictive value of peak VO2 in women HF patients is poorly established but is one of the indicators used to optimally time cardiac transplantation in women. METHODS A total of 594 ambulatory HF patients (mean age 52 +/- 12 years, 28% women, mean left ventricular ejection fraction 26 +/- 12%, 73% on beta-blocker) underwent symptom-limited exercise tests with breath-by-breath expired gas analyses using ramped treadmill protocols. Kaplan-Meier survival curves were generated for each gender and compared using log-rank tests. RESULTS Women had a significantly lower peak VO2 than men (14.0 +/- 4.9 ml/kg/min vs. 16.6 +/- 7.1 ml/kg/min; p < 0.0001), despite being younger (48.9 +/- 11.5 years vs. 53.2 +/- 12.4 years; p < 0.0001) and having a higher left ventricular ejection fraction (29 +/- 13% vs. 25 +/- 11%; p < 0.0003). However, the one-year transplant-free survival was significantly lower for men than for women (81% vs. 94%, p < 0.0001), a finding seen across each Weber class. Cox regression analyses confirmed the protective effects of female gender on transplant-free survival when controlling for peak VO2, age, race, beta-blocker use, and type of cardiomyopathy. The peak VO2 associated with 85% one-year transplant-free survival was significantly higher in men than in women (11.5 vs. 10.0 ml/kg/min). CONCLUSIONS Women had a significantly lower peak Vo(2) than men, but had better survival at all levels of exercise capacity. The current practice of uniform application of peak VO2 as an aid to determine cardiac transplantation timing should be re-examined.
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Affiliation(s)
- Sammy Elmariah
- Department of Medicine, Cardiovascular Division, Heart Failure and Cardiac Transplant Program, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Stolker JM, Heere B, Geltman EM, Schechtman KB, Peterson LR. Prospective comparison of ventilatory equivalent versus peak oxygen consumption in predicting outcomes of patients with heart failure. Am J Cardiol 2006; 97:1607-10. [PMID: 16728223 DOI: 10.1016/j.amjcard.2005.12.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Revised: 12/14/2005] [Accepted: 12/14/2005] [Indexed: 10/24/2022]
Abstract
In patients with heart failure (HF), peak exercise oxygen consumption (VO2) is an important prognostic tool on which critical clinical decisions are made. However, recent retrospective data have suggested that ventilatory equivalent (VE = ventilation [liters per minute]/VO2 [liters per minute]) may be a stronger predictor of outcomes than VO2 in patients with HF on modern medical therapies. We prospectively collected baseline demographics, cardiovascular history, hemodynamics, and exercise ventilatory data from 221 consecutive patients with HF who underwent treadmill exercise VO2 testing. The composite primary end point was death or heart transplantation. Mean follow-up was 508 days, during which 27 events occurred (13 deaths and 14 transplantations). One-year event-free survival was 88% (n = 104 with 1-year follow-up). Mean age was 49 years, 68% were men, 84% were taking beta blockers, 82% were taking angiotensin-converting enzyme inhibitors, and 21% had an implantable cardioverter-defibrillator. Mean VO2 was 16 +/- 5 ml/kg/min. Mean VE was 47.4 +/- 15.2. Univariate predictors of events included lower VO2 (p <0.0001), higher heart rate at rest (p = 0.05), and presence of an implantable cardioverter-defibrillator (p = 0.024). Higher VE (p = 0.10) and lower maximum systolic blood pressure (p = 0.09) were of borderline significance. Age, gender, HF etiology or severity, and other ventilatory parameters were not significant predictors. Multivariate models that incorporated VE, VO2, or their combination confirmed VO2 as an independent predictor of event-free survival (p < or =0.0002); VE did not independently predict outcomes. Other independent predictors were higher heart rate at rest (p < or =0.02) and presence of an implantable cardioverter-defibrillator (p < or =0.04). In conclusion, peak VO2, but not VE, predicts clinical outcomes of patients with HF who are treated with contemporary medical therapies.
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Affiliation(s)
- Joshua M Stolker
- The Department of Medicine, Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA.
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