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

Anuradha Lala; Keyur B Shah; David E Lanfear; Jennifer T Thibodeau; Maryse Palardy; Amrut V Ambardekar; Dennis M McNamara; Wendy C Taddei-Peters; J Timothy Baldwin; Neal Jeffries; Shokoufeh Khalatbari; Cathie Spino; Blair Richards; Douglas L Mann; Garrick C Stewart; Keith D Aaronson; Donna M Mancini; REVIVAL Investigators

doi:10.1016/j.jchf.2020.11.008

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

JACC Heart Fail. 2021 Mar;9(3):226-236. doi: 10.1016/j.jchf.2020.11.008. Epub 2021 Feb 3.

Authors

Anuradha Lala¹, Keyur B Shah², David E Lanfear³, Jennifer T Thibodeau⁴, Maryse Palardy⁵, Amrut V Ambardekar⁶, Dennis M McNamara⁷, Wendy C Taddei-Peters⁸, J Timothy Baldwin⁹, Neal Jeffries¹⁰, Shokoufeh Khalatbari¹¹, Cathie Spino¹², Blair Richards¹¹, Douglas L Mann¹³, Garrick C Stewart¹⁴, Keith D Aaronson⁵, Donna M Mancini¹⁵; REVIVAL Investigators

Affiliations

¹ Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
² Department of Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA.
³ Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan, USA.
⁴ Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
⁵ Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
⁶ University of Colorado, Boulder, Colorado, USA.
⁷ Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁸ Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA.
⁹ Michigan State University, East Lansing, Michigan, USA.
¹⁰ Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, USA.
¹¹ Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA.
¹² Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA.
¹³ Cardiovascular Division, Washington University School of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
¹⁴ Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
¹⁵ Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address: donna.mancini@mountsinai.org.

PMID: 33549559
DOI: 10.1016/j.jchf.2020.11.008

Abstract

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

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

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

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

Conclusions: Among patients with ambulatory advanced HF, the strongest maximal and submaximal CPX predictor of MCS implantation, transplantation, or death at 1 year were CP and VE/VCO_2, respectively. The patient-reported measure of exercise effort (Borg scale score) contributed substantially to the prediction of outcomes, a surprising and novel finding that warrants further investigation. (Registry Evaluation of Vital Information for VADs in Ambulatory Life [REVIVAL]; NCT01369407).

Keywords: ambulatory heart failure; cardiac transplant; cardiopulmonary exercise stress test; mechanical circulatory support; predictors.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Anaerobic Threshold
Exercise Test
Heart Failure* / diagnosis
Heart Failure* / therapy
Heart Failure, Systolic*
Heart-Assist Devices*
Humans
Oxygen Consumption
Prognosis

Associated data

ClinicalTrials.gov/NCT01369407

Abstract

Publication types

MeSH terms

Associated data

Grants and funding