Use of cardiopulmonary exercise testing with hemodynamic monitoring in the prognostic assessment of ambulatory patients with chronic heart failure

OBJECTIVES We studied whether direct assessment of the hemodynamic response to exercise could improve the prognostic evaluation of patients with heart failure (HF) and identify those in whom the main cause of the reduced functional capacity is related to extracardiac factors. BACKGROUND Peak exercise oxygen consumption (VO2) is one of the main prognostic variables in patients with HF, but it is influenced also by many extracardiac factors. METHODS Bicycle cardiopulmonary exercise testing with hemodynamic monitoring was performed, in addition to clinical evaluation and radionuclide ventriculography, in 219 consecutive patients with chronic HF (left ventricular ejection fraction, 22 ± 7%; peak VO2, 14.2 ± 4.4 ml/kg/min). RESULTS During follow-up of 19 ± 25 months, 32 patients died and 6 underwent urgent transplantation with 71% cumulative major event-free 2-year survival. Peak exercise stroke work index (SWI) was the most powerful prognostic variable selected by Cox multivariate analysis, followed by serum sodium and left ventricular ejection fraction, for one-year survival, and peak VO2 and serum sodium for two-year survival. Two-year survival was 54% in the patients with peak exercise SWI ≤30 g·m/m2 versus 91% in those with SWI >30 g·m/m2 (p < 0.0001). significant percentage of patients (41%) had normal cardiac output response to exercise with an excellent two-year survival (87% vs. 58% in the others) despite relatively low peak VO2 (15.1 ± 4.7 ml/kg/min). CONCLUSIONS Direct assessment of exercise hemodynamics in patients with HF provides additive independent prognostic information, compared to traditional noninvasive data.