Normalization for peak oxygen uptake increases the prognostic power of the ventilatory response to exercise in patients with chronic heart failure

Background Peak exercise oxygen uptake (peak VO2) and ventilation to CO2 production (VE/VCO2) slope are established prognostic indicators in patients with chronic heart failure (CHF). A high VE/VCO2 slope, however, does not take into account the level of physical performance as expressed by peak VO2. We hypothesized that the prognostic value of a high VE/VCO2 slope may be improved by normalization for peak VO2 (VE/VCO2/VO2). Methods One hundred patients with CHF underwent pulmonary function tests at rest (spirometry and lung diffusion capacity) and maximal cardiopulmonary exercise testing. The prognostic value of VE/VCO2 slope, peak VO2 and VE/VCO2/VO2 was probed prospectively. Results Twenty-one patients died from cardiac reasons during a mean follow-up of 26 ± 19 months. Nonsurvivors, compared to survivors, showed a lower peak VO2 (13.6 ± 4.0 vs 17.5 ± 4.1 mL · min−1 · kg−1, P < .01) and a steeper VE/VCO2 slope (43 ± 11 vs 31.6 ± 5.0, P < .01). Nonetheless, in patients whose VE/VCO2 slope exceeded 34 (upper normal limit), there was no correlation with peak VO2 (r = −35, P = not significant). Interestingly 35% of them showed a normal exercise performance (peak VO2 ≥18 mL · min−1 · kg−1). At multivariate analysis, the VE/VCO2 slope showed a prognostic power stronger than that of peak VO2; however, the VE/VCO2/VO2 index retained a prognostic power greater than that of both VE/VCO2 slope and peak VO2. A VE/VCO2/VO2 ≥2.4 signaled cases at higher risk. Conclusions Discrepancies between VE/VCO2 slope and peak VO2 may generate uncertainty. Normalization of the former by the latter improves outcome prediction and may be considered a simple and effective way for maximizing the clinical applicability of these 2 indicators.