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CLINICAL STUDIES

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

Marco Metra, MD^*, Pompilio Faggiano, MD, Antonio D’Aloia, MD^*, Savina Nodari, MD^*, Anna Gualeni, MD^*, Domenica Raccagni, MD^* and Livio Dei Cas, MD^*

^* Cattedra di Cardiologia, Universitá di Brescia, Brescia, Italy
Divisione di Cardiologia, Ospedale Fatebenefratelli, Brescia, Italy

Manuscript received October 9, 1997; revised manuscript received October 23, 1998, accepted December 11, 1998.

Reprint requests and correspondence: Dr. Marco Metra, Cattedra di Cardiologia, Università di Brescia, c/o Spedali Civili, P.zza Spedali Civili 25100 Brescia, Italy.
deicas{at}master.cci.unibs.it

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 a follow-up of 19 ± 25 months, 32 patients died and 6 underwent urgent transplantation with a 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 a SWI >30 g·m/m² (p < 0.0001). A significant percentage of patients (41%) had a normal cardiac output response to exercise with an excellent two-year survival (87% vs. 58% in the others) despite a 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.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   CO = cardiac output   HF = heart failure   LVEF = left ventricular ejection fraction   PWP = pulmonary wedge pressure   SWI = stroke work index   VO2 = oxygen consumption

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