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CLINICAL RESEARCH: HEART FAILURE/TRANSPLANTATION

Combining low-intensity and maximal exercise test results improves prognostic prediction in chronic heart failure

Hans Rickli, MD^*, Wolfgang Kiowski, MD^*, Manuel Brehm^*, Daniel Weilenmann, MD^*, Christoph Schalcher, MD^*, Alain Bernheim, MD^*, Erwin Oechslin, MD^* and Hans Peter Brunner-La Rocca, MD^*,*

^* Division of Cardiology, Department of Internal Medicine, University Hospital, Zürich, Switzerland
Division of Cardiology, Kantonsspital, St. Gallen, Switzerland
Division of Cardiology, Department of Internal Medicine, University Hospital, Basel, Switzerland.

Manuscript received September 27, 2002; revised manuscript received December 10, 2002, accepted January 24, 2003.

^* Reprint requests and correspondence: Dr. Hans Peter Brunner-La Rocca, Division of Cardiology, University Hospital, Petersgraben 4, 4031, Basel, Switzerland.
brunnerh{at}uhbs.ch

OBJECTIVES: This study investigated the combination of maximal and low-intensity exercise testing in predicting prognosis in chronic heart failure (CHF), using one single exercise test (two-step protocol).

BACKGROUND: Risk assessment based on any single factor has limited accuracy and reproducibility.

METHODS: Treadmill exercise testing was performed in 202 consecutive CHF patients (174 male; mean age 52 ± 11 years) using "breath-by-breath" gas exchange monitoring. Oxygen uptake (VO₂) kinetics were defined as oxygen deficit (VO₂ x time [rest to steady state] – VO₂ [rest to steady state]) and mean response time (MRT = oxygen-deficit/VO₂). Peak VO₂ (VO₂max) was defined as the highest VO₂. Mean follow-up was 873 ± 628 days. The primary end point was cardiac mortality and the need for urgent heart transplantation.

RESULTS: Forty-four patients (22%) died and 15 (7%) were urgently transplanted. In both univariate and multivariate analyses, MRT >50 s was the most powerful predictor of the primary end point (hazard ratio [HR] 4.44), followed by predicted VO₂max <50% (HR 3.50) and resting systolic blood pressure <105 mm Hg (HR 2.49, all p < 0.001). A majority (n = 130 [64%]) had one or none of these risk factors, with a one-year event rate of only 3%. Patients with two risk factors (n = 45 [22%]) were at medium risk (one-year event rate of 33%). Twenty-seven patients (13%) had all three risk factors, with a one-year event rate of 59%. The area under the curve, using the number of risk factors, was 0.86 ± 0.04 for the primary end point at one year. These results were independent of medication, in particular, beta-blockade.

CONCLUSIONS: A combination of low-intensity and maximal exercise test results improves assessment of prognosis in patients with CHF.

Abbreviations and Acronyms   BP   blood pressure   CHF   chronic heart failure   HR   hazard ratio   LVAD   left ventricular assist device   MRT   mean response time of oxygen uptake at onset of exercise   VE/VCO2   ventilatory response to exercise   VO2   oxygen consumption

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