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CLINICAL RESEARCH: HEART FAILURE

Cardiopulmonary Exercise Testing in the Clinical and Prognostic Assessment of Diastolic Heart Failure

Marco Guazzi, MD, PhD, FACC^_*,_*, Jonathan Myers, PhD and Ross Arena, PhD

^_* Cardiopulmonary Laboratory, University of Milan, San Paolo Hospital, Milan, Italy
VA Palo Alto Health Care System and Stanford University, Palo Alto, California
Virginia Commonwealth University, Richmond, Virginia.

Manuscript received May 7, 2005; revised manuscript received July 4, 2005, accepted July 18, 2005.

^_* Reprint requests and correspondence: Dr. Marco Guazzi, Cardiopulmonary Laboratory, Cardiology Division, University of Milano, San Paolo Hospital, Via A. di Rudini, 8, 20142 Milan, Italy. (Email: marco.guazzi{at}unimi.it).

Presented in part at the 77th American Heart Association Scientific Sessions, New Orleans, Louisiana, November 7 to 10, 2004.

OBJECTIVES: This study sought to define the relative prognostic value of cardiopulmonary exercise testing (CPET) variables in heart failure (HF) patients with preserved versus reduced systolic function.

BACKGROUND: Cardiopulmonary exercise testing has an established role in the assessment of patients with systolic heart failure (SHF). Two variables, peak Vo₂ and, more recently, the VE/VCO₂ slope, have been shown to be extremely valuable in risk stratification. However, data are lacking in terms of the prognostic value of CPET in patients with diastolic heart failure (DHF).

METHODS: A total of 409 HF patients underwent CPET. Patients were divided into three groups according to the following left ventricular ejection fraction (LVEF) cutoffs: 40%, 45%, and 50%. The CPET response and the ability of peak VO₂ and the VE/VCO₂ slope to predict total mortality and hospitalization were examined.

RESULTS: At univariate Cox regression analysis, both the peak VO₂ and the VE/VCO₂ slope were significant predictors in SHF and DHF. Multivariate analysis documented a similar prognostic power of VE/VCO₂ slope and peak VO₂ in all SHF groups. Conversely, in DHF patients, VE/VCO₂ slope outnumbered peak VO₂, remaining the only predictor regardless of LVEF. In DHF, the area under the receiver operating characteristic curve for the VE/VCO₂slope identified a cutoff of 32.6 (74% sensitivity, 52% specificity), 33.1 (76% sensitivity, 62% specificity), and 33.3 (97% sensitivity, 40% specificity) for an LVEF cutoff of 40%, 45%, and 50%, respectively.

CONCLUSIONS: These results extend the clinical and prognostic applicability of CPET to DHF. An impairment in exercise ventilation rather than peak VO₂ holds clinical and prognostic impact in this increasing subset of patients.

Abbreviations and Acronyms   CPET = cardiopulmonary exercise test   DHF = diastolic heart failure   HF = heart failure   LVEF = left ventricular ejection fraction   ROC = receiver operating characteristic   SHF = systolic heart failure   VCO2 = carbon dioxide production   VE = ventilation   VO2 = oxygen uptake

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