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Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Cardiopulmonary Exercise Testing in Patients with Heart Failure: Impact of Gender in Predictive Value for Heart Transplantation Listing. Life (Basel) 2023; 13:1985. [PMID: 37895367 PMCID: PMC10608092 DOI: 10.3390/life13101985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men. METHODS Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx. RESULTS A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percent of predicted pVO2 were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO2 ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO2 slope > 35, and percent of predicted pVO2 ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO2, VE/VCO2 slope and percent of predicted pVO2 cut-offs in each sex group presented a higher prognostic power than the recommended thresholds. CONCLUSION Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.
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Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - António Valentim Gonçalves
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - João Ferreira Reis
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rita Ilhão Moreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Tiago Pereira-da-Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Pedro Rio
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rui M. Soares
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rui Cruz Ferreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
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Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Age Differences in Cardiopulmonary Exercise Testing Parameters in Heart Failure with Reduced Ejection Fraction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1685. [PMID: 37763804 PMCID: PMC10535443 DOI: 10.3390/medicina59091685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Cardiopulmonary exercise testing (CPET) is a cornerstone of risk stratification in heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of evidence on its predictive power in older patients. The aim of this study was to evaluate the prognostic power of current heart transplantation (HTx) listing criteria in HFrEF stratified according to age groups. Materials and Methods: Consecutive patients with HFrEF undergoing CPET between 2009 and 2018 were followed-up for cardiac death and urgent HTx. Results: CPET was performed in 458 patients with HFrEF. The composite endpoint occurred in 16.8% of patients ≤50 years vs. 14.1% of patients ≥50 years in a 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percentage of predicted pVO2 were strong independent predictors of outcomes. The International Society for Heart and Lung Transplantation thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers), VE/VCO2 slope > 35 and percentage of predicted pVO2 ≤ 50% presented a higher overall diagnostic effectiveness in younger patients (≤50 years). Specific thresholds for each age subgroup outperformed the traditional cut-offs. Conclusions: Personalized age-specific thresholds may contribute to an accurate risk stratification in HFrEF. Further studies are needed to address the gap in evidence between younger and older patients.
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Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - António Valentim Gonçalves
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - João Ferreira Reis
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rita Ilhão Moreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Tiago Pereira-da-Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Pedro Rio
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rui M. Soares
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rui Cruz Ferreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
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Santas E, Palau P, Llácer P, de la Espriella R, Miñana G, Núñez‐Marín G, Lorenzo M, Heredia R, Sanchis J, Chorro FJ, Bayés‐Genís A, Núñez J. Sex-Related Differences in Mortality Following Admission for Acute Heart Failure Across the Left Ventricular Ejection Fraction Spectrum. J Am Heart Assoc 2021; 11:e022404. [PMID: 34927464 PMCID: PMC9075214 DOI: 10.1161/jaha.121.022404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Following a heart failure (HF)‐decompensation, there is scarce data about sex‐related prognostic differences across left ventricular ejection fraction (LVEF) status. We sought to evaluate sex‐related differences in 6‐month mortality risk across LVEF following admission for acute HF. Methods and Results We retrospectively evaluated 4812 patients consecutively admitted for acute HF in a multicenter registry from 3 hospitals. Study end points were all‐cause, cardiovascular, and HF‐related mortality at 6‐month follow‐up. Multivariable Cox regression models were fitted to investigate sex‐related differences across LVEF. A total of 2243 (46.6%) patients were women, 2569 (53.4%) were men, and 2608 (54.2%) showed LVEF≥50%. At 6‐month follow‐up, 645 patients died (13.4%), being 544 (11.3%) and 416 (8.6%) cardiovascular and HF‐related deaths, respectively. LVEF was not independently associated with mortality (HR, 1.02; 95% CI 0.99–1.05; P=0.135). After multivariable adjustment, we found no sex‐related differences in all‐cause mortality (P value for interaction=0.168). However, a significant interaction between sex and cardiovascular and HF mortality risks was found across LVEF (P value for interaction=0.030 and 0.007, respectively). Compared with men, women had a significantly lower risk of cardiovascular and HF‐mortality at LVEF<25% and <43%, respectively. On the contrary, women showed a higher risk of HF‐mortality at the upper extreme of LVEF (>80%). Conclusions Following an admission for acute HF, no sex‐related differences were found in all‐cause mortality risk. However, when compared with men, women showed a lower risk of cardiovascular and HF‐mortality at the lower extreme of LVEF. On the contrary, they showed a higher risk of HF death at the upper extreme.
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Affiliation(s)
- Enrique Santas
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Patricia Palau
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
| | - Pau Llácer
- Servicio de Medicina InternaHospital Universitario Ramón y CajalMadridSpain
| | - Rafael de la Espriella
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Gema Miñana
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
| | - Gonzalo Núñez‐Marín
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Miguel Lorenzo
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Raquel Heredia
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Juan Sanchis
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
- CIBERCVMadridSpain
| | - Francisco Javier Chorro
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
| | - Antoni Bayés‐Genís
- CIBERCVMadridSpain
- Servicio de CardiologíaHospital Germans Trias i PujolUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Julio Núñez
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
- CIBERCVMadridSpain
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Silva WT, Costa HS, Figueiredo PHS, Lima MMO, Lima VP, da Costa FSM, Ávila MR, Mendonça VA, Lacerda ACR, Nunes MCP, Rocha MOC. Determinants of Functional Capacity in Patients with Chagas Disease. Arq Bras Cardiol 2021; 117:934-941. [PMID: 34378673 PMCID: PMC8682109 DOI: 10.36660/abc.20200462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/24/2020] [Accepted: 12/02/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Chagas disease leads to reduced functional capacity. However, the stage at which functional impairment is detectable remains unclear. OBJECTIVES The present study was addressed to compare the functional capacity of patients at different stages of Chagas disease and healthy individuals and to verify the determinants of peak oxygen uptake (VO2peak). METHODS In a cross-sectional study, 160 individuals were selected, 35 healthy and 125 with Chagas disease. In the Chagasic group, 61 (49%) were in the indeterminate form of the disease, 45 (36%) with Chagas cardiomyopathy (ChC) and preserved cardiac function and 19 (15%) with cardiac dysfunction and dilated ChC. The data were analyzed using univariate and multivariate regression analysis. Statistical significance was set at 5%. RESULTS Patients in the indeterminate form of disease showed similar functional capacity to healthy individuals (p>0.05). Patients with ChC and preserved cardiac function had lower VO2peak than patients in the indeterminate form (p<0.05), but showed similar VO2peak values than dilated ChC (p=0.46). The age, male sex, NYHA functional class, diastolic blood pressure, ratio of the early diastolic transmitral flow velocity to early diastolic mitral annular velocity, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter were associated with functional capacity. However, only age, male sex, LVEF and NYHA functional class, remained associated with VO2peak in the final model (adjusted R2=0.60). CONCLUSION Patients with ChC had lower functional capacity than patients in the indeterminate form. LVEF, age, male sex and NYHA functional class were determinants with VO2peak in patients with Chagas disease.
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Affiliation(s)
- Whesley Tanor Silva
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Henrique Silveira Costa
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Pedro Henrique Scheidt Figueiredo
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Márcia Maria Oliveira Lima
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Vanessa Pereira Lima
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Fábio Silva Martins da Costa
- Universidade Federal de Minas GeraisHospital das ClínicasFaculdade de MedicinaBelo HorizonteMGBrasilPrograma de Pós-graduação em Infectologia e Medicina Tropical, Departamento de Medicina Interna, Faculdade de Medicina e Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil.
| | - Matheus Ribeiro Ávila
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Vanessa Amaral Mendonça
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Ana Cristina Rodrigues Lacerda
- Universidade Federal dos Vales do Jequitinhonha e MucuriFaculdade de Ciências Biológicas e da SaúdeEscola de FisioterapiaDiamantinaMGBrasilLaboratório de Reabilitação Cardiovascular, Escola de Fisioterapia, Faculdade de Ciências Biológicas e da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, MG - Brasil.
| | - Maria Carmo Pereira Nunes
- Universidade Federal de Minas GeraisHospital das ClínicasFaculdade de MedicinaBelo HorizonteMGBrasilPrograma de Pós-graduação em Infectologia e Medicina Tropical, Departamento de Medicina Interna, Faculdade de Medicina e Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil.
| | - Manoel Otávio Costa Rocha
- Universidade Federal de Minas GeraisHospital das ClínicasFaculdade de MedicinaBelo HorizonteMGBrasilPrograma de Pós-graduação em Infectologia e Medicina Tropical, Departamento de Medicina Interna, Faculdade de Medicina e Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil.
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Tomasoni D, Adamo M, Anker MS, von Haehling S, Coats AJS, Metra M. Heart failure in the last year: progress and perspective. ESC Heart Fail 2020; 7:3505-3530. [PMID: 33277825 PMCID: PMC7754751 DOI: 10.1002/ehf2.13124] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM‐HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA‐HF and EMPEROR‐Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65–0.85; P < 0.001 and HR 0.75; 95% CI 0.65–0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82–0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.
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Affiliation(s)
- Daniela Tomasoni
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.,Cardiology and Cardiac Catheterization Laboratory, Cardio-thoracic Department, Civil Hospitals, Brescia, Italy
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.,Cardiology and Cardiac Catheterization Laboratory, Cardio-thoracic Department, Civil Hospitals, Brescia, Italy
| | - Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité-University Medicine Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Department of Cardiology (CBF), Charité-University Medicine Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Andrew J S Coats
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.,Cardiology and Cardiac Catheterization Laboratory, Cardio-thoracic Department, Civil Hospitals, Brescia, Italy
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6
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Palau P, Domínguez E, Núñez J. Sex differences on peak oxygen uptake in heart failure. ESC Heart Fail 2019; 6:921-926. [PMID: 31325239 PMCID: PMC6816054 DOI: 10.1002/ehf2.12483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/04/2019] [Accepted: 06/01/2019] [Indexed: 12/28/2022] Open
Abstract
Women represent nearly half of the adult heart failure (HF) population and they remain underrepresented in HF studies. We aimed to evaluate the evidence about peak oxygen uptake (peak VO2) for clinical stratification in women with HF. This narrative review summarizes (i) the evidence endorsing the value of cardiopulmonary exercise testing for clinical stratification and phenotyping HF population; (ii) the determinants of a person's functional aerobic capacity to understand predicted values for patients with chronic HF; and (iii) sex differences on peak VO2 data in different forms of HF. Lastly, based on existing data in patients with HF, we provide a perspective on how to improve existing gaps about the utility of peak VO2 in clinical stratification in women. Peak VO2 provides prognosis information in patients with HF; however, its use has been limited for a reduced number of patients excluding women, elderly, and HF patients with preserved ejection fraction. Further studies will help to fill the wide gender gap about the utility of cardiopulmonary exercise testing in the risk assessment and management in women with HF.
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Affiliation(s)
- Patricia Palau
- Cardiology Department, Hospital General Universitario de Castellón, Universitat Jaume I, Castellón, Spain
| | - Eloy Domínguez
- Cardiology Department, Hospital General Universitario de Castellón, Universitat Jaume I, Castellón, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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