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Agdamag AC, Van Iterson EH, Tang WHW, Finet JE. Prognostic Role of Metabolic Exercise Testing in Heart Failure. J Clin Med 2023; 12:4438. [PMID: 37445473 DOI: 10.3390/jcm12134438] [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: 05/22/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Heart failure is a clinical syndrome with significant heterogeneity in presentation and severity. Serial risk-stratification and prognostication can guide management decisions, particularly in advanced heart failure, when progression toward advanced therapies or end-of-life care is warranted. Each currently utilized prognostic marker carries its own set of challenges in acquisition, reproducibility, accuracy, and significance. Left ventricular ejection fraction is foundational for heart failure syndrome classification after clinical diagnosis and remains the primary parameter for inclusion in most clinical trials; however, it does not consistently correlate with symptoms and functional capacity, which are also independently prognostic in this patient population. Utilizing the left ventricular ejection fraction as the sole basis of prognostication provides an incomplete characterization of this condition and is prone to misguide medical decision-making when used in isolation. In this review article, we survey and exposit the important role of metabolic exercise testing across the heart failure spectrum, as a complementary diagnostic and prognostic modality. Metabolic exercise testing, also known as cardiopulmonary exercise testing, provides a comprehensive evaluation of the multisystem (i.e., neurological, respiratory, circulatory, and musculoskeletal) response to exercise performance. These differential responses can help identify the predominant contributors to exercise intolerance and exercise symptoms. Additionally, the aerobic exercise capacity (i.e., oxygen consumption during exercise) is directly correlated with overall life expectancy and prognosis in many disease states. Specifically in heart failure patients, metabolic exercise testing provides an accurate, objective, and reproducible assessment of the overall circulatory sufficiency and circulatory reserve during physical stress, being able to isolate the concurrent chronotropic and stroke volume responses for a reliable depiction of the circulatory flow rate in real time.
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Affiliation(s)
- Arianne Clare Agdamag
- Section of Heart Failure and Transplantation Medicine, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Erik H Van Iterson
- Section of Preventive Cardiology and Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - W H Wilson Tang
- Section of Heart Failure and Transplantation Medicine, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - J Emanuel Finet
- Section of Heart Failure and Transplantation Medicine, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Chen S, Wu P, Wang L, Wei C, Cheng C, Fang H, Fang Y, Chen Y, Huang DK, Lee F, Chen M. Optimizing exercise testing‐based risk stratification to predict poor prognosis after acute heart failure. ESC Heart Fail 2022; 10:895-906. [PMID: 36460605 PMCID: PMC10053263 DOI: 10.1002/ehf2.14240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 09/04/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022] Open
Abstract
AIMS The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO2 ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO2 and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era. METHODS AND RESULTS We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO2 and HFSS in predicting primary outcomes. The median follow-up period was 3.3 years. The primary outcome occurred in 57 participants. Peak VO2 outperformed HFSS when predicting 1 year (0.81 vs. 0.61; P = 0.017) and 2 year (0.78 vs. 0.58; P < 0.001) major outcomes. The cutoff peak VO2 for predicting a 20% risk of a major outcome within 2 years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO2 , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes. CONCLUSIONS Optimizing the cutoff value of peak VO2 is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.
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Affiliation(s)
- Shyh‐Ming Chen
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
| | - Po‐Jui Wu
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
| | - Lin‐Yi Wang
- Department of Physical Medicine and Rehabilitation Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Chin‐Ling Wei
- Department of Nursing, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Cheng‐I Cheng
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
| | - Hsiu‐Yu Fang
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
| | - Yen‐Nan Fang
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
| | - Yung‐Lung Chen
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
| | - David Kwan‐Ru Huang
- Division of Cardiovascular Surgery, Department of Surgery Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Fan‐Yen Lee
- Division of Cardiovascular Surgery, Department of Surgery Kaohsiung Chang Gung Memorial Hospital Kaohsiung City Taiwan, Republic of China
| | - Mien‐Cheng Chen
- Section of Cardiology, Department of Internal Medicine, Heart Failure Center Kaohsiung Chang Gung Memorial Hospital 123 Tai Pei Road, Niao Sung District Kaohsiung City 83301 Taiwan, Republic of China
- Chang Gung University College of Medicine Taoyuan City Taiwan, Republic of China
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Cattadori G, Di Marco S, Farina S, Limongelli G, Monda E, Badagliacca R, Papa S, Tricarico L, Correale M. Beta-blockers in heart failure prognosis: Lessons learned by MECKI Score Group papers. Eur J Prev Cardiol 2020; 27:65-71. [PMID: 33238743 PMCID: PMC7691627 DOI: 10.1177/2047487320951109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Heart failure is a complex syndrome affecting several organs including kidney,
lungs, liver, brain muscles and sympathetic system. Each of these organs might
contribute to its severity and prognosis. The prognosis assessment is critical
for a correct heart failure management. It has already been demonstrated that a
single parameter is weaker for prognosis than different parameters combined. The
Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI)
score has been built and validated for heart failure with reduced ejection
fraction (HFrEF) patients by considering cardiopulmonary exercise test data
combined with clinical, laboratory and echocardiographic measurements. The
betablockers treatment is a milestone in the HFrEF management. In the MECKI
score database, the association of betablockers treatment with outcome has been
investigated in different settings.
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Affiliation(s)
| | | | | | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Italy
| | - Emanuele Monda
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Italy
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesioloigiche e Geriatriche, 'Sapienza', Rome University, Italy
| | - Silvia Papa
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesioloigiche e Geriatriche, 'Sapienza', Rome University, Italy
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Paolillo S, Veglia F, Salvioni E, Corrà U, Piepoli M, Lagioia R, Limongelli G, Sinagra G, Cattadori G, Scardovi AB, Metra M, Senni M, Bonomi A, Scrutinio D, Raimondo R, Emdin M, Magrì D, Parati G, Re F, Cicoira M, Minà C, Correale M, Frigerio M, Bussotti M, Battaia E, Guazzi M, Badagliacca R, Di Lenarda A, Maggioni A, Passino C, Sciomer S, Pacileo G, Mapelli M, Vignati C, Clemenza F, Binno S, Lombardi C, Filardi PP, Agostoni P. Heart failure prognosis over time: how the prognostic role of oxygen consumption and ventilatory efficiency during exercise has changed in the last 20 years. Eur J Heart Fail 2019; 21:208-217. [PMID: 30632680 DOI: 10.1002/ejhf.1364] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 10/15/2018] [Accepted: 10/18/2018] [Indexed: 12/11/2022] Open
Abstract
AIMS Exercise-derived parameters, specifically peak exercise oxygen uptake (peak VO2 ) and minute ventilation/carbon dioxide relationship slope (VE/VCO2 slope), have a pivotal prognostic value in heart failure (HF). It is unknown how the prognostic threshold of peak VO2 and VE/VCO2 slope has changed over the last 20 years in parallel with HF prognosis improvement. METHODS AND RESULTS Data from 6083 HF patients (81% male, age 61 ± 13 years), enrolled in the MECKI score database between 1993 and 2015, were retrospectively analysed. By enrolment year, four groups were generated: group 1 1993-2000 (n = 440), group 2 2001-2005 (n = 1288), group 3 2006-2010 (n = 2368), and group 4 2011-2015 (n = 1987). We compared the 10-year survival of groups and analysed how the overall risk (cardiovascular death, urgent heart transplantation, or left ventricular assist device implantation) changed over time according to peak VO2 and VE/VCO2 slope and to major clinical and therapeutic variables. At 10 years, a progressively higher survival from group 1 to group 3 was observed, with no further improvement afterwards. A 20% risk for peak VO2 15 mL/min/kg (95% confidence interval 16-13), 9 (11-8), 4 (4-2) and 5 (7-4) was observed in group 1, 2, 3, and 4, respectively, while the VE/VCO2 slope value for a 20% risk was 32 (37-29), 47 (51-43), 59 (64-55), and 57 (63-52), respectively. CONCLUSIONS Heart failure prognosis improved over time up to 2010 in a HF population followed by experienced centres. The peak VO2 and VE/VCO2 slope cut-offs identifying a definite risk progressively decreased and increased over time, respectively. The prognostic threshold of peak VO2 and VE/VCO2 slope must be updated whenever HF prognosis improves.
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Affiliation(s)
- Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | | | - Ugo Corrà
- Division of Cardiac Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Veruno, Veruno, Italy
| | - Massimo Piepoli
- Division of Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Rocco Lagioia
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Cassano Murge, Bari, Italy
| | - Giuseppe Limongelli
- Cardiology SUN, Monaldi Hospital (Azienda dei Colli), Second University of Naples, Naples, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Gaia Cattadori
- Division of Cardiac Rehabilitation, Multimedica IRCCS, Milan, Italy
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Michele Senni
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Domenico Scrutinio
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Cassano Murge, Bari, Italy
| | - Rosa Raimondo
- Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Tradate, Tradate, Italy
| | - Michele Emdin
- Gabriele Monasterio Foundation, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Chiara Minà
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT, Palermo, Italy
| | | | - Maria Frigerio
- 'A. De Gasperis' Cardiology Department, Niguarda Hospital, Milan, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Milan, Milan, Italy
| | - Elisa Battaia
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | - Marco Guazzi
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Health Authority 1 and University of Trieste, Trieste, Italy
| | | | - Claudio Passino
- Gabriele Monasterio Foundation, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Susanna Sciomer
- Department of Cardiovascular Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Pacileo
- Cardiology SUN, Monaldi Hospital (Azienda dei Colli), Second University of Naples, Naples, Italy
| | | | | | - Francesco Clemenza
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT, Palermo, Italy
| | - Simone Binno
- Division of Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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