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Pezzuto B, Contini M, Berna G, Galotta A, Cattaneo G, Maragna R, Gugliandolo P, Agostoni P. Dynamic trend of lung fluid movement during exercise in heart failure: From lung imaging to alveolar-capillary membrane function. Int J Cardiol 2024; 407:132041. [PMID: 38643800 DOI: 10.1016/j.ijcard.2024.132041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 03/10/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND In chronic heart failure (HF), exercise-induced increase in pulmonary capillary pressure may cause an increase of pulmonary congestion, or the development of pulmonary oedema. We sought to assess in HF patients the exercise-induced intra-thoracic fluid movements, by measuring plasma brain natriuretic peptide (BNP), lung comets and lung diffusion for carbon monoxide (DLCO) and nitric oxide (DLNO), as markers of hemodynamic load changes, interstitial space and alveolar-capillary membrane fluids, respectively. METHODS AND RESULTS Twenty-four reduced ejection fraction HF patients underwent BNP, lung comets and DLCO/DLNO measurements before, at peak and 1 h after the end of a maximal cardiopulmonary exercise test. BNP significantly increased at peak from 549 (328-841) to 691 (382-1207, p < 0.0001) pg/mL and almost completely returned to baseline value 1 h after exercise. Comets number increased at peak from 9.4 ± 8.2 to 24.3 ± 16.7, returning to baseline (9.7 ± 7.4) after 1 h (p < 0.0001). DLCO did not change significantly at peak (from 18.01 ± 4.72 to 18.22 ± 4.73 mL/min/mmHg), but was significantly reduced at 1 h (16.97 ± 4.26 mL/min/mmHg) compared to both baseline (p = 0.0211) and peak (p = 0.0174). DLNO showed a not significant trend toward lower values 1 h post-exercise. CONCLUSIONS Moderate/severe HF patients have a 2-step intra-thoracic fluid movement with exercise: the first during active exercise, from the vascular space toward the interstitial space, as confirmed by comets increase, without any effect on diffusion, and the second, during recovery, toward the alveolar-capillary membrane, clearing the interstitial space but worsening gas diffusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Agostoni P, Cattadori G, Salvioni E, Sciomer S. Artificial intelligence and anaerobic threshold: the winner is human physiology. Eur J Prev Cardiol 2024; 31:445-447. [PMID: 38271192 DOI: 10.1093/eurjpc/zwae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
- Piergiuseppe Agostoni
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea, 4, Milan 20138, Italy
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milano 20138, Italy
| | - Gaia Cattadori
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea, 4, Milan 20138, Italy
- Unità Operativa Cardiologia Riabilitativa, IRCCS Multimedica, Milano, Italy
| | | | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, 'Sapienza', Rome University, Rome, Italy
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Baracchini N, Zaffalon D, Merlo M, Baschino S, Barbati G, Pezzuto B, Capovilla TM, Rossi M, Carriere C, Agostoni P, Sinagra G. Prognostic value of cardiopulmonary exercise testing repetition during follow-up of clinically stable patients with severe dilated cardiomyopathy. A preliminary study. Int J Cardiol 2023; 390:131252. [PMID: 37558137 DOI: 10.1016/j.ijcard.2023.131252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) is a recognized tool for prognostic stratification in patients with dilated cardiomyopathy (DCM). Given the lack of data currently available, the aim of this study was to test the prognostic value of repeating CPET during the follow-up of patients with DCM. METHODS This multicenter, retrospective study, analyzed DCM patients who consecutively performed two echocardiographies and CPETs during clinical stability. The study end-point was a composite of death from all causes, heart transplantation, left ventricular assist device implantation, life-threatening ventricular arrhythmias or hospitalization for heart failure. RESULTS 216 DCM patients were enrolled (52 years, 78% male, NYHA I-II 82%, LVEF 32%, 94% on ACE inhibitors/ARNI, 95% on beta-blockers). The interval between CPETs was 15 months. During a median follow-up of 38 months from the second CPET, 102 (47%) patients experienced the study end-point. Among them, there was stability of echocardiographic values but a significant worsening of functional capacity. Among the 173 patients (80%) who did not show echocardiographic left ventricular reverse remodeling (LVRR), the 1-year prevalence of the study-end point was higher in patients who worsened vs patients who maintained stable their functional capacity at CPET (38 vs. 15% respectively, p-value: 0.001). These results were consistent also when excluding life-threatening ventricular arrhythmias from the composite end-point. CONCLUSION In clinically stable DCM patients with important depression of LVEF, the repetition of combined echocardiography and CPET might be recommended. When LVRR fails, 1-year repetition of CPET could identify higher-risk patients.
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Affiliation(s)
- Nikita Baracchini
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Denise Zaffalon
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy.
| | - Samantha Baschino
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Giulia Barbati
- Biostatistics Unit, Department of Medical Sciences, University of Trieste, Italy
| | | | - Teresa Maria Capovilla
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Maddalena Rossi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Cosimo Carriere
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy; Centro Cardiologico Monzino, IRCCS, Milan, Italy
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4
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Ogura A, Izawa KP, Tawa H, Wada M, Kanai M, Kubo I, Makihara A, Yoshikawa R, Matsuda Y. Determinants of Anaerobic Threshold at Each Stage of Renal Dysfunction in Patients With Heart Disease. Am J Cardiol 2023; 205:387-392. [PMID: 37689043 DOI: 10.1016/j.amjcard.2023.07.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 09/11/2023]
Abstract
Patients with heart disease have a low anaerobic threshold (AT), and the determinants of AT may differ, depending on the severity of renal dysfunction. This study aimed to verify the determinants of AT for each stage of renal function in patients with heart disease. We consecutively enrolled 250 patients with heart disease who underwent cardiopulmonary exercise testing in our institution. The patients were divided into 3 groups by their estimated glomerular filtration rate (eGFR): <45, 45 to 59, and ≥60 ml/min/1.73 m2. A multivariate linear regression analysis was performed to evaluate the independent determinants of AT for each group. In total, 201 patients were analyzed. AT decreased with the deterioration of renal function (eGFR <45, 10.9 ± 2.1 vs eGFR 45 to 59, 12.4 ± 2.5 vs eGFR ≥60, 14.0 ± 2.6 ml/min/kg, p <0.001). In the eGFR <45 group, left ventricular ejection fraction and hemoglobin were significantly associated with AT (β = 0.427, p = 0.006 and β = 0.488, p = 0.002, respectively). In the eGFR 45 to 59 and ≥60 groups, ΔPETO2 (end-tidal oxygen partial pressure from rest to AT) showed a significant association with AT (β = 0.576, p <0.001 and β = 0.308, p = 0.003, respectively). The determinants of AT depended on the stage of renal dysfunction in patients with heart disease. In conclusion, in the eGFR <45 group, the determinants of AT were left ventricular ejection fraction and hemoglobin, whereas in the eGFR 45 to 59 and eGFR ≥60 groups, the determinant of AT was ΔPETO2.
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Affiliation(s)
- Asami Ogura
- Departments of Rehabilitation, Sanda City Hospital, Hyogo, Japan; Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | - Kazuhiro P Izawa
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan.
| | - Hideto Tawa
- Departments of Cardiology, Sanda City Hospital, Hyogo, Japan
| | - Masaaki Wada
- Departments of Rehabilitation, Sanda City Hospital, Hyogo, Japan
| | - Masashi Kanai
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | - Ikko Kubo
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | - Ayano Makihara
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | | | - Yuichi Matsuda
- Departments of Cardiology, Sanda City Hospital, Hyogo, Japan
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Contini M, Mapelli M, Carriere C, Gugliandolo P, Aliverti A, Piepoli M, Angelucci A, Baracchini N, Capovilla TM, Agostoni P. Dysregulation of ventilation at day and night time in heart failure. Eur J Prev Cardiol 2023; 30:ii16-ii21. [PMID: 37819222 DOI: 10.1093/eurjpc/zwad208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 10/13/2023]
Abstract
Heart failure (HF) is characterized by an increase in ventilatory response to exercise of multifactorial aetiology and by a dysregulation in the ventilatory control during sleep with the occurrence of both central and obstructive apnoeas. In this setting, the study of the ventilatory behaviour during exercise, by cardiopulmonary exercise testing, or during sleep, by complete polysomnography or simplified nocturnal cardiorespiratory monitoring, is of paramount importance because of its prognostic value and of the possible effects of sleep-disordered breathing on the progression of the disease. Moreover, several therapeutic interventions can significantly influence ventilatory control in HF. Also, rest daytime monitoring of cardiac, metabolic, and respiratory activities through specific wearable devices could provide useful information for HF management. The aim of the review is to summarize the main studies conducted at Centro Cardiologico Monzino on these topics.
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Affiliation(s)
- Mauro Contini
- U.O. Scompenso Cardiaco e Cardiologia Clinica, Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Massimo Mapelli
- U.O. Scompenso Cardiaco e Cardiologia Clinica, Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Cosimo Carriere
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via C. Costantinides 2, 34128 Trieste, Italy
| | - Paola Gugliandolo
- U.O. Scompenso Cardiaco e Cardiologia Clinica, Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Piazza E. Malan 2, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Via Mangiagalli 31, 20133 Milan, Italy
| | - Alessandra Angelucci
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133 Milan, Italy
| | - Nikita Baracchini
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via C. Costantinides 2, 34128 Trieste, Italy
| | - Teresa Maria Capovilla
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via C. Costantinides 2, 34128 Trieste, Italy
| | - Piergiuseppe Agostoni
- U.O. Scompenso Cardiaco e Cardiologia Clinica, Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via della Commenda 19, 20122 Milan, Italy
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Mapelli M, Mattavelli I, Paolillo S, Salvioni E, Magrì D, Galotta A, De Martino F, Mantegazza V, Vignati C, Esposito I, Dell’Aversana S, Paolillo R, Capovilla T, Tamborini G, Nepitella AA, Filardi PP, Agostoni P. Effects of sacubitril/valsartan on exercise capacity: a prognostic improvement that starts during uptitration. Eur J Clin Pharmacol 2023; 79:1173-1184. [PMID: 37368004 PMCID: PMC10427709 DOI: 10.1007/s00228-023-03527-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE Sacubitril/valsartan is a mainstay of the treatment of heart failure with reduced ejection fraction (HFrEF); however, its effects on exercise performance yielded conflicting results. Aim of our study was to evaluate the impact of sacubitril/valsartan on exercise parameters and echocardiographic and biomarker changes at different drug doses. METHODS We prospectively enrolled consecutive HFrEF outpatients eligible to start sacubitril/valsartan. Patients underwent clinical assessment, cardiopulmonary exercise test (CPET), blood sampling, echocardiography, and completed the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Sacubitril/valsartan was introduced at 24/26 mg b.i.d. dose and progressively uptitrated in a standard monthly-based fashion to 97/103 mg b.i.d. or maximum tolerated dose. Study procedures were repeated at each titration visit and 6 months after reaching the maximum tolerated dose. RESULTS Ninety-six patients completed the study, 73 (75%) reached maximum sacubitril/valsartan dose. We observed a significant improvement in functional capacity across all study steps: oxygen intake increased, at peak exercise (from 15.6 ± 4.5 to 16.5 ± 4.9 mL/min/kg; p trend = 0.001), while minute ventilation/carbon dioxide production relationship reduced in patients with an abnormal value at baseline. Sacubitril/valsartan induced positive left ventricle reverse remodeling (EF from 31 ± 5 to 37 ± 8%; p trend < 0.001), while NT-proBNP reduced from 1179 [610-2757] to 780 [372-1344] pg/ml (p trend < 0.0001). NYHA functional class and the subjective perception of limitation in daily life at KCCQ-12 significantly improved. The Metabolic Exercise Cardiac Kidney Index (MECKI) score progressively improved from 4.35 [2.42-7.71] to 2.35% [1.24-4.96], p = 0.003. CONCLUSIONS A holistic and progressive HF improvement was observed with sacubitril/valsartan in parallel with quality of life. Likewise, a prognostic enhancement was observed.
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Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, University “La Sapienza”, Rome, Italy
| | | | - Fabiana De Martino
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Casa di Cura Tortorella, Salerno, Italy
| | - Valentina Mantegazza
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Immacolata Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Simona Dell’Aversana
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Teresa Capovilla
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- University of Trieste, Trieste, Italy
| | | | - Alessandro Alberto Nepitella
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Policlinico Universitario D. Casula, Cardiologia – AOU Cagliari Cagliari, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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7
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Mapelli M, Salvioni E, Mattavelli I, Vignati C, Galotta A, Magrì D, Apostolo A, Sciomer S, Campodonico J, Agostoni P. Cardiopulmonary exercise testing and heart failure: a tale born from oxygen uptake. Eur Heart J Suppl 2023; 25:C319-C325. [PMID: 37125287 PMCID: PMC10132578 DOI: 10.1093/eurheartjsupp/suad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Since 50 years, cardiopulmonary exercise testing (CPET) plays a central role in heart failure (HF) assessment. Oxygen uptake (VO2) is one of the main HF prognostic indicators, then paralleled by ventilation to carbon dioxide (VE/VCO2) relationship slope. Also anaerobic threshold retains a strong prognostic power in severe HF, especially if expressed as a percent of maximal VO2 predicted value. Moving beyond its absolute value, a modern approach is to consider the percentage of predicted value for peak VO2 and VE/VCO2 slope, thus allowing a better comparison between genders, ages, and races. Several VO2 equations have been adopted to predict peak VO2, built considering different populations. A step forward was made possible by the introduction of reliable non-invasive methods able to calculate cardiac output during exercise: the inert gas rebreathing method and the thoracic electrical bioimpedance. These techniques made possible to calculate the artero-venous oxygen content differences (ΔC(a-v)O2), a value related to haemoglobin concentration, pO2, muscle perfusion, and oxygen extraction. The role of haemoglobin, frequently neglected, is however essential being anaemia a frequent HF comorbidity. Finally, peak VO2 is traditionally obtained in a laboratory setting while performing a standardized physical effort. Recently, different wearable ergo-spirometers have been developed to allow an accurate metabolic data collection during different activities that better reproduce HF patients' everyday life. The evaluation of exercise performance is now part of the holistic approach to the HF syndrome, with the inclusion of CPET data into multiparametric prognostic scores, such as the MECKI score.
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Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
| | - Irene Mattavelli
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Arianna Galotta
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant’Andrea, ‘Sapienza’ Università degli Studi di Roma, Via di Grottarossa, 1035/1039, 00189 Rome, Italy
| | - Anna Apostolo
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, ‘Sapienza’, Rome University, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Jeness Campodonico
- Centro Cardiologico Monzino, IRCCS, University of Milan Via Parea, 4, 20138 Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Festa del Perdono, 7, 20122 Milan, Italy
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8
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Casaburi R. The Value of Cardiopulmonary Exercise Testing as a Predictor of Mortality in Heart Failure. Chest 2022; 162:957-958. [DOI: 10.1016/j.chest.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022] Open
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