Use of cardiopulmonary exercise testing with hemodynamic monitoring in theprognostic assessment of ambulatory patients with chronic heart failure

OBJECTIVES We studied whether direct assessment of the hemodynamic response to exercise could improve the prognostic evaluation of patients with heart failure (HF) and identify those in whom the main cause of the reduced func tional capacity is related to extracardiac factors. BACKGROUND Peak exercise oxygen consumption (VO2) is one of the main progno stic variables in patients with HF, but it is influenced also by many extra cardiac factors. METHODS Bicycle cardiopulmonary exercise testing with hemodynamic monitorin g was performed, in addition to clinical evaluation and radionuclide ventri culography, in 219 consecutive patients with chronic HF (left ventricular e jection fraction, 22 +/- 7%; peak VO2, 14.2 +/- 4.4 ml/kg/min). RESULTS During a follow-up of 19 +/- 25 months, 32 patients died and 6 unde rwent urgent transplantation with a 71% cumulative major event-free a-year survival. Peak exercise stroke work index (SWI) was the most powerful progn ostic variable selected by Cox multivariate analysis, followed by serum sod ium and left ventricular ejection fraction, for one-year survival, and peak VO2 and serum sodium for two-year survival. Two-year survival was 54% in t he patients with peak exercise SWI less than or equal to 30 g m/m(2) versus 91% in those with a SWI >30 g.m/m(2) (p < 0.0001). A significant percentag e of patients (41%) had a normal cardiac output response to exercise with a n excellent two-year survival (87% vs. 58% in the others) despite a relativ ely low peak VO2 (15.1 +/- 4.7 ml/kg/min). CONCLUSIONS Direct assessment of exercise hemodynamics in patients with HF provides additive independent prognostic information, compared to tradition al noninvasive data. (J Am Coil Cardiol 1999;33:943-50) (C) 1999 by the Ame rican College of Cardiology.