The prognostic value of exercise testing in elderly men

PURPOSE: Our purposes were to compare the responses to exercise testing in elderly (> or =65 years of age) and younger men, and to investigate whether exercise testing has similar prognostic value in the two age groups. METHODS: We included all elderly (n = 1185) and younger (n = 2789) male veterans without established coronary heart disease who underwent routine clinical exercise testing between 1987 and 2000 at two academically affiliated Veteran's Affairs medical center laboratories. Measurements included a standardized medical history, exercise testing, and all-cause mortality. RESULTS: Compared with younger patients, elderly patients achieved a lower workload (a mean [+/- SD] of 7 +/- 3 vs. 10 +/- 4 metabolic equivalents [METs], P <0.001) and were more likely to have abnormal ST depression (27% [n = 324] vs. 16% [n = 436], P <0.001). During the mean follow-up of 6 years, annual mortality was twice as high among elderly patients as among younger patients (4% vs. 2%, P <0.001). The only exercise test variable that was associated significantly with time to death in both age groups was maximal METs achieved: each 1 MET increase in exercise capacity was associated with an 11% reduction in annual mortality. Exercise-induced ST depression was more common in those who subsequently died, but was not an independent predictor of mortality. CONCLUSION: In elderly men, exercise testing provided prognostic information incremental to clinical data. Achieved workload (in METs) was the major exercise testing variable associated with all-cause mortality. Its prognostic importance was the same in elderly as in younger men.     

Role of cardiopulmonary exercise testing in clinical stratification in heart failure. A position paper from the Committee on Exercise Physiology and Training of the Heart Failure Association of the European Society of Cardiology

Traditionally, the main indication for cardiopulmonary exercise testing (CPET) in heart failure (HF) was for the selection of candidates to heart transplantation: CPET was mainly performed in middle‐aged male patients with HF and reduced left ventricular ejection fraction. Today, CPET is used in broader patients' populations, including women, elderly, patients with co‐morbidities, those with preserved ejection fraction, or left ventricular assistance device recipients, i.e. individuals with different responses to incremental exercise and markedly different prognosis. Moreover, the diagnostic and prognostic utility of symptom‐limited CPET parameters derived from submaximal tests is more and more considered, since many patients are unable to achieve maximal aerobic power. Repeated tests are also being used for risk stratification and evaluation of intervention, so that these data are now available. Finally, patients, physicians and healthcare decision makers are increasingly considering how treatments might impact morbidity and quality of life rather than focusing more exclusively on hard endpoints (such as mortality) as was often the case in the past. Innovative prognostic flowcharts, with CPET at their core, that help optimize risk stratification and the selection of management options in HF patients, have been developed.     

Cardiopulmonary exercise testing for prognosis in chronic heart failure: continuous and independent prognostic value from VE/VCO(2)slope and peak VO(2).

BACKGROUND: Chronic heart failure carries a poor prognosis. Cardiopulmonary exercise testing is useful in predicting survival. We set out to establish the prognostic value of peak VO(2)and VE/VCO(2)slope across a range of threshold values. METHOD AND RESULTS: Three hundred and three consecutive patients with stable chronic heart failure underwent cardiopulmonary exercise testing between 1992 and 1996. Their age was 59+/-11 years (mean+/-SD), peak VO(2)17. 8+/- 6.6 ml. kg(-1)min(-1), VE/VCO(2)slope 37+/-12. At the end of follow-up in January 1999, 91 patients had died (after a median of 7 months, interquartile range 3-16 months). The median follow-up for the survivors was 47 months (interquartile range 37-57 months). The areas under the receiver-operating characteristic curves for predicting mortality at 2 years were 0.77 for both peak VO(2)and VE/VCO(2)slope. With peak VO(2)and VE/VCO(2)slope viewed as continuous variables in the Cox proportional-hazards model, they were both highly significant prognostic indicators, both in univariate analysis and bivariate analysis (P<0.001 for VE/VCO(2)slope, P<0.003 for peak VO(2)). CONCLUSIONS: Lower peak VO(2)implies poorer prognosis across a range of values from 10 to 20 ml. kg(-1)min(-1), without a unique threshold. Gradations of elevation of the VE/VCO(2)slope also carry prognostic information over a wide range (30-55). The two parameters are comparable in terms of prognostic power, and contribute complementary prognostic information.     

心房颤动对慢性收缩性心力衰竭患者远期预后影响分析

目的 探讨心房颤动(房颤)对慢性收缩性心力衰竭(chronic systolic heart failure,CSHF)住院患者远期预后的影响.方法 回顾性调查和分析湖北地区8地市12家三级甲等医院2000年至2010年CSHF住院患者资料,单因素Kaplan-Meier曲线分析房颤和非房颤组总死亡、心血管病死亡、心脏泵功能衰竭死亡(心力衰竭死亡)、心脏性猝死和栓塞相关死亡差异.多因素Cox生存分析确认心力衰竭患者不同预后的危险因素.结果 ①共16681例患者纳入本次研究.房颤组与非房颤组相比,年龄(64.54 ±13.61)岁比(62.19±15.07)岁(P＜0.01)、左心室射血分数(LVEF)37.43± 12.72比38.42±13.96(P＜0.01)、心功能Ⅲ～Ⅳ级(NYHA分级)患者(5547/81.49％比7121/72.12％,P＜0.01)和病因等因素存在差异.②单因素Kaplan-Meier曲线分析发现,房颤组和非房颤组在总死亡、心血管病死亡、心力衰竭死亡和栓塞相关死亡存在差异,而在心律失常相关的心脏性猝死两组间差异无统计学意义.③多因素Cox回归分析发现房颤不是总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死增加的独立危险因素,而增加栓塞相关死亡(HR=2.134,95％ CI,1.846～2.430,P＜0.0l)结论 房颤不增加CSHF患者远期总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死,而增加栓塞相关死亡.提示房颤引起CSHF患者远期预后不良的原因可能在于其并发症.     

Diastolic exercise stress testing in heart failure with preserved ejection fraction: The DEST-HF study

Aims

Pulmonary capillary wedge pressure (PAWP) ≥25 mmHg during bicycle ergometry is recommended to uncover occult heart failure with preserved ejection fraction. We hypothesized that PAWP increase would differ in available diastolic stress tests and that the margin of PAWP ≥25 mmHg would only be reliably achieved through ergometry.

Methods and results

We conducted a prospective, single-arm study in patients with an intermediate risk for heart failure with preserved ejection fraction according to the ESC HFA-PEFF score. A total of 19 patients underwent four stress test modalities in randomized order: leg raise, fluid challenge, handgrip, and bicycle ergometry. The primary outcome was the difference (Δ) between resting and exercise PAWP in each modality. Secondary outcomes were differences (Δ) in mean pulmonary artery pressure (mPAP), cardiac output (CO), as well as the ratios between mPAP and PAWP to CO. Compared to resting values, passive leg raise (Δ7.7 ± 8.0 mmHg, p = 0.030), fluid challenge (Δ9.2 ± 6.4 mmHg, p = 0.003), dynamic handgrip (Δ9.6 ± 7.5 mmHg, p = 0.002), and bicycle ergometry (Δ22.3 ± 5.0 mmHg, p < 0.001) uncovered increased PAWP during exercise. Amongst these, bicycle ergometry also demonstrated the highest ΔmPAP (27.2 ± 7.1 mmHg, p < 0.001), ΔCO (3.3 ± 2.6 L/min, p < 0.001), ΔmPAP/CO ratio (2.3 ± 2.0 mmHg/L/min, p < 0.001), and ΔPAWP/CO ratio (2.2 ± 1.4 mmHg/L/min, p < 0.001) compared to other modalities. PAWP ≥25 mmHg was only reliably achieved in bicycle ergometry (31.1 ± 3.9 mmHg). In all other modalities only 10.5% of patients achieved PAWP ≥25 mmHg (handgrip 18.4 ± 6.6 mmHg, fluid 18.1 ± 5.6 mmHg, leg raise 16.5 ± 7.0 mmHg).

Conclusions

We demonstrate that bicycle ergometry exhibits a distinct haemodynamic response with higher increase of PAWP compared to other modalities. This finding needs to be considered for valid detection of exercise PAWP ≥25 mmHg when non-bicycle tests remain inconclusive.     

Early heart rate recovery after exercise predicts mortality in patients with chronic heart failure

BACKGROUND: Patients with chronic heart failure (CHF) have multiple abnormalities of autonomic regulation that have been associated to their high mortality rate. Heart rate recovery immediately after exercise is an index of parasympathetic activity, but its prognostic role in CHF patients has not been determined yet. METHODS: Ninety-two stable CHF patients (83M/9F, mean age: 51+/-12 years) performed an incremental symptom-limited cardiopulmonary exercise testing. Measurements included peak O2 uptake (VO2p), ventilatory response to exercise (VE/VCO2 slope), the first-degree slope of VO2 for the 1st minute of recovery (VO2/t-slope), heart rate recovery [(HRR1, bpm): HR difference from peak to 1 min after exercise] and chronotropic response to exercise [%chronotropic reserve (CR, %)=(peak HR-resting HR/220-age-resting HR)x100]. Left ventricular ejection fraction (LVEF, %) was also measured by radionuclide ventriculography. RESULTS: Fatal events occurred in 24 patients (26%) during 21+/-6 months of follow-up. HRR1 was lower in non-survivors (11.4+/-6.4 vs. 20.4+/-8.1; p<0.001). All cause-mortality rate was 65% in patients with HRR112 bpm (log-rank: 32.6; p<0.001). By multivariate survival analysis, HRR1 resulted as an independent predictor of mortality (chi2=19.2; odds ratio: 0.87; p<0.001) after adjustment for LVEF, VO2p, VE/VCO2 slope, CR and VO2/t-slope. In a subgroup of patients with intermediate exercise capacity (VO2p: 10-18, ml/kg/min), HRR1 was a strong predictor of mortality (chi2: 14.3; odds ratio: 0.8; p<0.001). CONCLUSIONS: Early heart rate recovery is an independent prognostic risk indicator in CHF patients and could be used in CHF risk stratification.     

心房颤动对慢性收缩性心力衰竭患者和射血分数正常心力衰竭患者预后的影响

目的 探讨心房颤动（简称房颤）对慢性收缩性心力衰竭（CSHF）及慢性射血分数正常心力衰竭（HF-PSF）住院患者预后的影响。方法 前瞻性分析武汉地区4家三级甲等教学医院848例心力衰竭（简称心衰）患者,根据左室射血分数分为CSHF组（n=560）、HFPSF组（n=288）。 每组根据有无房颤又分为房颤与非房颤亚组。 单因素Kaplan-Meier曲线分别分析CSHF和HFPSF患者房颤亚组和非房颤亚组总死亡 、 心脏泵功能衰竭死亡（心衰死亡）、 心源性猝死和栓塞相关死亡的差异 。多因素Cox风险比例模型分别比较CSHF和HFPSF患者房颤亚组与非房颤亚组不同预后的差异。 结果 单因素分析发现, CSHF和HFPSF组房颤亚组与非房颤亚组总死亡无差异。CSHF组中与非房颤亚组（n=374）相比,房颤亚组（n = 186）心衰死亡增高（P = 0. 01）、栓塞相关死亡增加（P0.05）。 多因素Cox风险比例模型分析发现房颤增加CSHF患者栓塞相关死亡风险（HR = 2. 106,95% CI：1. 436 - 2.719,P〈0. 01）。 结论 房颤对CSHF和HFPSF患者预后的影响存在差异,仅增加CSHF患者栓塞相关死亡风险。房颤影响CSHF患者预后的原因可能不在于心律失常本身而在于其并发症。     

Chronic heart failure in the elderly: value of cardiopulmonary exercise testing in risk stratification

OBJECTIVE: To assess the value of cardiopulmonary exercise testing in predicting prognosis in a cohort of elderly patients with chronic heart failure (CHF). DESIGN: A retrospective cohort study of all patients with CHF over the age of 70 years assessed between January 1992 and May 1997. SETTING: Tertiary centre. PATIENTS: 50 patients (mean (SD) age 75.9 (4.5) years, 8 women) with CHF New York Heart Association (NYHA) class I (3 patients), II (25 patients), III (20 patients), and IV (2 patients). Follow up was complete for two years in all patients. RESULTS: The patients underwent cardiopulmonary exercise testing (peak oxygen consumption 15.2 (4.5) ml/kg/min, minute ventilation/carbon dioxide production (VE/VCO(2)) slope 38.7 (11.8)); radionucleide ventriculography (left ventricular ejection fraction 32.8 (14.3)%); serum sodium measurement (139 (2.8) mmol/l); and echocardiography (left ventricular end diastolic dimension 6.1 (1.1) cm, left ventricular end systolic dimension 4.7 (1.5) cm). At the end of follow up in May 1999, 26 patients had died. The median follow up of the survivors was 47.7 months (interquartile range 31. 5-53.5 months). On univariate analysis VE/VCO(2) slope (p < 0.0001), NYHA class (p < 0.001), peak oxygen uptake (VO(2)) (p < 0.01), left ventricular end systolic dimension (p < 0.05), and serum sodium concentration (p < 0.05) had significant predictive power. Stepwise multivariate analysis identified only VE/VCO(2) slope (p < 0.01), NYHA class (p < 0.05), and peak VO(2) (p< 0.05) as conveying significant independent prognostic information. CONCLUSION: Elderly patients with CHF have a high mortality, with the majority dead within two years. Cardiopulmonary exercise testing provides important information for risk stratification within this group and its use should not be neglected.     

Multivariable analysis of heart rate recovery after cycle ergometry in heart failure: exercise in heart failure

Purpose

The purpose of this study was to investigate the association between impairment in heart rate recovery (HR_rec) after cycle ergometry and prognostic markers in patients with heart failure (HF) compared with healthy controls.

Methods

Fifty patients with chronic HF (systolic HF, N = 30; diastolic HF, N = 20; mean age = 62 ± 12 years) and 50 healthy controls (N = 50; mean age = 66 ± 13 years) underwent 2-dimensional and M-mode echocardiography followed by cardiopulmonary exercise testing. Independent predictors of HR_rec at 1 and 2 minutes after exercise were analyzed by univariable and multivariable regression analyses, and receiver operating characteristics were performed to obtain area under the curve.

Results

In HF, left ventricular end-diastolic diameter (millimeters), left ventricular ejection fraction (%), N-terminal pro-brain natriuretic peptide (picograms/milliliter), peak oxygen uptake (VO₂peak [milliliters/kilogram/min]), and peak heart rate (HR_peak) showed a significant association with HR_rec (beats/min) in univariate regression analyses (P < .001), but only VO₂peak remained independently predictive of both HR_rec1 (P = .034) and HR_rec2 (P = .008) in the multivariable regression analyses. In controls, VO₂peak (P = .035) and HR_peak (P = .032) were significantly associated with HR_rec2 in univariate analyses only. Optimal cutoff values for discriminating HF versus non-HF based on HR_rec were 17.5 beats/min (sensitivity 92%; specificity 74%) for HR_rec1 and 31.5 beats/min (sensitivity 94%; specificity 86%) for HR_rec2. Optimal cutoff values for discriminating systolic HF versus diastolic HF were 12.5 beats/min (sensitivity 78%; specificity 80%) for HR_rec1 and 24.5 beats/min (sensitivity 82%; specificity 90%) for HR_rec2.

Conclusion

Impairment in after exercise HR_rec is significantly and independently associated with VO2peak in HF and thus might constitute a useful tool for assessing the degree of functional status during exercise rehabilitation.     

低钠血症对慢性心力衰竭的预后价值

目的 探讨慢性心力衰竭患者低钠血症的预后价值.方法 对2007年1月至2013年1月于我院急诊内科住院治疗资料完整的786例慢性心力衰竭患者进行回顾性分析,根据入院24～48 h血清钠离子浓度最低值分为三组：A组,钠离子≥135 mmol/L;B组,钠离子120～135 mmol/L;C组,钠离子≤120 mmol/L.比较各组心功能、血清钾离子浓度、住院病死率等指标.结果 住院期间存活714例,死亡72例,存活组与死亡组平均血清钠离子浓度分别为（134.00±5.83）mmol/L和（121.00±7.15）mmol/L,差异有统计学意义（P＜0.01）,而血清钾离子浓度分别为（4.4±0.6）mmol/L和（4.3±0.8）mmol/L,差异无统计学意义（P＞0.05）.三组住院病死率分别为：A组7.8％（36/461）,B组8.0％（23/289）,C组36.1％（13/36）,C组病死率明显高于A组和B组,差异有统计学意义（P＜0.01）;A组与B组比较差异无统计学意义（P＞0.05）.结论 低钠血症是慢性心力衰竭患者预后不良的重要危险因素.     

先天性心脏病患者运动心肺功能表现

目的探讨先天性心脏病患者运动负荷测验特点。方法15例患者，男4例，女11例。其中房缺9例，室缺6例。并与年龄相近健康男性4例、女性11例作对照。进行踏车递增负荷运动测验。结果先天性心脏病组VO2max，VO2max占预计值％（＜正常84％）低于对照组；VO2AT，VO2AT／VO2maxpred低于对照组但在正常范围内；此外VO2／HRmax＜VO2／HRmaxpred。有3例心导管证实为肺动脉高压者，运动后PaO2及SaO2减低；P（A－a）O2加宽；P（a－et）CO2正值；VE／VCO2AT异常增高超过45，但BRmax正常。结论先天性心脏病患者运动负荷表现为最大有氧代谢能力减低。VE／VCO2AT异常增高为肺动脉高压、V／Q比率失调、肺循环障碍提供线索。运动后低血氧考虑有右至左分流。     

Cardiopulmonary exercise testing in congestive heart failure

Cardiopulmonary exercise testing includes the monitoring of respiratory gases and airflow to determine oxygen uptake, carbon dioxide (CO2) production, respiratory rate, tidal volume, and minute ventilation during a graded maximal exercise test. A plateau in oxygen uptake, which occurs despite an increase in work load, and which is termed maximal oxygen uptake (VO2 max), correlates with the maximal exercise cardiac output and can therefore be used to grade the severity of heart failure. The anaerobic threshold occurs at 60 to 70% of VO2 max and is another indicator of the severity of heart failure and, when attained, indicates that the patient is close to performing a maximal test. We have found VO2 max and anaerobic threshold to be objective measures of efficacy of both investigational and noninvestigational therapy in patients with heart failure. A pulmonary limitation to exercise can be identified by the failure to attain anaerobic threshold or VO2 max, as well as exhaustion of the ventilatory reserve, as estimated by maximal voluntary ventilation. Thus, cardiopulmonary exercise testing can be used to (1) grade the severity of heart failure, (2) objectively follow the response to therapy, and (3) differentiate a cardiac from a pulmonary limitation to exercise.     

Ventilatory threshold during exercise in patients with mild to moderate chronic heart failure: determination, relation with lactate threshold and reproducibility

Detection of the ventilatory threshold during exercise has been proposed in order to assess exercise tolerance in patients with chronic heart failure. The relation between the different methods of detecting the ventilatory threshold and the lactate threshold, however, and their reproducibility, have not really been assessed. Forty-three patients with chronic heart failure underwent an exercise test with respiratory gas analysis. A lactate threshold could be determined in 36 patients and a ventilatory threshold in 27 to 38 patients, depending on the method of determination of the ventilatory threshold. The greatest number of determinations (38) and the best correlation coefficient with the lactate threshold (r = 0.87 and 0.88, respectively) were obtained with the method of the ventilatory equivalent for oxygen and by averaging the different methods of determination. Reproducibility of the ventilatory threshold was only moderately good (r = 0.83) and less satisfactory than that of the peak oxygen uptake (r = 0.97). We conclude that unless the way of detecting the ventilatory threshold is improved in patients with chronic heart failure, the peak oxygen uptake will remain more reproducible.     

Reproducibility of cardiopulmonary parameters during exercise in patients with chronic cardiac failure. The need for a preliminary test

To examine the reproducibility of cardiopulmonary exercise testing in patients with heart failure, three consecutive tests were performed in 30 such patients. The first test underestimated treadmill exercise time by about 20% when compared with the second and third tests, which were not significantly different. Peak achieved VO2, VCO2 and VE were also less during the first test, but blood pressure, heart rate and respiratory rate responses were similar in the three tests. When cardiopulmonary exercise tests are used to assess functional capacity in either individual patients or groups (as in a therapeutic trial), at least two tests should be performed, as a single test is likely to underestimate exercise capacity.     

Cardiopulmonary exercise variables in diastolic versus systolic heart failure

The response to cardiopulmonary exercise (CPX) in patients with heart failure (HF) with normal left ventricular (LV) ejection fractions (EFs) is not well characterized. To determine if CPX testing could distinguish between patients with HF with normal EFs (>50%; i.e., diastolic HF) and those with decreased EFs (> or =50%; i.e., systolic HF), CPX responses were compared between 185 patients with systolic HF (79% men, mean age 62.6 +/- 10.9 years) and 43 with diastolic HF (54% men, mean age 67.4 +/- 9.8 years) enrolled in a phase II multicenter clinical trial. All patients were evaluated with echocardiography and a standardized CPX test as part of the trial. CPX variables, including oxygen uptake at peak exercise (peak VO(2)) and the slope of the ventilation/carbon dioxide production ratio (VE/VCO(2)), were determined and analyzed by core laboratory personnel. Echocardiographic measurements included the LV EF, the E/A ratio, filling time, cavity volumes, right ventricular function, and mitral regurgitation. Patients in the diastolic HF group tended to be older (p <0.08), with more women (p <0.006) and with greater body mass indexes (p <0.02), than those in the systolic HF group. There was no significant difference in the use of beta blockers or the incidence of coronary artery disease. Patients with diastolic HF had decreased E/A ratios (0.9 +/- 0.4 vs 1.4 +/- 1.1, p <0.02, diastolic HF vs systolic HF) and increased filling times (30.4 +/- 3.2 vs 26.5 +/- 4.7 ms, p <0.01, diastolic HF vs systolic HF). No significant differences in peak VO(2) (14.4 +/- 1.9 vs 15.6 +/- 3.2 ml/kg/min, p = 0.06, diastolic HF vs systolic HF) were observed. The VE/VCO(2) ratios for the 2 groups were abnormal and comparable (32 2 +/- 7.5 vs 34.0 +/- 8.3, p = 0.3, diastolic HF vs systolic HF). In conclusion, the CPX response in patients with diastolic HF and systolic HF is markedly abnormal and indistinguishable with regard to peak VO(2) and ventilation despite marked differences in the LV EF.