Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA.
Department of Internal Medicine, University of Campinas, Brazil.
J Am Heart Assoc. 2017 Oct 31;6(11):e006000. doi: 10.1161/JAHA.117.006000.
This study aimed to compare the independent and incremental prognostic value of peak oxygen consumption (VO) and minute ventilation/carbon dioxide production (VE/VCO) in heart failure (HF) with preserved (HFpEF), midrange (HFmEF), and reduced (HFrEF) ejection fraction (LVEF).
In 195 HFpEF (LVEF ≥50%), 144 HFmEF (LVEF 40-49%), and 630 HFrEF (LVEF <40%) patients, we assessed the association of cardiopulmonary exercise testing variables with the composite outcome of death, left ventricular assist device implantation, or heart transplantation (256 events; median follow-up of 4.2 years), and 2-year incident HF hospitalization (244 events). In multivariable Cox regression analysis, greater association with outcomes in HFpEF than HFrEF were noted with peak VO (HR [95% confidence interval]: 0.76 [0.67-0.87] versus 0.87 [0.83-0.90] for the composite outcome, =0.052; 0.77 [0.69-0.86] versus 0.92 [0.88-0.95], respectively for HF hospitalization, =0.003) and VE/VCO slope (1.11 [1.06-1.17] versus 1.04 [1.03-1.06], respectively for the composite outcome, =0.012; 1.10 [1.05-1.15] versus 1.04 [1.03-1.06], respectively for HF hospitalization, =0.019). In HFmEF, peak VO and VE/VCO slope were associated with the composite outcome (0.79 [0.70-0.90] and 1.12 [1.05-1.19], respectively), while only peak VO was related to HF hospitalization (0.81 [0.72-0.92]). In HFpEF and HFrEF, peak VO and VE/VCO slope provided incremental prognostic value beyond clinical variables based on the C-statistic, net reclassification improvement, and integrated diagnostic improvement, with models containing both measures demonstrating the greatest incremental value.
Both peak VO and VE/VCO slope provided incremental value beyond clinical characteristics and LVEF for predicting outcomes in HFpEF. Cardiopulmonary exercise testing variables provided greater risk discrimination in HFpEF than HFrEF.
本研究旨在比较心力衰竭（HF）伴射血分数保留（HFpEF）、中间范围（HFmEF）和射血分数降低（HFrEF）患者中峰值摄氧量（VO）和分钟通气量/二氧化碳产量（VE/VCO）的独立和增量预后价值。
在 195 例 HFpEF（LVEF≥50%）、144 例 HFmEF（LVEF 40-49%）和 630 例 HFrEF（LVEF<40%）患者中，我们评估了心肺运动试验变量与复合结局（死亡、左心室辅助装置植入或心脏移植[256 例事件；中位随访 4.2 年]和 2 年事件性 HF 住院[244 例事件]的关系。多变量 Cox 回归分析显示，HFpEF 中与结局的相关性大于 HFrEF，表现为峰值 VO（HR[95%置信区间]：复合结局为 0.76[0.67-0.87]比 0.87[0.83-0.90]，=0.052；HF 住院分别为 0.77[0.69-0.86]比 0.92[0.88-0.95]，=0.003）和 VE/VCO 斜率（复合结局分别为 1.11[1.06-1.17]比 1.04[1.03-1.06]，=0.012；HF 住院分别为 1.10[1.05-1.15]比 1.04[1.03-1.06]，=0.019）。在 HFmEF 中，峰值 VO 和 VE/VCO 斜率与复合结局相关（分别为 0.79[0.70-0.90]和 1.12[1.05-1.19]），而只有峰值 VO 与 HF 住院相关（0.81[0.72-0.92]）。在 HFpEF 和 HFrEF 中，基于 C 统计量、净重新分类改善和综合诊断改善，峰值 VO 和 VE/VCO 斜率在临床变量之外提供了增量预后价值，包含这两个指标的模型显示出最大的增量价值。
在 HFpEF 中，峰值 VO 和 VE/VCO 斜率均提供了临床特征和 LVEF 之外的增量价值，可用于预测结局。心肺运动试验变量在 HFpEF 中比 HFrEF 提供了更大的风险判别能力。
