心肺运动试验在射血分数降低、中间范围和保留的心衰中的预后价值。
Prognostic Value of Cardiopulmonary Exercise Testing in Heart Failure With Reduced, Midrange, and Preserved Ejection Fraction.
机构信息
Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA.
Department of Internal Medicine, University of Campinas, Brazil.
出版信息
J Am Heart Assoc. 2017 Oct 31;6(11):e006000. doi: 10.1161/JAHA.117.006000.
BACKGROUND
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).
METHODS AND RESULTS
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.
CONCLUSIONS
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.
背景
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。
方法和结果
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。
结论
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。
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