Guazzi Marco, Borlaug Barry, Metra Marco, Losito Maurizio, Bandera Francesco, Alfonzetti Eleonora, Boveri Sara, Sugimoto Tadafumi
Cardiology Division Department of Health Sciences San Paolo University Hospital Milano Italy.
Department of Cardiovascular Medicine Mayo Clinic Rochester MN.
J Am Heart Assoc. 2021 Feb;10(5):e018822. doi: 10.1161/JAHA.120.018822. Epub 2021 Feb 20.
Background In heart failure, the exercise gas exchange Weber (A to D) and ventilatory classifications (VC-1 to VC-4) historically define disease severity and prognosis. However, their applications in the modern heart failure population of any left ventricular ejection fraction combined with hemodynamics are undefined. We aimed at revisiting and implementing these classifications by cardiopulmonary exercise testing imaging. Methods and Results 269 patients with heart failure with reduced (n=105), mid-range (n=88) and preserved (n=76) ejection fraction underwent cardiopulmonary exercise testing imaging, primarily assessing the cardiac output (CO), mitral regurgitation, and mean pulmonary arterial pressure (mPAP)/CO slope. Within both classes, a progressively lower exercise CO, higher mPAP/CO slopes, and mitral regurgitation (<0.01 all) were observed. After adjustment for age and sex, Cox proportional hazard regression analyses showed that Weber (hazard ratio [HR], 2.9; 95% CI, 1.8-4.7; <0.001) and ventilatory classes (HR, 1.4; 95% CI, 1.1-2.0; =0.017) were independently associated with outcome. The best stratification was observed when combining Weber (A/B or C/D) with severe ventilation inefficiency (VC-4) (HR, 2.7; 95% CI, 1.6-4.8; <0.001). At multivariable analysis the best hemodynamic determinants of peak oxygen consumption and ventilation to carbon dioxide production slope were CO (β-coefficient, 0.72±0.16; <0.001) and mPAP/CO slope (β-coefficient, 0.72±0.16; <0.001), respectively. Conclusions In the contemporary heart failure population, the Weber and ventilatory classifications maintain their prognostic ability, especially when combined. Exercise CO and mPAP/CO slope are the best predictors of peak oxygen consumption and ventilation to carbon dioxide production slope classifications representing the main targets of interventions to impact functional class and, likely, event rate.
背景 在心力衰竭中,运动气体交换的韦伯分类(A至D)和通气分类(VC-1至VC-4)在历史上用于定义疾病严重程度和预后。然而,它们在任何左心室射血分数合并血流动力学的现代心力衰竭人群中的应用尚不明确。我们旨在通过心肺运动测试成像重新审视并应用这些分类。方法与结果 269例射血分数降低(n = 105)、中等范围(n = 88)和保留(n = 76)的心力衰竭患者接受了心肺运动测试成像,主要评估心输出量(CO)、二尖瓣反流和平均肺动脉压(mPAP)/CO斜率。在这两类患者中,均观察到运动CO逐渐降低、mPAP/CO斜率升高以及二尖瓣反流增加(所有P均<0.01)。在对年龄和性别进行调整后,Cox比例风险回归分析显示,韦伯分类(风险比[HR],2.9;95%可信区间[CI],1.8 - 4.7;P<0.001)和通气分类(HR,1.4;95% CI,1.1 - 2.0;P = 0.017)与预后独立相关。当将韦伯分类(A/B或C/D)与严重通气效率低下(VC-4)相结合时,观察到最佳分层(HR,2.7;95% CI,1.6 - 4.8;P<0.001)。在多变量分析中,峰值耗氧量和通气与二氧化碳产生斜率的最佳血流动力学决定因素分别是CO(β系数,0.72±0.16;P<0.001)和mPAP/CO斜率(β系数,0.72±0.16;P<0.001)。结论 在当代心力衰竭人群中,韦伯分类和通气分类保持其预后能力,尤其是联合使用时。运动CO和mPAP/CO斜率是峰值耗氧量和通气与二氧化碳产生斜率分类的最佳预测指标,这些分类代表了影响功能分级以及可能的事件发生率的主要干预目标。