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      Cardiopulmonary Exercise Testing in Mild Heart Failure: Impact of the Mode of Exercise on Established Prognostic Predictors

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          Abstract

          Objectives: In patients with heart failure (HF), peak oxygen consumption (peak VO<sub>2</sub>), the relationship between minute ventilation and carbon dioxide production (VE/VCO<sub>2</sub> slope) and heart rate recovery (HRR) are established prognostic predictors. However, treadmill exercise has been shown to elicit higher peak VO<sub>2</sub> values than bicycle exercise. We sought to assess whether the VE/VCO<sub>2</sub> slope and HRR in HF also depend on the exercise mode. Methods: Twenty-one patients with mild HF on chronic β-blocker therapy underwent treadmill and bicycle cardiopulmonary exercise testing for measurement of peak VO<sub>2</sub> and the VE/VCO<sub>2</sub> slope. In patients with sinus rhythm (n = 16), HRR at 1 (HRR-1) and 2 min (HRR-2) after exercise termination was assessed. Results: Peak VO<sub>2</sub> was higher during treadmill as compared with bicycle testing (21.7 ± 4.6 vs. 19.6 ± 3.4 ml/kg/min; p = 0.006). HRR-1 tended to be slower (15 bpm, interquartile range 8–19, vs. 18 bpm, interquartile range 11–22; p = 0.16), and HRR-2 was significantly slower after treadmill exercise (26 bpm, interquartile range 20–39, vs. 31 bpm, interquartile range 22–41; p = 0.04). In contrast, VE/VCO<sub>2</sub> slope values did not differ between the test modes (32.9 ± 5.5 vs. 32.3 ± 5.0; p = 0.56). Conclusions: In contrast to peak VO<sub>2</sub> and HRR, the VE/VCO<sub>2</sub> slope is not affected by the exercise mode in patients with mild HF.

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          Most cited references 22

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          Comparison of the ramp versus standard exercise protocols.

          To compare the hemodynamic and gas exchange responses of ramp treadmill and cycle ergometer tests with standard exercise protocols used clinically, 10 patients with chronic heart failure, 10 with coronary artery disease who were asymptomatic during exercise, 11 with coronary artery disease who were limited by angina during exercise and 10 age-matched normal subjects performed maximal exercise using six different exercise protocols. Gas exchange data were collected continuously during each of the following protocols, performed on separate days in randomized order: Bruce, Balke and an individualized ramp treadmill; 25 W/stage, 50 W/stage and an individualized ramp cycle ergometer test. Maximal oxygen uptake was 16% greater on the treadmill protocols combined (21.4 +/- 8 ml/kg per min) versus the cycle ergometer protocols combined (18.1 +/- 7 ml/kg per min) (p less than 0.01), although no differences were observed in maximal heart rate (131 +/- 24 versus 126 +/- 24 beats/min for the treadmill and cycle ergometer protocols, respectively). No major differences were observed in maximal heart rate or maximal oxygen uptake among the various treadmill protocols or among the various cycle ergometer protocols. The ratio of oxygen uptake to work rate, expressed as a slope, was highest for the ramp tests (slope +/- SEE ml/kg per min = 0.80 +/- 2.5 and 0.78 +/- 1.7 for ramp treadmill and ramp cycle ergometer, respectively). The slopes were poorest for the tests with the largest increments in work (0.62 +/- 4.0 and 0.59 +/- 2.8 for the Bruce treadmill and 50 W/stage cycle ergometer, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)
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            Peak VO2 and VE/VCO2 slope in patients with heart failure: a prognostic comparison.

            Exercise testing with ventilatory expired gas analysis has proven to be a valuable tool for assessing patients with heart failure (HF). Peak oxygen consumption (peak VO2) continues to be considered the gold standard for assessing prognosis in HF. The minute ventilation--carbon dioxide production relationship (VE/VCO2 slope) has recently demonstrated prognostic significance in patients with HF, and in some studies, it has outperformed peak VO2. Two hundred thirteen subjects, in whom HF was diagnosed, underwent exercise testing between April 1, 1993, and October 19, 2001. The ability of peak VO2 and VE/VCO2 slope to predict cardiac-related mortality and hospitalization was examined. Peak VO2 and VE/VCO2 slope were demonstrated with univariate Cox regression analysis both to be significant predictors of cardiac-related mortality and hospitalization (P <.01). Multivariate analysis revealed that peak VO2 added additional value to the VE/VCO(2) slope in predicting cardiac-related hospitalization, but not cardiac mortality. The VE/VCO2 slope was demonstrated with receiver operating characteristic curve analysis to be significantly better than peak VO2 in predicting cardiac-related mortality (P <.05). Although area under the receiver operating characteristic curve for the VE/VCO2 slope was greater than peak VO2 in predicting cardiac-related hospitalization (0.77 vs 0.73), the difference was not statistically significant (P =.14). These results add to the present body of knowledge supporting the use of cardiopulmonary exercise testing in HF. Consideration should be given to revising clinical guidelines to reflect the prognostic importance of the VE/VCO2 slope in addition to peak VO2.
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              Cardiopulmonary exercise testing for prognosis in chronic heart failure: continuous and independent prognostic value from VE/VCO(2)slope and peak VO(2).

              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. 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)). 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. Copyright 2000 The European Society of Cardiology.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2008
                April 2008
                31 October 2007
                : 110
                : 2
                : 135-141
                Affiliations
                aDivision of Cardiology, Department of Internal Medicine, and bInstitute for Clinical Chemistry and Hematology, Kantonsspital St. Gallen, St. Gallen, and cDivision of Cardiology, University Hospital Basel, Basel, Switzerland; dCardiology Division, Palo Alto Veterans Affairs Medical Center, Stanford University, Palo Alto, Calif., USA
                Article
                110493 Cardiology 2008;110:135–141
                10.1159/000110493
                17975313
                © 2007 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 3, References: 30, Pages: 7
                Categories
                Original Research

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