Cardiopulmonary Exercise Testing Variables Reflect the Degree of Diastolic Dysfunction in Patients With Heart Failure–Normal Ejection Fraction

Cardiology Division, University of Milano, San Paolo Hospital, Milan, Italy.
Journal of cardiopulmonary rehabilitation and prevention (Impact Factor: 1.58). 03/2010; 30(3):165-72. DOI: 10.1097/HCR.0b013e3181d0c1ad
Source: PubMed


Previous investigations have reported a relationship between variables obtained from echocardiography with tissue Doppler imaging (TDI) and cardiopulmonary exercise testing (CPX) in systolic heart failure (HF) cohorts. The purpose of the present investigation was to perform a comparative analysis between echocardiography with TDI and CPX in patients with HF and normal ejection fraction (NEF).
Patients with HF-NEF (N = 32) underwent echocardiography with TDI and CPX to determine the following variables: (1) the ratio between mitral early velocity (E) and mitral annular velocity (E'), (2) ejection fraction, (3) left ventricular (LV) mass, (4) left ventricular end systolic volume, (5) peak oxygen uptake (.VO2), (6) ventilatory efficiency, (7) the partial pressure of end-tidal carbon dioxide (P(ET)CO2) at rest and peak exercise, and (8) heart rate recovery at 1 minute (HRR1).
Pearson correlation revealed that E/E' was significantly correlated with peak oxygen uptake (r = -0.55, P = .001), the ventilatory efficiency slope (r = 0.60, P < .001), resting P(ET)CO2 (r = -0.39, P = .03), peak P(ET)CO2 (r = -0.50, P = .004), and HRR1 (r = -0.63, P < .001). Left ventricular mass and left ventricular end systolic volume were not correlated with any CPX variable. Ejection fraction was correlated with HRR1 (r = -0.55, P = .001). An HRR1 threshold of less than 16 and/or 16 or more beats per minute (higher value positive) effectively identified subjects with an E/E' > 10 (positive likelihood ratio: 13:2).
E/E' provides an accurate reflection of LV filling pressure and thus, insight into diastolic function. The results of the present investigation indicate CPX provides insight into cardiac dysfunction in patients with HF-NEF and thus, may eventually prove to be a valuable and accepted clinical assessment.

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    • "Original definition of Kremser et al. (1987) [12]: Ventilatory oscillations lasting N66% of the exercise protocol, with an amplitude N15% of the average value at rest. Modified N60% duration; amplitude N15% [9] [48] [37] [49] [47] [19] [20] [80] ≥60% duration; amplitude ≥15% [9] [48] [74] [63] [64] [52] [73] [32] [69] [70] [51] [72] [81] [75] [82] Cyclic fluctuations in minute VE at rest that persist during effort ≥50% of the exercise duration [58] Original definition of Leite et al. (2003) [46]: ≥3 regular oscillations (i.e., clearly discernible from inherent data noise) in VE; Regularity was defined if the SD of 3 consecutive cycle lengths (time between 2 consecutive nadirs) was within 20% of the average; minimal average amplitude of ventilatory oscillation ≥5 l (peak value minus the average of 2 in-between consecutive nadirs). [47] [33] [35] [21] [30] [68] [45] [60] [57] [56] Modified ≥3 regular oscillations in ventilation [83] Amplitude of oscillation N30% of the mean value for VE, VO 2 or VCO 2 , ≥3 consecutive oscillations with amplitude of ≥5 L/min for VE and ≥3 ml/kg/min for VO 2 or VCO 2 . "
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    • "New developments in echocardiography enable a much fuller assessment of LV systolic and diastolic function, including measurement of myocardial deformation or strain.44,45,47 Stress echocardiography using these newer techniques to assess LV tissue velocities, strain, and torsion has been shown to have increased sensitivity to predict diastolic dysfunction.45,48–50 "
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    • "That evidence has also been extended to patients with HF who have preserved left ventricular ejection fraction [15] [16] [17]. The most important measurements obtained from CPX include peak oxygen uptake (peak _ VO 2 ) [7] [8] [15] [16], anaerobic (gas exchange) threshold (AT) [9] [10] [11], increase rate in ventilation per unit increase in carbon dioxide production ( _ VE– _ VCO 2 slope) [12] [13] [17], and the ratio of the increase in _ VO 2 to the increase in work rate (Δ _ VO 2 /ΔWR) [14], all of which reflect heart disease severity and the ability of cardiac patients to perform activities of daily living. In the present study, we evaluated whether H2ARDD score is related to these 4 classic CPX parameters in patients with AF to clarify its pathophysiological implications. "
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    ABSTRACT: Background A novel risk scoring system (H2ARDD) for estimating the incidence of heart failure (HF) events in atrial fibrillation (AF) has been developed, which represents points assigned for organic heart disease (2 points), anemia (1 point), renal dysfunction (1 point), diabetes (1 point), and diuretic use (1 point). We aimed to clarify whether H2ARDD score is related to cardiopulmonary exercise testing (CPX) parameters in patients with AF. Methods The study population included 344 consecutive patients with AF who underwent CPX as initial screening between June 2004 and March 2012. The association between 4 CPX parameters and the incidence of HF events was analyzed by using multiple linear regression models. Results The peak O2 uptake (peak V̇O2), anaerobic (gas exchange) threshold (AT), and ratio of the increase in V̇O2 to the increase in work rate (ΔV̇O2/ΔWR) were lower and the slope of the increase in ventilation to the increase in CO2 output (V̇E–V̇CO2 slope) was higher in patients with than in those without each H2ARDD score component. Accordingly, the parameters significantly increased or decreased according to H2ARDD score. With the multiple linear regression models, H2ARDD score was independently associated with each CPX parameter even after adjustment for various cofactors. Conclusions H2ARDD score was independently associated with the well-established CPX parameters in patients with AF, suggesting a potential pathophysiological basis for a risk stratification system for predicting HF events in patients with AF.
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