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A meta-analysis of the prognostic significance of cardiopulmonary exercise testing in patients with heart failure

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Abstract

The objective of the study is to assess the role of cardiopulmonary exercise testing (CPX) variables, including peak oxygen consumption (VO2), which is the most recognized CPX variable, the minute ventilation/carbon dioxide production (VE/VCO2) slope, the oxygen uptake efficiency slope (OUES), and exercise oscillatory ventilation (EOV) in a current meta-analysis investigating the prognostic value of a broader list of CPX-derived variables for major adverse cardiovascular events in patients with HF. A search for relevant CPX articles was performed using standard meta-analysis methods. Of the initial 890 articles found, 30 met our inclusion criteria and were included in the final analysis. The total subject populations included were as follows: peak VO2 (7,319), VE/VCO2 slope (5,044), EOV (1,617), and OUES (584). Peak VO2, the VE/VCO2 slope and EOV were all highly significant prognostic markers (diagnostic odds ratios ≥ 4.10). The OUES also demonstrated promise as a prognostic marker (diagnostic odds ratio = 8.08) but only in a limited number of studies (n = 2). No other independent variables (including age, ejection fraction, and beta-blockade) had a significant effect on the meta-analysis results for peak VO2 and the VE/VCO2 slope. CPX is an important component in the prognostic assessment of patients with HF. The results of this meta-analysis strongly confirm this and support a multivariate approach to the application of CPX in this patient population.

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Abbreviations

AUC:

Area under curve

CPX:

Cardiopulmonary exercise testing

CV:

Cardiovascular

DOR:

Diagnostic odds ratio

EOV:

Exercise oscillatory ventilation

EST:

Exercise stress testing

FN:

False negative

FP:

False positive

HF:

Heart failure

HT:

Heart transplantation

LVEF:

Left ventricular ejection fraction

NYHA:

New York heart association

OUES:

Oxygen uptake efficiency slope

SROC:

Summary receiver operating characteristic

TN:

True negative

TP:

True positive

VE/VCO2 :

Minute ventilation/carbon dioxide production

VO2 :

Oxygen consumption

References

  1. Weber KT, Kinasewitz GT, Janicki JS, Fishman AP (1982) Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure. Circulation 65:1213–1223

    Article  PubMed  CAS  Google Scholar 

  2. Wilson JR, Ferraro N, Weber KT (1983) Respiratory gas analysis during exercise as a noninvasive measure of lactate concentration in chronic congestive heart failure. Am J Cardiol 51:1639–1643

    Article  PubMed  CAS  Google Scholar 

  3. Arena R, Myers J, Guazzi M (2008) The clinical and research applications of aerobic capacity and ventilatory efficiency in heart failure: an evidence-based review. Heart Fail Rev 13:245–269

    Article  PubMed  Google Scholar 

  4. Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, Forman D, Franklin B, Guazzi M, Gulati M, Keteyian SJ, Lavie CJ, Macko R, Mancini D, Milani RV (2010) Clinician’s guide to cardiopulmonary exercise testing in adults. A scientific statement from the American heart association. Circulation 122:191–225

    Article  PubMed  Google Scholar 

  5. Piepoli MF, Corra U, Agostoni PG, Belardinelli R, Cohen-Solal A, Hambrecht R, Vanhees L (2006) Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: recommendations for performance and interpretation Part II: how to perform cardiopulmonary exercise testing in chronic heart failure. Eur J Cardiovasc Prev Rehabil 13:300–311

    PubMed  Google Scholar 

  6. Piepoli MF, Corra U, Agostoni PG, Belardinelli R, Cohen-Solal A, Hambrecht R, Vanhees L (2006) Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: recommendations for performance and interpretation. Part I: definition of cardiopulmonary exercise testing parameters for appropriate use in chronic heart failure. Eur J Cardiovasc Prev Rehabil 13:150–164

    Article  PubMed  Google Scholar 

  7. Piepoli MF, Corra U, Agostoni PG, Belardinelli R, Cohen-Solal A, Hambrecht R, Vanhees L (2006) Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: recommendations for performance and interpretation Part III: interpretation of cardiopulmonary exercise testing in chronic heart failure and future applications. Eur J Cardiovasc Prev Rehabil 13:485–494

    Article  Google Scholar 

  8. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, Konstam MA, Mancini DM, Rahko PS, Silver MA, Stevenson LW, Yancy CW (2009) 2009 Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in Collaboration With the International Society for Heart and Lung Transplantation. Circulation 119:1977–2016

    Article  PubMed  Google Scholar 

  9. Gibbons RJ, Balady GJ, Timothy BJ, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC (2002) ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 40:1531–1540

    Article  PubMed  Google Scholar 

  10. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25

    Article  PubMed  Google Scholar 

  11. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB, for the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) Group (2000) Meta-analysis of observational studies in epidemiology. JAMA 283:2008–2012

  12. Corra U, Giordano A, Bosimini E, Mezzani A, Piepoli M, Coats AJ, Giannuzzi P (2002) Oscillatory ventilation during exercise in patients with chronic heart failure: clinical correlates and prognostic implications. Chest 121:1572–1580

    Article  PubMed  Google Scholar 

  13. Mancini DM, Eisen H, Kussmaul W, Mull R, Edmunds LH Jr, Wilson JR (1991) Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. Circulation 83:778–786

    Article  PubMed  CAS  Google Scholar 

  14. Myers J, Gullestad L, Vagelos R, Do D, Bellin D, Ross H, Fowler MB (2000) Cardiopulmonary exercise testing and prognosis in severe heart failure: 14 mL/kg/min revisited. Am Heart J 139:78–84

    Article  PubMed  CAS  Google Scholar 

  15. Parikh MN, Lund LH, Goda A, Mancini D (2009) Usefulness of peak exercise oxygen consumption and the heart failure survival score to predict survival in patients >65 years of age with heart failure. Am J Cardiol 103:998–1002

    Article  PubMed  Google Scholar 

  16. O’Neill JO, Young JB, Pothier CE, Lauer MS (2005) Peak oxygen consumption as a predictor of death in patients with heart failure receiving {beta}-blockers. Circulation 111:2313–2318

    Article  PubMed  Google Scholar 

  17. Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, Mark DB, Marwick TH, McCallister BD, Thompson PD Jr, Winters WL, Yanowitz FG, Ritchie JL, Gibbons RJ, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O’Rourke RA, Ryan TJ (1997) ACC/AHA guidelines for exercise testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 30:260–311

    Article  PubMed  CAS  Google Scholar 

  18. Arena R, Myers J, Abella J, Peberdy MA, Bensimhon D, Chase P, Guazzi M (2007) Development of a ventilatory classification system in patients with heart failure. Circulation 115:2410–2417

    Article  PubMed  Google Scholar 

  19. Francis DP, Shamim W, Davies LC, Piepoli MF, Ponikowski P, Anker SD, Coats AJ (2000) Cardiopulmonary exercise testing for prognosis in chronic heart failure: continuous and independent prognostic value from VE/VCO(2)slope and peak VO(2). Eur Heart J 21:154–161

    Article  PubMed  CAS  Google Scholar 

  20. Guazzi M, Arena R, Ascione A, Piepoli M, Guazzi MD (2007) Exercise oscillatory breathing and increased ventilation to carbon dioxide production slope in heart failure: an unfavorable combination with high prognostic value. Am Heart J 153:859–867

    Article  PubMed  Google Scholar 

  21. Davies LC, Wensel R, Georgiadou P, Cicoira M, Coats AJ, Piepoli MF, Francis DP (2006) Enhanced prognostic value from cardiopulmonary exercise testing in chronic heart failure by non-linear analysis: oxygen uptake efficiency slope. Eur Heart J 27:684–690

    Article  PubMed  Google Scholar 

  22. Poggio R, Arazi HC, Giorgi M, Miriuka SG (2010) Prediction of severe cardiovascular events by VE/Vco2 slope versus peak Vo2 in systolic heart failure: a meta-analysis of the published literature. Am Heart J 160:1004–1014

    Article  PubMed  Google Scholar 

  23. Baba R, Nagashima M, Goto M, Nagano Y, Yokota M, Tauchi N, Nishibata K (1996) Oxygen intake efficiency slope: a new index of cardiorespiratory functional reserve derived from the relationship between oxygen consumption and minute ventilation during incremental exercise. Nagoya J Med Sci 59:55–62

    PubMed  CAS  Google Scholar 

  24. Arena R, Myers J, Guazzi M (2011) Cardiopulmonary exercise testing is a core assessment for patients with heart failure. Congest Heart Failure 17:115–119

    Article  Google Scholar 

  25. Guazzi M, Arena R, Myers J (2006) Comparison of the prognostic value of cardiopulmonary exercise testing between male and female patients with heart failure. Int J Cardiol 113:395–400

    Article  PubMed  Google Scholar 

  26. O’Connor CM, Whellan DJ, Wojdyla D, Leifer E, Clare RM, Ellis SJ, Fine LJ, Fleg JL, Zannad F, Keteyian SJ, Kitzman DW, Kraus WE, Rendall D, Piña IL, Cooper LS, Fiuzat M, Lee KL (2012) Factors related to morbidity and mortality in patients with chronic heart failure with systolic dysfunction. Clin Perspect Circ Heart Fail 5:63–71

    Article  Google Scholar 

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Acknowledgments

Partial support provided by Cosmed, Rome, Italy.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Physical Therapy, Leonard M. Miller School of Medicine, University of Miami, 5915 Ponce de Leon Blvd., 5th Floor, Coral Gables, FL, 33146-2435, USA

    Lawrence P. Cahalin

  2. Lebauer Cardiovascular Research Foundation, Greensboro, NC, USA

    Paul Chase & Daniel Bensimhon

  3. Physical Therapy Program, Department of Orthopaedics and Department of Internal Medicine, Division of Cardiology, University of New Mexico, Albuquerque, NM, USA

    Ross Arena

  4. Division of Cardiology, VA Palo Alto Healthcare System, Palo Alto, CA, USA

    Jonathan Myers

  5. Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA

    Mary Ann Peberdy

  6. Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA

    Euan Ashley

  7. Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Erin West & Daniel E. Forman

  8. Physical Therapy Program, Brooks College of Health, University of North Florida, Jacksonville, FL, USA

    Sherry Pinkstaff

  9. Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA

    Carl J. Lavie

  10. Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA, USA

    Carl J. Lavie

  11. Cardiology, I.R.C.C.S. Policlinico San Donato, University of Milano, San Donato Milanese, Italy

    Marco Guazzi

Authors
  1. Lawrence P. Cahalin
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  2. Paul Chase
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  3. Ross Arena
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  4. Jonathan Myers
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  6. Mary Ann Peberdy
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  7. Euan Ashley
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  8. Erin West
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  9. Daniel E. Forman
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  10. Sherry Pinkstaff
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  11. Carl J. Lavie
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  12. Marco Guazzi
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Correspondence to Lawrence P. Cahalin.

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Cahalin, L.P., Chase, P., Arena, R. et al. A meta-analysis of the prognostic significance of cardiopulmonary exercise testing in patients with heart failure. Heart Fail Rev 18, 79–94 (2013). https://doi.org/10.1007/s10741-012-9332-0

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  • DOI: https://doi.org/10.1007/s10741-012-9332-0

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