Hemodynamic exercise testing. A valuable tool in the selection of cardiac transplantation candidates.

BACKGROUND Peak exercise oxygen consumption (Vo2), a noninvasive index of peak exercise cardiac output (CO), is widely used to select candidates for heart transplantation. However, peak exercise Vo2 can be influenced by noncardiac factors such as deconditioning, motivation, or body composition and may yield misleading prognostic information. Direct measurement of the CO response to exercise may avoid this problem and more accurately predict prognosis. METHODS AND RESULTS Hemodynamic and ventilatory responses to maximal treadmill exercise were measured in 185 ambulatory patients with chronic heart failure who had been referred for cardiac transplantation (mean left ventricular ejection fraction, 22 +/- 7%; mean peak Vo2, 12.9 +/- 3.0 mL. min-1.kg-1). CO response to exercise was normal in 83 patients and reduced in 102. By univariate analysis, patients with normal CO responses had a better 1-year survival rate (95%) than did those with reduced CO responses (72%) (P < .0001). Survival in patients with peak Vo2 of > 14 mL.min-1.kg-1 (88%) was not different from that of patients with peak Vo2 of < or = 14 mL.min-1.kg-1 (79%) (P = NS). However, survival was worse in patients with peak Vo2 of < or = 10 mL.min-1.kg-1 (52%) versus those with peak Vo2 of > 10 mL.min-1.kg-1 (89%) (P < .0001). By Cox regression analysis, exercise CO response was the strongest independent predictor of survival (risk ratio, 4.3), with peak Vo2 dichotomized at 10 mL. min-1.kg-1 (risk ratio, 3.3) as the only other independent predictor. Patients with reduced CO responses and peak Vo2 of < or = 10 mL.min-1.kg-1 had an extremely poor 1-year survival rate (38%). CONCLUSIONS Both CO response to exercise and peak exercise Vo2 provide valuable independent prognostic information in ambulatory patients with heart failure. These variables should be used in combination to select potential heart transplantation candidates.

[1]  S. Adamopoulos,et al.  Controlled Trial of Physical Training in Chronic Heart Failure: Exercise Performance, Hemodynamics, Ventilation, and Autonomic Function , 1992, Circulation.

[2]  G. Borg Psychophysical bases of perceived exertion. , 1982, Medicine and science in sports and exercise.

[3]  A. Sniderman,et al.  Prognosis in patients with low left ventricular ejection fraction after myocardial infarction. Importance of exercise capacity. , 1989, Circulation.

[4]  J R Wilson,et al.  Value of Peak Exercise Oxygen Consumption for Optimal Timing of Cardiac Transplantation in Ambulatory Patients With Heart Failure , 1991, Circulation.

[5]  G. Roul,et al.  Prognostic factors of chronic heart failure in NYHA class II or III: value of invasive exercise haemodynamic data. , 1995, European heart journal.

[6]  A. Amery,et al.  Influence of Age on the Hemodynamic Response to Exercise , 1967, Circulation.

[7]  F. Tristani,et al.  Ejection Fraction, Peak Exercise Oxygen Consumption, Cardiothoracic Ratio, Ventricular Arrhythmias, and Plasma Norepinephrine as Determinants of Prognosis in Heart Failure , 1993, Circulation.

[8]  M. Higginbotham,et al.  Exercise training in patients with chronic heart failure delays ventilatory anaerobic threshold and improves submaximal exercise performance. , 1989, Circulation.

[9]  G. Couper,et al.  Target heart failure populations for newer therapies. , 1995, Circulation.

[10]  G. Dagenais,et al.  Influence of age and sex on exercise cardiac output. , 1965, Journal of applied physiology.

[11]  J. Wilson,et al.  Circulatory status and response to cardiac rehabilitation in patients with heart failure. , 1996, Circulation.

[12]  J. Wilson,et al.  Dissociation between peak exercise oxygen consumption and hemodynamic dysfunction in potential heart transplant candidates. , 1995, Journal of the American College of Cardiology.

[13]  B. Massie,et al.  Correlates and prognostic implication of exercise capacity in chronic congestive heart failure. , 1985, The American journal of cardiology.

[14]  J. Cohn,et al.  Prognosis of congestive heart failure and predictors of mortality. , 1988, The American journal of cardiology.

[15]  B. Griffin,et al.  Incremental prognostic value of exercise hemodynamic variables in chronic congestive heart failure secondary to coronary artery disease or to dilated cardiomyopathy. , 1991, The American journal of cardiology.

[16]  D. Driscoll,et al.  Cardiac transplantation: recipient selection, donor procurement, and medical follow-up. A statement for health professionals from the Committee on Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. , 1992, Circulation.

[17]  M. Moeschberger,et al.  Factors influencing the one-year mortality of dilated cardiomyopathy. , 1984, The American journal of cardiology.

[18]  M. Luu,et al.  Importance of hemodynamic response to therapy in predicting survival with ejection fraction ≤ 20% secondary to ischemic or nonischemic dilated cardiomyopathy , 1990 .

[19]  G. Francis Determinants of prognosis in patients with heart failure. , 1994, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[20]  D. Driscoll,et al.  Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. , 1995, Circulation.

[21]  G. Fonarow,et al.  The impending crisis awaiting cardiac transplantation. Modeling a solution based on selection. , 1994, Circulation.

[22]  R. Coleman,et al.  Regulation of Stroke Volume during Submaximal and Maximal Upright Exercise in Normal Man , 1986, Circulation research.

[23]  C Larizza,et al.  Predictors of prognosis in patients awaiting heart transplantation. , 1993, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[24]  J. Fleg,et al.  Role of muscle loss in the age-associated reduction in VO2 max. , 1988, Journal of applied physiology.

[25]  A. Damato,et al.  Hemodynamic response to treadmill exercise in normal subjects. , 1966, Journal of applied physiology.

[26]  B. Pitt,et al.  Predictors of total mortality and sudden death in mild to moderate heart failure. Captopril-Digoxin Study Group. , 1989, Journal of the American College of Cardiology.

[27]  H. Kay,et al.  Clinical determinants of mortality in chronic congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy. , 1987, The American journal of cardiology.

[28]  W. Kübler,et al.  Determinants of survival in patients with congestive cardiomyopathy: quantitative morphologic findings and left ventricular hemodynamics. , 1984, Circulation.

[29]  J. Copeland,et al.  Selection of patients for cardiac transplantation. , 1987, Circulation.