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Clinical, Hemodynamic, and Cardiopulmonary Exercise Test Determinants of Survival in Patients Referred for Evaluation of Heart Failure

Jonathan Myers, PhD; Lars Gullestad, MD; Randall Vagelos, MD; Dat Do, BS; Daniel Bellin, BS; Heather Ross, MD; and Michael B. Fowler, MD
[+] Article and Author Information

For author affiliations and current author addresses, see end of text. Requests for Reprints: Michael B. Fowler, MD, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 96305. Current Author Addresses: Dr. Myers and Mr. Bellin: Palo Alto Veterans Affairs Medical Center, Cardiology, 111 C, 3801 Miranda Avenue, Palo Alto, CA 94304.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;129(4):286-293. doi:10.7326/0003-4819-129-4-199808150-00004
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Background: Accurate prognosis in chronic heart failure has become increasingly important in assessing the efficacy of treatment and in appropriately allocating scarce resources for transplantation. Previous studies of severe heart failure have been limited by short follow-up periods and few deaths.

Objective: To establish clinical, hemodynamic, and cardiopulmonary exercise test determinants of survival in patients with heart failure.

Design: Retrospective study.

Setting: Hospital-based outpatient heart failure clinic.

Participants: 644 patients referred for evaluation of heart failure over 10 years.

Measurements: Age, cause of heart failure, body surface area, cardiac index, ejection fraction, pulmonary capillary wedge pressure, left ventricular dimensions, watts achieved during exercise, heart rate, maximum systolic blood pressure, and oxygen uptake (VO2) at the ventilatory threshold and at peak exercise were measured at baseline. Univariate and multivariate analyses were done for clinical, hemodynamic, and exercise test predictors of death. A Cox hazards model was developed for time of death.

Results: During a mean follow-up period of 4 years, 187 patients (29%) died and 101 underwent transplantation. Actuarial 1-year and 5-year survival rates were 90.5% and 73.4%, respectively. Resting systolic blood pressure, watts achieved, peak VO2, VO2 at the ventilatory threshold, and peak heart rate were greater among survivors than among nonsurvivors. Cause of heart failure (coronary artery disease or cardiomyopathy) was a strong determinant of death (relative risk for coronary artery disease, 1.73; P < 0.01). By multivariate analysis, only peak VO2 was a significant predictor of death. Stratification of peak VO2 above and below 12, 14, and 16 mL/kg per minute demonstrated significant differences in risk for death, but each cut-point predicted risk to a similar degree.

Conclusions: Peak VO2 outperforms clinical variables, right-heart catheterization data, exercise time, and other exercise test variables in predicting outcome in severe chronic heart failure. Direct measurement of VO2 should be included when clinical or surgical decisions are being made in patients referred for evaluation of heart failure or those considered for transplantation.

Figures

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Figure 1.
Survival curves in patients with chronic heart failure and idiopathic cardiomyopathy (squares) or underlying coronary artery disease (circles).P

The dotted line represents the annual mortality rate expected on the basis of sex and age. The difference between the two curves was significant ( < 0.001). Numbers given along the curves are numbers of patients evaluated at each time point; numbers in parentheses are cumulative numbers of deaths.

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Figure 2.
Top.PBottom.P

Survival curves for patients who had a regression score greater than 13 (squares) and those who had a regression score less than 13 or equal to (circles) among patients with chronic heart failure and underlying coronary artery disease ( < 0.001 between curves). Survival curves for patients who had a regression score greater than 18 (squares) and those who had a regression score ≤ 18 (circles) among patients with chronic heart failure and underlying cardiomyopathy ( = 0.006 between curves).

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Figure 3.
Survival curves for patients achieving above compared with below 12, 14, and 16 mL/kg per minute for peak oxygen uptake (VO2).

Numbers refer to patients evaluated at each time point for each survival curve; numbers in parentheses are cumulative numbers of deaths.

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Figure 4.
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Survival curves for patients in whom the peak oxygen uptake (V ) predicted from the work rate was greater than 14 mL/kg per minute (circles) and those in whom the predicted peak V was 14 mL/kg per minute or less (squares). Survival curves for patients in whom the peak V measured directly was greater than 14 mL/kg per minute (circles) and those in whom the peak V was 14 mL/kg per minute or less (squares). Patients in whom the predicted peak V was greater than 14 mL/kg per minute did not differ significantly from those in whom the predicted peak V was 14 mL/kg per minute or less, but for measured peak V , the difference in survival between patients achieving greater than and those achieving less than 14 mL/kg per minute was significant ( < 0.001).

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