Key result
Exercise-induced PH and VO2 peak <80% predict mortality and HF beyond cardiac staging in ≥moderate AS.
Why the study?
The added prognostic value of combined cardiopulmonary exercise testing and echocardiography beyond the cardiac damage staging system in patients with aortic stenosis was unknown.
Does combined cardiopulmonary exercise testing and echocardiography (CPETecho) improve prognostic risk stratification beyond the cardiac damage staging system in patients with at least moderate aortic stenosis?
Does combined cardiopulmonary exercise testing and echocardiography (CPETecho) improve prognostic risk stratification beyond the cardiac damage staging system in patients with at least moderate aortic stenosis?
In patients with at least moderate aortic stenosis, adding CPETecho parameters (%-predicted VO2 peak and exercise-induced pulmonary hypertension) to standard clinical and staging models significantly improves the prediction of mortality and heart failure hospitalizations.
Supports incremental prognostic stratification with CPETecho in moderate AS; extends staging systems but remains hypothesis-generating pending validation.
Background Cardiac damage correlates with adverse events in patients with severe aortic stenosis (AS). The added prognostic value of combined cardiopulmonary exercise testing and echocardiography (CPETecho) over the cardiac damage staging system is unknown. Methods A total of 402 patients (68% men; 74±10 years) with ≥moderate AS and no other significant primary valvular disease underwent CPETecho. They were subsequently evaluated for the occurrence of all-cause mortality and heart failure hospitalizations. Results Severe AS was present in 56% (60% classical). Only a minority of patients showed no cardiac damage (5%), while most (76%) had stage 2-4 (left atrial or mitral valve damage; pulmonary vasculature or tricuspid valve damage or right ventricular damage, respectively). Over a median follow-up of 40 months [25-49], 105 patients reached the primary endpoint. Incorporating exercise pulmonary hypertension and %-predicted VO2 peak to a baseline model (age, AS severity and cardiac damage staging system) significantly improved event prediction (Figure 1). Multivariable logistic regression identified age, exercise-induced pulmonary hypertension, and %-predicted VO2 peak < 80% as independent predictors (Figure 1). Among patients with a positive diastolic stress test and normal resting left ventricle filling pressures (52 patients) all but one had %-predicted VO2 peak < 80% or exercise-induced pulmonary hypertension. Adding left atrium reservoir strain, right ventricle global longitudinal strain or free wall strain did not significantly improve the proposed model. Conclusions In ≥moderate AS, age, %-predicted VO2 peak < 80% and exercise-induced pulmonary hypertension independently predicted mortality and heart failure hospitalizations, beyond AS severity and the cardiac damage staging system classification. CPETecho may refine risk stratification and guide management in patients with at least moderate AS.
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Ferreira et al. (2025) studied this question. In ≥moderate aortic stenosis, exercise-induced pulmonary hypertension and VO2 peak <80% independently predicted mortality and heart failure beyond cardiac damage staging.
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