Poor Increase in Pulse Pressure During Cardiopulmonary Exercise Testing Predicts Cardiovascular Death of Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND: The increase in stroke volume during inotropic stimulation in patients with heart failure with reduced ejection fraction (HFrEF) is called the "pump function reserve." Few studies have reported on the relationship between pump function reserve and HF prognosis. In HFrEF patients who have pump function reserve, stroke volume increases during exercise. Simply put, the pulse pressure change (∆PP) during cardiopulmonary exercise testing (CPX) is closely related to the prognosis of patients with HFrEF. We hypothesized that ∆PP could predict disease severity and cardiovascular death in patients with HFrEF. METHODS AND RESULTS: A total of 224 patients with HFrEF who underwent symptom-limited maximal CPX between 2012 and 2016 were enrolled. During a median follow-up of 1.5 years, cardiovascular death occurred in 54 participants (24%). Patients who died demonstrated a lower ∆PP between rest and peak exercise (∆PP [peak-rest]) than those who survived (P<0.001). Cox regression analyses revealed that ∆PP, slope of the relationship between minute ventilation and carbon dioxide production, and B-type natriuretic peptide level were independent predictors of cardiovascular death in patients with HFrEF (P=0.001, 0.021, and <0.001, respectively). CONCLUSIONS: ∆PP (peak-rest) can accurately predict cardiovascular death in patients with HFrEF and may be a useful new prognostic indicator in these patients.