Cardiopulmonary Exercise Testing in the Age of New Heart Failure Therapies: Still a Powerful Tool?

P Garcia Bras; António Valentim Gonçalves; João Reis; Rita Ilhão Moreira; Tiago Pereira‐da‐Silva; Pedro Rio; Ana Teresa Timóteo; Sofia Silva; Rui Soares; Rui Cruz Ferreira

doi:10.3390/biomedicines11082208

August 6, 2023BiomedicinesOpen Access

Cardiopulmonary Exercise Testing in the Age of New Heart Failure Therapies: Still a Powerful Tool?

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Why the study?

With the recent introduction of new therapies providing prognostic benefits in HFrEF, it was uncertain whether current listing criteria for heart transplantation remain prognostically powerful.

Does the prognostic power of traditional ISHLT CPET thresholds for heart transplantation listing differ between historical and contemporary HFrEF cohorts?

Structured PICO

Does the prognostic power of traditional ISHLT CPET thresholds for heart transplantation listing differ between historical and contemporary HFrEF cohorts?

P

Population

487 consecutive patients with heart failure with reduced ejection fraction (HFrEF) who underwent cardiopulmonary exercise testing (CPET)

I

Intervention

Prognostic evaluation using contemporary ISHLT thresholds in a recent cohort (Group B: 2015-2018)

C

Comparator

Historical cohort (Group A: 2009-2014)

O

Outcome

Composite of cardiac death and urgent heart transplantation (HT) at 36-month follow-upcomposite

Implication

Traditional ISHLT CPET thresholds for heart transplant listing have lower prognostic effectiveness in contemporary HFrEF patients, suggesting stricter cut-offs may be needed to improve risk stratification.

Abstract

Background: New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). Methods: Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. Results: CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO2 (pVO2) and VE/VCO2 slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO2 slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO2 ≤ 10 mL/kg/min and VE/VCO2 slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. Conclusion: ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.