Cardiopulmonary exercise testing utilization and clinical outcomes among patients with heart failure across racial and ethnic groups

Background and Aims Cardiopulmonary exercise testing (CPET) carries a Class I recommendation for advanced heart failure (HF) therapy candidacy. Whether CPET utilization and outcomes differ by race is unknown. Methods Using TriNetX, adults with HF (ICD-10 I50.x, 2010–23) were stratified by race/ethnicity and CPET receipt (CPT 94621) within 1 year of diagnosis. All-cause mortality and HF hospitalization were assessed at 1, 3, and 5 years after 1:1 propensity score matching for demographics, HF subtype, comorbidities, and guideline-directed medical therapy. Results Among 807 379 patients with HF (mean age 69.2 years, 46.2% female), 10 268 (1.27%) underwent CPET within 1 year. Utilization was 1.39% in White, 1.20% in Black, 0.69% in Hispanic, and 0.79% in Asian patients. After matching, 8355 pairs were analysed. CPET was associated with lower 1-year mortality in White (hazard ratio [HR] 0.58, 95% CI 0.51–0.65, P < .001) and Hispanic (HR 0.50, 0.25–0.98, P = .040) patients. Asian patients reached borderline significance at 5 years (HR 0.54, 0.29–1.00, P = .048). Black patients showed a non-significant trend (1-year HR 0.70, 0.39–1.24, P = .214). HF hospitalization was higher in White (1-year HR 1.18, 1.14–1.23, P < .001) and Asian (HR 1.73, 1.35–2.21, P < .001) CPET recipients, suggesting surveillance bias. Conclusions CPET utilization was associated with lower mortality in White and Hispanic patients, with borderline significance in Asian patients at 5 years and a non-significant trend in Black patients. These associations may reflect engagement with speciality HF care rather than testing itself. Minority patients were under-represented among CPET recipients, highlighting CPET access as a marker of inequity in advanced HF care.