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BP Response During Cardiopulmonary Exercise Testing in HF
Study Questions:
Do observed changes in blood pressure during cardiopulmonary exercise testing in patients with advanced heart failure (HF) provide additional prognostic information?
Methods:
A cohort of 151 patients with advanced HF was studied retrospectively after each was evaluated by cardiopulmonary exercise treadmill testing (Naughton or Ekeland protocol) to determine exercise time and changes in heart rate and blood pressure. Breath-to-breath gas analysis was performed during exercise to determine respiratory exchange ratio, peak oxygen consumption (VO2, an index of exercise capacity), percent achieved of predicted VO2, carbon dioxide production (VCO2), minute ventilation (VE), and calculations of ventilatory efficiency (VE/VCO2 slope, where lower is more efficient). The cohort was then stratified into tertiles based on increase in exercise systolic blood pressure (SBP)—lowest (<13 mmHg), moderate (13-16 mmHg), and highest (≥27 mmHg)—and then analyzed for how well the increase in SBP predicted failure of optimal medical management, defined by death, cardiac transplantation, or left ventricular assist device placement.
Results:
Baseline characteristics, such as demographics, medications, interventions, and ejection fraction, were not significantly different among tertiles, though the highest tertile of SBP increase was less likely to have resynchronization therapy than the other two. Patients in the lowest tertile had the lowest mean peak SBP and peak VO2, highest VE/VCO2 slope, and shortest mean exercise time and were more likely to fail optimal medical management. Every 1 mmHg increase in SBP during exercise lowered the risk of medical failure up to 20 mmHg. However, exercise-induced increases in SBP >20 mmHg were associated with increased risk of optimal medical management failure.
Conclusions:
This study characterizes blood pressure response to exercise in advanced HF. It demonstrates that attenuated increases in SBP during exercise predict poorer outcomes, as indexed by failure of optimal medical management up to 20 mmHg, after which medical failure becomes more likely.
Perspective:
Change in SBP during exercise is an easy-to-obtain, noninvasive, and inexpensive parameter that can provide a screening tool to risk stratify patients with advanced HF. Given the complexity of HF, it is likely that the best predictor of outcomes is a method that integrates other established cardiopulmonary exercise testing parameters such as VO2 and VE/VCO2 slope.
Keywords: Heart Failure, Blood Pressure, Exercise Test, Oxygen Consumption, Carbon Dioxide, Heart Rate, Prognosis, Sports
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