Value of Peak Exercise Oxygen Consumption Combined With B-type Natriuretic Peptide Levels for Optimal Timing of Cardiac Transplantation

Abstract

Background— Peak exercise oxygen consumption (VO 2 ) is widely used to select candidates for heart transplantation (HTx). However, the prognosis of patients with advanced heart failure and peak VO 2 of 10 to 14 mL/min per kg in the era of modern medical therapy for heart failure is not fully elucidated. B-type natriuretic peptide (BNP) is a useful prognostic marker in patients with heart failure. Methods and Results— A total of 424 patients undergoing HTx evaluation were classified according to peak VO 2 during cardiopulmonary exercise testing (>14, 10–14, and <10 mL/min per kg). Survival after cardiopulmonary exercise testing without HTx or ventricular assist device (VAD) support was compared with survival of 743 de novo HTx recipients. Multivariable analysis revealed that high BNP and low peak VO 2 were independently associated with death, HTx, or VAD requirements (hazard ratio, 3.5 and 0.6; 95% CI, 1.24–9.23 and 0.03–0.71; P =0.02 and <0.0001, respectively). VAD-free or HTx-free survival of patients with peak VO 2 10 to 14 mL/min per kg was identical to post-HTx survival. When patients with peak VO 2 10 to 14 mL/min per kg were dichotomized by a cutoff value of BNP of 506 pg/mL, those with BNP<506 pg/mL was equivalent to post-HTx survival (1 year: 90.8% versus 87.2%; P =0.61), whereas those with BNP≥506 showed worse VAD-free or HTx-free survival (1 year: 79.7%; P <0.001 versus post-HTx). Patients with peak VO 2 <10 mL/min per kg showed worse survival compared with post-HTx survival, and there was a survival difference between those with BNP≥506 and <506 pg/mL (1 year: 77.2% versus 56.1%; P =0.01). Conclusions— Patients with peak VO 2 10 to 14 mL/min per kg and low BNP levels have a VAD-free or HTx-free survival similar to post-HTx survival in heart recipients, whereas high BNP levels indicate worse outcome in this group of patients.

Status 2 Patients Had Poor Prognosis Without Mechanical Circulatory Support

“…Consistent with this, Kato et al reported that patients with peak V O2 10-14 ml · min −1 · kg −1 had a worse prognosis when they had plasma BNP ≥506 pg/ml. 26 All 10 deceased patients died due to acute deterioration of hemodynamics or fatal ventricu-…”

Aerobic exercise effect on prognostic markers for systolic heart failure patients: a systematic review and meta-analysis

“…Recently, a number of variables have been assessed for their diagnostic and prognostic capabilities, with hopes they will portend clinically valuable information [7][8][9][10][11][12][13][14][15]. Moreover, there has been a growing awareness of the additional benefit of applying multivariate scores to evaluate HF patients [14,16].…”

Novel Scoring System Using Cardiopulmonary Exercise Testing Predicts Prognosis in Heart Failure Patients Receiving Guideline-Directed Medical Therapy

“…25 Recent studies found that PV O2 maintained its prognostic value irrespective of β-blockade, although the optimal threshold might require a downward adjustment. 1,11, 26 We found that PV O2 still maintained its prognostic value but at a lower threshold, probably because of the somewhat decreased exercise tolerance from β-blocker treatment.…”

“…The International Society of Heart and Lung Transplantation recently stated that PV O2 12 ml · min -1 · kg -1 was the threshold for considering HTx under β-blocker treatment, 30 considering the recently accumulated evidence in the era of β-blockade. 11, 26 In contrast, PV O2 14 ml · min -1 · kg -1 is practically considered Recently, chronotropic incompetence, which is defined as insufficient exercise-induced HR response as well as lesselevated blood pressure, 28 was demonstrated to be an independent prognostic marker of cardiovascular death irrespective of β-blockade. 14 The mechanism was attributed to reduced myocardial sensitivity to sympathetic modulation, together with β-receptor downregulation, which indicated progression of HF.…”