CPX and Prognosis in Cardiovascular Disease

Transcription

1 CPX and Prognosis in Cardiovascular Disease Anselm K. Gitt, Piergiuseppe Agostoni Herzzentrum Ludwigshafen, Germany Instituto di Cardiologia Università di Milano, Milan, Italy Cardiopulmonary exercise testing (CPX): an introduction ESC Congress, Munich, Germany, August 25, 2012

2 Disclosure Declaration Declaration of Interest: Anselm K. Gitt: None Piergiuseppe Agostoni: None

3 Heart Failure in Clinical Practice - Facts U.S.A - Heart Failure Fact Sheet 2010

4 CPX in Cardiac Disease Determination of cardiopulmonary exercise capacity Differential diagnosis of exercise limitation Therapy control in heart failure Riskstratification in heart failure Decision for HTX

5 Cardiac Index - VO 2 Weber et al., Am. J. Cardiol., 1985

6 Weber-Classification Cardiopulmonary Exercise Capacity in Heart Failure Class Severity max. VO 2 [ml/kg/min] VO 2 AT [ml/kg/min] A mild to none > 20 > 14 B C mild to moderate moderate to severe D severe E very severe < 6 < 4 Weber et al., Am. J. Cardiol., 1985

7 ESC-Guidelines - Exercise Testing in CHF- Exercise tests only in stable heart failure Measured VO 2 better than estimated METs Individual exercise protocols (Ramp, Naughton) Work load increase by 1 MET 12.5% increase of increment (treadmill) watt increase (bicycle) Optimal test duration 8-12 min. Walking test for submaximal exercise Eur Heart J, 21, 2001: 37-45

8 ESC-Guidelines - Exercise Testing in CHF - Risk-Stratification Peak VO 2 > 14 ml/kg/min: same prognosis as HTX Increase of peak VO 2 by 2.0 ml/kg/min < 6 months 2 years survival 100% * No influence on prognosis ** V E /VCO 2 -Slope < 35: good" prognosis * Stevenson et al., JACC 1995, 25: Eur Heart J, 21, 2001: ** Gullestad et al., Am Heart J 1998, 135: 221-9

9 Physiology of Exercise Peripheral Circulation Pulmonary Circulation Parameter of cardiopulmonary exercise capacity Obesity Myopathy Deconditioning CAD Dilative CMP Hypert. HD Valvular D. Anemia Obstructive LD Restrictive LD Infiltrative LD Wasserman et al., 2012

10 Exercise Limitation Impaired Exercise Capacity (Peak VO 2 / VO 2 AT)

11 Peak VO 2 and LV-EF L V - E F ( % ) Correlation in Chronic Heart Failure L V - E F ( % ) V - H e F T I V - H e F T P e a k V O P e a 2 k ( Vm O l / k g 2 ( m l / k g / m i n ) Cohn et al., Circ. 87, Suppl. VI, 1993, VI 5 - VI 16

12 Y e a r l y M o r t a l i t y 1-Year-Mortality in CHF V - H e F T I V - H e F T I V - H e F T I I Y e a r l y M o r t a l i t y LV-EF and peak VO 2 V - H e F T I I L V - E F ( % ) P e a k V O 2 ( m l / k g / Cohn et al., Circ. 87, Suppl. VI, 1993, VI 5 - VI 16

13 Risk-Stratification in CHF Peak VO 2 Pea k VO 2 (m l/kg /m in) Peak VO 2 (%predmax) Survival (%) > < 1 0 * *p<0. 05 Event-free Survival (%) p< > 50% predmax < 50% predmax Mo nths Follow-up (Months) Mancini et al., Circulation, 1991 Stelken et al., JACC 27, 1996: 349

14 Population Changes over time Agostoni et al., Int. J. Cardiology, 2012

15 Survival rate by years Agostoni et al., Int. J. Cardiology, 2012

16 MECKI score Research group Agostoni et al., Int. J. Cardiology, 2012

17 Population Agostoni et al., Int. J. Cardiology, 2012

18 Multivariable analysis Agostoni et al., Int. J. Cardiology, 2012

19 Survival rate by peak VO 2 (VO 2 <8, 10<VO 2 <8, VO 2 >10) VO2 CAT Total Failed Censored Percent Censored VO2< <VO2< VO2> Total Agostoni et al., Int. J. Cardiology, 2012

20 Lung Function in CHF 190 pts with HF O = p<0.01 o o o o o o o o o Agostoni PG, et al. Eur Heart J 2006; 27:

21 Ventilation in CHF Minuteventilation versus VO 2 Wasserman et al., Circ 96, 1997:

22 Ventilation in CHF Tidal volume versus V E Wasserman et al., Circ 96, 1997:

23 Cardiac Limitation Perfusion-Ventilation- Mismatch Hyperventilation V E vs VCO 2 -Slope

24 Ventilatory Efficiency V E CHF: Slope 59.9* "Threshold": 35 Therapy Training Normal: Slope 21.5* VCO 2 *Metra et al., Am J Cardiol, 70: 622, 1992 Chua et al. JACC,29: , 1997 Kleber et al., Circulation 101: , 2000

25 Risk-Stratification in CHF Ventilatory Efficiency V E -vs-vco 2 -Slope Cumulative Survival Low V E /VCO 2 -Slope High V E /VCO 2 -Slope Cumulative Survival V E /VCO 2 -Slope <=130% V E /VCO 2 -Slope > 130% Days 540 Months 30 Chua et al., JACC,29: , 1997 Kleber et al., Circulation 101: , 2000

26 Peak VO 2 - Prognostic Value - 1 Survival 0,9 0,8 Peak VO 2 > 14ml/kg/min (n=126) p < ,7 0,6 Peak VO 2 < 14ml/kg/min (n=97) 0, Follow-up (Months) Gitt et al., Circulation 2002, 106:

27 VO 2 AT - Prognostic Value - 1 Survival VO 2 AT > 11ml/kg/min 0,9 0,8 (n=100) p < ,7 VO 2 AT < 11ml/kg/min (n=106) 0,6 0, Follow-up (Months) Gitt et al., Circulation 2002, 106:

28 Prognostic Value - Median Follow-up 644 Days - Peak VO2 <= 14ml/kg/min Peak VO2 <= 50% pred VE/VCO2-Slope > 34 VO2 AT < 11ml/kg/min Peak VO2+VO2 AT Peak VO2+VE/VCO2-Slope VO2 AT+VE/VCO2-Slope Lower Mortality 0, Higher Mortality Odds Ratio Gitt et al., Circulation 2002, 106:

29 Prognostic Value Early Mortality < 6 Months Peak VO2 <= 14ml/kg/min Peak VO2 <= 50% pred VE/VCO2-Slope > 34 VO2 AT < 11ml/kg/min Peak VO2 + VO2 AT Peak VO2+VE/VCO2-Slope VO2 AT+VE/VCO2-Slope Lower Mortality 0, Higher Mortality Odds Ratio Gitt et al., Circulation 2002, 106:

30 CPX and Prognosis of CVD Reproducible test to estimate prognosis Old parameter VO 2 max with limitations Newer parameter VO 2 AT and V E /VCO 2 -Slope Independent on patient motivation Combination of VO 2 AT and V E /VCO 2 -Slope Determined in one exercise test Identifies CHF patients at high risk