Ventricular arrhythmias not meeting criteria for terminating cardiopulmonary exercise testing stratify prognosis and disease severity in heart failure of preserved, midrange, and reduced ejection fraction

Dejana Popovic; Ross Arena; Djordje Jakovljevic; Arsen Ristic; Marco Guazzi

doi:10.1002/clc.23367

Ventricular arrhythmias not meeting criteria for terminating cardiopulmonary exercise testing stratify prognosis and disease severity in heart failure of preserved, midrange, and reduced ejection fraction

Dejana Popovic, Ross Arena, Djordje Jakovljevic, Arsen Ristic, Marco Guazzi

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Abstract

Background: Continued high mortality in heart failure patients indicates the need for additional methods of risk stratification and phenotyping. Hypothesis: We hypothesized that ventricular arrhythmias that do not meet test-termination criteria (non-terminating ventricular arrhythmias [NTVA]) during cardiopulmonary exercise testing (CPET) may help in phenotyping disease severity and prognosis in heart failure with reduced (HFrEF) and midrange (HFmrEF)/preserved (HFpEF) left ventricular ejection fraction (LVEF). Methods: About 319 patients with heart failure (199 HFrEF; 80 HFmrEF; 41 HFpEF) underwent CPET. Tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were measured by echocardiography. B-type natriuretic peptide (BNP) at rest and peak exercise was also determined. The patients were tracked for primary (cardiac death) and secondary composite outcomes (all-cause death, heart transplantation/left ventricular assist device implantation, hospitalization for cardiac reasons). Results: Forty-seven (15%) of the patients demonstrated NTVA during CPET, regardless of coronary artery disease prevalence. Patients without arrhythmias had a significantly higher LVEF (P <.05), TAPSE/PASP ratio (P <.001), peak oxygen consumption (P <.01), lower resting and peak BNP (P <.001), and the minute ventilation/carbon dioxide production slope (P <.001) compared to those with NTVA. Seventy-one patients died during the tracking period, 54 for cardiac reasons. NTVA during CPET was a significant predictor of primary and secondary outcomes in the total heart failure cohort (HR: 5.3, 3.7; 95% CI: 3.1-9.1, 2.4-5.5; P <.001, respectively), as well as in subgroups categorized according to reduced and middle-range/preserved LVEF (P <.001). Conclusion: Exercise-induced ventricular arrhythmias that do not reach test-termination criteria are nonetheless indicative of an advanced disease severity phenotype and worse prognosis.

Original language	English
Pages (from-to)	698-705
Number of pages	8
Journal	Clinical Cardiology
Volume	43
Issue number	7
Early online date	9 Apr 2020
DOIs	https://doi.org/10.1002/clc.23367
Publication status	Published - 1 Jul 2020
Externally published	Yes

Bibliographical note

© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Funder

European Horizon 2020 Research and Innovation Programme under grant agreement No 777204 and Monzino Foundation.

Funding

Funders	Funder number
European Horizon 2020	777204
Fondazione Antonio Carlo Monzino

Keywords

HFmrEF
HFpEF
HFrEF
cardiopulmonary exercise testing
prognosis

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

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Ventricular arrhythmias not meeting criteria for terminating cardiopulmonary exercise testing stratify prognosis and disease severity in heart failure of preserved, midrange, and reduced ejection fraction. / Popovic, Dejana; Arena, Ross; Jakovljevic, Djordje et al.
In: Clinical Cardiology, Vol. 43, No. 7, 01.07.2020, p. 698-705.

Research output: Contribution to journal › Article › peer-review

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abstract = "Background: Continued high mortality in heart failure patients indicates the need for additional methods of risk stratification and phenotyping. Hypothesis: We hypothesized that ventricular arrhythmias that do not meet test-termination criteria (non-terminating ventricular arrhythmias [NTVA]) during cardiopulmonary exercise testing (CPET) may help in phenotyping disease severity and prognosis in heart failure with reduced (HFrEF) and midrange (HFmrEF)/preserved (HFpEF) left ventricular ejection fraction (LVEF). Methods: About 319 patients with heart failure (199 HFrEF; 80 HFmrEF; 41 HFpEF) underwent CPET. Tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were measured by echocardiography. B-type natriuretic peptide (BNP) at rest and peak exercise was also determined. The patients were tracked for primary (cardiac death) and secondary composite outcomes (all-cause death, heart transplantation/left ventricular assist device implantation, hospitalization for cardiac reasons). Results: Forty-seven (15%) of the patients demonstrated NTVA during CPET, regardless of coronary artery disease prevalence. Patients without arrhythmias had a significantly higher LVEF (P <.05), TAPSE/PASP ratio (P <.001), peak oxygen consumption (P <.01), lower resting and peak BNP (P <.001), and the minute ventilation/carbon dioxide production slope (P <.001) compared to those with NTVA. Seventy-one patients died during the tracking period, 54 for cardiac reasons. NTVA during CPET was a significant predictor of primary and secondary outcomes in the total heart failure cohort (HR: 5.3, 3.7; 95% CI: 3.1-9.1, 2.4-5.5; P <.001, respectively), as well as in subgroups categorized according to reduced and middle-range/preserved LVEF (P <.001). Conclusion: Exercise-induced ventricular arrhythmias that do not reach test-termination criteria are nonetheless indicative of an advanced disease severity phenotype and worse prognosis.",

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T1 - Ventricular arrhythmias not meeting criteria for terminating cardiopulmonary exercise testing stratify prognosis and disease severity in heart failure of preserved, midrange, and reduced ejection fraction

AU - Popovic, Dejana

AU - Arena, Ross

AU - Jakovljevic, Djordje

AU - Ristic, Arsen

AU - Guazzi, Marco

N1 - © 2020 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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N2 - Background: Continued high mortality in heart failure patients indicates the need for additional methods of risk stratification and phenotyping. Hypothesis: We hypothesized that ventricular arrhythmias that do not meet test-termination criteria (non-terminating ventricular arrhythmias [NTVA]) during cardiopulmonary exercise testing (CPET) may help in phenotyping disease severity and prognosis in heart failure with reduced (HFrEF) and midrange (HFmrEF)/preserved (HFpEF) left ventricular ejection fraction (LVEF). Methods: About 319 patients with heart failure (199 HFrEF; 80 HFmrEF; 41 HFpEF) underwent CPET. Tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were measured by echocardiography. B-type natriuretic peptide (BNP) at rest and peak exercise was also determined. The patients were tracked for primary (cardiac death) and secondary composite outcomes (all-cause death, heart transplantation/left ventricular assist device implantation, hospitalization for cardiac reasons). Results: Forty-seven (15%) of the patients demonstrated NTVA during CPET, regardless of coronary artery disease prevalence. Patients without arrhythmias had a significantly higher LVEF (P <.05), TAPSE/PASP ratio (P <.001), peak oxygen consumption (P <.01), lower resting and peak BNP (P <.001), and the minute ventilation/carbon dioxide production slope (P <.001) compared to those with NTVA. Seventy-one patients died during the tracking period, 54 for cardiac reasons. NTVA during CPET was a significant predictor of primary and secondary outcomes in the total heart failure cohort (HR: 5.3, 3.7; 95% CI: 3.1-9.1, 2.4-5.5; P <.001, respectively), as well as in subgroups categorized according to reduced and middle-range/preserved LVEF (P <.001). Conclusion: Exercise-induced ventricular arrhythmias that do not reach test-termination criteria are nonetheless indicative of an advanced disease severity phenotype and worse prognosis.

AB - Background: Continued high mortality in heart failure patients indicates the need for additional methods of risk stratification and phenotyping. Hypothesis: We hypothesized that ventricular arrhythmias that do not meet test-termination criteria (non-terminating ventricular arrhythmias [NTVA]) during cardiopulmonary exercise testing (CPET) may help in phenotyping disease severity and prognosis in heart failure with reduced (HFrEF) and midrange (HFmrEF)/preserved (HFpEF) left ventricular ejection fraction (LVEF). Methods: About 319 patients with heart failure (199 HFrEF; 80 HFmrEF; 41 HFpEF) underwent CPET. Tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were measured by echocardiography. B-type natriuretic peptide (BNP) at rest and peak exercise was also determined. The patients were tracked for primary (cardiac death) and secondary composite outcomes (all-cause death, heart transplantation/left ventricular assist device implantation, hospitalization for cardiac reasons). Results: Forty-seven (15%) of the patients demonstrated NTVA during CPET, regardless of coronary artery disease prevalence. Patients without arrhythmias had a significantly higher LVEF (P <.05), TAPSE/PASP ratio (P <.001), peak oxygen consumption (P <.01), lower resting and peak BNP (P <.001), and the minute ventilation/carbon dioxide production slope (P <.001) compared to those with NTVA. Seventy-one patients died during the tracking period, 54 for cardiac reasons. NTVA during CPET was a significant predictor of primary and secondary outcomes in the total heart failure cohort (HR: 5.3, 3.7; 95% CI: 3.1-9.1, 2.4-5.5; P <.001, respectively), as well as in subgroups categorized according to reduced and middle-range/preserved LVEF (P <.001). Conclusion: Exercise-induced ventricular arrhythmias that do not reach test-termination criteria are nonetheless indicative of an advanced disease severity phenotype and worse prognosis.

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Ventricular arrhythmias not meeting criteria for terminating cardiopulmonary exercise testing stratify prognosis and disease severity in heart failure of preserved, midrange, and reduced ejection fraction

Abstract

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