Validation of peak exercise oxygen consumption and the Heart Failure Survival Score for serial risk stratification in advanced heart failure

doi:10.1016/j.amjcard.2004.11.024

The American Journal of Cardiology

Volume 95, Issue 6, 15 March 2005, Pages 734-741

https://doi.org/10.1016/j.amjcard.2004.11.024 Get rights and content

The Heart Failure Survival Score (HFSS) and peak exercise oxygen consumption (Vo₂) accurately assess mortality in ambulatory patients who have advanced heart failure and are referred for initial cardiac transplant evaluation. We investigated the prognostic value of the HFSS and peak Vo₂ when applied serially to these patients. This study included 227 adults (mean age ± SD 52 ± 10 years old) who presented for reevaluation >60 days after initial evaluation (352 ± 238 days). The HFSS was determined from mean arterial blood pressure, heart rate, left ventricular ejection fraction, serum sodium, peak Vo₂, heart failure etiology, and width of QRS complex. Survival without reevaluation, United Network of Organ Sharing 1 transplant, or left ventricular assist device was determined by the Kaplan-Meier method with censoring at United Network of Organ Sharing 2 transplant. Survival differed by HFSS stratum (p <0.001) and by peak Vo₂ stratum (p <0.001). Patients whose HFSS or peak Vo₂ deteriorated from low risk to medium or high risk had lower survival rates than did patients whose values remained at low risk (p <0.01 and p <0.001, respectively). Patients who started at medium or high risk and improved to low risk tended to have higher survival rates than those who remained medium or high risk (p = 0.06 and p <0.16, respectively). Patients who improved to low risk had a 1-year survival rate of 72% for HFSS and peak Vo₂. However, patients who improved to low risk and were treated with β blockers had a 1-year survival rate (89% for HFSS and 83% for peak Vo₂) comparable to that after transplant (84%). Peak Vo₂ and the HFSS can be successfully used for serial evaluation of mortality risk in ambulatory patients who have advanced heart failure.

Section snippets

Subjects and testing

The study sample included 227 adults ≤70 years old (176 men and 51 women, mean age ± SD at reevaluation 52 ± 10 years old, range 21 to 70) who presented for heart transplant reevaluation >60 days after an initial evaluation (352 ± 238 days; Table 1 and Figure 1). Initial evaluation occurred from 1992 to 1999, and reevaluation occurred from 1993 to 2004. All patients were from the Columbia-Presbyterian Medical Center (New York, New York). The most common indication for reevaluation was routine

Clinical characteristics

Patient characteristics at the time of initial and repeat evaluations are presented in Table 1 and Figure 1. Compared with values obtained at the initial evaluation, peak Vo₂ and the HFSS were slightly higher at reevaluation but the difference was significant only for the HFSS.

Outcomes

Patients were followed for 826 ± 766 days from reevaluation, with no losses to follow-up. Outcome events occurred in 141 of 227 patients: 64 patients died before transplant, 11 received a left ventricular assist device,

Discussion

Assessment of the continued appropriateness of using serial peak Vo₂ to determine candidacy for transplantation is standard practice in most North American transplant centers.⁴ Transplant physicians have assumed the validity of this approach with limited supporting information. The present results demonstrate the value of serial risk stratification using the HFSS or peak Vo₂. Event-free survival rates significantly differed by HFSS and peak Vo₂ at assessments performed after initial

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The predictive value of peak V̇O2 and percent-predicted peak V̇O2 in HFrEF patients has been widely demonstrated and prospectively validated.4, 10, 12-17 Different studies have shown an incremental value of peak V̇O2.10, 17, 18 Peak V̇O2 and percent-predicted peak V̇O2 according to the Wasserman/Hansen reference value equation19 added prognostic value when included in a multivariate Cox regression analysis with standard risk variables including NYHA class and left ventricular ejection fraction.17
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Heart failureValidation of peak exercise oxygen consumption and the Heart Failure Survival Score for serial risk stratification in advanced heart failure

Section snippets

Subjects and testing

Clinical characteristics

Outcomes

Discussion

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure

Circulation

Heart failure
Validation of peak exercise oxygen consumption and the Heart Failure Survival Score for serial risk stratification in advanced heart failure