Enhanced ventilatory response to exercise in patients with chronic heart failure and preserved exercise tolerance: marker of abnormal cardiorespiratory reflex control and predictor of poor prognosis.
BACKGROUND
In patients with chronic heart failure (CHF) and preserved exercise tolerance, the value of cardiopulmonary exercise testing for risk stratification is not known. Elevated slope of ventilatory response to exercise (VE/VCO(2)) predicts poor prognosis in advanced CHF. Derangement of cardiopulmonary reflexes may trigger exercise hyperpnea. We assessed the relationship between cardiopulmonary reflexes and VE/VCO(2)and investigated the prognostic value of (VE/VCO(2)) in CHF patients with preserved exercise tolerance.


RESULTS
Among 344 consecutive CHF patients, we identified 123 with preserved exercise capacity, defined as a peak oxygen consumption (PEAK VO(2)) >/=18 mL. kg(-1). min(-1) (age 56 years; left ventricular ejection fraction 28%; peak VO(2) 23.5 mL. kg(-1). min(-1)). Hypoxic and hypercapnic chemosensitivity (n=38), heart rate variability (n=34), baroreflex sensitivity (n=20), and ergoreflex activity (n=20) were also assessed. We identified 40 patients (33%) with high VE/VCO(2) (ie, >34.0). During follow-up (49+/-22 months, >3 years in all survivors), 34 patients died (3-year survival 81%). High VE/VCO(2) (hazard ratio 4.3, P<0.0001) but not peak f1.gif" BORDER="0">O(2) (P=0.7) predicted mortality. In patients with high VE/VCO(2), 3-year survival was 57%, compared with 93% in patients with normal VE/VCO(2) P<0.0001). Patients with high VE/VCO(2) demonstrated impaired reflex control, as evidenced by augmented peripheral (P=0.01) and central (P=0.0006) chemosensitivity, depressed low-frequency component of heart rate variability (P<0.0001) and baroreflex sensitivity (P=0.03), and overactive ergoreceptors (P=0.003) compared with patients with normal VE/VCO(2).


CONCLUSIONS
In CHF patients with preserved exercise capacity, enhanced ventilatory response to exercise is a simple marker of a widespread derangement of cardiovascular reflex control; it predicts poor prognosis, which VO(2) does not.
Ponikowski
P
P
Cardiac Medicine Department, Imperial College, National Heart & Lung Institute, London, UK.
Francis
D P
DP
Piepoli
M F
MF
Davies
L C
LC
Chua
T P
TP
Davos
C H
CH
Florea
V
V
Banasiak
W
W
Poole-Wilson
P A
PA
Coats
A J
AJ
Anker
S D
SD
D002908:Chronic Disease; D005080:Exercise Test / Q000706:statistics & numerical data; D017079:Exercise Tolerance; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000503:physiopathology*; D006334:Heart Function Tests / Q000706:statistics & numerical data; D006801:Humans; D008875:Middle Aged; D015999:Multivariate Analysis; D010101:Oxygen Consumption; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D012129:Respiratory Function Tests / Q000706:statistics & numerical data*; D018570:Risk Assessment; D015996:Survival Rate; D014691:Ventilation / Q000706:statistics & numerical data*