Multiparametric risk stratification in patients with mild to moderate chronic heart failure.
BACKGROUND
Whether brain natriuretic peptide (BNP) combined with cardiopulmonary exercise test (CPx) and echocardiographic findings improves prognostic stratification in mild-to-moderate systolic heart failure (HF) is unclear.


RESULTS
A total of 244 consecutive stable outpatients, median age of 71 (62-76) years, with New York Heart Association (NYHA) Class I-III HF and left ventricular ejection fraction (LVEF) < 45% underwent BNP measurement, Doppler echocardiography, and a maximal CPx. Median BNP was 166 (70-403) pg/mL, median LVEF 35% (28%-40%). A restrictive filling pattern (RFP) was present in 44 patients (18%). At CPx, peak oxygen uptake was 12 (9.7, 14.4) mL/kg/min and an enhanced ventilatory response to exercise (EVR, slope of the ventilation to CO2 production ratio, > or = 35) was found in 90 patients (37%) During 18 (9-37) follow-up months, 80 patients died or were admitted for worsening HF (33%). In addition to simple bedside clinical variables (NYHA Class III, creatinine clearance, hemoglobin), BNP levels were predictive of outcome (HR 1.35 [1.12-1.63]). However, both RFP (HR 3.36 [2.09-5.41]) and a steeper minute ventilation-carbon dioxide output slope (HR 1.50 [1.19-1.88]) outperformed BNP as prognostic markers. Patients with both RFP and EVR had a 7.30 (95% CI 4.02-13.25) HR for death or HF-admission versus subjects with neither predictor.


CONCLUSIONS
This study highlights the importance of a multiparametric approach for optimal risk stratification in the elderly with mild-to-moderate HF. Patients at high risk should undergo closer follow-up and be carefully evaluated for different therapeutic options, including nonpharmacologic treatment.
Department of Cardiology, S. Spirito Hospital, Rome, Italy.
Angela Beatrice
AB
Scardovi
Renata
R
De Maria
Claudio
C
Coletta
Nadia
N
Aspromonte
Silvia
S
Perna
Giuseppe
G
Cacciatore
Marina
M
Parolini
Roberto
R
Ricci
Vincenzo
V
Ceci
D000368:Aged; D015415:Biomarkers / Q000097:blood; D001944:Breath Tests; D002245:Carbon Dioxide / Q000378:metabolism; D018450:Disease Progression; D015150:Echocardiography, Doppler; D005080:Exercise Test; D005260:Female; D015200:Fluoroimmunoassay; D005500:Follow-Up Studies; D006333:Heart Failure / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010045:Outpatients; D010100:Oxygen / Q000378:metabolism; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology*
D015415:Biomarkers; D020097:Natriuretic Peptide, Brain; D002245:Carbon Dioxide; D010100:Oxygen