title: Echocardiography of Right Ventriculoarterial Coupling Combined With Cardiopulmonary Exercise Testing to Predict Outcome in Heart Failure.
abstract: BACKGROUND
  Pulmonary hypertension, which is related to right ventricular (RV) failure, indicates a poor prognosis in heart failure (HF). Increased ventilatory response and exercise oscillatory ventilation (EOV) also have a negative impact. We hypothesized that the severity classification of HF and risk prediction could be improved by combining functional capacity with cardiopulmonary exercise testing (CPET) and RV-pulmonary circulation coupling, as evaluated by the tricuspid annular plane systolic excursion (TAPSE)-pulmonary artery systolic pressure (PASP) relationship.
  
  
  METHODS
  Four hundred fifty-nine patients with HF were assessed with Doppler echocardiography and CPET and were tracked for outcome. The subjects were followed for major cardiac events (cardiac mortality, left ventricular assist device implant, or heart transplant). Cox regression and Kaplan-Meier analyses were performed with TAPSE and PASP as individual measures that were then combined into a ratio form.
  
  
  RESULTS
  The TAPSE/PASP ratio (TAPSE/PASP) was the strongest predictor, whereas the New York Heart Association classification and EOV added predictive value. A four-quadrant group prediction risk was created based on TAPSE (< 16 mm or ≥ 16 mm) vs PASP (< 40 mm Hg or ≥ 40 mm Hg) thresholds and the CPET variables distribution as follows: group A (TAPSE > 16 mm and PASP < 40 mm Hg) presented the lowest risk (hazard ratio, 0.17) and best ventilation; group B exhibited a low risk (hazard ratio, 0.88) with depressed TAPSE (< 16 mm) and normal PASP, a preserved peak oxygen consumption (V.o2), but high ventilation. Group C had an increased risk (hazard ratio, 1.3; TAPSE ≥ 16 mm, PASP ≥ 40 mm Hg), a reduced peak V.o2, and a high EOV prevalence. Group D had the highest risk (hazard ratio, 5.6), the worse RV-pulmonary pressure coupling (TAPSE < 16 and PASP ≥ 40 mm Hg), the lowest peak V.o2, and the highest EOV rate.
  
  
  CONCLUSIONS
  TAPSE/PASP, combined with exercise ventilation, provides relevant clinical and prognostic insights into HF. A low TAPSE/PASP with EOV identifies patients at a particularly high risk of cardiac events.
authors: Heart Failure Unit, University of Milano, IRCCS Policlinico San Donato, Milan, Italy. Electronic address: marco.guazzi@unimi.it.
authors: Marco
authors: M
authors: Guazzi
authors: Department of Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium.
authors: Robert
authors: R
authors: Naeije
authors: Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL.
authors: Ross
authors: R
authors: Arena
authors: Fondazione "Salvatore Maugeri", IRCCS, Veruno, Italy.
authors: Ugo
authors: U
authors: Corrà
authors: Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, University Hospital, Pavia, Italy.
authors: Stefano
authors: S
authors: Ghio
authors: Cardiovascular Medicine Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors: Paul
authors: P
authors: Forfia
authors: Department of Biomedical and Surgical Sciences, Cardiology Section, University of Verona, Verona, Italy.
authors: Andrea
authors: A
authors: Rossi
authors: Department of Physical Therapy, Leonard M. Miller School of Medicine, University of Miami, Miami, FL; Department of Physical Therapy, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
authors: Lawrence P
authors: LP
authors: Cahalin
authors: Heart Failure Unit, University of Milano, IRCCS Policlinico San Donato, Milan, Italy.
authors: Francesco
authors: F
authors: Bandera
authors: Fondazione "Salvatore Maugeri", IRCCS, Veruno, Italy.
authors: Pierluigi
authors: P
authors: Temporelli
mesh_terms: D000368:Aged; D015150:Echocardiography, Doppler; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D011651:Pulmonary Artery / Q000502:physiology; D012720:Severity of Illness Index; D016019:Survival Analysis; D018497:Ventricular Dysfunction, Right / Q000150:complications / Q000175:diagnosis* / Q000401:mortality