title: Sex Profile and Risk Assessment With Cardiopulmonary Exercise Testing in Heart Failure: Propensity Score Matching for Sex Selection Bias.
abstract: In heart failure (HF), women show better survival despite a comparatively low peak oxygen consumption (V˙o2): this raises doubt about the accuracy of risk assessment by cardiopulmonary exercise testing (CPET) in women. Accordingly, we aimed to check (1) whether the predictive role of well-known CPET risk indexes, ie, peak V˙o2 and ventilatory response (V˙e/V˙co2 slope), is sex independent and (2) if sex-related characteristics that impact outcome in HF should be considered as associations that may confound the effect of sex on survival.
  
  
  
  The study population consisted of 2985 patients with HF, 498 (17%) of whom were women, from the multicentre Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI): the end point was cardiovascular death within a 3-year period.
  
  
  
  During the follow-up, 305 (12%) men and 39 (8%) women (P = 0.005) died, and female sex was linked to better survival on univariate analysis (P = 0.008) and independent of peak V˙o2 and V˙e/V˙co2 slope on multivariate analysis. According to propensity score matching for female sex to exclude a sex selection bias and sample discrepancy, 498 men were selected: the standardized percentage bias ranged from 20.8 (P < 0.0001) to 3.3 (P = 0.667). After clinical profile harmonizing, female sex was predictive of HF at univariate analysis.
  
  
  
  The low peak V˙o2 and female association with better outcome in HF might be counterfeit: the female prognostic advantage is lost when sex-specific differences are correctly taken into account with propensity score matching, suggesting that for an effective and efficient HF model, adjustment must be made for sex-related characteristics.
authors.affiliation: Department of Cardiac Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Veruno (NO), Italy.
authors.forename: Ugo
authors.initials: U
authors.lastname: Corrà
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy; Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, Washington, USA. Electronic address: piergiuseppe.agostoni@unimi.it.
authors.forename: Piergiuseppe
authors.initials: P
authors.lastname: Agostoni
authors.affiliation: Bioengineering Department, Salvatore Maugeri Foundation, IRCCS, Veruno (NO), Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Giordano
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Gaia
authors.initials: G
authors.lastname: Cattadori
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy; Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: Battaia
authors.affiliation: Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
authors.forename: Rocco
authors.initials: R
authors.lastname: La Gioia
authors.affiliation: Cardiology Department, Ospedale S. Spirito, Roma Lungotevere in Sassia 3, Roma, Italy.
authors.forename: Angela B
authors.initials: AB
authors.lastname: Scardovi
authors.affiliation: Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Emdin
authors.affiliation: Department of Cardiology, Department of Medical and Surgical Specialities, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.affiliation: Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Sinagra
authors.affiliation: Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Limongelli
authors.affiliation: Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Tradate, Dipartimento di Medicina e Riabilitazione Cardiorespiratoria Unità Operativa di Cardiologia Riabilitativa, Tradate, Italy.
authors.forename: Rosa
authors.initials: R
authors.lastname: Raimondo
authors.affiliation: Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, St. Camillo-Forlanini Hospital, Roma, Italy.
authors.forename: Federica
authors.initials: F
authors.lastname: Re
authors.affiliation: Department of Medical Sciences, Cardiology, IRCCS San Donato Hospital, University of Milan, San Donato Milanese, Milano, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Guazzi
authors.affiliation: Cardiologia Riabilitativa, Azienda Ospedali Riuniti, Ancona, Italy.
authors.forename: Romualdo
authors.initials: R
authors.lastname: Belardinelli
authors.affiliation: Department of Health Science, University of Milano Bicocca and Department of Cardiology, S. Luca Hospital, Istituto Auxologico Italiano, Milano, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Parati
authors.affiliation: Dipartimento di Medicina Clinica e Molecolare, "Sapienza" Università degli Studi di Roma, Roma, Italy.
authors.forename: Damiano
authors.initials: D
authors.lastname: Magrì
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy.
authors.forename: Cesare
authors.initials: C
authors.lastname: Fiorentini
authors.affiliation: Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
authors.forename: Mariantonietta
authors.initials: M
authors.lastname: Cicoira
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Salvioni
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Marta
authors.initials: M
authors.lastname: Giovannardi
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Veglia
authors.affiliation: Department of Cardiac Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Veruno (NO), Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Mezzani
authors.affiliation: Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Scrutinio
authors.affiliation: Centro Cardiovascolare, Azienda per i Servizi Sanitari n°1, Trieste, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Di Lenarda
authors.affiliation: Cardiology Department, Ospedale S. Spirito, Roma Lungotevere in Sassia 3, Roma, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Ricci
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Apostolo
authors.affiliation: Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli, Italy.
authors.forename: Anna Maria
authors.initials: AM
authors.lastname: Iorio
authors.affiliation: Department of Advanced Biomedical Sciences, University of Naples Federico II University, Naples, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Paolillo
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Palermo
authors.affiliation: Cardiology Center of Monzino, IRCCS, Milan, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Contini
authors.affiliation: Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
authors.forename: Corrado
authors.initials: C
authors.lastname: Vassanelli
authors.affiliation: Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy; Scuola Superiore S. Anna, Pisa, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Passino
authors.affiliation: Department of Cardiac Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Veruno (NO), Italy.
authors.forename: Pantaleo
authors.initials: P
authors.lastname: Giannuzzi
authors.affiliation: UOC Cardiologia, G da Saliceto Hospital, Piacenza, Italy.
authors.forename: Massimo F
authors.initials: MF
authors.lastname: Piepoli
mesh_terms: D000368:Aged; D015992:Body Mass Index; D016208:Databases, Factual; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality*; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption; D057216:Propensity Score; D018570:Risk Assessment; D012307:Risk Factors; D015983:Selection Bias; D016277:Ventricular Function, Left