title: Mechanisms of Effort Intolerance in Patients With Heart Failure and Borderline Ejection Fraction.
abstract: Combining echocardiography and cardiopulmonary stress testing allows noninvasive assessment of hemodynamics, and oxygen extraction (A-VO2difference). We evaluated mechanisms of effort intolerance in patients with heart failure with borderline (40% to 49%) left ventricular ejection fraction (EF) (HF and Borderline Ejection fraction). We included 89 consecutive patients with HF and Borderline Ejection fraction (n = 25; 63.6 ± 14 years, 64% men), control subjects (n = 22), patients with HF with preserved EF (n = 26; EF ≥50%), and patients with HF with reduced EF (n = 16; <40%). Various echo parameters (left ventricular volumes, EF, stroke volume, mitral regurgitation [MR] volume, e', right ventricle end-diastolic area, and right ventricle end-systolic area), and ventilatory or combined parameters (peak oxygen consumption [VO2] and A-VO2difference) were measured at 4 predefined activity stages. Effort-induced functional MR was frequent and more prevalent in HF and Borderline Ejection fraction than in all the other types of HF. In multivariable analysis heart rate response (p <0.0001), A-VO2difference (p = 0.02), stroke volume (p = 0.002), and right ventricle end-systolic area were the only independent predictors of exercise capacity in HF and Borderline Ejection fraction but peak EF was not. In HF and Borderline Ejection fraction exercise intolerance is predominantly due to chronotropic incompetence, peripheral factors, and limited stroke volume reserve, which are related to right ventricle dysfunction and functional MR but not to left ventricular ejection fraction. Combined testing can be helpful in determining mechanisms of exercise intolerance in HF and Borderline Ejection fraction.
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel. Electronic address: topilskyyan@gmail.com.
authors.forename: Yan
authors.initials: Y
authors.lastname: Topilsky
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Zach
authors.initials: Z
authors.lastname: Rozenbaum
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Shafik
authors.initials: S
authors.lastname: Khoury
authors.affiliation: Heart and Vascular Institute USA Einstein Medical Center, Philadelphia, Pennsylvania.
authors.forename: Gregg S
authors.initials: GS
authors.lastname: Pressman
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Yaniv
authors.initials: Y
authors.lastname: Gura
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Jack
authors.initials: J
authors.lastname: Sherez
authors.affiliation: Pulmonology Department, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Avi
authors.initials: A
authors.lastname: Man
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Jason
authors.initials: J
authors.lastname: Shimiaie
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Sanford
authors.initials: S
authors.lastname: Edwards
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Joshua
authors.initials: J
authors.lastname: Berookhim
authors.affiliation: Division of Cardiovascular Diseases Universite de Nantes, Philadelphia, Pennsylvania.
authors.forename: Thierry
authors.initials: T
authors.lastname: Le Tourneau
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Amir
authors.initials: A
authors.lastname: Halkin
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Simon
authors.initials: S
authors.lastname: Biner
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Gad
authors.initials: G
authors.lastname: Keren
authors.affiliation: Division of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Galit
authors.initials: G
authors.lastname: Aviram
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D004452:Echocardiography; D025401:Echocardiography, Stress; D005080:Exercise Test; D017079:Exercise Tolerance / Q000502:physiology*; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging / Q000503:physiopathology*; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption; D012189:Retrospective Studies; D013318:Stroke Volume; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000503:physiopathology*