Does Exercise Ventilatory Inefficiency Predict Poor Outcome in Heart Failure Patients With COPD?

• Published in: Journal of cardiopulmonary rehabilitation and prevention Vol. 36; no. 6; pp. 454 - 459
• Main Authors: Alencar, Maria Clara, Arbex, Flavio F, Souza, Aline, Mazzuco, Adriana, Sperandio, Priscila A, Rocha, Alcides, Hirai, Daniel M, Mancuso, Frederico, Berton, Danilo C, Borghi-Silva, Audrey, Almeida, Dirceu, OʼDonnel, Denis E, Neder, J Alberto
• Format: Journal Article
• Language: English
• Published: United States Copyright Wolters Kluwer Health, Inc. All rights reserved 01-11-2016
• Subjects: Aged; Exercise Tolerance - physiology; Follow-Up Studies; Heart Failure - complications; Heart Failure - physiopathology; Heart Failure - therapy; Humans; Lung - physiopathology; Male; Patient Outcome Assessment; Prospective Studies; Pulmonary Disease, Chronic Obstructive - complications; Pulmonary Disease, Chronic Obstructive - physiopathology; Pulmonary Disease, Chronic Obstructive - therapy; Pulmonary Ventilation - physiology; Respiratory Function Tests; Severity of Illness Index
• ISSN: 1932-7501; 1932-751X
• DOI: 10.1097/HCR.0000000000000212

PURPOSE:To investigate whether the opposite effects of heart failure (HF) and chronic obstructive pulmonary disease (COPD) on exercise ventilatory inefficiency (minute ventilation [(Equation is included in full-text article.)E]-carbon dioxide output [(Equation is included in full-text article.)CO2] relationship) would negatively impact its prognostic relevance.
METHODS:After treatment optimization and an incremental cardiopulmonary exercise test, 30 male patients with HF-COPD (forced expiratory volume in 1 second [FEV1] = 57% ± 17% predicted, ejection fraction = 35% ± 6%) were prospectively followed up during 412 ± 261 days for major cardiac events.
RESULTS:Fourteen patients (46%) had a negative outcome. Patients who had an event had lower echocardiographically determined right ventricular fractional area change (RVFAC), greater ventilatory inefficiency (higher (Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2 nadir), and lower end-tidal CO2 (PETCO2) (all P < .05). Multivariate Cox models revealed that (Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2 nadir >36, ΔPETCO2(PEAK-REST)≥2 mm Hg, and PETCO2PEAK≤33 mm Hg added prognostic value to RVFAC≤45%. Kaplan-Meyer analyses showed that although 18% of patients with RVFAC>45% had a major cardiac event after 1 year, no patient with RVFAC>45% and (Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2 nadir ≤36 (or PETCO2PEAK>33 mm Hg) had a negative event. Conversely, although 69% of patients with RVFAC≤45% had a major cardiac event after 1 year, all patients with RVFAC≤45% and ΔPETCO2(PEAK-REST)≥2 mm Hg had a negative event.
CONCLUSION:Ventilatory inefficiency remains a powerful prognostic marker in HF despite the presence of mechanical ventilatory constraints induced by COPD. If these preliminary findings are confirmed in larger studies, optimal thresholds for outcome prediction are likely greater than those traditionally recommended for HF patients without COPD.