All‐cause mortality predicted by peak oxygen uptake differs depending on spirometry pattern in patients with heart failure and reduced ejection fraction

Abstract

AimsIn patients with heart failure and reduced ejection fraction (HFrEF), it remains unclear how exacerbated impairments in peak exercise oxygen uptake (V O 2peak ) caused by coexistent obstructive or restrictive ventilatory defects affect mortality risk. We evaluated in patients with HFrEF, whether demonstrating either an obstructive or restrictive-patterned ventilatory defect on spirometry affects V O 2peak to yield all-cause mortality risk predicted by V O 2peak that is spirometry pattern specific. Methods and resultsWe retrospectively analysed resting spirometry and treadmill cardiopulmonary exercise testing data of patients with HFrEF (left ventricular ejection fraction ≤ 40%). The study sample (N = 329) was grouped by spirometry pattern: normal [Group 1: N = 101; forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) ≥ 0.70; FVC ≥ 80% predicted], restrictive without airflow obstruction (Group 2: N = 104; FEV 1 /FVC ≥ 0.70; FVC < 80% predicted), or obstructive (Group 3: N = 124; FEV 1 /FVC < 0.70). Patients were followed up to 1 year for the endpoint of all-cause mortality. V O 2peak was higher in Group 1 versus Groups 2 and 3 (13.4 ± 4.0 vs. 12.1 ± 3.7 and 12.2 ± 3.3 mL/kg/min, respectively; P = 0.014). Over the 1 year follow-up, n = 9, n = 16, and n = 12 deaths occurred in Groups 1-3, respectively, with corresponding crude survival rates of 88%, 81%, and 92%, respectively (log-rank; P = 0.352). V O 2peak was associated with all-cause mortality (crude hazard ratio = 0.77; P < 0.001). In multivariate analyses, a significant V O 2peak -by-spirometry group interaction yielded 1.99 (95% confidence interval, 1.14-3.46) and 2.43 (95% confidence interval, 1.44-4.11) higher mortality risk associated with V O 2peak in Group 2 versus Groups 1 and 3, respectively. Conclusions Demonstrating a restrictive pattern on spirometry yields the severest mortality risk associated with V O 2peak . Using spirometry to screen patients with HFrEF for ventilatory defects has a potential role in improving risk stratification based on V O 2peak .

Risk Stratification in Transthyretin Cardiac Amyloidosis: The Added Value of Lung Spirometry

“…In accordance with earlier studies, we thus confirmed that reduced pVO 2 and increased VEVCO 2 slope seem to be strongly and independently predictive of MACE in ATTR-CA patients [5][6][7]9,10]. In addition, we also found that the presence of a restrictive spirometry pattern was associated with increased MACE risk in ATTR-CA, consistent with other authors reporting that the presence of a restrictive ventilatory pattern is predictive of all-cause and cardiovascular mortality [11][12][13]. Indeed, spirometry parameters can predict outcomes and improve risk stratification based on pVO 2 in chronic heart failure patients with reduced ejection fraction [13].…”

“…While being a safe and useful diagnostic tool in many pathological conditions, CPET requires sophisticated and expensive devices, as well as specialized medical staff, which may limit its clinical use, notably in low-resource settings. In contrast, spirometry is a simple method to evaluate pulmonary function, which is successfully used to stratify heart failure severity [11][12][13]. The use of spirometry to screen for ventilatory defects in patients with heart failure is known to improve risk stratification based on pVO 2 [13].…”

“…In contrast, spirometry is a simple method to evaluate pulmonary function, which is successfully used to stratify heart failure severity [11][12][13]. The use of spirometry to screen for ventilatory defects in patients with heart failure is known to improve risk stratification based on pVO 2 [13].…”

Patient selection for heart transplant: balancing risk

“…The direct prognostic utility of spirometry is less clear among waitlisted patients [49]. However, severe intrinsic pulmonary disease with forced expiratory volume in 1 second <40% of predicted, forced vital capacity <50% of predicted, or diffusion capacity of carbon dioxide <40% are considered contraindications to heart transplantation [3,50]. The referral of such patients for simultaneous heart-lung combined transplantation at select centers may be beneficial.…”

Alveolar Volume Impairment Affects the Prognostic Value of Peak Exercise Oxygen Uptake in Heart Failure With Reduced Ejection Fraction

“…More recent studies demonstrate that the V A measurement is a correlate of peak exercise oxygen uptake (V˙ o 2peak ),6 and the association between V˙ o 2peak and mortality risk is directly impacted by spirometry phenotype 7. Demonstrating that there is prognostic value associated with the V A measurement could further improve the clinical interpretation of V˙ o 2peak .…”