Prognostic value of exercise testing

Paolo PalangeUniversità “La Sapienza” – Roma

paolo.palange@uniroma1.it

PG 12 Cardiopulmonary exercise testing and interpretation

Objectives

To discuss the role of exercise testing the prognostic evaluation of patients with chronic lung and heart diseases

Exercise variables/indexes that have high prognostic value in patients with chronic lung and heart diseases

Gibbons RJ, 2002

Duke Treadmill Score

N Engl J Med 2002

MET “Metabolic Equivalent Term”

1 MET = 3.5 mlO2/min/Kg (3.5x70=245 mlO2/min)

MET = speed x [0.1 + (inclination x 1.8)] + 3.5

3.5

Evaluating the severity/prognosis of patients with chronic pulmonary and

cardiac diseses

FEV1 (CF, COPD)DLco (ILD, PPH)PaO2, PaCO2 (COPD, CF, PPH)BMI (CF, COPD, PPH)Dyspnea (COPD, PF)EF, NYHA (CHF)

100100

8080

6060

4040

2020

00

11 33 44 55 6622

No CHFCHF I

CHF II

CHF III

CHF IV

Time, yrs

Su

rviv

al,

%S

urv

ival,

%Survival rate and NYHA classesSurvival rate and NYHA classes

FEV1 and prognosis in COPD

AJRCCM 2003; 167:544-549AJRCCM 2003; 167:544-549

*

* ATS severity of COPD

B, body mass index

O, obstruction (FEV1)

D, dyspnea (Borg scale) E, exercise (6’WT)

NEJM 2004; 350: 1005-12

The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary

Disease

Exercise limitation in lung diseases

V/Q mismatch Work of breathing VD/VT airflow elastic

PAO2 pH obstruction recoil

ventilatory ventilatory requirement capacity

(K. Wasserman,2004)COPD

Muscle Fatigue

ATPATP LactateLactate V’COV’CO22

Exercise intolerance

Factors that may influence exercise ventilatory response in COPD

1) ventilatory drive (↓pH, ↓pO2)

2) wasted ventilation (↑ VD/VT)

3) ↑ pulmonary vascular resistances

4) metabolic acidosis (↑ CO2 output)5) differences in muscle mass and fiber

types recruited during exercise6) differences in neurogenic afferent

from exercising limbs

Johnson BD, CHEST 1999; 116: 488-503Johnson BD, CHEST 1999; 116: 488-503

Exercise testing in the prognostic evaluation

Exercise variables/indexes that have a high

prognostic value in patients with chronic pulmonary and cardiac diseses

V’O2 peak (COPD, CF, PPH, CHF)V’O2 at LT (CHF)V’E/V’CO2 slope or at LT (CHF)Arterial O2 desaturation (ILD, CF)Dyspnea (COPD, PF)

6’WT distance (CHF, CF, COPD, PH)

Classification of Exercise capacity in patient with CHF

Peak V’O2 ATClass Impairment (mL/kg/min) (mL/kg/min)A None to mild > 20 >14

B Mild to moderate 16-20 11-14

C Moderate to severe 10-16 8-11

D Severe < 10 < 8

Weber et al. Circulation 1987Weber et al. Circulation 1987

Circulation 1991; 83:778-786

V’O2 peak and prognosis in CHF

Circulation 1991; 83:778-786

Time (months)

Peak V’O2 (ml/kg/min)

Kaplan-Meier life-table analysis for V’O2 max > 45% vs < 45% predicted

Kleber FX, Circulation 2000Kleber FX, Circulation 2000

Ventilatory demand in CHF

Kaplan-Meier life-table analysis for V’E/V’CO2 slope <130% vs >130%

predicted

Kleber FX, Circulation 2000Kleber FX, Circulation 2000

Gitt AK, Circulation 2002

Exercise Anaerobic Threshold and Ventilatory Efficiency Identify Heart Failure Patients for

High Risk of Early Death

Gitt AK, Circulation 2002

Exercise Anaerobic Threshold and Ventilatory Efficiency Identify Heart Failure Patients for

High Risk of Early Death

Criterion for Cardiac Transplantation

Category for peak V’O2

Transplant (mL/kg/min)

Accepted indication <10

Probable indication <14

Inadequate indication >15

Mudge et al. J Am Coll Cardiol 1993Mudge et al. J Am Coll Cardiol 1993

JACC 2004:787-93

Patient with Heart Failure

Maximize medical therapy

Heart Failure Survival Score

Medium

Beta-blockers tolerated

Assess Peak VO2 (ml/min/kg)

10-14<10 >14Evaluate for transplant Continue medical therapy

High risk Low riskEvaluate for transplant

Beta-blockers not tolerated

Continue medical therapyReassess in one year

Selection of Patients for Heart Transplantation in the Current Era of Heart Failure Therapy

JACC 2003:2175-81

Periodic Breathing During Incremental Exercise Predicts Mortality in Patients with Chronic Heart Failure Evaluated for Cardiac

Transplantation

In COPD, V’O2 peak predicts mortality independently of FEV1

Oga T, AJRCCM 2003Oga T, AJRCCM 2003

The prognostic value of exercise testing in patients with

CF

Nixon PA, NEJM 1992

100 90 80 70 60 50 40 30 20 10 0

1 2 3 4 5 6 7 8 Year

Su

rviv

al R

ate

(%

)

V’O2 peak < 58% pred. V’O2 peak 59-81% pred.V’O2 peak > 82% pred.

AJRCCM 2002; 165:1629

An Elevated Breathing Reserve Index at the Lactate Threshold is a predictor of Mortality

in Patients with Cystic Fibrosis awaiting Lung Transplantation

Circulation 2002; 106:319-324

Assessment of Survival in Patients with Primary Pulmonary Hypertension

(PPH):Importance of Cardiopulmonary Exercise

Testing

Eur Respir J, Jan 2007

Eur Respir Monograph 2007

Future Directions

“Endurance” protocols

Recovery

Combination of variables