Multiparametric Risk Stratification in Patients With Mild to Moderate Chronic Heart Failure

Scardovi, Angela Beatrice; de Maria, Renata; Coletta, Claudio; Aspromonte, Nadia; Perna, Silvia; Cacciatore, Giuseppe; Parolini, Marina; Ricci, Roberto; Ceci, Vincenzo

doi:10.1016/j.cardfail.2007.03.003

« Previous Next »Journal of Cardiac Failure
Volume 13, Issue 6 , Pages 445-451, August 2007

Multiparametric Risk Stratification in Patients With Mild to Moderate Chronic Heart Failure

Angela Beatrice Scardovi, MD
- From the Department of Cardiology, S. Spirito Hospital, Rome, Italy
- Reprint requests: Dott. Angela Beatrice Scardovi, Cardiology Department, S. Spirito Hospital, Lungotevere in Sassia 1, 00143 Rome, Italy.
Renata de Maria, MD
- CNR Clinical Phisiology Institute, Milan, Italy
Claudio Coletta, MD
- From the Department of Cardiology, S. Spirito Hospital, Rome, Italy
Nadia Aspromonte, MD
- From the Department of Cardiology, S. Spirito Hospital, Rome, Italy
Silvia Perna, MD
- Department of Cardiology, S. Andrea Hospital, University of Medicine “La Sapienza”, Rome, Italy
Giuseppe Cacciatore, MD
- Department of Cardiology San Giovanni – Addolorata Hospital, Rome, Italy
Marina Parolini, MD
- CNR Clinical Phisiology Institute, Milan, Italy
Roberto Ricci, MD
- From the Department of Cardiology, S. Spirito Hospital, Rome, Italy
Vincenzo Ceci, MD
- From the Department of Cardiology, S. Spirito Hospital, Rome, Italy

Received 21 October 2006; received in revised form 5 February 2007; accepted 6 March 2007.

Rome, Italy; Milan, Italy

Abstract

Background

Whether brain natriuretic peptide (BNP) combined with cardiopulmonary exercise test (CPx) and echocardiographic findings improves prognostic stratification in mild-to-moderate systolic heart failure (HF) is unclear.

Methods and Results

A total of 244 consecutive stable outpatients, median age of 71 (62–76) years, with New York Heart Association (NYHA) Class I-III HF and left ventricular ejection fraction (LVEF) <45% underwent BNP measurement, Doppler echocardiography, and a maximal CPx. Median BNP was 166 (70–403) pg/mL, median LVEF 35% (28%–40%). A restrictive filling pattern (RFP) was present in 44 patients (18%). At CPx, peak oxygen uptake was 12 (9.7, 14.4) mL/kg/min and an enhanced ventilatory response to exercise (EVR, slope of the ventilation to CO₂ production ratio, ≥35) was found in 90 patients (37%) During 18 (9–37) follow-up months, 80 patients died or were admitted for worsening HF (33%). In addition to simple bedside clinical variables (NYHA Class III, creatinine clearance, hemoglobin), BNP levels were predictive of outcome (HR 1.35 [1.12–1.63]). However, both RFP (HR 3.36 [2.09–5.41]) and a steeper minute ventilation-carbon dioxide output slope (HR 1.50 [1.19–1.88]) outperformed BNP as prognostic markers. Patients with both RFP and EVR had a 7.30 (95% CI 4.02–13.25) HR for death or HF-admission versus subjects with neither predictor.

Conclusions

This study highlights the importance of a multiparametric approach for optimal risk stratification in the elderly with mild-to-moderate HF. Patients at high risk should undergo closer follow-up and be carefully evaluated for different therapeutic options, including nonpharmacologic treatment.

Key Words: Brain natriuretic peptide, heart failure, cardiopulmonary exercise test