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(Circulation. 2002;106:3079.)
© 2002 American Heart Association, Inc.

Clinical Investigation and Reports

Exercise Anaerobic Threshold and Ventilatory Efficiency Identify Heart Failure Patients for High Risk of Early Death

Anselm K. Gitt, MD; Karlman Wasserman, MD, PhD; Caroline Kilkowski, MD; Thomas Kleemann, MD; Andreas Kilkowski, MD; Matthias Bangert, MD; Steffen Schneider, PhD; Armin Schwarz, MD; Jochen Senges, MD, FESC

From Herzzentrum Ludwigshafen (A.K.G., C.K., T.K., A.K., M.B., S.S., A.S., J.S.), Department of Cardiology, Ludwigshafen, Germany; and Harbor–UCLA Medical Center (K.W.), Torrance, Calif.

Correspondence to Anselm K. Gitt, MD, Herzzentrum Ludwigshafen, Bremser Str 79, 67063 Ludwigshafen, Germany. E-mail gitta{at}klilu.de

Background— The maximal oxygen uptake (peak O₂) is used in risk stratification of patients with chronic heart failure (CHF). Peak O₂ might be lower than maximally possible if exercise is stopped early because of lack of patient motivation or premature cessation by the investigator. In contrast, the anaerobic threshold (O₂AT) and the ventilatory efficiency (E versus CO₂ slope) are less subject to these influences. Thus, we compared these parameters with peak O₂ in identifying patients with CHF at increased risk for death within 6 months after evaluation.

Methods and Results— We performed cardiopulmonary exercise tests with gas exchange measurements in 223 consecutive patients with CHF (114 coronary artery disease, 92 dilated cardiomyopathy, 17 others) at the Herzzentrum Ludwigshafen between 1995 and 1998. We measured peak O₂, O₂AT and E versus CO₂ slope. We selected peak O₂ of 14 mL/kg per minute, O₂AT of <11 mL/kg per minute, and E versus CO₂ slope of >34 as threshold values for high risk of death. The median follow-up time was 644 days. Patients with peak O₂ of 14 mL/kg per minute had a >3-fold-increased risk (OR=3.4; CI, 1.3 to 9.1), with O₂AT <11 mL/min per kg or E versus CO₂ slope >34 a 5-fold increased risk for early death (OR=5.3; CI, 1.5 to 19.0; OR=4.8; CI, 1.7 to 13.8, respectively). In patients with both O₂AT <11 mL/kg per minute and E versus CO₂ slope >34, the risk of early death was 10-fold higher (OR=9.6; CI, 2.1 to 44.7). After correction for age, sex, left ventricular ejection fraction, and New York Heart Association class in a multivariate analysis, the combination of O₂AT <11 mL/kg per minute and E versus CO₂ slope >34 was the best predictor of 6-month mortality (RR=5.1, P=0.001).

Conclusions— O₂AT of <11 mL/kg per minute and slope of E versus CO₂ >34, combined, better identified patients at high risk for early death from CHF than did peak O₂ and should therefore be considered when prioritizing patients for heart transplantation.

Key Words: heart failure • exercise • transplantation • ventilation • prognosis

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