Published Online
on November 18, 2002

A more recent version of this article appeared on December 10, 2002

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Submitted on July 24, 2002
Revised on September 24, 2002
Accepted on September 24, 2002

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, and 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.

^* To whom correspondence should be addressed. E-mail: gitta{at}klilu.de.

Background—The maximal oxygen uptake (peak VO₂) is used in risk stratification of patients with chronic heart failure (CHF). Peak VO₂ 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 (VO₂AT) and the ventilatory efficiency (VE versus VCO₂ slope) are less subject to these influences. Thus, we compared these parameters with peak VO₂ 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 VO₂, VO₂AT and VE versus VCO₂ slope. We selected peak VO₂ of 14 mL/kg per minute, VO₂AT of <11 mL/kg per minute, and VE versus VCO₂ slope of >34 as threshold values for high risk of death. The median follow-up time was 644 days. Patients with peak VO₂ of 14 mL/kg per minute had a >3-fold-increased risk (OR=3.4; CI, 1.3 to 9.1), with VO₂AT <11 mL/min per kg or VE versus VCO₂ 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 VO₂AT <11 mL/kg per minute and VE versus VCO₂ 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 VO₂AT <11 mL/kg per minute and VE versus VCO₂ slope >34 was the best predictor of 6-month mortality (RR=5.1, P=0.001).

Conclusions—VO₂AT of <11 mL/kg per minute and slope of VE versus VCO₂ >34, combined, better identified patients at high risk for early death from CHF than did peak VO₂ and should therefore be considered when prioritizing patients for heart transplantation.

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

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