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  • 1
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    Abstract 17154: Cardiopulmonary Exercise Testing and Prognosis in HFpEF: the Henry Ford HospITal CardioPulmonary EXercise Testing (FIT-CPX) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation Vol. 130, No. suppl_2 ( 2014-11-25)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 130, No. suppl_2 ( 2014-11-25)
    Abstract: The prognostic utility of cardiopulmonary exercise testing (CPX) in patients with heart failure and reduced ejection fraction (HFrEF) has received much attention. However, there are limited data on the value of CPX in patients with HF and preserved EF (HFpEF). Purpose: Among patients with HFpEF, describe the association between select CPX measures and prognosis for the composite endpoint of mortality, left ventricular assist device (LVAD), or cardiac transplant (CT). Methods: Patients with a CPX between 1997 and 2010 and confirmed HFrEF (EF ≤ 40%; n= 1,201) or HFpEF (EF ≥ 50%; n= 192) were identified. Patients with HFpEF (n= 189, age= 54 ± 14 y, 43% female, EF = 56 ± 5%) were matched (propensity score) to patients with HFrEF (n= 189, age= 54 ± 13 y, 43% female, EF = 22 ± 9%) based on age, gender, history of coronary artery disease, and body mass index. Endpoint data was obtained through 2011. The association between select CPX measures and the endpoint was assessed using Cox regression with adjustment for age, gender, EF, and beta-blocker therapy. Results: There were 53 events (28%; median follow-up = 5.1 y) among the HFpEF group and 88 events (47%; median follow-up = 3.6 y) among the HFrEF group. Results from the Cox regression analyses are shown in the Table. Percent predicted peak VO 2 was one of the best predictors of the endpoint in both HFpEF and HFrEF with similar hazard ratios. Although significantly related to the endpoint among HFrEF, V E -VCO 2 slope and peak P ET CO 2 were not significant among HFpEF. Conclusions: These data support the use of % predicted peak VO 2 to risk stratify patients with HFpEF and suggest that the prognostic utility of some CPX measures developed in HFrEF may not be relevant in HFpEF. Additional research is needed to define the association between CPX measures and prognosis specifically for patients with HFpEF.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.130.suppl_2.17154
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 2
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    Abstract 14036: An Algorithm to Guide Prognosis Based on the Combination of Peak VO 2 and V E -VCO 2 slope in Patients with HFrEF: The Henry Ford HospITal CardioPulmonary EXercise Testing (FIT-CPX) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation Vol. 130, No. suppl_2 ( 2014-11-25)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 130, No. suppl_2 ( 2014-11-25)
    Abstract: Many studies have reported the prognostic significance of peak oxygen consumption (VO 2 ) and V E -VCO 2 slope in patients with heart failure (HF). However, there are limited data stratifying risk based on a combination of these measures and how to best use them. Purpose: Describe 1 and 3-y event rates for the composite endpoint of mortality, left ventricular assist device (LVAD), or cardiac transplant (CT) based on the combined evaluation of peak VO 2 and V E -VCO 2 slope in patients with HF with reduced ejection fraction (≤ 40%; HFrEF). Methods: Patients (n= 1,116; 33% female; age= 54 ± 13 y) with a cardiopulmonary exercise test between 1997 and 2010 and confirmed HFrEF were identified. Endpoint data was obtained through 2011. Patients were grouped based on peak VO 2 ( 〈 12, 12 to18, and 〉 18 mL/kg/min) and (V E -VCO 2 slope ≥ 34 or 〈 34). Cumulative events were identified from life tables. Cox regression with adjustment for age, gender, ejection fraction, and beta-blocker therapy was used to calculate the hazard ratio for V E -VCO 2 slope ≥ 34 within each peak VO 2 group. Results: The 1 and 3-y event rates are shown in the Table. Among patients with a peak VO 2 〈 12, 1 and 3-y events were 23% and 44%, respectively. Within this group, V E -VCO 2 slope ≥ 34 represented more than twice the risk at both 1 y (HR 2.42, 95% CI 1.09, 5.38) and 3 y (HR 2.32, 95% CI 1.33, 4.05). Among patients with a peak VO 2 12 to 18, 1 and 3-y events were 14% and 30%, respectively. Within this group, a V E -VCO 2 slope ≥ 34 was associated with increased risk at both 1 y (HR 1.80, 95% CI 1.13, 2.87) and 3 y (HR 1.80, 95% CI 1.30, 2.50). Among patients with peak VO 2 〉 18, 1 and 3-y events were 2% and 10%, respectively, and V E -VCO 2 slope was not statistically associated with increased risk. Conclusion: Among patients with a peak VO 2 ≤ 18, V E -VCO 2 slope ≥ 34 further refines the risk for a composite endpoint of mortality, LVAD, or CT at both 1 and 3 y.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.130.suppl_2.14036
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 3
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    Abstract 18836: Differences in Cardiopulmonary Exercise Test Data and Prognosis in Black and White Men with Heart Failure: the Henry Ford HospITal CardioPulmonary EXercise Testing (FIT-CPX) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation Vol. 130, No. suppl_2 ( 2014-11-25)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 130, No. suppl_2 ( 2014-11-25)
    Abstract: Introduction: Numerous metrics from the cardiopulmonary exercise test (CPX) are associated with outcomes among patients with heart failure with reduced ejection fraction (HFrEF). Among patients with HFrEF, mortality rates differ by race; however, the influence of race on the association between common measures obtained during CPX and mortality has not been fully described. Purpose: Retrospective analysis to describe the relationship between key CPX measures and the composite endpoint of mortality, left ventricular assist device (LVAD), or cardiac transplant (CT) in white and black men with HFrEF. Methods: Self-identified white and black male patients (n= 761; age= 55 ± 12 y; BMI= 30.6±6.6) with a CPX between 1997 and 2010 and confirmed HFrEF (ejection fraction [EF] ≤ 40%) were identified. Endpoint data was obtained through 2011. The association with the composite endpoint was evaluated separately for 7 key CPX measures with adjustment for age, hypertension, beta-blocker therapy, EF, and ischemic etiology using Cox regression stratified by race. Results: During a median follow-up of 3.5 y there were 195 (54%) and 193 (48%) events for white and black patients, respectively. All CPX variables were associated (p 〈 0.05) with the composite endpoint in both white and black patients (Table). The greatest Wald statistic among white patients was % predicted peak oxygen uptake (ppVO 2 ) at 76.2, and among black patients it was ventilatory efficiency (V E -VCO 2 slope) at 90.8. Conclusion: Among white and black male patients, % predicted peak VO 2 and V E -VCO 2 slope, respectively, were most strongly associated with the combined end point of mortality, LVAD or CT. These data suggest that risk stratification using CPX variables may differ by race. Further research is needed to determine if race-specific methods of CPX-based risk stratification are needed.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.130.suppl_2.18836
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 4
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    Abstract 13468: The Interaction Between the Prognostic Value of Chronotropic Incompetence and Cardiorespiratory Fitness: The Henry Ford Exercise Testing (FIT) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Circulation Vol. 132, No. suppl_3 ( 2015-11-10)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 132, No. suppl_3 ( 2015-11-10)
    Abstract: Background: Cardiorespiratory fitness (CRF) and chronotropic incompetence (CI) have both been associated with increased all - cause mortality. We tested the hypothesis that the association of CI with all - cause mortality is modified by a CRF level above and below 10 metabolic equivalents of task (METs). Methods: We included 43,402 patients who completed a clinical exercise stress test between 1991 and 2009. Patients on AV nodal blocking agents, antiarrhythmics and with known coronary artery disease/heart failure were excluded. Patients were followed-up for a mean duration of 11.5±5.2 years for all-cause mortality ascertained by a search of the social security death index in April 2013. CRF was estimated in metabolic equivalents of task (METs). Cox proportional hazards regression models were used to assess the risk of all - cause mortality associated with CI with adjustments for confounders. Results: Compared to no CI, patients with CI were older (51±12 vs. 54±13 years), less often white (68% vs. 58%), dyslipidemic (41% vs. 37%) and more likely to be hypertensive (46% vs. 60%), diabetic (15% vs. 22%), and smoke (40% vs. 51%). On average, patients with CI had lower CRF (9.8±2.8 vs. 7.4±3.0, p 〈 .001). In adjusted Cox regression model, CI was associated with higher risk of mortality [Hazard ratio (HR), 2.12; 95% confidence interval (2.00 -2.27); p 〈 .001)]. The association of CI and mortality was attenuated when METs was included as a covariate in the regression model [HR, 1.49; 95% confidence interval (1.39-1.61); p 〈 .001]. There was a significant interaction of CRF ≥ 10 METs with the association of CI and mortality (p interaction 0.004) which is shown in Figure 1. This was a subaditive and multiplicative interaction of CRF with CI. Conclusions: This study demonstrates that CRF attenuates the mortality risk associated with CI. In addition, patients with CI in the presence of CRF ≥ 10 METs have a much lower risk than patients with CI and lower CRF.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.132.suppl_3.13468
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 5
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    Abstract 16899: Change in Cardiorespiratory Fitness is Inversely Related to Mortality Among Black and White Patients: Data From the Henry Ford Exercise Testing (FIT) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Circulation Vol. 132, No. suppl_3 ( 2015-11-10)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 132, No. suppl_3 ( 2015-11-10)
    Abstract: Background: Cardiorespiratory fitness (CRF) is inversely related to all-cause mortality and cardiovascular-related morbidity and mortality. However, there is limited data describing whether change in CRF is associated with improved outcomes. Hypothesis: Change in CRF between two clinical exercise stress tests is related to risk of all-cause mortality. Methods: In this retrospective, observational study, we identified 14,305 patients (age = 55 ± 11 y; 39% women; 30% non-white) who completed two clinically-indicated exercise tests that were at least 12 mo apart between 1991 and 2009 within the Henry Ford Health System. CRF was quantified in metabolic equivalents of task (METs) estimated from peak treadmill speed and grade. All-cause mortality was identified through April 2013 using the Social Security Death Index. Cox regression analysis was used to evaluate the risk of mortality associated with change in CRF between tests 1 and 2. Change in CRF was analyzed as the change in categorization between Poor Fitness ( 〈 7 METs) and Fit (≥ 7 METs) and as an absolute change in peak METs. Based on data at test 1, covariates included age; sex; race; cardiovascular risk factors; medications; and history of coronary artery disease, heart failure, and atrial fibrillation; as well as year of test 1 and years between tests 1 and 2. Results: The mean time between test 1 and 2 was 4.3 ± 2.8 y. During 9.4 ± 3.9 y of follow-up after test 2, there were 1,980 (14%) deaths. Adjusted Cox regression results are shown in the Table. Among all patients, each 1 MET increase in CRF at test 2 was associated with a 5% lower risk of mortality (hazard ratio 95% confidence interval 0.94, 0.97; p 〈 0.001). Conclusions: Among men and women referred for a clinical exercise test, change in CRF from Poor Fitness to Fit is associated with a 38% lower risk of all-cause mortality relative to patients who remain Unfit. These data support the importance of improving CRF and the clinical utility of serial assessments of CRF in risk assessment.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.132.suppl_3.16899
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 6
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    Abstract 14681: Uber Analysis of Cardiopulmonary Exercise Test Variables and Mortality in Patients with Heart Failure: the Henry Ford HospITal CardioPulmonary EXercise Testing (FIT-CPX) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation Vol. 130, No. suppl_2 ( 2014-11-25)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 130, No. suppl_2 ( 2014-11-25)
    Abstract: Introduction: Numerous metrics derived from the cardiopulmonary exercise test (CPX) are associated with outcomes among patients with heart failure with reduced ejection fraction (HFrEF). However few studies have examined the independent prognostic value of all variables assessed simultaneously. Purpose: Retrospective analysis to describe the relationship between all CPX measures and the composite outcome of mortality, left ventricular assist device (LVAD), or cardiac transplant (CT). Methods: Patients (n= 1,201; 33% female; age= 55 ± 13 y) with a CPX between 1997 and 2010 and confirmed HFrEF (ejection fraction [EF] 〈 40%) were identified. Death data through 2011 was obtained from the National Death Index. The association with the composite endpoint was evaluated separately for 30 CPX measures with adjustment for age, gender, EF, and beta-blocker therapy using Cox regression. Forward stepwise Cox regression was performed to identify which of the CPX variables contribute the most to outcome prediction. Results: During a median follow-up of 3.75 years there were 576 (48%) events. When tested separately, nearly all CPX variables (except heart rate reserve/metabolic reserve and peak respiratory exchange ratio) were associated (p 〈 0.05) with the composite endpoint. The top 5 predictors are shown in the Table. Stepwise Cox regression revealed that only % predicted peak oxygen uptake (VO 2 , Wald= 76.1), ventilatory power (peak systolic blood pressure/V E -VCO 2 slope, Wald= 58.0), and EF (Wald= 27.0) independently predicted outcomes. Conclusion: When considering all variables measured during a CPX test, % predicted peak VO 2 was the variable with the strongest independent association to outcomes in this cohort of patients with HFrEF. The % predicted peak VO 2 may represent a key variable in determining when to consider a patient for an LVAD or CT.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.130.suppl_2.14681
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 7
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    Inverse association of pulse pressure augmentation during exercise with heart failure and death
    BMJ ; 2018
    In:  Heart
    Details
    In: Heart, BMJ
    Abstract: Resting pulse pressure (PP) is a risk factor for heart failure (HF); however, whether PP augmentation during exercise, a parameter easily obtained from routine treadmill stress testing, is associated with incident HF is unknown. Thus, we aimed to study the relationship between a novel parameter, the pulse pressure stress index (P2SI), and adverse outcomes among adults undergoing clinical exercise stress testing in the Henry Ford Exercise Testing Project. Methods The P2SI was calculated as PP at peak exercise divided by resting PP and was analysed continuously and categorically using quartiles. Cox models examined the association between P2SI and adjusted HR (aHR) of incident HF, myocardial infarction (MI) or death. Receiver operating curve (ROC) analyses tested the optimal prognostic cut-point for P2SI. Results Among 55 524 participants without prior MI or HF, mean (SD) age was 53 (13) years, 51% were men and 29% black. A total of 2516 HF, 1606 MI and 6224 mortality outcomes occurred. Quartile 3 P2SI (2.0–2.4) was chosen as the reference category based on ROC analyses. There was a graded inverse association of low P2SI with excess HF (aHR of 1.3 (95% CI 1.1 to 1.5) for quartile 2 and 1.5 (95% CI 1.2 to 1.8) for quartile 1, p for trend 〈 0.001) and mortality (aHR of 1.1 (95% CI 1.01 to 1.2) for quartile 2 and 1.3 (95% CI 1.2 to 1.5) for quartile 1, p for trend 〈 0.001). There was no association between P2SI and MI after adjustment. P2SI added significant prognostic information to more established stress testing parameters such as peak systolic blood pressure, per cent maximal predicted heart rate achieved and metabolic equivalents of task achieved. Conclusions Poor augmentation of PP with exercise, specifically a P2SI below 2, is a novel and readily quantifiable exercise-based risk feature for HF and death.
    Type of Medium: Online Resource
    ISSN: 1355-6037 , 1468-201X
    URL: Article
    URL: Article
    DOI: 10.1136/heartjnl-2018-313736
    DOI: 10.1136/heartjnl-2018-313736.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2018
    detail.hit.zdb_id: 2378689-9
    detail.hit.zdb_id: 1475501-4
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  • 8
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    Age-dependent prognostic value of exercise capacity and derivation of fitness-associated biologic age
    BMJ ; 2016
    In:  Heart Vol. 102, No. 6 ( 2016-03), p. 431-437
    Details
    In: Heart, BMJ, Vol. 102, No. 6 ( 2016-03), p. 431-437
    Type of Medium: Online Resource
    ISSN: 1355-6037 , 1468-201X
    URL: Article
    DOI: 10.1136/heartjnl-2015-308537
    Language: English
    Publisher: BMJ
    Publication Date: 2016
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  • 9
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    Abstract 13614: Prognostic Value of Cardiorespiratory Fitness in Patients With Chronic Renal Dysfunction: The FIT (Henry Ford Exercise Testing) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Circulation Vol. 132, No. suppl_3 ( 2015-11-10)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 132, No. suppl_3 ( 2015-11-10)
    Abstract: Background: Chronic kidney disease (CKD) is associated with high morbidity and mortality. We tested the hypothesis that cardiorespiratory fitness (CRF) retains incremental prognostic value over renal function, as measured by estimated glomerular filtration rate (eGFR). Methods: Our analysis included 50,121 patients (mean age 55 ± 12.6 years and 47.5% females) from The Henry Ford Exercise Testing Project (FIT project), who underwent exercise stress testing between 1991 and 2009. Patients with heart failure or missing relevant covariate data were excluded. The mean duration between stress testing and creatinine measurement was 30 days and eGFR was estimated using the Modification of Diet in Renal Disease equation. Treadmill stress testing used the standard Bruce protocol and CRF was estimated using metabolic equivalent of task units (MET). Patients were followed-up for all-cause mortality. Multiple nested Cox models were used to determine the incremental prognostic value of CRF over eGFR. Results: The magnitude of renal dysfunction was inversely associated with (level of CRF (mean METs achieved 9.1, 9.0, 7.5, 5.5 METS for Stage I, II, III and more than III CKD respectively, p 〈 0.0001). Over a median follow-up duration of 6.7 yr, (IQR 3.9 to 10 yr), 6,308 (12.6%) patients died. CRF was a strong, independent predictor of mortality (p 〈 0.001) and at every stage of renal function, improved CRF was associated with improved survival. (figure). Using Cox analysis, CRF added improved discriminatory ability beyond traditional risk factors and renal function: Area under the curve (AUC) 0.837 (95% CI 0.832 - 0.842) vs. 0.814 (95% CI 0.809 - 0.8198), respectively, p-value 〈 0.0001. Renal function did not add incremental prognostic value once CRF was accounted for. Conclusion: Regardless of renal function, CRF is an independent predictor of mortality. Fitness adds incremental prognostic value over renal function in this large diverse clinical cohort.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.132.suppl_3.13614
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 10
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    Abstract 16395: Comparing Cardiopulmonary Exercise Measures of Men and Women With HFrEF and Their Relationship to Prognosis: The Henry Ford HospITal CardioPulmonary Exercise Testing (FIT-CPET) Project
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Circulation Vol. 132, No. suppl_3 ( 2015-11-10)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 132, No. suppl_3 ( 2015-11-10)
    Abstract: Introduction: Several cardiopulmonary exercise test (CPET) variables (e.g., peak oxygen consumption (VO2), ventilatory efficiency (VE-VCO2) slope, and % predicted peak VO2 (%pVO2)) are regularly used to estimate prognosis in patients with systolic heart failure (HFrEF). Although known sex differences in physiology (i.e., muscle mass, lung volume) result in lower peak VO2 values in healthy women vs. men, this influence on CPET variables and subsequent prognosis in patients with HFrEF is not well described. Purpose: Compare the peak VO2, VE-VCO2 slope and %pVO2 values in men and women that correspond to prognosis using the International Society of Heart Transplant (ISHT) reported North American 1 and 3-y cardiac transplant survival rates (i.e., 86% and 79%, respectively). Methods: Patients with a CPET between 1997 and 2010 were identified. HFrEF was confirmed through a manual query of the medical record. Deaths through December 2011 were identified from the National Death Index. Receiver operator characteristic (ROC) curves were developed for each CPET measure and the threshold values and area under the curve (AUC) values associated with 86% and 79% specificity for each sex were determined. Results: A total of 1,201 patients (33% female; 55% Black; 33% ischemic; age = 55 + 13 y; BMI = 31 +7 kg.m-2; EF = 22 + 9%) were included in this analysis. Specificity threshold values and the corresponding AUC, for each CPX variable, are shown in the Table. At 1-y there were 167 (14%) deaths with a 10% event rate for women and 16% for men. At 3-y there were 335 (31%) deaths with a 25% event rate for women and 35% for men. Conclusions: In this large, racially diverse population both peak VO2 and %pVO2 had clinically meaningful differences for risk stratification thresholds depending on sex. This was not true for VE-VCO2 slope. Clinical decisions regarding the need for advanced therapies such as transplant or ventricular assist devices, when based on peak VO2 or %pVO2, might consider the patient’s sex.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.132.suppl_3.16395
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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