Congestive heart failure
Prognostic value of neurohormonal activation and cardiopulmonary exercise testing in patients with chronic heart failure

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Abstract

We compared the value of plasma neurohormones and cardiopulmonary exercise testing for predicting long-term prognosis in patients with moderate congestive heart failure (CHF). We studied 264 consecutive patients with CHF due to left ventricular systolic dysfunction. Plasma atrial natriuretic peptide (ANP), norepinephrine, and endothelin-1 were measured at rest in all patients, who also underwent a symptom-limited maximal exercise with oxygen consumption (VO2) determination. After a median follow-up of 789 days, 52 deaths and 31 heart transplantations occurred, of which 4 were urgent. In an univariate analysis, New York Heart Association functional class, systolic blood pressure at rest, left ventricular end-diastolic diameter, left ventricular ejection fraction, peak VO2, percent of predicted peak VO2, plasma ANP, plasma norepinephrine, and plasma endothelin-1 were associated with survival without urgent heart transplantation. In a multivariate stepwise regression analysis, only plasma ANP (p = 0.0001), left ventricular ejection fraction (p = 0.007), and plasma norepinephrine (p = 0.035), but neither peak VO2 nor percentage of predicted peak VO2, were independent predictors of death or urgent heart transplantation. Determination of plasma ANP and norepinephrine provides additional independent information for long-term prognostic determination compared with exercise testing alone. Measurement of plasma neurohormones should therefore be considered routinely as a complementary or alternative tool for identifying high-risk patients with moderate CHF.

Section snippets

Patients

We studied 264 consecutive patients referred to the cardiology departments of the Pitié-Salpêtrière Hospital in Paris and in the Laennec Hospital in Nantes for CHF due to left ventricular systolic dysfunction (left ventricular ejection fraction <45%) from January 1992 to December 1997. All patients were clinically stable for at least 2 weeks before entering the study and on constant therapy. They were able to exercise on a bicycle and were excluded if they had significant pulmonary, renal, or

Results

Clinical and neurohormonal characteristics of the 264 patients enrolled in the study are listed in Table I. Patients were treated by angiotensin-converting enzyme inhibitors (86%), diuretics (82%), digoxin (40%), amiodarone (24%), aspirin (24%), and anticoagulants (44%). Few of them received β blockers (7%). Most patients had nonischemic cardiomyopathy and were in New York Heart Association functional class II or III. Mean peak VO2 was 17.1 ± 6.8 ml · kg−1 · min−1, and mean percentage of

Discussion

The main finding of the present study is that plasma ANP, in association with plasma norepinephrine and left ventricular ejection fraction, is a stronger marker of long-term prognosis than peak VO2 or percent predicted VO2 in this population of patients with moderate heart failure.

Few studies have compared the prognostic value of plasma neurohormones and exercise parameters in heart failure. In Veterans Adminstration Heart Failure Trials, both plasma norepinephrine and peak VO2 provided

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