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Development of a composite model derived from cardiopulmonary exercise tests to predict mortality risk in patients with mild-to-moderate heart failure

Sloan, Rebecca; Carroll, Sean; Clark, Andrew L; Goode, Kevin M; Ingle, Lee; Rigby, Alan S; Cleland, John G


Andrew L Clark

Kevin M Goode

Alan S Rigby

John G Cleland

Rebecca Sloan


Objective: Cardiopulmonary exercise testing (CPET) is used to predict outcome in patients with mild-to-moderate heart failure (HF). Single CPET-derived variables are often used, but we wanted to see if a composite score achieved better predictive power. Methods: Retrospective analysis of patient records at the Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull. 387 patients [median (25th-75th percentile)] [age 65 (56-72) years; 79% males; LVEF 34 (31-37) %] were included. Patients underwent a symptomlimited, maximal CPET on a treadmill. During a median follow up of 8.6 ± 2.1 years in survivors, 107 patients died. Survival models were built and validated using a hybrid approach between the bootstrap and Cox regression. Nine CPET-derived variables were included. Z-score defined each variable's predictive strength. Model coefficients were converted to a risk score. Results: Four CPET-related variables were independent predictors of all-cause mortality in the survival model: the presence of exertional oscillatory ventilation (EOV), increasing slope of the relation between ventilation and carbon dioxide production (VE/VCO2 slope), decreasing oxygen uptake efficiency slope (OUES), and an increase in the lowest ventilatory equivalent for carbon dioxide (VEqCO2 nadir). Individual predictors of mortality ranged from 0.60 to 0.71 using Harrell’s C-statistic, but the optimal combination of EOV + VE/VCO2 slope + OUES + VEqCO2 nadir reached 0.75. The Hull CPET risk score had a significantly higher area under the curve (0.78) when compared to the Heart Failure Survival Score (AUC=0.70;P<0.001). Conclusions: A composite risk score using variables from CPET out-performs the traditional single variable approach in predicting outcome in patients with mild-to-moderate HF.

Journal Article Type Article
Publication Date May 15, 2014
Journal Heart
Print ISSN 1355-6037
Electronic ISSN 1468-201X
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Volume 100
Issue 10
Pages 781-786
Keywords Cardiology and Cardiovascular Medicine
Publisher URL
Copyright Statement © 2015 University of Hull
Additional Information This is the authors accepted manuscript of an article published in Heart, 2014, v.100, iss.10 which can be found at:


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