Prognostic Value of Exercise Tolerance Testing in Asymptomatic Chronic Nonischemic Mitral Regurgitation - 16/08/11
, Karlheinz Schuleri, MD c, Anuj Gupta, MD b, Clare Hochreiter, MD a, Paul Kligfield, MD a, Edmund McM. Herrold, MD, PhD a, Jacek J. Preibisz, MD, PhD a
Corresponding author: Tel: 212-746-4646; fax: 212-746-8448.Riassunto |
In many heart diseases, exercise tolerance testing (ETT) has useful functional correlates and/or prognostic value. However, its predictive value in mitral regurgitation (MR) is undefined. To determine whether ETT descriptors predict death or indications for mitral valve surgery in patients with MR, we prospectively followed, for 7 ± 3 end-point–free years, a cohort of 38 patients with chronic severe nonischemic MR who underwent modified Bruce ETT; all lacked surgical indications at study entry. Their baseline exercise descriptors were also compared with those from 46 patients with severe MR who, at entry, already had reached surgical indications. End points during follow-up in the cohort included sudden death (n = 1), heart failure symptoms (n = 2), atrial fibrillation (n = 4), left ventricular (LV) ejection fraction <60% (n = 2), LV systolic dimensions ≥45 mm (n = 12) and >40 mm (n = 11), LV ejection fraction <60% plus LV systolic dimensions ≥45 mm (n = 3), and heart failure plus LV systolic dimensions ≥45 mm plus LV ejection fraction <60% (n = 1). In univariate analysis, exercise duration (p = 0.004), chronotropic response (p = 0.007), percent predicted peak heart rate (p = 0.01), and heart rate recovery (p <0.02) predicted events; in multivariate analysis, only exercise duration was predictive (p <0.02). Average annual event risk was fivefold lower (4.62%) with an exercise duration ≥15 versus <15 minutes (average annual risk 23.48%, p = 0.004). Relative risks in patients with and without exercise-inducible ST-segment depression were comparable (≤1.3, p = NS) whether defined at entry and/or during follow-up. Exercise duration, but not prevalence of exercise-inducible ST-segment depression, was lower (p <0.001) in patients with surgical indications at entry versus initially end-point–free patients. In conclusion, in asymptomatic patients with chronic severe nonischemic MR and no objective criteria for operation, progression to surgical indications generally is rapid. However, those with excellent exercise tolerance have a relatively benign course. Exercise-inducible ST-segment depression has no prognostic value in this population.
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| Dr. Borer was supported in part during this work by an endowment from the Gladys and Roland Harriman Foundation, New York, New York. This work was also supported by grants from the National Heart Lung and Blood Institute, Bethesda, Maryland (RO1-HL-26504, Dr. Borer, principal investigator); The Howard Gilman Foundation, New York, New York; The Schiavone Family Foundation, White House Station, New Jersey; The Charles and Jean Brunie Foundation, Bronxville, New York; The David Margolis Foundation, New York, New York; The American Cardiovascular Research Foundation, New York, New York; The Irving A. Hansen Foundation, New York, New York; The Mary A.H. Rumsey Foundation, New York, New York; The Messinger Family Foundation, New York, New York; The Daniel and Elaine Sargent Charitable Trust, New York, New York; The A.C. Israel Foundation, Greenwich, Connecticut; and by much appreciated gifts from Donna and William Acquavella, New York, New York; Maryjane Voute Arrigoni and the late William Voute, Bronxville, New York; Gerald Tanenbaum, New York, New York; and Stephen and Suzanne Weiss, Greenwich, Connecticut. |
Vol 100 - N° 8
P. 1274-1281 - ottobre 2007 Ritorno al numero
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