• Elisabetta Salvioni, Massimo Mapelli, Alice Bonomi, Damiano Magrì, Massimo Piepoli, Maria Frigerio, Stefania Paolillo, Ugo Corrà, Rosa Raimondo, Rocco Lagioia, Roberto Badagliacca, FilardiPasquale PerronePPDepartment of Advanced Biomedical Sciences, Federico II University of Naples and Mediterranea CardioCentro, Naples, Italy., Michele Senni, Michele Correale, Mariantonietta Cicoira, Enrico Perna, Marco Metra, Marco Guazzi, Giuseppe Limongelli, Gianfranco Sinagra, Gianfranco Parati, Gaia Cattadori, Francesco Bandera, Maurizio Bussotti, Federica Re, Carlo Vignati, Carlo Lombardi, Angela B Scardovi, Susanna Sciomer, Andrea Passantino, Michele Emdin, Claudio Passino, Caterina Santolamazza, Davide Girola, Denise Zaffalon, Fabiana De Martino, Piergiuseppe Agostoni, and MECKI Score Research Group.
• Heart failure unit, Centro Cardiologico Monzino, IRCCs, Milan, Italy.
• Chest. 2022 Nov 1; 162 (5): 110611151106-1115.

BackgroundIn clinical practice, anaerobic threshold (AT) is used to guide training and rehabilitation programs, to define risk of major thoracic or abdominal surgery, and to assess prognosis in heart failure (HF). AT of oxygen uptake (V.O2; V.O2AT) has been reported as an absolute value (V.O2ATabs), as a percentage of predicted peak V.O2 (V.O2AT%peak_pred), or as a percentage of observed peak V.O2 (V.O2AT%peak_obs). A direct comparison of the prognostic power among these different ways to report AT is missing.Research QuestionWhat is the prognostic power of these different ways to report AT?Study Design And MethodsIn this observational cohort study, we screened data of 7,746 patients with HF with a history of reduced ejection fraction (< 40%) recruited between 1998 and 2020 and enrolled in the Metabolic Exercise Combined With Cardiac and Kidney Indexes register. All patients underwent a maximum cardiopulmonary exercise test, executed using a ramp protocol on an electronically braked cycle ergometer.ResultsThis study considered 6,157 patients with HF with identified AT. Follow-up was median, 4.2 years (25th-75th percentiles, 1.9-5.0 years). Both V.O2ATabs (mean ± SD, 823 ± 305 mL/min) and V.O2AT%peak_pred (mean ± SD, 39.6 ± 13.9%), but not V.O2AT%peak_obs (mean ± SD, 69.2 ± 17.7%), well stratified the population regarding prognosis (composite end point: cardiovascular death, urgent heart transplant, or left ventricular assist device). Comparing area under the receiver operating characteristic curve (AUC) values, V.O2ATabs (0.680) and V.O2AT%peak_pred (0.688) performed similarly, whereas V.O2AT%peak_obs (0.538) was significantly weaker (P < .001). Moreover, the V.O2AT%peak_pred AUC value was the only one performing as well as the AUC based on peak V.O2 (0.710), with an even a higher AUC (0.637 vs 0.618, respectively) in the group with severe HF (peak V.O2 < 12 mL/min/kg). Finally, the combination of V.O2AT%peak_pred with peak V.O2 and V. per CO2 production shows the highest prognostic power.InterpretationIn HF, V.O2AT%peak_pred is the best way to report V.O2 at AT in relationship to prognosis, with a prognostic power comparable to that of peak V.O2 and, remarkably, in patients with severe HF.Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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