Ugo Corrà1, Piergiuseppe Agostoni2, Andrea Giordano3, Gaia Cattadori4, Elisa Battaia5, Rocco La Gioia6, Angela B Scardovi7, Michele Emdin8, Marco Metra9, Gianfranco Sinagra10, Giuseppe Limongelli11, Rosa Raimondo12, Federica Re13, Marco Guazzi14, Romualdo Belardinelli15, Gianfranco Parati16, Damiano Magrì17, Cesare Fiorentini18, Mariantonietta Cicoira19, Elisabetta Salvioni4, Marta Giovannardi4, Fabrizio Veglia4, Alessandro Mezzani1, Domenico Scrutinio6, Andrea Di Lenarda20, Roberto Ricci7, Anna Apostolo4, Anna Maria Iorio11, Stefania Paolillo21, Pietro Palermo4, Mauro Contini4, Corrado Vassanelli19, Claudio Passino22, Pantaleo Giannuzzi1, Massimo F Piepoli23. 1. Department of Cardiac Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Veruno (NO), Italy. 2. Cardiology Center of Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy; Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, Washington, USA. Electronic address: piergiuseppe.agostoni@unimi.it. 3. Bioengineering Department, Salvatore Maugeri Foundation, IRCCS, Veruno (NO), Italy. 4. Cardiology Center of Monzino, IRCCS, Milan, Italy. 5. Cardiology Center of Monzino, IRCCS, Milan, Italy; Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy. 6. Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy. 7. Cardiology Department, Ospedale S. Spirito, Roma Lungotevere in Sassia 3, Roma, Italy. 8. Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy. 9. Department of Cardiology, Department of Medical and Surgical Specialities, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy. 10. Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy. 11. Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli, Italy. 12. Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Tradate, Dipartimento di Medicina e Riabilitazione Cardiorespiratoria Unità Operativa di Cardiologia Riabilitativa, Tradate, Italy. 13. Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, St. Camillo-Forlanini Hospital, Roma, Italy. 14. Department of Medical Sciences, Cardiology, IRCCS San Donato Hospital, University of Milan, San Donato Milanese, Milano, Italy. 15. Cardiologia Riabilitativa, Azienda Ospedali Riuniti, Ancona, Italy. 16. Department of Health Science, University of Milano Bicocca and Department of Cardiology, S. Luca Hospital, Istituto Auxologico Italiano, Milano, Italy. 17. Dipartimento di Medicina Clinica e Molecolare, "Sapienza" Università degli Studi di Roma, Roma, Italy. 18. Cardiology Center of Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy. 19. Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy. 20. Centro Cardiovascolare, Azienda per i Servizi Sanitari n°1, Trieste, Italy. 21. Department of Advanced Biomedical Sciences, University of Naples Federico II University, Naples, Italy. 22. Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy; Scuola Superiore S. Anna, Pisa, Italy. 23. UOC Cardiologia, G da Saliceto Hospital, Piacenza, Italy.
Abstract
BACKGROUND: In heart failure (HF), women show better survival despite a comparatively low peak oxygen consumption (V˙o2): this raises doubt about the accuracy of risk assessment by cardiopulmonary exercise testing (CPET) in women. Accordingly, we aimed to check (1) whether the predictive role of well-known CPET risk indexes, ie, peak V˙o2 and ventilatory response (V˙e/V˙co2 slope), is sex independent and (2) if sex-related characteristics that impact outcome in HF should be considered as associations that may confound the effect of sex on survival. METHODS: The study population consisted of 2985 patients with HF, 498 (17%) of whom were women, from the multicentre Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI): the end point was cardiovascular death within a 3-year period. RESULTS: During the follow-up, 305 (12%) men and 39 (8%) women (P = 0.005) died, and female sex was linked to better survival on univariate analysis (P = 0.008) and independent of peak V˙o2 and V˙e/V˙co2 slope on multivariate analysis. According to propensity score matching for female sex to exclude a sex selection bias and sample discrepancy, 498 men were selected: the standardized percentage bias ranged from 20.8 (P < 0.0001) to 3.3 (P = 0.667). After clinical profile harmonizing, female sex was predictive of HF at univariate analysis. CONCLUSIONS: The low peak V˙o2 and female association with better outcome in HF might be counterfeit: the female prognostic advantage is lost when sex-specific differences are correctly taken into account with propensity score matching, suggesting that for an effective and efficient HF model, adjustment must be made for sex-related characteristics.
BACKGROUND: In heart failure (HF), women show better survival despite a comparatively low peak oxygen consumption (V˙o2): this raises doubt about the accuracy of risk assessment by cardiopulmonary exercise testing (CPET) in women. Accordingly, we aimed to check (1) whether the predictive role of well-known CPET risk indexes, ie, peak V˙o2 and ventilatory response (V˙e/V˙co2 slope), is sex independent and (2) if sex-related characteristics that impact outcome in HF should be considered as associations that may confound the effect of sex on survival. METHODS: The study population consisted of 2985 patients with HF, 498 (17%) of whom were women, from the multicentre Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI): the end point was cardiovascular death within a 3-year period. RESULTS: During the follow-up, 305 (12%) men and 39 (8%) women (P = 0.005) died, and female sex was linked to better survival on univariate analysis (P = 0.008) and independent of peak V˙o2 and V˙e/V˙co2 slope on multivariate analysis. According to propensity score matching for female sex to exclude a sex selection bias and sample discrepancy, 498 men were selected: the standardized percentage bias ranged from 20.8 (P < 0.0001) to 3.3 (P = 0.667). After clinical profile harmonizing, female sex was predictive of HF at univariate analysis. CONCLUSIONS: The low peak V˙o2 and female association with better outcome in HF might be counterfeit: the female prognostic advantage is lost when sex-specific differences are correctly taken into account with propensity score matching, suggesting that for an effective and efficient HF model, adjustment must be made for sex-related characteristics.
Authors: Elisabetta Salvioni; Ugo Corrà; Massimo Piepoli; Sara Rovai; Michele Correale; Stefania Paolillo; Mario Pasquali; Damiano Magrì; Giuseppe Vitale; Laura Fusini; Massimo Mapelli; Carlo Vignati; Rocco Lagioia; Rosa Raimondo; Gianfranco Sinagra; Federico Boggio; Lorenzo Cangiano; Giovanna Gallo; Alessandra Magini; Mauro Contini; Pietro Palermo; Anna Apostolo; Beatrice Pezzuto; Alice Bonomi; Angela B Scardovi; Pasquale Perrone Filardi; Giuseppe Limongelli; Marco Metra; Domenico Scrutinio; Michele Emdin; Lucrezia Piccioli; Carlo Lombardi; Gaia Cattadori; Gianfranco Parati; Sergio Caravita; Federica Re; Mariantonietta Cicoira; Maria Frigerio; Francesco Clemenza; Maurizio Bussotti; Elisa Battaia; Marco Guazzi; Francesco Bandera; Roberto Badagliacca; Andrea Di Lenarda; Giuseppe Pacileo; Claudio Passino; Susanna Sciomer; Giuseppe Ambrosio; Piergiuseppe Agostoni Journal: ESC Heart Fail Date: 2020-01-01