Optimizing risk stratification in heart failure and the selection of candidates for heart transplantation

Tiago Pereira-da-Silva, Rui M Soares, Ana Luísa Papoila, Iola Pinto, Joana Feliciano, Luís Almeida-Morais, Ana Abreu, Rui Cruz Ferreira

Research output: Contribution to journalArticlepeer-review

8 Citations (Scopus)
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INTRODUCTION AND AIMS: Selecting patients for heart transplantation is challenging. We aimed to identify the most important risk predictors in heart failure and an approach to optimize the selection of candidates for heart transplantation.

METHODS: Ambulatory patients followed in our center with symptomatic heart failure and left ventricular ejection fraction ≤40% prospectively underwent a comprehensive baseline assessment including clinical, laboratory, electrocardiographic, echocardiographic, and cardiopulmonary exercise testing parameters. All patients were followed for 60 months. The combined endpoint was cardiac death, urgent heart transplantation or need for mechanical circulatory support, up to 36 months.

RESULTS: In the 263 enrolled patients (75% male, age 54±12 years), 54 events occurred. The independent predictors of adverse outcome were ventilatory efficiency (VE/VCO2) slope (HR 1.14, 95% CI 1.11-1.18), creatinine level (HR 2.23, 95% CI 1.14-4.36), and left ventricular ejection fraction (HR 0.96, 95% CI 0.93-0.99). VE/VCO2slope was the most accurate risk predictor at any follow-up time analyzed (up to 60 months). The threshold of 39.0 yielded high specificity (97%), discriminated a worse or better prognosis than that reported for post-heart transplantation, and outperformed peak oxygen consumption thresholds of 10.0 or 12.0 ml/kg/min. For low-risk patients (VE/VCO2slope <39.0), sodium and creatinine levels and variations in end-tidal carbon dioxide partial pressure on exercise identified those with excellent prognosis.

CONCLUSIONS: VE/VCO2slope was the most accurate parameter for risk stratification in patients with heart failure and reduced ejection fraction. Those with VE/VCO2slope ≥39.0 may benefit from heart transplantation.

Original languageEnglish
Pages (from-to)129-137
Number of pages9
JournalRevista Portuguesa de Cardiologia
Issue number2
Publication statusPublished - Feb 2018


  • Cardiopulmonary exercise testing
  • Consumo de oxigénio de pico
  • Declive da eficiência ventilatória
  • Estratificação de risco
  • Heart failure
  • Heart transplantation
  • Insuficiência cardíaca
  • Peak oxygen consumption
  • Prova de esforço cardiorrespiratória
  • Risk stratification
  • Transplantação cardíaca
  • Ventilatory efficiency slope


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