Exercise Capacity and Prognosis in Chronic Heart Failure

The association among fitness, health, and longevity is probably as old as there are historical records. The writings of the classic Greek physicians Herodicus, Hippocrates, and Galen are replete with references to fitness, and each believed that a healthy body was a prerequisite for mental well-being.1 The US founding fathers were also conscious of the importance of fitness. Benjamin Franklin advocated 15 minutes of brisk stair climbing at intervals throughout the day, along with swimming and the use of dumbbells for health purposes.2 Thomas Jefferson recognized the need for fitness, although perhaps to an extreme, when he wrote, “Not less than 2 hours a day should be devoted to exercise and the weather shall be little regarded. If the body is feeble, the mind will not be strong.”3 Of course, none of these historical icons was cognizant that we would one day routinely measure an individual’s maximal physiological response to maximal exertion under controlled circumstances. Nor could they have imagined that the exercise test would be a valuable tool to predict the consequences of diseases related to 21st-century lifestyles.Article see p 3189 The use of the exercise test to stratify risk and optimize clinical management for patients with cardiovascular disease (CVD) spans several decades. However, evidence of the importance of exercise capacity as a risk marker in patients with CVD is relatively recent, and clinical practice has yet to embrace this evidence. In a growing number of studies, exercise capacity has been shown to outperform traditional markers of risk (including clinical history, hypertension, obesity, hyperlipidemia, and other exercise test responses) in persons with and without CVD. In patients with chronic heart failure (CHF), exercise capacity has even been demonstrated to outperform invasive hemodynamic data (cardiac output, pulmonary wedge pressure, and ejection fraction) in stratifying risk. Because …