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JANUARY 2008

Exercise Testing May Help Predict Seriousness of Mitral Regurgitation

In as many as one in five people over age 55, when the heart contracts to send blood around the body, some degree of backward leakage occurs  across the mitral valve, a condition known as  mitral regurgitation (MR). When sufficiently  severe, MR causes buildup of blood in the lungs,  leading to difficulty in breathing (dyspnea, or  “shortness of breath”), a serious condition called  congestive heart failure. MR also can cause heart  rhythm irregularities (arrhythmias) such as atrial  fibrillation, which can lead to strokes and other  problems, and ventricular tachycardia, which can  cause sudden death.

A new study finds that monitoring the capacity  of these patients to exercise on a treadmill—  an evaluation called exercise tolerance  testing (ETT)—may be useful in predicting the  condition’s progression and whether the patient  will need surgery. Led by NewYork-Presbyterian  Hospital/Weill Cornell Medical Center, the  research is published in the American Journal  of Cardiology.

“Mitral regurgitation can be very benign, going  unnoticed for many years, or can be severe,  impeding the heart’s proper function and leading  to complications, even death. There are few  accurate ways to predict the seriousness of a  single case, and these methods require fairly  sophisticated and expensive imaging. Our study  shows that exercise tolerance testing, a simple  procedure often performed in doctors’ offices,  is an excellent tool for predicting if the patient  is deteriorating and needs surgery,” says Dr.  Jeffrey S. Borer, a study co-author ; director of  the Howard Gilman Institute for Valvular Heart  Diseases at NewYork-Presbyterian/Weill Cornell;  and the Gladys and Roland Harriman Professor  of Cardiovascular Medicine and professor of cardiovascular  medicine in cardiothoracic surgery at  Weill Cornell Medical College.

“We found that exercise testing is a simple and  relatively inexpensive way to predict outcomes.  Patients with mitral regurgitation who perform  well on the treadmill will likely remain healthy  and not have to undergo further testing for a  number of years. This gives these patients peace  of mind,” says principal investigator Dr. Phyllis  G. Supino, associate research professor of public  health in medicine and associate research  professor of public health at Weill Cornell  Medical College.

Developed in its most simple form in the 1920s,  exercise tolerance testing (ETT) is used commonly  to assess the progression of coronary artery  disease and the severity of aortic stenosis.

In mitral regurgitation, the mitral valve does  not close completely, as it should, when the  heart contracts, allowing blood to flow backward  instead of forward, limiting blood flow to the  body. Symptoms include shortness of breath,  fatigue, cough, heart palpitations, swollen feet or  ankles, and excessive urination. A characteristic  heart murmur can be heard with a stethoscope.

In the current study, researchers followed 38  patients with chronic severe nonischemic MR  (that is, MR not due to a prior heart attack) for  an average of seven years. All underwent ETT at  study entry. Patients who could continue exercising  for 15 minutes or longer (of a maximum total  of 18 minutes) had a fivefold lower annual risk  of developing heart failure or other evidence of  severe heart dysfunction necessitating surgery,  compared to patients who were unable to exercise  for that length of time.

In patients with chronic severe nonischemic  MR, progression to surgical indications generally  is rapid. There are two surgical options for the  treatment of MR: mitral valve replacement and  mitral valve repair.#

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