# Valvular Heart Disease in Non-Valvular Heart Failure Continuum: The Role of Cardiopulmonary Exercise Testing

## TL;DR

This study explores how valvular heart disease affects patients with non-valvular heart failure and finds that cardiopulmonary exercise testing reveals worse functional capacity in those with moderate-to-severe valve issues.

## Contribution

The study introduces the role of cardiopulmonary exercise testing in assessing functional capacity in non-valvular heart failure patients with valvular disease.

## Key findings

- Mild mitral regurgitation was the most common valvular disease in non-valvular heart failure patients.
- Patients with moderate-to-severe valvular disease showed worse cardiopulmonary performance despite similar ejection fraction.
- Hypertension and atrial fibrillation were independently linked to more severe valvular disease.

## Abstract

Background/Objectives: Patients with non-valvular heart failure frequently develop valvular disease. However, the prevalence of valvular disease across patients with different heart failure etiologies remains underexplored. This study aimed to investigate the burden of VHD among patients with non-valvular heart failure, and secondly evaluate its association with cardiopulmonary test. Methods: We analyzed data from patients with non-valvular heart failure (HF) who were evaluated as outpatients at the HF clinic between February 2020 and November 2024. Patients were categorized into three groups: coronary artery disease-related HF (CAD-HF), dilated cardiomyopathy (DCM), and other causes (e.g., hypertension, diabetes, and various cardiomyopathies). Demographic and clinical characteristics, as well as echocardiographic and cardiopulmonary exercise testing (CPET) results, were evaluated. Results: Among all groups mild mitral regurgitation (MR) was the most common valvular disease, followed by mild tricuspid regurgitation (TR). Patients with CAD-HF frequently had mild aortic regurgitation (AR) compared to DCM (23.6% vs. 14.9%, p = 0.05). In the CPET subgroup, which included 41 patients who consented to participate, in patients with moderate-to-severe VHD had significantly lower VO2/HR (oxygen pulse), VO2max, and OUES, indicating worsened functional capacity despite similar left ventricular ejection fraction. Hypertension and atrial fibrillation were independently associated with greater valvular disease severity on multivariable analysis. Conclusions: No significant differences in valvular disease between patients with DCM and CAD-HF were documented, apart from a higher prevalence of mild AR in the CAD-HF group. Patients with moderate-to-severe valvular regurgitation demonstrated worse cardiopulmonary performance, regardless of ejection fraction, highlighting the important role of CPET in evaluating the functional impact of valvular heart disease in this population.