Similar predictive value of six-minute walking distance and B-type natriuretic peptide in heart failure with reduced to mid-range ejection fraction


  • Angela Beatrice Scardovi | Cardiology Division, Santo Spirito Hospital, Rome, Italy.
  • Renata De Maria CNR Clinical Physiology Institute, ASST Great Metropolitan Hospital Niguarda, Milan, Italy.
  • Gian Giacomo Galeotti Cardiac, Thoracic and Vascular Department, University of Pisa, Italy.
  • Pompilio Faggiano Cardiology Department, University of Brescia, Italy.
  • Luca Arcari Cardiology Division, Santo Spirito Hospital; Clinical and Molecular Medicine Department, Sapienza University of Rome, Italy.
  • Stefano Ghio Cardiology Division, IRCCS Policlinico San Matteo, Pavia, Italy.
  • Pier Luigi Temporelli Division of Cardiology, ICS Maugeri, IRCCS Veruno, Italy.
  • Andrea Rossi Department of Medicine, Section of Cardiology, University of Verona, Italy.
  • Giovanna Magni QBGROUP Spa, Padua, Italy.
  • Anca Simioniuc Cardiac, Thoracic and Vascular Department, University of Pisa, Italy.
  • Roberto Ricci Cardiology Division, Santo Spirito Hospital, Rome, Italy.
  • Frank Lloyd Dini Cardiac, Thoracic and Vascular Department, University of Pisa, Italy.


The prognostic insights of heart failure (HF) with mid-range (40-49%) ejection fraction (HFmrEF) are not fully elucidated. We investigated whether the six-minutes walking test (6MWT) and brain natriuretic peptide (BNP) are predictive of outcome across the spectrum of LV systolic dysfunction and whether the HFmrEF cut-off impacts the risk stratification abilities of these tests. We studied 538 outpatients, aged 70±12 years, 28% females, with stable chronic HF and EF<50%, 349 with HFmrEF and 189 with HFrEF. End-points were all-cause and cardiac death. HFrEF patients were more often male, with ischemic etiology, severe symptoms, higher BNP levels, and cardiac mortality than HFmrEF subjects. During 32 (15-46) months follow-up, 123 (23%) patients died, 95 (18%) for cardiac causes. Cut-offs of 125 pg/ml for BNP and 360 meters for 6MWT distance were associated with lower all-cause (10% vs 38%, p<0.001 and 10% vs 26%, p<0.001, respectively) and cardiac mortality (6% vs 36%, p<0.001 and 8% vs 23%, p<0.001, respectively). BNP (HR 2.144, 95%CI, 1.403-3.276) and 6MWT walked distance (HR 1.923, 95%CI, 1.195-3.096) independently predicted outcome, after adjustment for age, gender, obesity, kidney dysfunction, ischemic etiology, NYHA class, unlike the 40% LVEF threshold. Model discrimination and survival differences were significant across LVEF strata. Higher BNP levels and shorter walked distance combined identified patients (26% overall) at particularly poor prognosis in both phenotype groups. Despite differences between HFmrEF and HFrEF patients in clinical and biomarker profile, BNP levels and 6MWT walked distance retain prognostic value over the entire spectrum of LV systolic dysfunction.



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Cardiology - Original Articles
Heart failure, mid-range ejection fraction, 6-minute walking test, BNP
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How to Cite
Scardovi, Angela Beatrice, Renata De Maria, Gian Giacomo Galeotti, Pompilio Faggiano, Luca Arcari, Stefano Ghio, Pier Luigi Temporelli, Andrea Rossi, Giovanna Magni, Anca Simioniuc, Roberto Ricci, and Frank Lloyd Dini. 2019. “Similar Predictive Value of Six-Minute Walking Distance and B-Type Natriuretic Peptide in Heart Failure With Reduced to Mid-Range Ejection Fraction”. Monaldi Archives for Chest Disease 89 (2).

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