Rice J; Department of Internal Medicine, Galveston, TX 77555, USA.
Furqan Y; Elbanna S; O’Leary C; et al

ESC heart failure. 13(5), 2026 Aug 27.

BACKGROUND AND AIMS: Cardiopulmonary exercise testing (CPET) carries a
Class I recommendation for advanced heart failure (HF) therapy candidacy.
Whether CPET utilization and outcomes differ by race is unknown.

METHODS: Using TriNetX, adults with HF (ICD-10 I50.x, 2010-23) were
stratified by race/ethnicity and CPET receipt (CPT 94621) within 1 year of
diagnosis. All-cause mortality and HF hospitalization were assessed at 1,
3, and 5 years after 1:1 propensity score matching for demographics, HF
subtype, comorbidities, and guideline-directed medical therapy.

RESULTS: Among 807 379 patients with HF (mean age 69.2 years, 46.2%
female), 10 268 (1.27%) underwent CPET within 1 year. Utilization was
1.39% in White, 1.20% in Black, 0.69% in Hispanic, and 0.79% in Asian
patients. After matching, 8355 pairs were analysed. CPET was associated
with lower 1-year mortality in White (hazard ratio [HR] 0.58, 95% CI
0.51-0.65, P < .001) and Hispanic (HR 0.50, 0.25-0.98, P = .040) patients.
Asian patients reached borderline significance at 5 years (HR 0.54,
0.29-1.00, P = .048). Black patients showed a non-significant trend
(1-year HR 0.70, 0.39-1.24, P = .214). HF hospitalization was higher in
White (1-year HR 1.18, 1.14-1.23, P < .001) and Asian (HR 1.73, 1.35-2.21,
P < .001) CPET recipients, suggesting surveillance bias.

CONCLUSIONS: CPET utilization was associated with lower mortality in
White and Hispanic patients, with borderline significance in Asian
patients at 5 years and a non-significant trend in Black patients. These
associations may reflect engagement with speciality HF care rather than
testing itself. Minority patients were under-represented among CPET
recipien