Chronotropic Incompetence Limits Aerobic Exercise Capacity in Patients Taking Beta-Blockers: Real-Life Observation of Consecutive Patients

Background: Chronotropic incompetence in patients taking beta-blockers is associated with poor prognosis; however, its impact on exercise capacity (EC) remains unclear. Methods: We analyzed data from consecutive patients taking beta-blockers referred for cardiopulmonary exercise testing to assess EC. Chronotropic incompetence was defined as chronotropic index (CI) ≤ 62%. Results: Among 140 patients all taking beta-blockers (age 61 ± 9.7 years; 73% males), 64% with heart failure, chronotropic incompetence was present in 80.7%. EC assessed as peak oxygen uptake was lower in the group with chronotropic incompetence, 18.3 ± 5.7 vs. 24.0 ± 5.3 mL/kg/min, p < 0.001. EC correlated positively with CI (β = 0.14, p < 0.001) and male gender (β = 5.12, p < 0.001), and negatively with age (β = −0.17, p < 0.001) and presence of heart failure (β = −3.35, p < 0.001). Beta-blocker dose was not associated with EC. Partial correlation attributable to CI accounted for more than one-third of the variance in EC explained by the model (adjusted R2 = 59.8%). Conclusions: In patients taking beta-blockers, presence of chronotropic incompetence was associated with lower EC, regardless of the beta-blocker dose. CI accounted for more than one-third of EC variance explained by our model.

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Chronotropic Incompetence Limits Aerobic Exercise Capacity in Patients Taking Beta-Blockers

10.1101/2020.07.15.20149005 ◽

2020 ◽

Author(s):

Maciej Tysarowski ◽

Krzysztof Smarz ◽

Beata Zaborska ◽

Ewa Pilichowska-Paszkiet ◽

Malgorzata Sikora-Frac ◽

...

Keyword(s):

Exercise Capacity ◽

Beta Blocker ◽

Partial Correlation ◽

Beta Blockers ◽

Cardiopulmonary Exercise Testing ◽

Peak Oxygen Uptake ◽

Chronotropic Incompetence ◽

Peak Vo2 ◽

Aerobic Exercise Capacity ◽

Variance Explained

Background: Chronotropic incompetence in patients taking beta-blockers is associated with poor prognosis; however, its impact on exercise capacity (EC) remains unclear. Methods: We retrospectively analyzed data from consecutive patients taking beta-blockers referred for cardiopulmonary exercise testing. EC was expressed as peak oxygen uptake (peak VO2; mL/kg/min). Chronotropic incompetence was defined as chronotropic index (CI) ≤ 62%. CI was calculated as [(HR at peak-HR at rest) / (maximum predicted HR-HR at rest)] x 100%. Results: Among 140 patients all taking beta-blockers (age 61 ± 9.7 years; 73% males), there were 113 (80.7%) patients with chronotropic incompetence. EC was lower in the group with chronotropic incompetence than the group without it, peak VO2 18.3 ± 5.7 vs. 24.0 ± 5.3 mL/kg/min, p < 0.001. In multivariate analysis EC correlated positively with CI (β = 0.14, p < 0.001) and male gender (β = 5.12, p < 0.001), and negatively with age (β = −0.17, p < 0.001) and presence of heart failure (β = −3.35, p < 0.001). Beta-blocker dose was not associated with EC. Partial correlation attributable to CI accounted for more than one-third of the variance in EC explained by the model. Conclusions: In patients taking beta-blockers, presence of chronotropic incompetence was associated with lower EC, regardless of the beta-blocker dose. CI accounted for more than one-third of EC variance explained by our model.

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Abstract 16002: Chronotropic Incompetence Limits Exercise Capacity in Patients Taking Beta-Blockers

Circulation ◽

10.1161/circ.142.suppl_3.16002 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Maciej Tysarowski ◽

Krzysztof Smarz ◽

Beata Zaborska ◽

Ewa Pilichowska-Paszkiet ◽

Malgorzata Sikora-Frac ◽

...

Keyword(s):

Exercise Capacity ◽

Beta Blocker ◽

Partial Correlation ◽

Beta Blockers ◽

Cardiopulmonary Exercise Testing ◽

Peak Oxygen Uptake ◽

Male Gender ◽

Chronotropic Incompetence ◽

Cardiopulmonary Exercise ◽

Variance Explained

Introduction: Chronotropic incompetence in patients taking beta-blockers is associated with poor prognosis; however, its impact on exercise capacity (EC) remains unclear. Hypothesis: We assessed the hypothesis that chronotropic incompetence is associated with decreased exercise capacity in patients taking beta-blockers. Methods: We retrospectively analyzed data from consecutive patients taking beta-blockers referred for cardiopulmonary exercise testing. EC was expressed as peak oxygen uptake (VO 2 peak; mL/kg/min). Chronotropic incompetence was defined as chronotropic index (CI) ≤ 62%. CI was calculated as [(HR at peak-resting HR) / (maximum predicted HR-resting HR)] х 100%. Results: Among 140 patients all taking beta-blockers (age 61 ± 9.7 years; 73% males), there were 113 (80.7%) patients with chronotropic incompetence. EC was lower in the group with chronotropic incompetence than the group without it, VO 2 peak 18.3 ± 5.7 vs. 24.0 ± 5.3 mL/kg/min, p < 0.001. In multivariate analysis ( Table ), EC correlated positively with CI (β = 0.14, p < 0.001) and male gender (β = 5.12, p < 0.001), and negatively with age (β = –0.17, p < 0.001) and presence of heart failure (β = –3.35, p < 0.001). Beta-blocker dose was not associated with EC. Partial correlation attributable to CI (partial R 2 = 24.7%) accounted for more than one-third of the variance in EC explained by the model (adjusted R 2 = 59.8%). Conclusions: In patients taking beta-blockers, the presence of chronotropic incompetence was associated with lower EC, regardless of the beta-blocker dose. CI accounted for more than one-third of EC variance explained by our model.

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Abstract 17499: Addition of Myocardial Parameters to the Diagnosis of Stage B Heart Failure

Circulation ◽

10.1161/circ.130.suppl_2.17499 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Tom Marwick ◽

Wojciech Kosmala ◽

Christine Jellis

Keyword(s):

Heart Failure ◽

At Risk ◽

Heart Disease ◽

Ischemic Heart Disease ◽

Exercise Capacity ◽

Beta Blockers ◽

Cardiopulmonary Exercise Testing ◽

Structural Heart Disease ◽

Filling Pressure ◽

Ischemic Heart

Introduction: Stage B heart failure (BHF, asymptomatic structural heart disease) is diagnosed in the presence of myocardial scar or impaired LVEF. However, the insensitivity of LVEF may lead to under-recognition of BHF in non-ischemic heart disease. This may be important, as BHF may precede the onset of HF symptoms, and necessitates the initiation of treatment. We sought the implications of using additional LV assessment to identify BHF in pts at risk of HF (stage A HF, AHF). Methods: We studied 510 asymptomatic pts (age 58±12yrs) with AHF (diabetes, hypertension or obesity), but no history of ischemic heart disease and a normal stress echo. All pts underwent echocardiography (including assessment of strain and diastolic dysfunction) and cardiopulmonary exercise testing. Results: BHF was defined as the presence of at least one of; reduced LV longitudinal strain (<18%), increased LV filling pressure (E/e’>13) or moderate-to-severe LV hypertrophy (LV mass index ≥109 g/m 2 in women and 132 g/m 2 in men) in 243 patients (47%). Reduced exercise capacity (peakVO 2 and METS) was identified in BHF compared with other AHF (Table). Using this definition, BHF was associated with lower peak VO 2 (β=-0.20, p<0.00001) and METS (β=-0.21, p<0.0001), independent of higher BMI, insulin resistance, older patient age, male sex and treatment with beta-blockers. Conclusions: LV hypertrophy, elevated LV filling pressure elevation and abnormal myocardial deformation independently contribute to lower exercise capacity in pts at risk of HF. Given the association of exercise capacity with outcome, these factors should be considered grounds for the diagnosis of BHF.

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Abstract 17050: Association of Kidney Dysfunction with Chronotropic Incompetence in Heart Failure with Preserved Ejection Fraction

Circulation ◽

10.1161/circ.130.suppl_2.17050 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

David A Klein ◽

Daniel H Katz ◽

Lauren Beussink-Nelson ◽

Theresa A Strzelczyk ◽

Sanjiv J Shah

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Regression Models ◽

Beta Blockers ◽

Cardiopulmonary Exercise Testing ◽

Systolic Pressure ◽

Maximal Heart Rate ◽

Preserved Ejection Fraction ◽

Chronotropic Incompetence ◽

Chronotropic Response

Introduction: Chronotropic incompetence (CI) is an important pathophysiologic factor underlying reduced exercise capacity in heart failure with preserved ejection fraction (HFpEF), but clinical factors associated with CI in HFpEF are unknown. Based on anecdotal clinical experience, we hypothesized that coronary artery disease (CAD) and chronic kidney disease (CKD) are associated with CI in HFpEF. Methods: We studied 157 consecutive HFpEF patients undergoing cardiopulmonary exercise testing, and defined CI as maximal heart rate (HR) < 80% of estimated HR reserve (< 65% if using beta-blockers). Participants who achieved inadequate exercise effort (respiratory exchange ratio [RER] ≤ 1.05) were excluded. Unadjusted and multivariable-adjusted regression models were used to determine correlates of CI. Results were re-assessed using alternative formulations of chronotropic response. Results: Of 157 participants, 73% were women, 64% used beta-blockers, 32% had CKD, and 40% had CAD. RER > 1.05 was achieved by 108 (69%) participants, including 79/108 (76%) with CI. Lower estimated GFR, higher B-type natriuretic peptide, and higher pulmonary artery systolic pressure (but not CAD) were each associated with CI. A 1-SD decrease in GFR was independently associated with CI (adjusted odds ratio = 2.4, 95% confidence interval = [1.3, 4.6]) after adjustment for smoking status, log BNP, and beta blocker usage. Linear regression models demonstrated that GFR was independently and linearly associated with %HR reserve (β=0.31, SE=0.10; P=0.002; Figure). Findings were unchanged after re-calculation of %HR reserve and CI based on alternative formulations used in the literature. Conclusions: CI is common and strongly associated with GFR in HFpEF. Our results indicate that kidney function may mark or contribute to the development of CI in HFpEF. HFpEF patients with CKD may need to be screened for CI prior to starting medications (e.g., beta blockers) that could exacerbate CI.

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P3517Failure to achieve adequate heart rate control in women during therapy optimization

European Heart Journal ◽

10.1093/eurheartj/ehz745.0381 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

V Kutyifa ◽

J W Erath ◽

A Burch ◽

B Assmus ◽

D Bondermann ◽

...

Keyword(s):

Heart Failure ◽

Heart Rate ◽

Beta Blocker ◽

Rate Control ◽

Beta Blockers ◽

Heart Rate Control ◽

Blocker Therapy ◽

Cardioverter Defibrillator ◽

Beta Blocker Therapy ◽

The Mean

Abstract Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR <70 bpm at the end of the 3 months. Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

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Abstract 13135: Starting Beta-blockers in Hypertension is Followed by Excess Loop Diuretic Use: Beta-blocker Induced Heart Failure?

Circulation ◽

10.1161/circ.142.suppl_3.13135 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Daniel N Silverman ◽

Jeanne d de Lavallaz ◽

Timothy B Plante ◽

Margaret M Infeld ◽

Markus Meyer

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blocker ◽

Antihypertensive Medication ◽

Temporal Relationship ◽

Loop Diuretic ◽

Beta Blockers ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction

Introduction: Recent investigation has identified that discontinuation of beta-blockers in subjects with normal left ventricular ejection fraction (LVEF) leads to a reduction in natriuretic peptide levels. We investigated whether a similar trend would be seen in a hypertension clinical trial cohort. Methods: In 9,012 subjects hypertensive subjects without a history of symptomatic heart failure, known LVEF <35% or recent heart failure hospitalization enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT), we compared incidence of loop diuretic initiation and time to initiation following start of a new anti-hypertensive medication. The categorical relationship (new antihypertensive class followed by loop-diuretic use) and temporal relationship (time to loop diuretic initiation) were each analyzed. The categorical relationship was assessed using a Pearson’s chi-squared test and the temporal relationship using a Wilcoxon rank sum test. Bonferroni-corrected p-values were utilized for all comparisons. Results: Among the 9,012 subjects analyzed, the incidence of anti-hypertensive initiation and loop diuretic initiation was greatest following start of a beta-blocker (16.6%) compared with other antihypertensive medication classes (calcium channel blocker 13.8%, angiotensin converting enzyme-inhibitor/angiotensin receptor blocker 12.9% and thiazide diuretic 10.2%; p<0.001). In addition, the median time between starting a new antihypertensive medication and loop diuretic was the shortest for beta-blockers and longest for thiazides (both p <0.01). No significant differences in renal function were identified between groups. Conclusion: Compared to other major classes of hypertensive agents, starting beta-blockers was associated with more common and earlier initiation of a loop diuretics in a population without heart failure at baseline. This finding may suggest beta-blocker induced heart failure in a population with a predominantly normal ejection fraction.

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The Impact of Treatment with Beta-Blockers upon Mortality in Chronic Heart Failure Patients

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2016.022 ◽

2016 ◽

Vol 4 (1) ◽

pp. 94-97 ◽

Cited By ~ 1

Author(s):

Borjanka Taneva ◽

Daniela Caparoska

Keyword(s):

Heart Failure ◽

Relative Risk ◽

Chronic Heart Failure ◽

Beta Blocker ◽

Cardiovascular Mortality ◽

Conventional Therapy ◽

Therapy Group ◽

Beta Blockers ◽

Control Group ◽

Heart Failure Patients

BACKGROUND: Besides the conventional therapy for heart failure, the diuretics, cardiac glycosides and ACE-inhibitors, current pharmacotherapy includes beta-blockers, mainly because of their pathophysiological mechanisms upon heart remodeling.AIM: The study objective was to assess the cardiovascular mortality in the beta-blocker therapy group and to correlate it with the mortality in the control group as well as to correlate the combined outcome of death and/or hospitalization for cardiovascular reason between the two groups. MATERIALS AND METHODS: The study included 113 chronic heart failure patients followed up for a period of 18 months. The therapy group received conventional therapy plus the target dose of beta blockers, and the control group received the conventional therapy only. The therapy group was divided in three separate subgroups in terms of the type of beta-blocker (Metoprolol subgroup, Bisoprolol and Carvedilol subgroup). To compare the mortality and the combined outcome, the RRR (relative risk reduction) and NNT (number needed to treat) were used, as well as the survival analysis by Kaplan-Meier.RESULTS: The results showed the following: in regards of the cardiovascular mortality, the relative risk for death in the therapy group was 34%, which, though statistically not significant, is of great clinical significance. In regards of the combined outcome (death and/or number of hospitalizations) the results showed a RRR of 40% in the therapy group compared to the control group, which is statistically highly significant.CONCLUSION: The study confirmed that patients with stable chronic heart failure, treated with optimal doses of beta-blockers, show a significant reduction of the risk from death as well as combined outcome (death and/or number of hospitalizations).

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Abstract P113: Use of Guideline Recommended Therapies for Heart Failure in Outpatient Settings Among Medicare Beneficiaries

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.ap113 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Lisa D DiMartino ◽

Alisa Shea ◽

Adrian F Hernandez ◽

Lesley H Curtis

Keyword(s):

Heart Failure ◽

Beta Blocker ◽

Ace Inhibitor ◽

Beta Blockers ◽

Multivariable Analysis ◽

Community Dwelling ◽

Drug Coverage ◽

Self Report ◽

Medicare Beneficiaries ◽

Over Time

Background: Most information about the use of guideline recommended therapies for heart failure (HF) is based on what occurs at discharge following an inpatient stay. Using a nationally representative, community-dwelling sample of elderly Medicare beneficiaries, we examined how use of angiotensin-converting enzyme (ACE) inhibitor, angiotensin-receptor blocker (ARB), and beta-blocker therapies has changed over time and factors associated with their use. Methods: We used data from the Medicare Current Beneficiary Survey Cost and Use files matched with Medicare claims to identify beneficiaries for whom a diagnosis of HF was reported from January 1, 2000-December 31, 2004. Medications prescribed during the calendar year of cohort entry were obtained from patient self-report. We used descriptive statistics to examine prescription medication use over time. Multivariable logistic regression was used to explore the relationship between use of an ACE inhibitor/ARB or beta blocker and patient demographics. Results: There were 2,689 unweighted, or 8,288,306 weighted, elderly, community-dwelling Medicare beneficiaries with HF identified. Between 2000 and 2004, the reported use of ARBs increased from 12% (unweighted, 88/725) to 19% (unweighted, 82/421), while use of beta-blockers increased from 30% (unweighted, 215/725) to 41% (unweighted, 170/421). Use of ACE inhibitors remained constant at 45% (unweighted 2000, 329/725; unweighted 2004, 192/421). In multivariable analysis, beneficiaries reporting any prescription drug coverage were 32% (95%CI=1.09-1.59) more likely to have filled a prescription for an ACE inhibitor/ARB and 26% (95%CI=1.03-1.53) more likely to have filled a prescription for a beta-blocker. Compared to beneficiaries diagnosed with HF in 2000, beneficiaries diagnosed in 2004 were 38% (95%CI=1.06-1.79) more likely to have filled a prescription for an ACE inhibitor/ARB and 62% (95%CI=1.23-2.13) more likely to have filled a prescription for a beta-blocker. Conclusion: Although use of guideline recommended therapies for HF has increased over time, their use remains suboptimal. Further efforts are necessary in order to ensure all Medicare beneficiaries have adequate drug coverage for these therapies.

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P1666Do beta-blockers increase the risk for hospitalizations in heart failure with preserved ejection fraction? A secondary analysis of beta-blocker use in the TOPCAT trial

European Heart Journal ◽

10.1093/eurheartj/ehz748.0424 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

D N Silverman ◽

T B Plante ◽

M I Infeld ◽

S P Juraschek ◽

G Dougherty ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blocker ◽

Proportional Hazards ◽

Beta Blockers ◽

Secondary Analysis ◽

Cox Proportional Hazards ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Reduced Ejection Fraction

Abstract Background The use of beta-blockers for treatment of heart failure (HF) with a reduced ejection fraction (EF) is unequivocally beneficial, but their role in the treatment of preserved EF (HFpEF) remains unclear. Purpose In a contemporary HFpEF cohort, we sought to assess the association of HF hospitalizations and the use of beta-blockers in patients with an EF above and below 50%. Methods The TOPCAT trial tested spironolactone vs. placebo among patients with HFpEF, including some with mild reductions in EF between 45–50%. The primary outcome was a composite of cardiovascular (CV) mortality, aborted cardiac arrest, or HF hospitalizations. Medication use, including beta-blockers, was reported at each visit and hospitalization. In the 1,761 participants from the Americas, we compared the association of beta-blocker use (vs. no use) and HF hospitalization or CV mortality using Cox proportional hazards models adjusted for baseline demographics, history of myocardial infarction, atrial fibrillation, chronic obstructive pulmonary disease, asthma, and hypertension. The analyses were repeated in the EF strata ≥50% and <50%. Results Among patients included in the current analysis (mean age 72 years, 50% female, 78% white), 1,496/1,761 (85%) received beta-blockers and 1,566/1,761 (89%) had an EF ≥50%. HF hospitalizations and CV mortality occurred in 399/1,761 (23%) and 223/1,761 (13%) of participants, respectively. Beta-blocker use was associated with an increase in risk of HF hospitalization among patients with preserved EF ≥50% [HR 1.56, (95% CI 1.09–2.24), p=0.01] and was associated with a reduction in risk of hospitalization in patients with an EF <50% [HR 0.42, (95% CI 0.18- 0.99), p<0.05]. We found a significant interaction for EF threshold and beta-blocker use on incident HF hospitalizations (p=0.01). There were no differences in CV mortality. Figure 1. Kaplan Meier incidence plots Conclusions Beta-blocker use was associated with an increase in HF hospitalizations in patients with HFpEF (EF≥50%) but did not affect CV mortality. Further research is needed to confirm these findings and elucidate causality.

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Mismatch between self-estimated and objectively assessed exercise capacity in patients with congenital heart disease varies in regard to complexity of cardiac defects

Cardiology in the Young ◽

10.1017/s1047951120003406 ◽

2020 ◽

pp. 1-7

Author(s):

Julius M. Woile ◽

Stefan Dirks ◽

Friederike Danne ◽

Felix Berger ◽

Stanislav Ovroutski

Keyword(s):

Congenital Heart Disease ◽

Heart Disease ◽

Oxygen Uptake ◽

Exercise Capacity ◽

Congenital Heart ◽

Cardiopulmonary Exercise Testing ◽

Peak Oxygen Uptake ◽

Subjective Rating ◽

Cardiac Defects ◽

Cardiopulmonary Exercise

Abstract Aim: Regular evaluation of physical capacity takes a crucial part in long-term follow-up in patients with congenital heart disease (CHD). This study aims to examine the accuracy of self-estimated exercise capacity compared to objective assessments by cardiopulmonary exercise testing in patients with CHD of various complexity. Methods: We conducted a single centre, cross-sectional study with retrospective analysis on 382 patients aged 8–68 years with various CHD who completed cardiopulmonary exercise tests. Peak oxygen uptake was measured. Additionally, questionnaires covering self-estimation of exercise capacity were completed. Peak oxygen uptake was compared to patient’s self-estimated exercise capacity with focus on differences between complex and non-complex defects. Results: Peak oxygen uptake was 25.5 ± 7.9 ml/minute/kg, corresponding to 75.1 ± 18.8% of age- and sex-specific reference values. Higher values of peak oxygen uptake were seen in patients with higher subjective rating of exercise capacity. However, oxygen uptake in patients rating their exercise capacity as good (mean oxygen uptake 78.5 ± 1.6%) or very good (mean oxygen uptake 84.8 ± 4.8%) was on average still reduced compared to normal. In patients with non-complex cardiac defects, we saw a significant correlation between peak oxygen uptake and self-estimated exercise capacity (spearman-rho −0.30, p < 0.001), whereas in patients with complex cardiac defects, no correlation was found (spearman-rho −0.11, p < 0.255). Conclusion: The mismatch between self-estimated and objectively assessed exercise capacity is most prominent in patients with complex CHD. Registration number at Charité Universitätsmedizin Berlin Ethics Committee: EA2/106/14.

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