Increased vulnerability of COPD patient groups to urban climate in view of global warming.

PURPOSE: Patients with COPD show an increase in acute exacerbations (AECOPD) during the cold season as well as during heat waves in the summer months. Due to global climate changes, extreme weather conditions are likely to occur more frequently in the future. The goal of this study was to identify patient groups most at risk of exacerbations during the four seasons of the year and to determine at which temperature threshold the daily hospital admissions due to AECOPD increase during the summer. PATIENTS AND METHODS: We analyzed retrospective demographic and medical data of 990 patients, who were hospitalized for AECOPD in Berlin, Germany. The cases were grouped into the following cohorts: "spring" (admission between March and May), "summer" (June - August), "autumn" (September - November), and "winter" (December - February). AECOPD hospital admissions from 2006 and 2010 were grouped into a "hot summer" cohort and cases from 2011 and 2012 into a "cold summer" data-set. Climate data were obtained from the German Meteorological Office. RESULTS: Patients hospitalized for a COPD exacerbation during winter were significantly older than summertime patients (P=0.040) and also thinner than patients exacerbating in spring (P=0.042). COPD exacerbations during hot summer periods happened more often to patients with a history of myocardial infarction (P=0.014) or active smokers (P=0.011). An AECOPD during colder summers occurred in patients with a higher Charlson index, who suffered in increased numbers from peripheral vascular diseases (P=0.016) or tumors (P=0.004). Summertime hospital admissions increased above a daily minimum temperature of 18.3°C (P=0.006). CONCLUSION: The identification of COPD patient groups most at risk for climate related exacerbations enables climate-adapted prevention through patient guidance and treatment. In view of global climate changes, discovering vulnerabilities and implementing adaptive measures will be of growing importance.

Redefining Cut-Points for High Symptom Burden of the Global Initiative for Chronic Obstructive Lung Disease Classification in 18,577 Patients With Chronic Obstructive Pulmonary Disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) can be classified into groups A/C or B/D based on symptom intensity. Different threshold values for symptom questionnaires can result in misclassification and, in turn, different treatment recommendations. The primary aim was to find the best fitting cut-points for Global initiative for chronic Obstructive Lung Disease (GOLD) symptom measures, with an modified Medical Research Council dyspnea grade of 2 or higher as point of reference. METHODS: After a computerized search, data from 41 cohorts and whose authors agreed to provide data were pooled. COPD studies were eligible for analyses if they included, at least age, sex, postbronchodilator spirometry, modified Medical Research Council, and COPD Assessment Test (CAT) total scores. MAIN OUTCOMES: Receiver operating characteristic curves and the Youden index were used to determine the best calibration threshold for CAT, COPD Clinical Questionnaire, and St. Georges Respiratory Questionnaire total scores. Following, GOLD A/B/C/D frequencies were calculated based on current cut-points and the newly derived cut-points. FINDINGS: A total of 18,577 patients with COPD [72.0% male; mean age: 66.3 years (standard deviation 9.6)] were analyzed. Most patients had a moderate or severe degree of airflow limitation (GOLD spirometric grade 1, 10.9%; grade 2, 46.6%; grade 3, 32.4%; and grade 4, 10.3%). The best calibration threshold for CAT total score was 18 points, for COPD Clinical Questionnaire total score 1.9 points, and for St. Georges Respiratory Questionnaire total score 46.0 points. CONCLUSIONS: The application of these new cut-points would reclassify about one-third of the patients with COPD and, thus, would impact on individual disease management. Further validation in prospective studies of these new values are needed.

The Effects of Climate Change on Patients With Chronic Lung Disease. A Systematic Literature Review.

BACKGROUND: Ever since higher overall mortality rates due to heat stress were reported during the European heat waves of 2003 and 2006, the relation between heat waves and disease-specific events has been an object of scientific study. The effects of heat waves on the morbidity and mortality of persons with chronic lung disease remain unclear. METHODS: We conducted a systematic search using PubMed, the Cochrane Library, and Google Advanced Search to identify relevant studies published between 1990 and 2015. The reference lists of the primarily included articles were searched for further pertinent articles. All articles were selected according to the PRISMA guidelines. The heat-wave-related relative excess mortality was descriptively expressed as a mean daily rate ratio ([incidence 1]/[incidence 2]), and the cumulative excess risk (CER) was expressed in percent. RESULTS: 33 studies with evaluable raw data concerning the effect of heat waves on patients with chronic lung disease (chronic obstructive pulmonary disease, bronchial asthma, pulmonary arterial hypertension, and idiopathic pulmonary fibrosis) were analyzed in this review. By deriving statistics from the overall data set, we arrived at the conclusion that future heat waves will-with at least 90% probability-result in a mean daily excess mortality (expressed as a rate ratio) of at least 1.018, and-with 50% probability-in a mean daily excess mortality of at least 1.028. These figures correspond, respectively, to 1.8% and 2.8% rises in the daily risk of death. CONCLUSION: Heat waves significantly increase morbidity and mortality in patients with chronic lung disease. The argument that the excess mortality during heat waves is compensated for by a decrease in mortality in the subsequent weeks/months (mortality displacement) should not be used as an excuse for delay in implementing adaptive strategies to protect lung patients from this risk to their health.

An official European Respiratory Society statement on physical activity in COPD.

This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force of experts representing the ERS Scientific Group 01.02 "Rehabilitation and Chronic Care" determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5-8 years).

Heat stress is associated with reduced health status in pulmonary arterial hypertension: a prospective study cohort.

BACKGROUND: Summer heat waves with temperature extremes are becoming more frequent with growing numbers in morbidity and mortality in patients with respiratory diseases. The aim of this study was to evaluate the ramifications of heat stress (temperature >25 °C) on the health status of patients with pulmonary arterial hypertension (PAH). METHODS: Fifteen patients with PAH (mean age = 66.7 ± 5.2 years) continuously wore an accelerometer from April 1 to September 30, 2011, and their daily step count was recorded. In addition, patients kept a diary to record data on seven standardized questions regarding their daily symptoms. Echocardiography, 6-minute walk test, NTproBNP, and Modified Medical Research Council Scale (MMRC) were assessed at baseline and at the end of the study after 6 months. RESULTS: On heat-stress days, patients showed significantly more symptoms and lower total steps/day compared to thermal comfort days (3,995 ± 2,013 steps/day vs. 5,567 ± 2,434 steps/day, respectively; P < 0.001). There was a significant negative correlation between total steps/day and Temp(max) (R = -0.47; P < 0.001) and humidity (R = -0.34; P < 0.001). A significant positive correlation was found between daily symptoms and Temp(max) (R = +0.79; P < 0.001) and humidity (R = +0.23; P < 0.001). CONCLUSIONS: Heat stress is associated with a compromised clinical status in patients with PAH. Adaptation strategies must be implemented to prevent heart-related morbidity, including therapeutic adjustments and adequate room cooling in the patient's home and at the hospital.

Tele-monitoring reduces exacerbation of COPD in the context of climate change--a randomized controlled trial.

BACKGROUND: A home based tele-monitoring system was developed to assess the effects of heat stress (days > 25°C) on clinical and functional status in patients with chronic obstructive pulmonary disease (COPD). METHODS: Sixty-two COPD patients (GOLD II-IV) were randomized into a tele-monitoring Group (TG, N = 32) or Control Group (CG, N = 30). Tele-monitoring included 1) daily clinical status (COPD Assessment Test-CAT), 2) daily lung function and 3) weekly 6-minute walk test (6MWT). Duration of monitoring lasted a total of nine months (9 M). RESULTS: From June 1st-August 31st 2012, 32 days with heat stress (29.0 ± 2.5°C) were recorded and matched with 32 thermal comfort days (21.0 ± 2.9°C). During heat stress, the TG showed a significant reduction in lung function and exercise capacity (FEV1% predicted: 51.1 ± 7.2 vs. 57.7 ± 5.0%; P <0.001 and 6MWT performance: 452 ± 85 vs. 600 ± 76 steps; P <0.001) and increase in CAT scores (19.2 ± 7.9 vs. 16.2 ± 7.2; P <0.001).Over summer, significantly fewer TG patients suffered exacerbation of COPD compared to CG patients (3 vs. 14; P = 0.006). Over entire 9 M follow-up, the TG group had fewer exacerbations compared to CG (7 vs. 22; P = 0.012), shorter cumulative hospital stay (34 vs. 97 days) and 43% fewer specialist consultations (24. vs. 42; P = 0.04). CONCLUSION: Heat stress affects clinical and functional status in COPD. Tele-monitoring reduces exacerbation frequency and health care utilization during heat stress and other periods of the year. TRIAL REGISTRATION DRKS-ID: DRK00000705.

Tele-accelerometry as a novel technique for assessing functional status in patients with heart failure: feasibility, reliability and patient safety.

BACKGROUND: The six-minute walk test (6MWT) is an established measure of functional exercise capacity associated with clinical prognosis in Chronic Heart Failure (CHF). The aim of this study is to evaluate the employment of tele-accelerometry for the remote assessment of 6MWT in CHF. METHODS: 155 patients were subjected to tele-accelerometry in form of monthly 6MWTs in their home surroundings. Accelerometer output included steps/6 min and walking speed. Data was directly transferred via mobile network to the Telemedicine Centre subsequent to test completion. 6MWT distance was measured by hand wheel and steps were counted with a digital hand-counter at baseline (Test 1) and at 12 months follow-up (Test 2). RESULTS: Accelerometer accuracy was within the 99th percentile. There was a significant correlation between step count, walking speed and measured 6MWT distance (Test 1: steps: r=0.80, P<0.001; Test 2: steps: r=0.90, P<0.001 and Walking Speed Test 1: r=0.80, P<0.001; Walking Speed Test 2: r=0.86, P<0.001). The reproducibility of tele-accelerometry was within 95% margin for all performance parameters, which showed stronger associations to quality of life questionnaire (Short Form - 36) Physical Component Score (PCS) than New York Heart Association (NYHA) functional class. CONCLUSION: Tele-accelerometry is feasible in patients with CHF and output parameters are indicative of exercise capacity. The benefit of this approach lies in its simplicity under every day circumstances by enabling routine performance testing to assess patients' functional status.

Associations of daily walking activity with biomarkers related to cardiac distress in patients with chronic obstructive pulmonary disease.

BACKGROUND: The prevalence of cardiovascular mortality is high in Chronic Obstructive Pulmonary Disease (COPD) and the identification of clinical parameters to improve risk stratification is of great interest. OBJECTIVES: This study aims to assess the predictive strength of daily walking activity on expression of cardiac biomarkers in patients with COPD. METHODS: One hundred and five patients with COPD (66.1 ± 8.7 years of age) were prospectively analyzed. Daily walking activity was measured by means of accelerometry. Stepwise multivariate regression analyses were employed with either midregional proatrial natriuretic peptide (MRproANP) or plasma proadrenomedullin (MRproADM) as dependent variables, and age, age-adjusted Charlson score, Modified Medical Research Council Dyspnea Scale (MMRC), Saint Georges Respiratory Questionnaire total score and either total walk, steps per day or fast walk as covariates. RESULTS: Independent predictors of MRproANP included age (p = 0.015) and either total walk or steps per day (both p < 0.0001). Total walk or steps per day were the only independent predictors of MRproADM (p < 0.0001). There was a significant negative correlation between fast walk and MMRC (R = -0.70; p < 0.001) and fast walk was only independently predictive of MRproANP but not MRproADM once MMRC was excluded from the list of covariates (p = 0.023 and p = 0.057, respectively). CONCLUSIONS: Daily walking activity independently predicts levels of circulating MRproANP and MRproADM in stable COPD patients, two prognostic biomarkers of cardiac distress associated with long-term survival upon exacerbation of COPD. Employing activity monitors in the stable state might simplify risk stratification in daily living.

How to improve walking, balance and social participation following stroke: a comparison of the long term effects of two walking aids--canes and an orthosis TheraTogs--on the recovery of gait following acute stroke. A study protocol for a multi-centre, single blind, randomised control trial.

BACKGROUND: Annually, some 9000 people in Switzerland suffer a first time stroke. Of these 60% are left with moderate to severe walking disability. Evidence shows that rehabilitation techniques which emphasise activity of the hemiplegic side increase ipsilesional cortical plasticity and improve functional outcomes. Canes are commonly used in gait rehabilitation although they significantly reduce hemiplegic muscle activity. We have shown that an orthosis "TheraTogs" (a corset with elasticated strapping) significantly increases hemiplegic muscle activity during gait. The aim of the present study is to investigate the long term effects on the recovery of gait, balance and social participation of gait rehabilitation with TheraTogs compared to gait rehabilitation with a cane following first time acute stroke. METHODS/DESIGN: Multi-centre, single blind, randomised trial with 120 patients after first stroke. When subjects have reached Functional Ambulation Category 3 they will be randomly allocated into TheraTogs or cane group. TheraTogs will be applied to support hip extensor and abductor musculature according to a standardised procedure. Cane walking held at the level of the radial styloid of the sound wrist. Subjects will walk throughout the day with only the assigned walking aid. Standard therapy treatments and usual care will remain unchanged and documented. The intervention will continue for five weeks or until patients have reached Functional Ambulation category 5. Outcome measures will be assessed the day before begin of intervention, the day after completion, 3 months, 6 months and 2 years. PRIMARY OUTCOME: Timed "up and go" test, secondary outcomes: peak surface EMG of gluteus maximus and gluteus medius, activation patterns of hemiplegic leg musculature, temporo-spatial gait parameters, hemiplegic hip kinematics in the frontal and sagittal planes, dynamic balance, daily activity measured by accelerometry, Stroke Impact Scale. Significance levels will be 5% with 95% CI's. IntentionToTreat analyses will be performed. Descriptive statistics will be presented. DISCUSSION: This study could have significant implications for the clinical practice of gait rehabilitation after stroke, particularly the effect and appropriate use of walking aids.The results could be important for the development of clinical guidelines and for the socio-economic costs of post-stroke care. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT01366729.

Daily walking intensity as a predictor of quality of life in patients with chronic obstructive pulmonary disease.

PURPOSE: This study aimed to assess independent predictors of quality of life (QOL) in patients with chronic obstructive pulmonary disease, in particular, to evaluate the relationship between QOL and functional exercise capacity measured with an activity monitor. METHODS: Functional exercise capacity was measured with an accelerometer-based walking intensity. QOL was assessed by Short Form-36 and Saint Georges Respiratory Questionnaire. Stepwise multivariate regression analyses were used to identify significant independent predictors of health-related QOL. RESULTS: Daily walking intensity (fast walk) was the only significant independent predictor of the Short Form-36 domains "physical function" (P = 0.002) and "role physical" (P = 0.034). Age and depression were significant independent predictors of the domain "social functioning" (P = 0.035 and P = 0.002, respectively). Age and fast walk were significant independent predictors of the domain "mental health" (P = 0.006 and P = 0.017, respectively). Percent predicted forced expiratory volume in 1 s and fast walk were both significant independent predictors of the domains "general health" (P = 0.04 and P = 0.02, respectively) and "physical component score" (P = 0.038 and P = 0.017, respectively). In terms of the Saint Georges Respiratory Questionnaire, fast walk was a significant independent predictor of "activity score" (P = 0.001), "impact score" (P = 0.022), and "total score" (P = 0.01). CONCLUSIONS: QOL is an important aspect to be integrated into long-term disease management and the assessment of daily walking intensity using accelerometry can provide additional information about the patient's functional status and well-being during a certain period.

Association of daily physical activity volume and intensity with COPD severity.

PURPOSE: The purpose of this study was to assess whether daily walking activity is indicative of disease severity in patients with COPD. METHODS: Daily activity was measured by accelerometry in 107 COPD: GOLD II (N=28), GOLD III (N=51), and GOLD IV (N=25). Steps per day and times (min/day) spent passively, actively, walking (WLK, 0-5 km/h), and fast walking (FWLK, >5 km/h) were analyzed. Total walking time (TWT) was computed. RESULTS: Times spent WLK (P=0.031), FWLK (P=0.001), TWT (P=0.021), and steps per day (P=0.013) differed significantly between GOLD stages. There was a significant negative correlation between TWK and GOLD stage (R=-0.35; P<0.0001), BODE index (R=-0.58; P<0.0001), and MMRC dyspnea scale (R=-0.65; P<0.0001). Logistic regression analysis showed that both TWT and FWLK were independently and significantly associated with BODE index ≥ 6 (P=0.029 and P=0.040, respectively). The corresponding AUC-value with 95% CI for TWT was 0.80 (95% CI: 0.70 to 0.90) and 0.87 (95% CI: 0.81 to 0.94) for FWLK. The corresponding optimal cut-off value for TWT was 33.3 min/day (sensitivity: 86%; specificity 70%) and FWLK was 0.10 min/day (sensitivity: 93%; specificity 76%). CONCLUSION: Daily walking activity, in particular walking intensity, is significant predictor of disease severity in patients with COPD. Objective measures of habitual activity might provide additive value in assessing the likelihood of poor prognosis in this patient cohort.

Multivariable analysis of heart rate recovery after cycle ergometry in heart failure: exercise in heart failure.

PURPOSE: The purpose of this study was to investigate the association between impairment in heart rate recovery (HR(rec)) after cycle ergometry and prognostic markers in patients with heart failure (HF) compared with healthy controls. METHODS: Fifty patients with chronic HF (systolic HF, N = 30; diastolic HF, N = 20; mean age = 62 ± 12 years) and 50 healthy controls (N = 50; mean age = 66 ± 13 years) underwent 2-dimensional and M-mode echocardiography followed by cardiopulmonary exercise testing. Independent predictors of HR(rec) at 1 and 2 minutes after exercise were analyzed by univariable and multivariable regression analyses, and receiver operating characteristics were performed to obtain area under the curve. RESULTS: In HF, left ventricular end-diastolic diameter (millimeters), left ventricular ejection fraction (%), N-terminal pro-brain natriuretic peptide (picograms/milliliter), peak oxygen uptake (VO(2)peak [milliliters/kilogram/min]), and peak heart rate (HR(peak)) showed a significant association with HR(rec) (beats/min) in univariate regression analyses (P < .001), but only VO(2)peak remained independently predictive of both HR(rec)1 (P = .034) and HR(rec)2 (P = .008) in the multivariable regression analyses. In controls, VO(2)peak (P = .035) and HR(peak) (P = .032) were significantly associated with HR(rec)2 in univariate analyses only. Optimal cutoff values for discriminating HF versus non-HF based on HR(rec) were 17.5 beats/min (sensitivity 92%; specificity 74%) for HR(rec)1 and 31.5 beats/min (sensitivity 94%; specificity 86%) for HR(rec)2. Optimal cutoff values for discriminating systolic HF versus diastolic HF were 12.5 beats/min (sensitivity 78%; specificity 80%) for HR(rec)1 and 24.5 beats/min (sensitivity 82%; specificity 90%) for HR(rec)2. CONCLUSION: Impairment in after exercise HR(rec) is significantly and independently associated with VO2peak in HF and thus might constitute a useful tool for assessing the degree of functional status during exercise rehabilitation.

Association of physical activity and prognostic parameters in elderly patients with heart failure.

OBJECTIVE: Assessment of habitual physical activity (PA) in patients with heart failure. METHODS: This study included 50 patients with heart failure (61.9 ± 4.0 yr). Seven days of PA were assessed by questionnaire (AQ), pedometer, and accelerometer and correlated with prognostic markers including VO(2peak), percent left-ventricular ejection fraction, N-terminal pro-B-type natriuretic peptide, and New York Heart Association (NYHA) functional class. RESULTS: Accelerometry showed a stronger correlation with VO(2peak) and NYHA class (R = .73 and R = -.68; p < .001) than AQ (R = .58 and R = -.65; p < .001) or pedometer (R = .52 and R = -.50; p < .001). In the multivariable regression model accelerometry was the only consistent independent predictor of VO(2peak) (p = .002). Moreover, when its accuracy of prediction was tested, 59% of NYHA I and 95% of NYHA III patients were correctly classified into their assigned NYHA classes based on their accelerometer activity. CONCLUSION: PA assessed by accelerometer is significantly associated with exercise capacity in patients with heart failure and is predictive of disease severity. The data suggests that PA monitoring can aid in evaluating clinical status.

The 6-min walk test in heart failure: is it a max or sub-maximum exercise test?

The aim of the study is to compare the cardiorespiratory response during the 6-min walk test (6MWT) with a symptom-limited cardiopulmonary exercise test (CPET) in patients with varying degrees of heart failure. Thirty-seven patients with heart failure (New York Heart Association I-III) were asked to complete a 6MWT and a CPET on a cycle ergometer. Respiratory gases were measured during both the tests and patients were grouped into tertiles according to their VO(2peak) reached during the CPET prior to performing statistical analysis of all other respiratory parameters. Patients were grouped into the following tertiles: Group 1 (VO(2peak) >25.2 ml/kg per min, N = 13), Group 2 (VO(2peak) >17.5-25.2 ml/kg per min), and Group 3 (VO(2peak) < or =17.5 ml/kg per min). Despite the good overall correlation between 6MWT VO(2) and CPET VO(2peak) (r = 0.72, P < 0.001), significant differences were seen within Groups 1 and 3 (P < 0.05). In Group 1, 6MWT VO(2) was significantly lower compared with CPET VO(2peak), whereas Group 3 showed significantly higher 6MWT VO(2) compared with CPET VO(2peak). In conclusion, the use of the 6MWT to evaluate exercise capacity in patients with heart failure is highly dependent on the degree of functional impairment. In patients with advanced heart failure, the 6MWT elicits a maximum exercise response, whereas it only constitutes a sub-maximal exercise test in patients with mild heart failure and no functional limitations. This must be taken into consideration when using the 6MWT in large epidemiological studies to evaluate therapy outcome and clinical prognosis in patients with varying degrees of clinical disabilities.

Accelerometer-based quantification of 6-minute walk test performance in patients with chronic heart failure: applicability in telemedicine.

BACKGROUND: Distance walked in the 6-minute walk test (6MWT) is an important prognostic parameter used clinically to assess functional status in patients with chronic heart failure (CHF). In this study, we investigated if alternative performance parameters with similar prognostic value can be gained from accelerometers. METHODS AND RESULTS: Fifty CHF patients (age, 60.9 +/- 14.0 years) were asked to perform a 6MWT while wearing 2 accelerometers and 1 pedometer. Total 6MWT step frequency (SF) and activity counts (VMU) were correlated to 6MWT distance. The accelerometer was highly accurate at quantifying SF (detected vs. observed: r = 0.99; P < .001), whereas the pedometer was unreliable below 50 m/min. VMU increased linearly with walking speed (r = 0.99), and both SF and VMU correlated strongly with 6MWT distance (VMU: r = 0.91; SF: r = 0.87, respectively; P < .001) and each other (r = 0.80, P < .001). CONCLUSIONS: Accelerometers are reliable in measuring physical performance during the 6MWT in CHF patients. Besides the simple acquisition of 6MWT distance currently used for patient assessment, accelerometers provide new data that might be useful to evaluate exercise performance during the 6MWT. This allows for routine assessment of exercise capacity in a home-based setting in the context of telemedicine.

Daily walking performance as an independent predictor of advanced heart failure: Prediction of exercise capacity in chronic heart failure.

PURPOSE: The purpose of this study was to use an accelerometer to measure daily walking performance in patients with chronic heart failure (CHF) to investigate if this parameter is a determinant of New York Heart Association class and indicative of maximal and functional exercise capacity. METHODS: Fifty patients with CHF were instructed to wear an accelerometer for 7 consecutive days while going about their daily business. Maximal and functional exercise capacity was assessed by cardiopulmonary (VO(2peak)) and 6-minute walk testing, respectively. RESULTS: Patients in New York Heart Association I, II, and III reached an average total walking time (TWT) of 160.6 +/- 35.8 minutes, 133.9 +/- 59.0 minutes, and 76.1 +/- 22.5 minutes per day of which 19%, 19%, and 9% where spent in the fast walking mode (>83 m/minute), respectively. The TWT correlated strongly with VO(2peak) (r = 0.72; P <.001) and 6-minute walk testing distance (r = 0.68; P <.001). The TWT and time spent in fast walking mode were the strongest determinants in discriminating moderate CHF. CONCLUSION: Daily walking performance is a clear determinant of maximal and functional exercise capacities in patients with CHF. Walking intensity in particular is an independent predictor in discriminating patients with advanced heart failure. Monitoring of daily walking performance might aid in detecting disease progression and improve clinical outcome.