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Upadhya B, Hundley WG, Brubaker PH, Morgan TM, Stewart KP, Kitzman DW. Effect of Spironolactone on Exercise Tolerance and Arterial Function in Older Adults with Heart Failure with Preserved Ejection Fraction. J Am Geriatr Soc 2017; 65:2374-2382. [PMID: 28542926 PMCID: PMC5681414 DOI: 10.1111/jgs.14940] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To evaluate the effects of an aldosterone antagonist on exercise intolerance in older adults with heart failure and preserved ejection fraction (HFpEF). DESIGN Randomized, placebo-controlled, double-blind trial. SETTING Academic medical center, Winston-Salem, North Carolina. PARTICIPANTS Older adults (N = 80, aged 71 ± 1; 80% female) with stable compensated HFpEF and controlled blood pressure (BP). MEASUREMENTS Participants were randomized into a 9-month treatment of spironolactone 25 mg/d vs placebo. Assessments were peak exercise oxygen consumption (VO2 ), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), cardiac magnetic resonance imaging, Doppler echocardiography, and vascular ultrasound. RESULTS Seventy-one participants completed the trial: 37 in the spironolactone group and 34 in the placebo group. Adherence according to pill count was excellent (spironolactone 95%, placebo 97%). Mean spironolactone dose was 24.3 ± 2.9 mg/d and was well tolerated. Spironolactone significantly reduced systolic and diastolic BP at rest and peak exercise. At 9-month follow-up, baseline-adjusted peak VO2, the primary outcome, was 13.5 ± 0.3 mL/kg per minute in the spironolactone group versus 13.9 ± 0.3 mL/kg per minute in the placebo group (adjusted mean difference -0.4 mL/kg per minute; 95% confidence interval = -1.1-0.4 mL/kg per minute; P = .38). The 95% confidence intervals of spironolactone's effect on peak VO2 (-8.2% to 3.2%) excluded a clinically significant beneficial effect. There were also no significant differences in 6-minute walk distance, arterial stiffness, left ventricular (LV) mass, LV mass/end-diastolic volume, or MLHFQ score. CONCLUSION In older adults with stable compensated HFpEF, 9 months of spironolactone 25 mg/d was well tolerated and reduced BP but did not improve exercise capacity, quality of life, LV mass, or arterial stiffness.
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - W. Gregory Hundley
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Peter H. Brubaker
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina
| | - Timothy M. Morgan
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathryn P. Stewart
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dalane W. Kitzman
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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102
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Poole DC, Richardson RS, Haykowsky MJ, Hirai DM, Musch TI. Exercise limitations in heart failure with reduced and preserved ejection fraction. J Appl Physiol (1985) 2017; 124:208-224. [PMID: 29051336 DOI: 10.1152/japplphysiol.00747.2017] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The hallmark symptom of chronic heart failure (HF) is severe exercise intolerance. Impaired perfusive and diffusive O2 transport are two of the major determinants of reduced physical capacity and lowered maximal O2 uptake in patients with HF. It has now become evident that this syndrome manifests at least two different phenotypic variations: heart failure with preserved or reduced ejection fraction (HFpEF and HFrEF, respectively). Unlike HFrEF, however, there is currently limited understanding of HFpEF pathophysiology, leading to a lack of effective pharmacological treatments for this subpopulation. This brief review focuses on the disturbances within the O2 transport pathway resulting in limited exercise capacity in both HFpEF and HFrEF. Evidence from human and animal research reveals HF-induced impairments in both perfusive and diffusive O2 conductances identifying potential targets for clinical intervention. Specifically, utilization of different experimental approaches in humans (e.g., small vs. large muscle mass exercise) and animals (e.g., intravital microscopy and phosphorescence quenching) has provided important clues to elucidating these pathophysiological mechanisms. Adaptations within the skeletal muscle O2 delivery-utilization system following established and emerging therapies (e.g., exercise training and inorganic nitrate supplementation, respectively) are discussed. Resolution of the underlying mechanisms of skeletal muscle dysfunction and exercise intolerance is essential for the development and refinement of the most effective treatments for patients with HF.
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103
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Wolsk E, Kaye D, Borlaug BA, Burkhoff D, Kitzman DW, Komtebedde J, Lam CSP, Ponikowski P, Shah SJ, Gustafsson F. Resting and exercise haemodynamics in relation to six-minute walk test in patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2017; 20:715-722. [PMID: 28949052 DOI: 10.1002/ejhf.976] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/17/2017] [Accepted: 07/30/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS Patients with heart failure and preserved ejection fraction (HFpEF) are characterized by functional impairment and an abnormal haemodynamic response to exercise. The six-minute walk test (6MWT) serves as a standardized test for functional capacity quantification in heart failure patients, and is associated with cardiovascular outcomes. However, as the association between 6MWT and haemodynamic parameters during rest and exercise in HFpEF patients is unknown, we sought to elucidate this relationship. METHODS AND RESULTS Overall, 64 patients enrolled in the REDUCE LAP-HF trial completed a 6MWT at baseline. Univariate and multivariable linear regression models were used to assess the associations between 6MWT and measured or derived haemodynamic variables at baseline, during light/moderate exercise (20 W), and at peak supine exercise. The average 6MWT distance was 318 ± 106 m. At rest, in a multivariable model, only pulmonary capillary wedge pressure (PCWP) was significantly associated with 6MWT [coefficient: -5.4, 95% confidence interval (CI) -10.4, -0.5, P = 0.033]. During light/moderate exercise, mean pulmonary artery pressure was associated with 6MWT in a multivariable model (coefficient: -3.5, 95% CI -6.8, -0.3, P = 0.033). During peak exercise, central venous pressure, cardiac index (CI), and PCWP/CI correlated with 6MWT; however, workload corrected PCWP was the only variable independently associated with 6MWT (coefficient: -0.8, 95% CI -1.3, -0.4, P < 0.001). The variance in 6MWT was modestly explained by measured or derived haemodynamic variables at rest or at any stage of exercise (r2 = 7-17%). CONCLUSION Workload corrected PCWP correlated best with 6MWT performance in HFpEF patients. Baseline haemodynamic variables were modestly correlated with 6MWT, suggesting that 6MWT performance in HFpEF patients may be significantly influenced by extra-cardiac factors.
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Affiliation(s)
- Emil Wolsk
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - David Kaye
- Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN, USA
| | | | - Dalane W Kitzman
- Department of Internal Medicine, School of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore and Duke-National University of Singapore, Singapore
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University and Centre for Heart Diseases, Military Hospital, Wrocław, Poland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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104
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Li M, Lu Y, Fang C, Zhang X. Correlation between myocardial deformation on three-dimensional speckle tracking echocardiography and cardiopulmonary exercise testing. Echocardiography 2017; 34:1640-1648. [PMID: 28929529 DOI: 10.1111/echo.13675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Mei Li
- Ultrasound Department; Beijing Haidian Hospital; Peking University Third Hospital Haidian District; Haidian District, Beijing China
| | - Yaran Lu
- Ultrasound Department; Beijing Haidian Hospital; Peking University Third Hospital Haidian District; Haidian District, Beijing China
| | - Cui Fang
- Ultrasound Department; Beijing Haidian Hospital; Peking University Third Hospital Haidian District; Haidian District, Beijing China
| | - Xiaorong Zhang
- Ultrasound Department; Beijing Haidian Hospital; Peking University Third Hospital Haidian District; Haidian District, Beijing China
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105
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Milman A, Keren G, Topilsky Y. Decline in effort capacity with age: Echocardiographic stress analysis in the elderly. Echocardiography 2017; 34:1909-1916. [DOI: 10.1111/echo.13709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Anat Milman
- Department of Cardiology; Tel Aviv Medical Center and the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Gad Keren
- Department of Cardiology; Tel Aviv Medical Center and the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yan Topilsky
- Department of Cardiology; Tel Aviv Medical Center and the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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106
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Hong JA, Kim MS, Cho MS, Choi HI, Kang DH, Lee SE, Lee GY, Jeon ES, Cho JY, Kim KH, Yoo BS, Lee JY, Kim WJ, Kim KH, Chung WJ, Lee JH, Cho MC, Kim JJ. Clinical features of idiopathic restrictive cardiomyopathy: A retrospective multicenter cohort study over 2 decades. Medicine (Baltimore) 2017; 96:e7886. [PMID: 28885342 PMCID: PMC6393124 DOI: 10.1097/md.0000000000007886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Idiopathic restrictive cardiomyopathy (RCMP) has not been fully understood because this disease is difficult to diagnose. The present study aimed to assess the clinical profile and outcome of idiopathic RCMP from a multicenter cohort.This investigation is a retrospective study of consecutive patients with idiopathic RCMP at 10 centers in Korea between 1990 and 2010. We evaluated the clinical characteristics of the patients and prognostic factors associated with mortality using multivariate Cox proportional hazards regression analyses.The study included 53 patients (26 men, 49.1%). During a median follow-up of 1.7 years, 17 patients (32.1%) died and 5 patients (9.4%) received a heart transplant. The 5-year survival rate of the overall patients was 64.4% ± 7.8%. In multivariable analyses, the predictors of mortality were tricuspid regurgitation (TR) ≥ moderate (hazard ratio [HR] 32.55, P < .001) and left ventricular end-diastolic diameter (LVEDD) (HR 0.85, P < .001).Idiopathic RCMP showed unfavorable prognosis. Advanced TR and lower LVEDD are independent adverse predictors of mortality in patients with idiopathic RCMP.
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Affiliation(s)
- Jung Ae Hong
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Min-Seok Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Min-Su Cho
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyo In Choi
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Duk-Hyun Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang-Eun Lee
- Department of Internal Medicine, Seoul National University Hospital
| | - Ga-Yeon Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Eun-Seok Jeon
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jae-Yeong Cho
- Department of Cardiology, Translational Research Center on Aging, Chonnam National University Hospital, Gwangju
| | - Kye-Hun Kim
- Department of Cardiology, Translational Research Center on Aging, Chonnam National University Hospital, Gwangju
| | - Byung-Su Yoo
- Department of Internal Medicine, Wonju College of Medicine,Yonsei University, Wonju
| | - Jong-Young Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Seoul
| | - Won-Jang Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University school of Medicine, Bundang
| | | | - Wook-Jin Chung
- Department of Cardiovascular Medicine, Gachon University Gil Medical Center, Incheon
| | - Ju-Hee Lee
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
| | - Myeong-Chan Cho
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
| | - Jae-Joong Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
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107
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Tucker WJ, Lijauco CC, Hearon CM, Angadi SS, Nelson MD, Sarma S, Nanayakkara S, La Gerche A, Haykowsky MJ. Mechanisms of the Improvement in Peak VO 2 With Exercise Training in Heart Failure With Reduced or Preserved Ejection Fraction. Heart Lung Circ 2017; 27:9-21. [PMID: 28870770 DOI: 10.1016/j.hlc.2017.07.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/22/2017] [Accepted: 07/16/2017] [Indexed: 11/15/2022]
Abstract
Heart failure (HF) is a major health care burden associated with high morbidity and mortality. Approximately 50% of HF patients have reduced ejection fraction (HFrEF) while the remainder of patients have preserved ejection fraction (HFpEF). A hallmark of both HF phenotypes is dyspnoea upon exertion and severe exercise intolerance secondary to impaired oxygen delivery and/or use by exercising skeletal muscle. Exercise training is a safe and effective intervention to improve peak oxygen uptake (VO2peak) and quality of life in clinically stable HF patients, however, evidence to date suggests that the mechanism of this improvement appears to be related to underlying HF phenotype. The purpose of this review is to discuss the role of exercise training to improve VO2peak, and how the central and peripheral adaptations that mediate the improvements in exercise tolerance may be similar or differ by HF phenotype (HFrEF or HFpEF).
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Affiliation(s)
- Wesley J Tucker
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Cecilia C Lijauco
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Christopher M Hearon
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Siddhartha S Angadi
- Exercise Science and Health Promotion Program, Arizona State University, Phoenix, AZ, USA; Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Michael D Nelson
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shane Nanayakkara
- Heart Failure Research Group, Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - André La Gerche
- Sport Cardiology, Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, University of Leuven, Belgium
| | - Mark J Haykowsky
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia.
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108
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Lalande S, Mueller PJ, Chung CS. The link between exercise and titin passive stiffness. Exp Physiol 2017; 102:1055-1066. [PMID: 28762234 DOI: 10.1113/ep086275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/11/2017] [Indexed: 12/27/2022]
Abstract
NEW FINDINGS What is the topic of this review? This review focuses on how in vivo and molecular measurements of cardiac passive stiffness can predict exercise tolerance and how exercise training can reduce cardiac passive stiffness. What advances does it highlight? This review highlights advances in understanding the relationship between molecular (titin-based) and in vivo (left ventricular) passive stiffness, how passive stiffness modifies exercise tolerance, and how exercise training may be therapeutic for cardiac diseases with increased passive stiffness. Exercise can help alleviate the negative effects of cardiovascular disease and cardiovascular co-morbidities associated with sedentary behaviour; this may be especially true in diseases that are associated with increased left ventricular passive stiffness. In this review, we discuss the inverse relationship between exercise tolerance and cardiac passive stiffness. Passive stiffness is the physical property of cardiac muscle to produce a resistive force when stretched, which, in vivo, is measured using the left ventricular end diastolic pressure-volume relationship or is estimated using echocardiography. The giant elastic protein titin is the major contributor to passive stiffness at physiological muscle (sarcomere) lengths. Passive stiffness can be modified by altering titin isoform size or by post-translational modifications. In both human and animal models, increased left ventricular passive stiffness is associated with reduced exercise tolerance due to impaired diastolic filling, suggesting that increased passive stiffness predicts reduced exercise tolerance. At the same time, exercise training itself may induce both short- and long-term changes in titin-based passive stiffness, suggesting that exercise may be a treatment for diseases associated with increased passive stiffness. Direct modification of passive stiffness to improve exercise tolerance is a potential therapeutic approach. Titin passive stiffness itself may be a treatment target based on the recent discovery of RNA binding motif 20, which modifies titin isoform size and passive stiffness. Translating these discoveries that link exercise and left ventricular passive stiffness may provide new methods to enhance exercise tolerance and treat patients with cardiovascular disease.
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Affiliation(s)
- Sophie Lalande
- Department of Kinesiology & Health Education, The University of Texas at Austin, Austin, TX, USA
| | | | - Charles S Chung
- Department of Physiology, Wayne State University, Detroit, MI, USA
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109
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Laufer-Perl M, Gura Y, Shimiaie J, Sherez J, Pressman GS, Aviram G, Maltais S, Megidish R, Halkin A, Ingbir M, Biner S, Keren G, Topilsky Y. Mechanisms of Effort Intolerance in Patients With Rheumatic Mitral Stenosis. JACC Cardiovasc Imaging 2017; 10:622-633. [DOI: 10.1016/j.jcmg.2016.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/11/2016] [Accepted: 07/14/2016] [Indexed: 11/27/2022]
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110
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Diastolic Function Changes during Stress Echocardiography in Hypertensive Patients. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2017. [DOI: 10.5812/rijm.42876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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111
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Hoshida S, Shinoda Y, Ikeoka K, Minamisaka T, Fukuoka H, Inui H, Watanabe T. Fluctuation of Dynamic Diastolic Function Relative to Static Cardiac Structure - New Insights Into the Underlying Mechanism of Heart Failure With Preserved Ejection Fraction in Elderly Patients. Circ J 2017; 81:755-758. [PMID: 28132965 DOI: 10.1253/circj.cj-16-1126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The mechanisms of heart failure with preserved ejection fraction (HFpEF) need to be clarified immediately.Methods and Results:We examined diastolic function relative to arterial elasticity among hypertensive patients with preserved EF. Diastolic elastance (EdI)/effective arterial elastance (EaI), EdI/EaI=E/e'/(0.9×systolic blood pressure [SBP]) was significantly more impaired in women than in men among patients ≥75 years. The higher EdI/EaI value in elderly women implies they are intermittently exposed to higher left ventricular filling pressure relative to SBP during daily life. CONCLUSIONS Highly fluctuating impairment of diastolic function relative to arterial elasticity may predispose elderly women to pulmonary edema.
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Affiliation(s)
- Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital
| | | | - Kuniyasu Ikeoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital
| | | | | | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital
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112
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Cusmà Piccione M, Zito C, Khandheria B, Madaffari A, Oteri A, Falanga G, Donato D, D'Angelo M, Carerj ML, Di Bella G, Imbalzano E, Pugliatti P, Carerj S. Cardiovascular maladaptation to exercise in young hypertensive patients. Int J Cardiol 2017; 232:280-288. [DOI: 10.1016/j.ijcard.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/27/2016] [Accepted: 01/03/2017] [Indexed: 10/20/2022]
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113
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Takagi T. Diastolic stress echocardiography. J Echocardiogr 2017; 15:99-109. [PMID: 28271289 DOI: 10.1007/s12574-017-0335-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 01/28/2023]
Abstract
Evaluation of diastolic dysfunction and diagnosis of heart failure with preserved ejection fraction (HFpEF) by echocardiography are routinely performed at rest. However, many patients with modest HFpEF develop symptoms such as dyspnea only during exercise. Therefore, echocardiographic analysis at rest could be insufficient to identify these patients. Recent studies have demonstrated the utility of diastolic stress echocardiography to evaluate diastolic dysfunction during exercise. This review attempts to summarize and discuss current studies in diastolic stress echocardiography.
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Affiliation(s)
- Tsutomu Takagi
- Takagi Cardiology Clinic, Mibu Kayogosho-cho 3-3, Nakagyo-ku, Kyoto, 604-8811, Japan.
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114
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Masada K, Hidaka T, Harada Y, Kinoshita M, Itakura K, Higashi A, Utsunomiya H, Kihara Y. Mitral systolic velocity at peak exercise predicts impaired exercise capacity in patients with heart failure with preserved ejection fraction. Echocardiography 2017; 34:217-225. [DOI: 10.1111/echo.13440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Kenji Masada
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Takayuki Hidaka
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Yu Harada
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Mirai Kinoshita
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Kiho Itakura
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Akifumi Higashi
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Hiroto Utsunomiya
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine; Hiroshima University Graduate School of Biomedical and Health Science; Hiroshima Japan
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115
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Key Role of Pacing Site as Determinant Factor of Exercise Testing Performance in Pediatric Patients with Chronic Ventricular Pacing. Pediatr Cardiol 2017; 38:368-374. [PMID: 27913834 DOI: 10.1007/s00246-016-1523-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/10/2016] [Indexed: 11/27/2022]
Abstract
Chronic right ventricular (RV) apical pacing has been associated with deterioration of functional capacity and chronotropic incompetence during exercise testing in children. The effects of alternative pacing site on exercise performance in pediatric population remain unknown. We evaluated the influence of ventricular pacing site on exercise capacity in pediatric patients with complete congenital atrioventricular block requiring permanent pacemaker therapy. Sixty-four children paced from RV apex (n = 26), RV midseptum (n = 15) and left ventricular (LV) apex (n = 23) were studied cross-sectionally. Treadmill exercise stress testing was performed according to modified Bruce protocol. LV apical pacing was associated with greater exercise capacity. In comparison with the other study groups, children with RV apical pacing showed significantly lower VO2peak (37 ± 4.11; p = 0.003), O2 pulse (8.78 ± 1.15; p = 0.006), metabolic equivalents (7 ± 0.15; p = 0.001) and exercise time (6 ± 3.28; p = 0.03). Worse values in terms of maximum heart rate (139 ± 8.83 bpm; p = 0.008) and chronotropic index (0.6 ± 0.08; p = 0.002) were detected in the RV apical pacing group although maximal effort (respiratory exchange ratio) did not differ among groups (p = 0.216). Pacing from RV apex (odds ratio 9.4; confidence interval 2.5-18.32; Wald 4.91; p = 0.0036) and low peak heart rate achieved (odds ratio 3.66; confidence interval 0.19-7.4; Wald 4.083; p = 0.015) predicted significantly decrease in exercise capacity. Duration of pacing, gender, VVIR mode, baseline heart rate and QRS duration had not significant impact on exercise capacity. The site of ventricular pacing has the major impact on exercise capacity in children requiring permanent pacing. Among the sites assessed, LV apex is related to the better exercise performance.
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116
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do Prado DML, Rocco EA. The Benefits of Exercise Training on Aerobic Capacity in Patients with Heart Failure and Preserved Ejection Fraction. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1000:51-64. [PMID: 29098615 DOI: 10.1007/978-981-10-4304-8_4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is defined as an inability of the ventricles to optimally accept blood from atria with blunted end- diastolic volume response by limiting the stroke volume and cardiac output. The HEpEF prevalence is higher in elderly and women and may be associated to hypertension, diabetes mellitus and atrial fibrillation. Severe exercise intolerance, manifested by dyspnea and fatigue during physical effort is the important chronic symptom in HFpEF patients, in which is the major determinant of their reduced quality of life. In this sense, several studies demonstrated reduced aerobic capacity in terms of lower peak oxygen consumption (peak VO2) in patients with HFpEF. In addition, the lower aerobic capacity observed in HFpEF may be due to impaired both convective and diffusive O2 transport (i.e. reduced cardiac output and arteriovenous oxygen difference, respectively).Exercise training program can help restore physiological function in order to increase aerobic capacity and improve the quality of life in HFpEF patients. Therefore, the primary purpose of this chapter was to clarify the physiological mechanisms associated with reduced aerobic capacity in HFpEF patients. Secondly, special focus was devoted to show how aerobic exercise training can improve aerobic capacity and quality of life in HFpEF patients.
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117
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Einstein, the Blind Men, and the Elephant: Making Sense of Heart Failure With Preserved Ejection Fraction. J Card Fail 2016; 22:1028-1032. [PMID: 27765667 DOI: 10.1016/j.cardfail.2016.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 10/10/2016] [Accepted: 10/14/2016] [Indexed: 12/27/2022]
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High-Intensity Interval Training Versus Moderate-Intensity Continuous Training in the Prevention/Management of Cardiovascular Disease. Cardiol Rev 2016; 24:273-281. [DOI: 10.1097/crd.0000000000000124] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Margossian R, Sleeper LA, Pearson GD, Barker PC, Mertens L, Quartermain MD, Su JT, Shirali G, Chen S, Colan SD. Assessment of Diastolic Function in Single-Ventricle Patients After the Fontan Procedure. J Am Soc Echocardiogr 2016; 29:1066-1073. [PMID: 27624592 PMCID: PMC5302850 DOI: 10.1016/j.echo.2016.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with functional single ventricles after the Fontan procedure have abnormal cardiac mechanics. The aims of this study were to determine factors that influence diastolic function and to describe associations of diastolic function with current clinical status. METHODS Echocardiograms were obtained as part of the Pediatric Heart Network Fontan Cross-Sectional Study. Diastolic function grade (DFG) was assessed as normal (grade 0), impaired relaxation (grade 1), pseudonymization (grade 2), or restrictive (grade 3). Studies were also classified dichotomously (restrictive pattern present or absent). Relationships between DFG and pre-Fontan variables (e.g., ventricular morphology, age at Fontan, history of volume-unloading surgery) and current status (e.g., systolic function, valvar regurgitation, exercise performance) were explored. RESULTS DFG was calculable in 326 of 546 subjects (60%) (mean age, 11.7 ± 3.3 years). Overall, 32% of patients had grade 0, 9% grade 1, 37% grade 2, and 22% grade 3 diastolic function. Although there was no association between ventricular morphology and DFG, there was an association between ventricular morphology and E', which was lowest in those with right ventricular morphology (P < .001); this association remained significant when using Z scores adjusted for age (P < .001). DFG was associated with achieving maximal effort on exercise testing (P = .004); the majority (64%) of those not achieving maximal effort had DFG 2 or 3. No additional significant associations of DFG with laboratory or clinical measures were identified. CONCLUSIONS Assessment of diastolic function by current algorithms results in a high percentage of patients with abnormal DFG, but few clinically or statistically significant associations were found. This may imply a lack of impact of abnormal diastolic function on clinical outcomes in this cohort, or it may indicate that the methodology may not be applicable to pediatric patients with functional single ventricles.
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Affiliation(s)
- Renee Margossian
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Lynn A Sleeper
- New England Research Institutes, Watertown, Massachusetts
| | - Gail D Pearson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Luc Mertens
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Jason T Su
- University of Utah, Salt Lake City, Utah
| | - Girish Shirali
- Medical University of South Carolina, Charleston, South Carolina
| | - Shan Chen
- New England Research Institutes, Watertown, Massachusetts
| | - Steven D Colan
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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120
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Eyre V, Lang CC, Smith K, Jolly K, Davis R, Hayward C, Wingham J, Abraham C, Green C, Warren FC, Britten N, Greaves CJ, Doherty P, Austin J, Van Lingen R, Singh S, Buckingham S, Paul K, Taylor RS, Dalal HM. Rehabilitation Enablement in Chronic Heart Failure-a facilitated self-care rehabilitation intervention in patients with heart failure with preserved ejection fraction (REACH-HFpEF) and their caregivers: rationale and protocol for a single-centre pilot randomised controlled trial. BMJ Open 2016; 6:e012853. [PMID: 27798024 PMCID: PMC5093626 DOI: 10.1136/bmjopen-2016-012853] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The Rehabilitation EnAblement in CHronic Heart Failure in patients with Heart Failure (HF) with preserved ejection fraction (REACH-HFpEF) pilot trial is part of a research programme designed to develop and evaluate a facilitated, home-based, self-help rehabilitation intervention to improve self-care and quality of life (QoL) in heart failure patients and their caregivers. We will assess the feasibility of a definitive trial of the REACH-HF intervention in patients with HFpEF and their caregivers. The impact of the REACH-HF intervention on echocardiographic outcomes and bloodborne biomarkers will also be assessed. METHODS AND ANALYSIS A single-centre parallel two-group randomised controlled trial (RCT) with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention) or usual care alone (control) in 50 HFpEF patients and their caregivers. The REACH-HF intervention comprises a REACH-HF manual with supplementary tools, delivered by trained facilitators over 12 weeks. A mixed methods approach will be used to assess estimation of recruitment and retention rates; fidelity of REACH-HF manual delivery; identification of barriers to participation and adherence to the intervention and study protocol; feasibility of data collection and outcome burden. We will assess the variance in study outcomes to inform a definitive study sample size and assess methods for the collection of resource use and intervention delivery cost data to develop the cost-effectiveness analyses framework for any future trial. Patient outcomes collected at baseline, 4 and 6 months include QoL, psychological well-being, exercise capacity, physical activity and HF-related hospitalisation. Caregiver outcomes will also be assessed, and a substudy will evaluate impact of the REACH-HF manual on resting global cardiovascular function and bloodborne biomarkers in HFpEF patients. ETHICS AND DISSEMINATION The study is approved by the East of Scotland Research Ethics Service (Ref: 15/ES/0036). Findings will be disseminated via journals and presentations to clinicians, commissioners and service users. TRIAL REGISTRATION NUMBER ISRCTN78539530; Pre-results .
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Affiliation(s)
- V Eyre
- Peninsula Clinical Trials Unit, Plymouth University, Plymouth, UK
| | - C C Lang
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - K Smith
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
- School of Nursing & Midwifery, Dundee University, Dundee, UK
| | - K Jolly
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Davis
- Cardiology Department, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - C Hayward
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - J Wingham
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Research, Development & Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - C Abraham
- Psychology Applied to Health Group, University of Exeter Medical School, Exeter, UK
| | - C Green
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - F C Warren
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - N Britten
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - C J Greaves
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - P Doherty
- Department of Health Sciences, University of York, York, UK
| | - J Austin
- Heart Failure Services and Cardiac Rehabilitation, Aneurin Bevan University Health Board, Nevill Hall Hospital, Abergavenny, UK
| | - R Van Lingen
- Cardiology Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - S Singh
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - S Buckingham
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - K Paul
- REACH-HF Patient and Public Involvement Group, c/o Research, Development & Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - R S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - H M Dalal
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Research, Development & Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Chirinos JA, Zamani P. The Nitrate-Nitrite-NO Pathway and Its Implications for Heart Failure and Preserved Ejection Fraction. Curr Heart Fail Rep 2016; 13:47-59. [PMID: 26792295 DOI: 10.1007/s11897-016-0277-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The pathogenesis of exercise intolerance in patients with heart failure and preserved ejection fraction (HFpEF) is likely multifactorial. In addition to cardiac abnormalities (diastolic dysfunction, abnormal contractile reserve, chronotropic incompetence), several peripheral abnormalities are likely to be involved. These include abnormal pulsatile hemodynamics, abnormal arterial vasodilatory responses to exercise, and abnormal peripheral O2 delivery, extraction, and utilization. The nitrate-nitrite-NO pathway is emerging as a potential target to modify key physiologic abnormalities, including late systolic left ventricular (LV) load from arterial wave reflections (which has deleterious short- and long-term consequences for the LV), arterial vasodilatory reserve, muscle O2 delivery, and skeletal muscle mitochondrial function. In a recently completed randomized trial, the administration of a single dose of exogenous inorganic nitrate has been shown to exert various salutary arterial hemodynamic effects, ultimately leading to enhanced aerobic capacity in patients with HFpEF. These effects have the potential for both immediate improvements in exercise tolerance and for long-term "disease-modifying" effects. In this review, we provide an overview of key mechanistic contributors to exercise intolerance in HFpEF, and of the potential therapeutic role of drugs that target the nitrate-nitrite-NO pathway.
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Affiliation(s)
- Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Hospital of the University of Pennsylvania, Philadelphia, PA, USA. .,Ghent University, Ghent, Belgium.
| | - Payman Zamani
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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122
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Shantsila E, Haynes R, Calvert M, Fisher J, Kirchhof P, Gill PS, Lip GYH. IMproved exercise tolerance in patients with PReserved Ejection fraction by Spironolactone on myocardial fibrosiS in Atrial Fibrillation rationale and design of the IMPRESS-AF randomised controlled trial. BMJ Open 2016; 6:e012241. [PMID: 27707827 PMCID: PMC5073497 DOI: 10.1136/bmjopen-2016-012241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Patients with atrial fibrillation frequently suffer from heart failure with preserved ejection fraction. At present there is no proven therapy to improve physical capacity and quality of life in participants with permanent atrial fibrillation with preserved left ventricular contractility. OBJECTIVE The single-centre IMproved exercise tolerance In heart failure With PReserved Ejection fraction by Spironolactone On myocardial fibrosiS In Atrial Fibrillation (IMPRESS-AF) trial aims to establish whether treatment with spironolactone as compared with placebo improves exercise tolerance (cardiopulmonary exercise testing), quality of life and diastolic function in patients with permanent atrial fibrillation. METHODS AND ANALYSIS A total of 250 patients have been randomised in this double-blinded trial for 2-year treatment with 25 mg daily dose of spironolactone or matched placebo. Included participants are 50 years old or older, have permanent atrial fibrillation and ejection fraction >55%. Exclusion criteria include contraindications to spironolactone, poorly controlled hypertension and presence of severe comorbidities with life expectancy <2 years. The primary outcome is improvement in exercise tolerance at 2 years and key secondary outcomes include quality of life (assessed using the EuroQol EQ-5D-5L (EQ-5D) and Minnesota Living with Heart Failure (MLWHF) questionnaires), diastolic function and all-cause hospitalisation. ETHICS AND DISSEMINATION The study has been approved by the National Research and Ethics Committee West Midlands-Coventry and Warwickshire (REC reference number 14/WM/1211). The results of the trial will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBERS EudraCT2014-003702-33; NCT02673463; Pre-results.
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Affiliation(s)
- Eduard Shantsila
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Ronnie Haynes
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Melanie Calvert
- Department of Primary Care Clinical Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Fisher
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Paramjit S Gill
- Department of Primary Care Clinical Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
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123
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Evaluation of Cardiac, Vascular, and Skeletal Muscle Function With MRI: Novel Physiological End Points in Cardiac Rehabilitation Research. Can J Cardiol 2016; 32:S388-S396. [DOI: 10.1016/j.cjca.2016.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/23/2016] [Accepted: 07/09/2016] [Indexed: 12/16/2022] Open
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124
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Churilla JR, Richardson MR, Pinkstaff SO, Fletcher BJ, Fletcher GF. Associations between heart failure and physical function in US adults. QJM 2016; 109:669-674. [PMID: 27026699 DOI: 10.1093/qjmed/hcw042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a paucity of nationally representative data in the area of heart failure (HF) and physical function (PF). AIM Examine the relationship(s) between HF and PF in a nationally representative sample of United States (US) adults. DESIGN Cross-section analysis of US adults. METHODS Sample (n = 6623) included adult (≥40 years of age) participants from the 1999-2006 National Health and Nutrition Examination Survey. Participants reporting HF answered questions related to their abilities to accomplish specific upper extremity and lower extremity tasks, and household chores. RESULTS Prevalence estimates of reporting much difficulty or the inability to stand from an armless chair was 9.9% and 4.3% (P = 0.002) in those with and without HF, respectively. Similar estimates were revealed for much difficulty or inability to lift or carry 10 pounds (16.8% and 8.6%, P = 0.0004) and much difficulty or inability to do household chores (13.3% and 6.1%, P = 0.0008). Following adjustments participants reporting HF had significantly greater odds of reporting much difficulty or the inability to stand from an armless chair [odds ratio (OR) 1.93; 95% confidence intervals (CI) 1.25, 2.96], much difficulty or the inability to lift or carry 10 lbs (OR 1.90; 95% CI 1.36, 2.65) and much difficulty or inability to do household chores (OR 2.06; 95% CI 1.41, 3.02) compared with participants not reporting HF. CONCLUSIONS Findings suggest US adults reporting HF are more likely to report poorer PF.
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Affiliation(s)
- J R Churilla
- From the Department of Clinical and Applied Movement Sciences-Exercise Science, Brooks College of Health, University of North Florida, Jacksonville, FL 32224, USA
| | - M R Richardson
- From the Department of Clinical and Applied Movement Sciences-Exercise Science, Brooks College of Health, University of North Florida, Jacksonville, FL 32224, USA
| | - S O Pinkstaff
- Department of Clinical and Applied Movement Sciences-Physical Therapy, Brooks College of Health, University of North Florida, Jacksonville, FL 32224, USA
| | - B J Fletcher
- School of Nursing, Brooks College of Health, University of North Florida, Jacksonville, FL 32224, USA
- Mayo Clinic - Cardiology Division, Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - G F Fletcher
- Mayo Clinic - Cardiology Division, Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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125
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Christensen NL, Dahl JS, Carter-Storch R, Bakkestrøm R, Jensen K, Steffensen FH, Søndergaard EV, Videbæk L, Møller JE. Association Between Left Atrial Dilatation and Invasive Hemodynamics at Rest and During Exercise in Asymptomatic Aortic Stenosis. Circ Cardiovasc Imaging 2016; 9:CIRCIMAGING.116.005156. [DOI: 10.1161/circimaging.116.005156] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/26/2016] [Indexed: 01/05/2023]
Abstract
Background—
Transition from an asymptomatic to symptomatic state in severe aortic stenosis is often difficult to assess. Identification of a morphological sign of increased hemodynamic load may be important in asymptomatic aortic stenosis to identify patients at risk.
Methods and Results—
Thirty-nine patients with asymptomatic severe aortic stenosis (aortic valve area <1 cm
2
, peak jet velocity >3.5 m/s) underwent exercise testing with simultaneous invasive hemodynamic monitoring and Doppler echocardiography. Cardiac index, pulmonary artery pressure, and pulmonary capillary wedge pressure (PCWP) were recorded. Patients were followed up for the composite end point of death, unplanned hospitalization, or aortic valve replacement. Patients were stratified into 2 groups according to left atrial (LA) volume index ≥35 mL/m
2
. In 25 patients (64%) LA volume index was ≥35 mL/m
2
. Aortic valve area was similar between groups (0.81±0.15 versus 0.84±0.18 cm
2
;
P
=0.58). PCWP was higher at rest and during exercise in patients with LA volume index ≥35 mL/m
2
(
P
<0.01), despite similar cardiac index. At rest, PCWP was <12 mm Hg in 11 patients (44%) with LA dilatation, whereas PCWP was <25 mm Hg in 1 patient (4%) with exercise. LA volume index and E/e′ predicted exercise PCWP>30 mm Hg with areas under the receiver operating curve of 0.75 and 0.84, respectively. During follow-up, 14 cardiac events were recorded. LA volume was associated with a hazard ratio of 1.90 (95% confidence interval, 0.92–4.15).
Conclusions—
LA size reflects hemodynamic burden in patients with asymptomatic severe aortic stenosis. Quantitative measurements of LA and diastolic function are associated with left ventricular filling pressures with exercise and could be used to identify asymptomatic patients with increased hemodynamic burden.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT02395107.
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Affiliation(s)
- Nicolaj Lyhne Christensen
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Jordi Sanchez Dahl
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Rasmus Carter-Storch
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Rine Bakkestrøm
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Kurt Jensen
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Flemming Hald Steffensen
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Eva Vad Søndergaard
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Lars Videbæk
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
| | - Jacob Eifer Møller
- From the Department of Cardiology, Odense University Hospital, Denmark (N.L.C., J.S.D., R.C.-S., R.B., E.V.S., L.V., J.E.M.); Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense (K.J.), and Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.)
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Affiliation(s)
- Dennis A. Tighe
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gerard P. Aurigemma
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
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127
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Hsiao SH, Chiou KR. Diastolic Heart Failure Predicted by Left Atrial Expansion Index in Patients with Severe Diastolic Dysfunction. PLoS One 2016; 11:e0162599. [PMID: 27622475 PMCID: PMC5021281 DOI: 10.1371/journal.pone.0162599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/25/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Left atrial (LA) echocardiographic parameters are increasingly used to predict clinically relevant cardiovascular events. The study aims to evaluate the LA expansion index (LAEI) for predicting diastolic heart failure (HF) in patients with severe left ventricular (LV) diastolic dysfunction. METHODS This prospective study enrolled 162 patients (65% male) with preserved LV systolic function and severe diastolic dysfunction (132 grade 2 patients, 30 grade 3 patients). All patients had sinus rhythm at enrollment. The LAEI was calculated as (Volmax - Volmin) x 100% / Volmin, where Volmax was defined as maximal LA volume and Volmin was defined as minimal volume. The endpoint was hospitalization for HF withp reserved LV ejection fraction (HFpEF). RESULTS The median follow-up duration was 2.9 years. Fifty-four patients had cardiovascular events, including 41 diastolic and 8 systolic HF hospitalizations. In these 54 patients, 13 in-hospital deaths and 5 sudden out-of-hospital deaths occurred. Multivariate analyses revealed that HFpEF was associated with LAEI.and atrial fibrillation during follow-up. For predicting HFpEF, the LAEI had a hazard ratio of 1.197per 10% decrease. In patients who had HFpEF events, the LAEI significantly (P< 0.0001) decreased from 69±18% to 39±11% during hospitalization. Although the LAEI improved during follow-up (53±13%), it did not return to baseline. CONCLUSIONS The LAEI predicts HFpEF in patients with severe diastolic dysfunction; it worsens during HFpEF events and partially recovers during followup.
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Affiliation(s)
- Shih-Hung Hsiao
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Kuan-Rau Chiou
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- * E-mail:
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128
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Bekfani T, Pellicori P, Morris DA, Ebner N, Valentova M, Steinbeck L, Wachter R, Elsner S, Sliziuk V, Schefold JC, Sandek A, Doehner W, Cleland JG, Lainscak M, Anker SD, von Haehling S. Sarcopenia in patients with heart failure with preserved ejection fraction: Impact on muscle strength, exercise capacity and quality of life. Int J Cardiol 2016; 222:41-46. [PMID: 27454614 DOI: 10.1016/j.ijcard.2016.07.135] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 07/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND To describe the prevalence of sarcopenia in ambulatory patients with heart failure with preserved ejection fraction (HFpEF) and its relation to reduced exercise capacity, muscle strength, and quality of life (QoL). METHODS AND RESULTS A total of 117 symptomatic outpatients with HFpEF were prospectively enrolled in Germany, England, and Slovenia as part of the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Appendicular skeletal muscle (ASM) mass (the sum of muscle mass in both arms and legs) was assessed by DEXA. Echocardiography, 6-minute walk testing (6-MWT), muscle strength assessment, spiroergometry and QoL evaluation using EQ-5D Questionnaire were performed. Sarcopenia was defined as ASM 2 standard deviations below the mean of a healthy reference group aged 18-40years. Patients were divided into 3 groups according to the E/e' value: ≤8, 9-14, and ≥15. Sarcopenia was detected in 19.7% of all patients. These patients performed worse during 6-MWT (404±116 vs. 307±145m, p=0.003) and showed lower absolute peak oxygen consumption (1579±474 vs. 1211±442mL/min, p<0.05). Both ASM and muscle strength were lowest in patients with E/e' >15 (p<0.05). Higher values of muscle strength/ASM were associated with a better QoL (r=0.5, p<0.0005). Logistic regression showed ASM to be independently associated with reduced distance walked during the 6-MWT adjusted for NYHA, height, left atrium diameter, ferritin and forced expiratory volume in 1s (FEV1) (odds ratio 1.2, p=0.02). CONCLUSION Sarcopenia affects a clinically relevant proportion of patients with HFpEF. Low ASM is strongly linked to reduced muscle strength, exercise capacity and QoL in these patients.
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Affiliation(s)
- Tarek Bekfani
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany; Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, Friedrich-Schiller-University, Jena, Germany.
| | | | - Daniel A Morris
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany.
| | - Nicole Ebner
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany; University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany.
| | - Miroslava Valentova
- University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany; Department of Internal Medicine, Comenius University, Bratislava, Slovak Republic.
| | - Lisa Steinbeck
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany.
| | - Rolf Wachter
- University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany.
| | - Sebastian Elsner
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany.
| | - Veronika Sliziuk
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany.
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland.
| | - Anja Sandek
- University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany.
| | - Wolfram Doehner
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany; Center for Stroke Research Berlin, Charité Medical School, Berlin, Germany.
| | - John G Cleland
- University of Hull, Department of Cardiology, Hull, United Kingdom.
| | - Mitja Lainscak
- Golnik University, Department of Cardiology, Golnik, Slovenia.
| | - Stefan D Anker
- University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany.
| | - Stephan von Haehling
- Charité Medical School, Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany; University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany.
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129
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Melander S, Miller S. Heart Failure: Overcoming the Physiologic Dilemma Through Evidence-Based Practice. Nurs Clin North Am 2016; 51:13-27. [PMID: 26897421 DOI: 10.1016/j.cnur.2015.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Treatment options for patients with heart failure (HF) have improved in recent years. Medication combinations along with improved device management have improved survival rates and quality of life for patients with HF. Most patients with HF are older than 65 years. Because patients with HF with multiple comorbidities and any physical or cognitive impairments are often excluded from trials or studies, the evidence to guide therapy for most older patients with HF is not always representative and requires customization. Health care providers must remember that older patients with HF with multiple comorbidities and polypharmacy are at great risk for adverse effects and drug-to-drug interactions.
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Affiliation(s)
- Sheila Melander
- Norton's Healthcare System, University of Kentucky, 3682 Briarcliff Trace, Owensboro, KY 42303, USA.
| | - Stephen Miller
- Tennova Turkey Creek Medical Center, 10810 Parkside Drive, Knoxville, TN 37934, USA
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130
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Abstract
With longer life expectancy, as well as better survival rates after myocardial infarction, the population of elderly patients with congestive heart failure steadily increases. Large, randomized, placebo-controlled studies have shown significant beneficial effects for several classes of drugs (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β-blockers, aldosterone antagonists) in patients with congestive heart failure. In most of these studies, however, elderly patients were either excluded or represented only a minority of the study population. Therefore, the treatment benefit for the large population of patients aged 65 and older is still not very well documented. In this paper, we critically review the current literature with regard to outcome of heart failure therapy in this particular subpopulation.
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Affiliation(s)
- Peter C Burger
- Clinic of Cardiology, University Hospital, Basel, Switzerland
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131
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Flachskampf FA, Biering-Sørensen T, Solomon SD, Duvernoy O, Bjerner T, Smiseth OA. Cardiac Imaging to Evaluate Left Ventricular Diastolic Function. JACC Cardiovasc Imaging 2016; 8:1071-1093. [PMID: 26381769 DOI: 10.1016/j.jcmg.2015.07.004] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/02/2015] [Accepted: 07/15/2015] [Indexed: 01/31/2023]
Abstract
Left ventricular diastolic dysfunction in clinical practice is generally diagnosed by imaging. Recognition of heart failure with preserved ejection fraction has increased interest in the detection and evaluation of this condition and prompted an improved understanding of the strengths and weaknesses of different imaging modalities for evaluating diastolic dysfunction. This review briefly provides the pathophysiological background for current clinical and experimental imaging parameters of diastolic dysfunction, discusses the merits of echocardiography relative to other imaging modalities in diagnosing and grading diastolic dysfunction, summarizes lessons from clinical trials that used parameters of diastolic function as an inclusion criterion or endpoint, and indicates current areas of research.
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Affiliation(s)
- Frank A Flachskampf
- Institutionen för Medicinska Vetenskaper, Uppsala Universitet, Uppsala, Sweden.
| | - Tor Biering-Sørensen
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Olov Duvernoy
- Institutionen för Kirurgiska Vetenskaper, Enheten för Radiologi, Uppsala Universitet, Uppsala, Sweden
| | - Tomas Bjerner
- Institutionen för Kirurgiska Vetenskaper, Enheten för Radiologi, Uppsala Universitet, Uppsala, Sweden
| | - Otto A Smiseth
- Department of Cardiology and Institute for Surgical Research, Rikshospitalet, Oslo University Hospital, Center for Cardiological Innovation, K.G. Jebsen Cardiac Research Centre, Centre for Heart Failure Research, University of Oslo, Oslo, Norway
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132
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Roh J, Rhee J, Chaudhari V, Rosenzweig A. The Role of Exercise in Cardiac Aging: From Physiology to Molecular Mechanisms. Circ Res 2016; 118:279-95. [PMID: 26838314 DOI: 10.1161/circresaha.115.305250] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aging induces structural and functional changes in the heart that are associated with increased risk of cardiovascular disease and impaired functional capacity in the elderly. Exercise is a diagnostic and therapeutic tool, with the potential to provide insights into clinical diagnosis and prognosis, as well as the molecular mechanisms by which aging influences cardiac physiology and function. In this review, we first provide an overview of how aging impacts the cardiac response to exercise, and the implications this has for functional capacity in older adults. We then review the underlying molecular mechanisms by which cardiac aging contributes to exercise intolerance, and conversely how exercise training can potentially modulate aging phenotypes in the heart. Finally, we highlight the potential use of these exercise models to complement models of disease in efforts to uncover new therapeutic targets to prevent or treat heart disease in the aging population.
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Affiliation(s)
- Jason Roh
- From the Cardiovascular Division (J. Roh, J. Rhee, V.C., A.R.) and Department of Anesthesiology, Critical Care, and Pain Medicine (J. Rhee), Massachusetts General Hospital and Harvard Medical School, Boston
| | - James Rhee
- From the Cardiovascular Division (J. Roh, J. Rhee, V.C., A.R.) and Department of Anesthesiology, Critical Care, and Pain Medicine (J. Rhee), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Vinita Chaudhari
- From the Cardiovascular Division (J. Roh, J. Rhee, V.C., A.R.) and Department of Anesthesiology, Critical Care, and Pain Medicine (J. Rhee), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Anthony Rosenzweig
- From the Cardiovascular Division (J. Roh, J. Rhee, V.C., A.R.) and Department of Anesthesiology, Critical Care, and Pain Medicine (J. Rhee), Massachusetts General Hospital and Harvard Medical School, Boston.
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133
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Narayanan M, Bamba A, Liu S, Naqvi TZ. Impaired Left and Right Ventricular Systolic and Diastolic Function in Response to Exercise in Patients with Diastolic Dysfunction. Echocardiography 2016; 33:1209-18. [PMID: 27241948 DOI: 10.1111/echo.13242] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Diastolic dysfunction (DD) is associated with exercise intolerance. To evaluate mechanisms of exercise intolerance in patients with DD, we performed bicycle stress echocardiography. METHOD AND RESULTS Doppler measurements were performed at baseline, during exercise and recovery in 26 patients (58 ± 11 years) with DD and normal left ventricular ejection fraction and 6 normal controls (53 ± 5 years). Compared to controls, patients achieved similar target heart rates but lower METs (5.5 ± 2 vs. 9.8 ± 3, P < 0.01) and a higher peak pulmonary artery pressure (PAP) at peak exercise (50 ± 13 vs. 32 ± 7 mmHg, P < 0.01) despite similar PAP at rest and similar mean blood pressure at peak exercise (110.4 ± 18.0 vs. 106.9 ± 11.4 mmHg, P = NS). In patients versus controls, mitral E/E' was similar at baseline (10 ± 3 vs. 8 ± 1.3, P = NS) but higher at recovery (11 ± 2 vs. 7 ± 2, P < 0.05), % mitral filling time was shorter at baseline, onset, and peak exercise, whereas % LV and RV ejection time was similar to controls throughout exercise. Compared to controls, lateral mitral annular S' (11.8 ± 2.5 cm/sec vs. 14.9 ± 1.9 cm/sec, P < 0.02) and tricuspid annular S' (14.8 ± 4.1 cm/sec vs. 19.4 ± 4.0 cm/sec, P < 0.05) were lower at peak exercise in patients. CONCLUSION Diastolic filling time is reduced at rest and stress while LV ejection time increases normally during exercise in DD. There is a reduced systolic reserve in LV and RV during exercise in DD. These mechanisms contribute to exercise intolerance and elevation of left atrial and PAP in patients with DD.
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Affiliation(s)
- Meena Narayanan
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alyssa Bamba
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Shuang Liu
- Department of Cardiology, Mayo Clinic, Scottsdale, Arizona
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134
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Agarwal M, Waxman AB. Physiological Techniques and Pulmonary Hypertension - Left Heart Disease. Prog Cardiovasc Dis 2016; 59:30-41. [PMID: 27211586 DOI: 10.1016/j.pcad.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/06/2023]
Abstract
Group 2 Pulmonary hypertension (PH) is associated with left heart disease (LHD;Group 2 PH) and is the most common form of PH. Group 2 PH represents an important subgroup of patients with LHD where the development of PH leads to a significant increase in morbidity and mortality. Early diagnosis may provide an opportunity to intervene and significantly delay progression. In addition to clinical suspicion, several approaches including hemodynamic assessment, exercise testing, and imaging techniques play an important role in better disease characterization and management. Here, we review the role of physiologic based hemodynamic and exercise assessments of Group 2 PH patients.
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Affiliation(s)
- Manyoo Agarwal
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA; Pulmonary and Critical Care Medicine, Center for Pulmonary Heart Disease, Brigham and Women's Hospital Heart and Vascular Center
| | - Aaron B Waxman
- Pulmonary and Critical Care Medicine, Center for Pulmonary Heart Disease, Brigham and Women's Hospital Heart and Vascular Center; Pulmonary and Critical Care Medicine, Cardiovascular Medicine, Pulmonary Vascular Disease Program, Center for Pulmonary-Heart Diseases, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School.
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135
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Oldham WM, Lewis GD, Opotowsky AR, Waxman AB, Systrom DM. Unexplained exertional dyspnea caused by low ventricular filling pressures: results from clinical invasive cardiopulmonary exercise testing. Pulm Circ 2016; 6:55-62. [PMID: 27162614 PMCID: PMC4860548 DOI: 10.1086/685054] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
To determine whether low ventricular filling pressures are a clinically relevant etiology of unexplained dyspnea on exertion, a database of 619 consecutive, clinically indicated invasive cardiopulmonary exercise tests (iCPETs) was reviewed to identify patients with low maximum aerobic capacity (V̇o2max) due to inadequate peak cardiac output (Qtmax) with normal biventricular ejection fractions and without pulmonary hypertension (impaired: n = 49, V̇o2max = 53% predicted [interquartile range (IQR): 47%-64%], Qtmax = 72% predicted [62%-76%]). These were compared to patients with a normal exercise response (normal: n = 28, V̇o2max = 86% predicted [84%-97%], Qtmax = 108% predicted [97%-115%]). Before exercise, all patients received up to 2 L of intravenous normal saline to target an upright pulmonary capillary wedge pressure (PCWP) of ≥5 mmHg. Despite this treatment, biventricular filling pressures at peak exercise were lower in the impaired group than in the normal group (right atrial pressure [RAP]: 6 [IQR: 5-8] vs. 9 [7-10] mmHg, P = 0.004; PCWP: 12 [10-16] vs. 17 [14-19] mmHg, P < 0.001), associated with decreased stroke volume (SV) augmentation with exercise (+13 ± 10 [standard deviation (SD)] vs. +18 ± 10 mL/m(2), P = 0.014). A review of hemodynamic data from 23 patients with low RAP on an initial iCPET who underwent a second iCPET after saline infusion (2.0 ± 0.5 L) demonstrated that 16 of 23 patients responded with increases in Qtmax ([+24% predicted [IQR: 14%-34%]), V̇o2max (+10% predicted [7%-12%]), and maximum SV (+26% ± 17% [SD]). These data suggest that inadequate ventricular filling related to low venous pressure is a clinically relevant cause of exercise intolerance.
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Affiliation(s)
- William M Oldham
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory D Lewis
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA; Pulmonary and Critical Care Unit and Cardiology Division, Medical Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexander R Opotowsky
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiology, Boston Children's Hospital, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron B Waxman
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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136
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Oliveira RKF, Waxman AB, Agarwal M, Badr Eslam R, Systrom DM. Pulmonary haemodynamics during recovery from maximum incremental cycling exercise. Eur Respir J 2016; 48:158-67. [PMID: 27126692 DOI: 10.1183/13993003.00023-2016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/17/2016] [Indexed: 02/04/2023]
Abstract
Assessment of cardiac function during exercise can be technically demanding, making the recovery period a potentially attractive diagnostic window. However, the validity of this approach for exercise pulmonary haemodynamics has not been validated.The present study, therefore, evaluated directly measured pulmonary haemodynamics during 2-min recovery after maximum invasive cardiopulmonary exercise testing in patients evaluated for unexplained exertional intolerance. Based on peak exercise criteria, patients with exercise pulmonary hypertension (ePH; n=36), exercise pulmonary venous hypertension (ePVH; n=28) and age-matched controls (n=31) were analysed.By 2-min recovery, 83% (n=30) of ePH patients had a mean pulmonary artery pressure (mPAP) <30 mmHg and 96% (n=27) of ePVH patients had a pulmonary arterial wedge pressure (PAWP) <20 mmHg. Sensitivity of pulmonary hypertension-related haemodynamic measurements during recovery for ePH and ePVH diagnosis was ≤25%. In ePVH, pulmonary vascular compliance (PVC) returned to its resting value by 1-min recovery, while in ePH, elevated pulmonary vascular resistance (PVR) and decreased PVC persisted throughout recovery.In conclusion, we observed that mPAP and PAWP decay quickly during recovery in ePH and ePVH, compromising the sensitivity of recovery haemodynamic measurements in diagnosing pulmonary hypertension. ePH and ePVH had different PVR and PVC recovery patterns, suggesting differences in the underlying pulmonary hypertension pathophysiology.
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Affiliation(s)
- Rudolf K F Oliveira
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Aaron B Waxman
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Manyoo Agarwal
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Roza Badr Eslam
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
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137
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Kramer F, Dinh W. Molecular and Digital Biomarker Supported Decision Making in Clinical Studies in Cardiovascular Indications. Arch Pharm (Weinheim) 2016; 349:399-409. [DOI: 10.1002/ardp.201600055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Frank Kramer
- Clinical Sciences - Experimental Medicine; BAYER Pharma AG; Wuppertal Germany
| | - Wilfried Dinh
- Clinical Sciences - Experimental Medicine; BAYER Pharma AG; Wuppertal Germany
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138
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Irizarry Pagán EE, Vargas PE, López-Candales A. The clinical dilemma of heart failure with preserved ejection fraction: an update on pathophysiology and management for physicians. Postgrad Med J 2016; 92:346-55. [DOI: 10.1136/postgradmedj-2015-133859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/11/2016] [Indexed: 12/20/2022]
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139
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Abstract
Evidence-based management of heart failure (HF) with preserved left ventricular ejection fraction (LVEF; HFpEF) remains a major gap in the care of patients with HF. Clinical trials directed toward the population with HFpEF have been disappointing, although renin-angiotensin-aldosterone system blockade appears to prevent HF in populations predisposed to HFpEF. This paradox may partly be because of inhomogeneity within the HF populations studied. Although the term HFpEF is often used to imply a specific diagnosis, in fact this constellation may be due to a large variety of disease states with different underlying pathophysiologic mechanisms. Furthermore, in patients with HF, regardless of LVEF, myocardial dysfunction is common during both systole and diastole, and LVEF is influenced at least as much by the pattern of left ventricular remodeling as it is by myocardial contractility. The most common clinical-pathologic syndrome responsible for HFpEF is strongly associated with hypertension, with the metabolic syndrome, and with older age. Recent findings support that this condition is mediated via endothelial dysfunction, inflammation, oxidative stress, myocyte hypertrophy, and altered collagen turnover. We, therefore, propose the terms "metabolic HF" and "senile HF" to describe this specific disease state. The search for therapies designed to prevent, halt, or reverse HF should more strongly focus on populations carefully selected to represent specific underlying cardiovascular disease states.
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140
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Lee JF, Barrett-O'Keefe Z, Nelson AD, Garten RS, Ryan JJ, Nativi-Nicolau JN, Richardson RS, Wray DW. Impaired skeletal muscle vasodilation during exercise in heart failure with preserved ejection fraction. Int J Cardiol 2016; 211:14-21. [PMID: 26970959 DOI: 10.1016/j.ijcard.2016.02.139] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/28/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Exercise intolerance is a hallmark symptom of heart failure patients with preserved ejection fraction (HFpEF), which may be related to an impaired ability to appropriately increase blood flow to the exercising muscle. METHODS We evaluated leg blood flow (LBF, ultrasound Doppler), heart rate (HR), stroke volume (SV), cardiac output (CO), and mean arterial blood pressure (MAP, photoplethysmography) during dynamic, single leg knee-extensor (KE) exercise in HFpEF patients (n=21; 68 ± 2 yrs) and healthy controls (n=20; 71 ± 2 yrs). RESULTS HFpEF patients exhibited a marked attrition during KE exercise, with only 60% able to complete the exercise protocol. In participants who completed all exercise intensities (0-5-10-15 W; HFpEF, n=13; Controls, n=16), LBF was not different at 0 W and 5 W, but was 15-25% lower in HFpEF compared to controls at 10 W and 15 W (P<0.001). Likewise, leg vascular conductance (LVC), an index of vasodilation, was not different at 0 W and 5 W, but was 15-20% lower in HFpEF compared to controls at 10 W and 15 W (P<0.05). In contrast to these peripheral deficits, exercise-induced changes in central variables (HR, SV, CO), as well as MAP, were similar between groups. CONCLUSIONS These data reveal a marked reduction in LBF and LVC in HFpEF patients during exercise that cannot be attributed to a disease-related alteration in central hemodynamics, suggesting that impaired vasodilation in the exercising skeletal muscle vasculature may play a key role in the exercise intolerance associated with this patient population.
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Affiliation(s)
- Joshua F Lee
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States; Geriatric Research, Education, and Clinical Center, VA Medical Center, Salt Lake City, UT, United States
| | - Zachary Barrett-O'Keefe
- Geriatric Research, Education, and Clinical Center, VA Medical Center, Salt Lake City, UT, United States; Department of Exercise & Sport Science, University of Utah, Salt Lake City, UT, United States
| | - Ashley D Nelson
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Ryan S Garten
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States; Geriatric Research, Education, and Clinical Center, VA Medical Center, Salt Lake City, UT, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jose N Nativi-Nicolau
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Russell S Richardson
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States; Geriatric Research, Education, and Clinical Center, VA Medical Center, Salt Lake City, UT, United States; Department of Exercise & Sport Science, University of Utah, Salt Lake City, UT, United States
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States; Geriatric Research, Education, and Clinical Center, VA Medical Center, Salt Lake City, UT, United States; Department of Exercise & Sport Science, University of Utah, Salt Lake City, UT, United States.
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141
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142
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Sarcopenic obesity and the pathogenesis of exercise intolerance in heart failure with preserved ejection fraction. Curr Heart Fail Rep 2016; 12:205-14. [PMID: 25750186 DOI: 10.1007/s11897-015-0257-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure (HF) in older adults. The primary chronic symptom in patients with HFpEF, even when well compensated, is severe exercise intolerance. Cardiac and peripheral functions contribute equally to exercise intolerance in HFpEF, though the latter has been the focus of fewer studies. Of note, multiple studies with exercise training have shown that exercise intolerance can improve significantly in the absence of improvements in exercise cardiac output, indicating a role of peripheral, noncardiac adaptations. In addition, clinical drug trials performed to date in HFpEF, all of which have focused on influencing cardiovascular function, have not been positive on primary clinical outcomes and most have not improved exercise capacity. Mounting evidence indicates that sarcopenic obesity, characterized by the coexistence of excess fat mass and decreased muscle mass, could contribute to the pathophysiology of exercise intolerance in older HFpEF patients and may provide avenues for novel treatments.
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143
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Tucker WJ, Nelson MD, Beaudry RI, Halle M, Sarma S, Kitzman DW, Gerche AL, Haykowksy MJ. Impact of Exercise Training on Peak Oxygen Uptake and its Determinants in Heart Failure with Preserved Ejection Fraction. Card Fail Rev 2016; 2:95-101. [PMID: 28785460 DOI: 10.15420/cfr.2016:16:2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Heart failure with preserved ejection (HFpEF) accounts for over 50 % of all HF cases, and the proportion is higher among women and older individuals. A hallmark feature of HFpEF is dyspnoea on exertion and reduced peak aerobic power (VO2peak) secondary to central and peripheral abnormalities that result in reduced oxygen delivery to and/or utilisation by exercising skeletal muscle. The purpose of this brief review is to discuss the role of exercise training to improve VO2peak and the central and peripheral adaptations that reduce symptoms following physical conditioning in patients with HFpEF.
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Affiliation(s)
- Wesley J Tucker
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington,Texas, USA
| | - Michael D Nelson
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington,Texas, USA
| | - Rhys I Beaudry
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington,Texas, USA
| | | | - Satyam Sarma
- Institute for Exercise and Environmental Medicine,Texas Health Presbyterian Hospital, Dallas.,University of Texas Southwestern Medical Center,Dallas, Texas, USA
| | - Dalane W Kitzman
- Wake Forest School of MedicineWinston-Salem, North Carolina, USA
| | - Andre La Gerche
- Sport Cardiology, Baker IDI Heart Institute,Melbourne, Victoria, Australia
| | - Mark J Haykowksy
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington,Texas, USA.,Sport Cardiology, Baker IDI Heart Institute,Melbourne, Victoria, Australia
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144
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Belyavskiy E, Morris DA, Kraigher-Krainer E, Kropf M, Radha Krishnan AK, Schmidt A, Pieske B. Clinical perspectives and evidence of diastolic stress test in heart failure with preserved ejection fraction. Egypt Heart J 2015. [DOI: 10.1016/j.ehj.2015.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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145
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Kitzman DW, Haykowsky MJ. Vascular Dysfunction in Heart Failure with Preserved Ejection Fraction. J Card Fail 2015; 22:12-6. [PMID: 26585367 DOI: 10.1016/j.cardfail.2015.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Dalane W Kitzman
- Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States.
| | - Mark J Haykowsky
- College of Nursing and Health Innovation, The University of Texas at Arlington, Texas, United States
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146
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Shimiaie J, Sherez J, Aviram G, Megidish R, Viskin S, Halkin A, Ingbir M, Nesher N, Biner S, Keren G, Topilsky Y. Determinants of Effort Intolerance in Patients With Heart Failure. JACC-HEART FAILURE 2015; 3:803-14. [DOI: 10.1016/j.jchf.2015.05.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 11/29/2022]
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147
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Hadano Y, Matsuzaki M. Noninvasive assessment of exercise tolerance using mitral annular velocities. J Med Ultrason (2001) 2015; 43:37-45. [PMID: 26703165 DOI: 10.1007/s10396-015-0672-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/24/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the feasibility of evaluating exercise tolerance using lateral and septal mitral annular velocities in patients with preserved left ventricular ejection fraction (LVEF) and those with reduced LVEF. METHOD We studied 36 patients with LVEF ≥50% and 36 with LVEF <50%. We measured peak early diastolic velocity of transmitral flow (E) and peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus. The ratios of E to LEa (E/LEa) and E to SEa (E/SEa) were calculated. We measured peak oxygen consumption [Formula: see text] and anaerobic threshold (AT) by cardiopulmonary exercise testing. RESULTS In patients with LVEF ≥50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.69 and r = -0.74, respectively; p < 0.001); E/SEa correlated modestly (r = -0.59 and r = -0.60, respectively; p < 0.001). In patients with LVEF <50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.72 and r = -0.76; respectively, p < 0.001); E/SEa correlated modestly (r = -0.63 and r = -0.63, respectively; p < 0.001). CONCLUSION E/LEa may be more useful than E/SEa for the noninvasive estimation of exercise tolerance, throughout a wide range of LVEF.
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Affiliation(s)
- Yasuyuki Hadano
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan. .,Division of Cardiology, Tokuyama Central Hospital, 1-1 Kodacho, Shunan, 745-8522, Japan.
| | - Masunori Matsuzaki
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
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148
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Haykowsky MJ, Tomczak CR, Scott JM, Paterson DI, Kitzman DW. Determinants of exercise intolerance in patients with heart failure and reduced or preserved ejection fraction. J Appl Physiol (1985) 2015; 119:739-44. [PMID: 25911681 PMCID: PMC4687865 DOI: 10.1152/japplphysiol.00049.2015] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This mini-review summarizes the literature regarding the mechanisms of exercise intolerance in patients with heart failure and reduced or preserved ejection fraction (HFREF and HFPEF, respectively). Evidence to date suggests that the reduced peak pulmonary oxygen uptake (pulm V̇o₂) in patients with HFREF compared with healthy controls is due to both central (reduced convective O₂ transport) and peripheral factors (impaired skeletal muscle blood flow, decreased diffusive O₂ transport coupled with abnormal skeletal morphology, and metabolism). Although central and peripheral impairments also limit peak pulm V̇o₂ in HFPEF patients compared with healthy controls, emerging data suggest that the latter may play a relatively greater role in limiting exercise performance in these patients. Unlike HFREF, currently there is limited evidence-based therapies that improve exercise capacity in HFPEF patients, therefore future studies are required to determine whether interventions targeted to improve peripheral vascular and skeletal muscle function result in favorable improvements in peak pulm and leg V̇o2 and their determinants in HFPEF patients.
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Affiliation(s)
- Mark J Haykowsky
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada;
| | - Corey R Tomczak
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jessica M Scott
- Universities Space Research Association, Houston, Texas; and
| | - D Ian Paterson
- Faculty of Medicine (Division of Cardiology), University of Alberta, Edmonton, Alberta, Canada
| | - Dalane W Kitzman
- Department of Internal Medicine, Sections on Cardiology and Geriatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina
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149
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Nedeljkovic I, Banovic M, Stepanovic J, Giga V, Djordjevic-Dikic A, Trifunovic D, Nedeljkovic M, Petrovic M, Dobric M, Dikic N, Zlatar M, Beleslin B. The combined exercise stress echocardiography and cardiopulmonary exercise test for identification of masked heart failure with preserved ejection fraction in patients with hypertension. Eur J Prev Cardiol 2015; 23:71-7. [PMID: 26358991 DOI: 10.1177/2047487315604836] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is commonly associated with hypertension (HTN). However, resting echocardiography (ECHO) can underestimate the severity of disease. Exercise stress echocardiography (ESE) and the cardiopulmonary exercise testing (CPX) appeared to be useful tests in dynamic assessment of HFpEF. The value of combined exercise stress echocardiography cardiopulmonary testing (ESE-CPX) in the identification of masked HFpEF is still undetermined. OBJECTIVE The purpose of this study was to analyse the value of the combined ESE-CPX in the identification of masked HFpEF in patients with HTN, dyspnoea and normal resting left ventricular (LV) systolic and diastolic function. METHODOLOGY We studied 87 patients with HTN, exertional dyspnoea and normal resting LV function. They all underwent ESE-CPX testing (supine bicycle, ramp protocol, 15 W/min). ECHO measurements were performed at rest, and at peak load. Achievement of peak E/e' ratio>15 was a marker for masked HFpEF. RESULTS Increase of E/e'>15 occurred in 8/87 patients (9.2%) during ESE-CPX. Those patients had the lower peak VO2 (p = 0.012), the lower VO2 at anaerobic threshold (p = 0.025), the lower workload (p = 0.026), the lower peak partial pressure end tidal carbon dioxide (PetCO2) (p < 0.0001), and the higher VE/VCO2 slope (p < 0.0001) which was an independent multivariate predictor of HFpEF (p = 0.021), with the cut-off value of 32.95 according to the receiver-operator characteristic (ROC) curve (sensitivity (Sn) 100%, specificity (Sp) 90%). CONCLUSION The combined ESE-CPX test is feasible and reliable test that can unmask HFpEF and may become an important aid in the early diagnosis of HFpEF, excluding the other causes of exertional dyspnoea.
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Affiliation(s)
- Ivana Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Marko Banovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Jelena Stepanovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Danijela Trifunovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Petrovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Dobric
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Nenad Dikic
- Outpatient Clonoc for Sport Medicine 'Vita Maxima', Belgrade, Serbia
| | - Milan Zlatar
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
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150
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Hirai DM, Musch TI, Poole DC. Exercise training in chronic heart failure: improving skeletal muscle O2 transport and utilization. Am J Physiol Heart Circ Physiol 2015; 309:H1419-39. [PMID: 26320036 DOI: 10.1152/ajpheart.00469.2015] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/23/2015] [Indexed: 01/13/2023]
Abstract
Chronic heart failure (CHF) impairs critical structural and functional components of the O2 transport pathway resulting in exercise intolerance and, consequently, reduced quality of life. In contrast, exercise training is capable of combating many of the CHF-induced impairments and enhancing the matching between skeletal muscle O2 delivery and utilization (Q̇mO2 and V̇mO2 , respectively). The Q̇mO2 /V̇mO2 ratio determines the microvascular O2 partial pressure (PmvO2 ), which represents the ultimate force driving blood-myocyte O2 flux (see Fig. 1). Improvements in perfusive and diffusive O2 conductances are essential to support faster rates of oxidative phosphorylation (reflected as faster V̇mO2 kinetics during transitions in metabolic demand) and reduce the reliance on anaerobic glycolysis and utilization of finite energy sources (thus lowering the magnitude of the O2 deficit) in trained CHF muscle. These adaptations contribute to attenuated muscle metabolic perturbations (e.g., changes in [PCr], [Cr], [ADP], and pH) and improved physical capacity (i.e., elevated critical power and maximal V̇mO2 ). Preservation of such plasticity in response to exercise training is crucial considering the dominant role of skeletal muscle dysfunction in the pathophysiology and increased morbidity/mortality of the CHF patient. This brief review focuses on the mechanistic bases for improved Q̇mO2 /V̇mO2 matching (and enhanced PmvO2 ) with exercise training in CHF with both preserved and reduced ejection fraction (HFpEF and HFrEF, respectively). Specifically, O2 convection within the skeletal muscle microcirculation, O2 diffusion from the red blood cell to the mitochondria, and muscle metabolic control are particularly susceptive to exercise training adaptations in CHF. Alternatives to traditional whole body endurance exercise training programs such as small muscle mass and inspiratory muscle training, pharmacological treatment (e.g., sildenafil and pentoxifylline), and dietary nitrate supplementation are also presented in light of their therapeutic potential. Adaptations within the skeletal muscle O2 transport and utilization system underlie improvements in physical capacity and quality of life in CHF and thus take center stage in the therapeutic management of these patients.
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Affiliation(s)
- Daniel M Hirai
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil; and
| | - Timothy I Musch
- Departments of Anatomy and Physiology and Kinesiology, Kansas State University, Manhattan, Kansas
| | - David C Poole
- Departments of Anatomy and Physiology and Kinesiology, Kansas State University, Manhattan, Kansas
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