Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing

Six Minute Walk Test: A Tool for Predicting Mortality in Chronic Pulmonary Diseases

INTRODUCTION

Six Minute Walk Test (6MWT) is a simple test used to measure exercise capacity in Chronic Pulmonary Diseases (CPDs). Decreased exercise capacity significantly affects the quality of life. The 6MWT is a known tool to measure exercise capacity and quality of life in CPD. However, the role of change in follow up Six Minute Walk Distance (6MWD) in assessing mortality and its correlation with known prognostic factors haven't been tested to the best of our knowledge.

AIM

To study the correlation of change in 6MWD with change in spirometry and to study the role of 6MWD in predicting mortality in CPD.

SETTINGS AND DESIGN

Prospective cohort study.

MATERIALS AND METHODS

A total of 139 CPD patients were grouped into obstructive, restrictive and post Tuberculosis (TB) sequelae. Optimized treatment was given and they were followed up regularly. Spirometry and 6MWT was done at the beginning and after one year. Mean decline in FEV1, FVC was correlated with mean decline in 6MWD.

STATISTICAL ANALYSIS

With STATA 13.1 correlation between 6MWT and spirometric values were done using Wilcoxon signed rank test. Predictors of mortality were studied using multivariate analysis.

RESULTS

Overall mean decline in 6MWD was 16.07 m/year. There was no correlation between mean change in 6MWD and change in FEV1, FVC, and FEV1/FVC. On multivariate analysis, 6MWD was the better predictor of mortality than FEV1 (p<0.001), FVC (p<0.001). At cut off value of 240 meters, sensitivity and specificity of 6MWT in predicting mortality was 71.05% and 81.94% respectively.

CONCLUSION

The 6MWD changes independently and has no correlation with change in spirometry, it is an independent predictor of mortality in CPD.

Outcomes of a community-based lifestyle programme for adults with diabetes or pre-diabetes

INTRODUCTION Diabetes, a long-term condition increasing in prevalence, requires ongoing healthcare management. Exercise alongside lifestyle education and support is effective for diabetes management. AIM To investigate clinical outcomes and acceptability of a community-based lifestyle programme for adults with diabetes/prediabetes at programme completion and 3-month follow-up. METHODS The 12-week community programme included twice-weekly sessions of self-management education and exercise, supervised by a physiotherapist, physiotherapy students and a nurse. Clinical outcomes assessed were cardiorespiratory fitness, waist circumference, exercise behaviour and self-efficacy. A standardised evaluation form was used to assess programme acceptability. RESULTS Clinically significant improvements were found from baseline (n = 36) to programme completion (n = 25) and 3-months follow-up (n = 20) for the six minute walk test (87 m (95%CI 65-109; p ≤ 0.01), 60 m (95%CI 21-100; p ≤ 0.01)), waist circumference (-3 cm (95%CI -6 to -1), -3 cm (95%CI -6 to 1)), exercise behaviour (aerobic exercise 53 min/week (95%CI 26 to 81; p ≤ 0.01), 71 min/week (95%CI 25 to 118; p ≤ 0.01)) and self-efficacy (0.7 (95%CI -0.2 to 1.6), 0.8 (95%CI 0.04 to 1.5)). Good programme acceptability was demonstrated by themes suggesting a culturally supportive, motivating, friendly, informative atmosphere within the programme. The attrition rate was 30% but there were no adverse medical events related to the programme. DISCUSSION The programme was safe and culturally acceptable and outcomes demonstrated clinical benefit to participants. The attrition rate was largely due to medical reasons unrelated to the programme. This model of a community-based lifestyle programme has the potential to be reproduced in other regions and in adults with similar long-term conditions. KEYWORDS Diabetes Mellitus Type II; Prediabetic state; Co-morbidity; Exercise; Self-management.

Six-minute walk test predicts all-cause mortality and technique failure in ambulatory peritoneal dialysis patients

AIM

This study investigated the associated factors of 6-min walk test (6MWT) and its predictive value of outcome in patients undergoing peritoneal dialysis (PD).

METHODS

This is a single centre prospective observational cohort study. Stable ambulatory PD patients in our centre between 1 May 2010 and 30 April 2011 were enrolled in this study. All included subjects performed 6MWT, and 6-min walk distances (6MWDs) were recorded. Patients were divided into two groups according to 6MWD and prospectively followed up until death, cessation of PD or to the end of the study (30 September 2012).

RESULTS

A total of 145 patients were enrolled, including 63 (43%) males. Multiple stepwise regression showed that age (β = -0.295, P = 0.001), diastolic blood pressure (DBP) (β = 0.292, P = 0.001), left ventricular ejection fraction (LVEF) (β = 0.198, P = 0.019) were independently associated with lower 6MWD. By the end of the study, six (8%) patients died in long 6MWD group while 15 (20%) died in the short 6MWD group, a significantly lower patient survival was observed in short 6MWD group (Log-rank = 4.983, P = 0.026). Patients with short 6MWD also showed inferior technique survival (Log-rank = 4.838, P = 0.028). There was no significant difference in peritonitis-free survival between the two groups (Log-rank = 0.801, P = 0.371). However, more patients in short 6MWD group had been transferred to hemodialysis due to peritonitis (25% vs 4.2%, P = 0.013).

CONCLUSION

Age, diastolic blood pressure, LVEF are independent associated factors of 6MWD in patients undergoing PD. Having the advantages of easy applicability and safety, 6MWT may be proposed as an important predictor of outcome in ambulatory PD patients.

Follow-up tricuspid annular plane systolic excursion predicts survival in pulmonary arterial hypertension

Few studies have examined the utility of serial echocardiography in the evaluation, management, and prognosis of patients with pulmonary arterial hypertension (PAH). Therefore, we sought to evaluate the prognostic significance of follow-up tricuspid annular plane systolic excursion (TAPSE) in PAH. We prospectively studied 70 consecutive patients with PAH who underwent baseline right heart catheterization (RHC) and transthoracic echocardiogram, who survived to follow-up echocardiogram after initiation of PAH therapy. Baseline TAPSE was 1.6 ± 0.5 cm which increased to 2.0 ± 0.4 cm on follow-up (P < 0.0001). The cohort was dichotomized by TAPSE at one-year follow-up: Group 1 (n = 37): follow-up TAPSE ≥ 2 cm; Group 2 (n = 33): follow-up TAPSE < 2 cm. Group 1 participants were significantly more likely to reach WHO functional class I–II status and achieve a higher six-minute walk distance on follow-up. Of the 68 patients who survived more than one year, 18 died (26.5%) over a median follow-up of 941 days (range, 3–2311 days), with significantly higher mortality in Group 2 versus Group 1 (41.9% vs. 13.5%; P = 0.003). While baseline TAPSE stratified at 2 cm did not predict survival in this cohort, TAPSE ≥ 2 cm at follow-up strongly predicted survival in bivariable models (hazard ratio, 0.21; 95% confidence interval, 0.08–0.60). In conclusion, follow-up TAPSE ≥ 2 cm is a prognostic marker and potential treatment target in a PAH population.

A Systematic Review and Meta-Analysis Baduanjin Qigong for Health Benefits: Randomized Controlled Trials

Objective. To investigate the effects of practicing Baduanjin Qigong on different health outcomes. Methods. Six electronic databases were used for literature search through entering the following key words: Baduanjin Qigong, quality of life, sleep quality, and health-related outcomes. Results. Nineteen randomized controlled trials were used for meta-analysis. The aggregated results from this systematic review have shown significant benefits in favour of Baduanjin Qigong on quality of life (SMD, −0.75; 95% CI −1.26 to −0.24; P = 0.004), sleep quality (SMD, −0.55; 95% CI −0.97 to −0.12; P = 0.01), balance (SMD, −0.94; 95% CI −1.59 to 0.30; P = 0.004), handgrip strength (SMD, −0.69; 95% CI −1.2 to −0.19; P = 0.007), trunk flexibility (SMD, −0.66; 95% CI −1.13 to −0.19; P = 0.006), systolic (SMD, −0.60; 95% CI −0.94 to −0.27; P = 0.0004) and diastolic blood pressure (SMD, −0.46; 95% CI −0.73 to −0.20; P = 0.0005), and resting heart rate (SMD, −0.87; 95% CI −1.47 to −0.27; P = 0.005). The aggregated results of meta-analyses examining the effect of Baduanjin Qigong on leg power, cardiopulmonary endurance, and pulmonary function remain unclear because of a small number of studies. Conclusions. The aggregated results from this systematic review show that Baduanjin Qigong practice is beneficial for quality of life, sleep quality, balance, handgrip strength, trunk flexibility, systolic and diastolic blood pressure, and resting heart rate. Further studies are necessary to confirm the effects of Baduanjin Qigong on leg power, cardiopulmonary endurance, and pulmonary function (e.g., vital capacity), while considering a long-term follow-up. Registration Number. This trial is registered with International Prospective Register of Systematic Reviews (PROSPERO): CRD42016036966.

Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases

Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.

Right ventricular dyssynchrony in pulmonary hypertension: Phase analysis using FDG-PET imaging

BACKGROUND

Right ventricular (RV) performance in patients of pulmonary hypertension (PH) requires optimal assessment. The objective of this study is to develop phase analysis using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging as a feasible tool for evaluation of RV dyssynchrony in PH.

METHODS AND RESULTS

Fifty-four PH patients with well-characterized hemodynamic parameters were enrolled. All subjects performed FDG-PET imaging for RV phase analysis and RV function evaluation. Two-dimensional echocardiography with speckle tracking analysis was conducted to obtain RV time to peak systolic strain (PSST) as a comparison. The median contraction delay difference between RV middle free wall and septum measured by PET phase analysis (RVPDPET) was 20.12° (interquartile range, 4.99°-30.10°). The median difference of PSST between RV middle free wall and middle septal wall (RVPDEcho) measured by echocardiography was 43.98° (interquartile range, 6.25°-72.00°). RVPDPET was well correlated with RVPDEcho (r = 0.685, P < .001). RV phase standard deviation (RVSD) and histogram bandwidth (RVBW) derived from PET phase histogram were significantly correlated with cardiac index, RV ejection fraction, 6-minute walking distance, and serum N-terminal pro B-type natriuretic peptide (NT-proBNP) (RVSD: r = -0.532, P < .001; r = -0.551, P < .001; r = -0.544, P < .001; r = 0.404, P < .01; respectively, RVBW: r = -0.492, P < .001; r = -0.466, P < .001; r = -0.544, P < .001; r = 0.349, P = .01, respectively), while there were no significant correlations between RVSD and RVBW with hemodynamic parameters (right atrial pressure, right ventricular systolic pressure, right ventricular end-diastolic pressure, mean pulmonary artery pressure, and total pulmonary resistance).

CONCLUSIONS

Contraction delays between RV free wall and septum in PH measured by phase analysis and speckle tracking echocardiography were well correlated. RV dyssynchrony measured by phase analysis of FDG-PET was significantly related to RV dysfunction. Phase analysis of FDG-PET is feasible to evaluate RV mechanical dyssynchrony in patients of PH.

The utility of 6-minute walk distance in predicting waitlist mortality for lung transplant candidates

BACKGROUND

The lung allocation score (LAS) has led to improved organ allocation for transplant candidates. At present, the 6-minute walk distance (6MWD) is treated as a binary categorical variable of whether or not a candidate can walk more than 150 feet in 6 minutes. In this study, we tested the hypothesis that 6MWD is presently under-utilized with respect to discriminatory power, and that, as a continuous variable, could better prognosticate risk of waitlist mortality.

METHODS

A retrospective cohort analysis was performed using the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) transplant database. Candidates listed for isolated lung transplant between May 2005 and December 2011 were included. The population was stratified by 6MWD quartiles and unadjusted survival rates were estimated. Multivariable Cox proportional hazards modeling was used to assess the effect of 6MWD on risk of death. The Scientific Registry of Transplant Recipients (SRTR) Waitlist Risk Model was used to adjust for confounders. The optimal 6MWD for discriminative accuracy in predicting waitlist mortality was assessed by receiver-operating characteristic (ROC) curves.

RESULTS

Analysis was performed on 12,298 recipients. Recipients were segregated into quartiles by distance walked. Waitlist mortality decreased as 6MWD increased. In the multivariable model, significant variables included 6MWD, male gender, non-white ethnicity and restrictive lung diseases. ROC curves discriminated 6-month mortality was best at 655 feet.

CONCLUSIONS

The 6MWD is a significant predictor of waitlist mortality. A cut-off of 150 feet sub-optimally identifies candidates with increased risk of mortality. A cut-off between 550 and 655 feet is more optimal if 6MWD is to be treated as a dichotomous variable. Utilization of the LAS as a continuous variable could further enhance predictive capabilities.

Use of ECG and Other Simple Non-Invasive Tools to Assess Pulmonary Hypertension

Background

There is a broad consensus that pulmonary hypertension (PH) is to be diagnosed by right heart catheterization (RHC) and that the most important non-invasive tool is echocardiography. However, the role of simple non-invasive tools in the work-up of PH is not clearly defined. We hypothesized that the use of simple non-invasive techniques may help to guide important decisions in the diagnostics of pulmonary hypertension.

Objectives

We aimed to develop an algorithm with the use of simple, non-invasive tools in order to identify patients with very high or very low likelihood of PH.

Methods

We retrospectively analyzed all consecutive patients undergoing RHC between 2005 and 2010 in our center and performed logistic regression of simple non-invasive parameters regarding detection and exclusion of PH and derived a two-step algorithm. In a prospective study we evaluated this algorithm between 2011 and 2013.

Results

The retrospective cohort consisted of n = 394 patients of which 49% presented with PH. Right axis deviation in the ECG was present in 90/394 patients and had a positive predictive value (PPV) of 93% for PH. The combination of non-right axis deviation, N-terminal pro brain natriuretic peptide (NT-proBNP)<333pg/ml, arterial oxygen saturation (SO₂)≥95.5% and WHO functional class I-II was present in 69/394 patients and excluded PH with a negative predictive value (NPV) of 96%. The prospective study confirmed these results in a cohort of n = 168 patients (PPV:92%, NPV:97%). Taken together, simple non-invasive tools allowed a prediction regarding the presence or absence of PH in 42% of patients with suspected PH.

Conclusion

ECG, NT-proBNP, SO₂ and WHO functional class may predict the presence or absence of PH in almost half of the patients with suspected PH, suggesting an important role for these variables in the work-up of patients at risk for PH.

Clinical Trial Registration

NCT01607502

Interstitial lung disease increases mortality in systemic sclerosis patients with pulmonary arterial hypertension without affecting hemodynamics and exercise capacity

Published data suggest that coexisting interstitial lung disease (ILD) has an impact on mortality in patients with systemic sclerosis (SSc) and pulmonary arterial hypertension (PAH), but there is scarce knowledge if this is reflected by hemodynamics, exercise capacity, autoantibody profile, or pulmonary function. In this partially retrospective study, 27 SSc-PAH patients were compared to 24 SSc-PAH patients with coexisting ILD respecting to survival, pulmonary function, hemodynamics, exercise capacity, and laboratory parameters. Survival was significantly worse in SSc-PAH-ILD patients than in SSc patients with isolated PAH (1, 5, and 10-year survival rates 86, 54, and 54% versus 96, 92, and 82%, p = 0.013). Compared to isolated SSc-PAH patients, patients with SSc-PAH-ILD revealed lower forced expiratory volume after 1 s (FEV1) values at the time of PAH diagnosis as well as 1 and 2 years later (p = 0.002) without significant decrease in the PAH course in both groups. At PAH diagnosis, diffusion capacity for carbon monoxide (DLCO) values were lower in the ILD-PAH group. Coexisting ILD was not associated with lower exercise capacity, different FEV1/forced vital capacity (FVC) ratio, higher WHO functional class, or reduced hemodynamics. Higher levels of antibodies against angiotensin and endothelin receptors predict mortality in all SSc-PAH patients but could not differentiate between PAH patients with and without ILD. Our study confirmed an impact of ILD on mortality in SSc-PAH patients. Pulmonary function parameters can be used to distinguish PAH from PAH-ILD. The higher mortality rate cannot be explained by differences in hemodynamics, exercise capacity, or autoantibody levels. Mechanisms of mortality remain to be studied.

Serum Bilirubin and 6-min Walk Distance as Prognostic Predictors for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Prospective Cohort Study

Background:

Inoperable chronic thromboembolic pulmonary hypertension (CTEPH) is a severe clinical syndrome characterized by right cardiac failure and possibly subsequent liver dysfunction. However, whether serum markers of liver dysfunction can predict prognosis in inoperable CTEPH patients has not been determined. Our study aimed to evaluate the potential role of liver function markers (such as serum levels of transaminase, bilirubin, and gamma-glutamyl transpeptidase [GGT]) combined with 6-min walk test in the prediction of prognosis in patients with inoperable CTEPH.

Methods:

From June 2005 to May 2013, 77 consecutive patients with inoperable CTEPH without confounding co-morbidities were recruited for this prospective cohort study. Baseline clinical characteristics and 6-min walk distance (6MWD) results were collected. Serum biomarkers of liver function, including levels of aspartate aminotransferase, alanine aminotransferase, GGT, uric acid, and serum bilirubin, were also determined at enrollment. All-cause mortality was recorded during the follow-up period.

Results:

During the follow-up, 22 patients (29%) died. Cox regression analyses demonstrated that increased serum concentration of total bilirubin (hazard ratio [HR] = 7.755, P < 0.001), elevated N-terminal of the prohormone brain natriuretic peptide (HR = 1.001, P = 0.001), decreased 6MWD (HR = 0.990, P < 0.001), increased central venous pressure (HR = 1.074, P = 0.040), and higher pulmonary vascular resistance (HR = 1.001, P = 0.018) were associated with an increased risk of mortality. Serum concentrations of total bilirubin (HR = 4.755, P = 0.007) and 6MWD (HR = 0.994, P = 0.017) were independent prognostic predictors for CTEPH patients. Patients with hyperbilirubinemia (≥23.7 μmol/L) had markedly worse survival than those with normobilirubinemia.

Conclusion:

Elevated serum bilirubin and decreased 6MWD are potential predictors for poor prognosis in inoperable CTEPH.

Midterm Effect of Balloon Pulmonary Angioplasty on Hemodynamics and Subclinical Myocardial Damage in Chronic Thromboembolic Pulmonary Hypertension

BACKGROUND

The acute favourable effect of balloon pulmonary angioplasty (BPA) has been proven in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, data on its effect 6 months after therapy (from now on referred to as mid-term) and influence on the right ventricle and myocardial damage are sparse. To evaluate factors that influence improvement in cardiac output (CO) and subclinical myocardial damage, we examined hemodynamics and serum high-sensitivity troponin T (hs-TnT) levels before, 1 week after, and 6 months after BPA.

METHODS

In a retrospective study, we reviewed 67 consecutive patients from November 2012 to January 2016 with CTEPH who had undergone BPA at Keio University Hospital.

RESULTS

Six months after BPA, the mean right atrium pressure, mean pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), B-type natriuretic peptide (BNP), and hs-TnT levels decreased; CO and 6-minute walking distance increased. Changes in CO and hs-TnT levels varied compared with other hemodynamic parameters and BNP levels. The CO-increase group (n = 42) had higher mean PAP and PVR, and lower CO at baseline than the CO-decrease/stable group (n = 25). The hs-TnT-decrease group (n = 36) had higher mean right atrium pressure, PAP, PVR, and BNP levels, and lower CO at baseline than the hs-TnT-increase/stable group (n = 31).

CONCLUSIONS

Six months after BPA, hemodynamics and exercise capacity improved and hs-TnT levels decreased. Improvements in CO and hs-TnT levels were more prominent in CTEPH patients with impaired baseline hemodynamics, suggesting that BPA has a favourable mid-term effect on hemodynamics and subclinical myocardial damage in patients with CTEPH, especially in those with impaired hemodynamics.

The six-minute walk test predicts cardiorespiratory fitness in individuals with aneurysmal subarachnoid hemorrhage

BACKGROUND

Peak oxygen uptake (VO_2peak) established during progressive cardiopulmonary exercise testing (CPET) is the "gold-standard" for cardiorespiratory fitness. However, CPET measurements may be limited in patients with aneurysmal subarachnoid hemorrhage (a-SAH) by disease-related complaints, such as cardiovascular health-risks or anxiety. Furthermore, CPET with gas-exchange analyses require specialized knowledge and infrastructure with limited availability in most rehabilitation facilities.

OBJECTIVES

To determine whether an easy-to-administer six-minute walk test (6MWT) is a valid clinical alternative to progressive CPET in order to predict VO_2peak in individuals with a-SAH.

METHODS

Twenty-seven patients performed the 6MWT and CPET with gas-exchange analyses on a cycle ergometer. Univariate and multivariate regression models were made to investigate the predictability of VO_2peak from the six-minute walk distance (6MWD).

RESULTS

Univariate regression showed that the 6MWD was strongly related to VO_2peak (r = 0.75, p < 0.001), with an explained variance of 56% and a prediction error of 4.12 ml/kg/min, representing 18% of mean VO_2peak. Adding age and sex to an extended multivariate regression model improved this relationship (r = 0.82, p < 0.001), with an explained variance of 67% and a prediction error of 3.67 ml/kg/min corresponding to 16% of mean VO_2peak.

CONCLUSIONS

The 6MWT is an easy-to-administer submaximal exercise test that can be selected to estimate cardiorespiratory fitness at an aggregated level, in groups of patients with a-SAH, which may help to evaluate interventions in a clinical or research setting. However, the relatively large prediction error does not allow for an accurate prediction in individual patients.

Evaluation of predictive models for six minute walk test among children with pulmonary hypertension

BACKGROUND

Existing six minute walk distance (6MWD) prediction equations were developed using healthy children and include relatively small sample sizes. Children with congenital heart disease and pulmonary hypertension (PH) are often small-for-age, so the existing pediatric prediction equations are likely a poor fit for children with PH. Currently, there are no equations for 6MWD among children with PH.

OBJECTIVES

Evaluate the validity of five existing pediatric prediction equations among the 6MWD of children with PH, including for each World Health Organization (WHO) class. Develop a validated predictive equation for use in children with PH.

METHODS/RESULTS

The 6MWDs from 711 six minute walk tests (6MWTs) of children aged four through 18years with PH were analyzed retrospectively and were evaluated against existing pediatric prediction equations. Existing pediatric prediction equations overestimated the walk distance among our population. The predicted distances versus actual distances were significantly different for each WHO class, with higher class associated with greater difference. A new prediction equation for 6MWD among children with PH was developed and validated with 65 additional 6MWTs. Our prediction equation demonstrates higher goodness of fit for all WHO classes than the preexisting pediatric equations.

CONCLUSIONS

Existing prediction equations for 6MWD among healthy children are not accurate for children with PH, particularly for children with more advanced stages of the disease (WHO classes III and IV). We present a new prediction equation for children with PH (WHO classes I through IV) that provides reference for medical care and management.

Impaired right and left ventricular mechanics in adults with pulmonary hypertension and congenital shunts

AIMS

To assess left ventricle mechanics in Eisenmenger physiology patients with congenital shunts, and their relationship with the right ventricle, and to consider the clinical usefulness of this information.

METHODS

The study involved 28 patients with pulmonary artery hypertension (PAH) and congenital shunt, matched with 28 healthy participants. Standard echocardiography and pulsed wave tissue Doppler imaging were employed to analyze systolic and diastolic ventricular function, the myocardial performance index (MPI) of ventricles, and the strain and strain rate along the left ventricle lateral wall, septum, and right ventricle free wall.

RESULTS

The left ventricle ejection fraction was similar in the two groups. However, despite normal standard left ventricle measures, patients presented parameters of defective myocardial mechanics: mitral peak systolic velocity (S') (cm/s) (8.6 (7.6-10.9) vs. 10.7 (8.6-12.5); P = 0.002) was higher, whereas left ventricle-MPI was lower (0.54 ± 01 vs. 0.32 ± 0.07, P < 0.001). Right ventricle-MPI and right ventricle global strain were correlated significantly with left ventricle-MPI and left ventricle global strain (r = 0.74, P < 0.001; r = 0.442, P < 0.001, respectively). Clinically, the six-minute walking test results were correlated negatively with left ventricle-MPI (r = -0.69, P < 0.001), whereas the functional class was positively correlated (r = 0.36, P < 0.001). In conclusion, left ventricle mechanics and geometry are impaired in Eisenmenger syndrome patients, although conventional evaluation is in the normal range. Our results highlight the significance of ventricular interdependence in PAH and provide a useful tool for improving the clinical management of these patients.

Cardiopulmonary exercise testing improves diagnostic specificity in patients with echocardiography-suspected pulmonary hypertension

BACKGROUND

Doppler echocardiography is usually the first diagnostic investigation for patients suspected with pulmonary hypertension (PH), but it is often inaccurate when used alone, especially in mild PH.

HYPOTHESIS

Cardiopulmonary exercise testing (CPET) may serve as a complementary tool to improve diagnostic accuracy in echocardiography-suspected "PH possible" patients.

METHODS

Eighty-eight consecutive patients with suspected PH (referred to as "PH possible" hereafter) based on echocardiography were included in the study. CPET was assessed subsequently and PH was confirmed by right-heart catheterization in all subjects. We analyzed CPET data from patients and derived a CPET prediction rule to hemodynamically differentiate PH.

RESULTS

Eighty-eight patients (27 patients with confirmed PH, and PH ruled out in 61 patients) were included in the study. Compared with non-PH patients, the PH subjects had lower peak oxygen uptake (VO₂ ), aerobic capacity (AT), peak partial pressure of end-tidal CO₂ (P_ET CO₂ ), oxygen uptake efficiency plateau (OUEP), and oxygen uptake efficiency slope (OUES), along with higher minute ventilation (VE)/carbon dioxide output (VCO₂ ) slope and lowest VE/VCO₂ (P < 0.001). VE/VCO₂ slope and AT were independent predictors of PH derived from multivariate logistic regression adjusted for age and body mass index. A score combining VE/VCO₂ slope and AT reached a high area under the curve value of 0.98. A score ≥0.5 had 95% specificity and 92.6% sensitivity for diagnosis of PH.

CONCLUSIONS

A score combining VE/VCO₂ slope and AT provides high specificity in screening out PH from a pool of echocardiography-suspected PH patients.

Survival after pulmonary rehabilitation in patients with COPD: impact of functional exercise capacity and its changes

The impact of rehabilitation-induced changes in 6-minute walk distance (6MWD) on the survival of patients with chronic obstructive pulmonary disease (COPD) has not been fully elucidated. This study sought to determine the association of baseline 6MWD and its changes after pulmonary rehabilitation (PR) with 5-year survival in patients with COPD. Patients who were referred to a 12-week outpatient PR program were followed up for 5 years postcompletion, and survival status was verified. Survival was analyzed according to four groups based upon initial 6MWD (6MWDi) and its changes (Δ6MWD) after PR (Group 1: 6MWDi ≥350 m and Δ6MWD ≥30 m; Group 2: 6MWDi ≥350 m and Δ6MWD <30 m; Group 3: 6MWDi <350 m and Δ6MWD ≥30 m; and Group 4: 6MWDi <350 m and Δ6MWD <30 m) via Kaplan–Meier analysis and log rank test. Cox regression was performed to identify possible confounders of mortality estimates. In total, 423 patients (with mean ± standard deviation of forced expiratory volume in the first second [FEV₁] 43±16% predicted, age 65±8 years, and 6WMDi 381±134 m) underwent PR between 1999 and 2010. Survival rates decreased progressively from Group 1 to Group 4 (Group 1, 81%; Group 2, 69%; Group 3, 47%; Group 4, 27%; log rank test, P<0.05). 6MWDi ≥350 m (hazard ratio [HR] 0.39 [95% confidence interval {CI} 0.30–0.50]) and Δ6MWD ≥30 m (HR 0.66 [95% CI 0.51–0.85]) were strongly and independently associated with survival. Compared with Group 1, mortality risks progressively increased in Group 2 (HR 1.36 [95% CI 0.92–2.00]; not significant), Group 3 (HR 1.90 [95% CI 1.28–2.84]; P=0.001), and Group 4 (HR 3.28 [95% CI 2.02–5.33]; P<0.0001). Both poor 6MWD and lack of improvement >30 m after PR are associated with worse 5-year survival in patients with COPD.

Long-term outcomes of pulmonary arterial hypertension under specific drug therapy in Eisenmenger syndrome

BACKGROUND

The long-term effectiveness of pulmonary arterial hypertension-specific drug therapy (PAH-SDT) in Eisenmenger syndrome is controversial. We investigated short-term and long-term hemodynamic changes under PAH-SDT and their associations with outcomes in a bicentric cohort.

METHODS

Over 20 years, we included 69 patients with congenital heart disease, an indexed pulmonary vascular resistance (PVRi) >8 WU·m², and 292 standardized catheterizations at baseline and after PAH-SDT initiation or intensification. Oxygen consumption was measured and the Fick principle applied to calculate indexed pulmonary output (Qpi) and PVRi.

RESULTS

After PAH-SDT initiation or intensification, median (interquartile range) PVRi decrease was 5.1 WU·m² (-1.4, -12.6) (p < 0.0001). Median Qpi and 6-minute walk test increases were +0.4 liter/min/m² (0.0, +0.9) (p < 0.0001) and +49 m (+15, +93) (p = 0.0003), respectively. Hemodynamic response combining increased Qpi with decreases in transpulmonary gradient and PVRi occurred in 68.0% of patients. After a median of 4.9 years, PVRi and Qpi changes were no longer significant. Over a median of 7.2 years, 23 (33.3%) patients met a composite criterion (death, n = 8; heart-lung transplantation or listing for transplantation, n = 15). The 15-year cumulative event rate was 49.2%. By multivariate analysis, independent predictors of events were superior vena cava oxygen saturation and hemodynamic response (p = 0.048 and p < 0.0001).

CONCLUSIONS

In Eisenmenger syndrome, PAH-SDT induces early hemodynamic improvements, which decline over time. Hemodynamic changes under PAH-SDT vary across patients. Hemodynamic parameters at baseline and under PAH-SDT are associated with events. PAH-SDT may need to be individualized based on hemodynamic changes.

A review of therapeutic agents for the management of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is an uncommon, progressive and life threatening disease characterized by a proliferative vasculopathy of the small muscular pulmonary arterioles resulting in elevated pulmonary vascular resistance and eventually right ventricular failure. An increasing understanding of the pathobiology of PAH and its natural history has led to the development of numerous targeted therapies. Despite these advances there is significant progression of disease and the survival rate remains low. This article reviews the agents currently available for the medical management of PAH.

Use of Six-Minute Walk Test to Measure Functional Capacity After Liver Transplantation

BACKGROUND

Functional impairment is common in people with chronic liver disease (CLD), and improvement is expected following liver transplantation (LT). The Six-Minute Walk Test (6MWT) is an objective measure of functional performance.

OBJECTIVE

The aims of this study were: (1) to evaluate the feasibility of 6MWT performance after LT, (2) to compare post-LT 6MWT performance over time between patients with and without CLD, (3) to determine when post-LT 6MWT performance approaches expected values, and (4) to investigate predictors of poor 6MWT performance.

METHODS

The 6MWT was performed by 162 consecutive ambulatory participants (50 healthy controls, 62 with CLD, 50 with LT). Sex, age, and body mass index were used to predict expected 6MWT performance. Chi-square testing, analysis of variance, and Pearson coefficients compared percentage of predicted 6-minute walk distance (%6MWD) across groups. Multivariable mixed models assessed predictors of improvement.

RESULTS

The participants' mean age was 53.5 years (SD=13.0), 39.5% were female, and 39.1% were nonwhite. At 1-month post-LT, only 52% of all LT recipients met the inclusion criteria for 6MWT performance. Mean %6MWD values for female participants improved from 49.8 (SD=22.2) at 1 month post-LT to 90.6 (SD=12.8) at 1 year post-LT (P<.0001), which did not differ statistically from the CLD group (X̅=95.9, SD=15.6) or the control group (X̅=95.6, SD=18.0) (P=.58). However, at 1-year post-LT, mean %6MWD values for male participants (X̅=80.4, SD=19.5) remained worse than for both the CLD group (X̅=93.3, SD=13.7) and the control group (X̅=91.9, SD=14.3) (P=.03). Six-Minute Walk Test performance was directly correlated with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical component score (r=.51, P<.01) and was inversely correlated with nonalcoholic steatohepatitis (r=-.52, P<.01) and diabetes (r=-.48, P<.05). In multivariate analysis adjusted for age and sex, hepatitis C independently predicted 6MWT improvement (estimated β=69.8, standard error=27.6, P=.01).

LIMITATIONS

A significant proportion of patients evaluated for enrollment were excluded due to level of illness early after LT (n=99, 47.4%). Thus, sampling bias occurred in this study toward patients without significant postoperative complications.

CONCLUSIONS

The 6MWT is a simple test of physical functioning but may be difficult to apply in LT recipients. The 6MWT performance improved following LT but was lower than expected, suggesting a low level of fitness up to 1 year following LT.

Clinical Presentation, Differential Diagnosis, and Vasodilator Testing of Pulmonary Hypertension

Clinicians should be cognizant of the symptoms and risk factors associated with pulmonary hypertension (PH). While known PH poses significant therapeutic challenges, occult PH carries the added potential for unanticipated complications when treating concurrent medical illnesses. PH may occur with underlying medical conditions and risk factors or may occur de novo as idiopathic pulmonary arterial hypertension (IPAH). Symptoms of PH are frequently attributed to more common conditions, and their nonspecific nature and insidious onset may lead to delay in presentation, evaluation, and diagnosis. Initial symptoms are dyspnea, fatigue, chest pain, and palpitations. Lower extremity edema, presyncope, and syncope are symptoms of more advanced disease. Thorough evaluation of symptoms and identification of patients with risk factors for PH are critical in making a timely diagnosis. History and physical examination can identify patients with suspected PH. Further testing is necessary for definitive diagnosis, classification, assessment of severity, and guiding therapeutic decisions.

Guanylate cyclase stimulators for pulmonary hypertension

BACKGROUND

Pulmonary hypertension is a condition of complex aetiology that culminates in right heart failure and early death. Soluble guanylate cyclase (sGC) stimulators are a promising class of agents that have recently gained approval for use.

OBJECTIVES

To evaluate the efficacy of sGC stimulators in pulmonary hypertension.

SEARCH METHODS

We searched CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, EMBASE and the reference lists of articles. Searches are current as of 12 February 2016.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) involving participants with pulmonary hypertension of all ages, severities and durations of treatment.

DATA COLLECTION AND ANALYSIS

AW, MS and RW independently selected studies, assessed evidence quality and extracted data. This process was overseen by RT and SG. All included studies were sponsored by the drug manufacturer.

MAIN RESULTS

Five trials involving 962 participants are included in this review. All trials were of relatively short duration (< 16 weeks). Due to the heterogenous aetiology of pulmonary hypertension in participants, results are best considered according to each pulmonary hypertension subtype.Pooled analysis shows a mean difference (MD) increase in six-minute walking distance (6MWD) of 30.13 metres (95% CI 5.29 to 54.96; participants = 659; studies = 3). On subgroup analysis, for pulmonary arterial hypertension (PAH) there was no effect noted (6MWD; MD 11.91 metres, 95% CI -44.92 to 68.75; participants = 398; studies = 2), and in chronic thromboembolic pulmonary hypertension (CTEPH) sGC stimulators improved 6MWD by an MD of 45 metres (95% CI 23.87 to 66.13; participants = 261; studies = 1). Data for left heart disease-associated PH was not available for pooling. Importantly, when participants receiving phosphodiesterase inhibitors were excluded, sGC stimulators increased 6MWD by a MD of 36 metres in PAH. The second primary outcome, mortality, showed no change on pooled analysis against placebo (Peto odds ratio (OR) 0.57, 95% CI 0.18 to 1.80).Pooled secondary outcomes include an increase in World Health Organization (WHO) functional class (OR 1.53, 95% CI 0.87 to 2.72; participants = 858; studies = 4), no effect on clinical worsening (OR 0.45, 95% CI 0.17 to 1.14; participants = 842; studies = 3), and a reduction in mean pulmonary artery pressure (MD -2.77 mmHg, 95% CI -4.96 to -0.58; participants = 744; studies = 5). There was no significant difference in serious adverse events on pooled analysis (OR 1.12, 95% CI 0.66 to 1.90; participants = 818; studies = 5) or when analysed at PAH (MD -3.50, 95% CI -5.54 to -1.46; participants = 344; studies = 1), left heart disease associated subgroups (OR 1.56, 95% CI 0.78 to 3.13; participants = 159; studies = 2) or CTEPH subgroups (OR 1.29, 95% CI 0.65 to 2.56; participants = 261; studies = 1).It is important to consider the results for PAH in the context of a person who is not also receiving a phosphodiesterase-V inhibitor, a contra-indication to sGC stimulator use. It should also be noted that CTEPH results are applicable to inoperable or recurrent CTEPH only.Evidence was rated according to the GRADE scoring system. One outcome was considered high quality, two were moderate, and eight were of low or very low quality, meaning that for many of the outcomes the true effect could differ substantially from our estimate. There were only minor concerns regarding the risk of bias in these trials, all being RCTs largely following the original protocol. Most trials employed an intention-to-treat analysis.

AUTHORS' CONCLUSIONS

sGC stimulators improve pulmonary artery pressures in people with PAH (who are treatment naive or receiving a prostanoid or endothelin antagonist) or those with recurrent or inoperable CTEPH. In these settings this can be achieved without notable complication. However, sGC stimulators should not be taken by people also receiving phosphodiestase-V inhibitors or nitrates due to the risks of hypotension, and there is currently no evidence supporting their use in pulmonary hypertension associated with left heart disease. There is no evidence supporting their use in children. These conclusions are based on data with limitations, including unavailable data from two of the trials.

Review of the diagnosis and pharmacological management of pulmonary arterial hypertension in connective tissue disease

Connective-tissue-disease-associated pulmonary arterial hypertension (CTD-PAH) is a well-recognised pulmonary complication most commonly seen in patients with systemic sclerosis, followed by systemic lupus erythematosus and mixed connective tissue disease. In systemic-sclerosis-associated-pulmonary arterial hypertension (SSc-PAH), patients usually present late and the progression can be rapid with poor prognosis and survival. Early detection and prompt intervention of SSc-PAH is an important cornerstone to halt the disease progression. Various pulmonary vasodilatory agents were developed over the past two decades. They were shown to improve patients’ symptoms, functional status, exercise capacity, haemodynamics and long-term survival. Other immunosuppressive therapies also demonstrated to improve symptoms and functional status in certain group of patients. This article is to review the diagnosis and pharmacological management of patient with CTD-PAH.

Plasma myostatin levels are related to the extent of right ventricular dysfunction in exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To investigate the relationship between plasma myostatin levels and right ventricle (RV) dysfunction (RVD) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

The study recruited 84 patients with AECOPD. Plasma myostatin was analyzed and tricuspid annular plane systolic excursion (TAPSE) < 16 mm was used as the main indicator for RVD.

RESULTS

Plasma myostatin levels were significantly higher in 47 patients with RVD than 37 ones without (P < 0.005). Multivariate regression analysis revealed that myostatin levels correlated significantly with TAPSE values and RV myocardial performance index (p < 0.001) among the study patients.

CONCLUSION

Plasma myostatin is a potential biomarker for improving diagnosis of RVD in AECOPD.

Pulmonary Hypertension and Indicators of Right Ventricular Function

Pulmonary hypertension (PH) is a rare disease, whose underlying mechanisms are not fully understood. It is characterized by pulmonary arterial vasoconstriction and vessels wall thickening, mainly intimal and medial layers. Several molecular pathways have been studied, but their respective roles remain unknown. Cardiac repercussions of PH are hypertrophy, dilation, and progressive right ventricular dysfunction. Multiple echocardiographic parameters are being used, in order to assess anatomy and cardiac function, but there are no guidelines edited about their usefulness. Thus, it is now recommended to associate the best-known parameters, such as atrial and ventricular diameters or tricuspid annular plane systolic excursion. Cardiac catheterization remains necessary to establish the diagnosis of PH and to assess pulmonary hemodynamic state. Concerning energetic metabolism, free fatty acids, normally used to provide energy for myocardial contraction, are replaced by glucose uptake. These abnormalities are illustrated by increased (18)F-fluorodeoxyglucose ((18)F-FDG) uptake on positron emission tomography/computed tomography, which seems to be correlated with echocardiographic and hemodynamic parameters.

Bosentan use in systemic lupus erythematosus patients with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) in patients with systemic lupus erythematosus (SLE) is uncommon but is associated with poor survival. This study aimed to examine the long-term effects of bosentan, a dual endothelin-1 receptor antagonist, on symptomatology, haemodynamics and quality of life measures in SLE patients with symptomatic PAH. Four local patients had been followed up prospectively with pre-defined protocol during 12-months of bosentan treatment. Six minute walk distance (6MWD), NYHA functional class, Borg Dyspnoea Index (BDI) and SF-36 were measured at 0, 3, 6, 9 and 12 months. Systolic pulmonary arterial pressure (PAP) was measured by transthoracic echocardiography at zero, six and 12 months. Clinical parameters were analysed, pooling data from other SLE patients reported in the literature ( n = 4). Bosentan was found to result in significant improvement in 6MWD compared to baseline [+24.8 m, +26.2 m, +54 m and +62.7 m at three ( P = 0.001), six ( P = 0.001), nine ( P = 0.24) and 12 ( P = 0.01) months respectively]. A differential effect was found with greater response in patients with lower exercise capacity. This was accompanied by decrease in NYHA functional class, BDI, transient or sustained drop in systolic PAP and mild improvement in SF-36 domains including mental health, vitality, social function and general health. Significantly deranged liver function was found in one patient. Lupus (2007) 16, 279—285.

Ambrisentan response in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) - A subgroup analysis of the ARIES-E clinical trial

OBJECTIVE

Pulmonary arterial hypertension (PAH) is a condition which may lead to right ventricular failure and early mortality and is an important complication in patients with connective tissue disease (CTD). Previously, the endothelin A selective receptor antagonist, ambrisentan, demonstrated efficacy and safety in treating patients with PAH due to WHO Group I etiologies. These analyses describe the 3-year efficacy and safety of ambrisentan in patients specifically with CTD associated PAH (CTD-PAH).

METHODS

Patients with CTD-PAH participating in the ARIES-1 and -2 clinical trials and their long-term extension were evaluated. Efficacy evaluations including 6-min walk distance (6MWD), clinical worsening, and survival were collected at routine study visits. Additional analyses of 6MWD categorical (30 m) breakpoints were conducted to determine any relationship between 6MWD and a prognostic threshold for survival.

RESULTS

124 patients with CTD-PAH were evaluated. 62.6%, 57.3%, and 58.2% of CTD-PAH patients treated with ambrisentan exhibited increases in 6MWD at 1-, 2-, and 3- years respectively. At 3 years, 64% of patients were free from clinical worsening and 76% of patients were still alive (Kaplan-Meier estimates). Identified factors holding prognostic relevance for survival include: baseline functional class, CTD-PAH subgroup, patient sex, improvement in 6MWD ≥30 m over the first 12 weeks of treatment, the most recent 6MWD, and a 6MWD absolute threshold of 222 m.

CONCLUSION

These first analyses of the 3-year treatment of CTD-PAH patients with ambrisentan revealed fewer clinical worsening events and improved survival compared to historical controls. Key exercise parameters were also identified which appear important in guiding treatment.

Endothelin-Receptor Antagonists beyond Pulmonary Arterial Hypertension: Cancer and Fibrosis

The endothelin axis and in particular the two endothelin receptors, ETA and ETB, are targets for therapeutic intervention in human diseases. Endothelin-receptor antagonists are in clinical use to treat pulmonary arterial hypertension and have been under clinical investigation for the treatment of several other diseases, such as systemic hypertension, cancer, vasospasm, and fibrogenic diseases. In this Perspective, we review the molecules that have been evaluated in human clinical trials for the treatment of pulmonary arterial hypertension, as well as other cardiovascular diseases, cancer, and fibrosis. We will also discuss the therapeutic consequences of receptor selectivity with regard to ETA-selective, ETB-selective, or dual ETA/ETB antagonists. We will also consider which chemical characteristics are relevant to clinical use and the properties of molecules necessary for efficacy in treating diseases against which known molecules displayed suboptimal efficacy.

Echocardiographic findings associated with mortality ortransplant in patients with pulmonary arterial hypertension:A systematic review and meta-analysis

Background

Identification of patients at risk of deterioration is essential to guide clinical management in pulmonary arterial hypertension (PAH). This study aims to provide a comprehensive overview of well-investigated echocardiographic findings that are associated with clinical deterioration in PAH.

Methods

MEDLINE and EMBASE databases were systematically searched for longitudinal studies published by April 2015 that reported associations between echocardiographic findings and mortality, transplant or clinical worsening. Meta-analysis using random effect models was performed for echocardiographic findings investigated by four or more studies. In case of statistical heterogeneity a sensitivity analysis was conducted.

Results

Thirty-seven papers investigating 51 echocardiographic findings were included. Meta-analysis of univariable hazard ratios (HRs) and sensitivity analysis showed that presence of pericardial effusion (pooled HR 1.70; 95 % CI 1.44–1.99), right atrial area (pooled HR 1.71; 95 % CI 1.38–2.13) and tricuspid annular plane systolic excursion (TAPSE; pooled HR 1.72; 95 % CI 1.34–2.20) were the most well-investigated and robust predictors of mortality or transplant.

Conclusions

This meta-analysis substantiates the clinical yield of specific echocardiographic findings in the prognostication of PAH patients in day-to-day practice. In particular, pericardial effusion, right atrial area and TAPSE are of prognostic value.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-016-0845-3) contains supplementary material, which is available to authorized users.

Efficacy of cardiac rehabilitation after balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

Objective

To determine safety and efficacy of cardiac rehabilitation (CR) initiated immediately following balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) who presented with continuing exercise intolerance and symptoms on effort even after a course of BPA; 2–8 sessions/patient.

Methods

Forty-one consecutive patients with inoperable CTEPH who underwent their final BPA with improved resting mean pulmonary arterial pressure of 24.7±5.5 mm Hg and who suffered remaining exercise intolerance were prospectively studied. Participants were divided into two groups just after the final BPA (6.8±2.3 days): patients with (CR group, n=17) or without (non-CR group, n=24) participation in a 12-week CR of 1-week inhospital training followed by an 11-week outpatient programme. Cardiopulmonary exercise testing, haemodynamics, and quality of life (QOL) were assessed before and after CR.

Results

No significant between-group differences were found for any baseline characteristics. At week 12, peak oxygen uptake (VO₂), per cent predicted peak VO₂ (70.7±9.4% to 78.2±12.8%, p<0.01), peak workload, and oxygen pulse significantly improved in the CR group compared with the non-CR group, with a tendency towards improvement in mental health-related QOL. Quadriceps strength and heart failure (HF) symptoms (WHO functional class, 2.2–1.8, p=0.01) significantly improved within the CR group. During the CR, no patient experienced adverse events or deterioration of right-sided HF or haemodynamics as confirmed via catheterisation.

Conclusions

The combination of BPA and subsequent CR is a new treatment strategy for inoperable CTEPH to improve exercise capacity to near-normal levels and HF symptoms, with a good safety profile.

The role of an activity monitor in the objective evaluation of patients with pulmonary hypertension

INTRODUCTION

Patients with pulmonary hypertension (PH) show no symptoms at rest, but symptoms are triggered by physical activities.

OBJECTIVES

The primary aim of our study was to assess physical activity of patients with PH by using an activity monitor. The secondary aim was to evaluate the correlation between the activity monitor parameters and 6-min walk distance (6MWD), activity of daily living (ADL), quality of life, WHO functional class and PH classification.

METHODS

Thirty-eight patients with pulmonary arterial hypertension (PAH) and seven patients with chronic thromboembolic PH were included in the study. Physical activity was assessed using a SenseWear arm band. A 6-min walk test was performed. Daily living activities were assessed using the 'nottingham extended activity of daily living index' (NEADL). For quality of life assessments, 'Minnesota living with heart failure' (MLHF) and 'Short form-36' (SF-36) surveys were used.

RESULTS

Physical activity, exercise capacity, quality of life and contribution to ADL were lower in patients with PH. These data were associated with the 6MWD, quality of life and ADL index scores. We also found weak and moderate correlations between activity monitor data and SF-36 sub-group scores, MLHF and NEADL scores (P < 0.05). For the group with PAH, idiopathic PAH patients had more exercise capacity and total energy expenditure compared with patients with scleroderma-associated PAH.

CONCLUSION

Correlation between activity monitor data and 6MWD, most of SF-36 sub-group scores, MLHF scores and NEADL index scores suggest that activity monitor can be used in the evaluation of patients with PH.

Physiological Techniques and Pulmonary Hypertension - Left Heart Disease

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.

Efficacy and Safety of a Novel Endothelin Receptor Antagonist, Macitentan, in Japanese Patients With Pulmonary Arterial Hypertension

BACKGROUND

Macitentan is a novel, dual endothelin receptor antagonist with sustained receptor binding, used for the long-term treatment of pulmonary arterial hypertension (PAH). In the present study, we assessed the efficacy and safety of macitentan in Japanese patients with PAH.

METHODS AND RESULTS

Macitentan was administered at a once-daily dose of 10 mg in 30 patients. The primary endpoint was change in pulmonary vascular resistance (PVR) from baseline to week 24. Change to week 24 in the other hemodynamic parameters, 6-min walk distance (6MWD), World Health Organization (WHO) functional class, and plasmaN-terminal pro-brain natriuretic peptide (NT-pro-BNP), as well as time to clinical deterioration up to week 52 were also assessed as secondary endpoints. In the 28 patients on per-protocol analysis, PVR decreased from 667±293 to 417±214 dyn·sec·cm(-5)(P<0.0001). 6MWD increased from 427±128 to 494±116 m (P<0.0001). WHO functional class improved in 13 patients (46.4%) and was maintained in 15 patients (53.6%), and NT-pro-BNP was reduced by 18% (P<0.0001). The favorable treatment effect on PVR was apparent regardless of concomitant therapy for PAH.

CONCLUSIONS

Macitentan was efficacious and well tolerated and improved the hemodynamic parameters, exercise capacity, symptoms, and clinical biomarkers in Japanese PAH patients. Macitentan can be a valuable therapeutic option for Japanese patients with PAH. (

TRIAL REGISTRATION

JAPIC Clinical Trials Information [JapicCTI-121986].) (Circ J 2016; 80: 1478-1483).

Acupuncture for Dyspnea in Lung Cancer: Results of a Feasibility Trial

Purpose. Dyspnea is a common and distressing symptom for patients with lung cancer (LC) because of disease burden, therapy toxicity, and comorbid illnesses. Acupuncture is a centuries-old therapy with biological plausibility for relief of dyspnea in this setting. This pilot study aimed to evaluate the feasibility and preliminary effectiveness of acupuncture for dyspnea among patients with LC. Methods. Eligible patients had a diagnosis of LC and clinically significant dyspnea without a clear organic cause. The treatment consisted of 10 weekly acupuncture sessions, with a follow-up visit 4 weeks after therapy. The primary outcome was dyspnea severity as measured using a validated Numerical Rating Scale (NRS) of 0 to 10 (10 being “most severe shortness of breath imaginable”). Results. We enrolled 12 patients in the study. The median age was 64.5 years; 66.7% of the patients were female, and 66.7% were Caucasians. Among those enrolled, 10 (83.3%) were able to complete all 10 acupuncture sessions. Acupuncture was well tolerated; adverse events were mild and self-limited. Mean (SD) dyspnea scores on the NRS improved from 6.3 (1.7) at baseline to 3.6 (1.9; P = .003) at the end of treatment and 3.2 (2.3; P = .008) at follow-up. Fatigue and quality of life also improved significantly with acupuncture (P < .05). Conclusion. Among patients with LC, acupuncture was well tolerated and exhibited promising preliminary beneficial effects in the treatment of dyspnea, fatigue, and quality of life. Performing a trial in this population appears feasible.

Determinants of 6-minute walk distance in patients with idiopathic pulmonary fibrosis undergoing lung transplant evaluation

Little is known about the physiologic determinants of 6-minute walk distance in idiopathic pulmonary fibrosis. We investigated the demographic, pulmonary function, echocardiographic, and hemodynamic determinants of 6-minute walk distance in patients with idiopathic pulmonary fibrosis evaluated for lung transplantation. We performed a cross-sectional analysis of 130 patients with idiopathic pulmonary fibrosis who completed a lung transplantation evaluation at the Hospital of the University of Pennsylvania between 2005 and 2010. Multivariable linear regression analysis was used to generate an explanatory model for 6-minute walk distance. After adjustment for age, sex, race, height, and weight, the presence of right ventricular dilation was associated with a decrease of 50.9 m (95% confidence interval [CI], 8.4-93.3) in 6-minute walk distance ([Formula: see text]). For each 200-mL reduction in forced vital capacity, the walk distance decreased by 15.0 m (95% CI, 9.0-21.1; [Formula: see text]). For every increase of 1 Wood unit in pulmonary vascular resistance, the walk distance decreased by 17.3 m (95% CI, 5.1-29.5; [Formula: see text]). Six-minute walk distance in idiopathic pulmonary fibrosis depends in part on circulatory impairment and the degree of restrictive lung disease. Future trials that target right ventricular morphology, pulmonary vascular resistance, and forced vital capacity may potentially improve exercise capacity in patients with idiopathic pulmonary fibrosis.

Right atrial emptying fraction non-invasively predicts mortality in pulmonary hypertension

Right-sided heart failure is the most common cause of death in pulmonary hypertension (PH). Echocardiographic measurements of right atrial (RA) size are associated with worse outcome in PH, however the association between RA function and death in PH has not been well-described. 160 PH patients (World Health Organization groups 1-5) underwent cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) within 6 weeks of each other at a tertiary care academic medical center in the United States. We measured cMRI RA maximum and minimum volumes indexed to body surface area and calculated RA emptying fraction (RAEF). We evaluated the relationship between RAEF and clinical variables with death using Cox proportional hazard models. 57 deaths occurred during a median follow-up of 3.5 years (36 % died overall, 10 % per year). RAEF was directly correlated in univariate analyses with right ventricular (RV) ejection fraction, left ventricular (LV) ejection fraction, LV size, cardiac index, absence of tricuspid and pulmonic regurgitation, absence of pericardial effusion, estimated glomerular filtration rate, 6-minute walk distance, and pulmonary arterial oxygen saturation, whereas it was inversely correlated with death, BNP, heart rate, mean RA pressure, mean PA pressure, pulmonary and systemic vascular resistance, RV size, and RA size. Using multivariate analyses, RAEF had a robust inverse association with death after adjusting for measured risk factors (HR per 5 % change in RAEF: 0.83 [95 % CI 0.73-0.94], p = 0.003). In PH patients, decreased RAEF by cMRI is independently associated with worse survival after adjustment for other risk factors.

Pulmonary hypertension associated with thalassemia syndromes

Chronic hemolytic anemia has increasingly been identified as an important risk factor for the development of pulmonary hypertension (PH). Within the thalassemia syndromes, there are multiple mechanisms, both distinct and overlapping, by which PH develops and that differ among β-thalassemia major or intermedia patients. PH in β-thalassemia major correlates with the severity of hemolysis, yet in patients whose disease is well treated with chronic transfusion therapy, the development of PH can be related to cardiac dysfunction and the subsequent toxic effects of iron overload rather than hemolysis. β-Thalassemia intermedia, on the other hand, has a higher incidence of PH owing to the low level of hemolysis that exists over years without the requirement for frequent transfusions, while splenectomy is shown to play an important role in both types. Standard therapies such as chronic transfusion have been shown to mitigate PH, and appropriate chelation therapy can avoid the toxic effects of iron overload, yet is not indicated in many patients. Limited evidence exists for the use of pulmonary vasodilators or other therapies, such as l-carnitine, to treat PH associated with thalassemia. Here, we review the most recent findings regarding the pathogenic mechanisms, epidemiology, presentation, diagnosis, and treatment of PH in thalassemia syndromes.

Rationale, design, and baseline findings from HIPP: A randomized controlled trial testing a home-based, individually-tailored physical activity print intervention for African American women in the Deep South

African American women report high rates of physical inactivity and related health disparities. In our previous formative research, we conducted a series of qualitative assessments to examine physical activity barriers and intervention preferences among African American women in the Deep South. These data were used to inform a 12-month Home-based, Individually-tailored Physical activity Print (HIPP) intervention, which is currently being evaluated against a wellness contact control condition among 84 post-menopausal African American women residing in the metropolitan area of Birmingham, Alabama. This paper reports the rationale, design and baseline findings of the HIPP trial. The accrued participants had an average age of 57 (SD=4.7), a BMI of 32.1 kg/m(2) (SD=5.16) with more than half (55%) having a college education and an annual household income under $50,000 (53.6%). At baseline, participants reported an average of 41.5 min/week (SD=49.7) of moderate intensity physical activity, and 94.1% were in the contemplation or preparation stages of readiness for physical activity. While social support for exercise from friends and family was low, baseline levels of self-efficacy, cognitive and behavioral processes of change, decisional balance, outcome expectations, and enjoyment appeared promising. Baseline data indicated high rates of obesity and low levels of physical activity, providing strong evidence of need for intervention. Moreover, scores on psychosocial measures suggested that such efforts may be well received. This line of research in technology-based approaches for promoting physical activity in African American women in the Deep South has great potential to address health disparities and impact public health.

The utility of preoperative six-minute-walk distance in lung transplantation

RATIONALE

The use of 6-minute-walk distance (6MWD) as an indicator of exercise capacity to predict postoperative survival in lung transplantation has not previously been well studied.

OBJECTIVES

To evaluate the association between 6MWD and postoperative survival following lung transplantation.

METHODS

Adult, first time, lung-only transplantations per the United Network for Organ Sharing database from May 2005 to December 2011 were analyzed. Kaplan-Meier methods and Cox proportional hazards modeling were used to determine the association between preoperative 6MWD and post-transplant survival after adjusting for potential confounders. A receiver operating characteristic curve was used to determine the 6MWD value that provided maximal separation in 1-year mortality. A subanalysis was performed to assess the association between 6MWD and post-transplant survival by disease category.

MEASUREMENTS AND MAIN RESULTS

A total of 9,526 patients were included for analysis. The median 6MWD was 787 ft (25th-75th percentiles = 450-1,082 ft). Increasing 6MWD was associated with significantly lower overall hazard of death (P < 0.001). Continuous increase in walk distance through 1,200-1,400 ft conferred an incremental survival advantage. Although 6MWD strongly correlated with survival, the impact of a single dichotomous value to predict outcomes was limited. All disease categories demonstrated significantly longer survival with increasing 6MWD (P ≤ 0.009) except pulmonary vascular disease (P = 0.74); however, the low volume in this category (n = 312; 3.3%) may limit the ability to detect an association.

CONCLUSIONS

6MWD is significantly associated with post-transplant survival and is best incorporated into transplant evaluations on a continuous basis given limited ability of a single, dichotomous value to predict outcomes.

Use of exercise testing in the evaluation of interventional efficacy: an official ERS statement

This document reviews 1) the measurement properties of commonly used exercise tests in patients with chronic respiratory diseases and 2) published studies on their utilty and/or evaluation obtained from MEDLINE and Cochrane Library searches between 1990 and March 2015.

Exercise tests are reliable and consistently responsive to rehabilitative and pharmacological interventions. Thresholds for clinically important changes in performance are available for several tests. In pulmonary arterial hypertension, the 6-min walk test (6MWT), peak oxygen uptake and ventilation/carbon dioxide output indices appear to be the variables most responsive to vasodilators. While bronchodilators do not always show clinically relevant effects in chronic obstructive pulmonary disease, high-intensity constant work-rate (endurance) tests (CWRET) are considerably more responsive than incremental exercise tests and 6MWTs. High-intensity CWRETs need to be standardised to reduce interindividual variability. Additional physiological information and responsiveness can be obtained from isotime measurements, particularly of inspiratory capacity and dyspnoea. Less evidence is available for the endurance shuttle walk test. Although the incremental shuttle walk test and 6MWT are reliable and less expensive than cardiopulmonary exercise testing, two repetitions are needed at baseline. All exercise tests are safe when recommended precautions are followed, with evidence suggesting that no test is safer than others.

Chronic Pulmonary Complications of Sickle Cell Disease

Sickle cell disease (SCD), the most common genetic hemolytic anemia worldwide, affects 250,000 births annually. In the United States, SCD affects approximately 100,000 individuals, most of African descent. Hemoglobin S (HbS) results from a glutamate-to-valine mutation of the sixth codon of the β-hemoglobin allele; the homozygous genotype (HbSS) is associated with the most prevalent and severe form of the disease. Other SCD genotypes include HbSC, composed of one HbS allele and one HbC (glutamate-to-lysine mutation) allele; and HbS-β-thalassemia(0) or HbS-β-thalassemia(+), composed of one HbS allele and one β-thalassemia allele with absent or reduced β-chain production, respectively. Despite advances in care, median survival remains in the fifth decade, due in large part to chronic complications of the disease. Chronic pulmonary complications in SCD are major contributors to this early mortality. Although our understanding of these conditions has improved much over the past 10 to 15 years, there remains no specific treatment for pulmonary complications of SCD. It is unclear whether conventional treatment regimens directed at non-SCD populations have equivalent efficacy in patients with SCD. This represents a critical research need. In this review, the authors review the state-of-the-art understanding of the following pulmonary complications of SCD: (1) pulmonary hypertension; (2) venous thromboembolic disease; (3) sleep-disordered breathing; (4) asthma and recurrent wheezing; and (5) pulmonary function abnormalities. This review highlights the advances as well as the knowledge gaps in this field to update clinicians and other health care providers and to garner research interest from the medical community.