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Campodonico J, Contini M, Alimento M, Mapelli M, Salvioni E, Mattavelli I, Bonomi A, Agostoni P. Physiology of exercise and heart failure treatments: cardiopulmonary exercise testing as a tool for choosing the optimal therapeutic strategy. Eur J Prev Cardiol 2023; 30:ii54-ii62. [PMID: 37819227 DOI: 10.1093/eurjpc/zwad189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 10/13/2023]
Abstract
In the last decades, the pharmacological treatment of heart failure (HF) become more complex due to the availability of new highly effective drugs. Although the cardiovascular effects of HF therapies have been extensively described, less known are their effects on cardiopulmonary function considered as a whole, both at rest and in response to exercise. This is a 'holistic' approach to disease treatment that can be accurately evaluated by a cardiopulmonary exercise test. The aim of this paper is to assess the main differences in the effects of different drugs [angiotensin-converting enzyme (ACE)-inhibitors, Angiotensin II receptor blockers, β-blockers, Angiotensin receptor-neprilysin inhibitors, renal sodium-glucose co-transporter 2 inhibitors, iron supplementation] on cardiopulmonary function in patients with HF, both at rest and during exercise, and to understand how these differences can be taken into account when choosing the most appropriate treatment protocol for each individual patient leading to a precision medicine approach.
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Affiliation(s)
- Jeness Campodonico
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea 4, 20138 Milan, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Marina Alimento
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea 4, 20138 Milan, Italy
| | | | - Irene Mattavelli
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea 4, 20138 Milan, Italy
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Eser P, Marcin T, Prescott E, Prins LF, Kolkman E, Bruins W, van der Velde AE, Gil CP, Iliou MC, Ardissino D, Zeymer U, Meindersma EP, Van’t Hof AWJ, de Kluiver EP, Wilhelm M. Breathing pattern and pulmonary gas exchange in elderly patients with and without left ventricular dysfunction-modification with exercise-based cardiac rehabilitation and prognostic value. Front Cardiovasc Med 2023; 10:1219589. [PMID: 37727302 PMCID: PMC10505741 DOI: 10.3389/fcvm.2023.1219589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/01/2023] [Indexed: 09/21/2023] Open
Abstract
Background Inefficient ventilation is an established prognostic marker in patients with heart failure. It is not known whether inefficient ventilation is also linked to poor prognosis in patients with left ventricular dysfunction (LVD) but without overt heart failure. Objectives To investigate whether inefficient ventilation in elderly patients with LVD is more common than in patients without LVD, whether it improves with exercise-based cardiac rehabilitation (exCR), and whether it is associated with major adverse cardiovascular events (MACE). Methods In this large multicentre observational longitudinal study, patients aged ≥65 years with acute or chronic coronary syndromes (ACS, CCS) without cardiac surgery who participated in a study on the effectiveness of exCR in seven European countries were included. Cardiopulmonary exercise testing (CPET) was performed before, at the termination of exCR, and at 12 months follow-up. Ventilation (VE), breathing frequency (BF), tidal volume (VT), and end-expiratory carbon dioxide pressure (PETCO2) were measured at rest, at the first ventilatory threshold, and at peak exercise. Ventilatory parameters were compared between patients with and without LVD (based on cardio-echography) and related to MACE at 12 month follow-up. Results In 818 patients, age was 72.5 ± 5.4 years, 21.9% were women, 79.8% had ACS, and 151 (18%) had LVD. Compared to noLVD, in LVD resting VE was increased by 8%, resting BF by 6%, peak VE, peak VT, and peak PETCO2 reduced by 6%, 8%, and 5%, respectively, and VE/VCO2 slope increased by 11%. From before to after exCR, resting VE decreased and peak PETCO2 increased significantly more in patients with compared to without LVD. In LVD, higher resting BF, higher nadir VE/VCO2, and lower peak PETCO2 at baseline were associated with MACE. Conclusions Similarly to patients with HF, in elderly patients with ischemic LVD, inefficient resting and exercise ventilation was associated with worse outcomes, and ExCR alleviated abnormal breathing patterns and gas exchange parameters.
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Affiliation(s)
- Prisca Eser
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thimo Marcin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
| | | | | | | | | | - Carlos Peña Gil
- Department of Cardiology, Hospital Clínico Universitario de Santiago, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Marie-Christine Iliou
- Department of Cardiac Rehabilitation, Assistance Publique Hopitaux de Paris, Paris, France
| | - Diego Ardissino
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | | | - Arnoud W. J. Van’t Hof
- Isala Heart Centre, Zwolle, Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, Netherlands
| | | | - Matthias Wilhelm
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Takayama A, Yoshioka T, Nagamine T. Impact of beta blockers on resting respiratory rate in older adults: A cross-sectional study. Pulm Pharmacol Ther 2023; 78:102186. [PMID: 36603740 DOI: 10.1016/j.pupt.2022.102186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 12/09/2022] [Accepted: 12/31/2022] [Indexed: 01/03/2023]
Abstract
[Purpose] Beta blockers, commonly prescribed for older adults, affect heart rates and blood pressure and may reduce respiratory rates, which are used to evaluate patient status and predict outcomes. However, limited clinical evidence is available on the impact of beta blockers on respiratory rates. This study aimed to investigate the impact of beta blockers on respiratory rates in older adults. [Methods] This cross-sectional study included patients aged ≥60 years who underwent an annual checkup. Patients were excluded if they had a diagnosis of severe heart failure, chronic obstructive pulmonary disease, interstitial pneumonitis, severe anemia, or neurodegenerative disease. Doubly robust estimation with inverse probability weighting was applied to estimate the mean differences between beta blocker users and non-users. The dose-response relationship between the administered beta blockers and respiratory rates was examined using multivariable regression models. [Results] Of 637 participants, 108 had received beta blockers regularly. The adjusted mean differences (95% confidence interval, CI) in respiratory rates, pulse rates, systolic blood pressure, and diastolic blood pressure between beta blocker users and non-users were 0.35 (-0.68 to 1.37), -3.56 (-6.34 to -0.78), -5.53 (-8.53 to -2.52), and -4.70 (-8.27 to -1.14), respectively. The adjusted mean differences (95% CI) in respiratory rates per 1 mg of a carvedilol equivalent dose in all beta blocker users, liposoluble beta blocker users, and carvedilol users were -0.10 (-0.18 to -0.02), -0.35 (-0.59 to -0.11), and -0.29 (-0.54 to -0.06), respectively. [Conclusions] Beta blockers may dose-dependently reduce the respiratory rates of older adults. However, in clinical settings, the impact of beta-blocker use or non-use on the respiratory rate may not occur at a clinically important level. Clinicians should note the potentially suppressive impact of beta blockers on respiratory rates according to the situation.
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Affiliation(s)
- Atsushi Takayama
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Hikarigaoka 1, Fukushima City, Fukushima, 960-1295, Japan; Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto, 606-8501, Japan.
| | - Takashi Yoshioka
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Hikarigaoka 1, Fukushima City, Fukushima, 960-1295, Japan; Department of Preventive Medicine and Public Health, School of Medicine, Keio University, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takahiko Nagamine
- Department of Psychiatric Internal Medicine, Sunlight Brain Research Center, Hofu, Japan
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Forton K, Lamotte M, Gillet A, Chaumont M, van de Borne P, Faoro V. Beta-Adrenergic Receptor Blockade Effects on Cardio-Pulmonary Exercise Testing in Healthy Young Adults: A Randomized, Placebo-Controlled Trial. SPORTS MEDICINE - OPEN 2022; 8:150. [PMID: 36538192 PMCID: PMC9768047 DOI: 10.1186/s40798-022-00537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Beta-blockers are increasingly prescribed while the effects of beta-adrenergic receptor blockade on cardio-pulmonary exercise test (CPET)-derived parameters remain under-studied. METHODS Twenty-one young healthy adults repeated three CPET at the same time with an interval of 7 days between each test. The tests were performed 3 h after a random, double-blind, cross-over single-dose intake of placebo, 2.5 mg or 5.0 mg bisoprolol, a cardio-selective beta1-adrenoreceptor antagonist. Gas exchange, heart rate (HR) and blood pressure (BP) were measured at rest and during cyclo-ergometric incremental CPET. RESULTS Maximal workload and VO2max were unaffected by the treatment, with maximal respiratory exchange ratio > 1.15 in all tests. A beta-blocker dose-dependent effect reduced resting and maximal BP and HR and the chronotropic response to exercise, evaluated by the HR/VO2 slope (placebo: 2.9 ± 0.4 beat/ml/kg; 2.5 mg bisoprolol: 2.4 ± 0.5 beat/ml/kg; 5.0 mg bisoprolol: 2.3 ± 0.4 beat/ml/kg, p < 0.001). Ventilation efficiency measured by the VE/VCO2 slope and the ventilatory equivalent for CO2 at the ventilatory threshold were not affected by beta1-receptor blockade. Post-exercise chronotropic recovery measured after 1 min was enhanced under beta1-blocker (placebo: 26 ± 7 bpm; 2.5 mg bisoprolol: 32 ± 6 bpm; 5.0 mg bisoprolol: 33 ± 6 bpm, p < 0.01). CONCLUSION The present results suggest that a single dose of bisoprolol does not affect metabolism, respiratory response and exercise capacity. However, beta-adrenergic blockade dose dependently reduces exercise hemodynamic response by lowering BP and the chronotropic response.
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Affiliation(s)
- Kevin Forton
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium ,grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Michel Lamotte
- grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexis Gillet
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium ,grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Martin Chaumont
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium ,grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe van de Borne
- grid.4989.c0000 0001 2348 0746Department of Cardiology, Erasmus University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Vitalie Faoro
- grid.4989.c0000 0001 2348 0746Cardio-Pulmonary Exercise Laboratory, Faculty of Motor Sciences, Université Libre de Bruxelles, Erasme Campus CP 604, 808 Lennik Road, 1070 Brussels, Belgium
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Kulej-Lyko K, Niewinski P, Tubek S, Krawczyk M, Kosmala W, Ponikowski P. Inhibition of peripheral chemoreceptors improves ventilatory efficiency during exercise in heart failure with preserved ejection fraction − a role of tonic activity and acute reflex response. Front Physiol 2022; 13:911636. [PMID: 36111161 PMCID: PMC9470150 DOI: 10.3389/fphys.2022.911636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/19/2022] [Indexed: 11/22/2022] Open
Abstract
Peripheral chemoreceptors (PChRs) play a significant role in maintaining adequate oxygenation in the bloodstream. PChRs functionality comprises two components: tonic activity (PChT) which regulates ventilation during normoxia and acute reflex response (peripheral chemosensitivity, PChS), which increases ventilation following a specific stimulus. There is a clear link between augmented PChS and exercise intolerance in patients with heart failure with reduced ejection fraction. It has been also shown that inhibition of PChRs leads to the improvement in exercise capacity. However, it has not been established yet: 1) whether similar mechanisms take part in heart failure with preserved ejection fraction (HFpEF) and 2) which component of PChRs functionality (PChT vs. PChS) is responsible for the benefit seen after the acute experimental blockade. To answer those questions we enrolled 12 stable patients with HFpEF. All participants underwent an assessment of PChT (attenuation of minute ventilation in response to low-dose dopamine infusion), PChS (enhancement of minute ventilation in response to hypoxia) and a symptom-limited cardiopulmonary exercise test on cycle ergometer. All tests were placebo-controlled, double-blinded and performed in a randomized order. Under resting conditions and at normoxia dopamine attenuated minute ventilation and systemic vascular resistance (p = 0.03 for both). These changes were not seen with placebo. Dopamine also decreased ventilatory and mean arterial pressure responses to hypoxia (p < 0.05 for both). Inhibition of PChRs led to a decrease in V˙E/V˙CO2 comparing to placebo (36 ± 3.6 vs. 34.3 ± 3.7, p = 0.04), with no effect on peak oxygen consumption. We found a significant relationship between PChT and the relative decrement of V˙E/V˙CO2 on dopamine comparing to placebo (R = 0.76, p = 0.005). There was a trend for correlation between PChS (on placebo) and V˙E/V˙CO2 during placebo infusion (R = 0.56, p = 0.059), but the relative improvement in V˙E/V˙CO2 was not related to the change in PChS (dopamine vs. placebo). We did not find a significant relationship between PChT and PChS. In conclusion, inhibition of PChRs in HFpEF population improves ventilatory efficiency during exercise. Increased PChS is associated with worse (higher) V˙E/V˙CO2, whereas PChT predicts an improvement in V˙E/V˙CO2 after PChRs inhibition. This results may be meaningful for patient selection in further clinical trials involving PChRs modulation.
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Affiliation(s)
- Katarzyna Kulej-Lyko
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
- *Correspondence: Katarzyna Kulej-Lyko,
| | - Piotr Niewinski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | - Stanislaw Tubek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | | | - Wojciech Kosmala
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
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7
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Contini M, Angelucci A, Aliverti A, Gugliandolo P, Pezzuto B, Berna G, Romani S, Tedesco CC, Agostoni P. Comparison between PtCO 2 and PaCO 2 and Derived Parameters in Heart Failure Patients during Exercise: A Preliminary Study. SENSORS (BASEL, SWITZERLAND) 2021; 21:6666. [PMID: 34640985 PMCID: PMC8512849 DOI: 10.3390/s21196666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 12/13/2022]
Abstract
Evaluation of arterial carbon dioxide pressure (PaCO2) and dead space to tidal volume ratio (VD/VT) during exercise is important for the identification of exercise limitation causes in heart failure (HF). However, repeated sampling of arterial or arterialized ear lobe capillary blood may be clumsy. The aim of our study was to estimate PaCO2 by means of a non-invasive technique, transcutaneous PCO2 (PtCO2), and to verify the correlation between PtCO2 and PaCO2 and between their derived parameters, such as VD/VT, during exercise in HF patients. 29 cardiopulmonary exercise tests (CPET) performed on a bike with a ramp protocol aimed at achieving maximal effort in ≈10 min were analyzed. PaCO2 and PtCO2 values were collected at rest and every 2 min during active pedaling. The uncertainty of PCO2 and VD/VT measurements were determined by analyzing the error between the two methods. The accuracy of PtCO2 measurements vs. PaCO2 decreases towards the end of exercise. Therefore, a correction to PtCO2 that keeps into account the time of the measurement was implemented with a multiple regression model. PtCO2 and VD/VT changes at 6, 8 and 10 min vs. 2 min data were evaluated before and after PtCO2 correction. PtCO2 overestimates PaCO2 for high timestamps (median error 2.45, IQR -0.635-5.405, at 10 min vs. 2 min, p-value = 0.011), while the error is negligible after correction (median error 0.50, IQR = -2.21-3.19, p-value > 0.05). The correction allows removing differences also in PCO2 and VD/VT changes. In HF patients PtCO2 is a reliable PaCO2 estimation at rest and at low exercise intensity. At high exercise intensity the overall response appears delayed but reproducible and the error can be overcome by mathematical modeling allowing an accurate estimation by PtCO2 of PaCO2 and VD/VT.
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Affiliation(s)
- Mauro Contini
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
| | - Alessandra Angelucci
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy;
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy;
| | - Paola Gugliandolo
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
| | - Beatrice Pezzuto
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
| | - Giovanni Berna
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
| | - Simona Romani
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
| | - Calogero Claudio Tedesco
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy; (M.C.); (P.G.); (B.P.); (G.B.); (S.R.); (C.C.T.); (P.A.)
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milano, 20122 Milan, Italy
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Abstract
PURPOSE OF REVIEW Exercise causes various dynamic changes in all body parts either in healthy subject or in heart failure (HF) patients. The present review of current knowledge about HF patients with reduced ejection fraction focuses on dynamic changes along a "metabo-hemodynamic" perspective. RECENT FINDINGS Studies on the dynamic changes occurring during exercise span many years. Thanks to the availability of advanced methods, it is nowadays possible to properly characterize respiratory, hemodynamic, and muscular function adjustments and their mismatch with the pulmonary and systemic circulations. Exercise is a dynamic event that involves several body functions. In HF patients, it is important to know at what level the limitation takes place in order to better manage these patients and to optimize therapeutic strategies.
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9
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Agostoni P, Sciomer S, Palermo P, Contini M, Pezzuto B, Farina S, Magini A, De Martino F, Magrì D, Paolillo S, Cattadori G, Vignati C, Mapelli M, Apostolo A, Salvioni E. Minute ventilation/carbon dioxide production in chronic heart failure. Eur Respir Rev 2021; 30:30/159/200141. [PMID: 33536259 PMCID: PMC9489123 DOI: 10.1183/16000617.0141-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/21/2020] [Indexed: 11/05/2022] Open
Abstract
In chronic heart failure, minute ventilation (V'E) for a given carbon dioxide production (V'CO2 ) might be abnormally high during exercise due to increased dead space ventilation, lung stiffness, chemo- and metaboreflex sensitivity, early metabolic acidosis and abnormal pulmonary haemodynamics. The V'E versus V'CO2 relationship, analysed either as ratio or as slope, enables us to evaluate the causes and entity of the V'E/perfusion mismatch. Moreover, the V'E axis intercept, i.e. when V'CO2 is extrapolated to 0, embeds information on exercise-induced dead space changes, while the analysis of end-tidal and arterial CO2 pressures provides knowledge about reflex activities. The V'E versus V'CO2 relationship has a relevant prognostic power either alone or, better, when included within prognostic scores. The V'E versus V'CO2 slope is reported as an absolute number with a recognised cut-off prognostic value of 35, except for specific diseases such as hypertrophic cardiomyopathy and idiopathic cardiomyopathy, where a lower cut-off has been suggested. However, nowadays, it is more appropriate to report V'E versus V'CO2 slope as percentage of the predicted value, due to age and gender interferences. Relevant attention is needed in V'E versus V'CO2 analysis in the presence of heart failure comorbidities. Finally, V'E versus V'CO2 abnormalities are relevant targets for treatment in heart failure.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy .,Dept of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Susanna Sciomer
- Dept of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | | | | | | | | | | | - Damiano Magrì
- Dept of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefania Paolillo
- Dept of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, Multimedica IRCCS, Milan, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dept of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dept of Clinical Science and Community Health, University of Milan, Milan, Italy
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10
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Agostoni P, Emdin M, De Martino F, Apostolo A, Masè M, Contini M, Carriere C, Vignati C, Sinagra G. Roles of periodic breathing and isocapnic buffering period during exercise in heart failure. Eur J Prev Cardiol 2021; 27:19-26. [PMID: 33238742 PMCID: PMC7691624 DOI: 10.1177/2047487320952029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
In heart failure, exercise - induced periodic breathing and end tidal carbon dioxide pressure value during the isocapnic buffering period are two features identified at cardiopulmonary exercise testing strictly related to sympathetic activation. In the present review we analysed the physiology behind periodic breathing and the isocapnic buffering period and present the relevant prognostic value of both periodic breathing and the presence/absence of the identifiable isocapnic buffering period.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Italy.,Department of Clinical Sciences and Community Health, University of Milano, Italy
| | - Michele Emdin
- Life Science Institute, Scuola Superiore Sant'Anna, Italy.,Fondazione Gabriele Monasterio, CNR-Regione Toscana, Italy
| | | | | | - Marco Masè
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy
| | | | - Cosimo Carriere
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Italy.,Department of Clinical Sciences and Community Health, University of Milano, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy
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11
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Cardiopulmonary exercise testing in chronic heart failure patients treated with beta-blockers: Still a valid prognostic tool. Int J Cardiol 2020; 317:128-132. [DOI: 10.1016/j.ijcard.2020.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
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12
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Gas Exchange and Ventilatory Efficiency During Exercise in Pulmonary Vascular Diseases. Arch Bronconeumol 2020; 56:578-585. [DOI: 10.1016/j.arbres.2019.12.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 12/16/2019] [Accepted: 12/22/2019] [Indexed: 12/31/2022]
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13
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Laveneziana P, Weatherald J. Pulmonary Vascular Disease and Cardiopulmonary Exercise Testing. Front Physiol 2020; 11:964. [PMID: 32848882 PMCID: PMC7425313 DOI: 10.3389/fphys.2020.00964] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is of great interest and utility for clinicians dealing Pulmonary Hypertension (PH) in several ways, including: helping with differential diagnosis, evaluating exercise intolerance and its underpinning mechanisms, accurately assessing exertional dyspnea and unmasking its underlying often non-straightforward mechanisms, generating prognostic indicators. Pathophysiologic anomalies in PH can range from reduced cardiac output and aerobic capacity, to inefficient ventilation, dyspnea, dynamic hyperinflation, and locomotor muscle dysfunction. CPET can magnify the PH-related pathophysiologic anomalies and has a major role in the management of PH patients.
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Affiliation(s)
- Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMR S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Sites Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Chen SM, Wang LY, Wu PJ, Liaw MY, Chen YL, Chen AN, Tsai TH, Hang CL, Lin MC. The Interrelationship between Ventilatory Inefficiency and Left Ventricular Ejection Fraction in Terms of Cardiovascular Outcomes in Heart Failure Outpatients. Diagnostics (Basel) 2020; 10:E469. [PMID: 32664450 PMCID: PMC7399946 DOI: 10.3390/diagnostics10070469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/28/2022] Open
Abstract
The relationship between left ventricular ejection fraction (LVEF) and cardiovascular (CV) outcome is documented in patients with low LVEF. Ventilatory inefficiency is an important prognostic predictor. We hypothesized that the presence of ventilatory inefficiency influences the prognostic predictability of LVEF in heart failure (HF) outpatients. In total, 169 HF outpatients underwent the cardiopulmonary exercise test (CPET) and were followed up for a median of 9.25 years. Subjects were divided into five groups of similar size according to baseline LVEF (≤39%, 40-58%, 59-68%, 69-74%, and ≥75%). The primary endpoints were CV mortality and first HF hospitalization. The Cox proportional hazard model was used for simple and multiple regression analyses to evaluate the interrelationship between LVEF and ventilatory inefficiency (ventilatory equivalent for carbon dioxide (VE/VCO2) at anaerobic threshold (AT) >34.3, optimized cut-point). Only LVEF and VE/VCO2 at AT were significant predictors of major CV events. The lower LVEF subgroup (LVEF ≤ 39%) was associated with an increased risk of CV events, relative to the LVEF ≥75% subgroup, except for patients with ventilatory inefficiency (p = 0.400). In conclusion, ventilatory inefficiency influenced the prognostic predictability of LVEF in reduced LVEF outpatients. Ventilatory inefficiency can be used as a therapeutic target in HF management.
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Affiliation(s)
- Shyh-Ming Chen
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Lin-Yi Wang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (L.-Y.W.); (M.-Y.L.)
| | - Po-Jui Wu
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Mei-Yun Liaw
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (L.-Y.W.); (M.-Y.L.)
| | - Yung-Lung Chen
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - An-Ni Chen
- Department of Physical Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | - Tzu-Hsien Tsai
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Chi-Ling Hang
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Meng-Chih Lin
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
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15
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Sinagra G, Corrà U, Contini M, Magrì D, Paolillo S, Perrone Filardi P, Sciomer S, Badagliacca R, Agostoni P. Choosing among β-blockers in heart failure patients according to β-receptors' location and functions in the cardiopulmonary system. Pharmacol Res 2020; 156:104785. [PMID: 32224252 DOI: 10.1016/j.phrs.2020.104785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/05/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
Several large clinical trials showed a favorable effect of β-blocker treatment in patients with chronic heart failure (HF) as regards overall mortality, cardiovascular mortality, and hospitalizations. Indeed, the use of β-blockers is strongly recommended by current international guidelines, and it remains a cornerstone in the pharmacological treatment of HF. Although different types of β-blockers are currently approved for HF therapy, possible criteria to choose the best β-blocking agent according to HF patients' characteristics and to β-receptors' location and functions in the cardiopulmonary system are still lacking. In such a context, a growing body of literature shows remarkable differences between β-blocker types (β1-selective blockers versus β1-β2 blockers) with respect to alveolar-capillary gas diffusion and chemoreceptor response in HF patients, both factors able to impact on quality of life and, most likely, on prognosis. This review suggests an original algorithm for choosing among the currently available β-blocking agents based on the knowledge of cardiopulmonary pathophysiology. Particularly, starting from lung physiology and from some experimental models, it focuses on the mechanisms underlying lung mechanics, chemoreceptors, and alveolar-capillary unit impairment in HF. This paper also remarks the significant benefit deriving from the correct use of the different β-blockers in HF patients through a brief overview of the most important clinical trials.
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Affiliation(s)
- Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, Veruno Institute, Veruno, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | | | - Susanna Sciomer
- Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Roberto Badagliacca
- Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy.
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16
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Agostoni P, Dumitrescu D. How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure. Int J Cardiol 2019; 288:107-113. [DOI: 10.1016/j.ijcard.2019.04.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/04/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023]
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17
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Wilson RJT, Yates DRA, Walkington JP, Davies SJ. Ventilatory inefficiency adversely affects outcomes and longer-term survival after planned colorectal cancer surgery. Br J Anaesth 2019; 123:238-245. [PMID: 30916023 DOI: 10.1016/j.bja.2019.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 11/06/2018] [Accepted: 01/20/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Impaired cardiorespiratory reserve is an accepted risk factor for patients having major surgery. Ventilatory inefficiency, defined by an elevated ratio of minute ventilation to carbon dioxide excretion (VE/VCO2), and measured by cardiopulmonary exercise testing (CPET), is a pathophysiological characteristic of patients with cardiorespiratory disease. We set out to evaluate the prevalence of ventilatory inefficiency in a colorectal cancer surgical population, and its influence on surgical outcomes and long-term cancer survival. METHODS In this retrospective study of 1375 patients who had undergone preoperative CPET followed by colorectal cancer surgery, we used receiver operating characteristic curve analysis to identify an optimal value of VE/VCO2 associated with 90-day mortality. Binary logistic regression was used to evaluate whether this degree of ventilatory inefficiency was independently associated with decreased survival, both after surgery and in the longer term. RESULTS We identified an optimal VE/VCO2 >39 cut-off for predicting 90-day mortality; 245 patients (17.8%) had VE/VCO2 >39, of which 138 (10% of total cohort) had no known cardiorespiratory risk factors. Ventilatory inefficiency was independently associated with death at 90-days (8.2% mortality vs 1.9%; adjusted odds ratio [OR], 4.04; 95% confidence interval [CI], 2.09-7.84), with death after unplanned critical care admission (OR=4.45; 95% CI, 1.37-14.46) and with decreased survival at 2 yr (OR=2.21; 95%, 1.49-3.28) and 5 yr (OR=2.87; 95% CI, 1.54-5.37) after surgery. CONCLUSIONS A significant proportion of patients having colorectal cancer surgery have ventilatory inefficiency observed on CPET, the majority of whom have no history of cardiorespiratory risk factors. This group of patients has significantly decreased survival both after surgery and in the long-term, irrespective of cancer stage. Survival might be improved by formal medical evaluation and intervention in this group.
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18
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Carriere C, Corrà U, Piepoli M, Bonomi A, Salvioni E, Binno S, Magini A, Sciomer S, Pezzuto B, Gentile P, Schina M, Sinagra G, Agostoni P. Isocapnic buffering period: From physiology to clinics. Eur J Prev Cardiol 2019; 26:1107-1114. [DOI: 10.1177/2047487319829950] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background During cardiopulmonary exercise test, the isocapnic buffering period ranges between anaerobic threshold (AT) and respiratory compensation point (RCP). We investigated whether oxygen uptake (VO2) increase during the isocapnic buffering period (ΔVO2AT-RCP) is related to heart failure severity and prognosis. Methods We retrospectively analysed reduced ejection fraction heart failure patients who attained RCP at cardiopulmonary exercise test. The study endpoint was the composite of cardiovascular mortality and urgent heart transplantation/left ventricular assist device implantation. Hazard ratio was assessed to identify the increase of risk associated with ΔVO2AT-RCP (below and above the median of ΔVO2AT-RCP). Results AT and RCP were both identified in 782 (39.2%) out of 1995 reduced ejection fraction heart failure cases. Left ventricular ejection fraction and peak VO2 were 33 ± 9% and 16.5 ± 4.5 mL/kg per min (61 ± 16% of predicted value), suggesting moderate heart failure. At five years, endpoint did not vary between patients below and above the median ΔVO2AT-RCP (3.85 mL/min per kg (25–75th interquartile range = 2.69–5.46)). ΔVO2AT-RCP correlated with several parameters associated to heart failure prognosis, such as peak VO2, VE/VCO2 slope, brain natriuretic peptide and left ventricular ejection fraction. The ΔVO2AT-RCP value was associated with prognosis at univariate but not at multivariable analysis, where only VE/VCO2 slope endured. Conclusion ΔVO2AT-RCP correlates with several parameters linked to heart failure severity. Isocapnic buffering period stratifies heart failure patients, but not more than other prognostic indices.
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Affiliation(s)
- Cosimo Carriere
- Cardiovascular Department, Azienda Sanitaria-Universitaria Integrata of Trieste, Italy
| | - Ugo Corrà
- Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Italy
| | | | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milano, Italy
| | | | - Simone Binno
- UOC Cardiologia, G. da Saliceto Hospital, Piacenza, Italy
| | | | - Susanna Sciomer
- Department of Cardiovascular, Respiratory, Anaesthesiologic, Geriatric and Nephrologic Sciences, University ‘Sapienza’, Roma, Italy
| | | | - Piero Gentile
- Cardiovascular Department, Azienda Sanitaria-Universitaria Integrata of Trieste, Italy
| | - Mauro Schina
- Department of Cardiovascular, Respiratory, Anaesthesiologic, Geriatric and Nephrologic Sciences, University ‘Sapienza’, Roma, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria-Universitaria Integrata of Trieste, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy
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19
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Campodonico J, Piepoli M, Clemenza F, Bonomi A, Paolillo S, Salvioni E, Corrà U, Binno S, Veglia F, Lagioia R, Sinagra G, Cattadori G, Scardovi AB, Metra M, Senni M, Scrutinio D, Raimondo R, Emdin M, Magrì D, Parati G, Re F, Cicoira M, Minà C, Limongelli G, Correale M, Frigerio M, Bussotti M, Perna E, Battaia E, Guazzi M, Badagliacca R, Di Lenarda A, Maggioni A, Passino C, Sciomer S, Pacileo G, Mapelli M, Vignati C, Lombardi C, Filardi PP, Agostoni P. Dose-dependent efficacy of β-blocker in patients with chronic heart failure and atrial fibrillation. Int J Cardiol 2018; 273:141-146. [DOI: 10.1016/j.ijcard.2018.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/30/2018] [Accepted: 08/04/2018] [Indexed: 12/28/2022]
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Abstract
Heart failure treatment depends on several drugs, all providing improvement in outcome, but that cannot be realistically used all together in the same patient. It would be useful to have a tool that allows the arrangement of the most appropriate therapy cocktail for each patient. The aim of this article is to show the main differences in the effects of several drugs on cardiopulmonary function in patients with heart failure, both while resting and during exercise, and to discuss how these differences can be taken into account when choosing the most appropriate therapeutic protocol. In summary, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers act synergistically to increase exercise capacity and peak oxygen uptake, but through different mechanisms: the former improving lung diffusion and exercise ventilatory efficiency, an action that is counteracted by concomitant aspirin therapy, and the latter probably by improving muscle perfusion. As for β-blockers, nonselective compounds, such as carvedilol, improve ventilation efficiency on the one hand, but interfere with lung diffusion on the other, and they are probably less tolerated under hypoxic conditions. On the contrary, β1-selective compounds, such as bisoprolol or nebivolol, have a neutral effect on both lung diffusion and ventilation efficiency. These observations could be the basis for the choice of pharmacological therapy in patients with heart failure.
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21
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Weatherald J, Sattler C, Garcia G, Laveneziana P. Ventilatory response to exercise in cardiopulmonary disease: the role of chemosensitivity and dead space. Eur Respir J 2018; 51:51/2/1700860. [PMID: 29437936 DOI: 10.1183/13993003.00860-2017] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 11/11/2017] [Indexed: 12/30/2022]
Abstract
The lungs and heart are irrevocably linked in their oxygen (O2) and carbon dioxide (CO2) transport functions. Functional impairment of the lungs often affects heart function and vice versa The steepness with which ventilation (V'E) rises with respect to CO2 production (V'CO2 ) (i.e. the V'E/V'CO2 slope) is a measure of ventilatory efficiency and can be used to identify an abnormal ventilatory response to exercise. The V'E/V'CO2 slope is a prognostic marker in several chronic cardiopulmonary diseases independent of other exercise-related variables such as peak O2 uptake (V'O2 ). The V'E/V'CO2 slope is determined by two factors: 1) the arterial CO2 partial pressure (PaCO2 ) during exercise and 2) the fraction of the tidal volume (VT) that goes to dead space (VD) (i.e. the physiological dead space ratio (VD/VT)). An altered PaCO2 set-point and chemosensitivity are present in many cardiopulmonary diseases, which influence V'E/V'CO2 by affecting PaCO2 Increased ventilation-perfusion heterogeneity, causing inefficient gas exchange, also contributes to the abnormal V'E/V'CO2 observed in cardiopulmonary diseases by increasing VD/VT During cardiopulmonary exercise testing, the PaCO2 during exercise is often not measured and VD/VT is only estimated by taking into account the end-tidal CO2 partial pressure (PETCO2 ); however, PaCO2 is not accurately estimated from PETCO2 in patients with cardiopulmonary disease. Measuring arterial gases (PaO2 and PaCO2 ) before and during exercise provides information on the real (and not "estimated") VD/VT coupled with a true measure of gas exchange efficiency such as the difference between alveolar and arterial O2 partial pressure and the difference between arterial and end-tidal CO2 partial pressure during exercise.
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Affiliation(s)
- Jason Weatherald
- Dept of Medicine, Division of Respiratory Medicine, University of Calgary, Calgary, AB, Canada.,Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | - Caroline Sattler
- Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Gilles Garcia
- Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,These authors contributed equally to this work and are both last authors
| | - Pierantonio Laveneziana
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France .,Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, Dépt "R3S", Pôle PRAGUES, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,These authors contributed equally to this work and are both last authors
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Guazzi M, Bandera F, Ozemek C, Systrom D, Arena R. Cardiopulmonary Exercise Testing: What Is its Value? J Am Coll Cardiol 2017; 70:1618-1636. [PMID: 28935040 DOI: 10.1016/j.jacc.2017.08.012] [Citation(s) in RCA: 264] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 02/07/2023]
Abstract
Compared with traditional exercise tests, cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise integrative physiology involving the pulmonary, cardiovascular, muscular, and cellular oxidative systems. Due to the prognostic ability of key variables, CPET applications in cardiology have grown impressively to include all forms of exercise intolerance, with a predominant focus on heart failure with reduced or with preserved ejection fraction. As impaired cardiac output and peripheral oxygen diffusion are the main determinants of the abnormal functional response in cardiac patients, invasive CPET has gained new popularity, especially for diagnosing early heart failure with preserved ejection fraction and exercise-induced pulmonary hypertension. The most impactful advance has recently come from the introduction of CPET combined with echocardiography or CPET imaging, which provides basic information regarding cardiac and valve morphology and function. This review highlights modern CPET use as a single or combined test that allows the pathophysiological bases of exercise limitation to be translated, quite easily, into clinical practice.
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Affiliation(s)
- Marco Guazzi
- University of Milan, Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - Francesco Bandera
- University of Milan, Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Cemal Ozemek
- Department of Physical Therapy, Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - David Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ross Arena
- Department of Physical Therapy, Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
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Mezzani A, Giordano A, Komici K, Corrà U. Different Determinants of Ventilatory Inefficiency at Different Stages of Reduced Ejection Fraction Chronic Heart Failure Natural History. J Am Heart Assoc 2017; 6:JAHA.116.005278. [PMID: 28487387 PMCID: PMC5524084 DOI: 10.1161/jaha.116.005278] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It is not known whether determinants of ventilation (VE)/volume of exhaled carbon dioxide (VCO2) slope during incremental exercise may differ at different stages of reduced ejection fraction chronic heart failure natural history. Methods and Results VE/VCO2 slope was fitted up to lowest VE/VCO2 ratio, that is, a proxy of the VE/perfusion ratio devoid of nonmetabolic stimuli to ventilatory drive. VE/VCO2 slope tertiles were generated from our database (<27.5 [tertile 1], ≥27.5 to <32.0 [tertile 2], and ≥32.0 [tertile 3]), and 147 chronic heart failure patients with repeated tests yielding VE/VCO2 slopes in 2 different tertiles were selected. Determinants of VE/VCO2 slope changes across tertile pairs 1 versus 2, 2 versus 3, and 1 versus 3 were assessed by exploring changes in VE and VCO2 at lowest VE/VCO2 and those in VE/work rate (W) and VCO2/W slope. Resting and peak cardiac output (CO) were calculated as VO2/estimated arteriovenous O2 difference and the CO/W slope analyzed. Notwithstanding a progressively lower W with increasing tertile, VE at lowest VE/VCO2 and VE/W slope were significantly higher in tertiles 2 and 3 versus tertile 1. Conversely, VCO2 at lowest VE/VCO2 and CO/W slope significantly decreased across tertiles, whereas VCO2/W slope did not. Difference (Δ) in VE/W slope between tertiles accounted for 71% of ΔVE/VCO2 slope variance, with ΔVCO2/W slope explaining an additional 26% (model r=0.99; r2=0.97; P<0.0001). Similar results were obtained substituting ΔVCO2/W slope with ΔCO/W slope. Conclusions Ventilatory overactivation is the predominant cause of VE/VCO2 slope increase at initial stages of chronic heart failure, whereas hemodynamic impairment plays an additional role at more‐advanced pathophysiological stages.
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Affiliation(s)
- Alessandro Mezzani
- Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Istituti Clinici Scientifici Maugeri Spa SB-Scientific Institute of Veruno IRCCS, Veruno (NO), Italy
| | - Andrea Giordano
- Bioengineering Service, Istituti Clinici Scientifici Maugeri Spa SB-Scientific Institute of Veruno IRCCS, Veruno (NO), Italy
| | - Klara Komici
- Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Istituti Clinici Scientifici Maugeri Spa SB-Scientific Institute of Veruno IRCCS, Veruno (NO), Italy
| | - Ugo Corrà
- Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, Istituti Clinici Scientifici Maugeri Spa SB-Scientific Institute of Veruno IRCCS, Veruno (NO), Italy
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Dionne A, Leone M, Andrich DE, Pérusse L, Comtois AS. Acute breathing patterns in healthy and heart disease participants during cycling at different levels of immersion. Respir Physiol Neurobiol 2016; 235:1-7. [PMID: 27671205 DOI: 10.1016/j.resp.2016.09.011] [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] [Received: 04/15/2016] [Revised: 09/15/2016] [Accepted: 09/22/2016] [Indexed: 10/21/2022]
Abstract
We aimed to determine the effect of aquatic cycling and different levels of immersion on respiratory responses in healthy and heart disease (HD) volunteers. Thirty-four age matched volunteers, 21 HD and 13 healthy controls (HC) took part in this study. The ventilatory pattern, phase 1VE and steady-state ventilatory responses to progressive exercise from 40 to peak rpm, were measured while participants exercised on a water stationary bike (WSB) at different levels of immersion. No effect of immersion was observed on steady-state respiratory responses in the HD group, but immersion reduced VE phase 1 by ∼79% at pedaling cadences of 40, 50 and 60rpm. In conclusion, immersion at hips and xiphoid process blunted the fast drive to breathe in the HD group. This transient effect on the respiratory response to immersed exercise cannot be considered a contraindication for exercise in HD individuals.
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Affiliation(s)
- Andrée Dionne
- Department of kinesiology, Université Laval, 2300 rue de la Terrasse, Quebec, (QC), G1V 0A6, Canada.
| | - Mario Leone
- Department of Health Sciences, University of Quebec in Chicoutimi, 555 University boulevard, Saguenay, (QC), G7H 2B1, Canada; Centre for Interdisciplinary Research on Quality and Healthy Lifestyle, University of Quebec in Chicoutimi, 555 University boulevard, Saguenay, (QC), G7H 2B1, Canada.
| | - David E Andrich
- Department of Physical Activity Sciences, University of Quebec in Montreal, C.P. 8888, succ, Centre-ville, Montreal, (QC), H3C 3P8, Canada.
| | - Louis Pérusse
- Department of kinesiology, Université Laval, 2300 rue de la Terrasse, Quebec, (QC), G1V 0A6, Canada.
| | - Alain Steve Comtois
- Department of Physical Activity Sciences, University of Quebec in Montreal, C.P. 8888, succ, Centre-ville, Montreal, (QC), H3C 3P8, Canada; Centre for Interdisciplinary Research on Quality and Healthy Lifestyle, University of Quebec in Chicoutimi, 555 University boulevard, Saguenay, (QC), G7H 2B1, Canada.
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West MA, Parry M, Asher R, Key A, Walker P, Loughney L, Pintus S, Duffy N, Jack S, Torella F. The Effect of beta-blockade on objectively measured physical fitness in patients with abdominal aortic aneurysms--A blinded interventional study. Br J Anaesth 2015; 114:878-85. [PMID: 25716221 DOI: 10.1093/bja/aev026] [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] [Accepted: 11/03/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that beta-blocker therapy would significantly improve CPET-derived physical fitness in this group. METHODS We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (.VO2) at estimated lactate threshold and .VO2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. RESULTS Forty-eight patients completed the study. No difference was observed in .VO2 at estimated lactate threshold and .VO2 at peak; however, a significant decrease in .VE/.VCO2 at estimated lactate threshold and peak, an increase in workload at estimated lactate threshold., O2 pulse and heart rate both at estimated lactate threshold and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower .VO2 ). CONCLUSIONS Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing .VO2 at estimated lactate threshold and.VO2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. CLINICAL TRIAL REGISTRATION NCT 02106286.
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Affiliation(s)
- M A West
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - M Parry
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Waterhouse Building, University of Liverpool, Liverpool, UK
| | - A Key
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - P Walker
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - L Loughney
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - S Pintus
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building
| | - N Duffy
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - S Jack
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - F Torella
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Liverpool Vascular & Endovascular Service, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
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Surfactant-derived proteins as markers of alveolar membrane damage in heart failure. PLoS One 2014; 9:e115030. [PMID: 25514679 PMCID: PMC4267772 DOI: 10.1371/journal.pone.0115030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022] Open
Abstract
Background In heart failure (HF) alveolar-capillary membrane is abnormal. Surfactant-derived proteins (SPs) and plasma receptor for advanced-glycation-end-products (RAGE) have been proposed as lung damage markers. Methods Eighty-nine chronic HF and 17 healthy subjects were evaluated by echocardiography, blood parameters, carbon monoxide lung diffusion (DLCO) and cardiopulmonary exercise test. We measured immature SP-B, mature SP-B, SP-A, SP-D and RAGE plasma levels. Results Immature SP-B (arbitrary units), mature SP-A (ng/ml) and SP-D (ng/ml), but not mature SP-B (ng/ml) and RAGE (pg/ml) levels, were higher in HF than in controls [immature SP-B: 15.6 (13.1, 75th–25th interquartile range) Vs. 11.1 (6.4), p<0.01; SP-A, 29.6 (20.1) Vs. 18.3 (13.5), p = 0.01; SP-D: 125 (90) Vs. 78 (58), p<0.01]. Immature SP-B, SP-A, SP-D and RAGE values were related to DLCO, peak oxygen consumption, ventilatory efficiency, and brain natriuretic peptide (BNP), whereas plasma mature SP-B was not. The DLCO Vs. immature SP-B correlation was the strongest one. At multivariate analysis, RAGE was associated to age and creatinine, SP-A to DLCO and BNP, SP-D to BNP, mature SP-B to DLCO and creatinine, and immature SP-B only but strongly to DLCO. Conclusions Immature SP-B is the most reliable biological marker of alveolar-capillary membrane function in HF.
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Agostoni P, Sciomer S, Farina S. Reactive Pulmonary Hypertension in Heart Failure is Another Disease Identified by Cardiopulmonary Exercise Test. J Card Fail 2014; 20:658-61. [DOI: 10.1016/j.cardfail.2014.06.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 06/30/2014] [Indexed: 10/25/2022]
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Agostoni P, Corrà U, Cattadori G, Veglia F, Battaia E, La Gioia R, Scardovi AB, Emdin M, Metra M, Sinagra G, Limongelli G, Raimondo R, Re F, Guazzi M, Belardinelli R, Parati G, Magrì D, Fiorentini C, Cicoira M, Salvioni E, Giovannardi M, Mezzani A, Scrutinio D, Di Lenarda A, Mantegazza V, Ricci R, Apostolo A, Iorio A, Paolillo S, Palermo P, Contini M, Vassanelli C, Passino C, Piepoli MF. Prognostic Value of Indeterminable Anaerobic Threshold in Heart Failure. Circ Heart Fail 2013; 6:977-87. [DOI: 10.1161/circheartfailure.113.000471] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Piergiuseppe Agostoni
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Ugo Corrà
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Gaia Cattadori
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Fabrizio Veglia
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Elisa Battaia
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Rocco La Gioia
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Angela B. Scardovi
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Michele Emdin
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Marco Metra
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Gianfranco Sinagra
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Giuseppe Limongelli
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Rosa Raimondo
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Federica Re
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Marco Guazzi
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Romualdo Belardinelli
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Gianfranco Parati
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Damiano Magrì
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Cesare Fiorentini
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Mariantonietta Cicoira
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Elisabetta Salvioni
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Marta Giovannardi
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Alessandro Mezzani
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Domenico Scrutinio
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Andrea Di Lenarda
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Valentina Mantegazza
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Roberto Ricci
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Anna Apostolo
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - AnnaMaria Iorio
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Stefania Paolillo
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Pietro Palermo
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Mauro Contini
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Corrado Vassanelli
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Claudio Passino
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
| | - Massimo F. Piepoli
- From the Centro Cardiologico Monzino, IRCCS, Milano, Italy (P.A., G.C., F.V., E.B., C.F., E.S., M.G., V.M., A.A., P.P., M.C.); Department of Clinical Sciences and Community Health, Cardiovascular Section, Università di Milano, Milano, Italy (P.A., C.F.); Department of Respiratory and Critical Care Medicine, University of Washington, Seattle, WA (P.A.); Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy (U.C., A.M.); Section of
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Agostoni P. Considerations on Safety and Treatment of Patients with Chronic Heart Failure at High Altitude. High Alt Med Biol 2013; 14:96-100. [DOI: 10.1089/ham.2012.1117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Dipartimento di scienze cliniche e di comunità, Università di Milano, Milan Italy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Contini M, Apostolo A, Cattadori G, Paolillo S, Iorio A, Bertella E, Salvioni E, Alimento M, Farina S, Palermo P, Loguercio M, Mantegazza V, Karsten M, Sciomer S, Magrì D, Fiorentini C, Agostoni P. Multiparametric comparison of CARvedilol, vs. NEbivolol, vs. BIsoprolol in moderate heart failure: the CARNEBI trial. Int J Cardiol 2013; 168:2134-40. [PMID: 23506636 DOI: 10.1016/j.ijcard.2013.01.277] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/18/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several β-blockers, with different pharmacological characteristics, are available for heart failure (HF) treatment. We compared Carvedilol (β1-β2-α-blocker), Bisoprolol (β1-blocker), and Nebivolol (β1-blocker, NO-releasing activity). METHODS Sixty-one moderate HF patients completed a cross-over randomized trial, receiving, for 2 months each, Carvedilol, Nebivolol, Bisoprolol (25.6 ± 12.6, 5.0 ± 2.4 and 5.0 ± 2.4 mg daily, respectively). At the end of each period, patients underwent: clinical evaluation, laboratory testing, echocardiography, spirometry (including total DLCO and membrane diffusion), O2/CO2 chemoreceptor sensitivity, constant workload, in normoxia and hypoxia (FiO2=16%), and maximal cardiopulmonary exercise test. RESULTS No significant differences were observed for clinical evaluation (NYHA classification, Minnesota questionnaire), laboratory findings (including kidney function and BNP), echocardiography, and lung mechanics. DLCO was lower on Carvedilol (18.3 ± 4.8*mL/min/mmHg) compared to Nebivolol (19.9 ± 5.1) and Bisoprolol (20.0 ± 5.0) due to membrane diffusion 20% reduction (*=p<0.0001). Constant workload exercise showed in hypoxia a faster VO2 kinetic and a lower ventilation with Carvedilol. Peripheral and central sensitivity to CO2 was lower in Carvedilol while response to hypoxia was higher in Bisoprolol. Ventilation efficiency (VE/VCO2 slope) was 26.9 ± 4.1* (Carvedilol), 28.8 ± 4.0 (Nebivolol), and 29.0 ± 4.4 (Bisoprolol). Peak VO2 was 15.8 ± 3.6*mL/kg/min (Carvedilol), 16.9 ± 4.1 (Nebivolol), and 16.9 ± 3.6 (Bisoprolol). CONCLUSIONS β-Blockers differently affect several cardiopulmonary functions. Lung diffusion and exercise performance, the former likely due to lower interference with β2-mediated alveolar fluid clearance, were higher in Nebivolol and Bisoprolol. On the other hand, Carvedilol allowed a better ventilation efficiency during exercise, likely via a different chemoreceptor modulation. Results from this study represent the basis for identifying the best match between a specific β-blocker and a specific HF patient.
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Ludka O, Trna J, Galkova L, Musil V, Spinar J. Usefulness of exercise tissue doppler echocardiography for prognostic stratification of congestive heart failure patients with left ventricular systolic dysfunction. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:27-34. [DOI: 10.5507/bp.2012.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 01/04/2012] [Indexed: 11/23/2022] Open
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Hauton D, Holmes A, Ziff O, Kumar P. The impact of acute and chronic catecholamines on respiratory responses to hypoxic stress in the rat. Pflugers Arch 2013; 465:209-19. [PMID: 23291711 DOI: 10.1007/s00424-012-1210-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 12/10/2012] [Accepted: 12/16/2012] [Indexed: 10/27/2022]
Abstract
Chronic catecholamine production is associated with desensitisation and down-regulation of adrenergic receptors and occurs in conditions, such as heart failure and myocardial infarction. The effects of further acute adrenergic stimulation, which may occur during exercise, and their subsequent effects on chemosensitivity and ventilation are unclear. Chronic isoprenaline (ISO) increased ventilation by 50 % (P < 0.05) yet the sensitivity to graded hypoxia was preserved. Acute noradrenaline (NA) in control animals led to a doubling of ventilation in hyperoxia (P < 0.001), and this difference was preserved in graded hypoxia (P < 0.001). Yet, combination of NA + ISO did not increase ventilation beyond ISO at baseline or in hypoxia. ISO, NA, and NA + ISO all induced a metabolic acidosis (P < 0.05) with enhanced ventilation in partial compensation. Carotid sinus nerve (CSN) section led to a partial loss of catecholamine-induced augmentation in ventilation (P < 0.05), yet direct recording from CSN in vitro suggests catecholamine is inhibitory for CSN discharge. These observations suggest that chronic catecholamine exposure may result in decreased exercise performance as a direct consequence of the hyperpnea to compensate for an increased metabolic rate coupled with acidosis and leading to increased central chemosensitivity. A limited contribution from peripheral chemoreceptors was noted but was not a consequence of catecholamine stimulation of the carotid body.
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Affiliation(s)
- David Hauton
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK.
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Abstract
Lung function abnormalities both at rest and during exercise are frequently observed in patients with chronic heart failure, also in the absence of respiratory disease. Alterations of respiratory mechanics and of gas exchange capacity are strictly related to heart failure. Severe heart failure patients often show a restrictive respiratory pattern, secondary to heart enlargement and increased lung fluids, and impairment of alveolar-capillary gas diffusion, mainly due to an increased resistance to molecular diffusion across the alveolar capillary membrane. Reduced gas diffusion contributes to exercise intolerance and to a worse prognosis. Cardiopulmonary exercise test is considered the “gold standard” when studying the cardiovascular, pulmonary, and metabolic adaptations to exercise in cardiac patients. During exercise, hyperventilation and consequent reduction of ventilation efficiency are often observed in heart failure patients, resulting in an increased slope of ventilation/carbon dioxide (VE/VCO2) relationship. Ventilatory efficiency is as strong prognostic and an important stratification marker. This paper describes the pulmonary abnormalities at rest and during exercise in the patients with heart failure, highlighting the principal diagnostic tools for evaluation of lungs function, the possible pharmacological interventions, and the parameters that could be useful in prognostic assessment of heart failure patients.
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Carvalho VO. Aerobic exercise prescription in patients with chronic heart failure: a review in the beta-blocker era. J Cardiovasc Med (Hagerstown) 2012; 13:570-4. [PMID: 22828773 DOI: 10.2459/jcm.0b013e328356a3b2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aerobic exercise training is a well-established nonpharmacological tool in patients with clinically stable chronic heart failure. In recent years, β-blocker therapy has become a primary pharmacologic intervention in patients with chronic heart failure. Despite the undeniable improvements in patients, the β-blocker era has aroused uncertainties about aerobic exercise intensity prescription. It is well known that aerobic exercise prescription is performed by a percentage of the patient's heart rate reserve and the use of β-blockers could interfere in this method. For this reason, the aim of this review is to provide an update about aerobic exercise prescription in patients with chronic heart failure who are using β-blockers.
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Affiliation(s)
- Vitor Oliveira Carvalho
- Unidade de Cirurgia Cardíaca Pediátrica - Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da USP (InCor HC-FMUSP), São Paulo, Brazil.
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The Role of Carvedilol in the Treatment of Dilated and Anthracyclines-Induced Cardiomyopathy. Pharmaceuticals (Basel) 2011. [PMCID: PMC4055878 DOI: 10.3390/ph4050770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Although chronic sympathetic activation provides inotropic and chronotropic support to the failing heart, such activation may also have deleterious effects, including the direct cardiotoxic effects of catecholamines, activation of the renin-angiotensin-aldosterone system and an increase in myocardial oxygen demand. These observations indicate that β-blockade might be beneficial in the treatment of heart failure resulting from dilated cardiomyopathy or ischaemic heart disease. Carvedilol is a non-selective β-blocker acting on β1-, β2-, and α1-adrenoceptors. It possesses potent anti-oxidant and anti-apoptotic properties, along with neuroprotective, vasculoprotective, cardioprotective effects, and it has reduced overall mortality in patients with heart failure in controlled clinical trials. Its role in treating cardiomyopathy requires focus. The fact that anthracyclines are cardiotoxic seriously narrows their therapeutic index in cancer therapy. The cardiotoxic risk increases with the cumulative dose and may lead to congestive heart failure and dilated cardiomyopathy in adults and in children. This review focuses on recent research regarding the beneficial effects of carvedilol in the treatment of dilated cardiomyopathy and to revisit the available evidence on the cardioprotection of carvedilol when associated with anthracycline and to explain the mechanisms underlying the benefits of their co-administration.
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Malfatto G, Branzi G, Giglio A, Ciambellotti F, Villani A, Parati G, Facchini M. Diastolic dysfunction and abnormal exercise ventilation predict adverse outcome in elderly patients with chronic systolic heart failure. Eur J Prev Cardiol 2011; 19:396-403. [PMID: 21450576 DOI: 10.1177/1741826711401047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Heart failure is increasing in the elderly and represents a socioeconomic burden requiring the correct management for which risk stratification is mandatory. Among younger patients, echocardiogram and cardiopulmonary exercise test are useful in prognostic stratification. Few studies have analyzed the utility of these tests in elderly patients. METHODS We report on 90 patients over 70 years old, on whom cardiopulmonary tests and echocardiograms were performed between 1998 and 2006 (67 M, 23 F; 75 ± 3 years; ejection fraction (EF) 30 ± 6%; NYHA 2.1 ± 0.8; 60% ischemic; therapy according to international guidelines). Echocardiographic variables were (1) left ventricular ejection fraction (EF); (2) severity of diastolic dysfunction on multiparametric examination of Doppler and TDI parameters; (3) severity of functional mitral regurgitation. Cardiopulmonary variables were (1) peak VO(2); (2) peak O(2) pulse; (3) peak respiratory quotient (RQ); (4) VE/VCO(2) slope. Endpoint considered was mortality of any cause at three-years follow-up. RESULTS Mortality was 21%. At univariate analysis, survivors (n = 71) and deceased (n = 19) were similar for age, NYHA class, peakVO(2) and RQ; they differed for EF, severity of mitral regurgitation, severity of diastolic dysfunction, O(2) pulse and VE/VCO(2) slope. At multivariate analysis, only VE/VCO(2) slope and severe diastolic dysfunction (restrictive filling pattern) discriminated between the two groups. In particular, the association of restrictive filling pattern and VE/VCO(2) slope ≥ 45 predicted 3-year mortality with sensitivity of 84% and specificity of 88%. CONCLUSIONS Echocardiographic and cardiopulmonary data can identify high-risk elderly patients with systolic heart failure, who may need aggressive clinical management.
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Affiliation(s)
- Gabriella Malfatto
- Divisione di Cardiologia, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, piazzale Brescia 20, Milan, Italy.
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Valentini M, Revera M, Bilo G, Caldara G, Savia G, Styczkiewicz K, Parati S, Gregorini F, Faini A, Branzi G, Malfatto G, Magrì D, Agostoni P, Parati G. Effects of Beta-Blockade on Exercise Performance at High Altitude: A Randomized, Placebo-Controlled Trial Comparing the Efficacy of Nebivolol versus Carvedilol in Healthy Subjects. Cardiovasc Ther 2011; 30:240-8. [DOI: 10.1111/j.1755-5922.2011.00261.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Karsten M, Contini M, Cefalù C, Cattadori G, Palermo P, Apostolo A, Bussotti M, Magrì D, Salvioni E, Farina S, Sciomer S, Catai AM, Agostoni P. Effects of carvedilol on oxygen uptake and heart rate kinetics in patients with chronic heart failure at simulated altitude. Eur J Prev Cardiol 2011; 19:444-51. [DOI: 10.1177/1741826711402736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The response to moderate exercise at altitude in heart failure (HF) is unknown. Methods and results: We evaluated 30 HF patients, (NYHA I-III, 25 M/5 F; 59 ± 10 years; LVEF = 39.6 ± 7.1%), in stable clinical conditions, treated with carvedilol at the maximal tolerated dose. We performed a maximal cardiopulmonary exercise test (CPET) with ramp protocol at sea level to evaluate patients’ performance and two moderate intensity constant workload CPETs (50% of peak workload) at sea level (normoxia) and simulated altitude (hypoxia). Oxygen uptake ([Formula: see text]) and heart rate (HR) on-kinetics at constant workload were assessed calculating the time constant (τ) with a monoexponential equation. [Formula: see text] and HR were higher in hypoxia (0.944 ± 0.233 vs 1.031 ± 0.264 l/min; 100 ± 23 vs 108 ± 22 bpm; p < 0.001). On-kinetics showed a different behavior of τ being [Formula: see text] faster in hypoxia (67.1 ± 23.0 vs. 56.3 ± 19.7 s; p = 0.026) and HR faster in normoxia (49.3 ± 19.4 vs. 62.2 ± 22.5 s; p = 0.018). Ten patients, who lowered oxygen kinetics in hypoxia, had greater HR increase during maximal CPET suggesting lower functional betablockade. The higher τ of [Formula: see text] in hypoxia is likely to be due to a peripheral effect of carvedilol mediated either by β- or α-receptor. Conclusion: HF patients performing moderate exercise at 2000 m simulated altitude have 20% [Formula: see text] increase without trouble at the beginning of exercise when treated with carvedilol.
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Affiliation(s)
- Marlus Karsten
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Laboratório de Fisioterapia Cardiovascular, Núcleo de Pesquisa em Exercício Físico, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | | | | | | | | | | | - Maurizio Bussotti
- Cardiologia Riabilitativa, Fondazione S Maugeri, IRCCS, Milan, Italy
| | - Damiano Magrì
- U.O. Cardiologia, S. Andrea Hospital, “Sapienza”, Rome University, Rome, Italy
| | | | | | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche e Geriatriche, ‘Sapienza’, Rome University, Rome, Italy
| | - Aparecida Maria Catai
- Laboratório de Fisioterapia Cardiovascular, Núcleo de Pesquisa em Exercício Físico, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Division of Critical Care and Respiratory Medicine, University of Washington, Seattle, USA
- Dipartimento di Scienze Cardiovascolari, Università di Milano, Milan, Italy
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The prognostic value of left ventricular filling pressure during exercise in heart failure patients. COR ET VASA 2011. [DOI: 10.33678/cor.2011.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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