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Ozemek C, Hardwick J, Bonikowske A, Christle J, German C, Reddy S, Arena R, Faghy M. How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis. Prog Cardiovasc Dis 2024; 83:23-28. [PMID: 38417770 DOI: 10.1016/j.pcad.2024.02.014] [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: 02/25/2024] [Accepted: 02/25/2024] [Indexed: 03/01/2024]
Abstract
Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.
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Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA.
| | - Joel Hardwick
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Amanda Bonikowske
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey Christle
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | - Charles German
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Satyajit Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Mark Faghy
- Human Sciences Research Centre, College of Science and Engineering, University of Derby, UK
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2
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Pezzuto B, Agostoni P. The Current Role of Cardiopulmonary Exercise Test in the Diagnosis and Management of Pulmonary Hypertension. J Clin Med 2023; 12:5465. [PMID: 37685532 PMCID: PMC10487723 DOI: 10.3390/jcm12175465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis if left untreated. Despite remarkable achievements in understanding disease pathophysiology, specific treatments, and therapeutic strategies, we are still far from a definitive cure for the disease, and numerous evidences have underlined the importance of early diagnosis and treatment to improve the prognosis. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity and evaluating the pathophysiological mechanisms underlying exercise limitation. As effort dyspnea is the earliest and one of the main clinical manifestations of PAH, CPET has been shown to provide valid support in early detection, differential diagnosis, and prognostic stratification of PAH patients, being a useful tool in both the first approach to patients and follow-up. The purpose of this review is to present the current applications of CPET in pulmonary hypertension and to propose possible future utilization to be further investigated.
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Affiliation(s)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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3
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Goda A, Yanagisawa Y, Takeuchi S, Takeuchi K, Kikuchi H, Inami T, Kohno T, Satoh T, Soejima K. Characteristics of cardiopulmonary exercise testing in patients with combined post- and pre-capillary pulmonary hypertension due to left heart disease. PLoS One 2023; 18:e0286057. [PMID: 37216326 DOI: 10.1371/journal.pone.0286057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common and morbid complication of left heart disease (LHD), comprising two subtypes: (1) isolated post-capillary pulmonary hypertension (Ipc-PH) and (2) combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH). Knowledge regarding the physiological characteristics that distinguish Cpc-PH, which has a worse prognosis, from Ipc-PH remains limited. Therefore, this study aimed to assess the utility of cardiopulmonary exercise testing (CPET) variables in detecting Cpc-PH. METHODS AND RESULTS Among 105 consecutive patients with LHD (age: 55 ± 13 years; male/female = 79/26) who underwent right heart catheterization and CPET, 45 (43%) were classified as PH-LHD (mean pulmonary artery pressure >20 mmHg). Ipc-PH (n = 24) was defined as pulmonary vascular resistance (PVR) ≤ 3 WU and Cpc-PH (n = 21) as PVR > 3 WU. Patients with Cpc-PH had a significantly lower peak partial pressure of carbon dioxide (PETCO2) (Non-PH/Ipc-PH/Cpc-PH = 38.2 ± 6.6 vs. 38.3 ± 6.0 vs 33.0 ± 4.4 mmHg, p = 0.006), higher VE vs. VCO2 slope (Non-PH/Ipc-PH/Cpc-PH = 33.0 [28.3, 36.6] vs. 32.5 [28.1, 37.8] vs. 40.6 [33.6, 46.1], p = 0.007), and lower ΔVO2/ΔWR (Non-PH/Ipc-PH/Cpc-PH = 8.5 ± 1.4 vs. 8.0 ± 1.7 vs. 6.8 ± 2.0 mL/min/watt, p = 0.001) than those with Ipc-PH and non-PH. Using multivariable logistic regression analysis, CPET variables were found to be independent predictors of Cpc-PH (lower peak PETCO2: odds ratio, 0.728 [95% confidence interval {CI}: 0.616-0.840], p = 0.003 and lower ΔVO2/ΔWR: odds ratio, 0.747 [95% CI: 0.575-0.872], p = 0.003). CONCLUSION From our exploratory analysis, CPET variables, especially in the lower peak PETCO2 and lower ΔVO2/ΔWR, were associated with Cpc-PH in patients with left heart disease.
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Affiliation(s)
- Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Yoshiaki Yanagisawa
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
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4
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Ghio S, Acquaro M, Agostoni P, Ambrosio G, Carluccio E, Castiglione V, Colombo D, D’Alto M, Delle Grottaglie S, Dini FL, Emdin M, Fortunato M, Guaricci AI, Jacoangeli F, Marra AM, Paolillo S, Papa S, Scajola LV, Correale M, Palazzuoli A. Right heart failure in left heart disease: imaging, functional, and biochemical aspects of right ventricular dysfunction. Heart Fail Rev 2022:10.1007/s10741-022-10276-0. [DOI: 10.1007/s10741-022-10276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/17/2022]
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5
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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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6
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Arena R, Ozemek C, Canada JM, Lavie CJ, Borghi-Silva A, Bond S, Popovic D, Argiento P, Guazzi M. Right Ventricular Contractile Reserve: A Key Metric to Identifying when Cardiorespiratory Fitness will Improve with Pulmonary Vasodilators. Curr Probl Cardiol 2022; 48:101423. [PMID: 36167224 DOI: 10.1016/j.cpcardiol.2022.101423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022]
Abstract
Cardiorespiratory fitness (CRF) has been proposed as a vital sign for the past several years, supported by a wealth of evidence demonstrating its significance as a predictor of health trajectory, exercise/functional capacity, and quality of life. According to the Fick equation, oxygen consumption (VO2) is the product of cardiac output (CO) and arterial-venous oxygen difference, with the former being a primary driver of one's aerobic capacity. In terms of the dependence of aerobic capacity on a robust augmentation of CO from rest to maximal exercise, left ventricular (LV) CO has been the historic focal point. Patients with pulmonary arterial hypertension (PAH) or secondary pulmonary hypertension (PH) present with a significantly compromised CRF; as pathophysiology worsens, so too does CRF. Interventions to improve pulmonary hemodynamics continue to emerge and are now a standard of clinical care in several patient populations with increased pulmonary pressures; new pharmacologic options continue to be explored. Improvement in CRF/aerobic capacity has been and continues to be a primary or leading secondary endpoint in clinical trials examining the effectiveness of pulmonary vasodilators. A central premise for including CRF/aerobic capacity as an endpoint is that pulmonary vasodilation will lead to a significant downstream increase in LV CO and therefore peak VO2. However, the importance of right ventricular (RV) CO to the peak VO2 response continues to be overlooked. The current review provides an overview of relevant principles of exercise physiology, approaches to assessing RV contractile reserve and proposals for clinical trial design and subject phenotyping.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL ; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL.
| | - Cemal Ozemek
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL ; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL
| | - Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Carl J Lavie
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-University of Queensland School of Medicine, New Orleans, LA
| | - Audrey Borghi-Silva
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, São Carlos, SP, Brazil
| | - Samantha Bond
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Biomedical and Health Information Sciences, College of Applied Science, University of Illinois Chicago, Chicago, IL
| | - Dejana Popovic
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia; Mayo Clinic, Rochester, Minnesota
| | - Paola Argiento
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Marco Guazzi
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Biological Sciences, San Paolo Hospital, Cardiology Division, University of Milano School of Medicine, Milano, Italy
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7
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Gadioli LP, Costa FA, Moreira HT, Crescêncio JC, Bertini CQ, Marques F, Romano MMD, Junior LG, Schmidt A. Use of Cardiopulmonary Exercise Testing to Assess Pulmonary Hypertension in Patients with Rheumatic Mitral Valve Disease: A Comparative Study with Echocardiography. Curr Probl Cardiol 2022:101230. [DOI: 10.1016/j.cpcardiol.2022.101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/24/2022] [Indexed: 11/03/2022]
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8
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, College of Applied Sciences, University of Illinois at Chicago, Chicago, IL, USA.,Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, Il, USA
| | - Mark A Faghy
- Department of Physical Therapy, College of Applied Sciences, University of Illinois at Chicago, Chicago, IL, USA.,Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, Il, USA.,Human Sciences Research Centre, University of Derby, Derby, UK
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9
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Triantafyllidi H, Birmpa D, Benas D, Trivilou P, Fambri A, Iliodromitis EK. Cardiopulmonary exercise testing: The ABC for the Clinical Cardiologist. Cardiology 2021; 147:62-71. [PMID: 34649252 DOI: 10.1159/000520024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Helen Triantafyllidi
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Dionyssia Birmpa
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Dimitrios Benas
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Paraskevi Trivilou
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Anastasia Fambri
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Efstathios K Iliodromitis
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
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10
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Hager A. Minute ventilation/carbon dioxide production in congenital heart disease. Eur Respir Rev 2021; 30:30/161/200178. [PMID: 34526311 PMCID: PMC9488851 DOI: 10.1183/16000617.0178-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022] Open
Abstract
This review summarises various applications of how ventilatory equivalent (ventilatory efficiency or better still ventilatory inefficiency) and the minute ventilation (VʹE)/carbon dioxide production (VʹCO2) slope obtained from cardiopulmonary exercise testing (CPET) can be used in the diagnostic or prognostic workup of patients with congenital heart disease. The field of congenital heart disease comprises not only a very heterogeneous patient group with various heart diseases, but also various conditions in different stages of repair, as well as the different residuals seen in long-term follow-up. As such, various physiologic disarrangements must be considered in the analysis of increased VʹE/VʹCO2 slope from CPET in patients with congenital heart disease. In addition to congestive heart failure (CHF), cyanosis, unilateral pulmonary stenosis and pulmonary hypertension (PH) provide the background for this finding. The predictive value of increased VʹE/VʹCO2 slope on prognosis seems to be more important in conditions where circulatory failure is associated with failure of the systemic ventricle. In cyanotic patients, those with Fontan circulation, or those with substantial mortality from arrhythmia, the impact of VʹE/VʹCO2 on prognosis is not that important. VʹE/VʹCO2 elevation is a common finding in patients with congenital heart disease. It can be used as a sign for right-to-left shunting, unilateral pulmonary stenosis, pulmonary hypertension and circulatory failure. It is predictive for clinical worsening.https://bit.ly/33gj3NQ
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Affiliation(s)
- Alfred Hager
- Dept of Pediatric Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
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11
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Zhong X, Tang J, Jiang R, Yuan P, Zhao Q, Gong S, Liu J, Wang L. The predictive value of minute ventilation versus carbon dioxide production in pulmonary hypertension associated with left heart disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:351. [PMID: 33708978 PMCID: PMC7944330 DOI: 10.21037/atm-21-366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The aim of the present study was to investigate the role of key cardiopulmonary exercise testing (CPET) parameters in the identification of pre-capillary components in patients with pulmonary hypertension associated with left heart disease (PH-LHD), and to evaluate their correlations with hemodynamic parameters. Methods Ninety patients with PH-LHD underwent right-heart catheterization, echocardiography, and CPET. The differences in related indexes between a combined post- and pre-capillary PH (Cpc-PH) group (n=47) and an isolated post-capillary PH (Ipc-PH) group (n=43) were compared. Correlation analysis was performed. Logistic regression and receiver operator characteristic (ROC) analyses were performed to assess the ability of CPET variables to distinguish patients with Cpc-PH from those with Ipc-PH. Results The hemodynamics, hyperventilation and right ventricular function of Cpc-pH group were worse than those of Ipc-pH group. The parameters related to minute ventilation versus carbon dioxide production (VE/VCO2) played a significant role in the differentiation of Cpc-PH and Ipc-PH, and had a moderate positive correlation with pulmonary vascular resistance (PVR). Univariate and multivariate logistic analyses showed that lowest percentage of VE/VCO2 in predicted value (VE/VCO2%pred) was the single best predictor of Cpc-PH, and the area under ROC curve also confirmed that lowest VE/VCO2%pred (≥137%) could serve as a novel diagnostic marker for Cpc-PH. On the basis of this lowest VE/VCO2%pred threshold, patients were divided into two groups. Most hemodynamic parameters were worse in patients with a lowest VE/VCO2%pred ≥137%. Conclusions VE/VCO2-related parameters are powerful prognosticators for the presence of pre-capillary components in patients with PH-LHD, especially lowest VE/VCO2%pred.
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Affiliation(s)
- Xiujun Zhong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Tang
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qinhua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Sugang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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12
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Understanding Obesity-Related High Output Heart Failure and Its Implications. ACTA ACUST UNITED AC 2021; 3:160-171. [PMID: 36262639 PMCID: PMC9536652 DOI: 10.36628/ijhf.2020.0047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Abstract
Morbid obesity remains most common cause of high output failure. The prevalence of the obesity is growing when two-thirds of American adults already are overweight or obese. Obesity is the risk factor for heart disease and eventually leads to heart failure. High output heart failure is common in obese patients and is characterized by high cardiac output, decreased systemic vascular resistance, and increased oxygen consumption. It often occurs in patients with chronic severe anemia, hyperthyroidism, pregnancy, arterial-venous fistulas, and liver disease. However, the pathogenesis of obesity-related high output heart failure is not fully understood. The clinical management of obesity-related high output heart failure follows conventional heart failure regimens due to lack of specific clinical recommendations. This article reviews the possible pathophysiological mechanisms and causes that contribute to obesity-related high output heart failure. This review also focuses on the implications for clinical practice and future research involved with omics technologies to explore possible molecular pathways associated with obesity-related high output heart failure.
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13
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Lee F, Mielniczuk LM. Pulmonary Hypertension Due to Left Heart Disease-A Practical Approach to Diagnosis and Management. Can J Cardiol 2020; 37:572-584. [PMID: 33217522 DOI: 10.1016/j.cjca.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/01/2020] [Accepted: 11/10/2020] [Indexed: 01/07/2023] Open
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is a frequent complication of heart failure (HF) and is associated with exercise intolerance, poor quality of life, increased risk of hospitalisations, and reduced overall survival. Since the recent Sixth World Symposium on Pulmonary Hypertension in 2018, there have been significant changes in the hemodynamic definitions and clinical classification of PH-LHD. PH-LHD can be subdivided into (1) isolated postcapillary PH (IpcPH) and (2) combined precapillary and postcapillary PH (CpcPH). This categorisation of PH-LHD is important because CpcPH shares certain pathophysiologic, clinical, and hemodynamic characteristics with pulmonary arterial hypertension and is associated with worse outcomes compared with IpcPH. A systematic approach using clinical history and noninvasive investigations is required in the diagnosis of PH-LHD. Right heart catheterisation with and without provocative testing is performed in expert centres and is indicated in selected individuals. Although the definition of IpcPH and CpcPH is based on measurements made with right heart catheterisation, distinguishing between these two entities is not always necessary. Despite strong evidence for medical therapy in patients with pulmonary arterial hypertension, those options have limited benefit in PH-LHD. Expert PH centres in Canada have been established to provide ongoing care for the more complex patient subgroups.
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Affiliation(s)
- Felicity Lee
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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14
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Sayegh ALC, Silva BM, Ferreira EVM, Ramos RP, Fisher JP, Nery LE, Ota-Arakaki JS, Oliveira RKF. Clinical utility of ventilatory and gas exchange evaluation during low-intensity exercise for risk stratification and prognostication in pulmonary arterial hypertension. Respirology 2020; 26:264-272. [PMID: 33118293 DOI: 10.1111/resp.13959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Peak oxygen consumption (pVO2 ), determined from CPET, provides a valuable indication of PAH severity and patient prognosis. However, CPET is often contraindicated in severe PAH and frequently terminated prior to achievement of a sufficient exercise effort. We sought to determine whether in PAH low-intensity [i.e. freewheeling exercise (FW)] exercise reveals abnormal VE /VCO2 and PET CO2 responses that are associated with pVO2 and serve as indices of PAH risk stratification and mortality. METHODS Retrospective analysis of CPET from 97 PAH patients and 20 age-matched controls was undertaken. FW VE /VCO2 and PET CO2 were correlated with pVO2 % age-predicted. Prognostication analysis was conducted using pVO2 > 65% age-predicted, as known to represent a low mortality risk. Primary outcome was mortality from any cause. RESULTS FW PET CO2 was correlated with pVO2 (P < 0.0001; r = 0.52), while FW VE /VCO2 was not (P = 0.13; r = -0.16). ROC curve analyses showed that FW PET CO2 (AUC = 0.659), but not FW VE /VCO2 (AUC = 0.587), provided predictive information identifying pVO2 > 65% age-predicted (best cut-off value of 28 mm Hg). By Cox analysis, FW PET CO2 < 28 mm Hg remained a predictor of mortality after adjusting for age and PAH aetiology (HR: 2.360, 95% CI: 1.144-4.866, P = 0.020). CONCLUSION Low PET CO2 during FW is associated with reduced pVO2 in PAH and provides predictive information for PAH risk stratification and prognostication.
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Affiliation(s)
- Ana Luiza C Sayegh
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil.,Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Bruno Moreira Silva
- Department of Physiology, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Roberta P Ramos
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - James P Fisher
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Luiz E Nery
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
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Nicol M, Deney A, Lairez O, Vergaro G, Emdin M, Carecci A, Inamo J, Montfort A, Neviere R, Damy T, Harel S, Royer B, Baudet M, Cohen-Solal A, Arnulf B, Logeart D. Prognostic value of cardiopulmonary exercise testing in cardiac amyloidosis. Eur J Heart Fail 2020; 23:231-239. [PMID: 33006180 DOI: 10.1002/ejhf.2016] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/20/2020] [Accepted: 09/26/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS In amyloid patients, cardiac involvement dramatically worsens functional capacity and prognosis. We sought to study how the cardiopulmonary exercise test (CPET) could help in functional assessment and risk stratification of patients with cardiac amyloidosis (CA). METHODS AND RESULTS We carried out a multicentre study including patients with light chain (AL) or transthyretin (TTR) CA. All patients underwent exhaustive examination including CPET and follow-up. The primary prognostic endpoint was the occurrence of death or heart failure hospitalization. Overall, 150 patients were included (91 AL and 59 TTR CA). Median age, systolic blood pressure, N-terminal pro B-type natriuretic peptide (NT-proBNP) and cardiac troponin T were 70 (64-78) years, 121 [interquartile range (IQR) 109-139] mmHg, 2806 (IQR 1218-4638) ng/L and 64 (IQR 33-120) ng/L, respectively. New York Heart Association classes were I-II in 64%. Median peak oxygen consumption (VO2 ) and circulatory power were low at 13.0 (10.0-16.9) mL/kg/min and 1730 (1318-2614) mmHg/mL/min, respectively. The minute ventilation/carbon dioxide production slope was increased to 37 (IQR 33-45). A total of 77 patients (51%) had chronotropic insufficiency. After a median follow-up of 20 months, there were 37 deaths and 44 heart failure hospitalizations. At multivariate Cox analysis, peak VO2 ≤13 mL/kg/min [hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.6-4.8], circulatory power ≤1730 mmHg/mL/min (HR 2.4, 95% CI 1.2-4.6) and NT-proBNP ≥1800 ng/L (HR 2.2, 95% CI 1.1-4.3) were found to be associated with the primary outcome. No events occurred in patients with both peak VO2 >13 mL/kg/min and NT-proBNP <1800 ng/L, while the association of VO2 ≤13 mL/kg/min with NT-proBNP ≥1800 ng/L identified a very high-risk subgroup. CONCLUSION In CA, CPET is helpful in assessing functional capacity, circulatory and chronotropic responses as well as the prognosis of patients along with cardiac biomarkers.
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Affiliation(s)
- Martin Nicol
- Lariboisiere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Antoine Deney
- Rangueil Hospital, University Hospital of Toulouse, Toulouse, France
| | - Olivier Lairez
- Rangueil Hospital, University Hospital of Toulouse, Toulouse, France
| | - Giuseppe Vergaro
- Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana 'Gabriele Monasterio', Pisa, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana 'Gabriele Monasterio', Pisa, Italy
| | | | - Jocelyn Inamo
- University Hospital of Fort de France, Fort De France, France
| | - Astrid Montfort
- University Hospital of Fort de France, Fort De France, France
| | - Remi Neviere
- University Hospital of Fort de France, Fort De France, France
| | - Thibaud Damy
- Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Stephanie Harel
- Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Royer
- Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathilde Baudet
- Lariboisiere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Cohen-Solal
- Lariboisiere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Bertrand Arnulf
- University of Paris, Paris, France.,Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Damien Logeart
- Lariboisiere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
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16
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Galectin-3 is related to right ventricular dysfunction in heart failure patients with reduced ejection fraction and may affect exercise capacity. Sci Rep 2020; 10:16682. [PMID: 33028850 PMCID: PMC7542167 DOI: 10.1038/s41598-020-73634-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/14/2020] [Indexed: 12/03/2022] Open
Abstract
Galectin-3 is a biomarker of fibrosis, inflammation and oxidative stress, and its role in heart remodelling and exercise intolerance has not been conclusively proven in heart failure (HF) patients with reduced ejection fraction (rEF). We prospectively assessed 67 consecutive patients with symptomatic HF and left ventricular (LV) EF ≤ 35% during optimal medical therapy, with a mean serum galectin-3 concentration of 15.3 ± 6.4 and a median of 13.5 ng/mL. The group with galectin-3 concentrations greater than or equal to the median had significantly worse right ventricular (RV) systolic function parameters (s′, TAPSE), higher pulmonary artery systolic pressure, more advanced tricuspid regurgitation and lower RV-to-pulmonary circulation coupling index, while no significant differences were found in LV parameters. Moreover, this group achieved significantly lower parameters in cardiopulmonary exercise testing. Significant negative correlations were found between galectin-3 concentration and RV parameters and exercise capacity parameters and have persisted after adjustment for glomerular filtration rate, but not all of them have persisted after adjustment for NT-proBNP. Multivariate regression analysis revealed that TAPSE (β coefficient: − 0.605; p < 0.001) and heart rate at peak exercise (β coefficient: − 0.98; p = 0.009) were independently related to galectin-3 concentration. Elevated galectin-3 concentration in patients with HFrEF might indicate concomitant RV dysfunction and exercise intolerance.
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17
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Guimarães GV, Bocchi EA. Idiopathic Left-Bundle Branch Block and Unexplained Symptom At Exercise: A Case Report. Arq Bras Cardiol 2020; 115:10-13. [PMID: 32935757 PMCID: PMC8386955 DOI: 10.36660/abc.20190363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
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18
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Zhong XJ, Tang J, Zhao QH, Gong SG, Jiang R, Liu JM, Wang L. Can the diastolic pulmonary pressure gradient provide cardiopulmonary capacity information in patients with pulmonary hypertension and left heart disease? Int J Cardiol 2020; 305:138. [PMID: 32151339 DOI: 10.1016/j.ijcard.2019.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/10/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Xiu-Jun Zhong
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China; Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Jie Tang
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
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19
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Diagnostic Validity of Cardiopulmonary Exercise Testing for Screening Pulmonary Hypertension in Patients With Chronic Obstructive Pulmonary Disease. J Cardiopulm Rehabil Prev 2020; 40:189-194. [PMID: 31714394 DOI: 10.1097/hcr.0000000000000456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine diagnostic validity of cardiopulmonary exercise testing (CPX) parameters for detecting pulmonary hypertension (PH) in patients with chronic obstructive pulmonary disease (COPD) and to investigate association between CPX parameters and indices of PH. METHODS This cross-sectional study enrolled 48 moderate to very severe COPD patients in whom PH was confirmed by echocardiography. Symptom-limited CPX was performed using an incremental exercise protocol. Relevant CPX parameters were derived and were tested for their diagnostic ability for diagnosing PH. Logistic regression was applied to examine the effect of various clinical covariates on the diagnostic ability of exercise test variables for detecting PH. RESULTS Of the 48 patients, 29 were diagnosed with PH and 19 were negative for PH based on echocardiographic testing. CPX measures including peak oxygen uptake (% predicted (Equation is included in full-text article.)O2peak, (Equation is included in full-text article.)O2peak [mL/min], (Equation is included in full-text article.)O2/kg), oxygen pulse ((Equation is included in full-text article.)O2/HR % predicted, (Equation is included in full-text article.)O2/HR mL/beat), and peak minute ventilation ((Equation is included in full-text article.)Epeak [L/m]) were inversely correlated with mean pulmonary arterial pressure (mPAP). Peak (Equation is included in full-text article.)O2/HR and (Equation is included in full-text article.)O2peak were found to be significant predictors of PH in univariate analysis. (Equation is included in full-text article.)O2peak (%), (Equation is included in full-text article.)O2/HR (mL/beat), and desaturation (%) were identified as independent predictors of PH adjusted for age, forced expiratory volume in 1 sec (%), and forced vital capacity (L). CONCLUSION The present study validates the use of CPX parameters such as (Equation is included in full-text article.)O2peak and (Equation is included in full-text article.)O2/HR as a diagnostic tool for correctly identifying PH in COPD patients. Therefore, CPX may be used as an adjunct to echocardiographic measurement of PH where there is unavailability of equipment and expertise.
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20
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Sugimoto T. Acute Decompensated Heart Failure in Patients with Heart Failure with Preserved Ejection Fraction. Heart Fail Clin 2020; 16:201-209. [PMID: 32143764 DOI: 10.1016/j.hfc.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There are few treatment options for acute decompensated heart failure patients with preserved ejection fraction, but an increasing number of patients with heart failure with preserved ejection fraction. A deeper understanding of the cause, diagnosis, and prognosis of heart failure with preserved ejection fraction may be informative for clinical practice or clinical decision making and therapeutic investigation in the acute care setting.
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Affiliation(s)
- Tadafumi Sugimoto
- Department of Clinical Laboratory, Mie University Hospital, 2-174 Edobashi, Tsu 514-8507, Japan.
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21
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Taylor BJ, Shapiro BP, Johnson BD. Exercise intolerance in heart failure: The important role of pulmonary hypertension. Exp Physiol 2020; 105:1997-2003. [PMID: 32092200 DOI: 10.1113/ep088105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/20/2020] [Indexed: 12/21/2022]
Abstract
NEW FINDINGS What is the topic of this review? This review concerns the negative impact of pulmonary hypertension (PH) on the pulmonary haemodynamic and gas exchange responses to exercise, considering the mechanisms by which PH plays a role in exercise intolerance in heart failure (HF) patients. What advances does it highlight? The hallmark limited pulmonary vascular 'reserve' and impaired pulmonary gas exchange responses to exercise in HF are worsened by the development of PH; these are key determinants of exercise intolerance. Even HF patients who present with 'normal' pulmonary vascular function experience exercise-induced PH, which plays a role in exercise intolerance. ABSTRACT Patients with heart failure universally complain of exertional intolerance, but the underlying cause(s) of this intolerance may differ between patients with different disease phenotypes. Exercise introduces an impressive stress to the lungs, where elevations in venous return and cardiac output engender substantial increases in pulmonary blood volume and flow. Relative to healthy individuals, the pulmonary vascular reserve to accept this increase in pulmonary perfusion is compromised in heart failure, with a growing body of evidence suggesting that the development of pulmonary hypertension (PH), and in particular a precapillary component of PH, worsens the pulmonary haemodynamic response to exercise in these patients. Characterized by an exaggerated increase in pulmonary arterial pressure and an elevation in pulmonary vascular resistance, this dysfunctional pulmonary haemodynamic response plays a role in exercise intolerance, probably through an impairment of right ventricular function, underperfusion of the pulmonary circulation and a subsequent reduction in systemic blood flow and oxygen delivery. The hallmark abnormalities in ventilatory and pulmonary gas exchange that accompany heart failure, including a greater ventilatory equivalent for carbon dioxide, are also worsened by the development of PH. This raises the possibility that measures of exercise pulmonary gas exchange might help to 'describe' underlying PH in heart failure; however, several fundamental issues and questions need to be addressed before such gas exchange measures could truly be considered efficacious measures used to differentiate the type of PH and track the severity of PH in heart failure. exercise intolerance, heart failure, pulmonary gas exchange, pulmonary haemodynamics, pulmonary hypertension.
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Affiliation(s)
- Bryan J Taylor
- School of Biomedical Sciences, University of Leeds, Leeds, UK.,Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Brian P Shapiro
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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22
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Intracardiac multimorbidity: assessing right ventricular function in left-sided heart failure through cardiopulmonary exercise testing. Expert Rev Cardiovasc Ther 2019; 17:331-333. [PMID: 30786791 DOI: 10.1080/14779072.2019.1585808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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23
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Kaminsky LA, Arena R, Ellingsen Ø, Harber MP, Myers J, Ozemek C, Ross R. Cardiorespiratory fitness and cardiovascular disease - The past, present, and future. Prog Cardiovasc Dis 2019; 62:86-93. [PMID: 30639135 DOI: 10.1016/j.pcad.2019.01.002] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/06/2019] [Indexed: 01/12/2023]
Abstract
The importance of cardiorespiratory fitness (CRF) is now well established and it is increasingly being recognized as an essential variable which should be assessed in health screenings. The key findings that have established the clinical significance of CRF are reviewed in this report, along with an overview of the current relevance of exercise as a form of medicine that can provide a number of positive health outcomes, including increasing CRF. Current assessment options for assessing CRF are also reviewed, including the direct measurement via cardiopulmonary exercise testing which now can be interpreted with age and sex-specific reference values. Future directions for the use of CRF and related measures are presented.
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Affiliation(s)
- Leonard A Kaminsky
- Fisher Institute of Health and Well-Being, College of Health, Ball State University, Muncie, IN, United States.
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Øyvind Ellingsen
- Norwegian University Science and Technology and St Olavs University Hospital, Trondheim, Norway
| | - Matthew P Harber
- Clinical Exercise Physiology Program, College of Health, Ball State University, Muncie, IN, United States
| | - Jonathan Myers
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States; School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Robert Ross
- School of Kinesiology and Health Studies, Department of Medicine, Division of Endocrinology and Metabolism, Queens University, Ontario, Canada
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Lai YC, Wang L, Gladwin MT. Insights into the pulmonary vascular complications of heart failure with preserved ejection fraction. J Physiol 2018; 597:1143-1156. [PMID: 30549058 DOI: 10.1113/jp275858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (PH-HFpEF) is a growing public health problem that is increasing in prevalence. While PH-HFpEF is defined by a high mean pulmonary artery pressure, high left ventricular end-diastolic pressure and a normal ejection fraction, some HFpEF patients develop PH in the presence of pulmonary vascular remodelling with a high transpulmonary pressure gradient or pulmonary vascular resistance. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, which include obesity, diabetes and hypertension, are recognized as risk factors for PH-HFpEF. Qualitative studies have documented that patients with PH-HFpEF develop more severe symptoms than those with HFpEF and are associated with more significant exercise intolerance, frequent hospitalizations, right heart failure and reduced survival. Currently, there are no effective therapies for PH-HFpEF, although a number of candidate drugs are being evaluated, including soluble guanylate cyclase stimulators, phosphodiesterase type 5 inhibitors, sodium nitrite and endothelin receptor antagonists. In this review we attempt to provide an updated overview of recent findings pertaining to the pulmonary vascular complications in HFpEF in terms of clinical definitions, epidemiology and pathophysiology. Mechanisms leading to pulmonary vascular remodelling in HFpEF, a summary of pre-clinical models of HFpEF and PH-HFpEF, and new candidate therapeutic strategies for the treatment of PH-HFpEF are summarized.
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Affiliation(s)
- Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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25
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Hein S, Aus Dem Siepen F, Bauer R, Katus HA, Kristen AV. Peak V'O 2 is an independent predictor of survival in patients with cardiac amyloidosis. Amyloid 2018; 25:167-173. [PMID: 30193539 DOI: 10.1080/13506129.2018.1496077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) has repeatedly been reported to reliably predict adverse outcomes in different forms of heart failure. However, it has not been elucidated in detail in cardiac amyloidosis (CA). Therefore, we evaluated the predictive value of CPET parameters in patients with CA regarding disease severity and prediction of mortality. METHODS Twenty-seven consecutive patients with CA were assessed noninvasively, including electrocardiography, echocardiography, CPET, and laboratory tests. Clinical data were correlated with CPET findings. Univariate and multivariate analyses were performed to evaluate predictors of mortality. RESULTS Within median follow-up period of 38 (IQR 43) months 19 (70%) deaths occurred. Patient initially presented with signs and symptoms of congestive heart failure NYHA 3 (IQR 1), reduced exercise capacity (peak V'O2 15.2 mL/kg body weight) and inefficient ventilation in CPET (V'E/V'CO2 slope (30 (IQR 3)), markedly elevated cardiac biomarkers (NT-proBNP 1791 (IQR 3249) ng/mL) and echocardiographic signs of morphological (septum thickness 18 (IQR 6) mm) and functional cardiac involvement (TAPSE 19 (IQR 8) mm). Patients with peak V'O2 below median value presented with significantly longer QTc interval when compared to patients with peak V'O2 above the median. Further these patients tend to have more pronounced impairment of longitudinal function as indicated by lower MAPSE, TAPSE, and elevation of cardiac biomarkers. Multivariate analysis revealed peak V'O2 slope as the only independent predictor of survival. CONCLUSIONS We identified reduced peak V'O2 as an independent predictor of mortality in patients with cardiac involvement in different forms of systemic amyloidosis.
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Affiliation(s)
- Selina Hein
- a Department of Internal Medicine III, Cardiology , Heidelberg University Hospital , Heidelberg , Germany
| | - Fabian Aus Dem Siepen
- a Department of Internal Medicine III, Cardiology , Heidelberg University Hospital , Heidelberg , Germany
| | - Ralf Bauer
- a Department of Internal Medicine III, Cardiology , Heidelberg University Hospital , Heidelberg , Germany
| | - Hugo A Katus
- a Department of Internal Medicine III, Cardiology , Heidelberg University Hospital , Heidelberg , Germany.,b DZHK (German Centre for Cardiovascular Research) , Heidelberg , Germany
| | - Arnt V Kristen
- a Department of Internal Medicine III, Cardiology , Heidelberg University Hospital , Heidelberg , Germany
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Alsaied T, Niss O, Powell AW, Fleck RJ, Cnota JF, Chin C, Malik P, Quinn CT, Taylor MD. Diastolic dysfunction is associated with exercise impairment in patients with sickle cell anemia. Pediatr Blood Cancer 2018; 65:e27113. [PMID: 29781568 PMCID: PMC6019177 DOI: 10.1002/pbc.27113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Left ventricular diastolic dysfunction (DD) is an independent risk factor for mortality in sickle cell anemia (SCA) and is associated with increased extracellular volume (ECV) on cardiac MRI (CMR). Exercise impairment is common in SCA, but its causes and prognostic value are not well understood. OBJECTIVE To study the effects of DD and ECV on cardiopulmonary exercise test (CPET) in patients with SCA. METHODS AND RESULTS As part of a prospective study to characterize the cardiomyopathy of SCA (NCT02410811), 20 children and adults with SCA underwent CMR, echocardiography, and cycle ergometer CPET (age range 8-43 years). Maximum exercise was reached in 18 patients and 17 (94%) had reduced exercise capacity (%predicted VO2 less than 80%). Six patients had DD and none had systolic dysfunction. Patients with DD had lower exercise capacity compared to patients with normal diastolic function (%predicted VO2 48.2 ± 9.1% vs. 61.2 ± 11.7%; P = 0.01). The z-score of left ventricular lateral E/e' ratio, which is a marker of DD, was negatively associated with %predicted VO2 (r = -0.61, P = 0.01). All patients with moderate-to-severe exercise impairment (%predicted VO2 < 60%) had lateral E/e' z-score > 2. In a multivariate analysis, lateral E/e' z-score was independently associated with %predicted VO2 (P = 0.02). All participants had elevated ECV but the degree of elevation was not associated with exercise parameters. CONCLUSION Left ventricular DD is associated with decreased exercise capacity in SCA. Interventions to prevent or delay DD could improve exercise capacity, quality of life, and long-term outcomes in SCA.
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Affiliation(s)
- Tarek Alsaied
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Cardiac Imaging, Boston Children’s Hospital
| | - Omar Niss
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adam W. Powell
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Robert J. Fleck
- Department of Radiology at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - James F. Cnota
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Clifford Chin
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Punam Malik
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Charles T. Quinn
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Michael D. Taylor
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Popovic D, Arena R, Guazzi M. A flattening oxygen consumption trajectory phenotypes disease severity and poor prognosis in patients with heart failure with reduced, mid-range, and preserved ejection fraction. Eur J Heart Fail 2018; 20:1115-1124. [PMID: 29405511 DOI: 10.1002/ejhf.1140] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/12/2017] [Accepted: 12/27/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In heart failure (HF), a flattening oxygen consumption (VO2 ) trajectory during cardiopulmonary exercise test (CPET) reflects an acutely compromised cardiac output. We hypothesized that a flattening VO2 trajectory is helpful in phenotyping disease severity and prognosis in HF with either reduced (HFrEF), mid-range (HFmrEF), or preserved (HFpEF) ejection fraction. METHODS AND RESULTS Overall, 319 HF patients (198 HFrEF, 80 HFmrEF, and 41 HFpEF) underwent CPET. A flattening VO2 trajectory was tracked and defined as an inflection of VO2 linearity as a function of work rate with a second slope downward inflection >35% extent of the first one. Peak VO2 , the minute ventilation/carbon dioxide production (VE/VCO2 ) slope, and the presence of exercise oscillatory ventilation (EOV) were also determined. Pulmonary artery systolic pressure (PASP) and tricuspid annular plane systolic excursion (TAPSE) were measured by echocardiography. A flattening VO2 occurred in 92 patients (28.8%). PASP and TAPSE at rest were significantly higher and lower (P < 0.001), respectively. The primary outcome was the combination of all-cause death, heart transplantation and left ventricular assist device implantation. The secondary outcome was the primary outcome plus hospitalization for cardiac reasons. In the multivariate model including peak VO2 , VE/VCO2 slope, EOV and VO2 trajectory, a flattening VO2 trajectory and EOV were retained in the regression for primary (X2 = 35.78, and 36.36, respectively; P < 0.001) and secondary (X2 = 12.45 and 47.91, respectively; P < 0.001) outcomes. CONCLUSIONS Results point to a flattening VO2 trajectory as a likely new and strong predictor of events in HF with any ejection fraction. Given the relation of right-sided cardiac dysfunction to pulmonary hypertension, this oxygen pattern might suggest a real-time decrease in pulmonary blood flow to the left heart.
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Affiliation(s)
- Dejana Popovic
- Clinic for Cardiology, University Clinical Center Serbia, University of Belgrade, Belgrade, Serbia
| | - Ross Arena
- Department of Physical Therapy, College of Applied Science, University at Illinois, Chicago, IL, USA
| | - Marco Guazzi
- Heart Failure Unit and Cardiopulmonary Laboratory, University Cardiology Department, IRCCS Policlinico San Donato University Hospital, Milan, Italy
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Kovacs G, Herve P, Barbera JA, Chaouat A, Chemla D, Condliffe R, Garcia G, Grünig E, Howard L, Humbert M, Lau E, Laveneziana P, Lewis GD, Naeije R, Peacock A, Rosenkranz S, Saggar R, Ulrich S, Vizza D, Vonk Noordegraaf A, Olschewski H. An official European Respiratory Society statement: pulmonary haemodynamics during exercise. Eur Respir J 2017; 50:50/5/1700578. [DOI: 10.1183/13993003.00578-2017] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/08/2017] [Indexed: 01/18/2023]
Abstract
There is growing recognition of the clinical importance of pulmonary haemodynamics during exercise, but several questions remain to be elucidated. The goal of this statement is to assess the scientific evidence in this field in order to provide a basis for future recommendations.Right heart catheterisation is the gold standard method to assess pulmonary haemodynamics at rest and during exercise. Exercise echocardiography and cardiopulmonary exercise testing represent non-invasive tools with evolving clinical applications. The term “exercise pulmonary hypertension” may be the most adequate to describe an abnormal pulmonary haemodynamic response characterised by an excessive pulmonary arterial pressure (PAP) increase in relation to flow during exercise. Exercise pulmonary hypertension may be defined as the presence of resting mean PAP <25 mmHg and mean PAP >30 mmHg during exercise with total pulmonary resistance >3 Wood units. Exercise pulmonary hypertension represents the haemodynamic appearance of early pulmonary vascular disease, left heart disease, lung disease or a combination of these conditions. Exercise pulmonary hypertension is associated with the presence of a modest elevation of resting mean PAP and requires clinical follow-up, particularly if risk factors for pulmonary hypertension are present. There is a lack of robust clinical evidence on targeted medical therapy for exercise pulmonary hypertension.
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Dulgheru R, Marchetta S, Sugimoto T, Go YY, Girbea A, Oury C, Lancellotti P. Exercise Testing in Mitral Regurgitation. Prog Cardiovasc Dis 2017; 60:342-350. [PMID: 29128571 DOI: 10.1016/j.pcad.2017.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 10/29/2017] [Indexed: 12/29/2022]
Abstract
Mitral regurgitation (MR) is the second most common valvular heart disease referred for corrective surgery. Diagnostic and management dilemmas are not uncommon when dealing with MR patients. Exercise testing plays an important role in sorting out some of these clinical challenges. In primary asymptomatic MR, exercise testing allows symptom assessment, confident link of symptoms to valve disease severity, safe deferral of surgery for the next 1-year in patients with preserved exercise capacity, insights into the mechanism of exercise-induced dyspnea and helps in individual risk stratification. Moreover, exercise testing in the form of exercise stress echocardiography is also useful in the evaluation of patients with secondary ischemic MR for risk stratification as well as for the detection of patients with moderate ischemic MR in whom mitral valve repair at the time of surgical revascularization may add benefit.
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Affiliation(s)
- Raluca Dulgheru
- University of Liège Hospital, Department of Cardiology, Heart Valve Clinic, Liège, Belgium
| | - Stella Marchetta
- University of Liège Hospital, Department of Cardiology, Heart Valve Clinic, Liège, Belgium
| | - Tadafumi Sugimoto
- University of Liège Hospital, Department of Cardiology, Heart Valve Clinic, Liège, Belgium
| | - Yun Yun Go
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
| | - Alexandra Girbea
- University of Liège Hospital, Department of Cardiology, Heart Valve Clinic, Liège, Belgium
| | - Cécile Oury
- GIGA Cardiovascular Sciences, University Hospital Sart Tilman, Liège, Belgium
| | - Patrizio Lancellotti
- University of Liège Hospital, Department of Cardiology, Heart Valve Clinic, Liège, Belgium; GIGA Cardiovascular Sciences, University Hospital Sart Tilman, Liège, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy.
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Sato T, Yoshihisa A, Kanno Y, Suzuki S, Yamaki T, Sugimoto K, Kunii H, Nakazato K, Suzuki H, Saitoh SI, Ishida T, Takeishi Y. Cardiopulmonary exercise testing as prognostic indicators: Comparisons among heart failure patients with reduced, mid-range and preserved ejection fraction. Eur J Prev Cardiol 2017; 24:1979-1987. [DOI: 10.1177/2047487317739079] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yuki Kanno
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Satoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Koichi Sugimoto
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Kazuhiko Nakazato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Hitoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Shu-ichi Saitoh
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takafumi Ishida
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
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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: 253] [Impact Index Per Article: 36.1] [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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Abstract
Tetralogy of Fallot is the most common form of cyanotic congenital heart disease. As a result of the surgical strategies employed at the time of initial repair, chronic pulmonary regurgitation (PR) is prevalent in this population. Despite sustained research efforts, patient selection and timing of pulmonary valve replacement (PVR) to address PR in young asymptomatic patients with repaired tetralogy of Fallot (rToF) remain a fundamental but as yet unanswered question in the field of congenital heart disease. The ability of the heart to compensate for the chronic volume overload imposed by PR is critical in the evaluation of the risks and benefits of PVR. The difficulty in clarifying the functional impact of PR on the cardiovascular capacity may be in part responsible for the uncertainty surrounding the timing of PVR. Cardiopulmonary exercise testing (CPET) may be used to assess abnormal cardiovascular response to increased physiologic demands. However, its use as a tool for risk stratification in asymptomatic adolescents and young adults with rToF is still ill-defined. In this paper, we review the role of CPET as a potentially valuable adjunct to current risk stratification strategies with a focus on asymptomatic rToF adolescents and young adults being considered for PVR. The role of maximal and submaximal exercise measurements to identify young patients with a decreased or borderline low peak VO2 resulting from impaired ventricular function is explored. Current knowledge gaps and research perspectives are highlighted.
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Caravita S, Faini A, Deboeck G, Bondue A, Naeije R, Parati G, Vachiéry JL. Pulmonary hypertension and ventilation during exercise: Role of the pre-capillary component. J Heart Lung Transplant 2016; 36:754-762. [PMID: 28131663 DOI: 10.1016/j.healun.2016.12.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/08/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Excessive exercise-induced hyperventilation and high prevalence of exercise oscillatory breathing (EOB) are present in patients with post-capillary pulmonary hypertension (PH) complicating left heart disease (LHD). Patients with pre-capillary PH have even higher hyperventilation but no EOB. We sought to determine the impact of a pre-capillary component of PH on ventilatory response to exercise in patients with PH and left heart disease. METHODS We retrospectively compared patients with idiopathic or heritable pulmonary arterial hypertension (PAH, n = 29), isolated post-capillary PH (IpcPH, n = 29), and combined post- and pre-capillary PH (CpcPH, n = 12). Diastolic pressure gradient (DPG = diastolic pulmonary artery pressure - pulmonary wedge pressure) was used to distinguish IpcPH (DPG <7 mm Hg) from CpcPH (DPG ≥7 mm Hg). RESULTS Pulmonary vascular resistance (PVR) was higher in PAH, intermediate in CpcPH, and low in IpcPH. All patients with CpcPH but 1 had PVR >3 Wood unit. Exercise-induced hyperventilation (high minute ventilation over carbon dioxide production, low end-tidal carbon dioxide) was marked in PAH, intermediate in CpcPH, and low in IpcPH (p < 0.001) and correlated with DPG and PVR. Prevalence of EOB decreased from IpcPH to CpcPH to PAH (p < 0.001). CONCLUSIONS Patients with CpcPH may have worse hemodynamics than patients with IpcPH and distinct alterations of ventilatory control, consistent with more exercise-induced hyperventilation and less EOB. This might be explained at least in part by the presence and extent of pulmonary vascular disease.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium; Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Gael Deboeck
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Robert Naeije
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy; Department of Health Sciences, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium.
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Zhao QH, Wang L, Pudasaini B, Jiang R, Yuan P, Gong SG, Guo J, Xiao Q, Liu H, Wu C, Jing ZC, Liu JM. Cardiopulmonary exercise testing improves diagnostic specificity in patients with echocardiography-suspected pulmonary hypertension. Clin Cardiol 2016; 40:95-101. [PMID: 28244596 DOI: 10.1002/clc.22635] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Doppler echocardiography is usually the first diagnostic investigation for patients suspected with pulmonary hypertension (PH), but it is often inaccurate when used alone, especially in mild PH. HYPOTHESIS Cardiopulmonary exercise testing (CPET) may serve as a complementary tool to improve diagnostic accuracy in echocardiography-suspected "PH possible" patients. METHODS Eighty-eight consecutive patients with suspected PH (referred to as "PH possible" hereafter) based on echocardiography were included in the study. CPET was assessed subsequently and PH was confirmed by right-heart catheterization in all subjects. We analyzed CPET data from patients and derived a CPET prediction rule to hemodynamically differentiate PH. RESULTS Eighty-eight patients (27 patients with confirmed PH, and PH ruled out in 61 patients) were included in the study. Compared with non-PH patients, the PH subjects had lower peak oxygen uptake (VO2 ), aerobic capacity (AT), peak partial pressure of end-tidal CO2 (PET CO2 ), oxygen uptake efficiency plateau (OUEP), and oxygen uptake efficiency slope (OUES), along with higher minute ventilation (VE)/carbon dioxide output (VCO2 ) slope and lowest VE/VCO2 (P < 0.001). VE/VCO2 slope and AT were independent predictors of PH derived from multivariate logistic regression adjusted for age and body mass index. A score combining VE/VCO2 slope and AT reached a high area under the curve value of 0.98. A score ≥0.5 had 95% specificity and 92.6% sensitivity for diagnosis of PH. CONCLUSIONS A score combining VE/VCO2 slope and AT provides high specificity in screening out PH from a pool of echocardiography-suspected PH patients.
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Affiliation(s)
- Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Bigyan Pudasaini
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Qiang Xiao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Hui Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Cheng Wu
- Department of Statistics, the Second Military Medical University, Shanghai, China
| | - Zhi-Cheng Jing
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Jin-Ming Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China.,Department of Pulmonary Function, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
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Farr G, Shah K, Markley R, Abbate A, Salloum FN, Grinnan D. Development of Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction. Prog Cardiovasc Dis 2016; 59:52-8. [PMID: 27350563 DOI: 10.1016/j.pcad.2016.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 01/15/2023]
Abstract
Pulmonary hypertension (PH) is common in patients with heart failure with preserved ejection fraction (HFpEF). While PH-HFpEF may affect more than a million patients in the United States alone, it has been difficult to study its epidemiology and response to treatment due to difficulty in properly defining the illness. While chronic remodeling of the pulmonary vasculature is related to chronic passive congestion of the pulmonary circulation from the pulmonary veins, there are likely other contributors to the development of PH-HFpEF. We explore the potential direct contributions of obesity, diabetes mellitus, genetics, and sleep apnea on the pulmonary circulation in those with PH-HFpEF, and we discuss the potential role of exercise testing or fluid challenge during diagnostic testing.
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Affiliation(s)
- Grant Farr
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA.
| | - Keyur Shah
- VCU Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Roshi Markley
- VCU Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Fadi N Salloum
- Victoria Johnson Research Laboratories, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Dan Grinnan
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
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Agarwal M, Waxman AB. Physiological Techniques and Pulmonary Hypertension - Left Heart Disease. Prog Cardiovasc Dis 2016; 59:30-41. [PMID: 27211586 DOI: 10.1016/j.pcad.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/06/2023]
Abstract
Group 2 Pulmonary hypertension (PH) is associated with left heart disease (LHD;Group 2 PH) and is the most common form of PH. Group 2 PH represents an important subgroup of patients with LHD where the development of PH leads to a significant increase in morbidity and mortality. Early diagnosis may provide an opportunity to intervene and significantly delay progression. In addition to clinical suspicion, several approaches including hemodynamic assessment, exercise testing, and imaging techniques play an important role in better disease characterization and management. Here, we review the role of physiologic based hemodynamic and exercise assessments of Group 2 PH patients.
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Affiliation(s)
- Manyoo Agarwal
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA; Pulmonary and Critical Care Medicine, Center for Pulmonary Heart Disease, Brigham and Women's Hospital Heart and Vascular Center
| | - Aaron B Waxman
- Pulmonary and Critical Care Medicine, Center for Pulmonary Heart Disease, Brigham and Women's Hospital Heart and Vascular Center; Pulmonary and Critical Care Medicine, Cardiovascular Medicine, Pulmonary Vascular Disease Program, Center for Pulmonary-Heart Diseases, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School.
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Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J 2016; 39:1144-1161. [DOI: 10.1093/eurheartj/ehw180] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 Focused Update: Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations. Circulation 2016; 133:e694-711. [PMID: 27143685 DOI: 10.1161/cir.0000000000000406] [Citation(s) in RCA: 239] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In the past several decades, cardiopulmonary exercise testing (CPX) has seen an exponential increase in its evidence base. The growing volume of evidence in support of CPX has precipitated the release of numerous scientific statements by societies and associations. In 2012, the European Association for Cardiovascular Prevention & Rehabilitation and the American Heart Association developed a joint document with the primary intent of redefining CPX analysis and reporting in a way that would streamline test interpretation and increase clinical application. Specifically, the 2012 joint scientific statement on CPX conceptualized an easy-to-use, clinically meaningful analysis based on evidence-vetted variables in color-coded algorithms; single-page algorithms were successfully developed for each proposed test indication. Because of an abundance of new CPX research in recent years and a reassessment of the current algorithms in light of the body of evidence, a focused update to the 2012 scientific statement is now warranted. The purposes of this update are to confirm algorithms included in the initial scientific statement not requiring revision, to propose revisions to algorithms included in the initial scientific statement, to propose new algorithms based on emerging scientific evidence, to further clarify the application of oxygen consumption at ventilatory threshold, to describe CPX variables with an emerging scientific evidence base, to describe the synergistic value of combining CPX with other assessments, to discuss personnel considerations for CPX laboratories, and to provide recommendations for future CPX research.
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Pinkstaff SO, Burger CD, Daugherty J, Bond S, Arena R. Cardiopulmonary exercise testing in patients with pulmonary hypertension: clinical recommendations based on a review of the evidence. Expert Rev Respir Med 2016; 10:279-95. [DOI: 10.1586/17476348.2016.1144475] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hirashiki A, Kondo T, Okumura T, Kamimura Y, Nakano Y, Fukaya K, Sawamura A, Morimoto R, Adachi S, Takeshita K, Murohara T. Cardiopulmonary Exercise Testing as a Tool for Diagnosing Pulmonary Hypertension in Patients with Dilated Cardiomyopathy. Ann Noninvasive Electrocardiol 2016; 21:263-71. [PMID: 26833673 PMCID: PMC6931611 DOI: 10.1111/anec.12308] [Citation(s) in RCA: 5] [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] [Received: 04/16/2015] [Accepted: 07/07/2015] [Indexed: 01/25/2023] Open
Abstract
Background Recently, it has become increasingly recognized that pulmonary hypertension (PH) is a particularly threatening result of left‐sided heart disease. However, there have been few investigations of the impact of cardiopulmonary exercise testing (CPX) variables on PH in dilated cardiomyopathy (DCM). We evaluated the usefulness of crucial CPX variables for detecting elevated pulmonary arterial pressure (PAP) in patients with DCM. Methods Ninety subjects with DCM underwent cardiac catheterization and CPX at our hospital. Receiver operator characteristic (ROC) analysis was performed to assess the ability of CPX variables to distinguish between the presence and absence of PH. Results Overall mean values were: mean PAP (mPAP), 18.0 ± 9.6 mmHg; plasma brain natriuretic peptide, 233 ± 295 pg/mL; and left ventricular ejection fraction, 30.2 ± 11.0%. Patients were allocated to one of two groups on the basis of mean PAP, namely DCM without PH [mean PAP (mPAP) <25 mmHg; n = 75] and DCM with PH (mPAP ≥25 mmHg; n = 15). A cutoff achieved percentage of predicted peak VO2 (%PPeak VO2) of 52.5% was the best predictor of an mPAP ≥25 mmHg in the ROC analysis (area under curve: 0.911). In the multivariate analysis, %PPeak VO2 was the only significant independent predictor of PH (Wald 6.52, odds ratio 0.892, 95% CI 0.818–0.974; P = 0.011). Conclusions %PPeak VO2 was strongly associated with the presence of PH in patients with DCM. Taken together, these findings indicate that CPX variables could be important for diagnosing PH in patients with DCM.
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Affiliation(s)
- Akihiro Hirashiki
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Kamimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Fukaya
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akinori Sawamura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyosuke Takeshita
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Boutou AK, Pitsiou GG, Siakka P, Dimitroulas T, Paspala A, Sourla E, Chavouzis N, Garyfallos A, Argyropoulou P, Stanopoulos I. Phenotyping Exercise Limitation in Systemic Sclerosis: The Use of Cardiopulmonary Exercise Testing. Respiration 2016; 91:115-23. [DOI: 10.1159/000442888] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/25/2015] [Indexed: 11/19/2022] Open
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Dominguez-Rodriguez A, Thibodeau JT, Abreu-Gonzalez P, Ayers CR, Jimenez-Sosa A, Aranda JM, Drazner MH. Association Between Bendopnea and Key Parameters of Cardiopulmonary Exercise Testing in Patients With Advanced Heart Failure. J Card Fail 2015; 22:163-5. [PMID: 26708354 DOI: 10.1016/j.cardfail.2015.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/24/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Alberto Dominguez-Rodriguez
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain; Facultad de Ciencias de la Salud, Universidad Europea de Canarias, La Orotava, Tenerife, Spain
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pedro Abreu-Gonzalez
- Departmento de Ciencias Médicas Básicas (Unidad de Fisiología), Universidad de La Laguna, Tenerife, Spain
| | - Colby R Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Juan M Aranda
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Update in Exercise Testing. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0095-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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44
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Myers J, Arena R, Cahalin LP, Labate V, Guazzi M. Cardiopulmonary Exercise Testing in Heart Failure. Curr Probl Cardiol 2015; 40:322-72. [DOI: 10.1016/j.cpcardiol.2015.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Exercise physiology, testing, and training in patients supported by a left ventricular assist device. J Heart Lung Transplant 2015; 34:1005-16. [DOI: 10.1016/j.healun.2014.12.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 01/14/2023] Open
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Cornelis J, Beckers P, Vanroy C, Volckaerts T, Vrints C, Vissers D. An overview of the applied definitions and diagnostic methods to assess exercise oscillatory ventilation--a systematic review. Int J Cardiol 2015; 190:161-9. [PMID: 25918072 DOI: 10.1016/j.ijcard.2015.04.111] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/14/2015] [Indexed: 12/17/2022]
Abstract
The variable "exercise oscillatory ventilation" (EOV), assessed during cardiopulmonary exercise test (CPET), recently became a fundamental prognostic parameter in patients with heart failure. In literature, various definitions are suggested, but an uniformly accepted description to identify EOV still lacks. We performed a systematic review of the literature in order to determine the different definitions and diagnostic techniques to assess EOV. A systematic search strategy was established and executed in seven databases (PubMed, Google Scholar, Cochrane Clinical Trials, Science Direct, Pedro, Web Of Science library and Medline (Ovid)) resulting in 605 citations after de-duplication. Full-text articles (n=124) were assessed for eligibility, resulting in 75 citations. The review accounted 17,440 patients of whom 4,638 subjects presented EOV. Seven studies described EOV in a non-heart failure population accounting 168 EOV subjects. The definitions could be categorized in nine subdivisions of which four (n=43) referred to an original description. The other subdivisions were combinations of the original definitions (n=11), quantifications (n=4), computational (n=3), vaguely described (n=8) or not defined (n=6). Symptom limited maximal exercise tests were conducted to assess EOV, however the modes, protocols, software and data sampling were divers. Heterogeneity in the numerous definitions to identify EOV and the vaguely described assessment methods are hindering the evolution to a standardized uniformly accepted definition and technique to identify this abnormal breathing pattern. Unity in definition and international adopted assessment is warranted to strengthen its validity as a prognostic marker and could promote communication. It may facilitate clinical trials on pathophysiology and origin of EOV.
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Affiliation(s)
- Justien Cornelis
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium.
| | - Paul Beckers
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium; Antwerp University Hospital, Department of Cardiology, Wilrijkstraat 10, B-2650 Edegem, Belgium; University of Antwerp (Faculty of Medicine and Health Sciences), Department of Medicine, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Christel Vanroy
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium; University of Leuven (Faculty of Kinesiology and Rehabilitation Sciences), Tervuursevest 101, B-3001 Heverlee, Belgium; University of Antwerp (Faculty of Medicine and Health Sciences), Translational Neurosciences, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Tess Volckaerts
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium
| | - Christiaan Vrints
- Antwerp University Hospital, Department of Cardiology, Wilrijkstraat 10, B-2650 Edegem, Belgium; University of Antwerp (Faculty of Medicine and Health Sciences), Department of Medicine, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Dirk Vissers
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium
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Taylor BJ, Smetana MR, Frantz RP, Johnson BD. Submaximal Exercise Pulmonary Gas Exchange in Left Heart Disease Patients With Different Forms of Pulmonary Hypertension. J Card Fail 2015; 21:647-55. [PMID: 25887446 DOI: 10.1016/j.cardfail.2015.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/15/2015] [Accepted: 04/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND We determined whether pulmonary gas exchange indices during submaximal exercise are different in heart failure (HF) patients with combined post- and pre-capillary pulmonary hypertension (PPC-PH) versus HF patients with isolated post-capillary PH (IPC-PH) or no PH. METHODS AND RESULTS Pulmonary hemodynamics and pulmonary gas exchange were assessed during rest and submaximal exercise in 39 HF patients undergoing right heart catheterization. After hemodynamic evaluation, patients were classified as having no PH (n = 11), IPC-PH (n = 12), or PPC-PH (n = 16). At an equivalent oxygen consumption, end-tidal CO2 (PETCO2) and arterial oxygen saturation (SaO2) were greater in no-PH and IPC-PH versus PPC-PH patients (36.1 ± 3.2 vs. 31.7 ± 4.5 vs. 26.2 ± 4.7 mm Hg and 97 ± 2 vs. 96 ± 3 vs. 91 ± 1%, respectively). Conversely, dead-space ventilation (VD/VT) and the ventilatory equivalent for carbon dioxide (V˙(E)/V˙CO2 ratio) were lower in no-PH and IPC-PH versus PPC-PH patients (0.37 ± 0.05 vs. 0.38 ± 0.04 vs. 0.47 ± 0.03 and 38 ± 5 vs. 42 ± 8 vs. 51 ± 8, respectively). The exercise-induced change in V(D)/V(T), V˙(E)/V˙CO2 ratio, and PETCO2 correlated significantly with the change in mean pulmonary arterial pressure, diastolic pressure difference, and transpulmonary pressure gradient in PPC-PH patients only. CONCLUSIONS Noninvasive pulmonary gas exchange indices during submaximal exercise are different in HF patients with combined post- and pre-capillary PH compared with patients with isolated post-capillary PH or no PH.
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Affiliation(s)
- Bryan J Taylor
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Michael R Smetana
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert P Frantz
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bruce D Johnson
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Levett DZH, Grocott MPW. Cardiopulmonary exercise testing for risk prediction in major abdominal surgery. Anesthesiol Clin 2015; 33:1-16. [PMID: 25701925 DOI: 10.1016/j.anclin.2014.11.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Reduced exercise capacity is associated with increased postoperative morbidity. Cardiopulmonary exercise testing variables can be used to risk stratify patients. This information can be used to help guide the choice of surgical procedure and to decide on the most appropriate postoperative care environment. Thus CPET can aid collaborative decision making and improve the process of informed consent. In the future, CPET may be combined with other risk predictors to improve outcome prediction. Furthermore early evidence suggests that CPET can be used to guide prehabilitation training programs, improving fitness and thereby reducing perioperative risk.
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Affiliation(s)
- Denny Z H Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton SO17 1BJ, UK; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6DY, UK; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6DY, UK
| | - Michael P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton SO17 1BJ, UK; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6DY, UK; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6DY, UK.
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Levett DZH, Grocott MPW. Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2015. [PMID: 25608638 DOI: 10.1007/s12630-014-0307-6)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs. PRINCIPAL FINDINGS There is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain. CONCLUSIONS Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.
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Affiliation(s)
- Denny Z H Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
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Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2015; 62:131-42. [PMID: 25608638 PMCID: PMC4315486 DOI: 10.1007/s12630-014-0307-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/28/2014] [Indexed: 12/18/2022] Open
Abstract
PURPOSE This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs. PRINCIPAL FINDINGS There is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain. CONCLUSIONS Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.
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