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Adrogué HJ, Madias NE. Acute sodium bicarbonate administration improves ventilatory efficiency in experimental respiratory acidosis: clinical implications. Pflugers Arch 2024; 476:901-909. [PMID: 38532117 DOI: 10.1007/s00424-024-02949-6] [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: 10/20/2023] [Revised: 01/10/2024] [Accepted: 03/20/2024] [Indexed: 03/28/2024]
Abstract
Administering sodium bicarbonate (NaHCO3) to patients with respiratory acidosis breathing spontaneously is contraindicated because it increases carbon dioxide load and depresses pulmonary ventilation. Nonetheless, several studies have reported salutary effects of NaHCO3 in patients with respiratory acidosis but the underlying mechanism remains uncertain. Considering that such reports have been ignored, we examined the ventilatory response of unanesthetized dogs with respiratory acidosis to hypertonic NaHCO3 infusion (1 N, 5 mmol/kg) and compared it with that of animals with normal acid-base status or one of the remaining acid-base disorders. Ventilatory response to NaHCO3 infusion was evaluated by examining the ensuing change in PaCO2 and the linear regression of the PaCO2 vs. pH relationship. Strikingly, PaCO2 failed to increase and the ΔPaCO2 vs. ΔpH slope was negative in respiratory acidosis, whereas PaCO2 increased consistently and the ΔPaCO2 vs. ΔpH slope was positive in the remaining study groups. These results cannot be explained by differences in buffering-induced decomposition of infused bicarbonate or baseline levels of blood pH, PaCO2, and pulmonary ventilation. We propose that NaHCO3 infusion improved the ventilatory efficiency of animals with respiratory acidosis, i.e., it decreased their ratio of total pulmonary ventilation to carbon dioxide excretion (VE/VCO2). Such exclusive effect of NaHCO3 infusion in animals with respiratory acidosis might emanate from baseline increased VD/VT (dead space/tidal volume) caused by bronchoconstriction and likely reduced pulmonary blood flow, defects that are reversed by alkali infusion. Our observations might explain the beneficial effects of NaHCO3 reported in patients with acute respiratory acidosis.
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Affiliation(s)
- Horacio J Adrogué
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Division of Nephrology, Houston Methodist Hospital, Houston, TX, USA
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
- Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center, Boston, MA, USA.
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2
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Caruso FR, Goulart CDL, Jr JCB, de Oliveira CR, Mendes RG, Arena R, Borghi-Silva A. Predictors of cardiopulmonary exercise testing in COPD patients according to the Weber classification. Heart Lung 2023; 62:95-100. [PMID: 37364368 DOI: 10.1016/j.hrtlng.2023.06.022] [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: 02/04/2023] [Revised: 06/13/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Weber classification stratifies cardiac patients based on peak oxygen consumption (V̇O2), the gold-standard measure of exercise capacity. OBJECTIVE To determine if Weber classification is a useful tool to discriminate clinical phenotypes in COPD patients and to evaluate if disease severity and other clinical measures can predict V̇O2peak. METHODS Three hundred and six COPD patients underwent cardiopulmonary exercise testing (CPX) and were divided according to Weber class: 1) Weber A (n = 34); 2) Weber B (n = 88); 3) Weber C (n = 138); and 4) Weber D (n = 46). RESULTS Weber class D patients demonstrated a reduced V̇O2 peak, heart rate (HR), minute ventilation (V̇E), oxygen (O2) pulse, circulatory power (CP), oxygen uptake efficiency slope (OUES), oxygen saturation (SpO2%), delta (Δ)HR and ΔSpO2 when compared to Weber A and B (p<0.05). Moreover, Dyspnea and the V̇E/carbon dioxide production (V̇CO2) slope were higher in Weber D compared with Weber C and A (p<0.001). Hierarchical regression analysis demonstrated significant predictors of V̇O2peak (R2= 0.131; Adj R 2 = 1.25), including HR (β=0.5757; t = 5.7; P<0.001) and forced expiratory volume in one second (FEV1) (β=0.119; t = 2.16; P<0.03). Among the Weber C + D groups, predictors of V̇O2peak (R = 0.78; R2= 0.60; Adj R2 =0.59), dyspnea (β=0.076; t = 1.111; P<0.27) and maximal voluntary ventilation (MVV) (β=0.75; t = 1.14; P<0.00). CONCLUSION Weber classification may be a useful tool to stratify cardiorespiratory fitness in COPD patients. Other clinical measures may be useful in predicting peak V̇O2 in mild-to-severe COPD, moreover different phenotypes may be important tool to improve physical capacity of chronic disease patients.
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Affiliation(s)
- Flávia Rossi Caruso
- Physical Therapy Department, Federal University of Sao Carlos, Sao Carlos, Brazil
| | | | | | | | | | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Audrey Borghi-Silva
- Physical Therapy Department, Federal University of Sao Carlos, Sao Carlos, Brazil.
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3
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Lee K, Jung JH, Kwon W, Ohn C, Lee M, Kim DW, Kim TS, Park MW, Cho JS. The prognostic value of cardiopulmonary exercise testing and HFA-PEFF in patients with unexplained dyspnea and preserved left ventricular ejection fraction. Int J Cardiol 2023:S0167-5273(23)00731-3. [PMID: 37230429 DOI: 10.1016/j.ijcard.2023.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/10/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the incremental prognostic value of CPET for the HFA-PEFF score among patients with unexplained dyspnea with preserved ejection fraction (EF). METHODS Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography in the left ventricle, left atrium and right ventricle. The primary outcome was defined as a composite cardiovascular event including cardiovascular-related mortality, acute recurrent heart failure hospitalization, urgent repeat revascularization/myocardial infarction or any hospitalization due to cardiovascular events. RESULTS The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2-4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO2 slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure were independently associated with composite cardiovascular events. Furthermore, the addition of VE/VCO2 and HFA-PEFF to the base model showed incremental prognostic value for predicting composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement 0.129, p = 0.032; net reclassification improvement 1.043, p ≤0.001). CONCLUSIONS CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic value and diagnosis among patients with unexplained dyspnea with preserved EF.
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Affiliation(s)
- Kyusup Lee
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Hoon Jung
- Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Woojin Kwon
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chaeryeon Ohn
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myunhee Lee
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dae-Won Kim
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Seok Kim
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mahn-Won Park
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Sun Cho
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Ashikaga K, Itoh H, Maeda T, Itoh H, Tanaka S, Ichikawa Y, Nagayama M, Akashi YJ, Isobe M. Usefulness of the predicted percentage ventilatory efficiency for carbon dioxide output during exercise in patients with chronic heart failure. Heart Vessels 2023; 38:56-65. [PMID: 35895151 DOI: 10.1007/s00380-022-02132-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/29/2022] [Indexed: 01/06/2023]
Abstract
The ventilatory efficiency for carbon dioxide output ([Formula: see text]CO2) during exercise, as measured by the minute ventilation vs. [Formula: see text]CO2 slope ([Formula: see text]E vs. [Formula: see text]CO2 slope), is a powerful prognostic index in patients with chronic heart failure (CHF). This measurement is higher in women than in men, and it increases with age. This study aimed to investigate the usefulness of the predicted value of the percentage [Formula: see text]E vs. [Formula: see text]CO2 slope (%[Formula: see text]E vs. [Formula: see text]CO2 slope) as a prognostic index in patients with CHF. A total of 320 patients with CHF and a left ventricular ejection fraction (LVEF) < 45% (male, 85.6%; mean age, 64.6 years) who underwent symptom-limited cardiopulmonary exercise tests using a cycle ergometer were included in the study. The %[Formula: see text]E vs. [Formula: see text]CO2 was calculated using predictive formulae based on age and sex. Cardiovascular-related death was defined as the primary endpoint. The mean follow-up duration was 7.5 ± 3.3 years. Of 101 patients who died during the study period, 75 experienced cardiovascular-related deaths. The average [Formula: see text]E vs. [Formula: see text]CO2 slope was 32.8 ± 8.0, and the average %[Formula: see text]E vs. [Formula: see text]CO2 slope was 119.6 ± 28.2%. The cumulative incidence of cardiovascular-related death after 10 years of follow-up were 44.7% (95% CI 34.4-54.6%) in patients with %[Formula: see text]E vs. [Formula: see text]CO2 slope > 120 and 15.0% (95% CI 9.4-21.8%) in patients with %[Formula: see text]E vs. [Formula: see text]CO2 slope ≤ 120. The multivariate Cox regression analysis indicated that a %[Formula: see text]E vs. [Formula: see text]CO2 slope > 120 was an independent predictor of cardiovascular-related death (adjusted hazard ratio, 3.24; 95% confidence interval 1.65-6.67; p < 0.01). The %[Formula: see text]E vs. [Formula: see text]CO2 slope can be used for risk stratification in patients with CHF and an LVEF < 45%.
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Affiliation(s)
- Kohei Ashikaga
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan. .,Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan. .,Department of Sports Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyakaeku, Kawasaki, Kanagawa, 216-8511, Japan.
| | - Haruki Itoh
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Tomoko Maeda
- Department of Clinical Laboratory, Sakakibara Heart Institute Clinic, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shiori Tanaka
- Department of Clinical Laboratory, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Yuri Ichikawa
- Department of Medical Technology, School of Health Science, Tokyo University of Technology, Hachioji, Tokyo, Japan
| | - Masatoshi Nagayama
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Mitsuaki Isobe
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
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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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Usui N, Yokoyama M, Nakata J, Suzuki Y, Tsubaki A, Kojima S, Inatsu A, Hisadome H, Uehata A. Association between social frailty as well as early physical dysfunction and exercise intolerance among older patients receiving hemodialysis. Geriatr Gerontol Int 2021; 21:664-669. [PMID: 34164894 DOI: 10.1111/ggi.14223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/25/2021] [Accepted: 06/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recently, social frailty has been increasingly recognized as a factor associated with adverse health outcomes, including physical disability and mortality. However, there are no studies about the importance of this factor among hemodialysis patients. Therefore, we investigated the relationship between social frailty and early physical dysfunction in this group of patients. METHODS This was a two-center cross-sectional study. Older patients receiving hemodialysis were prospectively enrolled. Moreover, participants were evaluated for social frailty based on the definition of previous study and for physical function, peak oxygen uptake (peak VO2 ), ventilatory equivalent for carbon dioxide (VE/VCO2 ) slope and heart rate reserve. Then, they were divided into two groups based on the presence of physical frailty. RESULTS Data collected from 158 individuals were statistically analyzed. The prevalence rate of social frailty was 59.5%. In the non-physical frailty group, social frailty was found to be independently associated with reduced gait speed (P = 0.007), leg strength (P = 0.040) and peak VO2 (P = 0.023), but not with hand grip strength (P = 0.36). In the physical frailty group, there was no association between social frailty and physical function. Moreover, in patients without physical and social frailty, physical function was maintained at above accepted threshold levels, whereas peak VO2 (14.1 ± 3.3 mL/kg/min), VE/VCO2 slope (32.3 ± 5.5) and heart rate reserve (50.8% ± 21.7%) were substantially impaired. CONCLUSIONS Patients receiving hemodialysis can present with social frailty and exercise intolerance with cardiac dysfunction in the early phase, which may contribute to subsequent dysfunction. Geriatr Gerontol Int 2021; 21: 664-669.
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Affiliation(s)
- Naoto Usui
- Department of Rehabilitation, Kisen Hospital, Tokyo, Japan.,Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | | | - Junichiro Nakata
- Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Atsuhiro Tsubaki
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Sho Kojima
- Department of Rehabilitation, Kisen Hospital, Tokyo, Japan.,Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | | | | | - Akimi Uehata
- Division of Cardiology, Kisen Hospital, Tokyo, Japan
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7
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Olímpio Júnior H, Lopes AJ, Guimarães FS, da Cunha Chermont SLSM, de Menezes SLS. Association between ventilatory efficiency, oxygen uptake, and Glittre-ADL test results in patients with chronic heart failure: a preliminary study. BMC Res Notes 2021; 14:62. [PMID: 33593417 PMCID: PMC7885201 DOI: 10.1186/s13104-021-05479-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Objective The Glittre-ADL test (GA-T) is a functional capacity test that stands out for encompassing multiple tasks similar to activities of daily living. As ventilatory efficiency is one of the variables valued in the prognosis of chronic heart failure (CHF), this study aimed to evaluate associations between functional capacity and ventilatory variables in patients with CHF during the GA-T. Results Eight patients with CHF and New York Heart Association (NYHA) functional classification II–III underwent the GA-T coupled with metabolic gas analysis to obtain data by means of telemetry. The median total GA-T time was 00:04:39 (00:03:29–00:05:53). Borg dyspnoea scale scores before and after the GA-T were 2 (0–9) and 3 (1–10), respectively (P = 0.011). The relationship between the regression slope relating minute ventilation to carbon dioxide output (VE/VCO2 slope) was correlated with the total GA-T time (rs = 0.714, P = 0.047) and Borg dyspnoea score (rs = 0.761, P = 0.028). The other ventilatory variables showed no significant correlations. Our results suggest that the total GA-T time can be applied to estimate the ventilatory efficiency of patients with CHF. Future studies may use the GA-T in conjunction with other functional capacity tests to guide the treatment plan and evaluate the prognosis.
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Affiliation(s)
- Hebert Olímpio Júnior
- Medical Sciences Post-Graduation Programme, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Av. Prof. Manoel de Abreu, 444, 2º andar, Vila Isabel, Rio de Janeiro, 20550-170, Brazil
| | - Agnaldo José Lopes
- Medical Sciences Post-Graduation Programme, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Av. Prof. Manoel de Abreu, 444, 2º andar, Vila Isabel, Rio de Janeiro, 20550-170, Brazil. .,Rehabilitation Sciences Post-Graduation Programme, Augusto Motta University Center (UNISUAM), Rua Dona Isabel, 94, Rio de Janeiro, Bonsucesso, 21032-060, Brazil.
| | - Fernando Silva Guimarães
- Department of Physiotherapy, Federal University of Rio de Janeiro (UFRJ), Rua Prof. Rodolpho Paulo Rocco, Cidade Universitária, Rio de Janeiro, 25521941-590, Brazil
| | | | - Sara Lúcia Silveira de Menezes
- Department of Physiotherapy, Federal University of Rio de Janeiro (UFRJ), Rua Prof. Rodolpho Paulo Rocco, Cidade Universitária, Rio de Janeiro, 25521941-590, Brazil
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8
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Blood carbon dioxide tension and risk in pulmonary arterial hypertension. Int J Cardiol 2020; 318:131-137. [DOI: 10.1016/j.ijcard.2020.06.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
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9
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Cherneva RV, Denchev SV, Cherneva ZV. The link between dynamic hyperinflation, autonomic dysfunction and exercise testing parameters with masked heart failure in patients with non-severe obstructive pulmonary disease. J Basic Clin Physiol Pharmacol 2020; 32:179-188. [PMID: 32658862 DOI: 10.1515/jbcpp-2019-0311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/20/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Autonomic dysfunction (AD) and dynamic hyperinflation (DH) have been implicated as pathophysiological mechanisms of heart failure with preserved ejection fraction (HFpEF) in chronic obstructive pulmonary disease (COPD) patients. Their association, however, remains elusive: The aims of the study were: (1) to determine the prevalence of AD and DH in non-severe COPD patients, with exertional dyspnea, without clinically overt cardio-vascular (CV) comorbidities; (2) to analyze the correlation and clinical significance between DH, AD, and maksed HFpEF. METHODS We applied CPET in 68 subjects. Echocardiography was performed before CPET and 1-2 min after peak exercise. IC manoeuvres were applied. Patients were divided into two groups: patients with and without masked HFpEF. Wilkoff method calculated the meatabolic - chronotropic relationship (MCR). Chronotropic incompetence (CI) and abnormal HR recovery (HRR) were determined. RESULTS The prevalence of CI was 77 vs. 52% in patients with/without masked HFpEF; of abnormal HRR - 98 vs. 62% respectively; of DH - 53 vs. 29%. ICdyn was associated with AD. Univariate regression showed association between masked HFpEF, ICdyn, HRR, oxygenuptake ('VO2), 'VO2 at anaerobic threshold, oxygen (O2) pulse and 'VE/'VCO2 slope. None of these parameters is an independent predictor for masked HFpEF. CONCLUSIONS DH, AD, and masked HFpEF are prevalent in non-severe COPD patients, who complain of exertional dyspnea and are free of clinically overt CV comorbidities. DH is independently associated with AD. Neither AD, nor DH and CPET are independent predictors for masked HFpEF.
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Affiliation(s)
- Radostina Vl Cherneva
- University Hospital for Respiratory Diseases "St. Sophia'', Han Presian 17, Sofia, Bulgaria
| | | | - Zheina Vl Cherneva
- Medical Institute of the Ministry of Internal Affairs, Gen Skobelev 79, Sofia, Bulgaria
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10
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Upright Cheyne-Stokes Respiration in Heart Failure: Look But Don't Touch. J Am Coll Cardiol 2020; 75:2947-2949. [PMID: 32527404 DOI: 10.1016/j.jacc.2020.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 11/20/2022]
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11
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Nayor M, Xanthakis V, Tanguay M, Blodgett JB, Shah RV, Schoenike M, Sbarbaro J, Farrell R, Malhotra R, Houstis NE, Velagaleti RS, Moore SA, Baggish AL, O'Connor GT, Ho JE, Larson MG, Vasan RS, Lewis GD. Clinical and Hemodynamic Associations and Prognostic Implications of Ventilatory Efficiency in Patients With Preserved Left Ventricular Systolic Function. Circ Heart Fail 2020; 13:e006729. [PMID: 32362167 DOI: 10.1161/circheartfailure.119.006729] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ventilatory efficiency (minute ventilation required to eliminate carbon dioxide, VE/VCO2) during exercise potently predicts outcomes in advanced heart failure with reduced ejection fraction, but its prognostic significance for at-risk individuals with preserved left ventricular systolic function is unclear. We aimed to characterize mechanistic determinants and prognostic implications of VE/VCO2 in a single-center dyspneic referral cohort (MGH-ExS [Massachusetts General Hospital Exercise Study]) and in a large sample of community-dwelling participants in the FHS (Framingham Heart Study). METHODS Maximum incremental cardiopulmonary exercise tests were performed. VE/VCO2 was assessed as the slope pre- and post-ventilatory anaerobic threshold (VE/VCO2pre-VATslope, VE/VCO2post-VATslope), the slope throughout exercise (VE/VCO2overall-slope), and as the lowest 30-second value (VE/VCO2nadir). RESULTS In the MGH-ExS (N=493, age 56±15 years, 61% women, left ventricular ejection fraction 64±8%), higher VE/VCO2nadir was associated with lower peak exercise cardiac output and steeper increases in exercise pulmonary capillary wedge pressure (both P<0.0001). VE/VCO2nadir (hazard ratio, 1.34 per 1-SD unit [95% CI, 1.10-1.62] P=0.003) was associated with future cardiovascular hospitalization/death and outperformed classical VE/VCO2 measures used in heart failure with reduced ejection fraction (VE/VCO2overall-slope). In FHS (N=1936, age 54±9 years, 53% women), VE/VCO2 measures taken in low-to-moderate intensity exercise (including VE/VCO2pre-VATslope, VE/VCO2nadir) were directly associated with cardiovascular risk factor burden (smoking, Framingham cardiovascular disease risk score, and lower fitness; all P<0.001). CONCLUSIONS Impaired ventilatory efficiency is associated with cardiovascular risk in the community and with adverse hemodynamic profiles and future hospitalizations/death in a referral population, highlighting the prognostic importance of easily acquired submaximum exercise ventilatory gas exchange measurements in broad populations with preserved left ventricular systolic function.
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Affiliation(s)
- Matthew Nayor
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Vanessa Xanthakis
- Department of Biostatistics, Boston University School of Public Health, MA (V.X.).,Section of Preventive Medicine and Epidemiology (V.X., R.S. Vasan), Department of Medicine, Boston University School of Medicine, MA
| | - Melissa Tanguay
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jasmine B Blodgett
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ravi V Shah
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark Schoenike
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - John Sbarbaro
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Robyn Farrell
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Rajeev Malhotra
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston.,Cardiovascular Research Center (R.M., J.E.H.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Nicholas E Houstis
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Raghava S Velagaleti
- Cardiology Section, Department of Medicine, Boston VA Healthcare System, West Roxbury, MA (R.S. Velagaleti, S.A.M.)
| | - Stephanie A Moore
- Cardiology Section, Department of Medicine, Boston VA Healthcare System, West Roxbury, MA (R.S. Velagaleti, S.A.M.)
| | - Aaron L Baggish
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - George T O'Connor
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine (G.T.O.), Department of Medicine, Boston University School of Medicine, MA
| | - Jennifer E Ho
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston.,Cardiovascular Research Center (R.M., J.E.H.), Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Ramachandran S Vasan
- Section of Preventive Medicine and Epidemiology (V.X., R.S. Vasan), Department of Medicine, Boston University School of Medicine, MA.,Division of Cardiology (R.S. Vasan), Department of Medicine, Boston University School of Medicine, MA
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston.,Pulmonary Critical Care Unit (G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
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12
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Tsujinaga S, Iwano H, Chiba Y, Ishizaka S, Sarashina M, Murayama M, Nakabachi M, Nishino H, Yokoyama S, Okada K, Kaga S, Anzai T. Heart Failure With Preserved Ejection Fraction vs. Reduced Ejection Fraction - Mechanisms of Ventilatory Inefficiency During Exercise in Heart Failure. Circ Rep 2020; 2:271-279. [PMID: 33693241 PMCID: PMC7925313 DOI: 10.1253/circrep.cr-20-0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: Ventilatory inefficiency during exercise assessed using the lowest minute ventilation/carbon dioxide production (V̇E/V̇CO2) ratio was recently proven to be a strong prognostic marker of heart failure (HF) regardless of left ventricular ejection fraction (LVEF). Its physiological background, however, has not been elucidated. Methods and Results: Fifty-seven HF patients underwent cardiopulmonary exercise testing and exercise-stress echocardiography. The lowest V̇E/V̇CO2 ratio was assessed on respiratory gas analysis. Echocardiography was obtained at rest and at peak exercise. LVEF was measured using the method of disks. Cardiac output (CO) and the ratio of transmitral early filling velocity (E) to early diastolic tissue velocity (e') were calculated using the Doppler method. HF patients were divided into preserved EF (HFpEF) and reduced EF (HFrEF) using the LVEF cut-off 40% at rest. Twenty-four patients were classified as HFpEF and 33 as HFrEF. In HFpEF, age (r=0.58), CO (r=-0.44), e' (r=-0.48) and E/e' (r=0.45) during exercise correlated with the lowest V̇E/V̇CO2 ratio (P<0.05 for all). In contrast, in HFrEF, age (r=0.47) and CO (r=-0.54) during exercise, but not e' and E/e', correlated with the lowest V̇E/V̇CO2 ratio. Conclusions: Loss of CO augmentation was associated with ventilatory inefficiency in HF regardless of LVEF, although lung congestion determined ventilatory efficiency only in HFpEF.
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Affiliation(s)
- Shingo Tsujinaga
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Sapporo Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Sapporo Japan
| | - Yasuyuki Chiba
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Sapporo Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Sapporo Japan
| | - Miwa Sarashina
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Sapporo Japan
| | - Michito Murayama
- Diagnostic Center for Sonography, Hokkaido University Hospital Sapporo Japan
| | - Masahiro Nakabachi
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital Sapporo Japan
| | - Hisao Nishino
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital Sapporo Japan
| | - Shinobu Yokoyama
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital Sapporo Japan
| | - Kazunori Okada
- Faculty of Health Sciences, Hokkaido University Sapporo Japan
| | - Sanae Kaga
- Faculty of Health Sciences, Hokkaido University Sapporo Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Sapporo Japan
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13
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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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14
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Cherneva R, Denchev S, Cherneva ZV. Autonomic dysfunction, cardio-pulmonary exercise testing and masked heart failure with preserved ejection fraction in non-severe chronic obstructive pulmonary disease. Clin Physiol Funct Imaging 2020; 40:224-231. [PMID: 32073740 DOI: 10.1111/cpf.12623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/19/2020] [Accepted: 02/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Autonomic dysfunction (AD) and cardiopulmonary exercise testing (CPET) parameters have been associated with masked heart failure with preserved ejection fraction (HFpEF) in the general population. Their clinical significance for masked HFpEF in chronic obstructive pulmonary disease (COPD) is however elusive. AIM The aim of the study was to determine the prevalence, correlation and clinical significance of AD and CPET with masked HFpEF, in non-severe COPD patients, complaining of exertional dyspnoea, without clinically overt cardio-vascular (CV) comorbidities. METHODS AND RESULTS We applied CPET and echocardiography in 68 COPD subjects. Echocardiography was performed before CPET and 1-2 min after peak exercise. Patients were divided into two groups: patients with and without masked HFpEF. Peak E/e' - 15 was applied as a cut-off. Chronotropic incompetence (CI) was assumed if both failure to reach the target heart rate (HR) on exercise and diminished heart rate reserve <80% occurred. Abnormal HR recovery (HRR) was taken if the decline is <12 beats within the first minute after exercise cessation. Univariate regression showed association between masked HFpEF, HRR, VO2, VO2 at AT, oxygen pulse and VE/VCO2 slope. The multivariate regression demonstrated HRR as the only independent predictor of masked HFpEF - (OR 10.28; 95% CI (3.55-29.80)). CONCLUSION Abnormal HRR is the only independent predictor of masked HFpEF in non-severe COPD patients. Despite of being associated with masked HFpEF, the lower VO2, lower oxygen pulse, higher VE/VCO2 slope and lower exercise load seem to be the consequences, rather than the triggers for it.
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Affiliation(s)
| | - Stefan Denchev
- Medical Institute of the Ministry of Interior, Sofia, Bulgaria
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15
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Abstract
The heart and lungs are intimately linked. Hence, impaired function of one organ may lead to changes in the other. Accordingly, heart failure is associated with airway obstruction, loss of lung volume, impaired gas exchange, and abnormal ventilatory control. Cardiopulmonary exercise testing is an excellent tool for evaluation of gas exchange and ventilatory control. Indeed, many parameters routinely measured during cardiopulmonary exercise testing, including the level of minute ventilation per unit of carbon dioxide production and the presence of exercise oscillatory ventilation, have been found to be strongly associated with prognosis in patients with heart failure.
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Affiliation(s)
- Ivan Cundrle
- Department of Anesthesiology and Intensive Care, St. Anne's University Hospital, Pekarska 53, Brno 65691, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Lyle J Olson
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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16
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Salvioni E, Corrà U, Piepoli M, Rovai S, Correale M, Paolillo S, Pasquali M, Magrì D, Vitale G, Fusini L, Mapelli M, Vignati C, Lagioia R, Raimondo R, Sinagra G, Boggio F, Cangiano L, Gallo G, Magini A, Contini M, Palermo P, Apostolo A, Pezzuto B, Bonomi A, Scardovi AB, Filardi PP, Limongelli G, Metra M, Scrutinio D, Emdin M, Piccioli L, Lombardi C, Cattadori G, Parati G, Caravita S, Re F, Cicoira M, Frigerio M, Clemenza F, Bussotti M, Battaia E, Guazzi M, Bandera F, Badagliacca R, Di Lenarda A, Pacileo G, Passino C, Sciomer S, Ambrosio G, Agostoni P. Gender and age normalization and ventilation efficiency during exercise in heart failure with reduced ejection fraction. ESC Heart Fail 2020; 7:371-380. [PMID: 31893579 PMCID: PMC7083437 DOI: 10.1002/ehf2.12582] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/21/2019] [Accepted: 11/11/2019] [Indexed: 01/20/2023] Open
Abstract
Aims Ventilation vs. carbon dioxide production (VE/VCO2) is among the strongest cardiopulmonary exercise testing prognostic parameters in heart failure (HF). It is usually reported as an absolute value. The current definition of normal VE/VCO2 slope values is inadequate, since it was built from small groups of subjects with a particularly limited number of women and elderly. We aimed to define VE/VCO2 slope prediction formulas in a sizable population and to test whether the prognostic power of VE/VCO2 slope in HF was different if expressed as a percentage of the predicted value or as an absolute value. Methods and results We calculated the linear regressions between age and VE/VCO2 slope in 1136 healthy subjects (68% male, age 44.9 ± 14.5, range 13–83 years). We then applied age‐adjusted and sex‐adjusted formulas to predict VE/VCO2 slope to HF patients included in the metabolic exercise test data combined with cardiac and kidney indexes score database, which counts 6112 patients (82% male, age 61.4 ± 12.8, left ventricular ejection fraction 33.2 ± 10.5%, peakVO2 14.8 ± 4.9, mL/min/kg, VE/VCO2 slope 32.7 ± 7.7) from 24 HF centres. Finally, we evaluated whether the use of absolute values vs. percentages of predicted VE/VCO2 affected HF prognosis prediction (composite of cardiovascular mortality + urgent transplant or left ventricular assist device). We did so in the entire cardiac and kidney indexes score population and separately in HF patients with severe (peakVO2 < 14 mL/min/kg, n = 2919, 61.1 events/1000 pts/year) or moderate (peakVO2 ≥ 14 mL/min/kg, n = 3183, 19.9 events/1000 pts/year) HF. In the healthy population, we obtained the following equations: female, VE/VCO2 = 0.052 × Age + 23.808 (r = 0.192); male, VE/VCO2 = 0.095 × Age + 20.227 (r = 0.371) (P = 0.007). We applied these formulas to calculate the percentages of predicted VE/VCO2 values. The 2‐year survival prognostic power of VE/VCO2 slope was strong, and it was similar if expressed as absolute value or as a percentage of predicted value (AUCs 0.686 and 0.690, respectively). In contrast, in severe HF patients, AUCs significantly differed between absolute values (0.637) and percentages of predicted values (0.650, P = 0.0026). Moreover, VE/VCO2 slope expressed as a percentage of predicted value allowed to reclassify 6.6% of peakVO2 < 14 mL/min/kg patients (net reclassification improvement = 0.066, P = 0.0015). Conclusions The percentage of predicted VE/VCO2 slope value strengthens the prognostic power of VE/VCO2 in severe HF patients, and it should be preferred over the absolute value for HF prognostication. Furthermore, the widespread use of VE/VCO2 slope expressed as percentage of predicted value can improve our ability to identify HF patients at high risk, which is a goal of utmost clinical relevance.
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Affiliation(s)
| | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno Institute, Veruno, Italy
| | | | - Sara Rovai
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy.,Università degli Studi di Padova, Padova, Italy
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Mario Pasquali
- Dipartimento di medicina e scienze dell'invecchiamento, Università G. D'Annunzio, Chieti, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" Università degli Studi di Roma, Roma, Italy
| | - Giuseppe Vitale
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy
| | - Laura Fusini
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Rocco Lagioia
- Division of Cardiology, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy
| | - Rosa Raimondo
- Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Tradate, Tradate, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Federico Boggio
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Lorenzo Cangiano
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Giovanna Gallo
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" Università degli Studi di Roma, Roma, Italy
| | - Alessandra Magini
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Pietro Palermo
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Anna Apostolo
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Beatrice Pezzuto
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy
| | | | | | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Domenico Scrutinio
- Division of Cardiology, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy
| | - Michele Emdin
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Lucrezia Piccioli
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, Multimedica IRCCS, Milano, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
| | - Sergio Caravita
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | | | - Maria Frigerio
- Dipartimento Cardiologico "A. De Gasperis", Ospedale Cà Granda-A.O. Niguarda, Milano, Italy
| | - Francesco Clemenza
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Fondazione Salvatore Maugeri, IRCCS, Scientific Institute of Milan, Milan, Italy
| | - Elisa Battaia
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | - Marco Guazzi
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza", Rome University, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Health Authority no. 1, University of Trieste, Trieste, Italy
| | - Giuseppe Pacileo
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli, Italy
| | - Claudio Passino
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza", Rome University, Rome, Italy
| | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy
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17
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Agostoni P, Dumitrescu D. How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure. Int J Cardiol 2019; 288:107-113. [DOI: 10.1016/j.ijcard.2019.04.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/04/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023]
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18
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Kim CH, Sajgalik P, Van Iterson EH, Jae SY, Johnson BD. The effect of remote ischemic pre-conditioning on pulmonary vascular pressure and gas exchange in healthy humans during hypoxia. Respir Physiol Neurobiol 2019; 261:62-66. [PMID: 30658096 DOI: 10.1016/j.resp.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/26/2018] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
Abstract
This study investigated whether rIPC alters the typical changes in pulmonary arterial pressure, pulmonary gas exchange associated with exercise in hypoxia. METHODS 16 healthy adults were randomized to either rIPC treatment (n = 8) or control (n = 8). Afterward, subjects performed supine ergometry at constant load (30 W, 40˜50 rpm) for 25 min during hypoxia (12.5% O2). Following a 90˜120 min rest, either rIPC or sham treatment was performed, which was then followed by post-assessment exercise. Throughout exercise, pulmonary arterial systolic pressure (PASP) and mean pulmonary arterial pressure (mPAP) were measured via echocardiography, while pulmonary gas exchange was being assessed. RESULTS The rICP group demonstrated improved PASP and mPAP (p < 0.05), whereas the control group did not. Additionally, breathing efficiency (VE/VCO2) and end-tidal CO2 (PETCO2) were improved in rIPC group (p < 0.05), but not in controls. CONCLUSION These data suggest that rIPC contributes to reduced pulmonary arterial pressure, and improved pulmonary gas exchange during hypoxic exercise. However, follow-up studies are needed to apply these findings to patient care settings.
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Affiliation(s)
- Chul-Ho Kim
- Human Integrative Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States.
| | - Pavol Sajgalik
- Human Integrative Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Erik H Van Iterson
- Human Integrative Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Sae Young Jae
- Department of Sports Science, University of Seoul, Seoul, Republic of Korea
| | - Bruce D Johnson
- Human Integrative Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
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19
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Gergius YS, El-Sheshtawy NE, El-Arousi NH, Fathalla MM, Abdel Rahman MA, Gharib AM. Functional capacity-based rehabilitation of patients with chronic stable left ventricular heart failure. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2018. [DOI: 10.4103/err.err_5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Wagner J, Agostoni P, Arena R, Belardinelli R, Dumitrescu D, Hager A, Myers J, Rauramaa R, Riley M, Takken T, Schmidt-Trucksäss A. The Role of Gas Exchange Variables in Cardiopulmonary Exercise Testing for Risk Stratification and Management of Heart Failure with Reduced Ejection Fraction. Am Heart J 2018; 202:116-126. [PMID: 29933148 DOI: 10.1016/j.ahj.2018.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/18/2018] [Indexed: 01/14/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in the developed world and results in significant morbidity and mortality. Accurate risk assessment methods and prognostic variables are therefore needed to guide clinical decision making for medical therapy and surgical interventions with the ultimate goal of decreasing risk and improving health outcomes. The purpose of this review is to examine the role of cardiopulmonary exercise testing (CPET) and its most commonly used ventilatory gas exchange variables for the purpose of risk stratification and management of HFrEF. We evaluated five widely studied gas exchange variables from CPET in HFrEF patients based on nine previously used systematic criteria for biomarkers. This paper provides clinicians with a comprehensive and critical overview, class recommendations and evidence levels. Although some CPET variables met more criteria than others, evidence supporting the clinical assessment of variables beyond peak V̇O2 is well-established. A multi-variable approach also including the V̇E-V̇CO2 slope and EOV is therefore recommended.
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Affiliation(s)
- Jonathan Wagner
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy & Department of Clinical sciences and Community health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL
| | - Romualdo Belardinelli
- Department of Cardiovascular Sciences, Cardiac Rehabilitation Lancisi, Ancona, Italy
| | - Daniel Dumitrescu
- Herzzentrum der Universitaet zu Koeln, Klinik III fuer Innere Medizin, Cologne, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technical University of Munich, Germany
| | - Jonathan Myers
- Cardiology Division, VA Palo Alto Health Care System and Stanford University, Palo Alto, CA
| | - Rainer Rauramaa
- Foundation for Research in Health, Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
| | - Marshall Riley
- Department of Medicine, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Tim Takken
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
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21
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Pudasaini B, Yang GL, Yang C, Guo J, Yuan P, Wen-lan Y, Zhang R, Wang L, Zhao QH, Gong SG, Jiang R, Chen TX, Wei X, Liu JM. Characteristics of exercise capacity in female systemic lupus erythematosus associated pulmonary arterial hypertension patients. BMC Cardiovasc Disord 2018; 18:56. [PMID: 29566672 PMCID: PMC5865350 DOI: 10.1186/s12872-018-0783-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 02/26/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To study the oxygen uptake efficiency and determine usefulness of submaximal parameters of oxygen uptake in systemic lupus erythematosus associated pulmonary arterial hypertension (SLE PAH) on performing a cardiopulmonary exercise test (CPET). METHODS CPET was performed in 21 SLE PAH patients, equal number of idiopathic pulmonary arterial hypertension (IPAH) patients and controls. Peak VO2, anaerobic threshold (AT), oxygen uptake efficiency slope (OUES) and oxygen uptake efficiency plateau (OUEP) and other CPET parameters were examined. All subjects had pulmonary function test (PFT) at rest, which included FEV1, FVC, FEV1/FVC, DLCO measurements. Right heart catheterization (RHC) was also done in SLE PAH and IPAH patients. CPET parameters were compared with RHC parameters to determine potential correlations. RESULTS Peak VO2, PETCO2 and peak O2 pulse were lower in SLE PAH than IPAH and controls with OUE being lower during all stages of exercise in SLE PAH. DLCO and FVC values were significantly lower in SLE PAH (p < 0.05). Peak O2 pulse and VO2@AT in SLE PAH and IPAH was low (p < 0.05) and significant difference between SLE PAH and IPAH was seen (p < 0.05). PVR correlated with the lowest VE/VCO2, O2 pulse, peak PETCO2 and OUE in SLE PAH patients (all p < 0.05). CONCLUSIONS SLE PAH patients have cardiopulmonary exercise limitation with reduced oxygen uptake efficiency. VO2@ at AT, peak O2 pulse and O2 pulse at AT were significantly reduced (p < 0.05). Key CPET parameters correlated with elevated pulmonary vascular resistance (PVR). Submaximal parameters of oxygen uptake are equally useful in SLE PAH.
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Affiliation(s)
- Bigyan Pudasaini
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Guo-ling Yang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Chen Yang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Ping Yuan
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Yang Wen-lan
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Rui Zhang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Tian-Xiang Chen
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Xiong Wei
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Jin-Ming Liu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
- Shanghai Pulmonary Hospital, Tongji University, School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433 China
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22
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Nogami Y, Seo Y, Yamamoto M, Ishizu T, Aonuma K. Wave intensity as a useful modality for assessing ventilation-perfusion imbalance in subclinical patients with hypertension. Heart Vessels 2018; 33:931-938. [PMID: 29435641 DOI: 10.1007/s00380-018-1138-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/09/2018] [Indexed: 01/09/2023]
Abstract
Wave intensity (WI) is a novel noninvasive index of circulatory dynamics that reflects ventriculo-arterial coupling. It is calculated as the product of the first derivative of blood pressure and that of flow velocity measured by carotid echocardiography. This study aimed to clarify the clinical implications of WI and its relation with carbon dioxide production (VE/VCO2 slope). Twenty-one healthy volunteers (control group) and 21 patients with hypertension (HT group) underwent cardiopulmonary exercise testing (CPX) and exercise stress echocardiography. WI was assessed in the right carotid artery using an ultrasound system. The first peak of WI (W1) during the early ejection phase was measured at baseline and mitral annular velocity was assessed by tissue Doppler imaging. Ventilatory kinetics during exercise was assessed using the relation of minute ventilation to VE/VCO2 slope. VE/VCO2 slope, W1, and E/E' were greater in the HT group than in the control group. PeakVO2 and VO2 at the anaerobic threshold were lower in the HT group than in the control group. VE/VCO2 slope was significantly correlated with W1 (r = 0.58, p < 0.01) and E/E' (r = 0.44, p < 0.01). Stepwise multivariate analysis revealed that W1 was an independent determinant of VE/VCO2 slope (β = 0.43, p < 0.01). In conclusion, W1 might be able to predict the severity of heart failure without the need for CPX. Moreover, WI may be a useful modality in assessing heart failure pathophysiology based on ventriculo-arterial coupling.
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Affiliation(s)
- Yoshie Nogami
- Faculty of Engineering, Department of Human Environmental Sciences, Shonan Institute of Technology, Fujisawa, Kanagawa, Japan.,Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Masayoshi Yamamoto
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
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23
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Evaluation of end-tidal CO2 pressure at the anaerobic threshold for detecting and assessing pulmonary hypertension. Heart Vessels 2017; 32:1350-1357. [DOI: 10.1007/s00380-017-0999-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/26/2017] [Indexed: 11/25/2022]
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24
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Use of 'ideal' alveolar air equations and corrected end-tidal PCO 2 to estimate arterial PCO 2 and physiological dead space during exercise in patients with heart failure. Int J Cardiol 2017; 250:176-182. [PMID: 29054325 DOI: 10.1016/j.ijcard.2017.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/05/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Arterial CO2 tension (PaCO2) and physiological dead space (VD) are not routinely measured during clinical cardiopulmonary exercise testing (CPET). Abnormal changes in PaCO2 accompanied by increased VD directly contribute to impaired exercise ventilatory function in heart failure (HF). Because arterial catheterization is not standard practice during CPET, this study tested the construct validity of PaCO2 and VD prediction models using 'ideal' alveolar air equations and basic ventilation and gas-exchangegas exchange measurements during CPET in HF. METHODS Forty-seven NYHA class II/III HF (LVEF=21±7%; age=55±9years; male=89%; BMI=28±5kg/m2) performed step-wise cycle ergometry CPET to volitional fatigue. Breath-by-breath ventilation and gas exchange were measured continuously. Steady-state PaCO2 was measured at rest and peak exercise via radial arterial catheterization. Criterion VD was calculated via 'ideal' alveolar equations, whereas PaCO2 or VD models were based on end-tidal CO2 tension (PETCO2), tidal volume (VT), and/or weight. RESULTS Criterion measurements of PaCO2 (38±5 vs. 33±5mmHg, P<0.01) and VD (0.26±0.07 vs. 0.41±0.15L, P<0.01) differed at rest vs. peak exercise, respectively. The equation, 5.5+0.90×PETCO2-0.0021×VT, was the strongest predictor of PaCO2 at rest and peak exercise (bias±95%LOA=-3.24±6.63 and -0.98±5.76mmHg; R2=0.57 and 0.75, P<0.001, respectively). This equation closely predicted VD at rest and peak exercise (bias±95%LOA=-0.03±0.06 and -0.02±0.13L; R2=0.86 and 0.83, P<0.001, respectively). CONCLUSIONS These data suggest predicted PaCO2 and VD based on breath-by-breath gas exchange and ventilatory responses demonstrate acceptable agreement with criterion measurements at peak exercise in HF patients. Routine assessment of PaCO2 and VD can be used to improve interpretability of exercise ventilatory responses in HF.
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25
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Machhada A, Trapp S, Marina N, Stephens RCM, Whittle J, Lythgoe MF, Kasparov S, Ackland GL, Gourine AV. Vagal determinants of exercise capacity. Nat Commun 2017; 8:15097. [PMID: 28516907 PMCID: PMC5454375 DOI: 10.1038/ncomms15097] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 02/28/2017] [Indexed: 11/22/2022] Open
Abstract
Indirect measures of cardiac vagal activity are strongly associated with exercise capacity, yet a causal relationship has not been established. Here we show that in rats, genetic silencing of the largest population of brainstem vagal preganglionic neurons residing in the brainstem's dorsal vagal motor nucleus dramatically impairs exercise capacity, while optogenetic recruitment of the same neuronal population enhances cardiac contractility and prolongs exercise endurance. These data provide direct experimental evidence that parasympathetic vagal drive generated by a defined CNS circuit determines the ability to exercise. Decreased activity and/or gradual loss of the identified neuronal cell group provides a neurophysiological basis for the progressive decline of exercise capacity with aging and in diverse disease states. Demonstrating a causal relationship between cardiac vagal tone and exercise capacity has been previously limited by methodological constraints. Using genetic targeting, silencing and optogenetic recruitment of vagal motor neuron activity in rodents, Machhada et al. provide direct evidence that vagal drive determines the ability to exercise.
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Affiliation(s)
- Asif Machhada
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK.,UCL Centre for Advanced Biomedical Imaging, Division of Medicine, University College London, London WC1E 6DD, UK
| | - Stefan Trapp
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Nephtali Marina
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Robert C M Stephens
- University College London Hospitals NIHR Biomedical Research Centre, London WC1E 6BT, UK
| | - John Whittle
- Division of Medicine, University College London, London WC1E 6BT, UK
| | - Mark F Lythgoe
- UCL Centre for Advanced Biomedical Imaging, Division of Medicine, University College London, London WC1E 6DD, UK
| | - Sergey Kasparov
- Department of Physiology and Pharmacology, University of Bristol, Bristol BS8 1TD, UK
| | - Gareth L Ackland
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK.,Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
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26
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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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27
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Abstract
PURPOSE OF REVIEW Surgery is considered the best treatment option for patients with early stage lung cancer. Nevertheless, lung resection may cause a variable functional impairment that could influence the whole cardio-respiratory system with potential life-threatening complications. The aim of the present study is to review the most relevant evidences about the evaluation of surgical risk before lung resection, in order to define a practical approach for the preoperative functional assessment in lung cancer patients. RECENT FINDINGS The first step in the preoperative functional evaluation of a lung resection candidate is a cardiac risk assessment. The predicted postoperative values of forced expiratory volume in one second and carbon monoxide lung diffusion capacity should be estimated next. If both values are greater than 60 % of the predicted values, the patients are regarded to be at low surgical risk. If either or both of them result in values lower than 60 %, then a cardiopulmonary exercise test is recommended. Patients with VO2max >20 mL/kg/min are regarded to be at low risk, while those with VO2max <10 mL/kg/min at high risk. Values of VO2max between 10 and 20 mL/kg/min require further risk stratification by the VE/VCO2 slope. A VE/VCO2 <35 indicates an intermediate-low risk, while values above 35 an intermediate-high risk. SUMMARY The recent scientific evidence confirms that the cardiologic evaluation, the pulmonary function test with DLCO measurement, and the cardiopulmonary exercise test are the cornerstones of the preoperative functional evaluation before lung resection. We present a simplified functional algorithm for the surgical risk stratification in lung resection candidates.
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Affiliation(s)
- Michele Salati
- Division of Thoracic Surgery, Ospedali Riuniti Ancona, Via Conca 1, 60020 Ancona, Italy
| | - Alessandro Brunelli
- Department Thoracic Surgery, St. James’s University Hospital, Beckett Street, Leeds, LS9 7TF UK
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28
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Arena R, Humphrey R, Peberdy MA. Prognostic ability of VE/VCO2 slope calculations using different exercise test time intervals in subjects with heart failure. ACTA ACUST UNITED AC 2016; 10:463-8. [PMID: 14671470 DOI: 10.1097/01.hjr.0000102817.74402.5b] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The minute ventilation-carbon dioxide production (VE/VCO2) slope, obtained during exercise testing, possesses prognostic value in heart failure (HF). The VE-VCO2 relationship is generally linear thereby hypothetically producing similar slope values regardless of the exercise-test time interval used for calculation. DESIGN This study assesses the ability of the VE/VCO2 slope, calculated at different time intervals throughout a progressive exercise test, to predict 1-year cardiac-related hospitalization and mortality in subjects with HF. METHODS Seventy-two subjects underwent symptom-limited exercise testing with ventilatory expired gas analysis. Mean age and left ventricular ejection fraction for 44 male and 28 female subjects were 51.2 years (+/-13.0) and 27.0% (+/-12.3) respectively. The VE/VCO2 slope was calculated from time 0 to 25, 50, 75 and 100% of exercise time and subsequently used to create five randomly selected VE/VCO2 slope categories. RESULTS (The intraclass correlation coefficient found calculation of the VE/VCO2 slope, when divided into quartiles, to be a reliable measure (alpha=0.94, P<0.0001). Univariate Cox regression analysis revealed all VE/VCO2 slope categories (25-100% and random selections) were significant predictors of cardiac-related hospitalization and mortality over a 1-year period. Multivariate Cox regression analysis revealed all VE/VCO2 slope categories outperformed peak oxygen consumption (VO2) in predicting hospitalization and mortality at 1 year. CONCLUSIONS Although the different classification schemes were not identical, these results suggest VE/VCO2 slope maintains prognostic significance regardless of exercise-test time interval. Calculation of VE/VCO2 slope may therefore still be valuable in subjects putting forth a sub-maximal effort while effort-dependent measures, such as peak VO2, are not.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, Virginia Commonwealth University, Health Sciences Campus, Richmond, Virginia 23298-0224, USA.
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29
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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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30
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Brunelli A. Ventilatory efficiency slope: an additional prognosticator after lung cancer surgery. Eur J Cardiothorac Surg 2016; 50:780-781. [DOI: 10.1093/ejcts/ezw127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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31
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Nelson A, Otto J, Whittle J, Stephens RCM, Martin DS, Prowle JR, Ackland GL. Subclinical cardiopulmonary dysfunction in stage 3 chronic kidney disease. Open Heart 2016; 3:e000370. [PMID: 27127638 PMCID: PMC4847133 DOI: 10.1136/openhrt-2015-000370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/09/2016] [Accepted: 01/12/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Reduced exercise capacity is well documented in end-stage chronic kidney disease (CKD), preceded by changes in cardiac morphology in CKD stage 3. However, it is unknown whether subclinical cardiopulmonary dysfunction occurs in CKD stage 3 independently of heart failure. METHODS Prospective observational cross-sectional study of exercise capacity assessed by cardiopulmonary exercise testing in 993 preoperative patients. Primary outcome was peak oxygen consumption (VO2peak). Anaerobic threshold (AT), oxygen pulse and exercise-evoked measures of autonomic function were analysed, controlling for CKD stage 3, age, gender, diabetes mellitus and hypertension. RESULTS CKD stage 3 was present in 93/993 (9.97%) patients. Diabetes mellitus (RR 2.49 (95% CI 1.59 to 3.89); p<0.001), and hypertension (RR 3.20 (95% CI 2.04 to 5.03); p<0.001)) were more common in CKD stage 3. Cardiac failure (RR 0.83 (95% CI 0.30 to 2.24); p=0.70) and ischaemic heart disease (RR 1.40 (95% CI 0.97 to 2.02); p=0.09) were not more common in CKD stage 3. Patients with CKD stage 3 had lower predicted VO2peak (mean difference: 6% (95% CI 1% to 11%); p=0.02), lower peak heart rate (mean difference:9 bpm (95% CI 3 to 14); p=0.03)), lower AT (mean difference: 1.1 mL/min/kg (95% CI 0.4 to 1.7); p<0.001) and impaired heart rate recovery (mean difference: 4 bpm (95% CI 1 to 7); p<0.001)). CONCLUSIONS Subclinical cardiopulmonary dysfunction in CKD stage 3 is common. This study suggests that maladaptive cardiovascular/autonomic dysfunction may be established in CKD stage 3, preceding pathophysiology reported in end-stage CKD.
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Affiliation(s)
| | - James Otto
- Royal Free London NHS Foundation Trust , London , UK
| | - John Whittle
- Division of Medicine, Department of Clinical Physiology , University College London , London , UK
| | - Robert C M Stephens
- Department of Anaesthesia , University College London Hospitals NHS Trust , London , UK
| | | | - John R Prowle
- William Harvey Research Institute, Queen Mary University of London , London , UK
| | - Gareth L Ackland
- William Harvey Research Institute, Queen Mary University of London , London , UK
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32
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Giannoni A, Raglianti V, Mirizzi G, Taddei C, Del Franco A, Iudice G, Bramanti F, Aimo A, Pasanisi E, Emdin M, Passino C. Influence of central apneas and chemoreflex activation on pulmonary artery pressure in chronic heart failure. Int J Cardiol 2016; 202:200-6. [DOI: 10.1016/j.ijcard.2015.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 08/16/2015] [Accepted: 09/06/2015] [Indexed: 10/23/2022]
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33
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Nedeljkovic I, Banovic M, Stepanovic J, Giga V, Djordjevic-Dikic A, Trifunovic D, Nedeljkovic M, Petrovic M, Dobric M, Dikic N, Zlatar M, Beleslin B. The combined exercise stress echocardiography and cardiopulmonary exercise test for identification of masked heart failure with preserved ejection fraction in patients with hypertension. Eur J Prev Cardiol 2015; 23:71-7. [PMID: 26358991 DOI: 10.1177/2047487315604836] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is commonly associated with hypertension (HTN). However, resting echocardiography (ECHO) can underestimate the severity of disease. Exercise stress echocardiography (ESE) and the cardiopulmonary exercise testing (CPX) appeared to be useful tests in dynamic assessment of HFpEF. The value of combined exercise stress echocardiography cardiopulmonary testing (ESE-CPX) in the identification of masked HFpEF is still undetermined. OBJECTIVE The purpose of this study was to analyse the value of the combined ESE-CPX in the identification of masked HFpEF in patients with HTN, dyspnoea and normal resting left ventricular (LV) systolic and diastolic function. METHODOLOGY We studied 87 patients with HTN, exertional dyspnoea and normal resting LV function. They all underwent ESE-CPX testing (supine bicycle, ramp protocol, 15 W/min). ECHO measurements were performed at rest, and at peak load. Achievement of peak E/e' ratio>15 was a marker for masked HFpEF. RESULTS Increase of E/e'>15 occurred in 8/87 patients (9.2%) during ESE-CPX. Those patients had the lower peak VO2 (p = 0.012), the lower VO2 at anaerobic threshold (p = 0.025), the lower workload (p = 0.026), the lower peak partial pressure end tidal carbon dioxide (PetCO2) (p < 0.0001), and the higher VE/VCO2 slope (p < 0.0001) which was an independent multivariate predictor of HFpEF (p = 0.021), with the cut-off value of 32.95 according to the receiver-operator characteristic (ROC) curve (sensitivity (Sn) 100%, specificity (Sp) 90%). CONCLUSION The combined ESE-CPX test is feasible and reliable test that can unmask HFpEF and may become an important aid in the early diagnosis of HFpEF, excluding the other causes of exertional dyspnoea.
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Affiliation(s)
- Ivana Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Marko Banovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Jelena Stepanovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Danijela Trifunovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Petrovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Dobric
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Nenad Dikic
- Outpatient Clonoc for Sport Medicine 'Vita Maxima', Belgrade, Serbia
| | - Milan Zlatar
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
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Exercise Physiology and Pulmonary Hemodynamic Abnormality in PH Patients with Exercise Induced Venous-To-Systemic Shunt. PLoS One 2015; 10:e0121690. [PMID: 25918847 PMCID: PMC4412481 DOI: 10.1371/journal.pone.0121690] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 02/16/2015] [Indexed: 12/27/2022] Open
Abstract
Objectives To identify the pulmonary hypertension (PH) patients who develop an exercise induced venous-to-systemic shunt (EIS) by performing the cardiopulmonary exercise test (CPET), analyse the changes of CPET measurements during exercise and compare the exercise physiology and resting pulmonary hemodynamics between shunt-PH and no-shunt-PH patients. Methods Retrospectively, resting pulmonary function test (PFT), right heart catheterization (RHC), and CPET for clinical evaluation of 104 PH patients were studied. Results Considering all 104 PH patients by three investigators, 37 were early EIS+, 61 were EIS-, 3 were late EIS+, and 3 others were placed in the discordant group. PeakVO2, AT and OUES were all reduced in the shunt-PH patients compared with the no-shunt-PH subjects, whereas VE/VCO2 slope and the lowest VE/VCO2 increased. Besides, the changes and the response characteristics of the key CPET parameters at the beginning of exercise in the shunt group were notably different from those of the no shunt one. At cardiac catheterization, the shunt patients had significantly increased mean pulmonary artery pressure (mPAP), mean right atrial pressure (mRAP) and pulmonary vascular resistance (PVR), reduced cardiac output (CO) and cardiac index (CI) compared with the no shunt ones (P<0.05). Resting CO was significantly correlated with exercise parameters of AT (r = 0.527, P<0.001), OUES (r = 0.410, P<0.001) and Peak VO2 (r = 0.405, P<0.001). PVR was significantly, but weakly, correlated with the above mentioned CPET parameters. In Conclusions CPET may allow a non-invasive method for detecting an EIS and assessing the severity of the disease in PH patients.
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Influence of exercise-induced pulmonary hypertension on exercise capacity in asymptomatic degenerative mitral regurgitation. J Cardiol 2014; 66:246-52. [PMID: 25533424 DOI: 10.1016/j.jjcc.2014.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 10/29/2014] [Accepted: 11/19/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Exercise capacity is helpful in the management of patients with mitral regurgitation (MR). However, the determinants of exercise capacity reduction in MR have remained unclear. This study was designed to objectively assess exercise capacity, identify the echocardiographic predictors of exercise capacity, and investigate its impact on development of symptoms in asymptomatic degenerative MR. METHODS A total of 49 consecutive asymptomatic patients (age, 58.9±13.1 years; 82% males) with at least moderate degenerative MR (effective regurgitant orifice area=0.40±0.14cm(2); regurgitant volume=60.9±19.6mL) underwent the symptom-limited cardiopulmonary exercise testing for assessing exercise capacity (peak oxygen uptake, peak V˙O2; the minute ventilation/carbon dioxide production, V˙E/V˙CO2 slope). All patients also underwent exercise stress echocardiography for detecting exercise-induced pulmonary hypertension (EIPH) defined by systolic pulmonary arterial pressure (SPAP) ≥60mmHg. RESULTS The mean peak V˙O2 was 22.6±5.1mL/kg/min (86.7±14.1% of age, gender-predicted); peak V˙O2 widely varied (48-121% of predicted), and was markedly reduced (<80.4% of predicted) in 24% of the study patients. The patients with EIPH had lower 2-year symptom-free survival than those without EIPH (p=0.003). The multivariable analysis demonstrated that EIPH was an independent echocardiographic determinant of peak V˙O2 (p=0.001) and V˙E/V˙CO2 slope (p=0.021). Furthermore, the area under curve of age- and gender-adjusted exercise SPAP was 0.88 (95% confidence interval: 0.78-0.97) for reduced exercise capacity. CONCLUSIONS In asymptomatic moderate to severe degenerative MR, EIPH was independently associated with exercise capacity and predicted the occurrence of symptoms. Exercise stress echocardiography is an important tool in managing patients with asymptomatic degenerative MR.
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Exercise Ventilatory Parameters for the Diagnosis of Reactive Pulmonary Hypertension in Patients With Heart Failure. J Card Fail 2014; 20:650-7. [DOI: 10.1016/j.cardfail.2014.06.355] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 05/30/2014] [Accepted: 06/12/2014] [Indexed: 11/20/2022]
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Tan X, Yang W, Guo J, Zhang Y, Wu C, Sapkota R, Kushwaha SP, Gong S, Sun X, Liu J. Usefulness of decrease in oxygen uptake efficiency to identify gas exchange abnormality in patients with idiopathic pulmonary arterial hypertension. PLoS One 2014; 9:e98889. [PMID: 24905576 PMCID: PMC4048265 DOI: 10.1371/journal.pone.0098889] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 05/08/2014] [Indexed: 12/21/2022] Open
Abstract
Background Decline in oxygen uptake efficiency (OUE), especially during exercise, is found in patients with chronic heart failure. In this study we aimed to test the validity and usefulness of OUE in evaluating gas exchange abnormality of patients with idiopathic pulmonary arterial hypertension (IPAH). Methods We retrospectively investigated the cardiopulmonary exercise test (CPET) with gas exchange measurements in 32 patients with confirmed IPAH. All patients also had resting hemodynamic measurements and pulmonary function test (PFT). Sixteen healthy subjects, matched by age, sex, and body size were used as controls, also had CPET and PFT measurements. Results In IPAH patients, the magnitude of absolute and percentage of predicted (%pred) oxygen uptake efficiency slope (OUES) and oxygen uptake efficiency plateau (OUEP), as well as several other CPET parameters, were strikingly worse than healthy subjects (P<0.0001). Pattern of changes in OUE in patients is similar to that in controls, In IPAH patients, OUE values at rest, warming up, anaerobic threshold and peak exercise were all significantly lower than in normal (P<0.0001). OUEP%pred, better than OUES%pred, correlated significantly with New York Heart Association (NYHA) functional Class (r = −0.724, P<0.005), Total Pulmonary Vascular Resistance (TPVR) (r = −0.694, P<0.005), diffusing capacity for carbon monoxide (DLCO) (r = 0.577, P<0.05), and the lowest ventilation versus CO2 output ratio during exercise (LowestV˙E/V˙CO2) (r = −0.902, P<0.0001). In addition, the coefficient of variation (COV) of OUEP was lower (20.9%) markedly than OUES (34.3%) (P<0.0001). Conclusions In patients with IPAH, OUES and OUEP are both significantly lower than the healthy subjects. OUEP is a better physiological parameter than OUES in evaluating the gas exchange abnormality of patients with IPAH.
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Affiliation(s)
- Xiaoyue Tan
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
- State Key Laboratory of Cardiovascular Disease, Heart-Lung Function Testing Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenlan Yang
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Yan Zhang
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
- Respiratory Division, Hangzhou, Zhejiang Provincial Hospital of traditional Chinese Medicine, The First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Changwei Wu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Rikesh Sapkota
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Shailendra Prasad Kushwaha
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Sugang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Xingguo Sun
- State Key Laboratory of Cardiovascular Disease, Heart-Lung Function Testing Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- * E-mail: (XGS); (JML)
| | - Jinming Liu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
- * E-mail: (XGS); (JML)
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Guazzi M. Abnormalities in Cardiopulmonary Exercise Testing Ventilatory Parameters in Heart Failure: Pathophysiology and Clinical Usefulness. Curr Heart Fail Rep 2014; 11:80-7. [DOI: 10.1007/s11897-013-0183-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Guazzi M, Cahalin LP, Arena R. Cardiopulmonary Exercise Testing as a Diagnostic Tool for the Detection of Left-sided Pulmonary Hypertension in Heart Failure. J Card Fail 2013; 19:461-7. [DOI: 10.1016/j.cardfail.2013.05.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 10/26/2022]
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Brown SJ, Raman A, Schlader Z, Stannard SR. Ventilatory efficiency in juvenile elite cyclists. J Sci Med Sport 2013; 16:266-70. [DOI: 10.1016/j.jsams.2012.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 05/06/2012] [Accepted: 06/27/2012] [Indexed: 12/17/2022]
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Schmeisser A, Schroetter H, Braun-Dulleaus RC. Management of pulmonary hypertension in left heart disease. Ther Adv Cardiovasc Dis 2013; 7:131-51. [DOI: 10.1177/1753944713477518] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Pulmonary hypertension (PH) due to left heart disease is classified as group II according to the Dana Point classification, which includes left ventricular systolic and/or diastolic left heart failure, and left-sided valvular disease. PH due to left heart disease is the most common cause and when present, especially with right ventricular dysfunction, is associated with a worse prognosis. Left heart disease with secondary PH is associated with increased left atrial pressure, which causes a passive increase in pulmonary pressure. Passive PH could be superimposed by an active protective, and in some patients by an ‘out of proportion’, elevated precapillary pulmonary vasoconstriction and vascular remodelling which leads to greater or lesser further increase of the pulmonary artery pressure. In this review, epidemiological and pathophysiologic mechanisms for the development of group II PH are summarized. The conflicting data about the haemodynamic and possible parameters to diagnose passive versus reactive and ‘out of proportion’ PH are presented. The different therapeutic concepts, along with novel treatment strategies, are reviewed in detail and critically discussed regarding their effectiveness and safety.
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Affiliation(s)
- Alexander Schmeisser
- Internal Medicine/Cardiology, Angiology and Pneumology, Magdeburg University, Leipziger Str.44, 39120 Magdeburg, Germany
| | - Hagen Schroetter
- Technical University Dresden, Heart Centre Dresden, University Hospital, Department of Internal Medicine and Cardiology, Dresden, Germany
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Guazzi M, Labate V, Cahalin LP, Arena R. Cardiopulmonary exercise testing reflects similar pathophysiology and disease severity in heart failure patients with reduced and preserved ejection fraction. Eur J Prev Cardiol 2013; 21:847-54. [PMID: 23382540 DOI: 10.1177/2047487313476962] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We are unaware of any previous investigation that has compared the relationship of key cardiopulmonary exercise testing (CPX) variables to various measures of pathophysiology between heart failure-reduced ejection fraction (HFrEF) and HF-preserved ejection fraction (HFpEF) cohorts that are well matched with respect to baseline characteristics and their exercise response, which is the purpose of the present study. METHODS Thirty-four patients with HFpEF were randomly matched to 34 subjects with HFrEF according to age and sex as well as peak oxygen consumption (VO2), ventilatory efficiency (VE/VCO2 slope), and exercise oscillatory ventilation (EOV). In addition to CPX, patients also underwent echocardiography with tissue Doppler imaging (TDI) and assessment of N-terminal pro-B-type natriuretic peptide (NT-proBNP). RESULTS When matched for age, sex, and CPX variables, the HFrEF and HFpEF cohorts had similar echocardiography with TDI and NT-proBNP values, indicating comparable disease severity. In addition, the correlations between key CPX measures (peak VO2 and VE/VCO2 slope) and echocardiography with TDI and NT-proBNP measures were similar between HFrEF and HFpEF groups. Of note, the correlation between the VE/VCO2 slope and pulmonary artery systolic pressure and NT-proBNP was highly significant in both groups (r ≥ 0.65, p < 0.01). Moreover, subjects with EOV in both groups had a significantly higher PASP (∼47 vs. ∼35 mmHg, p < 0.05). CONCLUSIONS The results of the current study indicate CPX equally represents disease severity in HFrEF and HFpEF patients. This is a novel finding supporting the key role of CPX in the clinical follow-up of HF patients irrespective of LVEF and cardiac phenotype.
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Affiliation(s)
| | | | | | - Ross Arena
- University of New Mexico, Albuquerque, New Mexico
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Yan J, Gong SJ, Li L, Yu HY, Dai HW, Chen J, Tan CW, Xv QH, Cai GL. Combination of B-type natriuretic peptide and minute ventilation/carbon dioxide production slope improves risk stratification in patients with diastolic heart failure. Int J Cardiol 2013; 162:193-8. [DOI: 10.1016/j.ijcard.2011.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 05/20/2011] [Accepted: 07/03/2011] [Indexed: 11/30/2022]
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, Cardiology, I.R.C.C.S., Policlinico San Donato, Department of Medical Sciences, University of Milano, Piazza Malan 1 20097, San Donato Milanese, Milano, Italy.
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Patients with heart failure in the "intermediate range" of peak oxygen uptake: additive value of heart rate recovery and the minute ventilation/carbon dioxide output slope in predicting mortality. J Cardiopulm Rehabil Prev 2012; 32:141-6. [PMID: 22487616 DOI: 10.1097/hcr.0b013e31824f9ddf] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE While patients with heart failure who achieve a peak oxygen uptake (peak VO2) of 10 mL·kg(-1)·min(-1) or less are often considered for intensive surveillance or intervention, those achieving 14 mL·kg(-1)·min(-1) or more are generally considered to be at lower risk. Among patients in the "intermediate" range of 10.1 to 13.9 mL·kg(-1)·min(-1), optimally stratifying risk remains a challenge. METHODS Patients with heart failure (N = 1167) referred for cardiopulmonary exercise testing were observed for 21 ± 13 months. Patients were classified into 3 groups of peak VO2 (≤10, 10.1-13.9, and ≥14 mL·kg(-1)·min(-1)). The ability of heart rate recovery at 1 minute (HRR1) and the minute ventilation/carbon dioxide output (VE/VCO2) slope to complement peak VO2 in predicting cardiovascular mortality were determined. RESULTS Peak VO2, HRR1 (<16 beats per minute), and the VE/VCO2 slope (>34) were independent predictors of mortality (hazard ratio 1.6, 95% CI: 1.2-2.29, P = .006; hazard ratio 1.7, 95% CI: 1.1-2.5, P = .008; and hazard ratio 2.4, 95% CI: 1.6-3.4, P < .001, respectively). Compared with those achieving a peak VO2 ≥ 14 mL·kg(-1)·min(-1), patients within the intermediate range with either an abnormal VE/VCO2 slope or HRR1 had a nearly 2-fold higher risk of cardiac mortality. Those with both an abnormal HRR1 and VE/VCO2 slope had a higher mortality risk than those with a peak VO2 ≤ 10 mL·kg(-1)·min(-1). Survival was not different between those with a peak VO2 ≤ 10 mL·kg(-1)·min(-1) and those in the intermediate range with either an abnormal HRR1 or VE/VCO2 slope. CONCLUSIONS HRR1 and the VE/VCO2 slope effectively stratify patients with peak VO2 within the intermediate range into distinct groups at high and low risk.
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Prognostic Impact of the Addition of Ventilatory Efficiency to the Seattle Heart Failure Model in Patients With Heart Failure. J Card Fail 2012; 18:614-9. [DOI: 10.1016/j.cardfail.2012.06.417] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 03/22/2012] [Accepted: 06/08/2012] [Indexed: 11/23/2022]
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Exercise intolerance in pulmonary arterial hypertension. Pulm Med 2012; 2012:359204. [PMID: 22737582 PMCID: PMC3377355 DOI: 10.1155/2012/359204] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 04/13/2012] [Accepted: 04/16/2012] [Indexed: 01/12/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is associated with symptoms of dyspnea and fatigue, which contribute to exercise limitation. The origins and significance of dyspnea and fatigue in PAH are not completely understood. This has created uncertainly among healthcare professionals regarding acceptable levels of these symptoms, on exertion, for patients with PAH. Dysfunction of the right ventricle (RV) contributes to functional limitation and mortality in PAH; however, the role of the RV in eliciting dyspnea and fatigue has not been thoroughly examined. This paper explores the contribution of the RV and systemic and peripheral abnormalities to exercise limitation and symptoms in PAH. Further, it explores the relationship between exercise abnormalities and symptoms, the utility of the cardiopulmonary exercise test in identifying RV dysfunction, and offers suggestions for further research.
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Schwaiblmair M, Faul C, von Scheidt W, Berghaus TM. Ventilatory efficiency testing as prognostic value in patients with pulmonary hypertension. BMC Pulm Med 2012; 12:23. [PMID: 22676304 PMCID: PMC3420250 DOI: 10.1186/1471-2466-12-23] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 06/07/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increased ventilatory response has been shown to have a high prognostic value in patients with chronic heart failure. Our aim was therefore to determine the ventilatory efficiency in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension by cardiopulmonary exercise testing (CPET) identifying PH-patients with increased risk for death within 24 months after evaluation. METHODS 116 patients (age: 64 ± 1 years) with a mean pulmonary arterial pressure of 35 ± 1 mmHg underwent CPET and right heart catheterization. During a follow-up of 24 months, we compared the initial characteristics of survivors (n = 87) with nonsurvivors (n = 29). RESULTS Significant differences (p ≤ 0.005) between survivors and nonsurvivors existed in ventilatory equivalents for oxygen (42.1 ± 2.1 versus 56.9 ± 2.6) and for carbon dioxide (Ve/VCO2) (47.5 ± 2.2 versus 64.4 ± 2.3). Patients with peak oxygen uptake ≤ 10.4 ml/min/kg had a 1.5-fold, Ve/VCO2 ≥ 55 a 7.8-fold, alveolar-arterial oxygen difference ≥ 55 mmHg a 2.9-fold, and with Ve/VCO2 slope ≥ 60 a 5.8-fold increased risk of mortality in the next 24 months. CONCLUSIONS Our results demonstrate that abnormalities in exercise ventilation powerfully predict outcomes in PH. Consideration should be given to add clinical guidelines to reflect the prognostic importance of ventilatory efficiency parameters in addition to peak VO2.
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Affiliation(s)
- Martin Schwaiblmair
- Department of Internal Medicine I, Klinikum Augsburg, Ludwig Maximilians University of Munich, Munich, Germany.
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Tereno Valente B, Feliciano J, Soares R, Toste A, Ferreira F, Hamad H, Santos N, Silva S, Abreu A, Ferreira R. [Thoracic fluid content - a possible determinant of ventilatory efficiency in patients with heart failure]. Rev Port Cardiol 2011; 30:711-6. [PMID: 21958995 DOI: 10.1016/s0870-2551(11)70014-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 05/11/2011] [Indexed: 12/29/2022] Open
Abstract
UNLABELLED Ventilatory efficiency, evaluated by cardiopulmonary exercise testing (CPET), has considerable prognostic value in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD). Its determinants nevertheless remain controversial. AIM To investigate the possible correlation between parameters of ventilatory efficiency obtained by CPET and thoracic fluid content (TFC), assessed by thoracic electrical bioimpedance (TEB), in patients with CHF due to LVSD. METHODS We studied 120 patients with LVSD and CHF, referred to our laboratory for CPET: 76% male, age 52.1 ± 12.1 years, 37% of ischemic etiology, left ventricular ejection fraction 27.6 ± 7.9%, 83% in sinus rhythm, 96% receiving ACEIs and/or ARBs and 79% beta-blockers, and 20% treated with a cardiac resynchronization device. TEB studies were performed after 15 minutes of rest, prior to symptom-limited treadmill CPET, using the modified Bruce protocol. CPET-derived peak oxygen consumption (pVO(2)), the slope of the relationship between minute ventilation (VE) and carbon dioxide production (VCO(2)), VE/VCO(2) at the anaerobic threshold (AT), and TFC assessed by TEB were considered for analysis. RESULTS TFC ranged between 20.6 and 45.8kOhm-1, mean 32.2, SD=5.7, median 32.7, pVO(2) 8.9-40.6 ml/kg/min, mean 21.0, SD 6.2, median 20.2, VE/VCO(2) slope 19.8-60.7, mean 30.7, SD 7.9, median 29.1 and VE/VCO(2) at AT 21-62, mean 33.1, SD 7.5, median 31.5. By linear regression, TFC did not correlate with pVO(2) (r=0.05, p=0.58), but showed correlation with parameters of ventilatory efficiency: r=0.20, p=0.032, r(2)=0.04 for VE/VCO(2) slope and r=0.25, p=0.009, r(2)=0.06 for VE/VCO(2) at AT. CONCLUSION TFC correlates with CPET parameters of ventilatory efficiency in patients with CHF due to LVSD, suggesting that it may be one of its determinants.
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Valente BT, Feliciano J, Soares R, Toste A, Ferreira F, Hamad H, Santos N, Silva S, Abreu A, Ferreira R. Thoracic fluid content — a possible determinant of ventilatory efficiency in patients with heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2174-2049(11)70014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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