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Richalet JP, Hermand E, Lhuissier FJ. Cardiovascular physiology and pathophysiology at high altitude. Nat Rev Cardiol 2024; 21:75-88. [PMID: 37783743 DOI: 10.1038/s41569-023-00924-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 10/04/2023]
Abstract
Oxygen is vital for cellular metabolism; therefore, the hypoxic conditions encountered at high altitude affect all physiological functions. Acute hypoxia activates the adrenergic system and induces tachycardia, whereas hypoxic pulmonary vasoconstriction increases pulmonary artery pressure. After a few days of exposure to low oxygen concentrations, the autonomic nervous system adapts and tachycardia decreases, thereby protecting the myocardium against high energy consumption. Permanent exposure to high altitude induces erythropoiesis, which if excessive can be deleterious and lead to chronic mountain sickness, often associated with pulmonary hypertension and heart failure. Genetic factors might account for the variable prevalence of chronic mountain sickness, depending on the population and geographical region. Cardiovascular adaptations to hypoxia provide a remarkable model of the regulation of oxygen availability at the cellular and systemic levels. Rapid exposure to high altitude can have adverse effects in patients with cardiovascular diseases. However, intermittent, moderate hypoxia might be useful in the management of some cardiovascular disorders, such as coronary heart disease and heart failure. The aim of this Review is to help physicians to understand the cardiovascular responses to hypoxia and to outline some recommendations that they can give to patients with cardiovascular disease who wish to travel to high-altitude destinations.
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Affiliation(s)
- Jean-Paul Richalet
- Hypoxie et Poumon, Université Sorbonne Paris Nord, INSERM U1272, Paris, France.
| | - Eric Hermand
- Unité de Recherche Pluridisciplinaire Sport Santé Société, ULR 7369-URePSSS, Université Littoral Côte d'Opale, Université Artois, Université Lille, CHU Lille, Dunkirk, France
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2
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Vignati C, Contini M, Salvioni E, Lombardi C, Caravita S, Bilo G, Swenson ER, Parati G, Agostoni P. Exercise in hypoxia: a model from laboratory to on-field studies. Eur J Prev Cardiol 2023; 30:ii40-ii46. [PMID: 37819224 DOI: 10.1093/eurjpc/zwad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/05/2023] [Accepted: 05/31/2023] [Indexed: 10/13/2023]
Abstract
Clinical outcome and quality of life of patients with chronic heart failure (HF) have greatly improved over the last two decades. These results and the availability of modern lifts allow many cardiac patients to spend leisure time at altitude. Heart failure per se does not impede a safe stay at altitude, but exercise at both simulated and real altitudes is associated with a reduction in performance, which is inversely proportional to HF severity. For example, in normal subjects, the reduction in functional capacity is ∼2% every 1000 m altitude increase, whereas it is 4 and 10% in HF patients with normal or slightly diminished exercise capacity and in HF patients with markedly diminished exercise capacity, respectively. Also, the on-field experience with HF patients at altitude confirms safety and shows overall similar data to that reported at simulated altitude. Even 'optimal' HF treatment in patients spending time at altitude or at hypoxic conditions is likely different from optimal treatment at sea level, particularly with regard to the selectivity of β-blockers. Furthermore, high altitude, both simulated and on-field, represents a stimulating model of hypoxia in HF patients and healthy subjects. Our data suggest that spending time at altitude (<3500 m) can be safe even for HF patients, provided that subjects are free from comorbidities that may directly interfere with the adaptation to altitude and are stable. However, HF patients experience a reduction of exercise capacity directly proportional to HF severity and altitude. Finally, HF patients should be tested for functional capacity and must undergo a specific 'hypoxic-tailored treatment' to avoid pharmacological interference with altitude adaptation mechanisms, particularly with regard to the selectivity of β-blockers.
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Affiliation(s)
- Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Via Parea, Milano 20138, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Parea, Milano 20138, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, IRCCS, Via Parea, Milano 20138, Italy
| | | | - Carolina Lombardi
- Sleep Medicine Center, Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Grzegorz Bilo
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea, Milano 20138, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Parea, Milano 20138, Italy
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3
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Affiliation(s)
- Andrew M Luks
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (A.M.L.); and the Altitude Research Center, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (P.H.H.)
| | - Peter H Hackett
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (A.M.L.); and the Altitude Research Center, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (P.H.H.)
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4
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Travelling with heart failure: risk assessment and practical recommendations. Nat Rev Cardiol 2022; 19:302-313. [PMID: 34992256 DOI: 10.1038/s41569-021-00643-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 01/08/2023]
Abstract
Patients with heart failure are at a higher risk of cardiovascular events compared with the general population, particularly during domestic or international travel. Patients with heart failure should adhere to specific recommendations during travel to lower their risk of developing heart failure symptoms. In this Review, we aim to provide clinicians with a set of guidelines for patients with heart failure embarking on national or international travel. Considerations when choosing a travel destination include travel distance and time, the season upon arrival, air pollution levels, jet lag and altitude level because all these factors can increase the risk of symptom development in patients with heart failure. In particular, volume depletion is of major concern while travelling given that it can contribute to worsening heart failure symptoms. Pre-travel risk assessment should be performed by a clinician 4-6 weeks before departure, and patients should receive advice on potential travel-related illness and on strategies to prevent volume depletion. Oxygen supplementation might be useful for patients who are very symptomatic. Upon arrival at the destination, potential drug-induced photosensitivity (particularly in tropical destinations) and risks associated with the local cuisine require consideration. Special recommendations are needed for patients with cardiac implantable electronic devices or left ventricular assist devices as well as for those who have undergone major cardiac surgery.
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Cornwell WK, Baggish AL, Bhatta YKD, Brosnan MJ, Dehnert C, Guseh JS, Hammer D, Levine BD, Parati G, Wolfel EE. Clinical Implications for Exercise at Altitude Among Individuals With Cardiovascular Disease: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2021; 10:e023225. [PMID: 34496612 PMCID: PMC8649141 DOI: 10.1161/jaha.121.023225] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An increasing number of individuals travel to mountainous environments for work and pleasure. However, oxygen availability declines at altitude, and hypoxic environments place unique stressors on the cardiovascular system. These stressors may be exacerbated by exercise at altitude, because exercise increases oxygen demand in an environment that is already relatively oxygen deplete compared with sea‐level conditions. Furthermore, the prevalence of cardiovascular disease, as well as diseases such as hypertension, heart failure, and lung disease, is high among individuals living in the United States. As such, patients who are at risk of or who have established cardiovascular disease may be at an increased risk of adverse events when sojourning to these mountainous locations. However, these risks may be minimized by appropriate pretravel assessments and planning through shared decision‐making between patients and their managing clinicians. This American Heart Association scientific statement provides a concise, yet comprehensive overview of the physiologic responses to exercise in hypoxic locations, as well as important considerations for minimizing the risk of adverse cardiovascular events during mountainous excursions.
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Herberg U, Knies R, Müller N, Breuer J. Altitude exposure in pediatric pulmonary hypertension-are we ready for (flight) recommendations? Cardiovasc Diagn Ther 2021; 11:1122-1136. [PMID: 34527538 DOI: 10.21037/cdt-20-494] [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: 05/14/2020] [Accepted: 08/27/2020] [Indexed: 11/06/2022]
Abstract
Patients with congenital heart disease are surviving further into adulthood and want to participate in multiple activities. This includes exposure to high altitude by air travel or recreational activities, such as hiking and skiing. However, at an altitude of about 2,500 m, the barometric environmental pressure is reduced and the partial pressure of inspired oxygen drops from 21% to 15% (hypobaric hypoxia). In physiologic response to high-altitude-related hypoxia, pulmonary vasoconstriction is induced within minutes of exposure followed by compensatory hyperventilation and increased cardiac output. Even in healthy children and adults, desaturation can be profound and lead to a significant rise in pulmonary pressure and resistance. Individuals with already increased pulmonary pressure may be placed at risk during high-altitude exposure, as compensatory mechanisms may be limited. Little is known about the physiological response and risk of developing clinically relevant events on altitude exposure in pediatric pulmonary hypertension (PAH). Current guidelines are, in the absence of clinical studies, mainly based on expert opinion. Today, healthcare professionals are increasingly faced with the question, how best to assess and advise on the safety of individuals with PAH planning air travel or an excursion to mountain areas. To fill the gap, this article summarises the current clinical knowledge on moderate to high altitude exposure in patients with different forms of pediatric PAH.
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Affiliation(s)
- Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Ralf Knies
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Nicole Müller
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Breuer
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
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Mallet RT, Burtscher J, Richalet JP, Millet GP, Burtscher M. Impact of High Altitude on Cardiovascular Health: Current Perspectives. Vasc Health Risk Manag 2021; 17:317-335. [PMID: 34135590 PMCID: PMC8197622 DOI: 10.2147/vhrm.s294121] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
Globally, about 400 million people reside at terrestrial altitudes above 1500 m, and more than 100 million lowlanders visit mountainous areas above 2500 m annually. The interactions between the low barometric pressure and partial pressure of O2, climate, individual genetic, lifestyle and socio-economic factors, as well as adaptation and acclimatization processes at high elevations are extremely complex. It is challenging to decipher the effects of these myriad factors on the cardiovascular health in high altitude residents, and even more so in those ascending to high altitudes with or without preexisting diseases. This review aims to interpret epidemiological observations in high-altitude populations; present and discuss cardiovascular responses to acute and subacute high-altitude exposure in general and more specifically in people with preexisting cardiovascular diseases; the relations between cardiovascular pathologies and neurodegenerative diseases at altitude; the effects of high-altitude exercise; and the putative cardioprotective mechanisms of hypobaric hypoxia.
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Affiliation(s)
- Robert T Mallet
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Johannes Burtscher
- Department of Biomedical Sciences, University of Lausanne, Lausanne, CH-1015, Switzerland
- Institute of Sport Sciences, University of Lausanne, Lausanne, CH-1015, Switzerland
| | - Jean-Paul Richalet
- Laboratoire Hypoxie & Poumon, UMR Inserm U1272, Université Sorbonne Paris Nord 13, Bobigny Cedex, F-93017, France
| | - Gregoire P Millet
- Department of Biomedical Sciences, University of Lausanne, Lausanne, CH-1015, Switzerland
- Institute of Sport Sciences, University of Lausanne, Lausanne, CH-1015, Switzerland
| | - Martin Burtscher
- Department of Sport Science, University of Innsbruck, Innsbruck, A-6020, Austria
- Austrian Society for Alpine and High-Altitude Medicine, Mieming, Austria
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Luks AM, Grissom CK. Return to High Altitude After Recovery from Coronavirus Disease 2019. High Alt Med Biol 2021; 22:119-127. [PMID: 33978479 DOI: 10.1089/ham.2021.0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Luks, Andrew M. and Colin K. Grissom. Return to high altitude after recovery from coronavirus disease 2019. High Alt Med Biol. 22: 119-127, 2021.-With the increasing availability of coronavirus disease 2019 (COVID-19) vaccines and the eventual decline in the burden of the disease, it is anticipated that all forms of tourism, including travel to high altitude, will rebound in the near future. Given the physiologic challenges posed by hypobaric hypoxia at high altitude, it is useful to consider whether high-altitude travel will pose risks to those previously infected with severe acute respiratory syndrome coronavirus 2, particularly those with persistent symptoms after resolution of their infection. Although no studies have specifically examined this question as of yet, available data on the cardiopulmonary sequelae of COVID-19 provide some sense of the problems people may face at high altitude and who warrants evaluation before such endeavors. On average, most individuals who have recovered from COVID-19 have normal or near normal gas exchange, pulmonary function testing, cardiovascular function, and exercise capacity, although a subset of individuals have persistent functional deficits in some or all of these domains when examined up to 5 months after infection. Evaluation is warranted before planned high-altitude travel in individuals with persistent symptoms at least 2 weeks after a positive test or hospital discharge as well as in those who required care in an intensive care unit or suffered from myocarditis or arterial or venous thromboembolism. Depending on the results of this testing, planned high-altitude travel may need to be modified or even deferred pending resolution of the identified abnormalities. As more people travel to high altitude after the pandemic and further studies are conducted, additional data should become available to provide further guidance on these issues.
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Affiliation(s)
- Andrew M Luks
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, Utah, USA
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Koh CH. Commercial Air Travel for Passengers With Cardiovascular Disease: Recommendations for Common Conditions. Curr Probl Cardiol 2020; 46:100768. [PMID: 33348221 DOI: 10.1016/j.cpcardiol.2020.100768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022]
Abstract
The exponential growth of commercial flights has resulted in an explosion of air travelers over the last few decades, including passengers with a wide range of cardiovascular conditions. Notwithstanding the ongoing COVID-19 pandemic that had set back the aviation industry for the next 1-2 years, air travel is expected to rebound fully by 2024. Guidelines and evidence-based recommendations for safe air travel in this group vary, and physicians often encounter situations where opinions and assessments on fitness for flights are sought. This article aims to provide an updated suite of recommendations for the aeromedical disposition of passenger with common cardiovascular conditions, such as ischemic heart disease, congestive heart failure, valvular heart disease, cardiomyopathies, and common arrhythmias.
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Affiliation(s)
- Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore; Changi Aviation Medical Centre, Changi General Hospital, Singapore.
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Koh CH. Commercial Air Travel for Passengers With Cardiovascular Disease: Stressors of Flight and Aeromedical Impact. Curr Probl Cardiol 2020; 46:100746. [PMID: 33213942 PMCID: PMC8514285 DOI: 10.1016/j.cpcardiol.2020.100746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/27/2020] [Indexed: 12/04/2022]
Abstract
The exponential growth of commercial flights has resulted in a sharp rise of air travellers over the last 2 decades, including passengers with a wide range of cardiovascular conditions. Notwithstanding the ongoing COVID-19 pandemic that had set back the aviation industry for the next 1 to 2 years, air travel is expected to rebound fully by 2023-2024. Guidelines and evidence-based recommendations for safe air travel in this group vary, and physicians often encounter situations where opinions and assessments on fitness for flights are sought. This article aims to provide an overview of the stressors of commercial passenger flights with an impact on cardiovascular health for the general cardiologist and family practitioner, when assessing the suitability of such patients for flying fitness.
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Affiliation(s)
- Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore; Changi Aviation Medical Centre, Changi General Hospital, Singapore.
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Jaarsma T, Hill L, Bayes-Genis A, La Rocca HPB, Castiello T, Čelutkienė J, Marques-Sule E, Plymen CM, Piper SE, Riegel B, Rutten FH, Ben Gal T, Bauersachs J, Coats AJS, Chioncel O, Lopatin Y, Lund LH, Lainscak M, Moura B, Mullens W, Piepoli MF, Rosano G, Seferovic P, Strömberg A. Self-care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 23:157-174. [PMID: 32945600 PMCID: PMC8048442 DOI: 10.1002/ejhf.2008] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022] Open
Abstract
Self-care is essential in the long-term management of chronic heart failure. Heart failure guidelines stress the importance of patient education on treatment adherence, lifestyle changes, symptom monitoring and adequate response to possible deterioration. Self-care is related to medical and person-centred outcomes in patients with heart failure such as better quality of life as well as lower mortality and readmission rates. Although guidelines give general direction for self-care advice, health care professionals working with patients with heart failure need more specific recommendations. The aim of the management recommendations in this paper is to provide practical advice for health professionals delivering care to patients with heart failure. Recommendations for nutrition, physical activity, medication adherence, psychological status, sleep, leisure and travel, smoking, immunization and preventing infections, symptom monitoring, and symptom management are consistent with information from guidelines, expert consensus documents, recent evidence and expert opinion.
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Affiliation(s)
- Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nursing Science, Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; and CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Teresa Castiello
- Department of Cardiology, Croydon Health Service and Department of Cardiovascular Imaging, Kings College London, London, UK
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Carla M Plymen
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Susan E Piper
- Department of Cardiology, King's College Hospital, London, UK
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Frans H Rutten
- Department of General Practice. Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology department, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease, Bucharest, Romania
| | - Yuri Lopatin
- Department of Cardiology, Cardiology Centre, Volgograd State Medical University, Volgograd, Russia
| | - Lars H Lund
- Department of Medicine Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Brenda Moura
- Hospital das Forças Armadas and Cintesis- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; and Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Massimo F Piepoli
- Department of Cardiology, G. da Saliceto Hospital, Piacenza, Italy.,Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, IRCCS San Raffaele Roma, Rome, Italy
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Cardiology, Linköping University, Linköping, Sweden
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Carta AF, Bitos K, Furian M, Mademilov M, Sheraliev U, Marazhapov NH, Lichtblau M, Schneider SR, Sooronbaev T, Bloch KE, Ulrich S. ECG changes at rest and during exercise in lowlanders with COPD travelling to 3100 m. Int J Cardiol 2020; 324:173-179. [PMID: 32987054 DOI: 10.1016/j.ijcard.2020.09.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/08/2020] [Accepted: 09/20/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The incidence and magnitude of cardiac ischemia and arrhythmias in patients with chronic obstructive pulmonary disease (COPD) during exposure to hypobaric hypoxia is insufficiently studied. We investigated electrocardiogram (ECG) markers of ischemia at rest and during incremental exercise testing (IET) in COPD-patients travelling to 3100 m. STUDY DESIGN AND METHODS Lowlanders (residence <800 m) with COPD (forced volume in the first second of expiration (FEV1) 40-80% predicted, oxygen saturation (SpO2) ≥92%, arterial partial pressure of carbon dioxide (PaCO2) <6 kPa at 760 m) aged 18 to 75 years, without history of cardiovascular disease underwent 12‑lead ECG recordings at rest and during cycle IET to exhaustion at 760 m and after acute exposure of 3 h to 3100 m. Mean ST-changes in ECGs averaged over 10s were analyzed for signs of ischemia (≥1 mm horizontal or downsloping ST-segment depression) at rest, peak exercise and 2-min recovery. RESULTS 80 COPD-patients (51% women, mean ± SD, 56.2 ± 9.6 years, body mass index (BMI) 27.0 ± 4.5 kg/m2, SpO2 94 ± 2%, FEV1 63 ± 10% prEd.) were included. At 3100 m, 2 of 53 (3.8%) patients revealed ≥1 mm horizontal ST-depression during IET vs 0 of 64 at 760 m (p = 0.203). Multivariable mixed regression revealed minor but significant ST-depressions associated with altitude, peak exercise or recovery and rate pressure product (RPP) in multiple leads. CONCLUSION In this study, ECG recordings at rest and during IET in COPD-patients do not suggest an increased incidence of signs of ischemia with ascent to 3100 m. Whether statistically significant ST changes below the standard threshold of clinical relevance detected in multiple leads reflect a risk of ischemia during prolonged exposure remains to be elucidated.
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Affiliation(s)
- Arcangelo F Carta
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland
| | - Konstantinos Bitos
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland
| | - Michael Furian
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland
| | - Maamed Mademilov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Ulan Sheraliev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Nuriddin H Marazhapov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Mona Lichtblau
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland
| | - Simon R Schneider
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland
| | - Talant Sooronbaev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Konrad E Bloch
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland
| | - Silvia Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Switzerland.
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Schneider SR, Mayer LC, Lichtblau M, Berlier C, Schwarz EI, Saxer S, Furian M, Bloch KE, Ulrich S. Effect of Normobaric Hypoxia on Exercise Performance in Pulmonary Hypertension: Randomized Trial. Chest 2020; 159:757-771. [PMID: 32918899 DOI: 10.1016/j.chest.2020.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/24/2020] [Accepted: 09/04/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Many patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension (PH) wish to travel to altitude or by airplane, but their risk of hypoxia-related adverse health effects is insufficiently explored. RESEARCH QUESTION How does hypoxia, compared with normoxia, affect constant work-rate exercise test (CWRET) time in patients with PH, and which physiologic mechanisms are involved? STUDY DESIGN AND METHODS Stable patients with PH with resting Pao2 ≥ 7.3 kPa underwent symptom-limited cycling CWRET (60% of maximal workload) while breathing normobaric hypoxic air (hypoxia; Fio2, 15%) and ambient air (normoxia; Fio2, 21%) in a randomized cross-over design. Borg dyspnea score, arterial blood gases, tricuspid regurgitation pressure gradient, and mean pulmonary artery pressure/cardiac output ratio (mean PAP/CO) by echocardiography were assessed before and during end-CWRET. RESULTS Twenty-eight patients (13 women) were included: median (quartiles) age, 66 (54; 74) years; mean pulmonary artery pressure, 41 (29; 49) mm Hg; and pulmonary vascular resistance, 5.4 (4; 8) Wood units. Under normoxia and hypoxia, CWRET times were 16.9 (8.0; 30.0) and 6.7 (5.5; 27.3) min, respectively, with a median difference (95% CI) of -0.7 (-3.1 to 0.0) min corresponding to -7 (-32 to 0.0)% (P = .006). At end-exercise in normoxia and hypoxia, respectively, median values and differences in corresponding variables were as follows: Pao2: 8.0 vs 6.4, -1.7 (-2.7 to -1.1) kPa; arterial oxygen content: 19.2 vs 17.2, -1.7 (-3 to -0.1) mL/dL; Paco2: 4.7 vs 4.3, -0.3 (-0.5 to -0.1) kPa; lactate: 3.7 vs 3.7, 0.9 (0.1 to 1.6) mM (P < .05 all differences). Values for Borg scale score: 7 vs 6, 0.5 (0 to 1); tricuspid pressure gradient: 89 vs 77, -3 (-9 to 16) mm Hg; and mean PAP/CO: 4.5 vs 3.3, 0.3 (-0.8 to 1.4) Wood units remained unchanged. In multivariable regression, baseline pulmonary vascular resistance was the sole predictor of hypoxia-induced change in CWRET time. INTERPRETATION In patients with PH, short-time exposure to hypoxia was well tolerated but reduced CWRET time compared with normoxia in association with hypoxemia, lactacidemia, and hypocapnia. Because pulmonary hemodynamics and dyspnea at end-exercise remained unaltered, the hypoxia-induced exercise limitation may be due to a reduced oxygen delivery causing peripheral tissue hypoxia, augmented lactic acid loading and hyperventilation. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03592927; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Simon R Schneider
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Laura C Mayer
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Esther I Schwarz
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Furian
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Konrad E Bloch
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland.
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14
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Ji Q, Zhang Y, Zhang H, Liu J, Cao C, Yuan Z, Ma Q, Zhang W. Effects of β-adrenoceptor activation on haemodynamics during hypoxic stress in rats. Exp Physiol 2020; 105:1660-1668. [PMID: 32706493 DOI: 10.1113/ep088669] [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: 04/05/2020] [Accepted: 07/23/2020] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? The acute hypoxic compensatory reaction is based on haemodynamic changes, and β-adrenoceptors are involved in haemodynamic regulation. What is the role of β-adrenoceptors in haemodynamics during hypoxic exposure? What is the main finding and its importance? Activation of β2 -adrenoceptors attenuates the increase in pulmonary artery pressure during hypoxic exposure. This compensatory reaction activated by β2 -adrenoceptors during hypoxic stress is very important to maintain the activities of normal life. ABSTRACT The acute hypoxic compensatory reaction is accompanied by haemodynamic changes. We monitored the haemodynamic changes in rats undergoing acute hypoxic stress and applied antagonists of β-adrenoceptor (β-ARs) subtypes to reveal the regulatory role of β-ARs on haemodynamics. Sprague-Dawley rats were randomly divided into control, atenolol (β1 -AR antagonist), ICI 118,551 (β2 -AR antagonist) and propranolol (non-selective β-AR antagonist) groups. Rats were continuously recorded for changes in haemodynamic indexes for 10 min after administration. Then, a hypoxic ventilation experiment [15% O2 , 2200 m a.sl., 582 mmHg (0.765 Pa), P O 2 87.3 mmHg; Xining, China] was conducted, and the indexes were monitored for 5 min after induction of hypoxia. Plasma catecholamine concentrations were also measured. We found that, during normoxia, the mean arterial pressure, heart rate, ascending aortic blood flow and pulmonary artery pressure were reduced in the propranolol and atenolol groups. Catecholamine concentrations were increased significantly in the atenolol group compared with the control group. During hypoxia, mean arterial pressure and total peripheral resistance were decreased in the control, propranolol and ICI 118,551 groups. Pulmonary arterial pressure and pulmonary vascular resistance were increased in the propranolol and ICI 118,551 groups. During hypoxia, catecholamine concentrations were increased significantly in the control group, but decreased in β-AR antagonist groups. In conclusion, the β2 -AR is involved in regulation of pulmonary haemodynamics in the acute hypoxic compensatory reaction, and the activation of β2 -ARs attenuates the increase in pulmonary arterial pressure during hypoxic stress. This compensatory reaction activated by β2 -ARs during hypoxic stress is very important to maintain activities of normal life.
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Affiliation(s)
- Qiaorong Ji
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China.,Pathophysiology Laboratory, The Key Laboratory of Science and Technology for High Altitude Medicine, No.16 kunlun road, Xining, Qinghai, 810001, China
| | - Yu Zhang
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China
| | - Huan Zhang
- Department of Pathology, Weinan Central Hospital, Shengli street, Weinan, Shaanxi, 714000, China
| | - Jie Liu
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China.,Pathophysiology Laboratory, The Key Laboratory of Science and Technology for High Altitude Medicine, No.16 kunlun road, Xining, Qinghai, 810001, China
| | - Chengzhu Cao
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China.,Pathophysiology Laboratory, The Key Laboratory of Science and Technology for High Altitude Medicine, No.16 kunlun road, Xining, Qinghai, 810001, China
| | - Zhouyang Yuan
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China.,Pathophysiology Laboratory, The Key Laboratory of Science and Technology for High Altitude Medicine, No.16 kunlun road, Xining, Qinghai, 810001, China
| | - Qianqian Ma
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China.,Pathophysiology Laboratory, The Key Laboratory of Science and Technology for High Altitude Medicine, No.16 kunlun road, Xining, Qinghai, 810001, China
| | - Wei Zhang
- Department of Basic Medicine, Medical College of Qinghai University, No.16 kunlun road, Xining, Qinghai, 810001, China.,Pathophysiology Laboratory, The Key Laboratory of Science and Technology for High Altitude Medicine, No.16 kunlun road, Xining, Qinghai, 810001, China
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15
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Stewart GM, Chase S, Cross TJ, Wheatley-Guy CM, Joyner MJ, Curry T, Lehrer-Graiwer J, Dufu K, Vlahakis NE, Johnson BD. Effects of an allosteric hemoglobin affinity modulator on arterial blood gases and cardiopulmonary responses during normoxic and hypoxic low-intensity exercise. J Appl Physiol (1985) 2020; 128:1467-1476. [PMID: 32324473 DOI: 10.1152/japplphysiol.00185.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Numerous pathophysiological conditions induce hypoxemia-related cardiopulmonary perturbations, decrements in exercise capacity, and debilitating symptoms. Accordingly, this study investigated the efficacy of an allosteric hemoglobin modulator (voxelotor) to enhance arterial oxygen saturation during low-intensity exercise in hypoxia. Eight normal healthy subjects (36 ± 7 yr; 73.8 ± 9.5 kg; 3 women) completed a submaximal cycling test (60 W) under normoxic ([Formula: see text]: 0.21; O2 partial pressure: 144 mmHg) and hypoxic ([Formula: see text]: 0.125; O2 partial pressure: 82 mmHg) conditions before (day 1) and after (day 15) 14 days of oral drug administration. While stationary on a cycle ergometer and during exercise, ratings of perceived exertion (RPE) and dyspnea, oxygen consumption (V̇o2), and cardiac output (Q) were measured noninvasively, while arterial blood pressure (MAP) and blood gases ([Formula: see text], [Formula: see text], and [Formula: see text]) were measured invasively. The 14-day drug administration left shifted the oxygen-hemoglobin dissociation curve (ODC; p50 measured at standard pH and Pco2; day 1: 28.0 ± 2.1 mmHg vs. day 15: 26.1 ± 1.8 mmHg, P < 0.05). RPE, dyspnea, V̇o2, Q, and MAP were not different between day 1 and day 15. [Formula: see text] was similar during normoxia on day 1 and day 15 while stationary but higher during exercise (day 1: 95.2 ± 0.4% vs. day 15: 96.6 ± 0.3%, P < 0.05). [Formula: see text] was higher during hypoxia on day 15 while stationary (day 1: 82.9 ± 3.4% vs. day 15: 90.9 ± 1.8%, P < 0.05) and during exercise (day 1: 73.6 ± 2.5% vs. day 15: 84.8 ± 2.7%, P < 0.01). [Formula: see text] and [Formula: see text]were systematically higher and lower, respectively, after drug (P < 0.01), while the alveolar-arterial oxygen difference was unchanged suggesting hyperventilation contributed to the rise in [Formula: see text]. Oral administration of voxelotor left shifted the ODC and stimulated a mild hyperventilation, leading to improved arterial oxygen saturation without altering V̇o2 and central hemodynamics during rest and low-intensity exercise. This effect was more pronounced during submaximal hypoxic exercise, when arterial desaturation was more evident. Additional studies are needed to determine the effects of voxelotor during maximal exercise and under chronic forms of hypoxia.NEW & NOTEWORTHY In humans, a novel allosteric hemoglobin-oxygen affinity modulator was administered to comprehensively examine the cardiopulmonary consequences of stabilizing a portion of the available hemoglobin in a high-oxygen affinity state during submaximal exercise in normoxia and hypoxia. Oral administration of voxelotor enhanced arterial oxygen saturation during submaximal exercise without altering oxygen consumption and central hemodynamics; however, the partial pressure of arterial carbon dioxide was reduced and the partial pressure of arterial oxygen was increased implying that hyperventilation also contributed to the increase in oxygen saturation. The preservation of arterial oxygen saturation and content was particularly evident during hypoxic submaximal exercise, when arterial desaturation typically occurs, but this did not influence arterial-venous oxygen difference.
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Affiliation(s)
- Glenn M Stewart
- Human Integrative and Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Steven Chase
- Human Integrative and Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Troy J Cross
- Human Integrative and Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Courtney M Wheatley-Guy
- Human Integrative and Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Michael J Joyner
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Timothy Curry
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Kobina Dufu
- Global Blood Therapeutics, South San Francisco, California
| | | | - Bruce D Johnson
- Human Integrative and Environmental Physiology Laboratory, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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16
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Abstract
Objective: It is well known that the altitude may affect the cardiovascular system. However, there were a few data related to the effect of altitude on the adverse outcome in patients with heart failure with reduced ejection fraction (HFREF). The aim of the present study was to investigate the role of intermediate high altitude on the major adverse cardiovascular outcome in patients with HFREF. Methods: Patients with HFREF admitted to the outpatient clinics at the first center at sea level and the second center at 1890 m were prospectively enrolled in the study. HFREF was defined as symptoms/signs of heart failure and left ventricular ejection fraction <40%. The major adverse cardiac outcome (MACE) was defined as all-cause death, stroke, and re-hospitalization due to heart failure. The median follow-up period of the study population was 27 months. Results: The study included 320 (58.55% male, mean age 65.7±11.2 years) patients. The incidence of all-cause death was 8.5%, stroke 6.1%, re-hospitalization due to decompensated heart failure 34.3%, and MACE 48.9%. In Kaplan-Meier analysis, patients with HFREF living at high altitude had more MACE (71.1% vs. 25.3%, log rank p=0.005) and presented with more stroke (11.3% vs. 2.1%, log rank p=0.001) and re-hospitalization due to heart failure (65.1% vs. 20.1%, log rank p<0.001) rates than those at low altitude in the follow-up; however, the rate of all-cause death was similar (9.4% vs. 8.1%, log rank p=0.245). Conclusion: In the present study, we demonstrated that the intermediate high altitude is the independent predictor of MACE in patients with HFREF. High altitude may be considered as a risk factor in decompensating heart failure.
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17
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Parati G, Agostoni P, Basnyat B, Bilo G, Brugger H, Coca A, Festi L, Giardini G, Lironcurti A, Luks AM, Maggiorini M, Modesti PA, Swenson ER, Williams B, Bärtsch P, Torlasco C. Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions: A joint statement by the European Society of Cardiology, the Council on Hypertension of the European Society of Cardiology, the European Society of Hypertension, the International Society of Mountain Medicine, the Italian Society of Hypertension and the Italian Society of Mountain Medicine. Eur Heart J 2019; 39:1546-1554. [PMID: 29340578 PMCID: PMC5930248 DOI: 10.1093/eurheartj/ehx720] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 12/15/2017] [Indexed: 01/22/2023] Open
Abstract
Adapted from Bärtsch and Gibbs2 Physiological response to hypoxia. Life-sustaining oxygen delivery, in spite of a reduction in the partial pressure of inhaled oxygen between 25% and 60% (respectively at 2500 m and 8000 m), is ensured by an increase in pulmonary ventilation, an increase in cardiac output by increasing heart rate, changes in vascular tone, as well as an increase in haemoglobin concentration. BP, blood pressure; HR, heart rate; PaCO2, partial pressure of arterial carbon dioxide. ![]()
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Affiliation(s)
- Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, Italy
| | - Piergiuseppe Agostoni
- Department of Cardiology, Heart Failure Unit, Centro Cardiologico Monzino, via Parea 4, 20138 Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, via Festa del Perdono 7, 20122 Milan, Italy
| | - Buddha Basnyat
- Nuffield Department of Clinical Medicine, Oxford University Clinical Research Unit-Nepal and Centre for Tropical Medicine and Global Health, University of Oxford, Old Road campus, Roosevelt Drive, Headington, Oxford OX3 7FZ, UK
| | - Grzegorz Bilo
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine at the EURAC Research, viale Druso 1, 39100 Bolzano, Italy.,Medical University, Christoph-Probst-Platz 1, Innrain 52 A - 6020 Innsbruck, Austria
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic (IDIBAPS), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Luigi Festi
- Surgery Department, Ospedale di Circolo Fondazione Macchi, viale Luigi Borri, 57, 21100 Varese, Italy.,University of Insubria, via Ravasi 2, 21100 Varese, Italy
| | - Guido Giardini
- Department of Neurology, Neurophysiopathology Unit, Valle d'Aosta Regional Hospital, via Ginevra, 3, 11100 Aosta, Italy
| | - Alessandra Lironcurti
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy
| | - Andrew M Luks
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, 98195 WA, USA
| | - Marco Maggiorini
- Medical Intensive Care Unit, University Hospital, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Pietro A Modesti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134 Florence, Florence, Italy
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, 98195 WA, USA.,Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, 98108 WA, USA
| | - Bryan Williams
- University College London (UCL) and NIHR UCL Hospitals Biomedical Research Centre, NHS Foundation Trust, University College, Gower St, Bloomsbury, London WC1E 6BT, UK
| | - Peter Bärtsch
- Department of Internal Medicine, University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Camilla Torlasco
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy
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18
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Mourot L. Limitation of Maximal Heart Rate in Hypoxia: Mechanisms and Clinical Importance. Front Physiol 2018; 9:972. [PMID: 30083108 PMCID: PMC6064954 DOI: 10.3389/fphys.2018.00972] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/02/2018] [Indexed: 12/17/2022] Open
Abstract
The use of exercise intervention in hypoxia has grown in popularity amongst patients, with encouraging results compared to similar intervention in normoxia. The prescription of exercise for patients largely rely on heart rate recordings (percentage of maximal heart rate (HRmax) or heart rate reserve). It is known that HRmax decreases with high altitude and the duration of the stay (acclimatization). At an altitude typically chosen for training (2,000-3,500 m) conflicting results have been found. Whether or not this decrease exists or not is of importance since the results of previous studies assessing hypoxic training based on HR may be biased due to improper intensity. By pooling the results of 86 studies, this literature review emphasizes that HRmax decreases progressively with increasing hypoxia. The dose–response is roughly linear and starts at a low altitude, but with large inter-study variabilities. Sex or age does not seem to be a major contributor in the HRmax decline with altitude. Rather, it seems that the greater the reduction in arterial oxygen saturation, the greater the reduction in HRmax, due to an over activity of the parasympathetic nervous system. Only a few studies reported HRmax at sea/low level and altitude with patients. Altogether, due to very different experimental design, it is difficult to draw firm conclusions in these different clinical categories of people. Hence, forthcoming studies in specific groups of patients are required to properly evaluate (1) the HRmax change during acute hypoxia and the contributing factors, and (2) the physiological and clinical effects of exercise training in hypoxia with adequate prescription of exercise training intensity if based on heart rate.
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Affiliation(s)
- Laurent Mourot
- EA 3920 Prognostic Markers and Regulatory Factors of Cardiovascular Diseases and Exercise Performance, Health, Innovation Platform, University of Franche-Comté, Besançon, France.,Tomsk Polytechnic University, Tomsk, Russia
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19
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Kim MS, Lee JH, Kim EJ, Park DG, Park SJ, Park JJ, Shin MS, Yoo BS, Youn JC, Lee SE, Ihm SH, Jang SY, Jo SH, Cho JY, Cho HJ, Choi S, Choi JO, Han SW, Hwang KK, Jeon ES, Cho MC, Chae SC, Choi DJ. Korean Guidelines for Diagnosis and Management of Chronic Heart Failure. Korean Circ J 2017; 47:555-643. [PMID: 28955381 PMCID: PMC5614939 DOI: 10.4070/kcj.2017.0009] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 06/19/2017] [Accepted: 06/23/2017] [Indexed: 11/11/2022] Open
Abstract
The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea.
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.
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Affiliation(s)
- Min-Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eung Ju Kim
- Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Dae-Gyun Park
- Division of Cardiology, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Sang Eun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Hyun Ihm
- Department of Cardiology, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Se Yong Jang
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Sang-Ho Jo
- Division of Cardiology, Hallym University Pyeongchon Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seonghoon Choi
- Division of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Woo Han
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Kyung Kuk Hwang
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eun Seok Jeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myeong-Chan Cho
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Shung Chull Chae
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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20
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Hammadah M, Kindya BR, Allard-Ratick MP, Jazbeh S, Eapen D, Wilson Tang WH, Sperling L. Navigating air travel and cardiovascular concerns: Is the sky the limit? Clin Cardiol 2017; 40:660-666. [PMID: 28597566 DOI: 10.1002/clc.22741] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 11/06/2022] Open
Abstract
As the population ages and our ability to care for patients with cardiac disease improves, an increasing number of passengers with cardiovascular conditions will be traveling long distances. Many have had cardiac symptoms, recent interventions, devices, or surgery. Air travel is safe for most individuals with stable cardiovascular disease. However, a thorough understanding of the physiologic changes during air travel is essential given the potential impact on cardiovascular health and the risk of complications in passengers with preexisting cardiac conditions. It is important for clinicians to be aware of the current recommendations and precautions that need to be taken before and during air travel for passengers with cardiovascular concerns.
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Affiliation(s)
- Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Bryan R Kindya
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Marc P Allard-Ratick
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sammer Jazbeh
- Department of Radiology, University of Oklahoma, Oklahoma City
| | - Danny Eapen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Laurence Sperling
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
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21
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Riley CJ, Gavin M. Physiological Changes to the Cardiovascular System at High Altitude and Its Effects on Cardiovascular Disease. High Alt Med Biol 2017; 18:102-113. [PMID: 28294639 DOI: 10.1089/ham.2016.0112] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Riley, Callum James, and Matthew Gavin. Physiological changes to the cardiovascular system at high altitude and its effects on cardiovascular disease. High Alt Med Biol. 18:102-113, 2017.-The physiological changes to the cardiovascular system in response to the high altitude environment are well understood. More recently, we have begun to understand how these changes may affect and cause detriment to cardiovascular disease. In addition to this, the increasing availability of altitude simulation has dramatically improved our understanding of the physiology of high altitude. This has allowed further study on the effect of altitude in those with cardiovascular disease in a safe and controlled environment as well as in healthy individuals. Using a thorough PubMed search, this review aims to integrate recent advances in cardiovascular physiology at altitude with previous understanding, as well as its potential implications on cardiovascular disease. Altogether, it was found that the changes at altitude to cardiovascular physiology are profound enough to have a noteworthy effect on many forms of cardiovascular disease. While often asymptomatic, there is some risk in high altitude exposure for individuals with certain cardiovascular diseases. Although controlled research in patients with cardiovascular disease was largely lacking, meaning firm conclusions cannot be drawn, these risks should be a consideration to both the individual and their physician.
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Affiliation(s)
| | - Matthew Gavin
- 2 University of Leeds School of Biomedical Sciences , Leeds, United Kingdom
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Naouri D, Lapostolle F, Rondet C, Ganansia O, Pateron D, Yordanov Y. Prevention of Medical Events During Air Travel: A Narrative Review. Am J Med 2016; 129:1000.e1-6. [PMID: 27267286 PMCID: PMC7093858 DOI: 10.1016/j.amjmed.2016.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 01/23/2023]
Abstract
Prior to traveling, and when seeking medical pretravel advice, patients consult their personal physicians. Inflight medical issues are estimated to occur up to 350 times per day worldwide (1/14,000-40,000 passengers). Specific characteristics of the air cabin environment are associated with hypoxia and the expansion of trapped gases into body cavities, which can lead to harm. The most frequent medical events during air travel include abdominal pain; ear, nose, and throat pathologies; psychiatric disorders; and life-threatening events such as acute respiratory failure or cardiac arrest. Physicians need to be aware of the management of these conditions in this unusual setting. Chronic respiratory and cardiovascular diseases are common and are at increased risk of acute exacerbation. Physicians must be trained in these conditions and inform their patients about their prevention.
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Affiliation(s)
- Diane Naouri
- Service des Urgences, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Frederic Lapostolle
- SAMU 93, Hopital Avicenne, Assistance Publique des Hôpitaux de Paris, Bobigny, France; Faculté de Médecine, Université Paris 13, Sorbonne Paris Cité, Paris, France
| | - Claire Rondet
- Faculté de Médecine, Université Pierre et Marie-Curie, Departement de Médecine Générale, Paris, France
| | - Olivier Ganansia
- Service des Urgences, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Dominique Pateron
- Service des Urgences, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université Pierre et Marie-Curie, Paris, France and NOT Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Youri Yordanov
- Service des Urgences, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université Pierre et Marie-Curie, Paris, France and NOT Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Centre de Recherche Epidémiologie et Statistique, INSERM U1153, Paris, France.
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Vona M, Mazzuero G, Lupi A, Vettorato C, Bosso P, Cohen-Solal A. Effects of altitude on effort tolerance in non-acclimatized patients with ischemic left ventricular dysfunction. ACTA ACUST UNITED AC 2016; 13:617-24. [PMID: 16874154 DOI: 10.1097/01.hjr.0000220583.27140.9b] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few studies exist on the effects, in terms of work capacity and safety, of exposure to moderately high altitudes in patients with stable ischemic left ventricular dysfunction. Moreover no data are currently available on the cardiorespiratory response to walks in the mountains. AIM The objective of this study is to evaluate the effects of altitude on effort tolerance during walks in the mountains and to determine whether exposure to altitude may be harmful to patients with ischemic left ventricular dysfunction. METHODS Forty-five patients with stable chronic ischemic left ventricular dysfunction (ejection fraction=35+/-4%, and peak VO2>/=18/ml/kg per min in a preliminary effort test) were compared to 24 normal subjects. All subjects underwent a series of 6-min walking tests at three different altitudes: 500, 2000 and 2970 m above sea level. Cardiorespiratory response was assessed by a validated portable instrument. The resting arterial PO2 was measured at the three altitudes. RESULTS No complications were observed during any tests in either the patients or the healthy controls. Overall, healthy subjects had higher values of 6-min walking test VO2 and walked longer distances in the test than did the patients with left ventricular dysfunction. The mean distances walked in the 6-min walking test were similar at 500 and at 2000 m in both the healthy controls and the patients; at 2970 m, however, the distances decreased in both groups, and more so in the patients (-11+/-3%) than in the controls (-5+/-2%) (P<0.01). VO2 during the 6-min walking test remained stable when the test was carried out at 500 and 2000 m (20.4+/-3.6 versus 19.9+/-4.1 ml/kg per min in patients, and 30.2+/-3.4 versus 29.8+/-4.2 ml/kg per min in the controls; P, NS), but decreased at 2970 m by 13.9+/-3% in patients (P<0.01) and by 6.6+/-2.1% in controls (P<0.01) (patients versus controls, P<0.01). Finally, a similar, significant decrease in arterial PO2 was observed in both groups only at 2970 m (-29%, P<0.01). CONCLUSION Patients with stable ischemic left ventricular dysfunction had good tolerance while walking at high altitudes, but showed a moderate decrease in work capacity at 2970 m, which was greater than in normal subjects.
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Affiliation(s)
- Margherita Vona
- Cardiac Rehabilitation Center, Cardiology, Beauregard Hospital, Aosta bS. Maugeri Foundation, IRCCS, Veruno, Italy.
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Serebrovskaya TV, Xi L. Intermittent hypoxia training as non-pharmacologic therapy for cardiovascular diseases: Practical analysis on methods and equipment. Exp Biol Med (Maywood) 2016; 241:1708-23. [PMID: 27407098 DOI: 10.1177/1535370216657614] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The global industrialization has brought profound lifestyle changes and environmental pollutions leading to higher risks of cardiovascular diseases. Such tremendous challenges outweigh the benefits of major advances in pharmacotherapies (such as statins, antihypertensive, antithrombotic drugs) and exacerbate the public healthcare burdens. One of the promising complementary non-pharmacologic therapies is the so-called intermittent hypoxia training (IHT) via activation of the human body's own natural defense through adaptation to intermittent hypoxia. This review article primarily focuses on the practical questions concerning the utilization of IHT as a non-pharmacologic therapy against cardiovascular diseases in humans. Evidence accumulated in the past five decades of research in healthy men and patients has suggested that short-term daily sessions consisting 3-4 bouts of 5-7 min exposures to 12-10% O2 alternating with normoxic durations for 2-3 weeks can result in remarkable beneficial effects in treatment of cardiovascular diseases such as hypertension, coronary heart disease, and heart failure. Special attentions are paid to the therapeutic effects of different IHT models, along with introduction of a variety of specialized facilities and equipment available for IHT, including hypobaric chambers, hypoxia gas mixture deliver equipment (rooms, tents, face masks), and portable rebreathing devices. Further clinical trials and thorough evaluations of the risks versus benefits of IHT are much needed to develop a series of standardized and practical guidelines for IHT. Taken together, we can envisage a bright future for IHT to play a more significant role in the preventive and complementary medicine against cardiovascular diseases.
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Affiliation(s)
- Tatiana V Serebrovskaya
- Department of Hypoxia, Bogomoletz Institute of Physiology, National Academy of Sciences of Ukraine, Kiev 01024, Ukraine
| | - Lei Xi
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298-0204, USA Department of Sports Medicine, Chengdu Sport University, Chengdu 610041, China
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Schmid JP, Nobel D, Brugger N, Novak J, Palau P, Trepp A, Wilhelm M, Saner H. Short-term high altitude exposure at 3454 m is well tolerated in patients with stable heart failure. Eur J Heart Fail 2015; 17:182-6. [DOI: 10.1002/ejhf.227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 11/15/2014] [Accepted: 11/21/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jean-Paul Schmid
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Daniel Nobel
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Jan Novak
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Patricia Palau
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Anja Trepp
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Matthias Wilhelm
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
| | - Hugo Saner
- Department of Cardiology, Unit of Preventive Cardiology & Sports Medicine; Bern University Hospital, and University of Bern; Switzerland
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Izadi M, Alemzadeh-Ansari MJ, Kazemisaleh D, Moshkani-Farahani M. Air travel considerations for the patients with heart failure. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e17213. [PMID: 25068047 PMCID: PMC4102980 DOI: 10.5812/ircmj.17213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/02/2014] [Accepted: 03/16/2014] [Indexed: 12/04/2022]
Abstract
Context: Prevalence of patients with heart failure (HF) is increasing in worldwide, and also the number of people with HF traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. However, observational studies about problems of HF patients during flight and appropriated considerations for them are limited. Evidence Acquisition: We evaluated the conditions that may be encountered in a HF patient and provide the recommendations to prevent the exacerbation of cardiac failure during air travel. For this review article, a comprehensive search was undertaken for the studies that evaluated the complications and considerations of HF patients during flight. Data bases searched were: MEDLINE, EMBASE, Science Direct, and Google Scholar. Results: HF patients are more prone to experience respiratory distress, anxiety, stress, cardiac decompensation, and venous thromboembolism (VTE) during air travel. Although stable HF patients can tolerate air travel, but those with acute heart failure syndrome should not fly until complete improvement is achieved. Conclusions: Thus, identifying the HF patients before the flight and providing them proper education about the events that may occur during flight is necessary.
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Affiliation(s)
- Morteza Izadi
- Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Javad Alemzadeh-Ansari
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Mohammad Javad Alemzadeh-Ansari, Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9166174016, E-mail:
| | - Davood Kazemisaleh
- Department of Cardiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Seccombe LM, Peters MJ. Physiology in Medicine: Acute altitude exposure in patients with pulmonary and cardiovascular disease. J Appl Physiol (1985) 2014; 116:478-85. [DOI: 10.1152/japplphysiol.01013.2013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Travel is more affordable and improved high-altitude airports, railways, and roads allow rapid access to altitude destinations without acclimatization. The physiology of exposure to altitude has been extensively described in healthy individuals; however, there is a paucity of data pertaining to those who have reduced reserve. This Physiology in Medicine article discusses the physiological considerations relevant to the safe travel to altitude and by commercial aircraft in patients with pulmonary and/or cardiac disease.
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Affiliation(s)
- Leigh M. Seccombe
- Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia; and
- Thoracic Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Matthew J. Peters
- Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia; and
- Thoracic Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Hobkirk JP, Damy T, Walters M, Bennett A, Smith SJ, Ingle L, Clark AL, Cleland JG. Effects of reducing inspired oxygen concentration for one hour in patients with chronic heart failure: implications for air travel. Eur J Heart Fail 2014; 15:505-10. [DOI: 10.1093/eurjhf/hft003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
| | - Thibaud Damy
- Department of Academic Cardiology; University of Hull; Hull UK
- Fédération de Cardiologie; Henri Mondor Hospital, INSERM U955, Université Paris Est Créteil All; Creteil France
| | - Mandy Walters
- Department of Academic Cardiology; University of Hull; Hull UK
| | - Anna Bennett
- Department of Academic Cardiology; University of Hull; Hull UK
| | - Sarah J. Smith
- Department of Academic Cardiology; University of Hull; Hull UK
| | - Lee Ingle
- Department of Sport, Health and Exercise Science; University of Hull; Hull UK
| | - Andrew L. Clark
- Department of Academic Cardiology; University of Hull; Hull UK
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29
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Agostoni P. Considerations on Safety and Treatment of Patients with Chronic Heart Failure at High Altitude. High Alt Med Biol 2013; 14:96-100. [DOI: 10.1089/ham.2012.1117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Dipartimento di scienze cliniche e di comunità, Università di Milano, Milan Italy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Contini M, Apostolo A, Cattadori G, Paolillo S, Iorio A, Bertella E, Salvioni E, Alimento M, Farina S, Palermo P, Loguercio M, Mantegazza V, Karsten M, Sciomer S, Magrì D, Fiorentini C, Agostoni P. Multiparametric comparison of CARvedilol, vs. NEbivolol, vs. BIsoprolol in moderate heart failure: the CARNEBI trial. Int J Cardiol 2013; 168:2134-40. [PMID: 23506636 DOI: 10.1016/j.ijcard.2013.01.277] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/18/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several β-blockers, with different pharmacological characteristics, are available for heart failure (HF) treatment. We compared Carvedilol (β1-β2-α-blocker), Bisoprolol (β1-blocker), and Nebivolol (β1-blocker, NO-releasing activity). METHODS Sixty-one moderate HF patients completed a cross-over randomized trial, receiving, for 2 months each, Carvedilol, Nebivolol, Bisoprolol (25.6 ± 12.6, 5.0 ± 2.4 and 5.0 ± 2.4 mg daily, respectively). At the end of each period, patients underwent: clinical evaluation, laboratory testing, echocardiography, spirometry (including total DLCO and membrane diffusion), O2/CO2 chemoreceptor sensitivity, constant workload, in normoxia and hypoxia (FiO2=16%), and maximal cardiopulmonary exercise test. RESULTS No significant differences were observed for clinical evaluation (NYHA classification, Minnesota questionnaire), laboratory findings (including kidney function and BNP), echocardiography, and lung mechanics. DLCO was lower on Carvedilol (18.3 ± 4.8*mL/min/mmHg) compared to Nebivolol (19.9 ± 5.1) and Bisoprolol (20.0 ± 5.0) due to membrane diffusion 20% reduction (*=p<0.0001). Constant workload exercise showed in hypoxia a faster VO2 kinetic and a lower ventilation with Carvedilol. Peripheral and central sensitivity to CO2 was lower in Carvedilol while response to hypoxia was higher in Bisoprolol. Ventilation efficiency (VE/VCO2 slope) was 26.9 ± 4.1* (Carvedilol), 28.8 ± 4.0 (Nebivolol), and 29.0 ± 4.4 (Bisoprolol). Peak VO2 was 15.8 ± 3.6*mL/kg/min (Carvedilol), 16.9 ± 4.1 (Nebivolol), and 16.9 ± 3.6 (Bisoprolol). CONCLUSIONS β-Blockers differently affect several cardiopulmonary functions. Lung diffusion and exercise performance, the former likely due to lower interference with β2-mediated alveolar fluid clearance, were higher in Nebivolol and Bisoprolol. On the other hand, Carvedilol allowed a better ventilation efficiency during exercise, likely via a different chemoreceptor modulation. Results from this study represent the basis for identifying the best match between a specific β-blocker and a specific HF patient.
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Ingle L, Hobkirk J, Damy T, Nabb S, Clark AL, Cleland JGF. Experiences of air travel in patients with chronic heart failure. Int J Cardiol 2012; 158:66-70. [PMID: 21256607 PMCID: PMC3387374 DOI: 10.1016/j.ijcard.2010.12.101] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 12/13/2010] [Accepted: 12/30/2010] [Indexed: 11/29/2022]
Abstract
AIM To conduct a survey in a representative cohort of ambulatory patients with stable, well managed chronic heart failure (CHF) to discover their experiences of air travel. METHODS An expert panel including a cardiologist, an exercise scientist, and a psychologist developed a series of survey questions designed to elicit CHF patients' experiences of air travel (Appendix 1). The survey questions, information sheets and consent forms were posted out in a self-addressed envelope to 1293 CHF patients. RESULTS 464 patients (response rate 39%) completed the survey questionnaires. 54% of patients had travelled by air since their heart failure diagnosis. 20% of all patients reported difficulties acquiring travel insurance. 65% of patients who travelled by air experienced no health-related problems. 35% of patients who travelled by air experienced health problems, mainly at the final destination, going through security and on the aircraft. 27% of all patients would not travel by air in the future. 38% of patients would consider flying again if there were more leg room on the aeroplane, if their personal health improved (18%), if they could find cheaper travel insurance (19%), if there were less waiting at the airport (11%), or if there were less walking/fewer stairs to negotiate at the airport (7%). CONCLUSION For most patients in this sample of stable, well managed CHF, air travel was safe.
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Affiliation(s)
- Lee Ingle
- Carnegie Research Institute, Leeds Metropolitan University, Beckett's Park, Headingley, Leeds, LS6 3QS, United Kingdom.
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Clinical manifestations and long-term follow-up in pediatric patients living at altitude with isolated pulmonary artery of ductal origin. Pediatr Cardiol 2012; 33:775-81. [PMID: 22430374 PMCID: PMC3360790 DOI: 10.1007/s00246-012-0213-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/09/2011] [Indexed: 10/28/2022]
Abstract
This study's aim was to define the clinical manifestations and long-term outcome of pediatric patients living at altitude with isolated pulmonary artery (PA) of ductal origin (IPADO). This was a retrospective cohort study of 17 consecutive cases of IPADO at a single center. All patients lived at modest altitude (median 2050 m [range 1700 m to 3050 m]). Fifteen children (88%) were symptomatic at presentation. High-altitude pulmonary edema was present in 2 patients (12%) at diagnosis, and only 1 patient had episodes of hemoptysis during follow-up. Fourteen patients (82%) demonstrated evidence of pulmonary arterial hypertension (PAH). Among 14 patients with PAH, 11 patients had surgical interventions. PAH resolved in 5 of 11 patients (45%) undergoing surgical rehabilitation. One patient died during follow-up, and 7 patients are receiving oral vasodilator therapies due to residual PAH; 14 patients remained asymptomatic. Our study showed that early intervention in patients with IPADO at modest altitude can potentially rehabilitate the isolated PA and reverse PAH. Whether surgery is indicated for patients with this disorder in the absence of PAH is unknown.
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Improved Exercise Performance and Skeletal Muscle Strength After Simulated Altitude Exposure: A Novel Approach for Patients With Chronic Heart Failure. J Card Fail 2012; 18:387-91. [DOI: 10.1016/j.cardfail.2012.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 01/26/2012] [Accepted: 02/01/2012] [Indexed: 11/24/2022]
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Schommer K, Bärtsch P. Basic medical advice for travelers to high altitudes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:839-47; quiz 848. [PMID: 22238560 DOI: 10.3238/arztebl.2011.0839] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 09/08/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND High-altitude travel, for mountain climbing, trekking, or sightseeing, has become very popular. Therefore, the awareness of its dangers has increased, and many prospective travelers seek medical advice before setting forth on their trip. METHODS We selectively searched the literature for relevant original articles and reviews about acclimatization to high altitude and about high-altitude-related illnesses, including acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE) (search in Medline for articles published from 1960-2010). RESULTS High-altitude-related illnesses are caused by hypoxia and the resulting hypoxemia in otherwise healthy persons who travel too high too fast, with too little time to become acclimatized. The individual susceptibility to high-altitude-related illness is a further risk factor that can only be recognized in persons who have traveled to high altitudes in the past. In an unselected group of mountain climbers, 50% had AMS at 4500 meters, while 0.5-1% had HACE and 6% had HAPE at the same altitude. Persons with preexisting illnesses, particularly of the heart and lungs, can develop symptoms of their underlying disease at high altitudes because of hypoxia. Thus, medical advice is based on an assessment of the risk of illness in relation to the intended altitude profile of the trip, in consideration of the prospective traveler's suitability for high altitudes (cardiopulmonary performance status, exercise capacity) and individual susceptibility to high-altitude-related illnesses, as judged from previous exposures. The symptoms and treatment of high-altitude-related illnesses should be thoroughly explained. CONCLUSION An understanding of the physiology of adaptation to high altitudes and of the pathophysiology and clinical manifestations of high-altitude-related illnesses provides a basis for the proper counseling of prospective travelers, through which life-threatening conditions can be prevented.
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Affiliation(s)
- Kai Schommer
- Medizinische Universitätsklinik Heidelberg, Innere Medizin VII Sportmedizin.
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Vearrier D, Greenberg MI. Occupational health of miners at altitude: adverse health effects, toxic exposures, pre-placement screening, acclimatization, and worker surveillance. Clin Toxicol (Phila) 2011; 49:629-40. [PMID: 21861588 DOI: 10.3109/15563650.2011.607169] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Mining operations conducted at high altitudes provide health challenges for workers as well as for medical personnel. OBJECTIVE To review the literature regarding adverse health effects and toxic exposures that may be associated with mining operations conducted at altitude and to discuss pre-placement screening, acclimatization issues, and on-site surveillance strategies. METHODS We used the Ovid ( http://ovidsp.tx.ovid.com ) search engine to conduct a MEDLINE search for "coal mining" or "mining" and "altitude sickness" or "altitude" and a second MEDLINE search for "occupational diseases" and "altitude sickness" or "altitude." The search identified 97 articles of which 76 were relevant. In addition, the references of these 76 articles were manually reviewed for relevant articles. CARDIOVASCULAR EFFECTS: High altitude is associated with increased sympathetic tone that may result in elevated blood pressure, particularly in workers with pre-existing hypertension. Workers with a history of coronary artery disease experience ischemia at lower work rates at high altitude, while those with a history of congestive heart failure have decreased exercise tolerance at high altitude as compared to healthy controls and are at higher risk of suffering an exacerbation of their heart failure. PULMONARY EFFECTS: High altitude is associated with various adverse pulmonary effects, including high-altitude pulmonary edema, pulmonary hypertension, subacute mountain sickness, and chronic mountain sickness. Mining at altitude has been reported to accelerate silicosis and other pneumoconioses. Miners with pre-existing pneumoconioses may experience an exacerbation of their condition at altitude. Persons traveling to high altitude have a higher incidence of Cheyne-Stokes respiration while sleeping than do persons native to high altitude. Obesity increases the risk of pulmonary hypertension, acute mountain sickness, and sleep-disordered breathing. NEUROLOGICAL EFFECTS: The most common adverse neurological effect of high altitude is acute mountain sickness, while the most severe adverse neurological effect is high-altitude cerebral edema. Poor sleep quality and sleep-disordered breathing may contribute to daytime sleepiness and impaired cognitive performance that could potentially result in workplace injuries, particularly in miners who are already at increased risk of suffering unintentional workplace injuries. OPHTHALMOLOGICAL EFFECTS: Adverse ophthalmological effects include increased exposure to ultraviolet light and xerophthalmia, which may be further exacerbated by occupational dust exposure. RENAL EFFECTS: High altitude is associated with a protective effect in patients with renal disease, although it is unknown how this would affect miners with a history of chronic renal disease from exposure to silica and other renal toxicants. HEMATOLOGICAL EFFECTS: Advanced age increases the risk of erythrocytosis and chronic mountain sickness in miners. Thrombotic and thromboembolic events are also more common at high altitude. MUSCULOSKELETAL EFFECTS: Miners are at increased risk for low back pain due to occupational factors, and the easy fatigue at altitude has been reported to further predispose workers to this disorder. TOXIC EXPOSURES: Diesel emissions at altitude contain more carbon monoxide due to increased incomplete combustion of fuel. In addition, a given partial pressure of carbon monoxide at altitude will result in a larger percentage of carboxyhemoglobin at altitude. Miners with a diagnosis of chronic obstructive pulmonary disease may be at higher risk for morbidity from exposure to diesel exhaust at altitude. CONCLUSIONS Both mining and work at altitude have independently been associated with a number of adverse health effects, although the combined effect of mining activities and high altitude has not been adequately studied. Careful selection of workers, appropriate acclimatization, and limited on-site surveillance can help control most health risks. Further research is necessary to more completely understand the risks of mining at altitude and delineate what characteristics of potential employees put them at risk for altitude-related morbidity or mortality.
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Affiliation(s)
- David Vearrier
- Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA 19102, USA
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Karsten M, Contini M, Cefalù C, Cattadori G, Palermo P, Apostolo A, Bussotti M, Magrì D, Salvioni E, Farina S, Sciomer S, Catai AM, Agostoni P. Effects of carvedilol on oxygen uptake and heart rate kinetics in patients with chronic heart failure at simulated altitude. Eur J Prev Cardiol 2011; 19:444-51. [DOI: 10.1177/1741826711402736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The response to moderate exercise at altitude in heart failure (HF) is unknown. Methods and results: We evaluated 30 HF patients, (NYHA I-III, 25 M/5 F; 59 ± 10 years; LVEF = 39.6 ± 7.1%), in stable clinical conditions, treated with carvedilol at the maximal tolerated dose. We performed a maximal cardiopulmonary exercise test (CPET) with ramp protocol at sea level to evaluate patients’ performance and two moderate intensity constant workload CPETs (50% of peak workload) at sea level (normoxia) and simulated altitude (hypoxia). Oxygen uptake ([Formula: see text]) and heart rate (HR) on-kinetics at constant workload were assessed calculating the time constant (τ) with a monoexponential equation. [Formula: see text] and HR were higher in hypoxia (0.944 ± 0.233 vs 1.031 ± 0.264 l/min; 100 ± 23 vs 108 ± 22 bpm; p < 0.001). On-kinetics showed a different behavior of τ being [Formula: see text] faster in hypoxia (67.1 ± 23.0 vs. 56.3 ± 19.7 s; p = 0.026) and HR faster in normoxia (49.3 ± 19.4 vs. 62.2 ± 22.5 s; p = 0.018). Ten patients, who lowered oxygen kinetics in hypoxia, had greater HR increase during maximal CPET suggesting lower functional betablockade. The higher τ of [Formula: see text] in hypoxia is likely to be due to a peripheral effect of carvedilol mediated either by β- or α-receptor. Conclusion: HF patients performing moderate exercise at 2000 m simulated altitude have 20% [Formula: see text] increase without trouble at the beginning of exercise when treated with carvedilol.
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Affiliation(s)
- Marlus Karsten
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Laboratório de Fisioterapia Cardiovascular, Núcleo de Pesquisa em Exercício Físico, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | | | | | | | | | | | - Maurizio Bussotti
- Cardiologia Riabilitativa, Fondazione S Maugeri, IRCCS, Milan, Italy
| | - Damiano Magrì
- U.O. Cardiologia, S. Andrea Hospital, “Sapienza”, Rome University, Rome, Italy
| | | | | | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche e Geriatriche, ‘Sapienza’, Rome University, Rome, Italy
| | - Aparecida Maria Catai
- Laboratório de Fisioterapia Cardiovascular, Núcleo de Pesquisa em Exercício Físico, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Division of Critical Care and Respiratory Medicine, University of Washington, Seattle, USA
- Dipartimento di Scienze Cardiovascolari, Università di Milano, Milan, Italy
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High-Altitude Exposure in Patients with Cardiovascular Disease: Risk Assessment and Practical Recommendations. Prog Cardiovasc Dis 2010; 52:512-24. [DOI: 10.1016/j.pcad.2010.03.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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de Vries ST, Komdeur P, Aalbersberg S, van Enst GC, Breeman A, van 't Hof AWJ. Effects of altitude on exercise level and heart rate in patients with coronary artery disease and healthy controls. Neth Heart J 2010; 18:118-21. [PMID: 20390061 PMCID: PMC2848353 DOI: 10.1007/bf03091749] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background. To evaluate the safety and effects of high altitude on exercise level and heart rate in patients with coronary artery disease compared with healthy controls.Methods. Eight patients with a history of an acute myocardial infarction (ejection fraction >5%) with a low-risk score were compared with seven healthy subjects during the Dutch Heart Expedition at the Aconcagua in Argentina in March 2007. All subjects underwent a maximum exercise test with a cycle ergometer at sea level and base camp, after ten days of acclimatisation, at an altitude of 4200 m. Exercise capacity and maximum heart rate were compared between groups and within subjects.Results. There was a significant decrease in maximum heart rate at high altitude compared with sea level in both the patient and the control group (166 vs. 139 beats/min, p<0.001 and 181 vs. 150 beats/min, p<0.001). There was no significant difference in the decrease of the exercise level and maximum heart rate between patients and healthy controls (-31 vs. -30%, p=0.673).Conclusion. Both patients and healthy controls showed a similar decrease in exercise capacity and maximum heart rate at 4200 m compared with sea level, suggesting that patients with a history of coronary artery disease may tolerate stay and exercise at high altitude similarly to healthy controls. (Neth Heart J 2010;18:118-21.).
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Affiliation(s)
- S T de Vries
- Department of Sports Medicine, Isala Clinics, Zwolle, the Netherlands
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Higgins JP, Tuttle T, Higgins JA. Altitude and the heart: is going high safe for your cardiac patient? Am Heart J 2010; 159:25-32. [PMID: 20102863 DOI: 10.1016/j.ahj.2009.10.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 10/21/2009] [Indexed: 11/24/2022]
Abstract
Our aging population combined with the ease of travel and the interest in high altitude recreation pursuits exposes more patients to the acute physiologic effects of high altitude and lower oxygen availability. Acute exposure to high altitude is associated with significant alterations to the cardiovascular system. These may be important in patients with underlying cardiovascular disease who are not able to compensate to such physiologic changes. Exacerbating factors pertinent to patients with cardiovascular disease include acute hypoxia, increased myocardial work, increased epinephrine release, and increased pulmonary artery pressures. This review summarizes the physiology and clinical evidence regarding acute altitude exposure on the cardiopulmonary system with practical recommendations to address the question: "Is it safe for me to ski in the Rockies or climb Mt. Kilimanjaro?"
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Mieske K, Flaherty G, O'Brien T. Journeys to high altitude--risks and recommendations for travelers with preexisting medical conditions. J Travel Med 2010; 17:48-62. [PMID: 20074100 DOI: 10.1111/j.1708-8305.2009.00369.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kelly Mieske
- Department of Medicine, National University of Ireland, Galway, Ireland.
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Abstract
Almost 2 billion people travel aboard commercial airlines every year. Health-care providers and travellers need to be aware of the potential health risks associated with air travel. Environmental and physiological changes that occur during routine commercial flights lead to mild hypoxia and gas expansion, which can exacerbate chronic medical conditions or incite acute in-flight medical events. The association between venous thromboembolism and long-haul flights, cosmic-radiation exposure, jet lag, and cabin-air quality are growing health-care issues associated with air travel. In-flight medical events are increasingly frequent because a growing number of individuals with pre-existing medical conditions travel by air. Resources including basic and advanced medical kits, automated external defibrillators, and telemedical ground support are available onboard to assist flight crew and volunteering physicians in the management of in-flight medical emergencies.
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Affiliation(s)
- Danielle Silverman
- Department of Emergency Medicine, Georgetown University Hospital and Washington Hospital Center, Washington, DC, USA
| | - Mark Gendreau
- Department of Emergency Medicine, Lahey Clinic Medical Center, Burlington, MA, USA
- Tufts Medical School, Boston, MA, USA
- Correspondence to: Dr Mark Gendreau, Department of Emergency Medicine, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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Affiliation(s)
- Peter Bärtsch
- Department of Internal Medicine VII, Division of Sports Medicine, Medical University Clinic, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
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Agostoni P, Contini M, Magini A, Apostolo A, Cattadori G, Bussotti M, Veglia F, Andreini D, Palermo P. Carvedilol reduces exercise-induced hyperventilation: A benefit in normoxia and a problem with hypoxia. Eur J Heart Fail 2006; 8:729-35. [PMID: 16533619 DOI: 10.1016/j.ejheart.2006.02.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 10/27/2005] [Accepted: 02/01/2006] [Indexed: 11/25/2022] Open
Abstract
AIMS To evaluate whether carvedilol influences exercise hyperventilation and the ventilatory response to hypoxia in heart failure (HF). METHODS AND RESULTS Fifteen HF patients participated to this double blind, randomised, placebo controlled, cross-over study. Patients were evaluated by quality of life questionnaire, echocardiography, pulmonary function and cardiopulmonary exercise tests (ramp and constant workload) both in normoxia (FiO2 = 21%) and hypoxia (FiO2 = 16%, equivalent to a simulated altitude of 2000 m). Carvedilol improved clinical condition and reduced left ventricle size, but had no effect on lung mechanics. In normoxia during exercise, ventilation was lower, V(CO2) unchanged and PaCO2 (constant workload) or PetCO2 (ramp) higher with carvedilol, exercise capacity was unchanged (peak workload 92+/-22 and 90+/-22W for placebo and carvedilol, respectively). Abnormal V(E)/V(CO2) slope was reduced by carvedilol. Hypoxia increased ventilation but less with carvedilol; exercise capacity decreased to 87+/-21W (placebo) and to 80+/-11 W (carvedilol, p < 0.01). With hypoxia, carvedilol decreased V(E)/V(CO2) slope. At constant workload exercise with hypoxia, PaO2 decreased to 69+/-6 mm Hg (placebo) and to 64+/-5 (carvedilol, p < 0.01). CONCLUSION Carvedilol reduced hyperventilation possibly by reducing peripheral chemoreflex sensitivity as suggested by PaCO2 increase with normoxia and PaO2 decrease with hypoxia without V(CO2) and V(D)/V(T) changes. Lessening hyperventilation is beneficial when breathing normally, but detrimental when hyperventilation is needed for exercise at high altitude.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Istituto di Cardiologia, Università di Milano, Italy.
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Schmid JP, Noveanu M, Gaillet R, Hellige G, Wahl A, Saner H. Safety and exercise tolerance of acute high altitude exposure (3454 m) among patients with coronary artery disease. Heart 2005; 92:921-5. [PMID: 16339809 PMCID: PMC1860700 DOI: 10.1136/hrt.2005.072520] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To assess the safety and cardiopulmonary adaptation to high altitude exposure among patients with coronary artery disease. METHODS 22 patients (20 men and 2 women), mean age 57 (SD 7) years, underwent a maximal, symptom limited exercise stress test in Bern, Switzerland (540 m) and after a rapid ascent to the Jungfraujoch (3454 m). The study population comprised 15 patients after ST elevation myocardial infarction and 7 after a non-ST elevation myocardial infarction 12 (SD 4) months after the acute event. All patients were revascularised either by percutaneous coronary angioplasty (n = 15) or by coronary artery bypass surgery (n = 7). Ejection fraction was 60 (SD 8)%. beta blocking agents were withheld for five days before exercise testing. RESULTS At 3454 m, peak oxygen uptake decreased by 19% (p < 0.001), maximum work capacity by 15% (p < 0.001) and exercise time by 16% (p < 0.001); heart rate, ventilation and lactate were significantly higher at every level of exercise, except at maximum exertion. No ECG signs of myocardial ischaemia or significant arrhythmias were noted. CONCLUSIONS Although oxygen demand and lactate concentrations are higher during exercise at high altitude, a rapid ascent and submaximal exercise can be considered safe at an altitude of 3454 m for low risk patients six months after revascularisation for an acute coronary event and a normal exercise stress test at low altitude.
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Affiliation(s)
- J-P Schmid
- Swiss Cardiovascular Centre Bern, Cardiovascular Prevention & Rehabilitation, University Hospital (Inselspital), Bern, Switzerland.
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Angerer P, Nowak D. Working in permanent hypoxia for fire protection-impact on health. Int Arch Occup Environ Health 2003; 76:87-102. [PMID: 12733081 DOI: 10.1007/s00420-002-0394-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2002] [Accepted: 08/28/2002] [Indexed: 10/25/2022]
Abstract
OBJECTIVES A new technique to prevent fires is continuous exchange of oxygen with nitrogen which leads to an oxygen concentration of between 15% and 13% in the ambient air. This paper reviews the effect of short-term, intermittent hypoxia on health and performance of people working in such atmospheres. METHODS We reviewed the effect of ambient air hypoxia on human health in the literature using Medline, as well as reference lists of articles and handbooks. Articles were assessed from the perspective of working conditions in fire-protected rooms. RESULTS Oxygen reduced to 15% and 13% in normobaric atmospheres is equivalent to the hypobaric atmospheres found at 2,700 and 3,850-m altitudes. When acutely exposed, a healthy person responds within minutes to hours with increased ventilation, stimulation of the sympathetic system, increased heart rate, increased pulmonary-circulation resistance, reduced plasma volume, and stimulation of erythropoesis. Acute mountain sickness occurs frequently at these oxygen partial pressures, but the full syndrome is rare if continuous exposure is limited to 6 h. Mood, cognitive, and psychomotor functions may be mildly impaired in these conditions, but data are inconclusive. Persons suffering from cardiac, pulmonary, or hematological diseases should consult a specialist in order for their individual risk to be assessed, and medical screening for any of these diseases is strongly recommended prior to exposure. CONCLUSION Preliminary evidence suggests that working environments with low oxygen concentrations to a minimum of 13% and normal barometric pressure do not impose a health hazard, provided that precautions are observed, comprising medical examinations and limitation of exposure time. However, evidence is limited, particularly with regard to workers performing strenuous tasks or having various diseases. Therefore, close monitoring of the health problems of people working in low oxygen atmospheres is necessary.
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Affiliation(s)
- Peter Angerer
- Institute and Outpatient Clinic for Occupational and Environmental Medicine, Ludwig-Maximilians-University, Ziemssenstrasse 1, 80336, Munich, Germany.
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Agostoni PG, Bussotti M, Palermo P, Guazzi M. Does lung diffusion impairment affect exercise capacity in patients with heart failure? Heart 2002; 88:453-9. [PMID: 12381630 PMCID: PMC1767418 DOI: 10.1136/heart.88.5.453] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether there is a relation between impairment of lung diffusion and reduced exercise capacity in chronic heart failure. DESIGN 40 patients with heart failure in stable clinical condition and 40 controls participated in the study. All subjects underwent standard pulmonary function tests plus measurements of resting lung diffusion (carbon monoxide transfer, TLCO), pulmonary capillary volume (VC), and membrane resistance (DM), and maximal cardiopulmonary exercise testing. In 20 patients and controls, the following investigations were also done: (1) resting and constant work rate TLCO; (2) maximal cardiopulmonary exercise testing with inspiratory O2 fractions of 0.21 and 0.16; and (3) rest and peak exercise blood gases. The other subjects underwent TLCO, DM, and VC measurements during constant work rate exercise. RESULTS In normoxia, exercise induced reductions of haemoglobin O2 saturation never occurred. With hypoxia, peak exercise uptake (peak O2) decreased from (mean (SD)) 1285 (395) to 1081 (396) ml/min (p < 0.01) in patients, and from 1861 (563) to 1771 (457) ml/min (p < 0.05) in controls. Resting TLCO correlated with peak O2 in heart failure (normoxia < hypoxia). In heart failure patients and normal subjects, TLCO and peak O2 correlated with O2 arterial content at rest and during peak exercise in both normoxia and hypoxia. TLCO, VC, and DM increased during exercise. The increase in TLCO was greater in patients who had a smaller reduction of exercise capacity with hypoxia. Alveolar-arterial O2 gradient at peak correlated with exercise capacity in heart failure during normoxia and, to a greater extent, during hypoxia. CONCLUSIONS Lung diffusion impairment is related to exercise capacity in heart failure.
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Affiliation(s)
- P G Agostoni
- Centro Cardiologico Monzino, IRCCS, Institute of Cardiology, University of Milan, Milan, Italy.
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