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Nanah A, Garcia MVF, Lane J, Paul D, Tonelli AR. Plasma catecholamines in patients undergoing invasive cardiopulmonary exercise test for exercise intolerance. Respir Med 2024; 233:107775. [PMID: 39147212 DOI: 10.1016/j.rmed.2024.107775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 08/11/2024] [Accepted: 08/12/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Invasive cardiopulmonary exercise testing (iCPET) combines traditional cardiopulmonary exercise testing with invasive hemodynamic measurements to assess exercise intolerance, which can be caused by preload insufficiency (PI), characterized by low ventricular filling pressures and reduced cardiac output during exertion. We hypothesize that plasma catecholamine levels at rest and during exercise correlate with hemodynamic parameters in PI. METHODS We included adult patients who underwent iCPET for exercise intolerance and had plasma catecholamines measured at rest and peak exercise. RESULTS Among 84 patients, PI was identified in 57 (67.8 %). Compared to patients without PI, those with PI were younger [median (IQR) 37 (28, 46) vs 47 (39,55) years, p = 0.005] and had lower workload at peak exercise [81 (66, 96) vs 95 (83.5, 110.50) Watts, p = 0.006]. Patients with PI had higher heart rates at rest and peak exercise [87 (78, 97) vs 79 (74, 87) bpm, p = 0.04; and 167 (154, 183) vs 156 (136, 168) bpm, p = 0.01, respectively]. In all patients, epinephrine and norepinephrine at peak exercise directly correlated with peak workload (r:0.41, p < 0.001 and r:0.47, p < 0.001, respectively). Resting epinephrine was higher in patients with PI [136 (60, 210) vs 77 (41, 110) pg/mL, p = 0.02]. There was no significant difference in the change in catecholamines from rest to peak exercise between patients with or without PI. CONCLUSION PI patients exhibited elevated heart rate and epinephrine at rest, indicating increased sympathetic activity. We did not find strong associations between catecholamines and cardiac filling pressures, suggesting that catecholamine levels are predominantly influenced by peak workload.
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Affiliation(s)
- Abdelrahman Nanah
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Marcos V F Garcia
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - James Lane
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Deborah Paul
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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2
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Keller B, Receno CN, Franconi CJ, Harenberg S, Stevens J, Mao X, Stevens SR, Moore G, Levine S, Chia J, Shungu D, Hanson MR. Cardiopulmonary and metabolic responses during a 2-day CPET in myalgic encephalomyelitis/chronic fatigue syndrome: translating reduced oxygen consumption to impairment status to treatment considerations. J Transl Med 2024; 22:627. [PMID: 38965566 PMCID: PMC11229500 DOI: 10.1186/s12967-024-05410-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 06/17/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Post-exertional malaise (PEM), the hallmark symptom of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), represents a constellation of abnormal responses to physical, cognitive, and/or emotional exertion including profound fatigue, cognitive dysfunction, and exertion intolerance, among numerous other maladies. Two sequential cardiopulmonary exercise tests (2-d CPET) provide objective evidence of abnormal responses to exertion in ME/CFS but validated only in studies with small sample sizes. Further, translation of results to impairment status and approaches to symptom reduction are lacking. METHODS Participants with ME/CFS (Canadian Criteria; n = 84) and sedentary controls (CTL; n = 71) completed two CPETs on a cycle ergometer separated by 24 h. Two-way repeated measures ANOVA compared CPET measures at rest, ventilatory/anaerobic threshold (VAT), and peak effort between phenotypes and CPETs. Intraclass correlations described stability of CPET measures across tests, and relevant objective CPET data indicated impairment status. A subset of case-control pairs (n = 55) matched for aerobic capacity, age, and sex, were also analyzed. RESULTS Unlike CTL, ME/CFS failed to reproduce CPET-1 measures during CPET-2 with significant declines at peak exertion in work, exercise time, V ˙ e, V ˙ O2, V ˙ CO2, V ˙ T, HR, O2pulse, DBP, and RPP. Likewise, CPET-2 declines were observed at VAT for V ˙ e/ V ˙ CO2, PetCO2, O2pulse, work, V ˙ O2 and SBP. Perception of effort (RPE) exceeded maximum effort criteria for ME/CFS and CTL on both CPETs. Results were similar in matched pairs. Intraclass correlations revealed greater stability in CPET variables across test days in CTL compared to ME/CFS owing to CPET-2 declines in ME/CFS. Lastly, CPET-2 data signaled more severe impairment status for ME/CFS compared to CPET-1. CONCLUSIONS Presently, this is the largest 2-d CPET study of ME/CFS to substantiate impaired recovery in ME/CFS following an exertional stressor. Abnormal post-exertional CPET responses persisted compared to CTL matched for aerobic capacity, indicating that fitness level does not predispose to exertion intolerance in ME/CFS. Moreover, contributions to exertion intolerance in ME/CFS by disrupted cardiac, pulmonary, and metabolic factors implicates autonomic nervous system dysregulation of blood flow and oxygen delivery for energy metabolism. The observable declines in post-exertional energy metabolism translate notably to a worsening of impairment status. Treatment considerations to address tangible reductions in physiological function are proffered. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, retrospectively registered, ID# NCT04026425, date of registration: 2019-07-17.
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Affiliation(s)
- Betsy Keller
- Department of Exercise Science and Athletic Training, Ithaca College, Ithaca, NY, 14850, USA.
| | - Candace N Receno
- Department of Exercise Science and Athletic Training, Ithaca College, Ithaca, NY, 14850, USA
| | - Carl J Franconi
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, 14853, USA
| | - Sebastian Harenberg
- Department of Human Kinetics, St. Francis Xavier University, Antigonish, NS, B2G 2W5, Canada
| | - Jared Stevens
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | | | - Staci R Stevens
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Geoff Moore
- Department of Exercise Science and Athletic Training, Ithaca College, Ithaca, NY, 14850, USA
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, 14853, USA
| | - Susan Levine
- Susan Levine, MD Clinical Practice, New York, NY, 10021, USA
| | | | | | - Maureen R Hanson
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, 14853, USA
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Campedelli L, Nouraie SM, Risbano MG. Non-arterial line cardiac output calculation misclassifies exercise pulmonary hypertension and increases risk of data loss particularly in black, scleroderma and Raynaud's patients during invasive exercise testing. Eur Respir J 2024; 64:2302232. [PMID: 38782468 DOI: 10.1183/13993003.02232-2023] [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: 12/13/2023] [Accepted: 05/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The direct Fick principle is the standard for calculating cardiac output (CO) to detect CO-dependent conditions like exercise pulmonary hypertension (ePH). Fick COarterial incorporates arterial haemoglobin (Hba) and oxygen saturation (S aO2 ) with oxygen consumption from exercise testing, while Fick COnon-arterial substitutes mixed venous haemoglobin (Hbmv) and peripheral oxygen saturation (S pO2 ) in the absence of an arterial line. The decision to employ an arterial catheter for exercise testing varies, and discrepancies in oxygen saturation and haemoglobin between arterial and non-arterial methods may lead to differences in Fick CO, potentially affecting ePH classification. METHODS We performed a retrospective analysis of 296 consecutive invasive cardiopulmonary exercise testing (iCPET) studies comparing oxygen saturation from pulse oximetry (S pO2 ) and radial arterial (S aO2 ), Hba and Hbmv, and CO calculated with arterial (COarterial) and non-arterial (COnon-arterial) values. We assessed the risk of misclassification of pre- and post-capillary ePH and data loss due to inaccurate S pO2 . RESULTS When considering all stages from rest to peak exercise, Hba and Hbmv demonstrated high correlation, while S pO2 and S aO2 as well as COarterial and COnon-arterial demonstrated low correlation. Data loss was significantly higher across all stages of exercise for S pO2 (n=346/1926 (18%)) compared to S aO2 (n=17/1923 (0.88%)). We found that pre- and post-capillary ePH were misclassified as COnon-arterial data (n=7/41 (17.1%) and n=2/23 (8.7%), respectively). Patients with scleroderma and/or Raynaud's (n=11/33 (33.3%)) and black patients (n=6/19 (31.6%)) had more S pO2 data loss. CONCLUSION Reliance upon S pO2 during invasive exercise testing results in the misclassification of pre- and post-capillary ePH, and unmeasurable S pO2 for black, scleroderma and Raynaud's patients can preclude accurate exercise calculations, thus limiting the diagnostic and prognostic value of invasive exercise testing without an arterial line.
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Affiliation(s)
- Luiz Campedelli
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - S Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
- Centre for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Michael G Risbano
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
- Centre for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
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Novak P. Head-down tilt reduces the heart rate in postural tachycardia syndrome in acute setting: a pilot study. Neurol Sci 2024; 45:1719-1723. [PMID: 37919442 DOI: 10.1007/s10072-023-07153-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/21/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Reduced preload and thoracic blood volume accompany postural tachycardia syndrome (POTS). Head-down tilt (HDT) increases both preload and intrathoracic blood volume. The objective of this study was to assess the safety and efficacy of HDT in POTS in acute settings. METHODS This retrospective study evaluated POTS patients. Analyzed data included heart rate, blood pressure, cerebral blood flow velocity (CBFv) in the middle cerebral artery, and capnography. The baseline supine hemodynamic data were compared with the data obtained at the second minute of the -10° HDT. A linear mixed-effects model was used to assess the effect of HDT on hemodynamic variables. RESULTS The HDT was explored in seven POTS patients and an additional seven POTS patients without HDT served as controls. In the HDT arm, four POTS patients had overlapping diagnoses of myalgic encephalopathy/chronic fatigue syndrome (ME/CFS) and one patient had comorbidity of post-acute sequelae of SARS-CoV-2 infection (PASC). HDT lowered heart rate by 10% and increased end-tidal CO2 by 8%. There was no change in other cardiovascular variables. CONCLUSIONS In the acute setting, HDT is safe. HDT reduces the heart rate presumably by modulating baroreflex by enhancing preload and stroke volume, which in turn increases thoracic blood volume with a net effect of parasympathetic cardiovagal activation and/or sympathetic withdrawal. This pilot study provides a foundation to proceed with longitudinal studies exploring the long-term effect of repetitive HDT in conditions associated with preload failure such as POTS, ME/CSF, and PASC.
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Affiliation(s)
- Peter Novak
- Autonomic Laboratory, Department of Neurology, Brigham and Women's Faulkner Hospital, Harvard Medical School, 1153 Centre Street, Boston, MA, 02130, USA.
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Ahlers CG, Patel P, Parikh K, Fudim M. Use of invasive cardiopulmonary exercise testing to diagnose preload reserve failure in patients with liver disease. ESC Heart Fail 2024; 11:587-593. [PMID: 38012064 PMCID: PMC10804147 DOI: 10.1002/ehf2.14598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 10/02/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023] Open
Abstract
In this case series, we describe the use of invasive cardiopulmonary exercise testing (iCPET) to diagnose heart failure due to preload reserve failure in two patients with progressive dyspnoea. We demonstrate that underlying liver disease contributes to preload reserve failure as a cause of exertional dysfunction. In liver diseases such as non-alcoholic fatty liver disease (NAFLD), fibrotic changes to the sinusoidal liver architecture occur leading to an increased transhepatic sinusoidal pressure gradient. Even at the earliest stage of hepatic fibrosis in patients with NAFLD, changes in hepatic blood flow are seen due to outflow block in the sinusoidal area. In this way, changes to the sinusoidal liver architecture can lead to limitations in preload reserve. This case series describes two patients with exertional dyspnoea found to have preload failure on iCPET due to underlying liver disease.
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Affiliation(s)
| | - Priyesh Patel
- Atrium Health Sanger Heart and Vascular InstituteConcordNCUSA
| | - Kishan Parikh
- Department of MedicineDuke University HospitalDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Marat Fudim
- Department of MedicineDuke University HospitalDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
- Department of CardiologyUniversity of WrocławWrocławPoland
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6
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Kirupaharan P, Lane J, Melillo C, Paul D, Amoushref A, Abdi SA, Tonelli AR. Impact of body position on hemodynamic measurements during exercise: A tale of two bikes. Pulm Circ 2024; 14:e12334. [PMID: 38223421 PMCID: PMC10784616 DOI: 10.1002/pul2.12334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024] Open
Abstract
The addition of exercise testing during right heart catheterization (RHC) is often required to accurately diagnose causes of exercise intolerance like early pulmonary vascular disease, occult left heart disease, and preload insufficiency. We tested the influence of body position (supine vs. seated) on hemodynamic classification both at rest and during exercise. We enrolled patients with exercise intolerance due to dyspnea who were referred for exercise RHC at the Cleveland Clinic. Patients were randomized (1:1) to exercise in seated or supine position to a goal of 60 W followed by maximal exercise in the alternate position. We analyzed 17 patients aged 60.3 ± 10.9 years, including 13 females. At rest in the sitting position, patients had significantly lower right atrial pressure (RAP), mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP) and cardiac index (CI). In every stage of exercise (20, 40, and 60 W), the RAP, mPAP, and PAWP were lower in the sitting position. Exercise in the sitting position allowed the identification of preload insufficiency in nine patients. Exercise in either position increased the identification of postcapillary pulmonary hypertension (PH). Body position significantly influences hemodynamics at rest and with exercise; however, mPAP/CO and PAWP/CO were not positionally affected. Hemodynamic measurements in the seated position allowed the detection of preload insufficiency, a condition that was predominantly identified as no PH during supine exercise.
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Affiliation(s)
- Pradhab Kirupaharan
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - James Lane
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - Celia Melillo
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - Deborah Paul
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - Alla Amoushref
- Department of Nephrology, Glickman Urological & Kidney InstituteCleveland ClinicClevelandOhioUSA
| | - Sami Al Abdi
- Department of Internal MedicineCleveland Clinic Fairview HospitalFairviewOhioUSA
| | - Adriano R. Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
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7
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Kahn PA, Joseph P, Heerdt PM, Singh I. Differential cardiopulmonary haemodynamic phenotypes in PASC-related exercise intolerance. ERJ Open Res 2024; 10:00714-2023. [PMID: 38348243 PMCID: PMC10860209 DOI: 10.1183/23120541.00714-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/04/2023] [Indexed: 02/15/2024] Open
Abstract
Background Post-acute sequelae of COVID-19 (PASC) affect a significant proportion of patients who have previously contracted SARS-CoV-2, with exertional intolerance being a prominent symptom. This study aimed to characterise the invasive haemodynamic abnormalities of PASC-related exertional intolerance using invasive cardiopulmonary exercise testing (iCPET). Study design and intervention 55 patients were recruited from the Yale Post-COVID-19 Recovery Program, with most experiencing mild acute illness. Supine right heart catheterisation and iCPET were performed on all participants. Main results The majority (75%) of PASC patients exhibited impaired peak systemic oxygen extraction (pEO2) during iCPET in conjunction with supranormal cardiac output (CO) (i.e., PASC alone group). On average, the PASC alone group exhibited a "normal" peak exercise capacity, V'O2 (89±18% predicted). ∼25% of patients had evidence of central cardiopulmonary pathology (i.e., 12 with resting and exercise heart failure with preserved ejection fraction (HFpEF) and two with exercise pulmonary hypertension (PH)). PASC patients with HFpEF (i.e., PASC HFpEF group) exhibited similarly impaired pEO2 with well compensated PH (i.e., peak V'O2 and CO >80% respectively) despite aberrant central cardiopulmonary exercise haemodynamics. PASC patients with HFpEF also exhibited increased body mass index of 39±7 kg·m-2. To examine the relative contribution of obesity to exertional impairment in PASC HFpEF, a control group comprising obese non-PASC group (n=61) derived from a historical iCPET cohort was used. The non-PASC obese patients with preserved peak V'O2 (>80% predicted) exhibited a normal peak pulmonary artery wedge pressure (17±14 versus 25±6 mmHg; p=0.03) with similar maximal voluntary ventilation (90±12 versus 86±10% predicted; p=0.53) compared to PASC HFpEF patients. Impaired pEO2 was not significantly different between PASC patients who underwent supervised rehabilitation and those who did not (p=0.19). Conclusions This study highlights the importance of considering impaired pEO2 in PASC patients with persistent exertional intolerance unexplained by conventional investigative testing. Results of the current study also highlight the prevalence of a distinct high output HFpEF phenotype in PASC with a primary peripheral limitation to exercise.
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Affiliation(s)
- Peter A. Kahn
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, USA
| | - Phillip Joseph
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, USA
| | - Paul M. Heerdt
- Department of Anesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Inderjit Singh
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, USA
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8
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Marwaha B. Role of Tau protein in long COVID and potential therapeutic targets. Front Cell Infect Microbiol 2023; 13:1280600. [PMID: 37953801 PMCID: PMC10634420 DOI: 10.3389/fcimb.2023.1280600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Long COVID is an emerging public health burden and has been defined as a syndrome with common symptoms of fatigue, shortness of breath, cognitive dysfunction, and others impacting day-to-day life, fluctuating or relapsing over, occurring for at least two months in patients with a history of probable or confirmed SARS CoV-2 infection; usually three months from the onset of illness and cannot be explained by an alternate diagnosis. The actual prevalence of long-term COVID-19 is unknown, but it is believed that more than 17 million patients in Europe may have suffered from it during pandemic. Pathophysiology Currently, there is limited understanding of the pathophysiology of this syndrome, and multiple hypotheses have been proposed. Our literature review has shown studies reporting tau deposits in tissue samples of the brain from autopsies of COVID-19 patients compared to the control group, and the in-vitro human brain organoid model has shown aberrant phosphorylation of tau protein in response to SARS-CoV-2 infection. Tauopathies, a group of neurodegenerative disorders with the salient features of tau deposits, can manifest different symptoms based on the anatomical region of brain involvement and have been shown to affect the peripheral nervous system as well and explained even in rat model studies. Long COVID has more than 203 symptoms, with predominant symptoms of fatigue, dyspnea, and cognitive dysfunction, which tauopathy-induced CNS and peripheral nervous system dysfunction can explain. There have been no studies up till now to reveal the pathophysiology of long COVID. Based on our literature review, aberrant tau phosphorylation is a promising hypothesis that can be explored in future studies. Therapeutic approaches for tauopathies have multidimensional aspects, including targeting post-translational modifications, tau aggregation, and tau clearance through the autophagy process with the help of lysosomes, which can be potential targets for developing therapeutic interventions for the long COVID. In addition, future studies can attempt to find the tau proteins in CSF and use those as biomarkers for the long COVID.
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Affiliation(s)
- Bharat Marwaha
- Department of Cardiology, Adena Health System, Chillicothe, OH, United States
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Behrooz L, Barillas-Lara M, Fattouh M, Loubeau B, Ibrahim M. The role of invasive cardiopulmonary exercise testing in patients with unexplained dyspnea: a systemic review. Acta Cardiol 2023; 78:754-760. [PMID: 36345986 DOI: 10.1080/00015385.2022.2141434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Dyspnoea is a common complaint that often remains unexplained with no diagnosis and poor management despite extensive, repetitive and costly testing. Invasive cardiopulmonary testing has been used in the evaluation of dyspnoea, however, its role is not yet well defined. We sought to perform a systematic review of the literature looking at the role of invasive cardiopulmonary testing in the evaluation of chronic dyspnoea and/or exercise intolerance. METHODS AND RESULTS We performed a literature review in accordance with PRISMA, analysing articles published in peer-reviewed journals between January 1st 1985 and January 31st 2020, available in 3 databases. The aim was to identify randomised and non-randomised clinical studies that focussed on the utility of invasive cardiopulmonary exercise test in the evaluation of dyspnoea. Emphasis was placed on studies that noted the use of exercise stress testing with the concomitant use of right heart catheterisation to evaluate hemodynamics as part of the work up for dyspnoea. We identified 6 retrospective studies that assessed the use of exercise hemodynamics to identify the aetiology of dyspnoea. CONCLUSION Invasive cardiopulmonary exercise test is a useful tool for identifying the cause of unexplained dyspnoea. It can be helpful in early recognition and prognostication of patients with heart failure with preserved ejection fraction and pulmonary hypertension. It has also shown to be beneficial for constructing a multidisciplinary approach to chronic dyspnoea.
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Affiliation(s)
- Leili Behrooz
- Department of Medicine, Division of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Maria Barillas-Lara
- Department of Medicine, Division of Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael Fattouh
- Department of Medicine, Division of Internal Medicine, Monte Fiore Medical Center, Bronx, NY, USA
| | - Bérénice Loubeau
- Centro de Diagnóstico Medicina Avanzada y Telemedicina, Santo Domingo, Dominican Republic
| | - Michel Ibrahim
- Department of Medicine, Division of Cardiovascular Medicine, Temple University Hospital, Philadelphia, PA, USA
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10
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Joseph P, Singh I, Oliveira R, Capone CA, Mullen MP, Cook DB, Stovall MC, Squires J, Madsen K, Waxman AB, Systrom DM. Exercise Pathophysiology in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Postacute Sequelae of SARS-CoV-2: More in Common Than Not? Chest 2023; 164:717-726. [PMID: 37054777 PMCID: PMC10088277 DOI: 10.1016/j.chest.2023.03.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023] Open
Abstract
TOPIC IMPORTANCE Postacute sequelae of SARS-CoV-2 (PASC) is a long-term consequence of acute infection from COVID-19. Clinical overlap between PASC and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) has been observed, with shared symptoms including intractable fatigue, postexertional malaise, and orthostatic intolerance. The mechanistic underpinnings of such symptoms are poorly understood. REVIEW FINDINGS Early studies suggest deconditioning as the primary explanation for exertional intolerance in PASC. Cardiopulmonary exercise testing reveals perturbations related to systemic blood flow and ventilatory control associated with acute exercise intolerance in PASC, which are not typical of simple detraining. Hemodynamic and gas exchange derangements in PASC have substantial overlap with those observed with ME/CFS, suggestive of shared mechanisms. SUMMARY This review illustrates exercise pathophysiologic commonalities between PASC and ME/CFS that will help guide future diagnostics and treatment.
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Affiliation(s)
- Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, Yale University, New Haven, CT
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, Yale University, New Haven, CT
| | - Rudolf Oliveira
- Division of Respiratory Disease, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Christine A Capone
- Division of Pediatric Cardiology Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra, Manhasset, NY
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dane B Cook
- Research Service, William S. Middleton Memorial Veterans Hospital & Department of Kinesiology, University of Wisconsin-Madison, Madison, WI
| | - Mary Catherine Stovall
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Johanna Squires
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kristine Madsen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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11
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Neder JA. Cardiopulmonary exercise testing applied to respiratory medicine: Myths and facts. Respir Med 2023; 214:107249. [PMID: 37100256 DOI: 10.1016/j.rmed.2023.107249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O2 uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate ("anaerobic") threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO2 output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea "quantity" and "quality". Based on a conceptual framework that links exertional dyspnoea to "excessive" and/or "restrained" breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Department of Medicine, Division of Respirology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada.
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12
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Editorial commentary: Postural orthostatic tachycardia syndrome: Moving forward, not standing still. Trends Cardiovasc Med 2023; 33:70-71. [PMID: 34732359 DOI: 10.1016/j.tcm.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 02/07/2023]
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13
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Sheikh AB, Fudim M, Garg I, Minhas AMK, Sobotka AA, Patel MR, Eng MH, Sobotka PA. The Clinical Problem of Pelvic Venous Disorders. Interv Cardiol Clin 2022; 11:307-324. [PMID: 35710285 DOI: 10.1016/j.iccl.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.
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Affiliation(s)
- Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Abdul Mannan Khan Minhas
- Department of Internal Medicine, Forrest General Hospital, 6051 US 49, Hattiesburg, MS 39401, USA
| | | | - Manesh R Patel
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Marvin H Eng
- Division of Cardiology, University of Arizona, Banner University Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006, USA
| | - Paul A Sobotka
- The Ohio State University, 281 West Lane Avenue, Columbus, OH 43210, USA.
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14
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Association of Cardiac Autonomic Responses with Clinical Outcomes of Myasthenia Gravis: Short-Term Analysis of the Heart-Rate and Blood Pressure Variability. J Clin Med 2022; 11:jcm11133697. [PMID: 35806988 PMCID: PMC9267657 DOI: 10.3390/jcm11133697] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: The aim of the study was to assess cardiac and autonomic function in patients with myasthenia gravis (MG) and to explore its relationship with disease outcomes. Methods: Thirty-eight patients with an MG were enrolled (median age 40.5 years; median disease duration 5.5 years). Cardiovascular parameters, baroreflex sensitivity (BRS), spectral indices of short-term heart rate (HRV), and systolic blood pressure variability (SBPV) were compared with age- and gender-matched controls (n = 30). Cardiac autonomic function was assessed during the response to standing (tilt) and deep breathing tests (expiration/inspiration ratio-E/I). Results: HR and BP responses to the tilt test were similar in both groups. MG patients, as compared to controls, were characterized by altered SBPV at rest, significantly reduced HR response to the deep breathing test (p < 0.001), increased sympathovagal balance after tilt (delta LF/HF-RRI, p = 0.037), and lower values of BRS (p = 0.007) and hemodynamic parameters, i.e., cardiac index, index contractility, left ventricular work index, at rest and during tilt. There was no association between disease duration and autonomic parameters. Disease severity, as determined by MGFA (Myasthenia Gravis Foundation of America) corrected for age and sex, was an independent predictor of diminished vagal tone (E/I ratio) and increased sympathetic response to tilt (delta LF/HF-RRI) as measured with HRV. Lower BRS was associated with greater disease severity and older age. Hemodynamic parameters were predominantly predicted by age and sex. Conclusion: Our results confirm cardiac autonomic dysfunction among MG patients with predominant parasympathetic impairment. Clinicians should consider evaluation of autonomic balance in MG patients with, or at risk for, cardiovascular disease.
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Joseph P, Pari R, Miller S, Warren A, Stovall MC, Squires J, Chang CJ, Xiao W, Waxman AB, Systrom DM. Neurovascular Dysregulation and Acute Exercise Intolerance in ME/CFS: A Randomized, Placebo-Controlled Trial of Pyridostigmine. Chest 2022; 162:1116-1126. [PMID: 35526605 DOI: 10.1016/j.chest.2022.04.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is characterized by intractable fatigue, postexertional malaise, and orthostatic intolerance, but its pathophysiology is poorly understood. Pharmacologic cholinergic stimulation was used to test the hypothesis that neurovascular dysregulation underlies exercise intolerance in ME/CFS. RESEARCH QUESTION Does neurovascular dysregulation contribute to exercise intolerance in ME/CFS, and can its treatment improve exercise capacity? STUDY DESIGN AND METHODS Forty-five subjects with ME/CFS were enrolled in a single-center, randomized, double-blind, placebo-controlled trial. Subjects were assigned in a 1:1 ratio to receive a 60-mg dose of oral pyridostigmine or placebo after an invasive cardiopulmonary exercise test (iCPET). A second iCPET was performed 50 min later. The primary end point was the difference in peak exercise oxygen uptake (Vo2). Secondary end points included exercise pulmonary and systemic hemodynamics and gas exchange. RESULTS Twenty-three subjects were assigned to receive pyridostigmine and 22 to receive placebo. The peak Vo2 increased after pyridostigmine but decreased after placebo (13.3 ± 13.4 mL/min vs -40.2 ± 21.3 mL/min; P < .05). The treatment effect of pyridostigmine was 53.6 mL/min (95% CI, -105.2 to -2.0). Peak vs rest Vo2 (25.9 ± 15.3 mL/min vs -60.8 ± 25.6 mL/min; P < .01), cardiac output (-0.2 ± 0.6 L/min vs -1.9 ± 0.6 L/min; P < .05), and right atrial pressure (1.0 ± 0.5 mm Hg vs -0.6 ± 0.5 mm Hg; P < .05) were greater in the pyridostigmine group compared with placebo. INTERPRETATION Pyridostigmine improves peak Vo2 in ME/CFS by increasing cardiac output and right ventricular filling pressures. Worsening peak exercise Vo2, cardiac output, and right atrial pressure following placebo may signal the onset of postexertional malaise. We suggest that treatable neurovascular dysregulation underlies acute exercise intolerance in ME/CFS. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03674541; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, Yale University, New Haven, CT
| | - Rosa Pari
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Sarah Miller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Arabella Warren
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mary Catherine Stovall
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Johanna Squires
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Chia-Jung Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Wenzhong Xiao
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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16
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Brown JT, Saigal A, Karia N, Patel RK, Razvi Y, Constantinou N, Steeden JA, Mandal S, Kotecha T, Fontana M, Goldring J, Muthurangu V, Knight DS. Ongoing Exercise Intolerance Following COVID-19: A Magnetic Resonance-Augmented Cardiopulmonary Exercise Test Study. J Am Heart Assoc 2022; 11:e024207. [PMID: 35470679 PMCID: PMC9238618 DOI: 10.1161/jaha.121.024207] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Ongoing exercise intolerance of unclear cause following COVID-19 infection is well recognized but poorly understood. We investigated exercise capacity in patients previously hospitalized with COVID-19 with and without self-reported exercise intolerance using magnetic resonance-augmented cardiopulmonary exercise testing. Methods and Results Sixty subjects were enrolled in this single-center prospective observational case-control study, split into 3 equally sized groups: 2 groups of age-, sex-, and comorbidity-matched previously hospitalized patients following COVID-19 without clearly identifiable postviral complications and with either self-reported reduced (COVIDreduced) or fully recovered (COVIDnormal) exercise capacity; a group of age- and sex-matched healthy controls. The COVIDreducedgroup had the lowest peak workload (79W [Interquartile range (IQR), 65-100] versus controls 104W [IQR, 86-148]; P=0.01) and shortest exercise duration (13.3±2.8 minutes versus controls 16.6±3.5 minutes; P=0.008), with no differences in these parameters between COVIDnormal patients and controls. The COVIDreduced group had: (1) the lowest peak indexed oxygen uptake (14.9 mL/minper kg [IQR, 13.1-16.2]) versus controls (22.3 mL/min per kg [IQR, 16.9-27.6]; P=0.003) and COVIDnormal patients (19.1 mL/min per kg [IQR, 15.4-23.7]; P=0.04); (2) the lowest peak indexed cardiac output (4.7±1.2 L/min per m2) versus controls (6.0±1.2 L/min per m2; P=0.004) and COVIDnormal patients (5.7±1.5 L/min per m2; P=0.02), associated with lower indexed stroke volume (SVi:COVIDreduced 39±10 mL/min per m2 versus COVIDnormal 43±7 mL/min per m2 versus controls 48±10 mL/min per m2; P=0.02). There were no differences in peak tissue oxygen extraction or biventricular ejection fractions between groups. There were no associations between COVID-19 illness severity and peak magnetic resonance-augmented cardiopulmonary exercise testing metrics. Peak indexed oxygen uptake, indexed cardiac output, and indexed stroke volume all correlated with duration from discharge to magnetic resonance-augmented cardiopulmonary exercise testing (P<0.05). Conclusions Magnetic resonance-augmented cardiopulmonary exercise testing suggests failure to augment stroke volume as a potential mechanism of exercise intolerance in previously hospitalized patients with COVID-19. This is unrelated to disease severity and, reassuringly, improves with time from acute illness.
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Affiliation(s)
- James T. Brown
- National Pulmonary Hypertension ServiceRoyal Free London NHS Foundation TrustLondonUnited Kingdom
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
| | - Anita Saigal
- Department of Respiratory MedicineRoyal Free London NHS Foundation TrustLondonUnited Kingdom
| | - Nina Karia
- National Pulmonary Hypertension ServiceRoyal Free London NHS Foundation TrustLondonUnited Kingdom
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
| | - Rishi K. Patel
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- National Amyloidosis CentreDivision of MedicineUniversity College LondonUnited Kingdom
| | - Yousuf Razvi
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- National Amyloidosis CentreDivision of MedicineUniversity College LondonUnited Kingdom
| | - Natalie Constantinou
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
| | | | - Swapna Mandal
- Department of Respiratory MedicineRoyal Free London NHS Foundation TrustLondonUnited Kingdom
| | - Tushar Kotecha
- National Pulmonary Hypertension ServiceRoyal Free London NHS Foundation TrustLondonUnited Kingdom
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
- Department of CardiologyRoyal Free London NHS Foundation TrustLondonUnited Kingdom
| | - Marianna Fontana
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- National Amyloidosis CentreDivision of MedicineUniversity College LondonUnited Kingdom
| | - James Goldring
- Department of Respiratory MedicineRoyal Free London NHS Foundation TrustLondonUnited Kingdom
| | - Vivek Muthurangu
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
| | - Daniel S. Knight
- National Pulmonary Hypertension ServiceRoyal Free London NHS Foundation TrustLondonUnited Kingdom
- UCL Department of Cardiac MRIUniversity College London (Royal Free Campus)LondonUnited Kingdom
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
- Department of CardiologyRoyal Free London NHS Foundation TrustLondonUnited Kingdom
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17
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Affiliation(s)
- Esther de Boer
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Irina Petrache
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Michael P Mohning
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
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18
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Rao VN, Kelsey MD, Blazing MA, Pagidipati NJ, Fortin TA, Fudim M. Unexplained Dyspnea on Exertion: The Difference the Right Test Can Make. Circ Heart Fail 2022; 15:e008982. [PMID: 35038884 PMCID: PMC8847234 DOI: 10.1161/circheartfailure.121.008982] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Vishal N. Rao
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | | | | | - Terry A. Fortin
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC
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19
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Masterclass: Hypermobility and hypermobility related disorders. Musculoskelet Sci Pract 2022; 57:102465. [PMID: 34808594 DOI: 10.1016/j.msksp.2021.102465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/27/2021] [Accepted: 10/10/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Hypermobile joints display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility may present in a single joint, a few joints or in multiple joints and may be congenital or acquired with training, disease or injury. Hypermobile joints may be asymptomatic or may be associated with pain, fatigue, multisystemic complaints and significant disability. Furthermore, joint hypermobility may be a sign of an underlying hereditary disorder of connective tissue. PURPOSE This masterclass aims to provides a state-of-the-art review of the aetiology, epidemiology, clinical presentation, assessment and management of joint hypermobility and hypermobility related disorders using an evidence based and biopsychosocial approach. The new framework for classifying the spectrum of joint hypermobility disorders along with new diagnostic criteria for the hypermobile Ehlers Danlos syndrome, published by an international consortium of clinical experts and researchers in 2017 is integrated into the paper. IMPLICATIONS FOR PRACTICE People with joint hypermobility related disorders present to healthcare professionals with a wide range of symptoms which extend beyond the musculoskeletal system. Early recognition and treatment are key to effective management. A biopsychosocial and patient empowerment approach to functional restoration is recommended.
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20
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Mancini DM, Brunjes DL, Lala A, Trivieri MG, Contreras JP, Natelson BH. Use of Cardiopulmonary Stress Testing for Patients With Unexplained Dyspnea Post-Coronavirus Disease. JACC. HEART FAILURE 2021; 9:927-937. [PMID: 34857177 PMCID: PMC8629098 DOI: 10.1016/j.jchf.2021.10.002] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 12/31/2022]
Abstract
Objectives The authors used cardiopulmonary exercise testing (CPET) to define unexplained dyspnea in patients with post-acute sequelae of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection (PASC). We assessed participants for criteria to diagnose myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Background Approximately 20% of patients who recover from coronavirus disease (COVID) remain symptomatic. This syndrome is named PASC. Its etiology is unclear. Dyspnea is a frequent symptom. Methods The authors performed CPET and symptom assessment for ME/CFS in 41 patients with PASC 8.9 ± 3.3 months after COVID. All patients had normal pulmonary function tests, chest X-ray, and chest computed tomography scans. Peak oxygen consumption (peak VO2), slope of minute ventilation to CO2 production (VE/VCO2 slope), and end tidal pressure of CO2 (PetCO2) were measured. Ventilatory patterns were reviewed with dysfunctional breathing defined as rapid erratic breathing. Results Eighteen men and 23 women (average age: 45 ± 13 years) were studied. Left ventricular ejection fraction was 59% ± 9%. Peak VO2 averaged 20.3 ± 7 mL/kg/min (77% ± 21% predicted VO2). VE/VCO2 slope was 30 ± 7. PetCO2 at rest was 33.5 ± 4.5 mm Hg. Twenty-four patients (58.5%) had a peak VO2 <80% predicted. All patients with peak VO2 <80% had a circulatory limitation to exercise. Fifteen of 17 patients with normal peak VO2 had ventilatory abnormalities including peak respiratory rate >55 (n = 3) or dysfunctional breathing (n = 12). For the whole cohort, 88% of patients (n = 36) had ventilatory abnormalities with dysfunctional breathing (n = 26), increased VE/VCO2 (n = 17), and/or hypocapnia PetCO2 <35 (n = 25). Nineteen patients (46%) met criteria for ME/CFS. Conclusions Circulatory impairment, abnormal ventilatory pattern, and ME/CFS are common in patients with PASC. The dysfunctional breathing, resting hypocapnia, and ME/CFS may contribute to symptoms. CPET is a valuable tool to assess these patients.
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Affiliation(s)
- Donna M Mancini
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Danielle L Brunjes
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anuradha Lala
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Johanna P Contreras
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin H Natelson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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21
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Ewert R, Stubbe B, Heine A, Desole S, Habedank D, Knaack C, Hortien F, Opitz CF. [Invasive Cardiopulmonary Exercise Testing: A Review]. Pneumologie 2021; 76:98-111. [PMID: 34844269 DOI: 10.1055/a-1651-7450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.
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Affiliation(s)
- Ralf Ewert
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Beate Stubbe
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Alexander Heine
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Susanna Desole
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Dirk Habedank
- DRK Kliniken Berlin Köpenick, Medizinische Klinik Kardiologie, Berlin
| | - Christine Knaack
- Universitätsmedizin Greifswald, Klinik für Innere Medizin C, Greifswald
| | - Franziska Hortien
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Christian F Opitz
- DRK Kliniken Berlin Westend, Klinik für Innere Medizin, Schwerpunkt Kardiologie, Berlin
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22
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Stewart JM, Pianosi PT. Postural orthostatic tachycardia syndrome: A respiratory disorder? Curr Res Physiol 2021; 4:1-6. [PMID: 34746821 PMCID: PMC8562237 DOI: 10.1016/j.crphys.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 11/28/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a disorder epitomized by the story of the blind men and the elephant. Patients may see primary care internists or pediatricians due to fatigue, be referred to neurologists for “spells”, to cardiologists for evaluation of pre-syncope or chest pain, to gastroenterologists for nausea or dyspepsia, and even pulmonologists for dyspnea. Adoption of a more systematic approach to their evaluation and better characterization of patients has led to greater understanding of comorbidities, hypotheses prompting mechanistic investigations, and pharmacologic trials. Recent work has implicated disordered sympathetic nervous system activation in response to central (thoracic) hypovolemia. It is this pathway that leads one zero in on a putative focal point from which many of the clinical manifestations can be explained – specifically the carotid body. Despite heterogeneity in etiopathogenesis of a POTS phenotype, we propose that aberrant activation and response of the carotid body represents one potential common pathway in evolution. To understand this postulate, one must jettison isolationist or reductionist ideas of chemoreceptor and baroreceptor functions of the carotid body or sinus, respectively, and consider their interaction and interdependence both locally and centrally where some of its efferents merge. Doing so enables one to connect the dots and appreciate origins of diverse manifestations of POTS, including dyspnea for which the concept of neuro-mechanical uncoupling is wanting, thereby expanding our construct of this symptom. This perspective expounds our premise that POTS has a prominent respiratory component. Dyspnea affects ~⅓ patients with postural orthostatic tachycardia syndrome (POTS). POTS is characterized by thoracic hypovolemia and compromised cephalad perfusion when upright. Carotid body and adjacent carotid sinus mediate chemo- and baro- reflexes, respectively. These are not independent and stimulation of either activates sympathetic discharge. We speculate that carotid body mediates hyperventilation and dyspnea in POTS.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA.,Department of Physiology, New York Medical College, Valhalla, NY, USA
| | - Paolo T Pianosi
- Department of Pediatrics, Division of Pulmonary & Sleep Medicine, University of Minnesota, VCRC, 401 E River Parkway Rm 413, Minneapolis, UK
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Chronic Fatigue Syndrome and Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1056-1067. [PMID: 34474739 DOI: 10.1016/j.jacc.2021.06.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022]
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a medically unexplained illness characterized by severe fatigue limiting normal daily activities for at least 6 months accompanied by problems with unrefreshing sleep, exacerbation of symptoms following physical or mental efforts (postexertional malaise [PEM]), and either cognitive reports or physiological evidence of orthostatic intolerance in the form of either orthostatic tachycardia and/or hypocapnia. Although rarely considered to have cardiac dysfunction, ME/CFS patients frequently have reduced stroke volume with a significant inverse relation between cardiac output and PEM severity. Magnetic resonance imaging of ME/CFS patients compared with normal control subjects found significantly reduced stroke, end-systolic, and end-diastolic volumes together with reduced end-diastolic wall mass. Another cardiovascular abnormality is reduced nocturnal blood pressure assessed by 24-hour monitoring. Autonomic dysfunction is also frequently observed with postural orthostatic tachycardia and/or hypocapnia. Two consecutive cardiopulmonary stress tests may provide metabolic data substantiating PEM.
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Hoel F, Hoel A, Pettersen IK, Rekeland IG, Risa K, Alme K, Sørland K, Fosså A, Lien K, Herder I, Thürmer HL, Gotaas ME, Schäfer C, Berge RK, Sommerfelt K, Marti HP, Dahl O, Mella O, Fluge Ø, Tronstad KJ. A map of metabolic phenotypes in patients with myalgic encephalomyelitis/chronic fatigue syndrome. JCI Insight 2021; 6:e149217. [PMID: 34423789 PMCID: PMC8409979 DOI: 10.1172/jci.insight.149217] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/07/2021] [Indexed: 01/08/2023] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating disease usually presenting after infection. Emerging evidence supports that energy metabolism is affected in ME/CFS, but a unifying metabolic phenotype has not been firmly established. We performed global metabolomics, lipidomics, and hormone measurements, and we used exploratory data analyses to compare serum from 83 patients with ME/CFS and 35 healthy controls. Some changes were common in the patient group, and these were compatible with effects of elevated energy strain and altered utilization of fatty acids and amino acids as catabolic fuels. In addition, a set of heterogeneous effects reflected specific changes in 3 subsets of patients, and 2 of these expressed characteristic contexts of deregulated energy metabolism. The biological relevance of these metabolic phenotypes (metabotypes) was supported by clinical data and independent blood analyses. In summary, we report a map of common and context-dependent metabolic changes in ME/CFS, and some of them presented possible associations with clinical patient profiles. We suggest that elevated energy strain may result from exertion-triggered tissue hypoxia and lead to systemic metabolic adaptation and compensation. Through various mechanisms, such metabolic dysfunction represents a likely mediator of key symptoms in ME/CFS and possibly a target for supportive intervention.
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Affiliation(s)
| | - August Hoel
- Department of Biomedicine and.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Ingrid G Rekeland
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Kristin Risa
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Kine Alme
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Kari Sørland
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Alexander Fosså
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.,KJ Jebsen Centre for B-cell malignancies, University of Oslo, Oslo, Norway
| | - Katarina Lien
- CFS/ME Center, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | - Ingrid Herder
- CFS/ME Center, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Merete E Gotaas
- Department of Pain and Complex Disorders, St. Olav's Hospital, Trondheim, Norway
| | - Christoph Schäfer
- Department of Rehabilitation Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Rolf K Berge
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kristian Sommerfelt
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics and
| | - Hans-Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Olav Dahl
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Olav Mella
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Øystein Fluge
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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25
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Abstract
Dyspnea in low-preload states is an underrecognized but growing diagnosis in patients with unexplained dyspnea. Patients can often experience debilitating symptoms at rest and with exertion, as low measured preload often leads to decreased cardiac output and ultimately dyspnea. In the present article, we performed a review of the literature and a multidisciplinary evaluation to understand the pathophysiology, diagnosis, and treatment of dyspnea in low-preload states. We explored selected etiologies and suggested an algorithm to approach unexplained dyspnea. The mainstay of diagnosis remains as invasive cardiopulmonary exercise testing. We concluded with a variety of nonpharmacological and pharmacological therapies, highlighting that a multifactorial approach may lead to the best results.
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26
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Larsen NW, Stiles LE, Miglis MG. Preparing for the long-haul: Autonomic complications of COVID-19. Auton Neurosci 2021; 235:102841. [PMID: 34265539 PMCID: PMC8254396 DOI: 10.1016/j.autneu.2021.102841] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/13/2021] [Accepted: 06/28/2021] [Indexed: 12/25/2022]
Abstract
As global numbers of COVID-19 grow, chronic neurological symptoms, including those of autonomic dysfunction, are being reported with increasing frequency. Mounting evidence suggests that many patients experience chronic and sometimes debilitating symptoms long after their acute infectious period, leading to the new diagnostic category of post-acute COVID syndrome. Many symptoms of post-acute COVID syndrome appear autonomic in nature, suggesting that autonomic impairment may play a central role in the underlying pathophysiology. In this review, we discuss the autonomic symptoms and manifestations of post-acute COVID syndrome, potential mechanisms involved, and future directions for a better understanding of this novel condition.
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Affiliation(s)
- Nicholas W Larsen
- Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA, USA
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA, USA.
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27
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Doherty CM, Heresi GA, Tonelli AR, Goyanes A, Wilson R. Bilateral Pulmonary Emboli and Deep Venous Thrombi in Association With Chronic Inflammatory Demyelinating Polyneuropathy. Cureus 2021; 13:e14802. [PMID: 34123603 PMCID: PMC8191853 DOI: 10.7759/cureus.14802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune neurological disorder primarily affecting the peripheral nervous system. It is important to recognize because treatment with immunomodulators can improve symptoms. We present the case of a 61-year-old man who developed a saddle pulmonary embolus as well as right-sided deep venous thrombi following left knee arthroplasty. Two months later, he had persistent pre-syncopal symptoms with exertion and had developed paraesthesias in both feet. Invasive cardiopulmonary exercise testing revealed preload failure with no evidence of pulmonary hypertension. He was then referred to neurology where clinical history, physical examination, autonomic battery, and nerve biopsy were consistent with a diagnosis of CIDP with autonomic dysfunction. Extensive venous thromboembolism may be a unique presentation of CIDP. The mechanisms, which may lead to hypercoagulability in CIDP, include the presence of systemic inflammation and denervation of peripheral vasculature leading to stasis.
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Affiliation(s)
- Christine M Doherty
- Department of Neurology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Gustavo A Heresi
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, USA
| | | | - Alice Goyanes
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, USA
| | - Robert Wilson
- Department of Neurology, Cleveland Clinic, Cleveland, USA
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28
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Dillon HT, Dausin C, Claessen G, Lindqvist A, Mitchell A, Wright L, Willems R, La Gerche A, Howden EJ. The effect of posture on maximal oxygen uptake in active healthy individuals. Eur J Appl Physiol 2021; 121:1487-1498. [PMID: 33638017 DOI: 10.1007/s00421-021-04630-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/05/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Semi-supine and supine cardiopulmonary exercise testing (CPET) with concurrent cardiac imaging has emerged as a valuable tool for evaluating patients with cardiovascular disease. Yet, it is unclear how posture effects CPET measures. We aimed to discern the effect of posture on maximal oxygen uptake (VO2max) and its determinants using three clinically relevant cycle ergometers. METHODS In random order, 10 healthy, active males (Age 27 ± 7 years; BMI 23 ± 2 kg m2) underwent a ramp CPET and subsequent constant workload verification test performed at 105% peak ramp power to quantify VO2max on upright, semi-supine and supine cycle ergometers. Doppler echocardiography was conducted at peak exercise to measure stroke volume (SV) which was multiplied by heart rate (HR) to calculate cardiac output (CO). RESULTS Compared to upright (46.8 ± 11.2 ml/kg/min), VO2max was progressively reduced in semi-supine (43.8 ± 10.6 ml/kg/min) and supine (38.2 ± 9.3 ml/kg/min; upright vs. semi-supine vs. supine; all p ≤ 0.005). Similarly, peak power was highest in upright (325 ± 80 W), followed by semi-supine (298 ± 72 W) and supine (200 ± 51 W; upright vs. semi-supine vs. supine; all p < 0.01). Peak HR decreased progressively from upright to semi-supine to supine (186 ± 11 vs. 176 ± 13 vs. 169 ± 12 bpm; all p < 0.05). Peak SV and CO were lower in supine relative to semi-supine and upright (82 ± 22 vs. 92 ± 26 vs. 91 ± 24 ml and 14 ± 3 vs. 16 ± 4 vs. 17 ± 4 l/min; all p < 0.01), but not different between semi-supine and upright. CONCLUSION VO2max is progressively reduced in reclined postures. Thus, posture should be considered when comparing VO2max results between different testing modalities.
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Affiliation(s)
- Hayley T Dillon
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia.,Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Christophe Dausin
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Guido Claessen
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Anniina Lindqvist
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia
| | - Amy Mitchell
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia
| | - Leah Wright
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - André La Gerche
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia.,National Centre for Sports Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Erin J Howden
- Sports Cardiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia.
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Williams LR, Isaacson-Barash C. Three Cases of Severe ME/CFS in Adults. Healthcare (Basel) 2021; 9:215. [PMID: 33669438 PMCID: PMC7920463 DOI: 10.3390/healthcare9020215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/20/2022] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, only partially understood multi-system disease whose onset and severity vary widely. Symptoms include overwhelming fatigue, post-exertional malaise, sleep disruptions, gastrointestinal issues, headaches, orthostatic intolerance, cognitive impairment, etc. ME/CFS is a physiological disease with an onset often triggered by a viral or bacterial infection, and sometimes by toxins. Some patients have a mild case and are able to function nearly on a par with healthy individuals, while others are moderately ill and still others are severely, or even, very severely ill. The cohort of moderately to very severely ill is often housebound or bedbound, has lost employment or career, and has engaged in a long, and often futile, search for treatment and relief. Here, we present three case studies, one each of a moderately ill, a severely ill, and a very severely ill person, to demonstrate the complexity of the disease, the suffering of these patients, and what health care providers can do to help.
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30
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Joseph P, Arevalo C, Oliveira RKF, Faria-Urbina M, Felsenstein D, Oaklander AL, Systrom DM. Insights From Invasive Cardiopulmonary Exercise Testing of Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Chest 2021; 160:642-651. [PMID: 33577778 DOI: 10.1016/j.chest.2021.01.082] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) affects tens of millions worldwide; the causes of exertional intolerance are poorly understood. The ME/CFS label overlaps with postural orthostatic tachycardia (POTS) and fibromyalgia, and objective evidence of small fiber neuropathy (SFN) is reported in approximately 50% of POTS and fibromyalgia patients. RESEARCH QUESTION Can invasive cardiopulmonary exercise testing (iCPET) and PGP9.5-immunolabeled lower-leg skin biopsies inform the pathophysiology of ME/CFS exertional intolerance and potential relationships with SFN? STUDY DESIGN AND METHODS We analyzed 1,516 upright invasive iCPETs performed to investigate exertional intolerance. After excluding patients with intrinsic heart or lung disease and selecting those with right atrial pressures (RAP) <6.5 mm Hg, results from 160 patients meeting ME/CFS criteria who had skin biopsy test results were compared with 36 control subjects. Rest-to-peak changes in cardiac output (Qc) were compared with oxygen uptake (Qc/VO2 slope) to identify participants with low, normal, or high pulmonary blood flow by Qc/VO2 tertiles. RESULTS During exercise, the 160 ME/CFS patients averaged lower RAP (1.9 ± 2 vs 8.3 ± 1.5; P < .0001) and peak VO2 (80% ± 21% vs 101.4% ± 17%; P < .0001) than control subjects. The low-flow tertile had lower peak Qc than the normal and high-flow tertiles (88.4% ± 19% vs 99.5% ± 23.8% vs 99.9% ± 19.5% predicted; P < .01). In contrast, systemic oxygen extraction was impaired in high-flow vs low- and normal-flow participants (0.74% ± 0.1% vs 0.88 ± 0.11 vs 0.86 ± 0.1; P < .0001) in association with peripheral left-to-right shunting. Among the 160 ME/CFS patient biopsies, 31% were consistent with SFN (epidermal innervation ≤5.0% of predicted; P < .0001). Denervation severity did not correlate with exertional measures. INTERPRETATION These results identify two types of peripheral neurovascular dysregulation that are biologically plausible contributors to ME/CFS exertional intolerance-depressed Qc from impaired venous return, and impaired peripheral oxygen extraction. In patients with small-fiber pathology, neuropathic dysregulation causing microvascular dilation may limit exertion by shunting oxygenated blood from capillary beds and reducing cardiac return.
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Affiliation(s)
- Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, Yale University, New Haven, CT.
| | - Carlo Arevalo
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Mariana Faria-Urbina
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Donna Felsenstein
- Infectious Diseases Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Boston, MA; Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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31
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Fudim M, Sobotka PA, Dunlap ME. Extracardiac Abnormalities of Preload Reserve: Mechanisms Underlying Exercise Limitation in Heart Failure with Preserved Ejection Fraction, Autonomic Dysfunction, and Liver Disease. Circ Heart Fail 2021; 14:e007308. [PMID: 33464948 DOI: 10.1161/circheartfailure.120.007308] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
While many of the cardiac limitations to exercise performance are now well-characterized, extracardiac limitations to exercise performance have been less well recognized but are nevertheless important. We propose that abnormalities of cardiac preload reserve represents an under-recognized but common cause of exercise limitations. We further propose that mechanistic links exist between conditions as seemingly disparate as heart failure with preserved ejection fraction, nonalcoholic fatty liver disease, and pelvic venous compression/obstruction syndromes (eg, May-Thurner). We conclude that extracardiac abnormalities of preload reserve serve as a major pathophysiologic mechanism underlying these and other disease states.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (M.F.). Duke Clinical Research Institute, Durham, NC (M.F.)
| | - Paul A Sobotka
- Affiliated Faculty, Department of Medicine, Division of Cardiology, The Ohio State University, Columbus (P.A.S.)
| | - Mark E Dunlap
- Heart and Vascular Center, MetroHealth Campus of Case Western Reserve University, Cleveland, OH (M.E.D.)
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32
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李 卓, 何 杨, 向 涯, 易 鑫, 朱 中, 李 爱, 向 睿, 韩 晓, 王 璞, 黄 玮. [Diagnostic Application of Invasive Cardiopulmonary Exercise Test in Patients with Unexplained Dyspnea]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2021; 52:142-148. [PMID: 33474904 PMCID: PMC10408953 DOI: 10.12182/20210160205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To explore the clinical diagnostic application of invasive cardiopulmonary exercise test (iCPET) in patients with unexplained dyspnea. METHODS A retrospective analysis was conducted, covering patients with a chief complaint of exertional dyspnea between May 5, 2017 and October 1, 2020. Right cardiac catheterization examination was performed on patients whose cause had not been identified through routine examination, and further iCPET was performed on patients if no clear etiology was identified through right cardiac catheterization. According to the results and the diagnostic criteria of iCPET, patients showing no obvious abnormalities in the right cardiac catheterization examination were divided into four subgroups: exercise-induced pulmonary arterial hypertension (eiPAH), exercise-induced heart failure with preserved ejection fraction (eiHFpEF), preload failure, and oxidative myopathy. By comparing the lab test, echocardiography, right heart catheter and iCPET peak exercise data of the subgroups, the disease distribution and exercise hemodynamic characteristics of patients with unexplained dyspnea examined by iCPET were described. RESULTS Of the 1 046 patients with exertional dyspnea, 771 were diagnosed with routine examination, while among the remaining 275 patients, 131 (47.6%) were diagnosed with right cardiac catheterization and 144 (52.4%) showed no clear etiology after routine examination and right cardiac catheterization. Of these 144 patients, 49 (34.0%) received iCPET with a median exercise time of 375 s. A total of 47 patients completed the examination, with a male-to-female ratio of 0.27∶1 and an average age of (47.9±14.4) years old. Among the 47 patients, 76.6% (36/47) aged between 20 and 59 and 78.7% (36/47) lived in urban areas. The preload failure group ( n=27) showed low right atrium pressure at peak exercise intensity. The eiHFpEF group ( n=9) showed high wedge pressure of pulmonary capillaries at peak of exercise intensity. The eiPAH group ( n=8) showed high average pulmonary artery pressure at peak exercise intensity. The oxidative myopathy group ( n=3) was characterized by impairment of tissue uptake and/or utilization of oxygen during exercise. According to the comparison among the three subgroups of the preload failure, eiHFpEF and eiPAH, the eiPAH group had the highest blood K + level in routine examination, while the preload failure group had the lowest blood K + level ( P=0.014). The iCPET of the three subgroups showed statistically significant ( P=0.001) difference in right atrial pressure increase during exercise. Among the three, the eiHFpEF group had the highest increase and the preload failure group had the lowest increase. Conclusion In unexplained dyspnea patients showing no abnormal results in right cardiac catheterization examination, the main cause was preload failure, which manifested as low right atrial pressure at peak exercise intensity. The study showed that iCPET was of important value for dyspnea cases when the cause of the condition was not revealed with right cardiac catheterization.
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Affiliation(s)
- 卓霖 李
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 杨柯 何
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 涯洁 向
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 鑫 易
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 中凯 朱
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 爱凌 李
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 睿 向
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 晓黎 韩
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 璞 王
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 玮 黄
- 重庆医科大学附属第一医院 心血管内科 (重庆 400016)Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Wright SP, Dawkins TG, Eves ND, Shave R, Tedford RJ, Mak S. Hemodynamic function of the right ventricular-pulmonary vascular-left atrial unit: normal responses to exercise in healthy adults. Am J Physiol Heart Circ Physiol 2020; 320:H923-H941. [PMID: 33356960 DOI: 10.1152/ajpheart.00720.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
With each heartbeat, the right ventricle (RV) inputs blood into the pulmonary vascular (PV) compartment, which conducts blood through the lungs at low pressure and concurrently fills the left atrium (LA) for output to the systemic circulation. This overall hemodynamic function of the integrated RV-PV-LA unit is determined by complex interactions between the components that vary over the cardiac cycle but are often assessed in terms of mean pressure and flow. Exercise challenges these hemodynamic interactions as cardiac filling increases, stroke volume augments, and cycle length decreases, with PV pressures ultimately increasing in association with cardiac output. Recent cardiopulmonary exercise hemodynamic studies have enriched the available data from healthy adults, yielded insight into the underlying mechanisms that modify the PV pressure-flow relationship, and better delineated the normal limits of healthy responses to exercise. This review will examine hemodynamic function of the RV-PV-LA unit using the two-element Windkessel model for the pulmonary circulation. It will focus on acute PV and LA responses that accommodate increased RV output during exercise, including PV recruitment and distension and LA reservoir expansion, and the integrated mean pressure-flow response to exercise in healthy adults. Finally, it will consider how these responses may be impacted by age-related remodeling and modified by sex-related cardiopulmonary differences. Studying the determinants and recognizing the normal limits of PV pressure-flow relations during exercise will improve our understanding of cardiopulmonary mechanisms that facilitate or limit exercise.
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Affiliation(s)
- S P Wright
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - T G Dawkins
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - N D Eves
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R Shave
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - S Mak
- Division of Cardiology, Department of Medicine, Sinai Health, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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34
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Loughnan A, Gall N, James S. Observational case series describing features of cardiopulmonary exercise testing in Postural Tachycardia Syndrome (PoTS). Auton Neurosci 2020; 231:102762. [PMID: 33348296 DOI: 10.1016/j.autneu.2020.102762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/11/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
Postural Tachycardia Syndrome (PoTS) is a chronic condition often affecting multiple systems with varied presenting symptoms. Diagnosis is made by demonstrating cardiovascular criteria on standing along with clinical assessment. Cardiopulmonary exercise testing has been used to demonstrate and characterise the physiological response to exercise and the severity of the syndrome. Previous studies on exercise testing in these patients have focussed on cardiovascular changes alone. This series characterises the integrated cardiac and respiratory response to exercise seen with cardiopulmonary exercise testing. Our main findings show that peak oxygen uptake, work done and peak heart rate are significantly reduced from their respective predicted values in PoTS patients. However, despite this, most patients demonstrated a normal exercise capacity. Features of ventilatory inefficiency were also seen which suggest exercise capacity in these patients may be limited more by impaired ventilatory control such as dysfunctional breathing during exercise rather than by cardiovascular issues.
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Affiliation(s)
- Alice Loughnan
- King's College Hospital, Denmark Hill, Brixton, London SE5 9RS, United Kingdom of Great Britain and Northern Ireland.
| | - Nicholas Gall
- King's College Hospital, Denmark Hill, Brixton, London SE5 9RS, United Kingdom of Great Britain and Northern Ireland.
| | - Stephen James
- King's College Hospital, Denmark Hill, Brixton, London SE5 9RS, United Kingdom of Great Britain and Northern Ireland.
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36
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Ewert R, Heine A, Müller-Heinrich A, Bollmann T, Obst A, Desole S, Knaak C, Stubbe B, Opitz CF, Habedank D. Exercise and fluid challenge during right heart catheterisation for evaluation of dyspnoea. Pulm Circ 2020; 10:10.1177_2045894020917887. [PMID: 32577217 PMCID: PMC7290273 DOI: 10.1177/2045894020917887] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/14/2020] [Indexed: 12/23/2022] Open
Abstract
This prospective study compared exercise test and intravenous fluid challenge in a single right heart catheter procedure to detect latent diastolic heart failure in patients with echocardiographic heart failure with preserved ejection function. We included 49 patients (73% female) with heart failure with preserved ejection function and pulmonary artery wedge pressure ≤15 mmHg. A subgroup of 26 patients had precapillary pulmonary hypertension. Invasive haemodynamic and gas exchange parameters were measured at rest, 45° upright position, during exercise, after complete haemodynamic and respiratory recovery in lying position, and after rapid infusion of 500 mL isotonic solution. Most haemodynamic parameters increased at both exercise and intravenous fluid challenge, with the higher increase at exercise. Pulmonary vascular resistance decreased by –0.21 wood units at exercise and –0.56 wood units at intravenous fluid challenge (p = 0.3); 20% (10 of 49) of patients had an increase in pulmonary artery wedge pressure above the upper limit of 20 mmHg at exercise, and 20% above the respective limit of 18 mmHg after intravenous fluid challenge. However, only three patients exceeded the upper limit of pulmonary artery wedge pressure in both tests, i.e. seven patients only at exercise and seven other patients only after intravenous fluid challenge. In the subgroup of pulmonary hypertension patients, only two patients exceeded pulmonary artery wedge pressure limits in both tests, further five patients at exercise and four patients after intravenous fluid challenge. A sequential protocol in the same patient showed a significantly higher increase in haemodynamic parameters at exercise compared to intravenous fluid challenge. Both methods can unmask diastolic dysfunction at right heart catheter procedure, but in different patient groups.
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Affiliation(s)
- Ralf Ewert
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | - Alexander Heine
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | | | - Tom Bollmann
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | - Anne Obst
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | - Susanna Desole
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | - Christine Knaak
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | - Beate Stubbe
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| | | | - Dirk Habedank
- DRK Kliniken Berlin, Department Cardiology, Berlin, Germany
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37
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Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. ACTA ACUST UNITED AC 2020. [DOI: 10.21693/1933-088x-19.1.6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Eric L. Bonno
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Michael C. Viray
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Gregory R. Jackson
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Brian A. Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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38
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Jain CC, Borlaug BA. Performance and Interpretation of Invasive Hemodynamic Exercise Testing. Chest 2020; 158:2119-2129. [PMID: 32473950 DOI: 10.1016/j.chest.2020.05.552] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 01/06/2023] Open
Abstract
Exertional dyspnea is a common complaint for patients seen in pulmonary, cardiac, and general medicine clinics, and elucidating the cause is often challenging, particularly when physical examination, echocardiography, radiography, and pulmonary function test results are inconclusive. Invasive cardiopulmonary exercise testing has emerged as the gold standard test to define causes of dyspnea and exertional limitation in this population. In this review, we describe the methods for performing and interpreting invasive cardiopulmonary exercise testing, with particular attention to the hemodynamic and blood sampling data as they apply to patients being evaluated for heart failure and pulmonary hypertension.
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39
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Neder JA, Berton DC, O'Donnell DE. The Lung Function Laboratory to Assist Clinical Decision-making in Pulmonology: Evolving Challenges to an Old Issue. Chest 2020; 158:1629-1643. [PMID: 32428514 DOI: 10.1016/j.chest.2020.04.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/21/2020] [Accepted: 04/26/2020] [Indexed: 12/17/2022] Open
Abstract
The lung function laboratory frequently provides relevant information to the practice of pulmonology. Clinical interpretation of pulmonary function and exercise tests, however, has been complicated more recently by temporal changes in demographic characteristics (higher life expectancy), anthropometric attributes (increased obesity prevalence), and the surge of polypharmacy in a sedentary population with multiple chronic degenerative diseases. In this narrative review, we concisely discuss some key challenges to test interpretation that have been affected by these epidemiologic shifts: (a) the confounding effects of advanced age and severe obesity, (b) the contemporary controversies in the diagnosis of obstruction (including asthma and/or COPD), (c) the importance of considering the diffusing capacity of the lung for carbon monoxide (Dlco)/"accessible" alveolar volume (carbon monoxide transfer coefficient) in association with Dlco to uncover the causes of impaired gas exchange, and (d) the modern role of the pulmonary function laboratory (including cardiopulmonary exercise testing) in the investigation of undetermined dyspnea. Following a Bayesian perspective, we suggest interpretative algorithms that consider the pretest probability of abnormalities as indicated by additional clinical information. We, therefore, adopt a pragmatic approach to help the practicing pulmonologist to apply the information provided by the lung function laboratory to the care of individual patients.
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Affiliation(s)
- J Alberto Neder
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, ON, Canada.
| | - Danilo C Berton
- Division of Respirology, Department of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Denis E O'Donnell
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, ON, Canada
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40
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Rekeland IG, Fosså A, Lande A, Ktoridou-Valen I, Sørland K, Holsen M, Tronstad KJ, Risa K, Alme K, Viken MK, Lie BA, Dahl O, Mella O, Fluge Ø. Intravenous Cyclophosphamide in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. An Open-Label Phase II Study. Front Med (Lausanne) 2020; 7:162. [PMID: 32411717 PMCID: PMC7201056 DOI: 10.3389/fmed.2020.00162] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 04/09/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a disease with high symptom burden, of unknown etiology, with no established treatment. We observed patients with long-standing ME/CFS who got cancer, and who reported improvement of ME/CFS symptoms after chemotherapy including cyclophosphamide, forming the basis for this prospective trial. Materials and methods: This open-label phase II trial included 40 patients with ME/CFS diagnosed by Canadian criteria. Treatment consisted of six intravenous infusions of cyclophosphamide, 600-700 mg/m2, given at four-week intervals with follow-up for 18 months, extended to 4 years. Response was defined by self-reported improvements in symptoms by Fatigue score, supported by Short Form 36 (SF-36) scores, physical activity measures and other instruments. Repeated measures of outcome variables were assessed by General linear models. Responses were correlated with specific Human Leukocyte Antigen (HLA) alleles. Results: The overall response rate by Fatigue score was 55.0% (22 of 40 patients). Fatigue score and other outcome variables showed significant improvements compared to baseline. The SF-36 Physical Function score increased from mean 33.0 at baseline to 51.5 at 18 months (all patients), and from mean 35.0 to 69.5 among responders. Mean steps per 24 h increased from mean 3,199 at baseline to 4,347 at 18 months (all patients), and from 3,622 to 5,589 among responders. At extended follow-up to 4 years 68% (15 of 22 responders) were still in remission. Patients positive for HLA-DQB1*03:03 and/or HLA-C*07:04 (n = 12) had significantly higher response rate compared to patients negative for these alleles (n = 28), 83 vs. 43%, respectively. Nausea and constipation were common grade 1-2 adverse events. There were one suspected unexpected serious adverse reaction (aggravated POTS) and 11 serious adverse events in eight patients. Conclusion: Intravenous cyclophosphamide treatment was feasible for ME/CFS patients and associated with an acceptable toxicity profile. More than half of the patients responded and with prolonged follow-up, a considerable proportion of patients reported ongoing remission. Without a placebo group, clinical response data must be interpreted with caution. We nevertheless believe a future randomized trial is warranted. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02444091.
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Affiliation(s)
- Ingrid G Rekeland
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Alexander Fosså
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Asgeir Lande
- Department of Medical Genetics, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Irini Ktoridou-Valen
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Kari Sørland
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Mari Holsen
- Clinical Research Unit, Haukeland University Hospital, Bergen, Norway
| | - Karl J Tronstad
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Kristin Risa
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Kine Alme
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Marte K Viken
- Department of Medical Genetics, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Immunology, University of Oslo and Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Benedicte A Lie
- Department of Medical Genetics, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Immunology, University of Oslo and Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Olav Dahl
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Olav Mella
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Øystein Fluge
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Biomedicine, University of Bergen, Bergen, Norway
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41
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Medic Spahic J, Ricci F, Aung N, Hallengren E, Axelsson J, Hamrefors V, Melander O, Sutton R, Fedorowski A. Proteomic analysis reveals sex-specific biomarker signature in postural orthostatic tachycardia syndrome. BMC Cardiovasc Disord 2020; 20:190. [PMID: 32321428 PMCID: PMC7178975 DOI: 10.1186/s12872-020-01465-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/05/2020] [Indexed: 12/12/2022] Open
Abstract
Background Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular (CV) autonomic disorder of unknown etiology characterized by an excessive heart rate increase on standing and orthostatic intolerance. In this study we sought to identify novel CV biomarkers potentially implicated in POTS pathophysiology. Methods We conducted a nested case-control study within the Syncope Study of Unselected Population in Malmö (SYSTEMA) cohort including 396 patients (age range, 15–50 years) with either POTS (n = 113) or normal hemodynamic response during passive head-up-tilt test (n = 283). We used a targeted approach to explore changes in cardiovascular proteomics associated with POTS through a sequential two-stage process including supervised principal component analysis and univariate ANOVA with Bonferroni correction. Results POTS patients were younger (26 vs. 31 years; p < 0.001) and had lower BMI than controls. The discovery algorithm identified growth hormone (GH) and myoglobin (MB) as the most specific biomarker fingerprint for POTS. Plasma level of GH was higher (9.37 vs 8.37 of normalised protein expression units (NPX); p = 0.002), whereas MB was lower (4.86 vs 5.14 NPX; p = 0.002) in POTS compared with controls. In multivariate regression analysis, adjusted for age and BMI, and stratified by sex, lower MB level in men and higher GH level in women remained independently associated with POTS. Conclusions Cardiovascular proteomics analysis revealed sex-specific biomarker signature in POTS featured by higher plasma level of GH in women and lower plasma level of MB in men. These findings point to sex-specific immune-neuroendocrine dysregulation and deconditioning as potentially key pathophysiological traits underlying POTS.
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Affiliation(s)
- Jasmina Medic Spahic
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, 66100, Chieti, Italy.,Casa di Cura Villa Serena, Città Sant'Angelo, 65013, Pescara, Italy
| | - Nay Aung
- William Harvey Research Institute, NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
| | - Erik Hallengren
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Jonas Axelsson
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, 214 28, Malmö, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Ducane Road, W12 0NN, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Clinical Research Center, 214 28, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.
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42
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43
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Goda A, Takeuchi K, Kikuchi H, Finger M, Inami T, Sakata K, Soejima K, Satoh T. Etiology of Exercise-Induced Pulmonary Hypertension Can Be Differentiated by Echocardiography - Insight From Patients With Chronic Pulmonary Thromboembolism With Normal Resting Hemodynamics by Balloon Pulmonary Angioplasty. Circ J 2019; 83:2527-2536. [PMID: 31582639 DOI: 10.1253/circj.cj-19-0489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Exercise-induced pulmonary hypertension (PH) is often seen in chronic thromboembolic PH (CTEPH) patients with normalized resting hemodynamics, but it is difficult to differentiate precapillary PH as pulmonary vascular dysfunction and post-capillary PH from occult-left ventricular dysfunction (LVD). The aim of this study was to examine whether the exercise-induced elevation of pulmonary arterial wedge pressure (PAWP) can be predicted by the echocardiographic index at rest.Methods and Results:A total of 71 CTEPH patients (67±11 years old, male/female=15/56) treated by pulmonary angioplasty with near-normal pulmonary arterial pressure (PAP) and normal PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheterization. Exercise-induced elevation in PAWP of >20 mmHg during exercise was defined as occult-LVD. Resting echocardiography was performed within 3 months. In the occult-LVD (n=28), PAWP at rest after leg raising for exercise (14±4 vs. 11±3 mmHg, P<0.001), and mean PAP during exercise were higher compared with the non-LVD (n=43). Peak oxygen consumption, cardiac output, and pulmonary vascular resistance at peak exercise did not differ between groups. Left atrial volume index (LAVi) in the occult-LVD was significantly larger (39.7±8.1 vs. 34.4±9.6 mL/m2, P=0.017). LAVi correlated with exercise PAWP (r=0.356, P=0.002), but not resting PAWP (r=0.161, P=0.179). CONCLUSIONS Larger left atrial volume may reflect the exercise-induced PAWP elevation as occult-LVD in CTEPH patients.
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Affiliation(s)
- Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Mayumi Finger
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Konomi Sakata
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital
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44
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Claeys M, Claessen G, La Gerche A, Petit T, Belge C, Meyns B, Bogaert J, Willems R, Claus P, Delcroix M. Impaired Cardiac Reserve and Abnormal Vascular Load Limit Exercise Capacity in Chronic Thromboembolic Disease. JACC Cardiovasc Imaging 2019; 12:1444-1456. [DOI: 10.1016/j.jcmg.2018.07.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 01/14/2023]
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45
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Neder JA, Berton DC, Marillier M, Bernard AC, O’Donnell DE. Inspiratory Constraints and Ventilatory Inefficiency Are Superior to Breathing Reserve in the Assessment of Exertional Dyspnea in COPD. COPD 2019; 16:174-181. [DOI: 10.1080/15412555.2019.1631776] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- J. Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen’s University & Kingston General Hospital, Kingston, ON, Canada
| | - Danilo C. Berton
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen’s University & Kingston General Hospital, Kingston, ON, Canada
| | - Mathieu Marillier
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen’s University & Kingston General Hospital, Kingston, ON, Canada
| | - Anne-Catherine Bernard
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen’s University & Kingston General Hospital, Kingston, ON, Canada
| | - Denis E. O’Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen’s University & Kingston General Hospital, Kingston, ON, Canada
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46
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Stiles LE, Cinnamon J, Balan I. The patient perspective: What postural orthostatic tachycardia syndrome patients want physicians to know. Auton Neurosci 2018; 215:121-125. [PMID: 29903594 DOI: 10.1016/j.autneu.2018.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/30/2022]
Abstract
Diagnosing and treating postural orthostatic tachycardia syndrome (POTS) can be a frustrating experience for patients and physicians alike. Experienced patient leaders solicited input from the large online POTS community to identify patient suggestions and concerns, with the goal of improving the patient-physician relationship and outcomes in POTS. This review article offers practical tips to improve POTS patient care and links to credible resources for your patients. The authors emphasize the urgent need for improved physician education, a tailored treatment approach, and expanded research efforts.
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Affiliation(s)
| | | | - Irina Balan
- Dysautonomia International, East Moriches, New York, USA
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47
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Oldham WM, Oliveira RKF, Wang RS, Opotowsky AR, Rubins DM, Hainer J, Wertheim BM, Alba GA, Choudhary G, Tornyos A, MacRae CA, Loscalzo J, Leopold JA, Waxman AB, Olschewski H, Kovacs G, Systrom DM, Maron BA. Network Analysis to Risk Stratify Patients With Exercise Intolerance. Circ Res 2018; 122:864-876. [PMID: 29437835 PMCID: PMC5924425 DOI: 10.1161/circresaha.117.312482] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 01/09/2023]
Abstract
RATIONALE Current methods assessing clinical risk because of exercise intolerance in patients with cardiopulmonary disease rely on a small subset of traditional variables. Alternative strategies incorporating the spectrum of factors underlying prognosis in at-risk patients may be useful clinically, but are lacking. OBJECTIVE Use unbiased analyses to identify variables that correspond to clinical risk in patients with exercise intolerance. METHODS AND RESULTS Data from 738 consecutive patients referred for invasive cardiopulmonary exercise testing at a single center (2011-2015) were analyzed retrospectively (derivation cohort). A correlation network of invasive cardiopulmonary exercise testing parameters was assembled using |r|>0.5. From an exercise network of 39 variables (ie, nodes) and 98 correlations (ie, edges) corresponding to P<9.5e-46 for each correlation, we focused on a subnetwork containing peak volume of oxygen consumption (pVo2) and 9 linked nodes. K-mean clustering based on these 10 variables identified 4 novel patient clusters characterized by significant differences in 44 of 45 exercise measurements (P<0.01). Compared with a probabilistic model, including 23 independent predictors of pVo2 and pVo2 itself, the network model was less redundant and identified clusters that were more distinct. Cluster assignment from the network model was predictive of subsequent clinical events. For example, a 4.3-fold (P<0.0001; 95% CI, 2.2-8.1) and 2.8-fold (P=0.0018; 95% CI, 1.5-5.2) increase in hazard for age- and pVo2-adjusted all-cause 3-year hospitalization, respectively, were observed between the highest versus lowest risk clusters. Using these data, we developed the first risk-stratification calculator for patients with exercise intolerance. When applying the risk calculator to patients in 2 independent invasive cardiopulmonary exercise testing cohorts (Boston and Graz, Austria), we observed a clinical risk profile that paralleled the derivation cohort. CONCLUSIONS Network analyses were used to identify novel exercise groups and develop a point-of-care risk calculator. These data expand the range of useful clinical variables beyond pVo2 that predict hospitalization in patients with exercise intolerance.
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Affiliation(s)
- William M Oldham
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Rudolf K F Oliveira
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Rui-Sheng Wang
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Alexander R Opotowsky
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - David M Rubins
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Jon Hainer
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Bradley M Wertheim
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - George A Alba
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Gaurav Choudhary
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Adrienn Tornyos
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Calum A MacRae
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Joseph Loscalzo
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Jane A Leopold
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Aaron B Waxman
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Horst Olschewski
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Gabor Kovacs
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - David M Systrom
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.)
| | - Bradley A Maron
- From the Department of Medicine (W.M.O., R.K.F.O., R.-S.W., D.M.R., B.M.W., C.A.M., J.L., A.B.W., D.M.S., J.A.L.), Division of Pulmonary and Critical Care Medicine (W.M.O., B.M.W., A.B.W., D.M.S.), Division of Cardiovascular Medicine (A.R.O., C.A.M., J.L., J.A.L., B.A.M.), and Department of Radiology (J.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), Brazil (R.K.F.O.); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, MA (A.R.O.); Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (G.A.A.); Division of Cardiology, Department of Medicine, Providence Veterans Affairs Medical Center and Alpert Medical School of Brown University, Providence, RI (G.C.); Department of Pulmonology, Medical University of Graz, Austria (A.T., H.O., G.K.); Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria (A.T., H.O., G.K.); and Department of Cardiology, Boston VA Healthcare System, MA (B.A.M.).
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Exercise testing in heart failure: a contemporary discussion in an era of novel diagnostic techniques and biomarkers. Curr Opin Cardiol 2017; 33:217-224. [PMID: 29227300 DOI: 10.1097/hco.0000000000000490] [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: 10/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight recent advances in the field of exercise testing for patients with heart failure. RECENT FINDINGS The importance of assessment of cardiorespiratory fitness (CRF) and exercise testing in heart failure is highlighted in the consensus recommendation of the American Heart Association. Contemporary studies have validated the independent and incremental strength of CRF metrics in patients with heart failure and coronary artery disease. The use of respiratory gas analysis and imaging or hemodynamics during physical exercise is feasible and results in high prognostic utility across the continuum of heart failure. Understanding how CRF metrics complement existing and novel biomarkers and risk scores is an emerging subject of scientific inquiry. SUMMARY In the current era of personalized medicine, integrating CRF, imaging and circulating biomarkers will allow us to further develop individualized strategies for improving outcome in patients with heart failure.
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Chloros T, Burt C, Dunning J. The Role of Intraoperative Transesophageal Echocardiography in Identifying a Fenestrated Occlusion of the Inferior Vena Cava During Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth 2017; 32:1329-1332. [PMID: 29217240 DOI: 10.1053/j.jvca.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Thomas Chloros
- Department of Anaesthesia and Critical Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom
| | - Christiana Burt
- Department of Anaesthesia and Critical Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom.
| | - John Dunning
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom
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