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Naraen A, Duvva D, Rao A. Heart Failure and Cardiac Device Therapy: A Review of Current National Institute of Health and Care Excellence and European Society of Cardiology Guidelines. Arrhythm Electrophysiol Rev 2023; 12:e21. [PMID: 37457437 PMCID: PMC10345955 DOI: 10.15420/aer.2022.35] [Citation(s) in RCA: 2] [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: 10/15/2022] [Accepted: 01/21/2023] [Indexed: 07/18/2023] Open
Abstract
Guidelines help clinicians to deliver high-quality care with therapies based on up-to-date evidence. There has been significant progress in the management of heart failure with regards to both medication and cardiac device therapy. These advances have been incorporated into national and international guidelines with varying degrees of success. This article reviews current guidance from the National Institute of Health and Care Excellence in the UK and compares this with European Society of Cardiology guidelines, and evaluates how differences between them may impact on clinical practice.
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Affiliation(s)
- Akriti Naraen
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dileep Duvva
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Archana Rao
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool, UK
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2
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Sakellaropoulos S, Lekaditi D, Svab S. Cardiopulmonary Exercise Test in heart failure: A Sine qua non. ACTA ACUST UNITED AC 2020. [DOI: 10.34256/ijpefs2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A robust literature, over the last years, supports the indication of cardiopulmonary exercise testing (CPET) in patients with cardiovascular diseases. Understanding exercise physiology is a crucial component of the critical evaluation of exercise intolerance. Shortness of breath and exercise limitation is often treated with an improper focus, partly because the pathophysiology is not well understood in the frame of the diagnostic spectrum of each subspecialty. A vital field and research area have been cardiopulmonary exercise test in heart failure with preserved/reduced ejection fraction, evaluation of heart failure patients as candidates for LVAD-Implantation, as well as for LVAD-Explantation and ultimately for heart transplantation. All the CPET variables provide synergistic prognostic discrimination. However, Peak VO2 serves as the most critical parameter for risk stratification and prediction of survival rate.
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Irizarry Pagán EE, Vargas PE, López-Candales A. The clinical dilemma of heart failure with preserved ejection fraction: an update on pathophysiology and management for physicians. Postgrad Med J 2016; 92:346-55. [DOI: 10.1136/postgradmedj-2015-133859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/11/2016] [Indexed: 12/20/2022]
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Myers J, Arena R, Cahalin LP, Labate V, Guazzi M. Cardiopulmonary Exercise Testing in Heart Failure. Curr Probl Cardiol 2015; 40:322-72. [DOI: 10.1016/j.cpcardiol.2015.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Erdei T, Smiseth OA, Marino P, Fraser AG. A systematic review of diastolic stress tests in heart failure with preserved ejection fraction, with proposals from the EU-FP7 MEDIA study group. Eur J Heart Fail 2014; 16:1345-61. [PMID: 25393338 DOI: 10.1002/ejhf.184] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 11/06/2022] Open
Abstract
AIMS Cardiac function should be assessed during stress in patients with suspected heart failure with preserved ejection fraction (HFPEF), but it is unclear how to define impaired diastolic reserve. METHODS AND RESULTS We conducted a systematic review to identify which pathophysiological changes serve as appropriate targets for diagnostic imaging. We identified 38 studies of 1111 patients with HFPEF (mean age 65 years), 744 control patients without HFPEF, and 458 healthy subjects. Qualifying EF was >45-55%; diastolic dysfunction at rest was a required criterion in 45% of studies. The initial workload during bicycle exercise (25 studies) varied from 12.5 to 30 W (mean 23.1 ± 4.6), with increments of 10-25 W (mean 19.9 ± 6) and stage duration 1-5 min (mean 2.5 ± 1); targets were submaximal (n = 8) or maximal (n = 17). Other protocols used treadmill exercise, handgrip, dobutamine, lower body negative pressure, nitroprusside, fluid challenge, leg raising, or atrial pacing. Reproducibility of echocardiographic variables during stress and validation against independent reference criteria were assessed in few studies. Change in E/e' was the most frequent measurement, but there is insufficient evidence to establish this or other tests for routine use when evaluating patients with HFPEF. CONCLUSIONS To meet the clinical requirements of performing stress testing in elderly subjects, we propose a ramped exercise protocol on a semi-supine bicycle, starting at 15 W, with increments of 5 W/min to a submaximal target (heart rate 100-110 b.p.m., or symptoms). Measurements during submaximal and recovery stages should include changes from baseline in LV long-axis function and indirect echocardiographic indices of LV diastolic pressure.
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Affiliation(s)
- Tamás Erdei
- Wales Heart Research Institute, Cardiff University, Cardiff, UK
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Houstis NE, Lewis GD. Causes of exercise intolerance in heart failure with preserved ejection fraction: searching for consensus. J Card Fail 2014; 20:762-778. [PMID: 25108084 DOI: 10.1016/j.cardfail.2014.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 07/16/2014] [Accepted: 07/22/2014] [Indexed: 11/25/2022]
Abstract
Exercise intolerance is one of the cardinal symptoms of heart failure with preserved ejection fraction (HFpEF). We review its mechanistic basis using evidence from exercise studies. One barrier to a consensus understanding of the pathophysiology is heterogeneity of the patient population. Therefore, we pay special attention to varying study definitions of the disease and their possible impact on the causal factors that are implicated. We then discuss the role of exercise testing and its potential to subtype HFpEF in to more homogeneous mechanism-based subclasses.
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Affiliation(s)
- Nicholas E Houstis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Abstract
In patients with chronic but stable heart failure (HF) exercise training is a recommended and widely accepted adjunct to an evidence-based management involving pharmacological and non-pharmacological therapies. Various pathophysiological mechanisms, such as central hemodynamics, vasculature, ventilation, skeletal muscle function as well as neurohormonal activation and inflammation are responsible for exercise intolerance described in HF patients. There is sufficient and growing evidence that exercise training in HF with reduced (HFrEF) and with preserved ejection fraction (HFpEF) is effective in improving exercise capacity, HF symptoms and quality of life. The positive effects of exercise training in HF are mediated by an improvement of central hemodynamics, endothelial function, inflammatory markers, neurohumoral activation, as well as skeletal muscle structure and function. In contrast to convincing data from a large meta-analysis, the large HF-ACTION study (Heart Failure-A Controlled Trial Investigating Outcomes of exercise TraiNing) only demonstrated a modest improvement of all cause mortality and hospitalizations in HFrEF. Outcome data in HFpEF are lacking. Whether interval training incorporating variable and higher intensities or the addition of resistance exercise to a standard aerobic prescription is superior in improving clinical status of HF patients is currently being examined. Despite increasing validation of the potential of exercise training in chronic HF, challenges remain in the routine therapeutic application, including interdisciplinary management, financing of long-term exercise programs and the need to improve short-term and long-term adherence to exercise training.
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Nolte K, Herrmann-Lingen C, Wachter R, Gelbrich G, Düngen HD, Duvinage A, Hoischen N, von Oehsen K, Schwarz S, Hasenfuss G, Halle M, Pieske B, Edelmann F. Effects of exercise training on different quality of life dimensions in heart failure with preserved ejection fraction: the Ex-DHF-P trial. Eur J Prev Cardiol 2014; 22:582-93. [PMID: 24627449 DOI: 10.1177/2047487314526071] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/08/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite suffering from poor prognosis, progressive exercise intolerance, and impaired quality of life (QoL), effective therapeutic strategies in heart failure with preserved ejection fraction (HFpEF) are sparse. Exercise training (ET) improves physical QoL in HFpEF, but the effects on other aspects of QoL are unknown. METHODS The multicentre, prospective, randomized, controlled Exercise training in Diastolic Heart Failure Pilot study included 64 HFpEF patients (65 ± 7 years, 56% female). They were randomized to supervised endurance/resistance training in addition to usual care (ET, n = 44) or usual care alone (UC, n = 20). At baseline and after 3 months, QoL was assessed (36-item Short-form Health Survey (SF-36), Minnesota Living With Heart Failure Questionnaire (MLWHFQ), and Patient Health Questionnaire (PHQ-9). RESULTS Exercise improved the following SF-36 dimensions: physical functioning (p < 0.001, p = 0.001 vs. UC), bodily pain (p = 0.046), general health perception (p < 0.001, p = 0.016 vs. UC), general mental health (p = 0.002), vitality (p = 0.003), social functioning (p < 0.001) physical (p < 0.001, p = 0.001 vs. UC), and mental component score (p = 0.030). ET did not improve role limitations due to physical and emotional problems. The MLWHFQ total scale (p < 0.001) and the MLWHFQ physical limitation scale (p < 0.001, p = 0.04 vs. UC) also improved with ET. The MLWHFQ emotional limitation scale did not change with ET. With ET, also the PHQ-9 total score improved significantly (p = 0.004, p = 0.735 vs. UC). CONCLUSIONS In patients with HFpEF, exercise training improved emotional status, physical and social dimensions of QoL as well as symptoms of depression from pre to post test. Physical dimensions of QoL and general health perception also improved significantly with exercise in comparison to usual care.
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Affiliation(s)
- Kathleen Nolte
- Department of Cardiology, University of Göttingen, Göttingen, Germany
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine, University of Göttingen, Göttingen, Germany German Center for Cardiovascular Research (DZHK) Site Göttingen, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Göttingen, Göttingen, Germany German Center for Cardiovascular Research (DZHK) Site Göttingen, Germany
| | - Götz Gelbrich
- Institute for Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Hans-Dirk Düngen
- Department of Internal Medicine - Cardiology, Charité - Campus Virchow-Klinikum, University of Berlin, Augustenburger Platz 1, Berlin, Germany
| | - André Duvinage
- Department of Internal Medicine - Cardiology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Nadine Hoischen
- Department of Cardiology, University of Göttingen, Göttingen, Germany
| | - Karima von Oehsen
- Department of Cardiology, University of Göttingen, Göttingen, Germany Department of Psychosomatic Medicine, University of Göttingen, Göttingen, Germany
| | - Silja Schwarz
- Department of Prevention, Rehabilitation and Sports Medicine, Technische Universität München, Munich, Germany
| | - Gerd Hasenfuss
- Department of Cardiology, University of Göttingen, Göttingen, Germany German Center for Cardiovascular Research (DZHK) Site Göttingen, Germany
| | - Martin Halle
- Department of Prevention, Rehabilitation and Sports Medicine, Technische Universität München, Munich, Germany Munich Heart Alliance, Partner Site German Centre for Cardiovascular Research (DZHK), Germany
| | - Burkert Pieske
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Frank Edelmann
- Department of Cardiology, University of Göttingen, Göttingen, Germany German Center for Cardiovascular Research (DZHK) Site Göttingen, Germany
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Stringer WW. Cardiopulmonary exercise testing: current applications. Expert Rev Respir Med 2014; 4:179-88. [DOI: 10.1586/ers.10.8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Teixeira JAC, Teixeira PS, Miranda SMRD, Messias LR, Cascon RM, Costa WLBD, Dias KP, Jorge JG, Nobrega ACLD, Araujo DVD. Teste de esforco cardiopulmonar na insuficiencia cardiaca de fracao de ejecao normal. REV BRAS MED ESPORTE 2014. [DOI: 10.1590/s1517-86922014000100008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: O teste de esforço cardiopulmonar (TECP) fornece dados que orientam tratamento, prognóstico e tomadas de decisões. Entretanto, seu uso na insuficiência cardíaca de fração de ejeção normal (ICFEN) ainda não está bem esclarecido, em especial considerando novas variáveis que vêm despontando. OBJETIVOS: Comparar o comportamento das principais variáveis diagnósticas e prognósticas do TECP entre dois grupos: pacientes com insuficiência cardíaca de fração de ejeção reduzida (ICFER) e pacientes com ICFEN. MÉTODOS: Foram avaliados 36 pacientes com insuficiência cardíaca em classe funcional II-III da NYAH: 20 com ICFEN e 16 com ICFER do ambulatório de insuficiência cardíaca do Hospital Universitário Antônio Pedro (UFF). Os pacientes do Grupo ICFER selecionados foram os com FE < 35% e os do grupo ICFEN seguiram os critérios diagnósticos da Sociedade Europeia de Cardiologia de 2007. Realizou-se TECP, em esteira com protocolo de rampa, com analisador de gases VO2000. Foram aplicados teste t de Student, Mann-Whitney, teste de Fisher, modelo linear generalizado e de Cochran-Mantel-Haenszel para as análises estatísticas. RESULTADOS: O grupo ICFEN apresentou níveis mais elevados da pressão arterial em repouso, na resposta ao esforço, na potência circulatória e ventilatória, além de um maior tempo de recuperação da cinética do consumo de oxigênio. Não houve diferença em relação a outras variáveis prognósticas do TECP para o grupo ICFER. CONCLUSÕES: A pressão arterial de repouso e em esforço, a potência circulatória e ventilatória e a cinética de recuperação do VO2 (T1/2) foram as variáveis que apresentaram maior valor discriminativo entre os grupos pelo TECP.
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Edelmann F, Gelbrich G, Duvinage A, Stahrenberg R, Behrens A, Prettin C, Kraigher-Krainer E, Schmidt AG, Düngen HD, Kamke W, Tschöpe C, Herrmann-Lingen C, Halle M, Hasenfuss G, Wachter R, Pieske B. Differential interaction of clinical characteristics with key functional parameters in heart failure with preserved ejection fraction — Results of the Aldo-DHF trial. Int J Cardiol 2013; 169:408-17. [DOI: 10.1016/j.ijcard.2013.10.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 10/05/2013] [Indexed: 12/01/2022]
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Heart Failure With a Normal Left Ventricular Ejection Fraction: Epidemiology Pathophysiology, Diagnosis and Management. Am J Med Sci 2013; 346:129-36. [DOI: 10.1097/maj.0b013e31828c586e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ting SMS, Iqbal H, Hamborg T, Imray CHE, Hewins S, Banerjee P, Bland R, Higgins R, Zehnder D. Reduced functional measure of cardiovascular reserve predicts admission to critical care unit following kidney transplantation. PLoS One 2013; 8:e64335. [PMID: 23724043 PMCID: PMC3664577 DOI: 10.1371/journal.pone.0064335] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 04/13/2013] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND There is currently no effective preoperative assessment for patients undergoing kidney transplantation that is able to identify those at high perioperative risk requiring admission to critical care unit (CCU). We sought to determine if functional measures of cardiovascular reserve, in particular the anaerobic threshold (VO₂AT) could identify these patients. METHODS Adult patients were assessed within 4 weeks prior to kidney transplantation in a University hospital with a 37-bed CCU, between April 2010 and June 2012. Cardiopulmonary exercise testing (CPET), echocardiography and arterial applanation tonometry were performed. RESULTS There were 70 participants (age 41.7±14.5 years, 60% male, 91.4% living donor kidney recipients, 23.4% were desensitized). 14 patients (20%) required escalation of care from the ward to CCU following transplantation. Reduced anaerobic threshold (VO₂AT) was the most significant predictor, independently (OR = 0.43; 95% CI 0.27-0.68; p<0.001) and in the multivariate logistic regression analysis (adjusted OR = 0.26; 95% CI 0.12-0.59; p = 0.001). The area under the receiver-operating-characteristic curve was 0.93, based on a risk prediction model that incorporated VO₂AT, body mass index and desensitization status. Neither echocardiographic nor measures of aortic compliance were significantly associated with CCU admission. CONCLUSIONS To our knowledge, this is the first prospective observational study to demonstrate the usefulness of CPET as a preoperative risk stratification tool for patients undergoing kidney transplantation. The study suggests that VO₂AT has the potential to predict perioperative morbidity in kidney transplant recipients.
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Affiliation(s)
- Stephen M. S. Ting
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
- * E-mail: (ST); (DZ)
| | - Hasan Iqbal
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Thomas Hamborg
- Division of Health Sciences Statistics and Epidemiology, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Chris H. E. Imray
- Department of Vascular and Renal Transplantation Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Susan Hewins
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Prithwish Banerjee
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Rosemary Bland
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Robert Higgins
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Daniel Zehnder
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
- * E-mail: (ST); (DZ)
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Guazzi M, Labate V, Cahalin LP, Arena R. Cardiopulmonary exercise testing reflects similar pathophysiology and disease severity in heart failure patients with reduced and preserved ejection fraction. Eur J Prev Cardiol 2013; 21:847-54. [PMID: 23382540 DOI: 10.1177/2047487313476962] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We are unaware of any previous investigation that has compared the relationship of key cardiopulmonary exercise testing (CPX) variables to various measures of pathophysiology between heart failure-reduced ejection fraction (HFrEF) and HF-preserved ejection fraction (HFpEF) cohorts that are well matched with respect to baseline characteristics and their exercise response, which is the purpose of the present study. METHODS Thirty-four patients with HFpEF were randomly matched to 34 subjects with HFrEF according to age and sex as well as peak oxygen consumption (VO2), ventilatory efficiency (VE/VCO2 slope), and exercise oscillatory ventilation (EOV). In addition to CPX, patients also underwent echocardiography with tissue Doppler imaging (TDI) and assessment of N-terminal pro-B-type natriuretic peptide (NT-proBNP). RESULTS When matched for age, sex, and CPX variables, the HFrEF and HFpEF cohorts had similar echocardiography with TDI and NT-proBNP values, indicating comparable disease severity. In addition, the correlations between key CPX measures (peak VO2 and VE/VCO2 slope) and echocardiography with TDI and NT-proBNP measures were similar between HFrEF and HFpEF groups. Of note, the correlation between the VE/VCO2 slope and pulmonary artery systolic pressure and NT-proBNP was highly significant in both groups (r ≥ 0.65, p < 0.01). Moreover, subjects with EOV in both groups had a significantly higher PASP (∼47 vs. ∼35 mmHg, p < 0.05). CONCLUSIONS The results of the current study indicate CPX equally represents disease severity in HFrEF and HFpEF patients. This is a novel finding supporting the key role of CPX in the clinical follow-up of HF patients irrespective of LVEF and cardiac phenotype.
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Affiliation(s)
| | | | | | - Ross Arena
- University of New Mexico, Albuquerque, New Mexico
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McIntosh RA, Silberbauer J, Veasey RA, Raju P, Baumann O, Kelly S, Beale L, Brickley G, Sulke N, Lloyd GW. Tissue Doppler-Derived Contractile Reserve Is a Simple and Strong Predictor of Cardiopulmonary Exercise Performance across a Range of Cardiac Diseases. Echocardiography 2013; 30:527-33. [DOI: 10.1111/echo.12084] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Robert A. McIntosh
- Cardiology Department; Eastbourne Hospital; East Sussex Hospitals NHS Trust; Eastbourne; United Kingdom
| | - John Silberbauer
- Cardiology Department; Eastbourne Hospital; East Sussex Hospitals NHS Trust; Eastbourne; United Kingdom
| | - Rick A. Veasey
- Cardiology Department; Eastbourne Hospital; East Sussex Hospitals NHS Trust; Eastbourne; United Kingdom
| | - Prashanth Raju
- Cardiology Department; Eastbourne Hospital; East Sussex Hospitals NHS Trust; Eastbourne; United Kingdom
| | - Oliver Baumann
- Institute of Sound and Vibration Research; Southampton University; Southampton; United Kingdom
| | - Sarah Kelly
- Chelsea School; University of Brighton; Eastbourne; United Kingdom
| | - Louisa Beale
- Chelsea School; University of Brighton; Eastbourne; United Kingdom
| | - Gary Brickley
- Chelsea School; University of Brighton; Eastbourne; United Kingdom
| | - Neil Sulke
- Cardiology Department; Eastbourne Hospital; East Sussex Hospitals NHS Trust; Eastbourne; United Kingdom
| | - Guy W. Lloyd
- Cardiology Department; Eastbourne Hospital; East Sussex Hospitals NHS Trust; Eastbourne; United Kingdom
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Maeder MT, Thompson BR, Htun N, Kaye DM. Hemodynamic Determinants of the Abnormal Cardiopulmonary Exercise Response in Heart Failure With Preserved Left Ventricular Ejection Fraction. J Card Fail 2012; 18:702-10. [DOI: 10.1016/j.cardfail.2012.06.530] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 05/21/2012] [Accepted: 06/18/2012] [Indexed: 12/15/2022]
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Guazzi M, Vitelli A. Is Ventilation Efficiency an Additional Target of Exercise Training Benefits in Heart Failure With Preserved Ejection Fraction? J Am Coll Cardiol 2012; 59:1658; author reply 1658-9. [DOI: 10.1016/j.jacc.2011.10.906] [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: 10/14/2011] [Accepted: 10/18/2011] [Indexed: 11/30/2022]
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Body mass index is related to the perception of exertional breathlessness in patients presenting with dyspnoea of unknown origin. Int J Cardiol 2012; 157:300-3. [DOI: 10.1016/j.ijcard.2012.03.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 03/11/2012] [Indexed: 12/31/2022]
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Mahadevan G, Dwivedi G, Williams L, Steeds RP, Frenneaux M. Epidemiology and diagnosis of heart failure with preserved left ventricular ejection fraction: rationale and design of the study. Eur J Heart Fail 2011; 14:106-12. [PMID: 22120964 DOI: 10.1093/eurjhf/hfr153] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIMS Despite major advances in our understanding of 'systolic' heart failure, at present the epidemiology, pathophysiology, and therapy of heart failure with preserved left ventricular ejection fraction (HFpEF) is poorly understood, in large part because of the lack of robust and widely accepted diagnostic criteria. Although there is a good evidence base for the treatment of systolic heart failure, similar data are lacking for the treatment of HFpEF. Methods In our study, we will screen a consecutive series of 5000 subjects aged ≥60 from the community. Following symptom questionnaire and echocardiography, metabolic exercise testing will be used to confirm whether or not patients thought clinically to have HFpEF are in fact exercise limited and that this limitation is cardiac in origin. Blood samples for plasma brain natriuretic peptide (BNP) will be taken at rest and following exercise in symptomatic patients and matching controls. CONCLUSIONS At the end of our study we will establish community prevalence and population characteristics of HFpEF, and also evaluate the diagnostic accuracy of current echocardiography parameters and BNP for the diagnosis of the condition.
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Trivi M, Thierer J, Kuschnir P, Acosta A, Marino J, Guglielmone R, Ronderos R. [Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation]. Rev Esp Cardiol 2011; 64:1096-9. [PMID: 21907482 DOI: 10.1016/j.recesp.2011.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 06/04/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction. METHODS We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m. RESULTS Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1cm(2)), mitral E amplitude (88±5 vs 72±3cm/s) and systolic pulmonary pressure (37±1 vs 32±1mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: -6.52±2, P<.01). CONCLUSIONS In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.
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Affiliation(s)
- Marcelo Trivi
- Servicios de Cardiología Clínica e Imágenes, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
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21
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Forman DE, Myers J, Lavie CJ, Guazzi M, Celli B, Arena R. Cardiopulmonary exercise testing: relevant but underused. Postgrad Med 2011; 122:68-86. [PMID: 21084784 DOI: 10.3810/pgm.2010.11.2225] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cardiopulmonary exercise testing (CPX) is a relatively old technology, but has sustained relevance for many primary care clinical scenarios in which it is, ironically, rarely considered. Advancing computer technology has made CPX easier to administer and interpret at a time when our aging population is more prone to comorbidities and higher prevalence of nonspecific symptoms of exercise intolerance and dyspnea, for which CPX is particularly useful diagnostically and prognostically. These discrepancies in application are compounded by patterns in which CPX is often administered and interpreted by cardiology, pulmonary, or exercise specialists who limit their assessments to the priorities of their own discipline, thereby missing opportunities to distinguish symptom origins. When used properly, CPX enables the physician to assess fitness and uncover cardiopulmonary issues at earlier phases of work-up, which would therefore be especially useful for primary care physicians. In this article, we provide an overview of CPX principles and testing logistics, as well as some of the clinical contexts in which it can enhance patient care.
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Affiliation(s)
- Daniel E Forman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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22
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Palhares LC, Gallani MCBJ, Gemignani T, Matos-Souza JR, Ubaid-Girioli S, Moreno H, Franchini KG, Nadruz W, Rodrigues RCM. Quality of life, dyspnea and ventricular function in patients with hypertension. J Adv Nurs 2010; 66:2287-96. [PMID: 20735508 DOI: 10.1111/j.1365-2648.2010.05396.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM This paper is a report of an investigation of the relationship between health-related quality of life and left ventricular function among patients with hypertension who did not fulfil the criteria for heart failure. BACKGROUND Heart failure is a common consequence of hypertension, with Doppler echocardiography being the gold-standard tool to evaluate left ventricular function, mainly hypertension-induced left ventricular damage. Echocardiographic data indicating poorer ventricular function have been related to lower levels of health-related quality of life in patients with systolic and/or diastolic heart failure. However, data are still lacking regarding the correlation between health-related quality of life and left ventricular function and structure in patients with hypertension who do not fulfil the criteria for heart failure. METHOD Between September 2005 and February 2007, 98 patients with hypertension without systolic or diastolic heart failure were evaluated. Health-related quality of life was assessed using the Medical Outcomes Study Short Form-36. Left ventricular function was evaluated through Tissue Doppler echocardiography. RESULTS Statistically significant but weak correlations (varying from r = -0.22 to 0.35) were observed between some of the Short Form-36 domains and echo data. To consider the potential effect of dyspnoea in this relationship, patients were split according to the presence or absence of the symptom. In the subgroup without dyspnoea, similar patterns of correlation were observed (varying from r = 0.26 to 0.32). In the subgroup with dyspnoea, however, more and stronger correlations were observed between echo data and health-related quality of life domains, varying from r = -0.40 to 0.50. CONCLUSION Nurses should be aware of the relevance of evaluating the functional echocardiographic data of patients who not fulfil heart failure criteria, but who experience dyspnoea in order to implement appropriate action plans.
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23
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Phan TT, Shivu GN, Abozguia K, Davies C, Nassimizadeh M, Jimenez D, Weaver R, Ahmed I, Frenneaux M. Impaired Heart Rate Recovery and Chronotropic Incompetence in Patients With Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2010; 3:29-34. [DOI: 10.1161/circheartfailure.109.877720] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thanh Trung Phan
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Ganesh Nallur Shivu
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Khalid Abozguia
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Chris Davies
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Mohammad Nassimizadeh
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Donie Jimenez
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Rebekah Weaver
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Ibrar Ahmed
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Michael Frenneaux
- From the Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
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24
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Guazzi M, Dickstein K, Vicenzi M, Arena R. Six-Minute Walk Test and Cardiopulmonary Exercise Testing in Patients With Chronic Heart Failure. Circ Heart Fail 2009; 2:549-55. [DOI: 10.1161/circheartfailure.109.881326] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background—
The six-minute walk test (6MWT) and cardiopulmonary exercise testing (CPET) are the 2 testing modalities most broadly used for assessing functional limitation in patients with heart failure (HF). A comprehensive comparison on clinical and prognostic validity of the 2 techniques has not been performed and is the aim of the present investigation.
Methods and Results—
Two hundred fifty-three patients diagnosed with systolic (n=211) or diastolic (n=42) HF (age: 61.9�10.1 years; New York Heart Association Class: 2.2�0.78) underwent a 6MWT and a symptom-limited CPET evaluation and were prospectively followed up. During the 4-year tracking period, there were 43 cardiac-related deaths with an annual cardiac mortality rate of 8.7%. The 6MWT distance correlated with CPET-derived variables (ie, peak V
o
2
, V
o
2
at anaerobic threshold, and V
e
/V
co
2
slope) and was significantly reduced in proportion with lower peak V
o
2
and higher V
e
/V
co
2
slope classes and presence of an exercise oscillatory breathing (EOB) pattern (
P
<0.01). However, no significant differences were observed in distance covered between survivors and nonsurvivors (353.2�95.8 m versus 338.5�76.4 m;
P
=NS). At univariate and multivariate Cox proportional analyses, the association of the 6MWT distance with survival was not significant either as a continuous or dicotomized variable (≤300 m). Conversely, CPET-derived variables emerged as prognostic with the strongest association found for EOB (systolic HF) and V
e
/V
co
2
slope (entire population with HF and patients with a 6MWT≤300 m).
Conclusions—
The 6MWT is confirmed to be a simple and reliable first-line test for quantification of exercise intolerance in patients with HF. However, there is no supportive evidence for its use as a prognostic marker in alternative to or in conjunction with CPET-derived variables.
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Affiliation(s)
- Marco Guazzi
- From the Cardiopulmonary Unit (M.G., M.V.), University of Milano, Italy; Stavanger University Hospital (K.D.), Stavanger, Rogaland, Norway; Institute of Internal Medicine (K.D.), University of Bergen, Bergen, Norway; Virginia Commonwealth University (R.A.), Virginia, Richmond, Va
| | - Kenneth Dickstein
- From the Cardiopulmonary Unit (M.G., M.V.), University of Milano, Italy; Stavanger University Hospital (K.D.), Stavanger, Rogaland, Norway; Institute of Internal Medicine (K.D.), University of Bergen, Bergen, Norway; Virginia Commonwealth University (R.A.), Virginia, Richmond, Va
| | - Marco Vicenzi
- From the Cardiopulmonary Unit (M.G., M.V.), University of Milano, Italy; Stavanger University Hospital (K.D.), Stavanger, Rogaland, Norway; Institute of Internal Medicine (K.D.), University of Bergen, Bergen, Norway; Virginia Commonwealth University (R.A.), Virginia, Richmond, Va
| | - Ross Arena
- From the Cardiopulmonary Unit (M.G., M.V.), University of Milano, Italy; Stavanger University Hospital (K.D.), Stavanger, Rogaland, Norway; Institute of Internal Medicine (K.D.), University of Bergen, Bergen, Norway; Virginia Commonwealth University (R.A.), Virginia, Richmond, Va
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25
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Jurgens CY, Moser DK, Armola R, Carlson B, Sethares K, Riegel B. Symptom clusters of heart failure. Res Nurs Health 2009; 32:551-60. [PMID: 19650069 PMCID: PMC3234105 DOI: 10.1002/nur.20343] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with heart failure (HF) report multiple symptoms. Change in symptoms is an indicator of HF decompensation. Patients have difficulty differentiating HF symptoms from comorbid illness or aging. The study purpose was to identify the number, type, and combination of symptoms in hospitalized HF patients and test relationships with comorbid illness and age. A secondary analysis from a HF registry (N = 687) was conducted. The sample was 51.7% female, mean age 71 +/- 12.5 years. The theory of unpleasant symptoms informed the study regarding the multidimensional nature of symptoms. Factor analysis of nine items from the Minnesota Living with HF Questionnaire resulted in three factors, acute and chronic volume overload and emotional distress. Clusters occurred more frequently in older patients, but caused less impact.
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Affiliation(s)
- Corrine Y Jurgens
- School of Nursing, Stony Brook University, HSC L2-223, Stony Brook, NY 11794-8240, USA
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26
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Tan YT, Wenzelburger F, Lee E, Heatlie G, Leyva F, Patel K, Frenneaux M, Sanderson JE. The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. J Am Coll Cardiol 2009; 54:36-46. [PMID: 19555838 DOI: 10.1016/j.jacc.2009.03.037] [Citation(s) in RCA: 351] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 03/13/2009] [Accepted: 03/17/2009] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling. BACKGROUND A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation. METHODS Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise. RESULTS Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max. CONCLUSIONS In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole.
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Affiliation(s)
- Yu Ting Tan
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK
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27
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Phan TT, Shivu GN, Abozguia K, Gnanadevan M, Ahmed I, Frenneaux M. Left ventricular torsion and strain patterns in heart failure with normal ejection fraction are similar to age-related changes. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:793-800. [DOI: 10.1093/ejechocard/jep072] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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28
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Solal AC, Tournoux F, Beauvais F, Tartiere JM. Comment évaluer et traiter l’insuffisance cardiaque à fraction d’éjection préservée. Therapie 2009; 64:101-9. [DOI: 10.2515/therapie/2009012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/14/2008] [Accepted: 12/06/2008] [Indexed: 11/20/2022]
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29
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Maeder MT, Kaye DM. Heart Failure With Normal Left Ventricular Ejection Fraction. J Am Coll Cardiol 2009; 53:905-18. [DOI: 10.1016/j.jacc.2008.12.007] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 12/02/2008] [Accepted: 12/08/2008] [Indexed: 10/21/2022]
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30
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Guazzi M, Myers J, Peberdy MA, Bensimhon D, Chase P, Arena R. Exercise oscillatory breathing in diastolic heart failure: prevalence and prognostic insights. Eur Heart J 2008; 29:2751-9. [PMID: 18836201 DOI: 10.1093/eurheartj/ehn437] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIMS Exercise intolerance occurs in both systolic and diastolic heart failure (HF). Exercise oscillatory breathing (EOB) is a powerful predictor of survival in patients with systolic HF. In diastolic HF, EOB prevalence and prognostic impact are unknown. METHODS AND RESULTS A total of 556 HF patients (405 with systolic HF and 151 with diastolic HF) underwent cardiopulmonary exercise testing (CPET). Diastolic HF was defined as signs and symptoms of HF, a left ventricular ejection fraction > or =50%, and a Doppler early (E) mitral to early mitral annulus ratio (E') > or =8. CPET responses, EOB prevalence and its ability to predict cardiac-related events were examined. EOB prevalence in systolic and diastolic HF was similar (35 vs. 31%). Compared with the patients without EOB, patients with EOB and either systolic or diastolic HF had a higher New York Heart Association class, lower peak VO(2) and higher E/E' ratio (all P < 0.01). Univariate Cox regression analysis demonstrated that peak VO(2), VE/VCO(2) slope and EOB all were significant predictors of cardiac events in both systolic and diastolic HF. Multivariable analysis revealed that EOB was retained as a prognostic marker in systolic HF and was the strongest predictor of cardiac events in diastolic HF. CONCLUSION EOB occurrence is similar in diastolic and systolic HF and provides relevant clues for the identification of diastolic HF patients at increased risk of adverse events.
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Affiliation(s)
- Marco Guazzi
- Cardiopulmonary Unit, University of Milano, San Paolo Hospital, Milano, Italy.
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31
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Barmeyer A, Müllerleile K, Mortensen K, Meinertz T. Diastolic dysfunction in exercise and its role for exercise capacity. Heart Fail Rev 2008; 14:125-34. [PMID: 18758943 DOI: 10.1007/s10741-008-9105-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 07/23/2008] [Indexed: 01/08/2023]
Abstract
Diastolic dysfunction is frequent in elderly subjects and in patients with left ventricular hypertrophy, vascular disease and diabetes mellitus. Patients with diastolic dysfunction demonstrate a reduced exercise capacity and might suffer from congestive heart failure (CHF). Presence of symptoms of CHF in the setting of a normal systolic function is referred to as heart failure with normal ejection fraction (HFNEF) or, if evidence of an impaired diastolic function is observed, as diastolic heart failure (DHF). Reduced exercise capacity in diastolic dysfunction results from a number of pathophysiological alterations such as slowed myocardial relaxation, reduced myocardial distensibility, elevated filling pressures, and reduced ventricular suction forces. These alterations limit the increase of ventricular diastolic filling and cardiac output during exercise and lead to pulmonary congestion. In healthy subjects, exercise training can enhance diastolic function and exercise capacity and prevent deterioration of diastolic function in the course of aging. In patients with diastolic dysfunction, exercise capacity can be enhanced by exercise training and pharmacological treatment, whereas improvement of diastolic function can only be observed in few patients.
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Affiliation(s)
- A Barmeyer
- Department of Cardiology/Angiology, Center for Cardiology and Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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32
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Farr MJ, Lang CC, Lamanca JJ, Zile MR, Francis G, Tavazzi L, Gaasch WH, St John Sutton M, Itoh H, Mancini D. Cardiopulmonary exercise variables in diastolic versus systolic heart failure. Am J Cardiol 2008; 102:203-6. [PMID: 18602522 DOI: 10.1016/j.amjcard.2008.03.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Revised: 03/04/2008] [Accepted: 03/04/2008] [Indexed: 01/24/2023]
Abstract
The response to cardiopulmonary exercise (CPX) in patients with heart failure (HF) with normal left ventricular (LV) ejection fractions (EFs) is not well characterized. To determine if CPX testing could distinguish between patients with HF with normal EFs (>50%; i.e., diastolic HF) and those with decreased EFs (> or =50%; i.e., systolic HF), CPX responses were compared between 185 patients with systolic HF (79% men, mean age 62.6 +/- 10.9 years) and 43 with diastolic HF (54% men, mean age 67.4 +/- 9.8 years) enrolled in a phase II multicenter clinical trial. All patients were evaluated with echocardiography and a standardized CPX test as part of the trial. CPX variables, including oxygen uptake at peak exercise (peak VO(2)) and the slope of the ventilation/carbon dioxide production ratio (VE/VCO(2)), were determined and analyzed by core laboratory personnel. Echocardiographic measurements included the LV EF, the E/A ratio, filling time, cavity volumes, right ventricular function, and mitral regurgitation. Patients in the diastolic HF group tended to be older (p <0.08), with more women (p <0.006) and with greater body mass indexes (p <0.02), than those in the systolic HF group. There was no significant difference in the use of beta blockers or the incidence of coronary artery disease. Patients with diastolic HF had decreased E/A ratios (0.9 +/- 0.4 vs 1.4 +/- 1.1, p <0.02, diastolic HF vs systolic HF) and increased filling times (30.4 +/- 3.2 vs 26.5 +/- 4.7 ms, p <0.01, diastolic HF vs systolic HF). No significant differences in peak VO(2) (14.4 +/- 1.9 vs 15.6 +/- 3.2 ml/kg/min, p = 0.06, diastolic HF vs systolic HF) were observed. The VE/VCO(2) ratios for the 2 groups were abnormal and comparable (32 2 +/- 7.5 vs 34.0 +/- 8.3, p = 0.3, diastolic HF vs systolic HF). In conclusion, the CPX response in patients with diastolic HF and systolic HF is markedly abnormal and indistinguishable with regard to peak VO(2) and ventilation despite marked differences in the LV EF.
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Affiliation(s)
- Mary Jane Farr
- Division of Cardiology, Columbia University, New York, New York, USA
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