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Staes M, Gyselinck I, Goetschalckx K, Troosters T, Janssens W. Identifying limitations to exercise with incremental cardiopulmonary exercise testing: a scoping review. Eur Respir Rev 2024; 33:240010. [PMID: 39231595 PMCID: PMC11372471 DOI: 10.1183/16000617.0010-2024] [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: 01/20/2024] [Accepted: 05/28/2024] [Indexed: 09/06/2024] Open
Abstract
Cardiopulmonary exercise testing (CPET) is a comprehensive and invaluable assessment used to identify the mechanisms that limit exercise capacity. However, its interpretation remains poorly standardised. This scoping review aims to investigate which limitations to exercise are differentiated by the use of incremental CPET in literature and which criteria are used to identify them. We performed a systematic, electronic literature search of PubMed, Embase, Cochrane CENTRAL, Web of Science and Scopus. All types of publications that reported identification criteria for at least one limitation to exercise based on clinical parameters and CPET variables were eligible for inclusion. 86 publications were included, of which 57 were primary literature and 29 were secondary literature. In general, at the level of the cardiovascular system, a distinction was often made between a normal physiological limitation and a pathological one. Within the respiratory system, ventilatory limitation, commonly identified by a low breathing reserve, and gas exchange limitation, mostly identified by a high minute ventilation/carbon dioxide production slope and/or oxygen desaturation, were often described. Multiple terms were used to describe a limitation in the peripheral muscle, but all variables used to identify this limitation lacked specificity. Deconditioning was a frequently mentioned exercise limiting factor, but there was no consensus on how to identify it through CPET. There is large heterogeneity in the terminology, the classification and the identification criteria of limitations to exercise that are distinguished using incremental CPET. Standardising the interpretation of CPET is essential to establish an objective and consistent framework.
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Affiliation(s)
- Michaël Staes
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Iwein Gyselinck
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Kaatje Goetschalckx
- Research Unit Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Clinical Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Thierry Troosters
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Wim Janssens
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
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de Oliveira Saraiva NA, de Oliveira Farias I, Dos Santos BM, Xavier RS, Lopes AJ. Reference value for the 6-min walking distance in women with systemic sclerosis considering the impact of muscle strength. Clin Biomech (Bristol, Avon) 2023; 109:106094. [PMID: 37725867 DOI: 10.1016/j.clinbiomech.2023.106094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 09/02/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Early triage, the search for new therapies, and closer monitoring of patients with systemic sclerosis before their lung function irreversibly deteriorates are urgent concerns. Because it is an independent predictor of systemic sclerosis-related mortality, the 6-min walk test is a potentially useful tool to evaluate outcomes, along with pulmonary function and computed tomography. This study aimed to establish a reference value for the 6-min walking distance in women with diffuse cutaneous systemic sclerosis-associated interstitial lung disease that takes into account the effects of muscle and lung function. METHODS This was a cross-sectional study in which 69 women with systemic sclerosis underwent the 6-min walk test, Health Assessment Questionnaire-Disability Index, pulmonary function, handgrip strength test, and quadriceps strength test. FINDINGS The mean 6-min walking distance was 447 ± 78 m, and 43.5% of the participants did not reach 80% of their predicted value. 6-min walking distance correlated positively with quadriceps strength (r = 0.418, P = 0.0004), forced vital capacity (r = 0.306, P = 0.011), pulmonary diffusion (r = 0.360, P = 0.002), maximum inspiratory pressure (r = 0.268, P = 0.029), and maximum expiratory pressure (r = 0.288, P = 0.019) and negatively with age (r = -0.378, P = 0.001), body mass index (r = -0.248, P = 0.039), and Health Assessment Questionnaire-Disability Index (r = -0.438, P = 0.0001). In the multiple linear regression analysis, quadriceps strength, body mass index, pulmonary diffusion, age, and maximum expiratory pressure explained 72% of the 6-min walking distance variability. INTERPRETATION Muscle function and, to a lesser extent, lung function are key contributors in determining the reference value for the 6-min walking distance in women with diffuse cutaneous systemic sclerosis-associated interstitial lung disease.
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Affiliation(s)
| | | | | | - Rosemere Saldanha Xavier
- Local Development Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- Rehabilitation Sciences Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil; Local Development Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil.
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3
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Ross L, Costello B, Lindqvist A, Hansen D, Brown Z, Stevens W, Burns A, Prior D, Pianta M, Perera W, La Gerche A, Nikpour M. Disease specific determinants of cardiopulmonary fitness in systemic sclerosis. Semin Arthritis Rheum 2023; 58:152137. [PMID: 36434894 DOI: 10.1016/j.semarthrit.2022.152137] [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: 08/25/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to quantify the burden of exercise intolerance in systemic sclerosis (SSc) and explore the disease features that contribute to impaired exercise capacity (measured as peak oxygen uptake, peak VO2) to provide novel mechanistic insights into the causes of physical disability in SSc. METHODS Thirty-three SSc patients with no history of cardiac disease and no active myositis underwent cardiac and skeletal muscle MRI, transthoracic echocardiography, pulmonary function tests and cardiopulmonary exercise testing (CPET). CPET results were compared to an age-, sex-, and weight-matched controls with no overt cardiopulmonary disease. Native T1 and T2-mapping sequences were used to quantify diffuse fibroinflammatory myocardial disease and qualitative assessment of skeletal muscle oedema was performed. The associations between parameters of cardiorespiratory function and skeletal muscle abnormalities and peak VO2 were evaluated with linear regression analysis. RESULTS Exercise capacity was markedly impaired in SSc and significantly reduced when compared to control subjects (percent predicted peak VO2: 70% vs 98%, p < 0⋅01). Diffuse myocardial fibroinflammatory disease (p < 0⋅01) and skeletal muscle oedema (p = 0⋅01) were significantly associated with reduced exercise capacity. There was no association between impaired exercise capacity and left ventricular ejection fraction. CONCLUSION SSc is associated with marked functional impairment that is not explained by commonly used parameters of cardiac function such as left ventricular ejection fraction. Rather, only more sensitive measures of organ involvement are associated with impaired exercise tolerance. Our results show diffuse interstitial changes of the myocardium and skeletal muscle affect oxygen uptake and are important contributors to functional limitation in SSc.
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Affiliation(s)
- Laura Ross
- Department of Medicine, The University of Melbourne, Fitzroy, VIC, Australia; Department of Rheumatology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.
| | - Benedict Costello
- Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Department of Cardiology, St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia
| | - Anniina Lindqvist
- Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Dylan Hansen
- Department of Rheumatology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Zoe Brown
- Department of Medicine, The University of Melbourne, Fitzroy, VIC, Australia; Department of Rheumatology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Andrew Burns
- Department of Medicine, The University of Melbourne, Fitzroy, VIC, Australia; Department of Cardiology, St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia
| | - David Prior
- Department of Medicine, The University of Melbourne, Fitzroy, VIC, Australia; Department of Cardiology, St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia
| | - Marcus Pianta
- Department of Medical Imaging, St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia
| | - Warren Perera
- Department of Medical Imaging, St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia
| | - André La Gerche
- Department of Medicine, The University of Melbourne, Fitzroy, VIC, Australia; Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Department of Cardiology, St Vincent's Hospital, Melbourne, Fitzroy, VIC, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne, Fitzroy, VIC, Australia; Department of Rheumatology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
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Donnelly RP, Smyth AE, Mullan C, Riley MS, Nicholls DP. Responses to exercise in systemic sclerosis-associated interstitial lung disease. Clin Physiol Funct Imaging 2023. [PMID: 36660849 DOI: 10.1111/cpf.12813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 12/14/2022] [Accepted: 01/16/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pulmonary complications in systemic sclerosis (SSc) significantly increase morbidity and mortality. Our aim was to determine the factors limiting exercise capacity in SSc patients with and without interstitial lung disease (ILD), and to identify and quantify abnormalities during exercise that might assist in clinical assessment of this complication. METHODS Fifteen patients with SSc and ILD (SSc-ILD) were compared with 10 patients with SSc without ILD and 9 age- and sex-matched normal volunteers. Subjects performed symptom-limited incremental treadmill exercise with online measurement of respiratory gas exchange, arterial blood gas sampling and measurement of neurohormones in venous blood. RESULTS Patients with SSc-ILD had lower exercise capacity than SSc patients without ILD or normal subjects (peak oxygen consumption (PV̇O2 ) (17.1 [4.2] vs. 22.0 [4.7] and 23.0 [5.4] ml kg-1 min-1 , respectively, mean [SD], p < 0.01 ANOVA), but PV̇O2 did not correlate with static pulmonary function measurements. Ventilatory equivalent for CO2 (V̇E/V̇CO2 ; nadir) was higher in SSc-ILD patients than the other two groups (36.6 [8.0] vs. 29.9 [4.4] and 30.0 [2.5], p < 0.005) as were peak exercise dead-space tidal volume ratio (0.44 [0.06] vs. 0.26 [0.09] and 0.26 [0.05], p < 0.001) and peak exercise alveolar-arterial difference (28.9 [16.9] vs. 18.8 [14.0] and 11.5 [6.9] mmHg, p < 0.05). Atrial natriuretic peptide was elevated in both SSc patient groups. CONCLUSIONS SSc-ILD results in lower exercise capacity than SSc without ILD, and abnormalities of gas exchange are seen. The possible use of cardiopulmonary exercise testing to identify disease and quantify impairment in SSc-ILD merits further study.
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Affiliation(s)
| | - Anita E Smyth
- Department of Rheumatology, Ulster Hospital, Dundonald, Northern Ireland
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5
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Martis N, Leroy S. [Cardiopulmonary exercise testing in the management of systemic sclerosis]. Rev Med Interne 2022; 43:498-505. [PMID: 35691757 DOI: 10.1016/j.revmed.2022.05.005] [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: 02/14/2021] [Revised: 05/01/2022] [Accepted: 05/15/2022] [Indexed: 11/24/2022]
Abstract
Cardiopulmonary complications are the leading cause of mortality in patients with systemic sclerosis (SSc) requiring an early identification. The complexity of the overlapping aetiologies of dyspnoea in SSc often requires a global and comprehensive approach. Through its integrative approach of ventilatory, metabolic, cardiovascular, skeletal muscular and gas exchange findings, cardiopulmonary exercise testing (CPET) has been known to identify and sort competing mechanisms of exercise limitation in scleroderma patients presenting with dyspnoea. CPET may be used to screen for pulmonary arterial hypertension, suspect interstitial lung disease and guide therapeutic strategies including exercise rehabilitation. This review focuses on the clinical value of CPET in the decision-making processes for a more personalised diagnostic approach to SSc-related complications.
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Affiliation(s)
- N Martis
- Service de médecine interne, centre hospitalier universitaire de Nice, Hôpital l'Archet 1, Nice, France; Université Côte d'Azur, Nice, France; CNRS UMR7275, institut de pharmacologie moléculaire et cellulaire, 54831, équipe: génome non-codant et pathologies pulmonaires, Valbonne, France; Inserm U1065, centre méditerranéen de médecine moléculaire, équipe: contrôle de l'expression génique.
| | - S Leroy
- Université Côte d'Azur, Nice, France; CNRS UMR7275, institut de pharmacologie moléculaire et cellulaire, 54831, équipe: génome non-codant et pathologies pulmonaires, Valbonne, France; Service de pneumologie, centre hospitalier universitaire de Nice, Hôpital Pasteur, Nice, France; FHU OncoAge, Nice, France
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6
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Gille T, Laveneziana P. Cardiopulmonary exercise testing in interstitial lung diseases and the value of ventilatory efficiency. Eur Respir Rev 2021; 30:30/162/200355. [PMID: 34853093 DOI: 10.1183/16000617.0355-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/26/2021] [Indexed: 12/27/2022] Open
Abstract
Interstitial lung diseases (ILDs) are diverse parenchymal pulmonary disorders, primarily characterised by alveolar and interstitial inflammation and/or fibrosis, and sharing pathophysiological similarities. Thus, patients generally harbour common respiratory symptoms, lung function abnormalities and modified exercise adaptation. The most usual and disabling complaint is exertional dyspnoea, frequently responsible for premature exercise interruption. Cardiopulmonary exercise testing (CPET) is increasingly used for the clinical assessment of patients with ILD. This is because exercise performance or dyspnoea on exertion cannot reliably be predicted by resting pulmonary function tests. CPET, therefore, provides an accurate evaluation of functional capacity on an individual basis. CPET can unmask anomalies in the integrated functions of the respiratory, cardiovascular, metabolic, peripheral muscle and neurosensory systems in ILDs. CPET uniquely provides an evaluation of all above aspects and can help clinicians shape ILD patient management. Preliminary evidence suggests that CPET may also generate valuable prognostic information in ILDs and can be used to shed light on the presence of associated pulmonary hypertension. This review aims to provide comprehensive and updated evidence concerning the clinical utility of CPET in ILD patients, with particular focus on the physiological and clinical value of ventilatory efficiency (V˙E/V˙CO2 ).
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Affiliation(s)
- Thomas Gille
- Université Sorbonne Paris Nord (USPN), INSERM, UMR 1272 Hypoxia & the Lung, UFR SMBH Léonard de Vinci, Bobigny, France .,Assistance Publique - Hôpitaux de Paris (AP-HP), Groupe Hospitalo-Universitaire Paris-Seine-Saint-Denis (GHUPSSD), Hôpital Avicenne, Service de Physiologie et Explorations Fonctionnelles du Département Médico-Universitaire NARVAL, Bobigny, France
| | - Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Groupe Hospitalier Universitaire APHP-Sorbonne Université, sites Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
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7
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Bournia VK, Kallianos A, Panopoulos S, Gialafos E, Velentza L, Vlachoyiannopoulos PG, Sfikakis PP, Trakada G. Cardiopulmonary exercise testing and prognosis in patients with systemic sclerosis without baseline pulmonary hypertension: a prospective cohort study. Rheumatol Int 2021; 42:303-309. [PMID: 34189602 DOI: 10.1007/s00296-021-04937-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/24/2021] [Indexed: 11/24/2022]
Abstract
Cardiopulmonary Exercise Testing (CPET) is a standardized, non-invasive procedure assessing pulmonary, cardiovascular, hematopoietic, and skeletal muscle functions during a symptom-limited test. Few studies have examined whether CPET is of prognostic value in Systemic Sclerosis (SSc), a disease characterized by highly increased cardiorespiratory morbidity and mortality. To examine the prognostic value of CPET in SSc patients without baseline pulmonary hypertension (PH). Sixty-two consecutive SSc patients underwent CPET, Pulmonary Function Tests (PFTs) and echocardiography at baseline. Four patients with Right Ventricular Systolic Pressure ≥ 40 mmHg, were excluded. Participants repeated PFTs approximately every 3 years. At the end of the follow-up period [median (IQR): 9.79 (2.78) years] patient vital status was recorded. Cox Regression analysis was used to identify predictors of deterioration of PFTs and 10-year survival. Median (IQR) age of 58 patients (90% women) at baseline was 54.0 (15.0) years, whereas 10-year survival was 88%. Baseline respiratory Oxygen uptake (VO2max) predicted PFT deterioration, defined either as a decline in FVC ≥ 10% or a combined decline in FVC 5%-9% plus DLCO ≥ 15%, during follow-up, after correction for age, gender and smoking status (HR: 0.874, 95%CI: 0.779-0.979, p = 0.021). In addition, lower baseline VO2max (HR = 0.861, 95%CI:0.739-1.003, p = 0.054) and DLCO (HR = 0.957, 95%CI: 0.910-1.006 p = 0.088), as well as male gender (HR = 5.68, 95%CI: 1.090-29.610 p = 0.039) and older age (HR = 1.069, 95%CI: 0.990-1.154, p = 0.086) were associated, after adjustment, with an increased risk for death. In the absence of baseline PH, CPET indices may predict pulmonary function deterioration and death in SSc patients during a nearly 10-year follow-up period.
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Affiliation(s)
| | - Anastasios Kallianos
- Division of Pulmonology, Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra Hospital, 11528, Athens, Greece
| | - Stylianos Panopoulos
- Joint Rheumatology Program, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Gialafos
- Joint Rheumatology Program, National and Kapodistrian University of Athens, Athens, Greece
| | - Lemonia Velentza
- Division of Pulmonology, Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra Hospital, 11528, Athens, Greece
| | | | - Petros P Sfikakis
- Joint Rheumatology Program, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia Trakada
- Division of Pulmonology, Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra Hospital, 11528, Athens, Greece.
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8
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Boutou AK, Daniil Z, Pitsiou G, Papakosta D, Kioumis I, Stanopoulos I. Cardiopulmonary exercise testing in patients with asthma: What is its clinical value? Respir Med 2020; 167:105953. [PMID: 32280032 DOI: 10.1016/j.rmed.2020.105953] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/29/2020] [Accepted: 03/31/2020] [Indexed: 01/28/2023]
Abstract
Asthma is one of the most common respiratory disorders, characterized by fully or largely reversible airflow limitation. Asthma symptoms can be triggered or magnified during exertion, while physical activity limitation is often present among asthmatic patients. Cardiopulmonary exercise testing (CPET) is a dynamic, non-invasive technique which provides a thorough assessment of exercise physiology, involving the integrative assessment of cardiopulmonary, neuromuscular and metabolic responses during exercise. This review summarizes current evidence regarding the utility of CPET in the diagnostic work-up, functional evaluation and therapeutic intervention among patients with asthma, highlighting its potential role for thorough patient assessment and physician clinical desicion-making.
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Affiliation(s)
- Afroditi K Boutou
- Department of Respiratory Medicine, "G. Papanikolaou" Hospital, Thessaloniki, Greece.
| | - Zoi Daniil
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Georgia Pitsiou
- Department of Respiratory Failure, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despoina Papakosta
- Department of Respiratory Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kioumis
- Department of Respiratory Failure, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Stanopoulos
- Department of Respiratory Failure, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Hung G, Mercurio V, Hsu S, Mathai SC, Shah AA, Mukherjee M. Progress in Understanding, Diagnosing, and Managing Cardiac Complications of Systemic Sclerosis. Curr Rheumatol Rep 2019; 21:68. [PMID: 31813082 PMCID: PMC11151284 DOI: 10.1007/s11926-019-0867-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE REVIEW Systemic sclerosis (scleroderma) is a complex autoimmune disease that commonly involves the cardiovascular system. Even if often subclinical, cardiac involvement is considered a poor prognostic factor as it is a leading cause of death in scleroderma patients. We review the cardiac manifestations of scleroderma, the diagnostic methods useful in detection, and current advances in therapeutic management. RECENT FINDINGS Beside the routine exams for the assessment of cardiac status (including EKG, standard echocardiography, provocative tests) novel techniques such as myocardial strain imaging on echocardiography, cardiac magnetic resonance imaging, invasive hemodynamic assessment, and endomyocardial biopsy have been demonstrated to be useful in understanding the cardiac alterations that typically affect scleroderma patients. Recent application of novel cardiac detection strategies is providing increased insight into the breadth and pathogenesis of cardiac complications of scleroderma. Further studies coupling exercise provocation, invasive and imaging assessment, and mechanistic studies in scleroderma cardiac tissue are needed to develop the optimal approach to early detection of cardiac disease in scleroderma and targeted therapies.
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Affiliation(s)
- George Hung
- Division of Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4100, Baltimore, MD, 21224, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA.
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10
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Prognostic value of cardiopulmonary exercise testing in patients with systemic sclerosis. BMC Pulm Med 2019; 19:230. [PMID: 31783745 PMCID: PMC6884803 DOI: 10.1186/s12890-019-1003-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 11/20/2019] [Indexed: 02/04/2023] Open
Abstract
Background Systemic sclerosis (SSc) is a severe rheumatic disease of the interstitial tissue, in which heart and lung involvement can lead to disease-specific mortality. Our study tests the hypothesis that in addition to established prognostic factors, cardiopulmonary exercise testing (CPET) parameters, particularly peak oxygen uptake (peakVO2) and ventilation/carbon dioxide (VE/VCO2)-slope, can predict survival in patients with SSc. Subjects and methods We retrospectively assessed 210 patients (80.9% female) in 6 centres over 10 years with pulmonary testing and CPET. Survival was analysed with Cox regression analysis (adjusted for age and gender) by age, comorbidity (Charlson-Index), body weight, body-mass index, extensive interstitial lung disease, pulmonary artery pressure (measured by echocardiography and invasively), and haemodynamic, pulmonary and CPET parameters. Results Five- and ten-year survival of SSc patients was 93.8 and 86.9%, respectively. There was no difference in survival between patients with diffuse (dcSSc) and limited cutaneous manifestation (lcSSc; p = 0.3). Pulmonary and CPET parameters were significantly impaired. Prognosis was worst for patients with pulmonary hypertension (p = 0.007), 6-min walking distance < 413 m (p = 0.003), peakVO2 < 15.6 mL∙kg− 1∙min− 1, and VE/VCO2-slope > 35. Age (hazard ratio HR = 1.23; 95% confidence interval CI: 1.14;1.41), VE/VCO2-slope (HR = 0.9; CI 0.82;0.98), diffusion capacity (Krogh factor, HR = 0.92; CI 0.86;0.98), forced vital capacity (FVC, HR = 0.91; CI 0.86;0.96), and peakVO2 (HR = 0.87; CI 0.81;0.94) were significantly linked to survival in multivariate analyses (Harrell’s C = 0.95). Summary This is the first large study with SSc patients that demonstrates the prognostic value of peakVO2 < 15.6 mL∙kg− 1∙min− 1 (< 64.5% of predicted peakVO2) and VE/VCO2-slope > 35.
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11
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Andrade FM, Oliveira AD, Lopes AJ. Ventilation distribution as a contributor to the functional exercise capacity in patients with systemic sclerosis-associated interstitial lung disease without pulmonary hypertension. ACTA ACUST UNITED AC 2019; 52:e8513. [PMID: 31365695 PMCID: PMC6668959 DOI: 10.1590/1414-431x20198513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/05/2019] [Indexed: 02/08/2023]
Abstract
Phenotypic differences have been described between patients with systemic sclerosis (SSc)-associated interstitial lung disease (ILD) and SSc-associated pulmonary hypertension, including performance differences in the 6-min walk test (6MWT). Moreover, the correlations between the 6MWT and traditional pulmonary function tests (PFTs) are weak, indicating the need to search for new parameters that explain exercise performance. Thus, our objective was to evaluate the impact of ventilation distribution heterogeneity assessed by the nitrogen single-breath washout (N2SBW) test and peripheral muscle dysfunction on the exercise capacity in patients with SSc-ILD and limited involvement of the pulmonary parenchyma. In this cross-sectional study, 20 women with SSc-ILD and 20 matched controls underwent PFTs (including spirometry, diffusing capacity for carbon monoxide (DLco), and the N2SBW test) and performed the 6MWT and knee isometric dynamometry. The 6-min walking distance (6MWD, % predicted) was strongly correlated with the phase III slope of the single-breath nitrogen washout (phase III slopeN2SBW) (r=-0.753, P<0.0001) and reasonably correlated with the forced vital capacity (FVC) (r=0.466, P=0.008) and DLco (r=0.398, P=0.011). The peripheral oxygen saturation (SpO2) during exercise was not significantly correlated with any of the pulmonary or muscle function parameters. The phase III slopeN2SBW was the only predictive variable for the 6MWD, whereas quadriceps strength and FVC/DLco were predictive variables for SpO2. Ventilation distribution heterogeneity is one factor that contributes to a lower 6MWD in SSc-ILD patients. In addition, muscle dysfunction and abnormal lung diffusion at least partly explain the decreased SpO2 of these patients.
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Affiliation(s)
- F M Andrade
- Programa de Pós-Graduação em Ciências da Reabilitação, Centro Universitário Augusto Motta, Rio de Janeiro, RJ, Brasil
| | - A D Oliveira
- Programa de Pós-Graduação em Ciências da Reabilitação, Centro Universitário Augusto Motta, Rio de Janeiro, RJ, Brasil
| | - A J Lopes
- Programa de Pós-Graduação em Ciências da Reabilitação, Centro Universitário Augusto Motta, Rio de Janeiro, RJ, Brasil.,Programa de Pós-Graduação em Ciências Médicas, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Boutou AK, Pitsiou G, Panagiotidou E, Stanopoulos I. Exercise capacity in borderline mean pulmonary artery pressure: Is it all about peak VO 2 ? THE CLINICAL RESPIRATORY JOURNAL 2019; 13:480-481. [PMID: 31054184 DOI: 10.1111/crj.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/28/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Afroditi K Boutou
- Department of Respiratory Medicine, "G. Papanikolaou" Hospital, Thessaloniki, Greece
| | - Georgia Pitsiou
- Department of Respiratory Failure, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Panagiotidou
- Department of Respiratory Failure, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Stanopoulos
- Department of Respiratory Failure, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Rieth AJ, Richter MJ, Berkowitsch A, Frerix M, Tarner IH, Mitrovic V, Hamm CW. Intravenous sildenafil acutely improves hemodynamic response to exercise in patients with connective tissue disease. PLoS One 2018; 13:e0203947. [PMID: 30235235 PMCID: PMC6147445 DOI: 10.1371/journal.pone.0203947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 08/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Hemodynamic assessment during exercise may unmask an impaired functional reserve of the right ventricle and the pulmonary vasculature in patients with connective tissue disease. We assessed the effect of intravenous sildenafil on the hemodynamic response to exercise in patients with connective tissue disease. Methods In this proof-of-concept study, patients with connective tissue disease and mean pulmonary arterial pressure (mPAP) >20 mm Hg were subjected to a supine exercise hemodynamic evaluation before and after administration of intravenous sildenafil 10 mg. Results Ten patients (four with moderately elevated mPAP 21–24 mm Hg; six with mPAP >25 mm Hg) underwent hemodynamic assessment. All of them showed markedly abnormal exercise hemodynamics. Intravenous sildenafil was well tolerated and had significant hemodynamic effects at rest and during exercise, although without pulmonary selectivity. Sildenafil reduced median total pulmonary resistance during exercise from 6.22 (IQR 4.61–8.54) to 5.24 (3.95–6.96) mm Hg·min·L-1 (p = 0.005) and increased median pulmonary arterial capacitance during exercise from 1.59 (0.93–2.28) to 1.74 (1.12–2.69) mL/mm Hg (p = 0.005). Conclusions In patients with connective tissue disease who have an abnormal hemodynamic response to exercise, intravenous sildenafil improved adaption of the right ventricular-pulmonary vascular unit to exercise independent of resting mPAP. The impact of acute pharmacological interventions on exercise hemodynamics in patients with pulmonary vascular disease warrants further investigation. Trial registration Clinicaltrials.gov NCT01889966.
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Affiliation(s)
- Andreas J. Rieth
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
- * E-mail:
| | - Manuel J. Richter
- Department of Pneumology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany
| | | | - Marc Frerix
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
| | - Ingo H. Tarner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
| | - Veselin Mitrovic
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
- Department of Cardiology, Justus Liebig University Giessen, Universities of Giessen and Marburg, Giessen, Germany
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Babu AS, Morris NR, Arena R, Myers J. Exercise-based evaluations and interventions for pulmonary hypertension with connective tissue disorders. Expert Rev Respir Med 2018; 12:615-622. [PMID: 29798690 DOI: 10.1080/17476348.2018.1481393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Exercise intolerance is a common and often significant limitation in pulmonary arterial hypertension (PAH). This intolerance greatly affects the quality of life and function of the individual with PAH, irrespective of its etiology. In PAH associated with connective tissue disorders (PAH-CTD), exercise intolerance is further amplified by the presence of coexisting musculoskeletal manifestations of CTD. The evaluation of exercise capacity and prescription for exercise training therefore becomes a challenge to the clinician. Areas covered: This review highlights factors contributing to exercise intolerance in PAH-CTD, evaluation methods of exercise capacity and an overview on exercise training and a roadmap for future research. Expert commentary: Exercise intolerance is a complex interplay of cardiovascular, pulmonary, and musculoskeletal systems. Data from cardiopulmonary exercise tests have shown predictive abilities for both diagnosis and prognosis. In its absence, the 6-min walk test can be used to provide similar information thereby making the role of exercise testing an invaluable evaluation method in PAH-CTD. Exercise training data in PAH-CTD are still sparse, though, data from PAH studies suggest potential benefit. However, more research is required in this area of testing and training for greater understanding on exercise hemodynamic, phenotypes, and training benefits.
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Affiliation(s)
- Abraham Samuel Babu
- a Department of Physiotherapy , School of Allied Health Sciences, Manipal Academy of Higher Education , Manipal , Karnataka , India.,b Department of Cardiology/Medicine, Austin Health, Faculty of Medicine, Dentistry & Health Sciences , University of Melbourne , Melbourne , Australia
| | - Norman R Morris
- c Allied Health Research Collaborative , The Prince Charles Hospital , Brisbane , Queensland , Australia.,d School of Allied Health Sciences and Menzies Health Institute , Griffith University , Brisbane , Queensland , Australia
| | - Ross Arena
- e Department of Physical Therapy , College of Applied Science, University of Illinois at Chicago , Chicago , USA
| | - Jonathan Myers
- f Department of Cardiology , Veterans Affairs/Stanford University , Palo Alto , CA , USA
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Reply to the comment of Ursini et al. “Retrospective analysis of type 2 diabetes. Prevalence in a systemic sclerosis cohort from southern Italy”. Joint Bone Spine 2016; 83:613. [DOI: 10.1016/j.jbspin.2016.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 07/06/2016] [Indexed: 11/22/2022]
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Babu AS, Arena R, Myers J, Padmakumar R, Maiya AG, Cahalin LP, Waxman AB, Lavie CJ. Exercise intolerance in pulmonary hypertension: mechanism, evaluation and clinical implications. Expert Rev Respir Med 2016; 10:979-90. [PMID: 27192047 DOI: 10.1080/17476348.2016.1191353] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Exercise intolerance in pulmonary hypertension (PH) is a major factor affecting activities of daily living and quality of life. Evaluation strategies (i.e., non-invasive and invasive tests) are integral to providing a comprehensive assessment of clinical and functional status. Despite a growing body of literature on the clinical consequences of PH, there are limited studies discussing the contribution of various physiological systems to exercise intolerance in this patient population. AREAS COVERED This review, through a search of various databases, describes the physiological basis for exercise intolerance across the various PH etiologies, highlights the various exercise evaluation methods and discusses the rationale for exercise training amongst those diagnosed with PH. Expert commentary: With the growing importance of evaluating exercise capacity in PH (class 1, Level C recommendation), understanding why exercise performance is altered in PH is crucial. Thus, the further study is required for better quality evidence in this area.
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Affiliation(s)
- Abraham Samuel Babu
- a Department of Physiotherapy, School of Allied Health Sciences , Manipal University , Manipal , Karnataka , India
| | - Ross Arena
- b Department of Physical Therapy and Department of Kinesiology and Nutrition , University of Illinois at Chicago , Chicago , USA
| | - Jonathan Myers
- c Veterans Affairs Health Center , Stanford University , Palo Alto , CA , USA
| | | | - Arun G Maiya
- a Department of Physiotherapy, School of Allied Health Sciences , Manipal University , Manipal , Karnataka , India
| | - Lawrence P Cahalin
- e Department of Physical Therapy , Millers School of Medicine , Miami , FL , USA
| | - Aaron B Waxman
- f Pulmonary Vascular Disease Program, Dyspnea and Performance Evaluation Center, Pulmonary Critical Care Medicine, Cardiovascular Medicine , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - Carl J Lavie
- g Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School , The University of Queensland School of Medicine , New Orleans , LA , USA
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Tzilas V, Bouros D. Cardiopulmonary Exercise Testing in Systemic Sclerosis: 'Ars longa, vita brevis'. Respiration 2016; 91:202-3. [PMID: 26845222 DOI: 10.1159/000444091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Vasilios Tzilas
- First Academic Department of Pneumonology, Medical School, National and Kapodistrian University of Athens, and Hospital for Diseases of the CHEST x2018;SOTIRIA', Athens, Greece
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