SYMPOSIUM ON CONGESTIVE HEART FAILURE

The role of gas analysis with exercise testing

Evaluation of exercise performance is an integral component of every medical history. Currently, it is accomplished by means of subjective history taking. Routine exercise testing adds very little information; however, the addition of gas analysis (or cardio pulmonary exercise [CPX] testing) provides the crucial objective assessment by analyzing breath-by-breath oxygen uptake, carbon dioxide production, and anaerobic threshold (AT). Cardiac and pulmonary causes can be reliably differentiated, e.g., cardiac patients cross AT and attain VO2max, use less than 50% of maximal voluntary ventilation (MVV) at peak exercise, and do not develop desaturation. Pulmonary patients, on the contrary, fail to cross AT or achieve VO2max, utilize more than 70% of MVV at peak exercise, and develop arterial desaturation. In the current cost-conscious health care system, CPX proves to be a better cost-effective test because it is objective and more directly targeted to the issues than the conventional exercise test. CPX provides an important link between the disease process and its effect on exercise performance, which is crucial to a comprehensive clinical evaluation, diagnosis, prognosis, exercise prescription, and follow-up after medical or surgical intervention in patients with various diseases causing cardiopulmonary dysfunction.

Heart failure: lessons learned over the past 25 years

Over the past 25 years, a great deal has been learned about the pathophysiology and management of heart failure--a major health problem whose prevalence and incidence have not declined, unlike other cardiovascular disorders. Several of these lessons are reviewed herein. However, despite these advances, important issues remain to challenge both the practicing physician and the research scientist.

Value of New York Heart Association classification, radionuclide ventriculography, and cardiopulmonary exercise tests for selection of patients for congestive heart failure studies

To evaluate the necessity of an objective cardiopulmonary exercise test in the selection procedure of patients for heart failure studies, 50 patients with congestive heart failure New York Heart Association (NYHA) class II and III and a left ventricular ejection fraction less than 40% were subjected to a cardiopulmonary exercise test. The results of the exercise test were compared with the independent clinical estimation of NYHA class and data of measurements obtained at rest. The NYHA classification separated the patients with a mild to moderate impairment of aerobic capacity from patients with a moderate to severe impairment of aerobic capacity very well, but 32% of the NYHA class II patients had a near normal aerobic capacity, and 29% of the NYHA class III patients had a very severe impairment of aerobic capacity, more compatible with NYHA class IV. Only data from exercise measurements showed differences between groups. The determination of maximal aerobic capacity for an objective assessment of patients' performance at exercise is necessary for a proper selection procedure of patients for heart failure studies.

Pathophysiology of cardiac failure

The pathophysiologic cycle of heart failure is initiated by myocardial failure that accompanies a reduction in myocardial contractility secondary to ischemic or myopathic heart disease. Reduction in cardiac output and oxygen delivery to the tissues is followed by vasoconstriction that raises systemic vascular resistance to preserve systemic arterial pressure while maintaining regional O2 availability. As a consequence, however, impedance to left ventricular ejection is increased, creating an additional hemodynamic burden for the failing heart. A vicious cycle ensues. Hemodynamic features of acute cardiac failure include decreases in cardiac output and mixed venous O2 saturation, together with increases in left ventricular filling pressure and systemic resistance. If hypotension is present with failure, there is a markedly decreased cardiac output or an inappropriate increase in systemic resistance. If acidosis is also present with hypotension and failure, cardiac output is severely decreased and lactic acid is increased. A major objective of medical therapy in acute heart failure is to enhance ventricular emptying, thereby increasing cardiac output and O2 delivery while decreasing left ventricular filling pressure, pulmonary venous pressure and vascular resistance. Potent intravenous drugs that have a positive inotropic effect on the myocardium, including amrinone and dobutamine, have been shown to increase ventricular emptying in patients with acute heart failure. Intravenous amrinone improves pump performance without adversely raising myocardial O2 consumption, thereby enhancing myocardial efficiency. These drugs also promote a degree of vasodilation through both direct and secondary effects on the systemic circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary exercise testing for evaluation of chronic cardiac failure

The heart, lungs and hemoglobin form the body's gas transport system, which links the atmosphere and its supply of O2 with tissue, while simultaneously providing for the elimination of the metabolic end-product, CO2, into the atmosphere. The transport of these respiratory gases must be in accordance with metabolic need. This is particularly evident during the physiologic stress of isotonic exercise, when the O2 requirements and CO2 production of skeletal muscle are increased. The monitoring of these respiratory gases during exercise, referred to as cardiopulmonary exercise testing (CAR-PET), can be used to assess heart and lung function in patients with cardiovascular or lung disease or both. Chronic cardiac failure (CCF) may be defined in physiologic terms as that circumstance in which the heart fails to provide tissue with O2 at a rate commensurate with aerobic requirements. In patients with CCF, CAR-PET represents a noninvasive means to determine aerobic capacity (that is, maximal O2 uptake) and anaerobic threshold during incremental treadmill exercise. It can also provide an objective measure of the severity of failure, the functional status of the patient and the heart's pump reserve. By using additional measurements of ventilation, arterial O2 saturation and, in selected cases, hemodynamic monitoring, the nature and severity of cardiovascular and pulmonary disease may be evaluated.

Left ventricular function in experimental aorto-caval fistula with circulatory congestion and fluid retention

The mechanical properties of left ventricular contraction were described in terms of tension, velocity, length, and time in closed-chest, sedated dogs in which a large aorto-caval fistula had resulted in circulatory congestion, and the results were compared with those in normal dogs. Instantaneous contractile element velocity was calculated from left ventricular pressure and its first derivative during isovolumic left ventricular contractions produced by sudden balloon occlusion of the ascending aorta during diastole. A range of ventricular end-diastolic volumes was induced and heart rate was controlled at 150 beats/min. Wall tension (stress) was derived from ventricular pressure and volume, the latter being obtained from the pressure-volume relation of the passive ventricle. Extrapolated velocity at zero tension, V(max), averaged 3.0 circ/sec in the normal dogs and 2.9 circ/sec in the seven dogs with an aorto-caval fistula and fluid retention; in only one of these seven animals was V(max) below the lower limit of normal of 2.7 circ/sec. Isovolumic tension (P(o)) in dogs with aorto-caval fistulas tended to be slightly greater than normal at low ventricular filling pressures, and there was no difference in P(o) between the two groups of animals at high ventricular filling pressures. Time to peak pressure averaged 151 +/- 6 (SE) msec (normal 139 +/- 3). Left ventricular weight averaged 6.32 +/- 0.23 g/kg of initial body weight (normal 5.25 +/- 0.56 g/kg) (P < 0.001), which reflected moderate ventricular hypertrophy, and ventricular internal volume at a given filling pressure was increased proportionally. Therefore, the ventricular contractile state usually was normal in the dog with a large aorto-caval fistula, and it is proposed that mechanisms for fluid retention that results in circulatory congestion were activated because of the large hemodynamic burden despite normal myocardial contractile properties.

Biochemical studies of energy production in the failing human heart

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