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Borlaug BA, Larive B, Frantz RP, Hassoun P, Hemnes A, Horn E, Leopold J, Rischard F, Berman-Rosenzweig E, Beck G, Erzurum S, Farha S, Finet JE, Highland K, Jacob M, Jellis C, Mehra R, Renapurkar R, Singh H, Wilson Tang W, Vanderpool R, Wilcox J, Yu S, Hill N. Pulmonary hypertension across the spectrum of left heart and lung disease. Eur J Heart Fail 2024; 26:1642-1651. [PMID: 38837273 PMCID: PMC11269034 DOI: 10.1002/ejhf.3302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/18/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024] Open
Abstract
AIMS Patients with pulmonary hypertension (PH) are grouped based upon clinical and haemodynamic characteristics. Groups 2 (G2, left heart disease [LHD]) and 3 (G3, lung disease or hypoxaemia) are most common. Many patients display overlapping characteristics of heart and lung disease (G2-3), but this group is not well-characterized. METHODS AND RESULTS Patients with PH enrolled in the prospective, NHLBI-sponsored PVDOMICS network underwent intensive clinical, biomarker, imaging, gas exchange and exercise phenotyping. Patients with pure G2, pure G3, or overlapping G2-3 PH were compared across multiple phenotypic domains. Of all patients with predominant G2 (n = 136), 66 (49%) were deemed to have secondary lung disease/hypoxaemia contributors (G2/3), and of all patients categorized as predominant G3 (n = 172), 41 (24%) were judged to have a component of secondary LHD (G3/2), such that 107 had G2-3 (combined G2/3 and G3/2). As compared with G3, patients with G2 and G2-3 were more obese and had greater prevalence of hypertension, atrial fibrillation, and coronary disease. Patients with G2 and G2-3 were more anaemic, with poorer kidney function, more cardiac dysfunction, and higher N-terminal pro-B-type natriuretic peptide than G3. Lung diffusion was more impaired in G3 and G2-3, but commonly abnormal even in G2. Exercise capacity was severely and similarly impaired across all groups, with no differences in 6-min walk distance or peak oxygen consumption, and pulmonary vasoreactivity to nitric oxide did not differ. In a multivariable Cox regression model, patients with G2 had lower risk of death or transplant compared with G3 (hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.30-0.86), and patients with G2-3 also displayed lower risk compared with G3 (HR 0.57, 95% CI 0.38-0.86). CONCLUSIONS Overlap is common in patients with a pulmonary or cardiac basis for PH. While lung structure/function is clearly more impaired in G3 and G2-3 than G2, pulmonary abnormalities are common in G2, even when clinically judged as isolated LHD. Further study is required to identify optimal systematic evaluations to guide therapeutic innovation for PH associated with combined heart and lung disease. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02980887.
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Affiliation(s)
- Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Paul Hassoun
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Anna Hemnes
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Evelyn Horn
- Department of Medicine, Cornell Medical Center, New York, NY
| | - Jane Leopold
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Franz Rischard
- Department of Medicine, University of Arizona, Phoenix, AZ
| | | | - Gerald Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Serpil Erzurum
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Samar Farha
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - J. Emanuel Finet
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Kristen Highland
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Miriam Jacob
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Christine Jellis
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Reena Mehra
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Sleep Disorders Center, Neurologic Institute; Respiratory Institute; Cleveland Clinic, Cleveland OH
| | - Rahul Renapurkar
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Harsimran Singh
- Department of Medicine, Cornell Medical Center, New York, NY
| | - W.H. Wilson Tang
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Jennifer Wilcox
- Sleep Disorders Center, Neurologic Institute; Respiratory Institute; Cleveland Clinic, Cleveland OH
| | - Shilin Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Nicholas Hill
- Department of Medicine, Tufts Medical Center, Boston, MA
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2
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Omar M, Omote K, Sorimachi H, Popovic D, Kanwar A, Alogna A, Reddy YNV, Lim KG, Shah SJ, Borlaug BA. Hypoxaemia in patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2023; 25:1593-1603. [PMID: 37317621 DOI: 10.1002/ejhf.2930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023] Open
Abstract
AIMS It is widely held that heart failure (HF) does not cause exertional hypoxaemia, based upon studies in HF with reduced ejection fraction, but this may not apply to patients with HF and preserved ejection fraction (HFpEF). Here, we characterize the prevalence, pathophysiology, and clinical implications of exertional arterial hypoxaemia in HFpEF. METHODS AND RESULTS Patients with HFpEF (n = 539) and no coexisting lung disease underwent invasive cardiopulmonary exercise testing with simultaneous blood and expired gas analysis. Exertional hypoxaemia (oxyhaemoglobin saturation <94%) was observed in 136 patients (25%). As compared to those without hypoxaemia (n = 403), patients with hypoxaemia were older and more obese. Patients with HFpEF and hypoxaemia had higher cardiac filling pressures, higher pulmonary vascular pressures, greater alveolar-arterial oxygen difference, increased dead space fraction, and greater physiologic shunt compared to those without hypoxaemia. These differences were replicated in a sensitivity analysis where patients with spirometric abnormalities were excluded. Regression analyses revealed that increases in pulmonary arterial and pulmonary capillary pressures were related to lower arterial oxygen tension (PaO2 ), especially during exercise. Body mass index (BMI) was not correlated with the arterial PaO2 , and hypoxaemia was associated with increased risk for death over 2.8 (interquartile range 0.7-5.5) years of follow-up, even after adjusting for age, sex, and BMI (hazard ratio 2.00, 95% confidence interval 1.01-3.96; p = 0.046). CONCLUSION Between 10% and 25% of patients with HFpEF display arterial desaturation during exercise that is not ascribable to lung disease. Exertional hypoxaemia is associated with more severe haemodynamic abnormalities and increased mortality. Further study is required to better understand the mechanisms and treatment of gas exchange abnormalities in HFpEF.
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Affiliation(s)
- Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Alessio Alogna
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kaiser G Lim
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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3
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Izadi S, Esmaili S, Emami S, Izadi S, Eskandari M, Yadollahzadeh M, Saleh M, Khavandegar A, Bakhtiyari M. Association between DLCO index and the severity of heart failure: a cross-sectional study. Acta Cardiol 2022; 78:250-255. [PMID: 36082926 DOI: 10.1080/00015385.2022.2066776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The prognostic role of diffusing capacity of the lung for carbon monoxide (DLCO) in heart failure has not been thoroughly investigated. Therefore, this study aimed to evaluate DLCO variation in different systolic and diastolic heart failure stages. METHODS This was a prospective cross-sectional study on 51 patients with systolic (reduced LVEF) or diastolic (preserved LVEF) chronic heart failure (CHF). All patients underwent a standard DLCO test. The associations between the severity of heart failure and reduced carbon monoxide transfer factor (TLCO), carbon monoxide transfer coefficient (KCO), and alveolar volume (VA) were investigated. Data were analysed using SPSS software version 16. p-Values below 0.05 were considered statistically significant. RESULTS The mean age of participants was 59.29 ± 14.91 years, with 72% of the study population being male. Systolic heart failure was observed in 47% of patients, diastolic heart failure in 18%, and a mixed systolic and diastolic pattern in 35%. There were significant differences between TLCO percentage in patients with CHF types and the New York Heart Association (NYHA) functional classes (p = 0.042). Overall, an ejection fraction (EF) of less than 25% correlated with 3%, 53%, and 0.78 declines in TLCO, KCO%, and KCO index, respectively. CONCLUSION Despite the lack of statistically significant differences between DLCO indices and CHF severity, decreased DLCO parameters correlated with reduced EF. Therefore, DLCO testing might be helpful to predict HF severity.
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Affiliation(s)
- Shirin Izadi
- Assistant Professor of Pulmonary Disease, Department of Internal Medicine, School of Medicine, Firoozgar General Hospital, Iran University of Medical Sciences
| | - Saeedeh Esmaili
- Residence of Internal Medicine, Firoozgar Medical & Educational Hospital, Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Emami
- Assistant Professor of cardiology, Department of cardiology, School of Medicine, Firoozgar General Hospital, Iran University of Medical Sciences
| | - Shahrokh Izadi
- School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohana Eskandari
- Residence of Internal Medicine, Firoozgar Medical & Educational Hospital, Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Yadollahzadeh
- Assistant Professor of Pulmonary Disease, Department of Internal Medicine, School of Medicine, Firoozgar General Hospital, Iran University of Medical Sciences
| | - Maasoumeh Saleh
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Shariati hospital, Tehran, Iran
| | - Armin Khavandegar
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | - Mahmood Bakhtiyari
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
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4
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Triantafyllidi H, Birmpa D, Benas D, Trivilou P, Fambri A, Iliodromitis EK. Cardiopulmonary exercise testing: The ABC for the Clinical Cardiologist. Cardiology 2021; 147:62-71. [PMID: 34649252 DOI: 10.1159/000520024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Helen Triantafyllidi
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Dionyssia Birmpa
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Dimitrios Benas
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Paraskevi Trivilou
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Anastasia Fambri
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
| | - Efstathios K Iliodromitis
- 2nd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, ATTIKON Hospital, Athens, Greece
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5
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Yola IM, Oh A, Mitchell GF, O’Connor G, Cheng S, Vasan RS, Xanthakis V. Association of lung diffusion capacity with cardiac remodeling and risk of heart failure: The Framingham heart study. PLoS One 2021; 16:e0246355. [PMID: 33592021 PMCID: PMC7886141 DOI: 10.1371/journal.pone.0246355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Lung function abnormalities are ubiquitous in heart failure (HF). It is unclear, however, if abnormal lung diffusion capacity is associated with cardiac remodeling and antedates HF. We hypothesized that lower lung diffusion capacity for carbon monoxide (DLCO) is associated with worse left ventricular (LV) systolic and diastolic function cross-sectionally, and with higher risk of HF prospectively. Methods We evaluated 2423 Framingham Study participants (mean age 66 years, 55% women) free of HF who underwent routine echocardiography and pulmonary function tests. We used multivariable regression models to relate DLCO, forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) to left ventricular ejection fraction (LVEF), left atrial (LA) emptying fraction (LAEF), E/e’, E/A, LV mass, and LA diameter (LAD). Multivariable-adjusted Cox proportional hazards regression was used to relate DLCO, FEV1, and FVC to incident HF. Results In multivariable-adjusted cross-sectional analyses, DLCO, FEV1, and FVC (dependent variables) were associated positively with LVEF (βDLCO = 0.208, βFEV1 = 0.021, and βFVC = 0.025 per 5% increment in LVEF; p<0.005 for all), and LAEF (βDLCO = 0.707, βFEV1 = 0.058 and βFVC = 0.058 per 5% increment in LAEF; p<0.002 for all). DLCO and FVC were inversely related to E/A (βDLCO = -0.289, βFVC = -0.047 per SD increment in E/A; p<0.001 for all). Additionally, DLCO, FEV1 and FVC were inversely related to HF risk (108 events, median follow-up 9.7 years; multivariable-adjusted hazard ratios per SD increment 0.90, 95% CI 0.86–0.95; 0.42, 95% CI 0.28–0.65, and 0.51, 95% CI 0.36–0.73, respectively). These results remained robust in analyses restricted to non-smokers. Conclusions Our large community-based observations are consistent with the concept that lower lung diffusion capacity and expiratory flow rates are associated with cardiac remodeling and may antedate HF. Additional studies are needed to confirm our findings and to evaluate the prognostic utility of pulmonary function testing for predicting HF.
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Affiliation(s)
- Ibrahim Musa Yola
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - Albin Oh
- Department of Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Gary F. Mitchell
- Cardiovascular Engineering, Inc., Norwood, MA, United States of America
| | - George O’Connor
- Department of Medicine, Pulmonary Center, Boston Medical Center, Boston University, Boston, MA, United States of America
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Ramachandran S. Vasan
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
- National Heart, Lung, and Blood Institute, Framingham Heart Study, Framingham, MA, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Vanessa Xanthakis
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
- National Heart, Lung, and Blood Institute, Framingham Heart Study, Framingham, MA, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
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6
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Stewart GM, Johnson BD, Sprecher DL, Reddy YNV, Obokata M, Goldsmith S, Bart B, Oughton A, Fillmore C, Behm DJ, Borlaug BA. Targeting pulmonary capillary permeability to reduce lung congestion in heart failure: a randomized, controlled pilot trial. Eur J Heart Fail 2020; 22:1641-1645. [PMID: 32227554 DOI: 10.1002/ejhf.1809] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/07/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS Lung congestion in patients with heart failure (HF) has traditionally been treated using interventions that reduce pulmonary capillary hydrostatic pressure. The transient receptor potential vanilloid 4 (TRPV4) channel regulates fluid transit across the pulmonary capillary-interface, and represents a novel target to reduce lung water, independent of pulmonary capillary hypertension. This pilot study examined the safety and potential efficacy of TRPV4 blockade as a novel treatment for HF. METHODS AND RESULTS In this randomized, double-blind, placebo-controlled crossover pilot trial, 11 subjects with chronic, compensated HF were treated with a novel TRPV4 antagonist (GSK2798745) or placebo. The primary endpoint was lung diffusing capacity for carbon monoxide (DLCO ) after 7 days of treatment with GSK2798745 as compared to placebo. Secondary endpoints included additional diffusion parameters, spirometry and safety assessments. Compared to placebo, treatment with GSK2798745 resulted in a trend to improvement in DLCO (placebo: -0.336 mL/mmHg/min; GSK2798745: +0.458 mL/mmHg/min; treatment difference: +0.793 mL/mmHg/min; 95% confidence interval: -0.925 to 2.512) that was not statistically significant. GSK2798745 was well-tolerated with no serious adverse events. CONCLUSION In this pilot trial, GSK2798745 was found to be safe and well-tolerated, with a trend toward improved gas transfer. Further investigation is warranted in larger studies to determine whether treatment with TRPV4 antagonists or alternative treatments targeting capillary permeability might be effective to improve lung congestion, pulmonary gas transfer and clinical status in patients with acute or chronic HF.
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Affiliation(s)
- Glenn M Stewart
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bruce D Johnson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Steven Goldsmith
- Hennepin County Medical Centre, Minneapolis, MI, USA.,University of Minnesota, Minneapolis, MI, USA
| | - Brad Bart
- Hennepin County Medical Centre, Minneapolis, MI, USA.,University of Minnesota, Minneapolis, MI, USA
| | - Anna Oughton
- GlaxoSmithKline Pharmaceutical Ltd., Collegeville, PA, USA
| | | | - David J Behm
- GlaxoSmithKline Pharmaceutical Ltd., Collegeville, PA, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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7
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Kietsiriroje N, Wonghirundecha R, Suntornlohanakul O, Murray RD. Construction of a predictive scoring system as a guide to screening and confirmation of the diagnosis of primary aldosteronism. Clin Endocrinol (Oxf) 2020; 92:196-205. [PMID: 31840266 DOI: 10.1111/cen.14142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/30/2019] [Accepted: 12/11/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Primary aldosteronism (PA) is the most frequent cause of secondary hypertension. In Southern Thailand, the aldosterone-renin ratio (ARR) is only available within a small number of tertiary centres, necessitating need for a simple clinical assessment to determine the requirement for ARR. OBJECTIVE This study aimed to identify predictive factors for the diagnosis of PA and generate a predictive scoring system (PSS) for use in screening and diagnosis of PA. PATIENTS AND METHODS A total of 420 patients aged >15 years with paired plasma aldosterone concentration and plasma renin activity values allowing calculation of ARR were identified from the electronic hospital database between 2011 and 2016. RESULTS The overall prevalence of PA was 16.7% (range; adrenal incidentaloma 5.6% to hypokalaemia 30%). Predictive factors for diagnosis of PA were as follows: age <60 years, BMI < 25 kg/m2 , presence of diabetes, ≥3 antihypertensive agents, serum sodium ≥ 141 mmol/L and serum potassium < 3.5 mmol/L. A predictive scoring system (PSS) (range -2 to 13) was generated by the coefficients of the variables with ROC curve AUC 0.87 [95% CI: 0.83-0.91]. Using the PSS, a total score <4 provided a robust negative predictive value (sensitivity, 0.97; specificity, 0.48; NPV, 0.99; PPV, 0.27) for PA. In patients at high risk of PA (PAC > 15 ng/dL and PRA < 1.0 ng/mL/hr), a PSS score > 9 had specificity and PPV of 100%, essentially confirming PA in these individuals. CONCLUSION The proposed PSS for PA will enable more focused and cost-effective use of ARR screening and confirmatory testing. In our cohort, 40% and 42% of patients would not require ARR screening or confirmatory tests, respectively.
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Affiliation(s)
- Noppadol Kietsiriroje
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Rawipas Wonghirundecha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Onnicha Suntornlohanakul
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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8
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Agostoni P, Dumitrescu D. How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure. Int J Cardiol 2019; 288:107-113. [DOI: 10.1016/j.ijcard.2019.04.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/04/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023]
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9
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Deis T, Balling L, Rossing K, Wolsk E, Perch M, Gustafsson F. Lung diffusion capacity in advanced heart failure: relation to central haemodynamics and outcome. ESC Heart Fail 2019; 6:379-387. [PMID: 30784223 PMCID: PMC6437433 DOI: 10.1002/ehf2.12401] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 12/10/2018] [Indexed: 11/09/2022] Open
Abstract
Aims Patients with heart failure (HF) are known to have a reduced pulmonary diffusion capacity for carbon monoxide (DLCO), but little is known about how lung function relates to central haemodynamics. The aim of this study was to investigate the association between haemodynamic variables and pulmonary diffusion capacity adjusted for alveolar volume in congestive HF patients and to analyse how predicted DLCO/VA affects mortality in relation to the haemodynamic status. Methods and results We retrospectively studied right heart catheterization (RHC) and lung function data on 262 HF patients (mean age 51 ± 13 years) with a left ventricular ejection fraction < 45% referred non‐urgently for evaluation for heart transplantation (HTX) or left ventricular assist device (LVAD). Univariate and multivariate linear regression models were constructed to examine the associations between predicted values of DLCO/VA, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), and haemodynamic parameters [pulmonary capillary wedge pressure (PCWP), central venous pressure, cardiac index, mean pulmonary artery pressure, and mean arterial pressure] as well as other factors known to affect lung function in HF. FEV1 was reduced to <80% of predicted value in 55% of the population, and DLCO/VA was reduced in 63% of the population. DLCO/VA correlated positively with pulmonary capillary wedge pressure in both univariate and multivariate analyses for all included patients (P < 0.001 and P = 0.045, respectively) and a restricted population of patients with the shortest time between RHC and lung function testing (P = 0.005, P = 0.015). DLCO/VA predicted mortality in multivariate models [hazard ratio 1.5 (1.1–2.1)] but not the combined endpoint of death, LVAD implantation, or HTX. There was no significant correlation between haemodynamics and predicted FVC or FEV1. Conclusions Pulmonary diffusion capacity correlates positively with left ventricular fillings pressures, and reduced values predict increased mortality in patients with HF. This might be driven by increased lung capillary volume in patients with pulmonary congestion.
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Affiliation(s)
- Tania Deis
- Department of Cardiology, Rigshospitalet, 2142, 9 Blegdamsvej, DK-2100, Copenhagen, Denmark
| | - Louise Balling
- Department of Cardiology, Rigshospitalet, 2142, 9 Blegdamsvej, DK-2100, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Rigshospitalet, 2142, 9 Blegdamsvej, DK-2100, Copenhagen, Denmark
| | - Emil Wolsk
- Department of Cardiology, Rigshospitalet, 2142, 9 Blegdamsvej, DK-2100, Copenhagen, Denmark
| | - Michael Perch
- Department of Cardiology, Rigshospitalet, 2142, 9 Blegdamsvej, DK-2100, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, 2142, 9 Blegdamsvej, DK-2100, Copenhagen, Denmark
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10
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Kalhan R, Mutharasan RK. Reducing Readmissions in Patients With Both Heart Failure and COPD. Chest 2018; 154:1230-1238. [PMID: 29908152 DOI: 10.1016/j.chest.2018.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 01/27/2023] Open
Abstract
Patients with both COPD and heart failure (HF) pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies. Here we present 10 practical tips to reduce readmissions in this challenging population: (1) diagnose the population accurately, (2) detect admissions for exacerbations early and consider risk stratification, (3) use specialist management in hospital, (4) modify the underlying disease substrate, (5) apply and intensify evidence-based therapies, (6) activate the patient and develop critical health behaviors, (7) setup feedback loops, (8) arrange an early follow-up appointment prior to discharge, (9) consider and address other comorbidities, and (10) consider ancillary support services at home. The multidisciplinary care teams needed to support these care models pose expense to the health-care system. Although these costs may more easily be recouped under financial models such as accountable care organizations and bundled payments, the opportunity cost of an admission for COPD or HF may represent an underrecognized financial lever.
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Affiliation(s)
- Ravi Kalhan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Raja Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
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11
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Campodonico J, Mapelli M, Spadafora E, Ghilardi S, Agostoni P, Banfi C, Sciomer S. Surfactant proteins changes after acute hemodynamic improvement in patients with advanced chronic heart failure treated with Levosimendan. Respir Physiol Neurobiol 2018; 252-253:47-51. [PMID: 29548887 DOI: 10.1016/j.resp.2018.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
Alveolar-capillary membrane evaluated by carbon monoxide diffusion (DLCO) plays an important role in heart failure (HF). Surfactant Proteins (SPs) have also been suggested as a worthwhile marker. In HF, Levosimendan improves pulmonary hemodynamics and reduces lung fluids but associated SPs and DLCO changes are unknown. Sixty-five advanced HF patients underwent spirometry, cardiopulmonary exercise test (CPET) and SPs determination before and after Levosimendan. Levosimendan caused natriuretic peptide-B (BNP) reduction, peakVO2 increase and VE/VCO2 slope reduction. Spirometry improved but DLCO did not. SP-A, SP-D and immature SP-B reduced (73.7 ± 25.3 vs. 66.3 ± 22.7 ng/mL*, 247 ± 121 vs. 223 ± 110 ng/mL*, 39.4 ± 18.7 vs. 34.4 ± 17.9AU*, respectively); while mature SP-B increased (424 ± 218 vs. 461 ± 243 ng/mL, * = p < 0.001). Spirometry, BNP and CPET changes suggest hemodynamic improvement and lung fluid reduction. SP-A, SP-D and immature SP-B reduction indicates a reduction of inflammatory stress; conversely mature SP-B increase suggests alveolar cell function restoration. In conclusion, acute lung fluid reduction is associated with SPs but not DLCO changes. SPs are fast responders to alveolar-capillary membrane condition changes.
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Affiliation(s)
| | | | | | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy; Dipartimento di Scienze Cliniche e di Comunità, Sezione Cardiovascolare, Università di Milano, Italy.
| | | | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesioloigiche e Geriatriche, "Sapienza", Rome University, Rome, Italy
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12
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Robaeys W, Bektas S, Boyne J, van Empel V, Uszko-Lencer N, Knackstedt C, Brunner-La Rocca HP. Pulmonary and right ventricular dysfunction are frequently present in heart failure irrespective of left ventricular ejection fraction. HEART ASIA 2018; 9:e010914. [PMID: 29467838 DOI: 10.1136/heartasia-2017-010914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 12/28/2022]
Abstract
Background Heart failure (HF) may influence the lungs and vice versa. However, this interaction and the influence on right ventricular function (RVF) are insufficiently described in patients with HF divided into the recent groups based on left ventricular ejection fraction (LVEF): HF with reduced, midrange and preserved ejection fraction (HFrEF, HFmrEF and HFpEF, respectively). Methods Overall, 186 consecutive stable patients with HF seen in our outpatient clinic were retrospectively divided into HFrEF (n=70), HFmrEF (n=55) and HFpEF (n=61). Airflow limitation and gas exchange disturbance were measured by spirometry (forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) (%)) and diffusion capacity of the lungs for carbon monoxide (DLCO). Standard echocardiography was performed to measure RV structure (RV diameter) and function (tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP)). Correlations were used to assess possible relations between pulmonary dysfunction and measurements of the RV. Results None of the investigated parameters differed significantly between the three groups (all p>0.1); FEV1/FVC was 70%±12%, 70%±13% and 74%±10% in patients with HFrEF, HFmrEF and HFpEF (p=0.12) and DLCO was 5.7±1.6, 5.7±1.8 and 5.6±1.6 mmol/min/kPa, respectively (p=0.95). RV structure and function did not differ either (TAPSE/PASP 0.58, 0.60 and 0.57, respectively (p=0.84)). There was a correlation of DLCO with RV function (r=0.34, p<0.001). Conclusion The investigated cardiopulmonary parameters were comparable in the three HF groups. Diffusion capacity was impaired in more than half of the stable HF population independently of the LVEF and showed a correlation with RV function.
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Affiliation(s)
- Wouter Robaeys
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Sema Bektas
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Josiane Boyne
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nicole Uszko-Lencer
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO+), Horn, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
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13
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Prevalence of airflow obstruction in patients with stable systolic heart failure. BMC Pulm Med 2017; 17:6. [PMID: 28061834 PMCID: PMC5219786 DOI: 10.1186/s12890-016-0351-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/14/2016] [Indexed: 11/25/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is an important differential diagnosis in heart failure (HF). However, routine use of spirometry in outpatient HF clinics is not implemented. The aim of the present study was to determine the prevalence of both airflow obstruction and non obstructive lung function impairment in patients with HF and to examine the effect of optimal medical treatment for HF on lung function parameters. Methods Consecutive patients with HF (ejection fraction (EF) < 45%) and New York Heart Association (NYHA) functional class II-IV at 10 different outpatient heart failure clinics were examined with spirometry at their first visit and after optimal medical treatment for HF was achieved. airflow obstruction was classified and graded according to the GOLD 2011 revision. Results Baseline spirometry was performed in 593 included patients and 71 (12%) had a clinical diagnosis of COPD. Mean age was 69 ± 11 years and mean EF was 30 ± 9%. Thirty-two % of the patients were active smokers and 53% were previous smokers. Mean FEV1 and FVC was 77.9 ± 1.7% and 85.4 ± 1.5% of predicted respectively. Obstructive pattern was observed in 233 (39%) of the patients. Of these, 53 patients (9%) had mild disease (GOLD I) and 180 (30%) patients had moderate to very severe disease (GOLD II-IV). No difference in spirometric variables was observed following up titration of medication. Conclusion In stable patients with HF airflow obstruction is frequent and severely underdiagnosed. Spirometry should be considered in all patients with HF in order to improve diagnosis and treatment for concomitant pulmonary disease.
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14
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Olson TP, Johnson BD, Borlaug BA. Impaired Pulmonary Diffusion in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2016; 4:490-8. [PMID: 27256752 PMCID: PMC4893169 DOI: 10.1016/j.jchf.2016.03.001] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/29/2016] [Accepted: 03/02/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The purpose of this study was to compare measures of gas exchange at rest and during exercise in patients with heart failure and preserved ejection fraction (HFpEF) with age- and sex-matched control subjects. BACKGROUND Patients with HFpEF display elevation in left heart pressures, but it is unclear how this affects pulmonary gas transfer or its determinants at rest and during exercise. METHODS Patients with HFpEF (n = 20) and control subjects (n = 26) completed a recumbent cycle ergometry exercise test with simultaneous measurement of ventilation and gas exchange. Diffusion of the lungs for carbon monoxide (DLCO) and its subcomponents, pulmonary capillary blood volume (VC) and alveolar-capillary membrane conductance (DM), were measured at rest, and matched for low-intensity (20 W) and peak exercise. Stroke volume was measured by transthoracic echocardiography to calculate cardiac output. RESULTS Compared with control subjects, patients with HFpEF displayed impaired diastolic function and reduced exercise capacity. Patients with HFpEF demonstrated a 24% lower DLCO at rest (11.0 ± 2.3 ml/mm Hg/min vs. 14.4 ± 3.3 ml/mm Hg/min; p < 0.01) related to reductions in both DM (18.1 ± 4.9 ml/mm Hg/min vs. 23.1 ± 9.1 ml/mm Hg/min; p = 0.04), and VC (45.9 ± 15.2. ml vs. 58.9 ± 16.2 ml; p = 0.01). DLCO was lower in patients with HFpEF compared with control subjects in all stages of exercise, yet its determinants showed variable responses. With low-level exercise, patients with HFpEF demonstrated greater relative increases in VC, coupled with heightened ventilatory drive and more severe symptoms of dyspnea compared with control subjects. At 20-W exercise, DM was markedly reduced in patients with HFpEF compared with control subjects. From 20 W to peak exercise, there was no further increase in VC in patients with HFpEF, which in tandem with reduced DM, led to a 30% reduction in DLCO at peak exercise (17.3 ± 4.2 ml/mm Hg/min vs. 24.7 ± 7.1 ml/mm Hg/min; p < 0.01). CONCLUSIONS Subjects with HFpEF display altered pulmonary function and gas exchange at rest and especially during exercise, which contributes to exercise intolerance. Novel therapies that improve gas diffusion may be effective to improve exercise tolerance in patients with HFpEF.
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Affiliation(s)
- Thomas P Olson
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota.
| | - Bruce D Johnson
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
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15
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Glanville AR, Hoeper MM. Don't Let (Dl)CO Be Misunderstood. Am J Respir Crit Care Med 2016; 193:1200-1. [PMID: 27248589 DOI: 10.1164/rccm.201601-0079ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Allan R Glanville
- 1 The Lung Transplant Unit St. Vincent's Hospital Sydney, New South Wales, Australia and
| | - Marius M Hoeper
- 2 Department of Respiratory Medicine and German Center for Lung Research Hannover Medical School Hannover, Germany
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16
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Borlaug BA, Olson TP. The Lungs in Heart Failure. JACC-HEART FAILURE 2016; 4:450-2. [DOI: 10.1016/j.jchf.2016.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 01/08/2023]
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17
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Contini M, Compagnino E, Cattadori G, Magrì D, Camera M, Apostolo A, Farina S, Palermo P, Gertow K, Tremoli E, Fiorentini C, Agostoni P. ACE-Inhibition Benefit on Lung Function in Heart Failure is Modulated by ACE Insertion/Deletion Polymorphism. Cardiovasc Drugs Ther 2016; 30:159-68. [DOI: 10.1007/s10557-016-6645-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Lung function, transfusion, pulmonary capillary blood volume and sickle cell disease. Respir Physiol Neurobiol 2015; 222:6-10. [PMID: 26592148 DOI: 10.1016/j.resp.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 11/24/2022]
Abstract
Lung function abnormalities occur in children with sickle cell disease (SCD) and may be associated with elevated pulmonary blood volume. To investigate that association, we determined whether blood transfusion in SCD children acutely increased pulmonary capillary blood volume (PCBV) and increased respiratory system resistance (Rrs5). Measurements of Rrs5 and spirometry were made before and after blood transfusion in 18 children, median age 14.2 (6.6-18.5) years. Diffusing capacity for carbon monoxide and nitric oxide were assessed to calculate the PCBV. Post transfusion, the median Rrs5 had increased from 127.4 to 141.3% predicted (p<0.0001) and pulmonary capillary blood volume from 39.7 to 64.1 ml/m2 (p<0.0001); forced expiratory volume in one second (p=0.0056) and vital capacity (p=0.0008) decreased. The increase in Rrs5 correlated with the increase in PCBV (r=0.50, p=0.0493). Increased pulmonary capillary blood volume may at least partially explain the lung function abnormalities in SCD children.
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19
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Melenovsky V, Andersen MJ, Andress K, Reddy YN, Borlaug BA. Lung congestion in chronic heart failure: haemodynamic, clinical, and prognostic implications. Eur J Heart Fail 2015; 17:1161-71. [DOI: 10.1002/ejhf.417] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/26/2015] [Accepted: 09/05/2015] [Indexed: 11/10/2022] Open
Affiliation(s)
- Vojtech Melenovsky
- Division of Cardiovascular Diseases, Department of Medicine; Mayo Clinic; Rochester MN USA
- Department of Cardiology; Institute for Clinical and Experimental Medicine-IKEM; Prague Czech Republic
| | - Mads J. Andersen
- Division of Cardiovascular Diseases, Department of Medicine; Mayo Clinic; Rochester MN USA
- Department of Cardiology; Aarhus University Hospital; Aarhus Denmark
| | - Krystof Andress
- Department of Cardiology; Institute for Clinical and Experimental Medicine-IKEM; Prague Czech Republic
| | - Yogesh N. Reddy
- Division of Cardiovascular Diseases, Department of Medicine; Mayo Clinic; Rochester MN USA
| | - Barry A. Borlaug
- Division of Cardiovascular Diseases, Department of Medicine; Mayo Clinic; Rochester MN USA
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20
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Güder G, Brenner S, Störk S, Held M, Broekhuizen BDL, Lammers JWJ, Hoes AW, Rutten FH. Diagnostic and prognostic utility of mid-expiratory flow rate in older community-dwelling persons with respiratory symptoms, but without chronic obstructive pulmonary disease. BMC Pulm Med 2015; 15:83. [PMID: 26228243 PMCID: PMC4521503 DOI: 10.1186/s12890-015-0081-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 07/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The maximal expiratory flow at 50 % of the forced vital capacity (MEF50) is the flow where half of forced vital capacity (FVC) remains to be exhaled. A reduced MEF50 has been suggested as a surrogate marker of small airways disease. The diagnostic and prognostic utility of this easy to assess spirometric variable in persons with respiratory symptoms, but without COPD is unclear. METHODS We used data from the UHFO-COPD cohort in which 405 community-dwelling persons aged 65 years or over, and a general practitioner's diagnosis of chronic obstructive pulmonary disease (COPD) underwent pulmonary function testing and echocardiography. In total 161 patients had no COPD according to the spirometric GOLD criteria. We considered MEF50 as reduced if < 60 % of predicted. RESULTS Of the 161 patients without COPD (mean age 72 ± 5.7 years; 35 % male; follow-up 4.5 ± 1.1 years), 61 (37.9 %) had a reduced MEF50. They were older, had more pack-years of smoking, more respiratory symptoms, and used more frequently inhaled medication than the remaining 100 subjects. A reduced MEF50 was nearly twice as often associated with newly detected heart failure (HF) at assessment (29.5 % vs. 15.6 %, p = 0.045). In age-and sex-adjusted Cox regression analysis, a reduced MEF50 was significantly associated with episodes of acute bronchitis (hazard ratio 2.54 95 % confidence interval (1.26; 5.13) P = 0.009), and in trend with pneumonia (2.14 (0.98; 4.69) P = 0.06) and hospitalizations for pulmonary reasons (2.28 (0.93; 5.62) P = 0.07). CONCLUSIONS In older community-dwelling persons with pulmonary symptoms but without COPD, a reduced MEF50 may help to uncover unrecognized HF, and identify those at a higher risk for episodes of acute bronchitis, pneumonia and hospitalizations for pulmonary reasons. Echocardiography and close follow-up should be considered in these patients.
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Affiliation(s)
- Gülmisal Güder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacherstr. 6, D-97080, Würzburg, Germany. .,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany.
| | - Susanne Brenner
- Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacherstr. 6, D-97080, Würzburg, Germany. .,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany.
| | - Stefan Störk
- Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacherstr. 6, D-97080, Würzburg, Germany. .,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany.
| | - Matthias Held
- Medical Mission Hospital, Department of Internal Medicine, Respiratory Medicine and Cardiology, Würzburg, Germany.
| | - Berna D L Broekhuizen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jan-Willem J Lammers
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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21
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Bihari S, Wiersema UF, Schembri D, De Pasquale CG, Dixon DL, Prakash S, Lawrence MD, Bowden JJ, Bersten AD. Bolus intravenous 0.9% saline, but not 4% albumin or 5% glucose, causes interstitial pulmonary edema in healthy subjects. J Appl Physiol (1985) 2015; 119:783-92. [PMID: 26228998 DOI: 10.1152/japplphysiol.00356.2015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/23/2015] [Indexed: 01/08/2023] Open
Abstract
Rapid intravenous (iv) infusion of 0.9% saline alters respiratory mechanics in healthy subjects. However, the relative cardiovascular and respiratory effects of bolus iv crystalloid vs. colloid are unknown. Six healthy male volunteers were given 30 ml/kg iv 0.9% saline, 4% albumin, and 5% glucose at a rate of 100 ml/min on 3 separate days in a double-blinded, randomized crossover study. Impulse oscillometry, spirometry, lung volumes, diffusing capacity (DLCO), and blood samples were measured before and after fluid administration. Lung ultrasound B-line score (indicating interstitial pulmonary edema) and Doppler echocardiography indices of cardiac preload were measured before, midway, immediately after, and 1 h after fluid administration. Infusion of 0.9% saline increased small airway resistance at 5 Hz (P = 0.04) and lung ultrasound B-line score (P = 0.01) without changes in Doppler echocardiography measures of preload. In contrast, 4% albumin increased DLCO, decreased lung volumes, and increased the Doppler echocardiography mitral E velocity (P = 0.001) and E-to-lateral/septal e' ratio, estimated blood volume, and N-terminal pro B-type natriuretic peptide (P = 0.01) but not lung ultrasound B-line score, consistent with increased pulmonary blood volume without interstitial pulmonary edema. There were no significant changes with 5% glucose. Plasma angiopoietin-2 concentration increased only after 0.9% saline (P = 0.001), suggesting an inflammatory mechanism associated with edema formation. In healthy subjects, 0.9% saline and 4% albumin have differential pulmonary effects not attributable to passive fluid filtration. This may reflect either different effects of these fluids on active signaling in the pulmonary circulation or a protective effect of albumin.
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Affiliation(s)
- Shailesh Bihari
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia; Department of Critical Care Medicine, Flinders University, Adelaide, Australia;
| | - Ubbo F Wiersema
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia
| | - David Schembri
- Department of Respiratory Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Carmine G De Pasquale
- Cardiology, Flinders Medical Centre, Adelaide, Australia; and Department of Medicine, Flinders University, Adelaide, Australia
| | - Dani-Louise Dixon
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia; Department of Critical Care Medicine, Flinders University, Adelaide, Australia
| | - Shivesh Prakash
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia
| | - Mark D Lawrence
- Department of Critical Care Medicine, Flinders University, Adelaide, Australia
| | - Jeffrey J Bowden
- Department of Respiratory Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Andrew D Bersten
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia; Department of Critical Care Medicine, Flinders University, Adelaide, Australia
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22
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Guazzi M, Phillips SA, Arena R, Lavie CJ. Endothelial dysfunction and lung capillary injury in cardiovascular diseases. Prog Cardiovasc Dis 2014; 57:454-62. [PMID: 25446556 DOI: 10.1016/j.pcad.2014.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Cardiac dysfunction of both systolic and diastolic origins leads to increased left atrial pressure, lung capillary injury and increased resistance to gas transfer. Acutely, pressure-induced trauma disrupts the endothelial and alveolar anatomical configuration and definitively causes an impairment of cellular pathways involved in fluid-flux regulation and gas exchange efficiency, a process well identified as stress failure of the alveolar-capillary membrane. In chronic heart failure (HF), additional stimuli other than pressure may trigger the true remodeling process of capillaries and small arteries characterized by endothelial dysfunction, proliferation of myofibroblasts, fibrosis and extracellular matrix deposition. In parallel there is a loss of alveolar gas diffusion properties due to the increased path from air to blood (thickening of extracellular matrix) and loss of fine molecular mechanism involved in fluid reabsorption and clearance. Deleterious changes in gas transfer not only reflect the underlying lung tissue damage but also portend independent prognostic information and may play a role in the pathogenesis of exercise limitation and ventilatory abnormalities observed in these patients. Few currently approved treatments for chronic HF have the potential to positively affect structural remodeling of the lung capillary network; angiotensin-converting enzyme inhibitors are one of the few currently established options. Recently, more attention has been paid to novel therapies specifically targeting the nitric oxide pathway as a suitable target to improve endothelial function and permeability as well as alveolar gas exchange properties.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, I.R.C.C.S. Policlinico San Donato, University of Milano, San Donato Milanese, Italy.
| | - Shane A Phillips
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Carl J Lavie
- 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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23
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Güder G, Brenner S, Störk S, Hoes A, Rutten FH. Chronic obstructive pulmonary disease in heart failure: accurate diagnosis and treatment. Eur J Heart Fail 2014; 16:1273-82. [DOI: 10.1002/ejhf.183] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/08/2014] [Accepted: 09/12/2014] [Indexed: 01/08/2023] Open
Affiliation(s)
- Gülmisal Güder
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Susanne Brenner
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Arno Hoes
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Frans H. Rutten
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
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24
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Dupuis J, Guazzi M. Pathophysiology and clinical relevance of pulmonary remodelling in pulmonary hypertension due to left heart diseases. Can J Cardiol 2014; 31:416-29. [PMID: 25840093 DOI: 10.1016/j.cjca.2014.10.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 09/27/2014] [Accepted: 10/03/2014] [Indexed: 12/29/2022] Open
Abstract
Pulmonary hypertension (PH) in left heart disease, classified as group II, is the most common form of PH that occurs in approximately 60% of cases of reduced and preserved left ventricular ejection fraction. Although relatively much is known about hemodynamic stages (passive or reactive) and their consequences on the right ventricle (RV) there is no consensus on the best hemodynamic definition of group II PH. In addition, the main pathways that lead to lung capillary injury and impaired biology of small artery remodelling processes are largely unknown. Typical lung manifestations of an increased pulmonary pressure and progressive RV-pulmonary circulation uncoupling are an abnormal alveolar capillary gas diffusion, impaired lung mechanics (restriction), and exercise ventilation inefficiency. Of several classes of pulmonary vasodilators currently clinically available, oral phosphodiesterase 5 inhibition, because of its strong selectivity for targeting the cyclic guanosine monophosphate pathway in the pulmonary circulation, is increasingly emerging as an attractive opportunity to reach hemodynamic benefits, reverse capillary injury, and RV remodelling, and improve functional capacity. Guanylate cyclase stimulators offer an additional intriguing opportunity but the lack of selectivity and systemic effects might preclude some of the anticipated benefits on the pulmonary circulation. Future trials will determine whether new routes of pharmacologic strategy aimed at targeting lung structural and vascular remodelling might affect morbidity and mortality in left heart disease populations. We believe that this therapeutic goal rather than a pure hemodynamic effect might ultimately emerge as an important challenge for the clinician.
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Affiliation(s)
- Jocelyn Dupuis
- Department of Medicine, Université de Montréal and Research Center of the Montreal Heart Institute, Montreal, Québec, Canada
| | - Marco Guazzi
- University of Milano Heart Failure Unit, IRCCS Policlinico San Donato, Milano, Italy.
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25
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Taguchi T, Adachi H, Hoshizaki H, Oshima S, Kurabayashi M. Effect of physical training on ventilatory patterns during exercise in patients with heart disease. J Cardiol 2014; 65:343-8. [PMID: 25012061 DOI: 10.1016/j.jjcc.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 06/03/2014] [Accepted: 06/05/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Exercise training is known to improve the shortness of breath experienced by patients with heart disease when the ventilatory pattern becomes abnormal during exercise. However, the precise relationship between breathing patterns and the effect of exercise training has not been elucidated to date. We evaluated the relationship between the effect of exercise training on exercise tolerance and the amelioration of the ventilatory response during exercise in such patients. METHODS AND RESULTS Patients with heart disease (n=170) underwent cardiopulmonary exercise testing twice (pre- and postexercise training for 3-6 months). They were divided into the exercise training group (Group E, n=123) and control group (Group C, n=47). Regression line relating tidal volume to respiratory rate (TV-RR slope) during a ramp protocol below the inflection point was regarded as an indicator of rapid ventilation. Tidal volume after the inflection point was regarded as an indicator of shallow ventilation (TV at plateau). The TV-RR slope and TV at plateau improved after exercise training from 94.8±45.9 to 129.9±69.5 (p<0.001) and from 1473.6±321.9mL to 1673.2±355.1mL (p<0.001), respectively, in Group E. In contrast, no improvement was evident in Group C. In total, %anaerobic threshold (%AT) [AT improving ratio=(post-AT-pre-AT)/pre-AT×100] was positively correlated with both %TV-RR slope [TV-RR slope improving ratio=(post-TV-RR slope-pre-TV-RR slope)/pre-TV-RR slope×100] (r=0.60) and %TV at plateau [TV at plateau improving ratio=(post-TV at plateau-pre-TV at plateau)/pre-TV at plateau×100] (r=0.51). CONCLUSION Exercise training improved the rapidness and depth of breathing during exercise. Therefore, improvement of abnormal ventilatory patterns is correlated with exercise tolerance.
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Affiliation(s)
- Tetsuya Taguchi
- Department of Medicine and Biological Science, Graduate School of Medicine, Gunma University, Gunma, Japan.
| | | | | | | | - Masahiko Kurabayashi
- Department of Medicine and Biological Science, Graduate School of Medicine, Gunma University, Gunma, Japan
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Güder G, Rutten FH. Comorbidity of Heart Failure and Chronic Obstructive Pulmonary Disease: More than Coincidence. Curr Heart Fail Rep 2014; 11:337-46. [DOI: 10.1007/s11897-014-0212-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Wedderburn CJ, Rees D, Height S, Dick M, Rafferty GF, Lunt A, Greenough A. Airways obstruction and pulmonary capillary blood volume in children with sickle cell disease. Pediatr Pulmonol 2014; 49:716-22. [PMID: 23836699 DOI: 10.1002/ppul.22845] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 06/13/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES AND WORKING HYPOTHESIS Airways obstruction occurs in young children with sickle cell disease (SCD). Our aim was to test the hypothesis that increased pulmonary capillary blood volume at least in part explained the increased airways obstruction as this would inform which therapy might be most appropriate to treat the airway obstruction. STUDY DESIGN Observational study. PATIENT-SUBJECT SELECTION Twenty-five SCD children and 25 ethnic origin matched controls were recruited. METHODOLOGY Respiratory system resistance, using impulse oscillometry at 5 Hz (R5 %pred), pulmonary capillary blood volume (Vc), alveolar volume (VA), and spirometry were assessed before and after bronchodilator (ipratropium bromide). Lung volume measurements were also made. RESULTS The SCD children compared to the controls had a higher R5 %pred before (median 133 (range 88-181)% vs. 102 (83-184)%, P = 0.0046) and after (105 (79-150)% vs. 91 (64-147)%, P = 0.0489) bronchodilator and their median Vc/VA (ml/L) was higher before (26 (18-38) vs. 18 (14-28) P < 0.0001) and after (26 (19-41) vs. 18 (13-27) P < 0.0001) bronchodilator. There were similar decreases in R5 %pred post-bronchodilator in the two groups, but no significant changes in Vc/VA in either group. Vc/VA correlated significantly with R5 %pred in the SCD children only. CONCLUSIONS Increased pulmonary capillary blood volume contributes to the increased airways obstruction in children with SCD, hence, bronchodilators may be of limited benefit in reducing their airways obstruction.
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Affiliation(s)
- Catherine J Wedderburn
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, United Kingdom
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Iversen KK, Kjaergaard J, Akkan D, Kober L, Torp-Pedersen C, Hassager C, Vestbo J, Kjoller E. The prognostic importance of lung function in patients admitted with heart failure. Eur J Heart Fail 2014; 12:685-91. [DOI: 10.1093/eurjhf/hfq050] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Jesper Kjaergaard
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Dilek Akkan
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Lars Kober
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology; Copenhagen University Hospital, Gentofte Hospital; Copenhagen Denmark
| | - Christian Hassager
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Jorgen Vestbo
- Department of Cardiology and Respiratory Medicine; Copenhagen University Hospital, Hvidovre Hospital; Hvidovre Denmark
- School of Translational Medicine; University of Manchester, Wythenshawe Hospital; Manchester UK
| | - Erik Kjoller
- Department of Cardiology S105; Copenhagen University Hospital, Herlev Hospital; Herlev Ringvej 75, DK-2730 Herlev Copenhagen Denmark
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Ingle L. Prognostic value and diagnostic potential of cardiopulmonary exercise testing in patients with chronic heart failure. Eur J Heart Fail 2014; 10:112-8. [DOI: 10.1016/j.ejheart.2007.12.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 11/16/2007] [Accepted: 12/19/2007] [Indexed: 10/22/2022] Open
Affiliation(s)
- Lee Ingle
- Carnegie Faculty of Sport and Education; Leeds Metropolitan University; Beckett's Park, Headingley Leeds LS6 3QS UK
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Abstract
This review explores the pathophysiology of gas exchange abnormalities arising consequent to either acute or chronic elevation of pulmonary venous pressures. The initial experimental studies of acute pulmonary edema outlined the sequence of events from lymphatic congestion with edema fluid to frank alveolar flooding and its resultant hypoxemia. Clinical studies of acute heart failure (HF) suggested that hypoxemia was associated only with the final stage of alveolar flooding. However, in patients with chronic heart failure and normal oxygenation, hypoxemia could be produced by the administration of potent pulmonary vasodilators, suggesting that hypoxic pulmonary vasoconstriction is an important reflex for these patients. Patients with chronic left HF commonly manifest a reduced diffusing capacity, an abnormality that appears to be a consequence of chronic elevation of left atrial pressure. That reduction in diffusing capacity does not appear to be primarily attributable to increases in lung water but is improved by any sustained treatment that improves overall cardiac function. Patients with heart failure may also manifest an abnormally elevated VE/VCO2 during exercise, and that exercise ventilation abnormality arises as a consequence of both alveolar hyperventilation and elevated physiologic dead space. That elevated exercise VE/VCO2 in an HF patient has proven to be a powerful predictor of an adverse outcome and hence it has received sustained attention in the HF literature. At least three of the classes of drugs used to treat HF will normalize the exercise VE/VCO2, suggesting that the excessive ventilation response may be linked to elevated sympathetic activity.
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Affiliation(s)
- H Thomas Robertson
- Departments of Medicine and Physiology and Biophysics, University of Washington, Seattle, Washington, USA.
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Paolillo S, Pellegrino R, Salvioni E, Contini M, Iorio A, Bovis F, Antonelli A, Torchio R, Gulotta C, Locatelli A, Agostoni P. Role of alveolar β2-adrenergic receptors on lung fluid clearance and exercise ventilation in healthy humans. PLoS One 2013; 8:e61877. [PMID: 23613962 PMCID: PMC3627811 DOI: 10.1371/journal.pone.0061877] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 03/14/2013] [Indexed: 11/19/2022] Open
Abstract
Background In experimental conditions alveolar fluid clearance is controlled by alveolar β2-adrenergic receptors. We hypothesized that if this occurs in humans, then non-selective β-blockers should reduce the membrane diffusing capacity (DM), an index of lung interstitial fluid homeostasis. Moreover, we wondered whether this effect is potentiated by saline solution infusion, an intervention expected to cause interstitial lung edema. Since fluid retention within the lungs might trigger excessive ventilation during exercise, we also hypothesized that after the β2-blockade ventilation increased in excess to CO2 output and this was further enhanced by interstitial edema. Methods and Results 22 healthy males took part in the study. On day 1, spirometry, lung diffusion for carbon monoxide (DLCO) including its subcomponents DM and capillary volume (VCap), and cardiopulmonary exercise test were performed. On day 2, these tests were repeated after rapid 25 ml/kg saline infusion. Then, in random order 11 subjects were assigned to oral treatment with Carvedilol (CARV) and 11 to Bisoprolol (BISOPR). When heart rate fell at least by 10 beats·min−1, the tests were repeated before (day 3) and after saline infusion (day 4). CARV but not BISOPR, decreased DM (−13±7%, p = 0.001) and increased VCap (+20±22%, p = 0.016) and VE/VCO2 slope (+12±8%, p<0.01). These changes further increased after saline: −18±13% for DM (p<0.01), +44±28% for VCap (p<0.001), and +20±10% for VE/VCO2 slope (p<0.001). Conclusions These findings support the hypothesis that in humans in vivo the β2-alveolar receptors contribute to control alveolar fluid clearance and that interstitial lung fluid may trigger exercise hyperventilation.
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Affiliation(s)
- Stefania Paolillo
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
- Dipartimento di Medicina Interna, Scienze cardiovascolari ed immunologiche, Università Federico II, Napoli, Italy
| | - Riccardo Pellegrino
- Allergologia e Fisiopatologia Respiratoria, ASO S. Croce e Carle, Cuneo, Italy
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Annamaria Iorio
- Dipartimento cardiovascolare, Ospedali Riuniti e Università di Trieste, Trieste, Italy
| | - Francesca Bovis
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Andrea Antonelli
- Allergologia e Fisiopatologia Respiratoria, ASO S. Croce e Carle, Cuneo, Italy
| | - Roberto Torchio
- Pneumologia-Fisiopatologia Respiratoria, AOU S. Luigi, Orbassano, Torino, Italy
| | - Carlo Gulotta
- Pneumologia-Fisiopatologia Respiratoria, AOU S. Luigi, Orbassano, Torino, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Milan, Italy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Impact of chronic obstructive pulmonary disease severity on symptoms and prognosis in patients with systolic heart failure. Clin Res Cardiol 2012; 101:717-26. [PMID: 22484345 DOI: 10.1007/s00392-012-0450-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 03/22/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND Systolic heart failure (SHF) and chronic obstructive pulmonary disease (COPD) are frequently associated. The purpose of our study was to explore the impact of COPD severity on symptoms and prognosis in patients with SHF. METHODS AND RESULTS Chronic obstructive pulmonary disease was systematically screened by spirometry in 348 patients admitted for SHF from April 2002 to December 2006. Severity of COPD was defined according to the GOLD classification. Prevalence of COPD was 37.9 %. Patients' distribution according to GOLD stages I, II, II and IV were, respectively, 51.5, 37.9, 7.6 and 3.0 %. Severity of dyspnoea increases with GOLD stage. There was a significant correlation between NYHA stage and left ventricular ejection fraction in patients without COPD (R (2) = 0.03; P = 0.01) but not in patients with COPD. Mean follow-up was of 54.9 ± 27.4 months. Mortality was 46.6 % and was highest in the COPD group (53.8 vs. 42.3 %; P = 0.049). Kaplan-Meier survival curves showed that patients with GOLD stage I had the same prognosis than patients without COPD and mortality increased from GOLD stage II to stage IV. After multivariate analysis, GOLD stage and diuretics' dose were independently associated with mortality. CONCLUSIONS Chronic obstructive pulmonary disease is frequent in patients with SHF and increases mortality. Since dyspnoea is poorly specific of COPD in chronic heart failure patients, COPD remains underdiagnosed thus leading to inappropriate increase of diuretics' dose. COPD should be systematically screened in patients with SHF to adapt prescription of selective β1-blockers, and diuretics' dose and reduce the exposition to risk factors.
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Di Marco F, Guazzi M, Sferrazza Papa GF, Vicenzi M, Santus P, Busatto P, Piffer F, Blasi F, Centanni S. Salmeterol improves fluid clearance from alveolar-capillary membrane in COPD patients: A pilot study. Pulm Pharmacol Ther 2012; 25:119-23. [DOI: 10.1016/j.pupt.2011.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 11/27/2011] [Accepted: 12/30/2011] [Indexed: 10/14/2022]
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Arques S, Ambrosi P. Human Serum Albumin in the Clinical Syndrome of Heart Failure. J Card Fail 2011; 17:451-8. [DOI: 10.1016/j.cardfail.2011.02.010] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 02/15/2011] [Accepted: 02/24/2011] [Indexed: 11/15/2022]
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Abstract
Heart failure (HF) is a highly prevalent disease that leads to significant morbidity and mortality. There is increasing evidence that the symptoms of HF are exacerbated by its deleterious effects on lung function. HF appears to cause airway obstruction acutely and leads to impaired gas diffusing capacity and pulmonary hypertension in the longer term. It is postulated that this is the result of recurrent episodes of elevated pulmonary capillary pressure leading to pulmonary oedema and pulmonary capillary stress fracture, which produces lung fibrosis. It is likely that impaired lung function impairs the functional status of HF patients and makes them more prone to central sleep apnoea.
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Affiliation(s)
- Kirk Kee
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Victoria, Australia
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Ceridon ML, Snyder EM, Strom NA, Tschirren J, Johnson BD. Influence of rapid fluid loading on airway structure and function in healthy humans. J Card Fail 2009; 16:175-85. [PMID: 20142030 DOI: 10.1016/j.cardfail.2009.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 08/12/2009] [Accepted: 08/17/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The present study examined the influence of rapid intravenous fluid loading (RFL) on airway structure and pulmonary vascular volumes using computed tomography imaging and the subsequent impact on pulmonary function in healthy adults (n = 16). METHODS AND RESULTS Total lung capacity (DeltaTLC = -6%), forced vital capacity (DeltaFVC = -14%), and peak expiratory flow (DeltaPEF = -19%) decreased, and residual volume (DeltaRV = +38%) increased post-RFL (P < .05). Airway luminal cross-sectional area (CSA) decreased at the trachea, and at airway generation 3 (P < .05), wall thickness changed minimally with a tendency for increasing in generation five (P = .13). Baseline pulmonary function was positively associated with airway luminal CSA; however, this relationship deteriorated after RFL. Lung tissue volume and pulmonary vascular volumes increased 28% (P < .001) post-RFL, but did not fully account for the decline in TLC. CONCLUSIONS These data suggest that RFL results in obstructive/restrictive PF changes that are most likely related to structural changes in smaller airways or changes in extrapulmonary vascular beds.
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Affiliation(s)
- Maile L Ceridon
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
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Guazzi M, Arena R, Vicenzi M, Guazzi MD. Regulation of alveolar gas conductance by NO in man, as based on studies with NO donors and inhibitors of NO production. Acta Physiol (Oxf) 2009; 196:267-77. [PMID: 19032601 DOI: 10.1111/j.1748-1716.2008.01939.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Nitric oxide (NO) is a mediator of the pulmonary vessel tone and permeability. We hypothesized that it may also regulate the alveolar-capillary membrane gas conductance and lung diffusion capacity. METHODS In 20 healthy subjects (age = 23 +/- 3 years) we measured lung diffusion capacity for carbon monoxide (DLco), its determinants (membrane conductance, D(m), and pulmonary capillary blood volume, V(c)), systolic pulmonary artery pressure (PAPs) and pulmonary vascular resistance (PVR). Measurements were performed before and after administration of N(g)-monomethyl-L-arginine (L-NMMA, 0.5 mg kg(-1) min(-1)), as a NO production inhibitor, and L-arginine (L-Arg, 0.5 mg kg(-1) min(1)) as a NO pathway activator. The effects of L-NMMA were also tested in combination with active L-Arg and inactive stereoisomer D-Arg vehicled by 150 mL of 5%d-glucose solution. For L-Arg and L-NMMA, saline (150 mL) was also tested as a vehicle. RESULTS L-NMMA reduced D(m) (-41%P < 0.01), DLco (-20%, P < 0.01) and cardiac output (CO), and increased PAPs and PVR. In 10 additional subjects, a dose of L-NMMA of 0.03 mg kg(-1) min(1) infused in the main stem of the pulmonary artery was able to lower D(m) (-32%, P < 0.01) despite no effect on PVR and CO. D(m) depression was significantly greater when L-NMMA was vehicled by saline than by glucose. L-Arg but not D-Arg abolished the effects of L-NMMA. L-Arg alone increased D(m) (+14%, P < 0.01). CONCLUSION The findings indicate that NO mediates the respiratory effects of L-NMMA and L-Arg, and is involved in the physiology of the alveolar-capillary membrane gas conductance in humans. NO deficiency may cause an excessive endothelial sodium exchange/water conduction and fluid leakage in alveolar interstitial space, lengthening the air-blood path and depressing diffusion capacity.
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Affiliation(s)
- M Guazzi
- Cardiopulmonary Unit, University of Milan, San Paolo Hospital, Via A. di Rudinì 8, Milan, Italy.
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Guazzi M. Alveolar gas diffusion abnormalities in heart failure. J Card Fail 2008; 14:695-702. [PMID: 18926442 DOI: 10.1016/j.cardfail.2008.06.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 05/02/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022]
Abstract
In heart failure (HF), development of pressure or volume overload of the lung microcirculation elicits a series of structural adaptations, whose functional correlate is an increased resistance to gas transfer across the alveolar-capillary membrane. Acutely, hydrostatic mechanical injury causes endothelial and alveolar cell breaks, impairment of the cellular pathways involved in fluid filtration and reabsorption, and resistance to gas transfer. This process, which is reminiscent of the so-called alveolar-capillary stress failure, is generally reversible. When the alveolar membrane is chronically challenged, tissue alterations are sustained and a typical remodeling process may take place that is characterized by fixed extracellular matrix collagen proliferation and reexpression of fetal genes. Remodeling leads to a persistent reduction in alveolar-capillary membrane conductance and lung diffusion capacity. Changes in gas transfer not only reflect the underlying lung tissue damage but also bring independent prognostic information and may play a role in the pathogenesis of exercise limitation and ventilatory abnormalities. They are not responsive to fluid withdrawal by ultrafiltration and tend to be refractory even to heart transplantation. Some drugs can be effective that modulate lung remodeling (eg, angiotensin-converting enzyme inhibitors, whose impact on the natural course of cardiac remodeling is well known) or that increase nitric oxide availability and nitric oxide-mediated pulmonary vasodilation (eg, type 5 phosphodiesterase inhibitors). This review focuses on the current knowledge of these topics.
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Affiliation(s)
- Marco Guazzi
- Cardiopulmonary Unit, University of Milano, San Paolo Hospital, Milano, Italy
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Hochberg I, Abassi Z, Azzam ZS. Patterns of alveolar fluid clearance in heart failure. Int J Cardiol 2008; 130:125-30. [PMID: 18579236 DOI: 10.1016/j.ijcard.2008.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2007] [Revised: 02/19/2008] [Accepted: 03/01/2008] [Indexed: 11/17/2022]
Abstract
Alveolar fluid clearance (AFC) is important in keeping the airspaces free of edema. This process is accomplished via passive and active transport of Na(+) across the alveolo-capillary barrier mostly by apical Na(+) channels and basolateral Na,K-ATPases, respectively. Patterns of alveolar fluid clearance were found to be decreased in acutely elevated left atrial pressures, possibly due to the inhibition of alveolar epithelial active sodium transport. On the other hand, chronic elevation of pulmonary capillary pressure, such as seen in experimental and clinical congestive heart failure, increases alveolar fluid clearance most likely secondary to upregulation of active sodium transport.
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Affiliation(s)
- Irit Hochberg
- Internal Medicine B, Rambam: Human Health Care Campus, Haifa, Israel
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Guazzi M, Arena R, Guazzi MD. Evolving changes in lung interstitial fluid content after acute myocardial infarction: mechanisms and pathophysiological correlates. Am J Physiol Heart Circ Physiol 2008; 294:H1357-64. [PMID: 18192218 DOI: 10.1152/ajpheart.00866.2007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In acute myocardial infarction (AMI), alveolar interstitium edema is generally attributed to a hydrostatic imbalance. However, inflammatory burden and/or neural/hormonal/hemodynamic stimulation might injure the microvascular endothelium, eliciting interstitial overflow and altering alveolar-capillary gas diffusion. In 118 patients with AMI (ejection fraction >or=50% and wedge pulmonary pressure <16 mmHg), admission alveolar-capillary gas diffusing membrane conductance (DM) averaged 35.1 ml.min(-1).mmHg(-1) and was 27% lower than in 25 controls (P < 0.01). Infusion of saline in the pulmonary circulation (to test sodium exchange across the pulmonary capillary wall) lowered DM by 7.1% (P < 0.01) and was neutral in controls. At 1 wk, 83 patients that showed DM improvement >5% were assigned to group 1, and 28 patients with DM worsening >5% were assigned to group 2. Saline retained efficacy in group 2 and had no DM effect in group 1 (supporting a link between changes in baseline DM and those in microvascular salt exchange). Ventricular function was unchanged in group 1, whereas group 2 had developed diastolic dysfunction. At 1 yr, 3% of cases in group 1 and 37% of cases in group 2 had alveolar edema. Thus, AMI is frequently associated with abnormal pulmonary microvascular sodium transport/water conductance that, in the case of ventricular dysfunction supervenience, may persist and worsen the outcome. In 37 AMI similar patients and 11 control subjects, nitric oxide overexpression with l-arginine improved baseline DM and in AMI patients prevented DM reduction by saline, suggesting a mechanistic role of an impaired nitric oxide pathway in the microvascular barrier dysfunction.
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Affiliation(s)
- Marco Guazzi
- Cardiopulmonary Unit, Cardiology Division, University of Milano, San Paolo Hospital, Via A. di Rudinì 8, Milano 20142, Italy.
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Agostoni P, Contini M, Cattadori G, Apostolo A, Sciomer S, Bussotti M, Palermo P, Fiorentini C. Lung function with carvedilol and bisoprolol in chronic heart failure: is beta selectivity relevant? Eur J Heart Fail 2007; 9:827-33. [PMID: 17561440 DOI: 10.1016/j.ejheart.2007.04.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Accepted: 04/26/2007] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Carvedilol is a beta-blocker with similar affinity for beta1- and beta2 receptors, while bisoprolol has higher beta1 affinity. The respiratory system is characterized by beta2-receptor prevalence. Airway beta receptors regulate bronchial tone and alveolar beta receptors regulate alveolar fluid re-absorption which influences gas diffusion. AIMS To compare the effects of carvedilol and bisoprolol on lung function in patients with chronic heart failure (CHF). METHODS AND RESULTS We performed a double-blind, cross-over study in 53 CHF patients. After 2 months of full dose treatment with either carvedilol or bisoprolol, we assessed lung function by salbutamol challenge, carbon monoxide lung diffusion (DLCO), including membrane conductance (DM), and gas exchange during exercise. FEV1 and FVC were similar; after salbutamol FEV1 was higher with bisoprolol (p<0.04). DLco was 82+/-21% of predicted with carvedilol and 90+/-20% with bisoprolol (p<0.01) due to DM changes. Peak VO2 was 17.8+/-4.5 mL/min/kg on bisoprolol and 17.0+/-4.6 on carvedilol, (p<0.05) with no differences in bronchial tone (same expiratory time) throughout exercise. Differences were greater in the 22 subjects with DLCO<80%. CONCLUSION Carvedilol and bisoprolol have different effects on DLCO and response to salbutamol. DLCO differences, being DM related, are due to changes in active membrane transport which is under alveolar beta2-receptor control. Peak VO2 was slightly higher with bisoprolol particularly in CHF patients with reduced DLCO.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Istituto di Cardiologia, Università di Milano, Milan, Italy.
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Ingle L, Goode K, Carroll S, Sloan R, Boyes C, Cleland JG, Clark AL. Prognostic value of the VE/VCO2 slope calculated from different time intervals in patients with suspected heart failure. Int J Cardiol 2007; 118:350-5. [DOI: 10.1016/j.ijcard.2006.07.105] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 07/11/2006] [Indexed: 10/24/2022]
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Papazachou O, Anastasiou-Nana M, Sakellariou D, Tassiou A, Dimopoulos S, Venetsanakos J, Maroulidis G, Drakos S, Roussos C, Nanas S. Pulmonary function at peak exercise in patients with chronic heart failure. Int J Cardiol 2007; 118:28-35. [PMID: 16893579 DOI: 10.1016/j.ijcard.2006.04.091] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 04/02/2006] [Accepted: 04/28/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND Various respiratory abnormalities are associated with chronic heart failure (CHF). However, changes in inspiratory capacity (IC) and breathing pattern from rest to exercise in patients with CHF have not been thoroughly investigated in these patients. MATERIALS AND METHODS Seventy seven (66 male/11 female) patients with clinical stable CHF (age: 52+/-11 years) were studied. All the patients underwent pulmonary function tests, including measurements of IC and maximal inspiratory pressure (Pimax) at rest and then a maximal cardiopulmonary exercise testing (CPET) on a treadmill. During the CPET, IC was measured every 2 min. Pimax was measured again after the end of CPET. RESULTS Percent predicted forced expiratory volume in 1 s (FEV1) was 91+/-12, %predicted forced vital capacity (FVC) was 92+/-13, %FEV1/FVC was 81+/-4, and %predicted IC was 85+/-18. Peak exercise IC was lower than resting (2.4+/-0.6 vs. 2.6+/-0.6 l, p<0.001). Analysis of variance between Weber's groups revealed statistically significant differences in peak exercise IC (p<0.001), VE/VCO2slope (p<0.001), resting Pimax (p=0.005) and post-exercise Pimax (p<0.001). At rest, there was a statistically significant difference in end-tidal CO2 (P(ETCO2)) (p=0.002), in breathing frequency (p=0.004), in inspiratory time (Ti) (p=0.04) and in total respiratory time (T(Tot)) (p=0.004) among Weber's groups. At peak exercise there was a statistically significant decrease in minute ventilation (VE) (p<0.001), tidal volume (VT) (p<0.001), respiratory cycle (VT/TI) (p<0.001) and P(ETCO2) (p<0.001). Peak IC was correlated with peak VO2 (r=0.72, p<0.001), anaerobic threshold (r=0.71, p<0.001), VO2/t slope (r=0.54, p<0.0001), and post-exercise Pimax (r=0.62, p<0.001). CONCLUSIONS In patients with CHF, peak exercise IC is reduced in parallel with disease severity, which is probably due to respiratory muscle dysfunction.
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Affiliation(s)
- Ourania Papazachou
- Pulmonary and Critical Care Medicine Department, Cardiopulmonary Exercise Testing Laboratory and Rehabilitation Center, National and Kapodestrian University of Athens, Evgenidio Hospital, 20, Papadiamantopoulou str, Athens 115 28, Greece
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Glénet SN, De Bisschop C, Vargas F, Guénard HJP. Deciphering the nitric oxide to carbon monoxide lung transfer ratio: physiological implications. J Physiol 2007; 582:767-75. [PMID: 17495039 PMCID: PMC2075329 DOI: 10.1113/jphysiol.2007.133405] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Using simultaneous nitric oxide and carbon monoxide lung transfer measurements (T(LNO) and T(LCO)), the membrane transfer capacity (D(m)) and capillary lung volume (V(c)) as well as the dimensionless ratio T(LNO)/T(LCO) can be calculated. The significance of this ratio is yet unclear. Theoretically, the T(LNO)/T(LCO) ratio should be inversely related to the product of both lung alveolar capillary membrane (mu) and blood sheet thicknesses (K). NO and CO transfers were measured in healthy subjects in various conditions likely to be associated with changes in K and/or mu. Experimentally, deflation of the lung from 7.4 to 4.8 l decreased the T(LNO)/T(LCO) ratio from 4.9 to 4.2 (n=25) which was consistent mainly with a thickening of the blood sheet. Compared with continuous negative pressure breathing, continuous positive pressure breathing increased this ratio suggesting a thinning of the capillary sheet. It was also observed with 12 healthy subjects that slight haemodilution that may thicken the blood sheet decreased the T(LNO)/T(LCO) ratio from 4.85 to 4.52. In conclusion, the T(LNO)/T(LCO) ratio is related to the thickness of the alveolar blood barrier. This ratio provides novel information for the analysis of the diffusion properties.
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Affiliation(s)
- Stéphane N Glénet
- Laboratoire de Physiologie, Université Victor Segalen, 146 Rue Léo Saignat, 33076 Bordeaux Cedex, France
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Ingle L. Theoretical rationale and practical recommendations for cardiopulmonary exercise testing in patients with chronic heart failure. Heart Fail Rev 2007; 12:12-22. [PMID: 17393306 DOI: 10.1007/s10741-007-9000-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/10/2007] [Indexed: 10/23/2022]
Abstract
The syndrome of chronic heart failure (CHF) becomes increasingly prevalent in older patients, and while mortality rates are declining in most cardiovascular diseases, both prevalence and mortality in CHF remain high. The heart is unable to meet the demands of the skeletal musculature, and symptoms manifest as dyspnoea and signs of fatigue during exercise. The cardiopulmonary exercise test (CPET) can provoke symptoms which may be useful in improving the accuracy of diagnosis in CHF in a non-invasive setting. CPET also provides important information on the pathophysiology of exercise limitation, risk stratification and can establish exercise-training protocols. The information provided by the CPET allows suitable pharmacological or device-based adjustments to be considered in the management of CHF, which can be crucial in maintaining a patient's quality of life. This manuscript provides a useful insight into the theoretical rationale and practical recommendations for CPET in patients with CHF. Prior to CPET, it is important to consider the mode of exercise, as cycle ergometry or treadmill protocols will yield different outcomes in patients with CHF. We discuss how pre-CPET set-up procedures should be conducted and also the significance of electrocardiographic abnormalities found in CHF patients, and how these should be interpreted. The assessment of lung function is integral to the underlying pathophysiological basis of exercise limitation and we explain how this should be performed. CHF patients display the following abnormal exercise responses which can be identified by CPET: peak oxygen uptake ( [Formula: see text] peak), anaerobic threshold (AT), DeltaVO(2)/Delta work rate (WR), peak oxygen pulse, estimated peak stroke volume and predicted peak heart rate are reduced. The [Formula: see text] slope is abnormally high and the breathing reserve is normal or high. An immediate post-exercise increase in O(2) pulse is evident, and/or a regular oscillatory breathing pattern has been observed at lower exercise intensities in some CHF patients. Symptoms of breathlessness, fatigue, and/or leg pain occur earlier during CPET and may cause the CPET to be aborted early. We explain the significance of the 9-panelled array, and how it can help to determine the underlying pathophysiology of exercise intolerance in these patients.
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Affiliation(s)
- Lee Ingle
- Carnegie Faculty of Sport and Education, Leeds Metropolitan University, Beckett's Park Campus, Headingley, Leeds, LS6 3QS, UK.
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Arques S, Roux E, Luccioni R. Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function. Cardiovasc Ultrasound 2007; 5:16. [PMID: 17386087 PMCID: PMC1847510 DOI: 10.1186/1476-7120-5-16] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Accepted: 03/26/2007] [Indexed: 11/10/2022] Open
Abstract
Congestive heart failure with preserved left ventricular systolic function has emerged as a growing epidemic medical syndrome in developed countries, which is characterized by high morbidity and mortality rates. Rapid and accurate diagnosis of this condition is essential for optimizing the therapeutic management. The diagnosis of congestive heart failure is challenging in patients presenting without obvious left ventricular systolic dysfunction and additional diagnostic information is most commonly required in this setting. Comprehensive Doppler echocardiography is the single most useful diagnostic test recommended by the ESC and ACC/AHA guidelines for assessing left ventricular ejection fraction and cardiac abnormalities in patients with suspected congestive heart failure, and non-invasively determined basal or exercise-induced pulmonary capillary hypertension is likely to become a hallmark of congestive heart failure in symptomatic patients with preserved left ventricular systolic function. The present review will focus on the current clinical applications of spectral tissue Doppler echocardiography used as a reliable noninvasive surrogate for left ventricular diastolic pressures at rest as well as during exercise in the diagnosis of heart failure with preserved left ventricular systolic function. Chronic congestive heart failure, a disease of exercise, and acute heart failure syndromes are characterized by specific pathophysiologic and diagnostic issues, and these two clinical presentations will be discussed separately.
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Affiliation(s)
| | - Emmanuel Roux
- Department of Cardiology, Aubagne Hospital, Aubagne, France
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Olson LJ, Snyder EM, Beck KC, Johnson BD. Reduced rate of alveolar-capillary recruitment and fall of pulmonary diffusing capacity during exercise in patients with heart failure. J Card Fail 2006; 12:299-306. [PMID: 16679264 DOI: 10.1016/j.cardfail.2006.01.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Revised: 12/02/2005] [Accepted: 01/11/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with chronic heart failure (CHF) have reduced pulmonary diffusing capacity for carbon monoxide (DLCO). Acute pulmonary congestion also causes reduction of DLCO, which is reversible. We hypothesized for patients with CHF that the rate of rise of exercise DLCO is reduced compared to healthy controls and falls near end-exercise consistent with progressive interstitial edema. METHODS AND RESULTS DLCO and pulmonary blood flow (QC)) were measured by a rebreathe technique in CHF subjects (n = 11) and controls (n = 8) at rest, during constant workload exercise, and after exercise. DLCO of CHF subjects was less than controls at rest (16.5 +/- 1 vs. 21.9 +/- 2 mL/min/mm Hg, P < .01). CHF subjects exercised 11 +/- 2 minutes to 90% peak VO2, whereas controls exercised 17 +/- 2 minutes, reaching 88% peak VO2. In CHF subjects, DLCO increased to 19 +/- 2 mL/min/mm Hg and for controls to 38 +/- 3 mL/min/mm Hg. During the final 3 minutes of exercise, DLCO increased 5% in controls while decreasing 5% in CHF subjects (DLCO/Q(C)) was lower in CHF subjects at rest and progressively lower throughout exercise (P < .01). CONCLUSION In patients with CHF, DLCO has reduced rate of rise with exercise and falls near end-exercise consistent with limitation of alveolar-capillary recruitment and progressive interstitial edema.
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Affiliation(s)
- Lyle J Olson
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Nanas SN, Nanas JN, Sakellariou DC, Dimopoulos SK, Drakos SG, Kapsimalakou SG, Mpatziou CA, Papazachou OG, Dalianis AS, Anastasiou-Nana MI, Roussos C. VE/VCO2 slope is associated with abnormal resting haemodynamics and is a predictor of long-term survival in chronic heart failure. Eur J Heart Fail 2006; 8:420-7. [PMID: 16310408 DOI: 10.1016/j.ejheart.2005.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Revised: 07/01/2005] [Accepted: 10/03/2005] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients with chronic heart failure (CHF) present with exercise-induced hyperpnea, but its pathophysiological mechanism has not been thoroughly investigated. We aimed to determine the relationship between exercise-induced hyperpnea, resting haemodynamic measurements and the validity of ventilatory response (V(E)/V(CO(2)) slope) as a mortality predictor in CHF patients. METHODS Ninety-eight CHF patients (90M/8F) underwent a symptom-limited treadmill cardiopulmonary exercise test (CPET). Right heart catheterization and radionuclide ventriculography were performed within 72 h of CPET. RESULTS Twenty-seven patients died from cardiac causes during 20+/-6 months follow-up. Non-survivors had a lower peak oxygen consumption (V(O(2)p)), (16.5+/-4.9 vs. 20.2+/-6.1, ml/kg/min, p=0.003), a steeper V(E)/V(CO(2)) slope (34.8+/-8.3 vs. 28.9+/-4.8, p<0.001) and a higher pulmonary capillary wedge pressure (PCWP) (19.5+/-8.6 vs. 11.7+/-6.5 mm Hg, p=0.008) than survivors. By multivariate survival analysis, the V(E)/V(CO(2)) slope as a continuous variable was an independent prognostic factor (chi(2): 8.5, relative risk: 1.1, 95% CI: 1.03-1.18, p=0.004). Overall mortality was 52% in patients with V(E)/V(CO(2)) slope > or =34 and 18% in those with V(E)/V(CO(2)) slope <34 (log rank: 18.5, p<0.001). In a subgroup of patients (V(O(2)p): 10-18 ml/kg/min), V(E)/V(CO(2)) slope was a significant predictor of mortality (relative risk: 6.2, 95% CI: 1.7-22.2, p=0.002). Patients with high V(E)/V(CO(2)) slope had higher resting PCWP (19.9+/-9.1 vs. 11.3+/-5.7 mmHg, p<0.001) and V(E)/V(CO(2)) slope correlated significantly with PCWP (r: 0.57, p<0.001). CONCLUSIONS The V(E)/V(CO(2)) slope, as an index of ventilatory response to exercise, improves the risk stratification of CHF patients. Interstitial pulmonary oedema may be a pathophysiological mechanism of inefficient ventilation during exercise in these patients.
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Affiliation(s)
- Serafim N Nanas
- Pulmonary and Critical Care Medicine Department, Cardiopulmonary Exercise Testing And Rehabilitation Laboratory, Evgenidio Hospital, National and Kapodestrian University of Athens, Greece.
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Petersen CL, Kjaer A. Impact of medical treatment on lung diffusion capacity in elderly patients with heart failure. Baseline characteristics and 1-year follow up after medical treatment. Int J Cardiol 2005; 98:453-7. [PMID: 15708179 DOI: 10.1016/j.ijcard.2003.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2003] [Revised: 12/23/2003] [Accepted: 12/25/2003] [Indexed: 11/22/2022]
Abstract
AIM The aim of this investigation was (1) to study the effect of untreated chronic heart failure (CHF) on alveolar membrane diffusion capacity (transfer coefficient, K(CO)) in elderly patients and (2) to study the impact of the standard regime of medical treatment with diuretics and ACE-inhibitor/angiotensin-II receptor antagonists on K(CO) in these patients. METHODS Non-medicated patients (except for diuretics) with symptoms of heart failure (NYHA II-III) and echocardiographically estimated left ventricular ejection fraction (LVEF) <0.40 were recruited. All were characterized according to the results of multiple ECG-gated radionuclide ventriculography (MUGA). LVEF<0.50 when measured by MUGA was considered as heart failure (HF). A total of 20 patients fulfilled the criteria. All patients had a lung function test including measurement of K(CO) and a MUGA for LVEF measurement performed prior to medical treatment (baseline) and after 1 year of treatment with diuretics and ACE-inhibitors/angiotensin-II receptor antagonists. Age- and gender-matched healthy volunteers were included as control group. RESULTS (mean+/-S.E.M.): K(CO) at baseline was 0.95+/-0.06 and 1.25+/-0.04 mmol/min x kPa/l in HF patients and controls, respectively (p<0.05). After 1 year of treatment, K(CO) was normalized in the HF group (1.23+/-0.13 mmol/s x kPa, p<0.05). LVEF increased in the HF group from 0.28+/-0.03 at baseline to 0.34+/-0.03 after 1 year of treatment (p<0.05). CONCLUSION Elderly patients with symptomatic HF (NYHA II-III) and reduced systolic function have respiratory dysfunction in the form of reduced K(CO). One year of medical treatment had a significant beneficial effect on K(CO) and LVEF.
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Affiliation(s)
- Claus Leth Petersen
- Department of Clinical Physiology and Nuclear Medicine, H:S Frederiksberg Hospital, University of Copenhagen, Ndr. Fasanvej 57, 2000 F, Copenhagen, Denmark.
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