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Campedelli L, Nouraie SM, Risbano MG. Non-arterial line cardiac output calculation misclassifies exercise pulmonary hypertension and increases risk of data loss particularly in black, scleroderma and Raynaud's patients during invasive exercise testing. Eur Respir J 2024; 64:2302232. [PMID: 38782468 DOI: 10.1183/13993003.02232-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The direct Fick principle is the standard for calculating cardiac output (CO) to detect CO-dependent conditions like exercise pulmonary hypertension (ePH). Fick COarterial incorporates arterial haemoglobin (Hba) and oxygen saturation (S aO2 ) with oxygen consumption from exercise testing, while Fick COnon-arterial substitutes mixed venous haemoglobin (Hbmv) and peripheral oxygen saturation (S pO2 ) in the absence of an arterial line. The decision to employ an arterial catheter for exercise testing varies, and discrepancies in oxygen saturation and haemoglobin between arterial and non-arterial methods may lead to differences in Fick CO, potentially affecting ePH classification. METHODS We performed a retrospective analysis of 296 consecutive invasive cardiopulmonary exercise testing (iCPET) studies comparing oxygen saturation from pulse oximetry (S pO2 ) and radial arterial (S aO2 ), Hba and Hbmv, and CO calculated with arterial (COarterial) and non-arterial (COnon-arterial) values. We assessed the risk of misclassification of pre- and post-capillary ePH and data loss due to inaccurate S pO2 . RESULTS When considering all stages from rest to peak exercise, Hba and Hbmv demonstrated high correlation, while S pO2 and S aO2 as well as COarterial and COnon-arterial demonstrated low correlation. Data loss was significantly higher across all stages of exercise for S pO2 (n=346/1926 (18%)) compared to S aO2 (n=17/1923 (0.88%)). We found that pre- and post-capillary ePH were misclassified as COnon-arterial data (n=7/41 (17.1%) and n=2/23 (8.7%), respectively). Patients with scleroderma and/or Raynaud's (n=11/33 (33.3%)) and black patients (n=6/19 (31.6%)) had more S pO2 data loss. CONCLUSION Reliance upon S pO2 during invasive exercise testing results in the misclassification of pre- and post-capillary ePH, and unmeasurable S pO2 for black, scleroderma and Raynaud's patients can preclude accurate exercise calculations, thus limiting the diagnostic and prognostic value of invasive exercise testing without an arterial line.
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Affiliation(s)
- Luiz Campedelli
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - S Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
- Centre for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Michael G Risbano
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
- Centre for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
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Raza F, Chesler NC. Distensibility, an Early Disease Marker of Pulmonary Vascular Health: Ready for Clinical Application. J Am Heart Assoc 2023; 12:e031605. [PMID: 37815032 PMCID: PMC10757520 DOI: 10.1161/jaha.123.031605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Farhan Raza
- Department of Medicine‐Cardiovascular DivisionUniversity of Wisconsin‐MadisonMadisonWIUSA
| | - Naomi C. Chesler
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringUniversity of California, IrvineIrvineCAUSA
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Elliott J, Menakuru N, Martin KJ, Rahaghi FN, Rischard FP, Vanderpool RR. iCPET Calculator: A Web-Based Application to Standardize the Calculation of Alpha Distensibility in Patients With Pulmonary Arterial Hypertension. J Am Heart Assoc 2023; 12:e029667. [PMID: 37815026 PMCID: PMC10757516 DOI: 10.1161/jaha.123.029667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 10/11/2023]
Abstract
Background Pulmonary vascular distensibility associates with right ventricular function and clinical outcomes in patients with unexplained dyspnea and pulmonary hypertension. Alpha distensibility coefficient is determined from a nonlinear fit to multipoint pressure-flow plots. Study aims were to (1) create and test a user-friendly tool to standardize analysis of exercise hemodynamics including distensibility, and (2) investigate changes in distensibility following treatment in patients with pulmonary arterial hypertension. Methods and Results Participants with an exercise right heart catherization were retrospectively identified from the University of Arizona Pulmonary Hypertension (UA PH) registry and split into a pulmonary arterial hypertension group, a comparator group, and a control group. Right ventricular function was quantified using the coupling ratio and diastolic stiffness. Prototypes of the invasive cardiopulmonary exercise testing (iCPET) calculator were developed using Matlab, Python, and RShiny to analyze exercise hemodynamics and alpha distensibility coefficient, α (%/mm Hg) from multipoint pressure flow plots. Interclass correlation coefficients were calculated for interplatform and interobserver variability in alpha. No significant bias in the intraplatform (Matlab versus RShiny; intraclass correlation coefficient: 0.996) or interobserver (intraclass correlation coefficient: 0.982) comparison of alpha values. Afterload significantly decreased (P<0.05) with no change in alpha distensibility in the pulmonary arterial hypertension group at follow-up. The comparator group had no change in pressure, resistance or alpha distensibility. There were no significant changes in RV diastolic stiffness at follow-up. Conclusions The interactive user interface in the iCPET calculator allows exploration of alpha distensibility using standardized methods. No significant change in alpha distensibility at follow-up suggests that alpha may be less modifiable in patients with long-standing pulmonary arterial hypertension.
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Affiliation(s)
- Jordan Elliott
- Division of Translational and Regenerative MedicineUniversity of ArizonaTucsonAZUSA
| | - Nainika Menakuru
- Division of Translational and Regenerative MedicineUniversity of ArizonaTucsonAZUSA
| | - Kellan Juliet Martin
- Division of Translational and Regenerative MedicineUniversity of ArizonaTucsonAZUSA
| | | | - Franz P. Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep MedicineUniversity of ArizonaTucsonAZUSA
| | - Rebecca R. Vanderpool
- Division of Translational and Regenerative MedicineUniversity of ArizonaTucsonAZUSA
- Division of Cardiovascular Medicine, College of MedicineThe Ohio State UniversityColumbusOHUSA
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Forbes LM, Bull TM, Lahm T, Make BJ, Cornwell WK. Exercise Testing in the Risk Assessment of Pulmonary Hypertension. Chest 2023; 164:736-746. [PMID: 37061028 PMCID: PMC10504600 DOI: 10.1016/j.chest.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023] Open
Abstract
TOPIC IMPORTANCE Right ventricular dysfunction in pulmonary hypertension (PH) contributes to reduced exercise capacity, morbidity, and mortality. Exercise can unmask right ventricular dysfunction not apparent at rest, with negative implications for prognosis. REVIEW FINDINGS Among patients with pulmonary vascular disease, right ventricular afterload may increase during exercise out of proportion to increases observed among healthy individuals. Right ventricular contractility must increase to match the demands of increased afterload to maintain ventricular-arterial coupling (the relationship between contractility and afterload) and ultimately cardiac output. Impaired right ventricular contractile reserve leads to ventricular-arterial uncoupling, preventing cardiac output from increasing during exercise and limiting exercise capacity. Abnormal pulmonary vascular response to exercise can signify early pulmonary vascular disease and is associated with increased mortality. Impaired right ventricular contractile reserve similarly predicts poor outcomes, including reduced exercise capacity and death. Exercise provocation can be used to assess pulmonary vascular response to exercise and right ventricular contractile reserve. Noninvasive techniques (including cardiopulmonary exercise testing, transthoracic echocardiography, and cardiac MRI) as well as invasive techniques (including right heart catheterization and pressure-volume analysis) may be applied selectively to the screening, diagnosis, and risk stratification of patients with suspected or established PH. Further research is required to determine the role of exercise stress testing in the management of pulmonary vascular disease. SUMMARY This review describes the current understanding of clinical applications of exercise testing in the risk assessment of patients with suspected or established PH.
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Affiliation(s)
- Lindsay M Forbes
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd M Bull
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Barry J Make
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Kusunose K, Hirata Y, Yamaguchi N, Kosaka Y, Tsuji T, Kotoku J, Sata M. Deep Learning for Detection of Exercise-Induced Pulmonary Hypertension Using Chest X-Ray Images. Front Cardiovasc Med 2022; 9:891703. [PMID: 35783826 PMCID: PMC9240342 DOI: 10.3389/fcvm.2022.891703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022] Open
Abstract
Background Stress echocardiography is an emerging tool used to detect exercise-induced pulmonary hypertension (EIPH). However, facilities that can perform stress echocardiography are limited by issues such as cost and equipment. Objective We evaluated the usefulness of a deep learning (DL) approach based on a chest X-ray (CXR) to predict EIPH in 6-min walk stress echocardiography. Methods The study enrolled 142 patients with scleroderma or mixed connective tissue disease with scleroderma features who performed a 6-min walk stress echocardiographic test. EIPH was defined by abnormal cardiac output (CO) responses that involved an increase in mean pulmonary artery pressure (mPAP). We used the previously developed AI model to predict PH and calculated PH probability in this cohort. Results EIPH defined as ΔmPAP/ΔCO >3.3 and exercise mPAP >25 mmHg was observed in 52 patients, while non-EIPH was observed in 90 patients. The patients with EIPH had a higher mPAP at rest than those without EIPH. The probability of PH based on the DL model was significantly higher in patients with EIPH than in those without EIPH. Multivariate analysis showed that gender, mean PAP at rest, and the probability of PH based on the DL model were independent predictors of EIPH. A model based on baseline parameters (age, gender, and mPAP at rest) was improved by adding the probability of PH predicted by the DL model (AUC: from 0.65 to 0.74; p = 0.046). Conclusion Applying the DL model based on a CXR may have a potential for detection of EIPH in the clinical setting.
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Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
- *Correspondence: Kenya Kusunose,
| | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Natsumi Yamaguchi
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Yoshitaka Kosaka
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Takumasa Tsuji
- Department of Radiological Technology, Graduate School of Medical Care and Technology, Teikyo University, Tokyo, Japan
| | - Jun’ichi Kotoku
- Department of Radiological Technology, Graduate School of Medical Care and Technology, Teikyo University, Tokyo, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
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Risbano MG. Lowering Tricuspid Regurgitant Velocity Threshold to Identify a Mean Pulmonary Artery Pressure ≥ 20 mm Hg: Is It Time to Release the Hounds? Chest 2021; 160:2000-2002. [PMID: 34872663 DOI: 10.1016/j.chest.2021.07.2164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Michael G Risbano
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, and the Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA.
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Wernhart S, Hedderich J, Weihe E. Vital capacity and valvular dysfunction could serve as non-invasive predictors to screen for exercise pulmonary hypertension in the elderly based on a new diagnostic score. J Cardiovasc Thorac Res 2021; 13:68-78. [PMID: 33815705 PMCID: PMC8007893 DOI: 10.34172/jcvtr.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Exercise pulmonary hypertension (exPH) has been defined as total pulmonary resistance (TPR) >3 mm Hg/L/min and mean pulmonary artery pressure (mPAP) >30 mm Hg, albeit with a considerable risk of false positives in elderly patients with lower cardiac output during exercise.
Methods: We retrospectively analysed patients with unclear dyspnea receiving right heart catheterisation at rest and exercise (n=244) between January 2015 and January 2020. Lung function testing, blood gas analysis, and echocardiography were performed. We elaborated a combinatorial score to advance the current definition of exPH in an elderly population (mean age 67.0 years±11.9). A stepwise regression model was calculated to non-invasively predict exPH.
Results: Analysis of variables across the achieved peak power allowed the creation of a model for defining exPH, where three out of four criteria needed to be fulfilled: Peak power ≤100 Watt, pulmonary capillary wedge pressure ≥18 mm Hg, pulmonary vascular resistance >3 Wood Units, and mPAP ≥35 mm Hg. The new scoring model resulted in a lower number of exPH diagnoses than the current suggestion (63.1% vs. 78.3%). We present a combinatorial model with vital capacity (VCmax) and valvular dysfunction to predict exPH (sensitivity 93.2%; specificity 44.2%, area under the curve 0.73) based on our suggested criteria. The odds of the presence of exPH were 2.1 for a 1 l loss in VCmax and 3.6 for having valvular dysfunction.
Conclusion: We advance a revised definition of exPH in elderly patients in order to overcome current limitations. We establish a new non-invasive approach to predict exPH by assessing VCmax and valvular dysfunction for early risk stratification in elderly patients.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany.,University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Jürgen Hedderich
- Medistat-Biomedical Statistics, Medistat GmbH, Kronshagen, Germany
| | - Eberhard Weihe
- Institute of Anatomy and Cell Biology of the Philipps-University Marburg, Germany
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Zou RH, Wallace WD, Nouraie SM, Chan SY, Risbano MG. Lower DLco% identifies exercise pulmonary hypertension in patients with parenchymal lung disease referred for dyspnea. Pulm Circ 2020; 10:2045894019891912. [PMID: 32128158 PMCID: PMC7031800 DOI: 10.1177/2045894019891912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 11/11/2019] [Indexed: 01/13/2023] Open
Abstract
Exercise pulmonary hypertension is an underappreciated form of physical limitation related to early pulmonary vascular disease. A low diffusing capacity of lungs for carbon monoxide (DLco) can be seen in patients with resting pulmonary hypertension as well as parenchymal lung disease. It remains unclear whether low DLco% identifies early pulmonary vascular disease. We hypothesize that a reduced DLco% differentiates the presence of exercise pulmonary hypertension in patients with parenchymal lung disease. Fifty-six patients referred for unexplained exertional dyspnea with pulmonary function tests within six months of hemodynamic testing underwent exercise right heart catheterization. Exclusion criteria included resting pulmonary arterial or venous hypertension. Receiver operator characteristic curve determined the optimal DLco% cutoffs based on the presence or absence of parenchymal lung disease. Twenty-one (37%) patients had parenchymal lung disease, most common manifesting as chronic obstructive lung disease or interstitial lung disease. In patients with parenchymal lung disease, a DLco of 46% demonstrated 100% sensitivity and 73% specificity for detecting exercise pulmonary hypertension. In patients without parenchymal lung disease, a DLco of 73% demonstrated 58% sensitivity and 94% specificity for detecting exercise pulmonary hypertension. In both cohorts, DLco% below the optimum cutoffs were associated with higher peak mean pulmonary arterial pressure and peak total pulmonary resistance consistent with the hemodynamic definition of exercise pulmonary hypertension. Patients with a DLco < 46% were more often treated with pulmonary vasodilators and had a trend to higher mortality and lung transplant. DLco% is a simple non-invasive screening test for the presence of exercise pulmonary hypertension in our mixed referral population with progressive exertional dyspnea. DLco < 46% with parenchymal lung disease and DLco < 73% without parenchymal lung disease may play a role in differentiating the presence of pulmonary vascular disease prior to invasive hemodynamic testing.
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Affiliation(s)
- Richard H. Zou
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William D. Wallace
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - S. Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen Y. Chan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael G. Risbano
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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