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de Campos GGO, Goelzer LS, Augusto TRDL, Barbosa GW, Chiappa GR, van Iterson EH, Muller PT. Comparable Ventilatory Inefficiency at Maximal and Submaximal Performance in COPD vs. CHF subjects: An Innovative Approach. Arq Bras Cardiol 2024; 121:e20230578. [PMID: 38695473 DOI: 10.36660/abc.20230578] [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: 08/21/2023] [Accepted: 01/18/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Currently, excess ventilation has been grounded under the relationship between minute-ventilation/carbon dioxide output ( V ˙ E - V ˙ CO 2 ). Alternatively, a new approach for ventilatory efficiency ( η E V ˙ ) has been published. OBJECTIVE Our main hypothesis is that comparatively low levels of η E V ˙ between chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are attainable for a similar level of maximum and submaximal aerobic performance, conversely to long-established methods ( V ˙ E - V ˙ CO 2 slope and intercept). METHODS Both groups performed lung function tests, echocardiography, and cardiopulmonary exercise testing. The significance level adopted in the statistical analysis was 5%. Thus, nineteen COPD and nineteen CHF-eligible subjects completed the study. With the aim of contrasting full values of V ˙ E - V ˙ CO 2 and η V ˙ E for the exercise period (100%), correlations were made with smaller fractions, such as 90% and 75% of the maximum values. RESULTS The two groups attained matched characteristics for age (62±6 vs. 59±9 yrs, p>.05), sex (10/9 vs. 14/5, p>0.05), BMI (26±4 vs. 27±3 Kg m2, p>0.05), and peak V ˙ O 2 (72±19 vs. 74±20 %pred, p>0.05), respectively. The V ˙ E - V ˙ CO 2 slope and intercept were significantly different for COPD and CHF (27.2±1.4 vs. 33.1±5.7 and 5.3±1.9 vs. 1.7±3.6, p<0.05 for both), but η V ˙ E average values were similar between-groups (10.2±3.4 vs. 10.9±2.3%, p=0.462). The correlations between 100% of the exercise period with 90% and 75% of it were stronger for η V ˙ E (r>0.850 for both). CONCLUSION The η V ˙ E is a valuable method for comparison between cardiopulmonary diseases, with so far distinct physiopathological mechanisms, including ventilatory constraints in COPD.
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Affiliation(s)
- Gerson Gatass Orro de Campos
- Universidade Federal de Mato Grosso do Sul (UFMS) - Hospital Maria Aparecida Pedrossian (HUMAP), Laboratório de Fisiopatologia Respiratória (LAFIR), Campo Grande, MS - Brasil
| | - Leandro Steinhorst Goelzer
- Universidade Federal de Mato Grosso do Sul (UFMS) - Hospital Maria Aparecida Pedrossian (HUMAP), Laboratório de Fisiopatologia Respiratória (LAFIR), Campo Grande, MS - Brasil
| | - Tiago Rodrigues de Lemos Augusto
- Universidade Federal de Mato Grosso do Sul (UFMS) - Hospital Maria Aparecida Pedrossian (HUMAP), Laboratório de Fisiopatologia Respiratória (LAFIR), Campo Grande, MS - Brasil
| | - Gisele Walter Barbosa
- Universidade Federal de Mato Grosso do Sul (UFMS) - Hospital Maria Aparecida Pedrossian (HUMAP), Laboratório de Fisiopatologia Respiratória (LAFIR), Campo Grande, MS - Brasil
| | - Gaspar R Chiappa
- Programa de Pós-graduação em Movimento Humano e Reabilitação, Universidade Evangélica de Goiás, Anápolis, GO - Brasil
| | - Erik H van Iterson
- Seção de Cardiologia Preventiva e Reabilitação, Clínica Cleveland, MN - EUA
| | - Paulo T Muller
- Universidade Federal de Mato Grosso do Sul (UFMS) - Hospital Maria Aparecida Pedrossian (HUMAP), Laboratório de Fisiopatologia Respiratória (LAFIR), Campo Grande, MS - Brasil
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Boulmpou A, Boutou AK, Pella E, Sarafidis P, Papadopoulos CE, Vassilikos V. Cardiopulmonary Exercise Testing in Heart Failure With Preserved Ejection Fraction: Technique Principles, Current Evidence, and Future Perspectives. Cardiol Rev 2023; 31:299-317. [PMID: 36723460 DOI: 10.1097/crd.0000000000000454] [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] [Indexed: 02/02/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a multifactorial clinical syndrome involving a rather complex pathophysiologic substrate and quite a challenging diagnosis. Exercise intolerance is a major feature of HFpEF, and in many cases, diagnosis is suspected in subjects presenting with exertional dyspnea. Cardiopulmonary exercise testing (CPET) is a noninvasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic functions during maximal or submaximal exercise. The assessment is based on the principle that system failure typically occurs when the system is under stress, and thus, CPET is currently considered to be the gold standard for identifying exercise intolerance, allowing the differential diagnosis of underlying causes. CPET is used in observational studies and clinical trials in HFpEF; however, in most cases, only a few from a wide variety of CPET parameters are examined, while the technique is largely underused in everyday cardiology practice. This article discusses the basic principles and methodology of CPET and studies that utilized CPET in patients with HFpEF, in an effort to increase awareness of CPET capabilities among practicing cardiologists.
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Affiliation(s)
- Aristi Boulmpou
- From the Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Afroditi K Boutou
- Department of Respiratory Medicine, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Eva Pella
- Department of Nephrology, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christodoulos E Papadopoulos
- From the Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Vassilikos
- From the Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Shimono Y, Ishizaka S, Omote K, Nakamura K, Yasui Y, Mizuguchi Y, Takenaka S, Aoyagi H, Tamaki Y, Sato T, Kamiya K, Nagai T, Anzai T. Impact of Cardiac Power Output on Exercise Capacity and Clinical Outcome in Patients With Chronic Heart Failure. Am J Cardiol 2023; 206:4-11. [PMID: 37677882 DOI: 10.1016/j.amjcard.2023.08.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 09/09/2023]
Abstract
Less data are available regarding the impact of cardiac power output on exercise capacity or clinical outcome in patients with chronic heart failure (CHF). The study enrolled 280 consecutive patients with CHF referred for cardiopulmonary exercise testing and right-sided heart catheterization between 2013 and 2018. The primary outcome was composite of heart failure hospitalization or death. Cardiac power output was calculated as (mean arterial pressure × CO) ÷ 451. Patients with low cardiac power output (<0.53 W, n = 99) were older and had a higher brain natriuretic peptide level than patients with high cardiac power output (≥0.53W, n = 181). Cardiac power output was correlated with peak oxygen consumption (peak V̇O2), peak workload achievement, and ventilatory efficiency (V̇E/V̇CO2 slope) in cardiopulmonary exercise testing, whereas each of cardiac output or mean arterial pressure was not. There were 48 patients with events over a median follow-up period of 3.5 (interquartile range 1.0 to 6.0) years. Patients with low cardiac power output had about a 2-fold higher risk of events than those with a high cardiac power output (hazard ratio 1.97, 95% confidence interval 1.12 to 3.48). In the multivariable Cox regression, a 0.1-W decrease in cardiac power output was associated with 19% increased adverse events (hazard ratio 0.81, 95% confidence interval 0.67 to 0.99). In conclusion, cardiac power output was associated with reduced exercise capacity and poor clinical outcome, suggesting that cardiac power output is useful for risk stratification in patients with CHF. Further study is required to identify therapies targeting cardiac power output to improve the exercise capacity or clinical outcome in patients with CHF.
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Affiliation(s)
- Yui Shimono
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Kosuke Nakamura
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yutaro Yasui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Sakae Takenaka
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Aoyagi
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoji Tamaki
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Hope K, Chant B, Hinton T, Kendrick AH, Nightingale AK, Paton JFR, Hart EC. Ventilatory Efficiency Is Reduced in People With Hypertension During Exercise. J Am Heart Assoc 2023; 12:e024335. [PMID: 37345800 PMCID: PMC10356072 DOI: 10.1161/jaha.121.024335] [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: 09/06/2022] [Accepted: 03/06/2023] [Indexed: 06/23/2023]
Abstract
Background An elevated ventilatory efficiency slope during exercise (minute ventilation/volume of expired CO2; VE/VCO2 slope) is a strong prognostic indicator in heart failure. It is elevated in people with heart failure with preserved ejection, many of whom have hypertension. However, whether the VE/VCO2 slope is also elevated in people with primary hypertension versus normotensive individuals is unknown. We hypothesize that there is a spectrum of ventilatory inefficiency in cardiovascular disease, reflecting an increasingly abnormal physiological response to exercise. The aim of this study was to evaluate the VE/VCO2 slope in patients with hypertension compared with age-, peak oxygen consumption-, and sex-matched healthy subjects. Methods and Results Ramped cardiovascular pulmonary exercise tests to peak oxygen consumption were completed on a bike ergometer in 55 patients with primary hypertension and 24 normotensive controls. The VE/VCO2 slope was assessed from the onset of exercise to peak oxygen consumption. Data were compared using unpaired Student t test. Age (mean±SD, 66±6 versus 64±6 years; P=0.18), body mass index (25.4±3.5 versus 24±2.4 kg/m2; P=0.13), and peak oxygen consumption (23.2±6.6 versus 24±7.3 mL/min per kg; P=0.64) were similar between groups. The VE/VCO2 slope was elevated in the hypertensive group versus controls (31.8±4.5 versus 28.4±3.4; P=0.002). Only 27% of the hypertensive group were classified as having a normal VE/VCO2 slope (20-30) versus 71% in the control group. Conclusions Ventilatory efficiency is impaired people with hypertension without a diagnosis of heart failure versus normotensive individuals. Future research needs to establish whether those patients with hypertension with elevated VE/VCO2 slopes are at risk of developing future heart failure.
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Affiliation(s)
- Katrina Hope
- Bristol Heart Institute CardioNomics Research Group, School of Physiology, Pharmacology and Neuroscience, Biomedical SciencesUniversity of BristolBristolUnited Kingdom
| | - Ben Chant
- Bristol Heart Institute CardioNomics Research Group, School of Physiology, Pharmacology and Neuroscience, Biomedical SciencesUniversity of BristolBristolUnited Kingdom
| | - Thomas Hinton
- Bristol Heart Institute CardioNomics Research Group, School of Physiology, Pharmacology and Neuroscience, Biomedical SciencesUniversity of BristolBristolUnited Kingdom
| | - Adrian H. Kendrick
- Bristol Heart Institute CardioNomics Research Group, School of Physiology, Pharmacology and Neuroscience, Biomedical SciencesUniversity of BristolBristolUnited Kingdom
- Department of Respiratory MedicineUniversity Hospitals Bristol National Health Service Foundation TrustBristolUnited Kingdom
| | - Angus K. Nightingale
- Bristol Heart Institute CardioNomics Research Group, School of Physiology, Pharmacology and Neuroscience, Biomedical SciencesUniversity of BristolBristolUnited Kingdom
- Department of CardiologyBristol Heart Institute, University Hospitals Bristol National Health Service Foundation TrustBristolUnited Kingdom
| | - Julian F. R. Paton
- Department of Physiology, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | - Emma C. Hart
- Bristol Heart Institute CardioNomics Research Group, School of Physiology, Pharmacology and Neuroscience, Biomedical SciencesUniversity of BristolBristolUnited Kingdom
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Heart failure classification based on resting ejection fraction does not display a unique exercise response pattern. Int J Cardiol 2023; 376:157-164. [PMID: 36716970 DOI: 10.1016/j.ijcard.2023.01.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Heart failure with preserved (HFpEF), mildly reduced (HFmrEF) and reduced (HFrEF) ejection fraction (EF) remains a controversial categorization. Whether these three categories reflect a distinct pattern of exercise limitation in cardiopulmonary exercise testing (CPET) needs to be investigated. We aimed to analyze whether CPET variables differ between all heart failure categories (HF). METHODS We analyzed CPET variables of stable HFpEF (n = 123), HFmrEF (n = 31), and HFrEF (n = 153; 74 patients with and 79 patients without left ventricular assist device, LVAD) patients. The association between HF and peak oxygen consumption (VO2peak) was used as a primary outcome, while the association between HF, oxygen uptake efficiency slope (OUES), and increase of O2 pulse (ΔO2 pulse) were analyzed as secondary outcomes. RESULTS VO2peak displayed a consistent decline across all HF categories (19.8 ml ± 6.2/kg/min vs. 17.5 ± 7.9 ml/kg/min vs. 13.7 ± 4.0 ml/kg/min, p < 0.001). OUES only showed differences between HFpEF and HFrEF (1.8 ± 0.6 vs. 1.4 ± 0.5, p < 0.001) as well as HFmrEF and HFrEF (1.9 ± 0.9 vs. 1.4 ± 0.5, p = 0.004). ΔO2 pulse differed between HFpEF and HFrEF (7.7 ± 3.5 ml/beat/kg*100 vs. 5.5 ± 3.0 ml/beat/kg*100, p < 0.001) as well as HFpEF and HFmrEF (7.7 ± 3.5 ml/beat/kg*100 vs. 6.3 ± 4.1 ml/beat/kg*100, p = 0.049). Outcome variables did not differ between HFrEF with and without LVAD support (VO2peak: p = 0.364, OUES: p = 0.129, ΔO2 pulse: p = 0.564). CONCLUSIONS HF did not display a distinct CPET profile. Thus, EF-based categorization does not entirely reflect exercise limitations. CPET variables could contribute to better characterize HF phenotypes.
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Peak exercise myocardial deformation indices during cardiopulmonary exercise testing are associated with exercise capacity and ventilatory efficiency in patients with dilated cardiomyopathy. Hellenic J Cardiol 2022; 70:28-35. [PMID: 36586423 DOI: 10.1016/j.hjc.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Little is known about the exercise-induced changes in the multidimensional mechanical properties of the heart. We aimed to evaluate the myocardial deformation indices (MDI) at rest and their response at peak exercise during the same cardiopulmonary exercise testing (CPET) session, investigating their relationship to exercise capacity and ventilatory sufficiency in dilated cardiomyopathy (DCM) patients. METHODS We evaluated left ventricular (LV) function using speckle tracking imaging (STI) at rest and peak exercise during the same CPET session in 57 idiopathic DCM patients in New York Heart Association (NYHA) I-II class [54 ± 12 years, 42 males, ejection fraction (EF) 33 ± 9%]. We measured global longitudinal strain (GLS), longitudinal strain rate at systole (LSRS) and diastole (LSRD), and circumferential strain rate (CircS). RESULTS Resting GLS, LSRS, and LSRD were impaired compared with the predicted values but were improved at peak exercise (p < 0.001). All MDI at rest and/or at peak exercise were related to several CPET-derived parameters, including peak VO2, load, O2 pulse, and VE/VCO2 slope. Peak exercise LSRS > -1.10 sec-1 (AUC = 0.80, p < 0.001) and GLS > -13% (AUC = 0.81, p = 0.002) predicted impaired exercise capacity (peak VO2 < 20 ml/min/kg) and ventilatory inefficiency (VE/VCO2 slope>34). In multiple regression analysis, peak exercise LSRS and GLS were independently related to the peak VO2 (Beta = -0.39, p = 0.003) and VE/VCO2 slope (Beta = 0.35, p = 0.02), respectively. CONCLUSIONS Peak exercise LSRS and GLS in NYHA I-II DCM patients subjected to CPET were associated with aerobic exercise capacity and ventilatory efficiency. Consequently, LSRS and GLS at peak exercise, through their association with CPET-derived CV risk indices, may underline the severity of heart failure and predict future CV events in this DCM population.
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Omote K, Hsu S, Borlaug BA. Hemodynamic Assessment in Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:459-472. [PMID: 36210131 DOI: 10.1016/j.ccl.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is characterized by an inability of the heart to perfuse the body without pathologic increases in filling pressure at rest or during exertion. Right heart catheterization provides direct assessment for HF, providing the most robust and direct method to evaluate the central hemodynamic abnormalities, and serves as the gold standard to confirm or refute the presence of HFpEF. This article reviews current understanding of the best practices in the performance and interpretation of hemodynamic assessment, relates important pathophysiologic concepts to clinical care, and discusses current and evidence-based applications of hemodynamics in HFpEF.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 700 Rutland Avenue, Baltimore, MD 21205, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55905, USA.
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Harada K, Yamada S, Mamiya K, Higo S, Suzuki H, Teshima Y, Matsunaga S, Harada K, Nagao T, Shinoda N, Kato M, Marui N, Amano T, Murohara T. Cardiopulmonary exercise responses in patients with non-ischemic heart failure and a mildly reduced ejection fraction. Future Cardiol 2022; 18:627-634. [PMID: 35674279 DOI: 10.2217/fca-2021-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The cardiopulmonary response to exercise in patients with heart failure exhibiting a mildly reduced ejection fraction (41% ≤ EF ≤ 49%) remains unclear. Materials & methods: A total of 193 consecutive patients with heart failure (excluding those with coronary artery disease) who underwent cardiopulmonary exercise (CPX) tests were examined. CPX variables were compared among patients with reduced, mildly reduced, and preserved EF. Results: The CPX test responses of patients with mildly reduced EF were similar to those of patients with reduced or preserved EF; however, increases in systolic blood pressure during exercise differed significantly (32 ± 26, 50 ± 24, and 41 ± 31 mmHg, respectively; p = 0.016). Grip strength and an increase in systolic blood pressure during exercise were independently associated with peak oxygen uptake in patients with mildly reduced EF (β = 0.41, 0.35, respectively; p < 0.05). Conclusion: Measurements of grip strength and blood pressure during exercise are useful predictors of prognoses in patients with non-ischemic and mildly reduced EF.
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Affiliation(s)
- Ken Harada
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Sumio Yamada
- Department of Physical Therapy, School of Health Sciences, Nagoya University, Nagoya, 461-8673, Japan
| | - Kumiko Mamiya
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Sayaka Higo
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Hitomi Suzuki
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Yuto Teshima
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Shun Matsunaga
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Kazuhiro Harada
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Tomoyuki Nagao
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Norihiro Shinoda
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Masataka Kato
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Nobuyuki Marui
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, 455-8530, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University Hospital, Nagakute, 480-1195, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, 466-8560, Japan
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Raza F, Dharmavaram N, Hess T, Dhingra R, Runo J, Chybowski A, Kozitza C, Batra S, Horn EM, Chesler N, Eldridge M. Distinguishing exercise intolerance in early-stage pulmonary hypertension with invasive exercise hemodynamics: Rest V E /VCO 2 and ETCO 2 identify pulmonary vascular disease. Clin Cardiol 2022; 45:742-751. [PMID: 35419844 PMCID: PMC9286332 DOI: 10.1002/clc.23831] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Among subjects with exercise intolerance and suspected early-stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management. HYPOTHESIS Rest gas exchange parameters (minute ventilation to carbon dioxide production ratio: VE /VCO2 and end-tidal carbon dioxide: ETCO2 ) can identify PVD in early-stage PH. METHODS We conducted a retrospective review of 55 subjects with early-stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant. RESULTS The mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest VE /VCO2 and lower rest ETCO2 (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5-0.6*). On receiver-operating characteristic analysis to predict PVD (vs. non-PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest VE /VCO2 = 0.70* and ETCO2 = 0.73*. Based on this, optimal thresholds of rest VE /VCO2 > 40 mm Hg and rest ETCO2 < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group. CONCLUSIONS In a broad cohort of subjects with suspected early-stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (VE /VCO2 > 40 mm Hg and ETCO2 < 30 mm Hg) identify PVD.
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Affiliation(s)
- Farhan Raza
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Naga Dharmavaram
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Timothy Hess
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Ravi Dhingra
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - James Runo
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Amy Chybowski
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Callyn Kozitza
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Supria Batra
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Evelyn M. Horn
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Naomi Chesler
- University of California‐Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringIrvineCaliforniaUSA
| | - Marlowe Eldridge
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of PediatricsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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11
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Pugliese NR, Mazzola M, Madonna R, Gargani L, De Biase N, Dini FL, Taddei S, De Caterina R, Masi S. Exercise-induced pulmonary hypertension in HFpEF and HFrEF: Different pathophysiologic mechanism behind similar functional impairment. Vascul Pharmacol 2022; 144:106978. [PMID: 35301117 DOI: 10.1016/j.vph.2022.106978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 12/27/2022]
Abstract
AIMS Pathophysiological mechanisms behind cardio-pulmonary impairment in heart failure (HF) with reduced (HFrEF) and preserved (HFpEF) ejection fraction are likely different. We analysed them using combined cardiopulmonary-exercise stress echocardiography (CPET-ESE). METHODS We matched 1:1 subjects with HFrEF (n = 90) and HFpEF (n = 90) for age, sex, body mass index (BMI), peak oxygen consumption, and minute ventilation/carbon dioxide production slope. All patients underwent a symptom-limited graded ramp bicycle CPET-ESE compared with 40 age-, sex- and BMI-matched healthy controls. RESULTS During a median follow-up of 25 months, we observed 22 deaths and 80 HF hospitalisations, with similar distribution between HFpEF and HFrEF. Compared with HFrEF, HFpEF had a higher prevalence of metabolic syndrome (p = 0.02) with higher levels of high-sensitivity C-reactive protein and uric acid (p < 0.01). The multipoint mean pulmonary artery pressure/cardiac output (mPAP/CO) slope showed equally increased values in HFrEF and HFpEF (3.5 ± 1.8 and 3.7 ± 1.5 mmHg/L/min) compared with controls (1.8 ± 1.1 mmHg/L/min; p < 0.0001). During exercise, HFpEF displayed more adverse interaction of right ventricle-pulmonary artery (RV-PA; tricuspid annular plane systolic excursion/systolic pulmonary artery pressure: 0.40 ± 0.2 vs 0.47 ± 0.2 mm/mmHg in HFrEF; p < 0.01) and left atrium-left ventricle (LA-LV; LA reservoir strain/LV global longitudinal strain: 1.5 ± 0.8 vs 2.2 ± 1.1 in HFrEF; p < 0.01). The latter were independent predictors of mPAP/CO slope, along with hs-CRP (adjusted R2: 0.21; p < 0.0001). CONCLUSION Despite similar disease severity, HFpEF and HFrEF show different pathophysiological mechanisms. HFpEF is characterised by a worse LA-LV and RV-PA interaction than HFrEF, with more prevalent low-grade systemic inflammation. In HFpEF, these features may have a role in exercise-induced pulmonary hypertension.
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Affiliation(s)
| | - Matteo Mazzola
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalinda Madonna
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology - C.N.R., Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Raffale De Caterina
- Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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12
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Hager A. Minute ventilation/carbon dioxide production in congenital heart disease. Eur Respir Rev 2021; 30:30/161/200178. [PMID: 34526311 PMCID: PMC9488851 DOI: 10.1183/16000617.0178-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022] Open
Abstract
This review summarises various applications of how ventilatory equivalent (ventilatory efficiency or better still ventilatory inefficiency) and the minute ventilation (VʹE)/carbon dioxide production (VʹCO2) slope obtained from cardiopulmonary exercise testing (CPET) can be used in the diagnostic or prognostic workup of patients with congenital heart disease. The field of congenital heart disease comprises not only a very heterogeneous patient group with various heart diseases, but also various conditions in different stages of repair, as well as the different residuals seen in long-term follow-up. As such, various physiologic disarrangements must be considered in the analysis of increased VʹE/VʹCO2 slope from CPET in patients with congenital heart disease. In addition to congestive heart failure (CHF), cyanosis, unilateral pulmonary stenosis and pulmonary hypertension (PH) provide the background for this finding. The predictive value of increased VʹE/VʹCO2 slope on prognosis seems to be more important in conditions where circulatory failure is associated with failure of the systemic ventricle. In cyanotic patients, those with Fontan circulation, or those with substantial mortality from arrhythmia, the impact of VʹE/VʹCO2 on prognosis is not that important. VʹE/VʹCO2 elevation is a common finding in patients with congenital heart disease. It can be used as a sign for right-to-left shunting, unilateral pulmonary stenosis, pulmonary hypertension and circulatory failure. It is predictive for clinical worsening.https://bit.ly/33gj3NQ
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Affiliation(s)
- Alfred Hager
- Dept of Pediatric Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
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13
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Howden EJ, Foulkes S, Dillon HT, Bigaran A, Wright L, Janssens K, Comie P, Costello B, La Gerche A. Traditional markers of cardiac toxicity fail to detect marked reductions in cardiorespiratory fitness among cancer patients undergoing anti-cancer treatment. Eur Heart J Cardiovasc Imaging 2021; 22:451-458. [PMID: 33543256 DOI: 10.1093/ehjci/jeaa421] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS Left ventricular ejection fraction (LVEF) is standard of care for evaluating chemotherapy-associated cardiotoxicity, although global longitudinal strain (GLS) offers advantages. However, neither change in LVEF or GLS has been associated with short-term symptoms, functional capacity, or long-term heart failure (HF) risk. We sought to determine whether an integrative measure of cardiovascular function (VO2peak) that is strongly associated with HF risk would be more sensitive to cardiac damage induced by cancer treatment than LVEF, GLS, or cardiac biomarkers. METHODS AND RESULTS Patients (n = 206, 53 ± 13 years, 35% male) scheduled to commence anti-cancer treatment completed assessment prior to, and within 6 months after therapy. Changes in echocardiographic measures of LV function (LVEF, GLS), cardiac biomarkers (troponin and BNP), and cardiorespiratory fitness (VO2peak) were measured. LV function was normal prior to treatment (LVEF 61 ± 5%; GLS -19.4 ± 2.1), but VO2peak was only 88 ± 26% of age-predicted. After treatment, VO2peak was reduced by 7 ± 15% (equivalent of 7 years normal ageing, P < 0.0001) and the rates of functional disability (defined as VO2peak ≤ 18 mL/min/kg) almost doubled (15% vs. 26%, P = 0.016). In contrast, small, reductions in LVEF (59 ± 5% vs. 58 ± 5%, P = 0.03) and GLS (-19.4 ± 2.1 vs. -18.9 ± 2.2, P = 0.002) and an increase in troponin levels (4.0 ± 6.9 vs. 26.4 ± 26.2 ng/mL, P < 0.0001) were observed. CONCLUSION Anti-cancer treatment is associated with marked reductions in functional capacity that occur independent of reductions in LVEF and GLS. The assessment of VO2peak prior to, and following treatment may be a more sensitive means of identifying patients at increased risk of HF.
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Affiliation(s)
- Erin J Howden
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Steve Foulkes
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia.,Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Hayley T Dillon
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia.,Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Ashley Bigaran
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia.,Exercise and Nutrition Research Program, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne VIC, Australia
| | - Leah Wright
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Kristel Janssens
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Prue Comie
- Peter MaCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Oncology, Peter MacCallum Cancer Institute, The University of Melbourne, Melbourne, VIC, Australia
| | - Benedict Costello
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia.,Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - André La Gerche
- Sports Cardiology Lab, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia.,Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
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14
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Potratz M, Fox H, Rudolph V, Faber L, Dumitrescu D, Bitter T. Respiratory dyssynchrony is a predictor of prognosis in patients with hypertrophic non-obstructive cardiomyopathy. Int J Cardiol 2021; 332:105-112. [PMID: 33667581 DOI: 10.1016/j.ijcard.2021.02.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Respiratory dyssynchrony (RD) is a phenomenon that may be reflected by reduced breathing efficiency (CO2 output relative to minute ventilation, V̇E/V̇CO2 slope) or by Exercise oscillatory ventilation (EOV). Low breathing efficiency and EOV indicate a worse prognosis in chronic heart failure patients with reduced ejection fraction (HFrEF). However, only little is known about their role in other forms of structural myocardial diseases. In this study, we assessed the prognostic impact of RD in hypertrophic non-obstructive cardiomyopathy (HNCM) as a subgroup of patients with heart failure and preserved ejection fraction (HFpEF). METHODS AND RESULTS We selected n = 132 HNCM patients (pts) who underwent cardiopulmonary exercise testing (CPET) during baseline assessment. The average follow-up was 4.3 ± 3.6 years. The primary endpoint was a composite of death, heart transplantation (HTX), and implantation of a ventricular assist device (VAD). Respiratory dyssynchrony, as measured by EOV, was recorded in 18 pts. (14%), and as measured by a V̇E/V̇CO2 relationship of higher than 34 in 34 pts. (26%). In total, 22 (16.7%) pts. met the endpoint. Multivariate COX regression Analysis were made for EOV, V̇E/V̇CO2 and the combination of EOV andV̇E/V̇CO2. All parameters correlated significantly with the endpoint: EOV (hazard ratio [HR]: 3.7; p = 0.006), V̇E/V̇CO2 > 34 (HR: 5.6; p = 0.001) and EOV andV̇E/V̇CO2: (HR: 6.1; p ≤ 0.001). CONCLUSION This is the first study to demonstrate the prognostic impact of RD on pts. with HNCM, and to investigate EOV as a novel factor to aid risk stratification in HNCM.
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Affiliation(s)
- Max Potratz
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany.
| | - Henrik Fox
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Lothar Faber
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Thomas Bitter
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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15
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Maffeis C, Morris DA, Belyavskiy E, Kropf M, Radhakrishnan AK, Zach V, Rozados da Conceicao C, Trippel TD, Pieske-Kraigher E, Rossi A, Pieske B, Edelmann F. Left atrial function and maximal exercise capacity in heart failure with preserved and mid-range ejection fraction. ESC Heart Fail 2020; 8:116-128. [PMID: 33295106 PMCID: PMC7835603 DOI: 10.1002/ehf2.13143] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/28/2020] [Accepted: 11/15/2020] [Indexed: 01/02/2023] Open
Abstract
Aims Exercise intolerance is the leading manifestation of heart failure with preserved or mid‐range ejection fraction (HFpEF or HFmrEF), and left atrial (LA) function might contribute to modulating left ventricular filling and pulmonary venous pressures. We aim to assess the association between LA function and maximal exercise capacity in patients with HFpEF or HFmrEF. Methods and results Sixty‐five patients, prospectively enrolled in the German HFpEF Registry, were analysed. Inclusion criteria were New York Heart Association functional class ≥ II, left ventricular ejection fraction > 40%, structural heart disease or diastolic dysfunction, and elevated levels of N terminal pro brain natriuretic peptide (NT‐proBNP). LA function was evaluated through speckle‐tracking echocardiography by central reading in the Charité Academic Echocardiography core lab. All patients underwent maximal cardiopulmonary exercise test and were classified according to a peak VO2 cut‐off of prognostic value (14 mL/kg/min). NT‐pro‐BNP was measured. Twenty‐nine patients (45%) reached a peak VO2 < 14 mL/kg/min (mean value 12.4 ± 1.5) and 36 patients (55%) peak VO2 ≥ 14 mL/kg/min (mean value 19.4 ± 3.9). There was no significant difference in left ventricular ejection fraction (60 ± 9 vs. 59 ± 8%), left ventricular mass (109 ± 23 vs. 112 ± 32 g/m2), LA volume index (45 ± 17 vs. 47 ± 22 mL/m2), or E/e´ (13.1 ± 4.7 vs. 13.0 ± 6.0) between these groups. In contrast, all LA strain measures were impaired in patients with lower peak VO2 (reservoir strain 14 ± 5 vs. 21 ± 9%, P = 0.002; conduit strain 9 ± 2 vs. 13 ± 4%, P = 0.001; contractile strain 7 ± 4 vs. 11 ± 6%, P = 0.02; reported lower limits of normality for LA reservoir, conduit and contractile strains: 26.1%, 12.0%, and 7.7%). In linear regression analysis, lower values of LA reservoir strain were associated with impaired peak VO2 after adjustment for age, sex, body mass index, heart rhythm (sinus/AFib), and log‐NTproBNP [β 0.29, 95% confidence interval (CI) 0.02–0.30, P = 0.02], with an odds ratio 1.22 (95% CI 1.05–1.42, P = 0.01) for peak VO2 < 14 mL/kg/min for LA reservoir strain decrease after adjustment for these five covariates. Adding left ventricular ejection fraction, it did not influence the results. On the other hand, the addition of LA strain to the adjustment parameters alone described above provided a significant increase of the predictive value for lower peak VO2 values (R2 0.50 vs. 0.45, P = 0.02). With receiver operating characteristic curve analysis, we identified LA reservoir strain < 22% to have 93% sensitivity and 49% specificity in predicting peak VO2 < 14 mL/kg/min. Using this cut‐off, LA reservoir strain < 22% was associated with peak VO2 < 14 mL/kg/min in logistic regression analysis after comprehensive adjustment for age, sex, body mass index, heart rhythm, and log‐NTproBNP [odds ratio 95% CI 10.4 (1.4–74), P = 0.02]. Conclusions In this HFpEF and HFmrEF cohort, a reduction in LA reservoir strain was a sensible marker of decreased peak exercise capacity. Therefore, LA reservoir strain might be of clinical value in predicting exercise capacity in patients with HFpEF or HFmrEF.
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Affiliation(s)
- Caterina Maffeis
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy.,Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Daniel Armando Morris
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Evgeny Belyavskiy
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Martin Kropf
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Aravind Kumar Radhakrishnan
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Veronika Zach
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Cristina Rozados da Conceicao
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Tobias Daniel Trippel
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Andrea Rossi
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Institute, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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16
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Heizer J, Carbone S, Billingsley HE, VAN Tassell BW, Arena R, Abbate A, Canada JM. Left ventricular concentric remodeling and impaired cardiorespiratory fitness in patients with heart failure and preserved ejection fraction. Minerva Cardiol Angiol 2020; 69:438-445. [PMID: 32996304 DOI: 10.23736/s2724-5683.20.05295-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Left ventricular (LV) concentric remodeling refers to a process by which increased LV relative wall thickness alters myocardial geometry, resulting in reduced LV end-diastolic volume (LVEDV) and stroke volume (SV). While the degree of concentric remodeling is a negative prognostic factor in heart failure with preserved ejection fraction (HFpEF), it is not known how it contributes to cardiorespiratory fitness (CRF). METHODS We performed a retrospective analysis of patients with HFpEF who underwent treadmill single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) and cardiopulmonary exercise testing (CPX). From exercise SPECT-MPI, we recorded postexercise LVEDVi, LVESVi, SVi, LVEF, the presence and extent of perfusion defects, and perfusion reversibility. Peak oxygen consumption (VO<inf>2</inf>), the oxygen uptake efficiency slope (OUES), oxygen (O<inf>2</inf>) pulse, ventilatory efficiency (V<inf>E</inf>/VCO<inf>2</inf> slope), ventilatory anaerobic threshold, respiratory exchange ratio, exercise time, and maximum heart rate were obtained from CPX. Data are expressed as mean (±standard deviation). Univariate and multivariate linear regression was performed. RESULTS We identified 23 subjects who had completed both an exercise SPECT-MPI and a CPX. Patients were more commonly women (83%), black (65%), middle age (50 [±7.3] years), and obese (Body Mass Index [BMI] 39.7 [±6.0] kg/m2). Greater LVEDVi and LVESVi correlated positively with peak VO<inf>2</inf> (R=+0.648, P=0.001; R=+0.601, P=0.002), O<inf>2</inf> pulse (R=+0.686, P<0.001; R=+0.625, P=0.001) and OUES (R=+0.882, P<0.001; R=+0.779, P<0.001). The LVEF correlated inversely with peak VO<inf>2</inf> and OUES (R=-0.450, P=0.031; R=-0.485, P=0.035). Perfusion defect area, grade of severity, and presence of reversibility were not associated with CRF variables. CONCLUSIONS Postexercise reduced LV volumes correlate with measures of impaired CRF in patients with HFpEF, thus supporting a pathophysiologic role of concentric remodeling in impaired CRF in HFpEF.
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Affiliation(s)
- Justin Heizer
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Salvatore Carbone
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Hayley E Billingsley
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Benjamin W VAN Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA -
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17
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Beckers PJ, Gevaert AB. High intensity interval training for heart failure with preserved ejection fraction: High hopes for intense exercise. Eur J Prev Cardiol 2020; 27:1730-1732. [DOI: 10.1177/2047487320910294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Paul J Beckers
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Belgium
| | - Andreas B Gevaert
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
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18
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Donelli da Silveira A, Beust de Lima J, da Silva Piardi D, Dos Santos Macedo D, Zanini M, Nery R, Laukkanen JA, Stein R. High-intensity interval training is effective and superior to moderate continuous training in patients with heart failure with preserved ejection fraction: A randomized clinical trial. Eur J Prev Cardiol 2020; 27:1733-1743. [PMID: 31964186 DOI: 10.1177/2047487319901206] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a prevalent syndrome, with exercise intolerance being one of its hallmarks, contributing to worse quality of life and mortality. High-intensity interval training is an emerging training option, but its efficacy in HFpEF patients is still unknown. DESIGN Single-blinded randomized clinical trial. METHODS Single-blinded randomized clinical trial with exercise training 3 days per week for 12 weeks. HFpEF patients were randomly assigned to high-intensity interval training or moderate continuous training. At baseline and after 12 week follow-up, patients underwent clinical assessment, echocardiography and cardiopulmonary exercise testing (CPET). RESULTS Mean age was 60 ± 9 years and 63% were women. Both groups (N = 19) showed improved peak oxygen consumption (VO2), but high-intensity interval training patients (n = 10) had a significantly higher increase, of 22%, compared with 11% in the moderate continuous training (n = 9) individuals (3.5 (3.1 to 4.0) vs. 1.9 (1.2 to 2.5) mL·kg-1·min-1, p < 0.001). Ventilatory efficiency and other CPET measures, as well as quality of life score, increased equally in the two groups. Left ventricular diastolic function also improved with training, reflected by a significant reduction in E/e' ratio by echocardiography (-2.6 (-4.3 to -1.0) vs. -2.2 (-3.6 to -0.9) for high-intensity interval training and moderate continuous training, respectively; p < 0.01). There were no exercise-related adverse events. CONCLUSIONS This randomized clinical trial provided evidence that high-intensity interval training is a potential exercise modality for HFpEF patients, being more effective than moderate continuous training in improving peak VO2. However, the two strategies were equally effective in improving ventilatory efficiency and other CPET parameters, quality of life score and diastolic function after 3 months of training.
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Affiliation(s)
- Anderson Donelli da Silveira
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Exercise Cardiology Research Group (CardioEX), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Division of Rehabilitation, Porto Alegre, Brazil.,Post Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Vitta Exercício e Centro de Bem-estar Físico, Porto Alegre, Brazil
| | - Juliana Beust de Lima
- Exercise Cardiology Research Group (CardioEX), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Division of Rehabilitation, Porto Alegre, Brazil.,Post Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Diogo da Silva Piardi
- Post Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Débora Dos Santos Macedo
- Exercise Cardiology Research Group (CardioEX), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Division of Rehabilitation, Porto Alegre, Brazil
| | - Maurice Zanini
- Exercise Cardiology Research Group (CardioEX), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Division of Rehabilitation, Porto Alegre, Brazil
| | - Rosane Nery
- Exercise Cardiology Research Group (CardioEX), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Division of Rehabilitation, Porto Alegre, Brazil.,Post Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jari A Laukkanen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Division of Cardiology, Department of Medicine, Central Finland Hospital, Jyväskylä, Finland
| | - Ricardo Stein
- Exercise Cardiology Research Group (CardioEX), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Division of Rehabilitation, Porto Alegre, Brazil.,Post Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Vitta Exercício e Centro de Bem-estar Físico, Porto Alegre, Brazil.,School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Smith JR, Borlaug BA, Olson TP. Exercise Ventilatory Efficiency in Older and Younger Heart Failure Patients With Preserved Ejection Fraction. J Card Fail 2019; 25:278-285. [PMID: 30822511 DOI: 10.1016/j.cardfail.2019.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) exhibit pulmonary abnormalities, but the studies to date have reported wide variability in the ventilatory equivalent for carbon dioxide (V̇E/V̇CO2) slope. It is possible that aging may contribute to that variability. We sought to compare ventilatory efficiency and its components in older and younger HFpEF patients during exercise. METHODS AND RESULTS Eighteen older (O; 80 ± 4 y) and 19 younger (Y; 59 ± 7 y) HFpEF patients performed cardiopulmonary exercise testing to volitional fatigue. Measurements of arterial blood gases were used to derive VD/VT, dead space ventilation, and alveolar ventilation. V̇E/V̇CO2 slope was greater in older compared with younger HFpEF patients (O 36 ± 7vs Y 31 ± 7; P = .04). At peak exercise, older HFpEF exhibited greater VD/VT compared with younger HFpEF (O 0.37 ± 0.10vs Y 0.28 ± 0.10; P < .01), whereas PaCO2 was not different between groups (P = .58). V̇E and alveolar ventilation were similar (P > .23), but dead space ventilation was greater in older compared with younger HFpEF at peak exercise (P = .04). CONCLUSIONS Older HFpEF patients exhibit greater ventilatory inefficiency resulting from elevated physiologic dead space during peak exercise compared with younger HFpEF patients. These results suggest that aging can worsen the pathophysiologic mechanisms underlying ventilatory efficiency during exercise in HFpEF.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota.
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
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20
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Canada JM, Abbate A, Collen R, Billingsley H, Buckley LF, Carbone S, Trankle CR, Idowu MO, Kadariya D, Van Tassell B, Sanyal AJ, Siddiqui MS. Relation of Hepatic Fibrosis in Nonalcoholic Fatty Liver Disease to Left Ventricular Diastolic Function and Exercise Tolerance. Am J Cardiol 2019; 123:466-473. [PMID: 30502049 PMCID: PMC6331258 DOI: 10.1016/j.amjcard.2018.10.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 01/04/2023]
Abstract
The purpose of this study was to determine the relation between liver histology, exercise tolerance, and diastolic function in patients with nonalcoholic fatty liver disease (NAFLD). Myocardial remodeling and diastolic dysfunction have been associated with NAFLD. However, its physiological impact and relationship to the histological severity of NAFLD is not known. Cardiopulmonary exercise testing and stress echocardiography was performed in subjects with biopsy-confirmed NAFLD. Maximal aerobic exercise capacity (peak oxygen consumption [VO2]) was related to diastolic function (mitral annulus Doppler velocity e' and ratio of early diastolic filling pressure [E] to e' [E/e']) at rest and peak exercise. Autonomic dysfunction was determined from heart rate recovery after exercise. Independent predictors of cardiac function and exercise capacity were identified by multivariable regression. Thirty-six subjects (nonalcoholic fatty liver [NAFL = 15], nonalcoholic steatohepatitis [NASH = 21]) were enrolled. NASH was associated with impaired exercise capacity compared with NAFL (median peak VO2 17.0 [15.4, 18.9] vs 19.9 [17.4, 26.0], p = 001); pVO2 declined with increasing fibrosis (F0 = 22.5, F1 = 19.9, F2 = 19.0, F3 = 16.6 ml·kg-1·min-1; p = 0.01). Similarly, E/e' during exercise increased progressively with increasing fibrosis (F0 = 5.6, F1 = 6.5, F2 = 8.7, F3 = 9.8; P = 0.02). Finally, heart rate recovery, a marker of autonomic function, was blunted in those with higher fibrosis stages (F0 = 25 [20, 30], F1 = 23 [17.5, 27.0], F2 = 17 [11.8, 21.5], F3 = 11 [8.5, 18.0] beats per minute; p <0.01). Fibrosis was an independent predictor of these functional outcomes. In conclusion, NASH is associated with impaired exercise capacity and diastolic dysfunction compared with NAFL. The severity of impairment is directly related to the severity of fibrosis stage in precirrhotic stages of NAFLD.
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Affiliation(s)
- Justin McNair Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Department of Kinesiology & Health Sciences, Virginia Commonwealth University, Richmond, Virginia.
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Rebecca Collen
- Division of Gastroenterology - Hepatology Division, Virginia Commonwealth University, Richmond, Virginia
| | - Hayley Billingsley
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Leo Francis Buckley
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Salvatore Carbone
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Cory Ross Trankle
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Michael Ola Idowu
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Dinesh Kadariya
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | | | - Arun Jayant Sanyal
- Division of Gastroenterology - Hepatology Division, Virginia Commonwealth University, Richmond, Virginia
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology - Hepatology Division, Virginia Commonwealth University, Richmond, Virginia
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21
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Arena R, Ozemek C, Laddu D, Campbell T, Rouleau CR, Standley R, Bond S, Abril EP, Hills AP, Lavie CJ. Applying Precision Medicine to Healthy Living for the Prevention and Treatment of Cardiovascular Disease. Curr Probl Cardiol 2018; 43:448-483. [DOI: 10.1016/j.cpcardiol.2018.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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22
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Lanier GM, Fallon JT, Naidu SS. Role of Advanced Testing: Invasive Hemodynamics, Endomyocardial Biopsy, and Cardiopulmonary Exercise Testing. Cardiol Clin 2018; 37:73-82. [PMID: 30447718 DOI: 10.1016/j.ccl.2018.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hypertrophic cardiomyopathy affects 0.5% of the population. Advanced testing is considered, including cardiac catheterization, endomyocardial biopsy, and cardiopulmonary exercise testing. Right and left heart catheterization provides essential hemodynamic data, identifies patients who might benefit from septal reduction therapy, and assesses for comorbidities. Pathologic analysis reveals ventricular hypertrophy, myocardial disarray, and endocardial and interstitial fibrosis. Routine endomyocardial biopsy is not recommended unless other conditions that cause hypertrophy need to be ruled out. Cardiopulmonary exercise testing provides useful physiologic data, allows monitoring of the response to medication and surgical interventions, estimates prognosis, and guides referral for orthotopic heart transplantation.
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Affiliation(s)
- Gregg M Lanier
- Pulmonary Hypertension Program, Heart Failure, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion Room 110, Valhalla, NY 10595, USA.
| | - John T Fallon
- Department of Clinical Laboratories and Pathology, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion Room 106, Valhalla, NY 10595, USA
| | - Srihari S Naidu
- Hypertrophic Cardiomyopathy Program, Cardiac Catheterization Laboratory, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion Room 106, Valhalla, NY 10595, USA
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23
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Smith JR, Van Iterson EH, Johnson BD, Borlaug BA, Olson TP. Exercise ventilatory inefficiency in heart failure and chronic obstructive pulmonary disease. Int J Cardiol 2018; 274:232-236. [PMID: 30201380 DOI: 10.1016/j.ijcard.2018.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 08/13/2018] [Accepted: 09/03/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dyspnea on exertion is common to both heart failure (HF) and chronic obstructive pulmonary disease (COPD), and it is important to discriminate whether symptoms are caused by HF or COPD in clinical practice. The ventilatory equivalent for carbon dioxide (V̇E/V̇CO2) slope and V̇E intercept (a reflection of pulmonary dead space) are two candidate non-invasive indices that could be used for this purpose. Thus, we compared non-invasive indexes of ventilatory efficiency in patients with HF and preserved or reduced ejection fraction (HFpEF and HFrEF, respectively) or COPD. METHODS Patients with HFpEF (n = 21), HFrEF (n = 20), and COPD (n = 22) patients performed cardiopulmonary exercise testing to volitional fatigue. V̇E and gas exchange were measured via breath-by-breath open circuit spirometry. All data from rest to peak exercise were used to calculate V̇E/V̇CO2 slope and V̇E intercept using linear regression. Receiver operating characteristic (ROC) curves were constructed to determine optimized cutoffs for V̇E/V̇CO2 slope and V̇E intercept to discriminate HFpEF and HFrEF from COPD. RESULTS HFrEF patients had a greater V̇E/V̇CO2 slope than HFpEF and COPD patients (HFrEF: 40 ± 9; HFpEF: 32 ± 7; COPD: 32 ± 7) (p < 0.01). COPD patients had a greater V̇E intercept than HFpEF and HFrEF patients (COPD: 3.32 ± 1.66; HFpEF: 0.77 ± 1.23; HFrEF: 1.28 ± 1.19 L/min) (p < 0.01). A V̇E intercept of 2.64 L/min discriminated COPD from HF patients (AUC: 0.88, p < 0.01), while V̇E/V̇CO2 slope did not (p = 0.11). CONCLUSION These findings demonstrate that V̇E intercept, not V̇E/V̇CO2 slope, may discriminate COPD from both HFpEF and HFrEF patients.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Erik H Van Iterson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Bruce D Johnson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
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24
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Reddy YNV, Olson TP, Obokata M, Melenovsky V, Borlaug BA. Hemodynamic Correlates and Diagnostic Role of Cardiopulmonary Exercise Testing in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2018; 6:665-675. [PMID: 29803552 PMCID: PMC6076329 DOI: 10.1016/j.jchf.2018.03.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 02/23/2018] [Accepted: 03/06/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study sought to define the invasive hemodynamic correlates of peak oxygen consumption (Vo2) in both supine and upright exercise in heart failure with preserved ejection fraction (HFpEF) and evaluate its diagnostic role as a method to discriminate HFpEF from noncardiac etiologies of dyspnea (NCD). BACKGROUND Peak Vo2 is depressed in patients with HFpEF. The hemodynamic correlates of reduced peak Vo2 and its role in the clinical evaluation of HFpEF are unclear. METHODS Consecutive patients with dyspnea and normal EF (N = 206) undergoing both noninvasive upright and invasive supine cardiopulmonary exercise testing were examined. Patients with invasively verified HFpEF were compared with those with NCD. RESULTS Compared with NCD (n = 72), HFpEF patients (n = 134) displayed lower peak Vo2 during upright and supine exercise. Left heart filling pressures during exercise were inversely correlated with peak Vo2 in HFpEF, even after accounting for known determinants of O2 transport according to the Fick principle. Very low upright peak Vo2 (<14 ml/kg/min) discriminated HFpEF from NCD with excellent specificity (91%) but poor sensitivity (50%). Preserved peak Vo2 (>20 ml/kg/min) excluded HFpEF with high sensitivity (90%) but had poor specificity (49%). Intermediate peak Vo2 cutoff points were associated with substantial overlap between cases and NCD. CONCLUSIONS Elevated cardiac filling pressure during exercise is independently correlated with reduced exercise capacity in HFpEF, irrespective of body position, emphasizing its importance as a novel therapeutic target. Noninvasive cardiopulmonary testing discriminates HFpEF and NCD at high and low values, but additional testing is required for patients with intermediate peak Vo2.
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Abstract
Understanding the functional limitation in hypertrophic cardiomyopathy, the most common inherited heart disease, is challenging. In addition to the occurrence of disease-related complications, several factors are potential determinants of exercise limitation, including left ventricular hypertrophy, myocardial fiber disarray, left ventricular outflow tract obstruction, microvascular ischemia, and interstitial fibrosis. Furthermore, drugs commonly used in the daily management of these patients may interfere with exercise capacity, especially those with a negative chronotropic effect. Cardiopulmonary exercise testing can safely and objectively evaluate the functional capacity of these patients and help the physician in understanding the mechanisms that underlie this limitation. Features that reduce exercise capacity may predict progression to heart failure in these patients and even the risk of sudden cardiac death.
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26
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Guazzi M. Cardiopulmonary exercise testing and risk stratification in heart failure with reduced, midrange or preserved ejection fraction: When nomenclature may not match with pathophysiology. Eur J Prev Cardiol 2017; 25:392-394. [PMID: 29243505 DOI: 10.1177/2047487317748456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marco Guazzi
- University of Milano, Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy
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27
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Exercise testing in heart failure: a contemporary discussion in an era of novel diagnostic techniques and biomarkers. Curr Opin Cardiol 2017; 33:217-224. [PMID: 29227300 DOI: 10.1097/hco.0000000000000490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight recent advances in the field of exercise testing for patients with heart failure. RECENT FINDINGS The importance of assessment of cardiorespiratory fitness (CRF) and exercise testing in heart failure is highlighted in the consensus recommendation of the American Heart Association. Contemporary studies have validated the independent and incremental strength of CRF metrics in patients with heart failure and coronary artery disease. The use of respiratory gas analysis and imaging or hemodynamics during physical exercise is feasible and results in high prognostic utility across the continuum of heart failure. Understanding how CRF metrics complement existing and novel biomarkers and risk scores is an emerging subject of scientific inquiry. SUMMARY In the current era of personalized medicine, integrating CRF, imaging and circulating biomarkers will allow us to further develop individualized strategies for improving outcome in patients with heart failure.
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Klaassen SH, Liu LC, Hummel YM, Damman K, van der Meer P, Voors AA, Hoendermis ES, van Veldhuisen DJ. Clinical and Hemodynamic Correlates and Prognostic Value of VE/VCO 2 Slope in Patients With Heart Failure With Preserved Ejection Fraction and Pulmonary Hypertension. J Card Fail 2017; 23:777-782. [DOI: 10.1016/j.cardfail.2017.07.397] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 06/28/2017] [Accepted: 07/17/2017] [Indexed: 11/25/2022]
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Sato T, Yoshihisa A, Kanno Y, Suzuki S, Yamaki T, Sugimoto K, Kunii H, Nakazato K, Suzuki H, Saitoh SI, Ishida T, Takeishi Y. Cardiopulmonary exercise testing as prognostic indicators: Comparisons among heart failure patients with reduced, mid-range and preserved ejection fraction. Eur J Prev Cardiol 2017; 24:1979-1987. [DOI: 10.1177/2047487317739079] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yuki Kanno
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Satoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Koichi Sugimoto
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Kazuhiko Nakazato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Hitoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Shu-ichi Saitoh
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takafumi Ishida
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
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30
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Does Exercise Ventilatory Inefficiency Predict Poor Outcome in Heart Failure Patients With COPD? J Cardiopulm Rehabil Prev 2016; 36:454-459. [DOI: 10.1097/hcr.0000000000000212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Guazzi M. Cardiopulmonary exercise testing in heart failure preserved ejection fraction: Time to expand the paradigm in the prognostic algorithm. Am Heart J 2016; 174:164-6. [PMID: 26995384 DOI: 10.1016/j.ahj.2016.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/05/2016] [Indexed: 11/28/2022]
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Shafiq A, Brawner CA, Aldred HA, Lewis B, Williams CT, Tita C, Schairer JR, Ehrman JK, Velez M, Selektor Y, Lanfear DE, Keteyian SJ. Prognostic value of cardiopulmonary exercise testing in heart failure with preserved ejection fraction. The Henry Ford HospITal CardioPulmonary EXercise Testing (FIT-CPX) project. Am Heart J 2016; 174:167-72. [PMID: 26995385 DOI: 10.1016/j.ahj.2015.12.020] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/22/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although cardiopulmonary exercise (CPX) testing in patients with heart failure and reduced ejection fraction is well established, there are limited data on the value of CPX variables in patients with HF and preserved ejection fraction (HFpEF). We sought to determine the prognostic value of select CPX measures in patients with HFpEF. METHODS This was a retrospective analysis of patients with HFpEF (ejection fraction ≥ 50%) who performed a CPX test between 1997 and 2010. Selected CPX variables included peak oxygen uptake (VO2), percent predicted maximum oxygen uptake (ppMVO2), minute ventilation to carbon dioxide production slope (VE/VCO2 slope) and exercise oscillatory ventilation (EOV). Separate Cox regression analyses were performed to assess the relationship between each CPX variable and a composite outcome of all-cause mortality or cardiac transplant. RESULTS We identified 173 HFpEF patients (45% women, 58% non-white, age 54 ± 14 years) with complete CPX data. During a median follow-up of 5.2 years, there were 42 deaths and 5 cardiac transplants. The 1-, 3-, and 5-year cumulative event-free survival was 96%, 90%, and 82%, respectively. Based on the Wald statistic from the Cox regression analyses adjusted for age, sex, and β-blockade therapy, ppMVO2 was the strongest predictor of the end point (Wald χ(2) = 15.0, hazard ratio per 10%, P < .001), followed by peak VO2 (Wald χ(2) = 11.8, P = .001). VE/VCO2 slope (Wald χ(2)= 0.4, P = .54) and EOV (Wald χ(2) = 0.15, P = .70) had no significant association to the composite outcome. CONCLUSION These data support the prognostic utility of peak VO2 and ppMVO2 in patients with HFpEF. Additional studies are needed to define optimal cut points to identify low- and high-risk patients.
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Magrì D, Limongelli G, Re F, Agostoni P, Zachara E, Correale M, Mastromarino V, Santolamazza C, Casenghi M, Pacileo G, Valente F, Musumeci B, Maruotti A, Volpe M, Autore C. Cardiopulmonary exercise test and sudden cardiac death risk in hypertrophic cardiomyopathy. Heart 2016; 102:602-9. [DOI: 10.1136/heartjnl-2015-308453] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 01/02/2016] [Indexed: 11/03/2022] Open
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34
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Abnormal adrenergic activation is the major determinant of reduced functional capacity in heart failure with preserved ejection fraction. Int J Cardiol 2016; 203:900-2. [PMID: 26609687 DOI: 10.1016/j.ijcard.2015.10.224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 11/21/2022]
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35
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Magrì D, Re F, Limongelli G, Agostoni P, Zachara E, Correale M, Mastromarino V, Santolamazza C, Casenghi M, Pacileo G, Valente F, Morosin M, Musumeci B, Pagannone E, Maruotti A, Uguccioni M, Volpe M, Autore C. Heart Failure Progression in Hypertrophic Cardiomyopathy – Possible Insights From Cardiopulmonary Exercise Testing –. Circ J 2016; 80:2204-11. [DOI: 10.1253/circj.cj-16-0432] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Damiano Magrì
- Department of Clinical and Molecular Medicine, University of Rome “La Sapienza”
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo–Forlanini Hospital
| | | | - Piergiuseppe Agostoni
- “Monzino” Cardiologic Center, IRCCS
- Department of Clinical Sciences and Community Health, University of Milan
| | - Elisabetta Zachara
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo–Forlanini Hospital
| | | | | | | | - Matteo Casenghi
- Department of Clinical and Molecular Medicine, University of Rome “La Sapienza”
| | | | - Fabio Valente
- Cardiology SUN, Monaldi Hospital, II University of Naples
| | - Marco Morosin
- “Monzino” Cardiologic Center, IRCCS
- Cardiovascular Department, “Ospedali Riuniti” Trieste and Postgraduate School Cardiovascular Sciences, University of Trieste
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, University of Rome “La Sapienza”
| | - Erika Pagannone
- Department of Clinical and Molecular Medicine, University of Rome “La Sapienza”
| | - Antonello Maruotti
- Department of Economic, Political Sciences and Modern Languages “Libera Università-SS Maria Assunta”
- Centre for Innovation and Leadership in Health Sciences, University of Southampton
| | - Massimo Uguccioni
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo–Forlanini Hospital
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, University of Rome “La Sapienza”
- IRCCS–Neuromed
| | - Camillo Autore
- Department of Clinical and Molecular Medicine, University of Rome “La Sapienza”
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36
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Myers J, Arena R, Cahalin LP, Labate V, Guazzi M. Cardiopulmonary Exercise Testing in Heart Failure. Curr Probl Cardiol 2015; 40:322-72. [DOI: 10.1016/j.cpcardiol.2015.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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37
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Cornelis J, Beckers P, Vanroy C, Volckaerts T, Vrints C, Vissers D. An overview of the applied definitions and diagnostic methods to assess exercise oscillatory ventilation--a systematic review. Int J Cardiol 2015; 190:161-9. [PMID: 25918072 DOI: 10.1016/j.ijcard.2015.04.111] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/14/2015] [Indexed: 12/17/2022]
Abstract
The variable "exercise oscillatory ventilation" (EOV), assessed during cardiopulmonary exercise test (CPET), recently became a fundamental prognostic parameter in patients with heart failure. In literature, various definitions are suggested, but an uniformly accepted description to identify EOV still lacks. We performed a systematic review of the literature in order to determine the different definitions and diagnostic techniques to assess EOV. A systematic search strategy was established and executed in seven databases (PubMed, Google Scholar, Cochrane Clinical Trials, Science Direct, Pedro, Web Of Science library and Medline (Ovid)) resulting in 605 citations after de-duplication. Full-text articles (n=124) were assessed for eligibility, resulting in 75 citations. The review accounted 17,440 patients of whom 4,638 subjects presented EOV. Seven studies described EOV in a non-heart failure population accounting 168 EOV subjects. The definitions could be categorized in nine subdivisions of which four (n=43) referred to an original description. The other subdivisions were combinations of the original definitions (n=11), quantifications (n=4), computational (n=3), vaguely described (n=8) or not defined (n=6). Symptom limited maximal exercise tests were conducted to assess EOV, however the modes, protocols, software and data sampling were divers. Heterogeneity in the numerous definitions to identify EOV and the vaguely described assessment methods are hindering the evolution to a standardized uniformly accepted definition and technique to identify this abnormal breathing pattern. Unity in definition and international adopted assessment is warranted to strengthen its validity as a prognostic marker and could promote communication. It may facilitate clinical trials on pathophysiology and origin of EOV.
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Affiliation(s)
- Justien Cornelis
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium.
| | - Paul Beckers
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium; Antwerp University Hospital, Department of Cardiology, Wilrijkstraat 10, B-2650 Edegem, Belgium; University of Antwerp (Faculty of Medicine and Health Sciences), Department of Medicine, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Christel Vanroy
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium; University of Leuven (Faculty of Kinesiology and Rehabilitation Sciences), Tervuursevest 101, B-3001 Heverlee, Belgium; University of Antwerp (Faculty of Medicine and Health Sciences), Translational Neurosciences, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Tess Volckaerts
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium
| | - Christiaan Vrints
- Antwerp University Hospital, Department of Cardiology, Wilrijkstraat 10, B-2650 Edegem, Belgium; University of Antwerp (Faculty of Medicine and Health Sciences), Department of Medicine, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Dirk Vissers
- University of Antwerp (Faculty of Medicine and Health Sciences), Department of Rehabilitation Sciences and Physiotherapy, Universiteitsplein 1, CDE S0.22, B-2610 Wilrijk, Belgium
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38
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Prognostic respiratory parameters in heart failure patients with and without exercise oscillatory ventilation — A systematic review and descriptive meta-analysis. Int J Cardiol 2015; 182:476-86. [DOI: 10.1016/j.ijcard.2015.01.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/06/2015] [Accepted: 01/10/2015] [Indexed: 12/21/2022]
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39
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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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Borghi-Silva A, Labate V, Arena R, Bandera F, Generati G, Pellegrino M, Alfonzetti E, Guazzi M. Exercise ventilatory power in heart failure patients: Functional phenotypes definition by combining cardiopulmonary exercise testing with stress echocardiography. Int J Cardiol 2014; 176:1348-9. [DOI: 10.1016/j.ijcard.2014.07.268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 07/28/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
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41
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Canada JM, Van Tassell BW, Christopher S, Oddi C, Abouzaki NA, Gambill ML, Mueller G, Melchior R, Shah KB, Dinarello CA, Abbate A, Arena R. Clinical predictors of response to anakinra in patients with heart failure. Int J Cardiol 2014; 173:537-9. [PMID: 24679681 DOI: 10.1016/j.ijcard.2014.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 03/09/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Benjamin W Van Tassell
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States; Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, United States
| | - Sanah Christopher
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Claudia Oddi
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Nayef A Abouzaki
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Michael L Gambill
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - George Mueller
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Ryan Melchior
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Keyur B Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | | | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States; Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States.
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