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Zandijk AJL, Boorsma EM, Maaten JMT, Rienstra M, Voors AA. Characteristics and Clinical Outcomes of Patients Hospitalized for Acute Heart Failure Who Develop Atrial Fibrillation or Convert to Sinus Rhythm. J Card Fail 2024:S1071-9164(24)00233-1. [PMID: 39029616 DOI: 10.1016/j.cardfail.2024.05.017] [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: 12/22/2023] [Revised: 05/23/2024] [Accepted: 05/23/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia in acute heart failure (AHF), with a prevalence of approximately 35%. However, little is known about the clinical characteristics and outcomes of in-hospital conversion from AF to sinus rhythm and vice versa. METHODS In a post hoc secondary analysis of the randomized, double-blind, placebo-controlled PROTECT trial in patients with AHF, we identified 4 groups of patients: AF at admission and in-hospital conversion to sinus rhythm (n = 44); in-hospital development of AF (n = 31); persistent AF (n = 278); and continuous sinus rhythm (n = 410). RESULTS Conversion from AF to sinus rhythm (13.7%) and from sinus rhythm to AF (7.0%) occurred only in a minority of patients. Patients with AF who converted to sinus rhythm were more often classified as being in New York Heart Association class IV, had higher heart rates and higher respiratory rates at hospital admission, whereas patients who developed AF were older, more likely to be female and had the highest ejection fractions compared to continuous sinus rhythm (all P < 0.05). Conversion to sinus rhythm or development of AF occurred mainly within the first 24 hours after hospital admission. Patients with persistent AF and those who developed AF had longer median lengths of hospital stay (8 vs 7 days; P < 0.001 and 9 vs 7 days; P < 0.001, respectively), compared to those with continuous sinus rhythm. In both univariable and multivariable analyses, there was no significant association between the AF groups and the primary clinical outcomes of either 180-day all-cause mortality or 60-day death or readmission for heart failure. CONCLUSION In patients hospitalized for AHF, only few converted from AF to sinus rhythm or sinus rhythm to AF. Although development of AF or persistent AF was associated with longer lengths of hospitalization, midterm mortality and readmission rates were similar in the groups.
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Affiliation(s)
- Arietje J L Zandijk
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eva M Boorsma
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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2
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Yang L, Luo D, Huang T, Li X, Zhang G, Zhang C, Fei H. Echocardiographic assessment for cardiopulmonary function in patients with congenital heart disease-related pulmonary arterial hypertension. BMC Pulm Med 2024; 24:306. [PMID: 38944669 PMCID: PMC11214696 DOI: 10.1186/s12890-024-03113-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 06/19/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND For patients with congenital heart disease-related pulmonary arterial hypertension (CHD-PAH), cardiopulmonary exercise testing (CPET) can reflect cardiopulmonary reserve function. However, CPET may not be readily accessible for patients with high-risk conditions or limited mobility due to disability. Echocardiography, on the other hand, serves as a widely available diagnostic tool for all CHD-PAH patients. This study was aimed to identify the parameters of echocardiography that could serve as indicators of cardiopulmonary function and exercise capacity. METHODS A cohort of 70 patients contributed a total of 110 paired echocardiogram and CPET results to this study, with 1 year interval for repeated examinations. Echocardiography and exercise testing were conducted following standardized procedures, and the data were collected together with clinically relevant indicators for subsequent statistical analysis. Demographic comparisons were performed using t-tests and chi-square tests. Univariate and multivariate analyses were conducted to identify potential predictors of peak oxygen uptake (peak VO2) and the carbon dioxide ventilation equivalent slope (VE/VCO2 slope). Receiver operating characteristic (ROC) analysis was used to assess the performance of the parameters. RESULTS The ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) was found to be the only independent indicator significantly associated with both peak VO2 and VE/VCO2 slope (both p < 0.05). Additionally, left ventricular ejection fraction (LVEF) and right ventricular fractional area change (FAC) were independently correlated with the VE/VCO2 slope (both p < 0.05). TAPSE/PASP showed the highest area under the ROC curve (AUC) for predicting both a peak VO2 ≤ 15 mL/kg/min and a VE/VCO2 slope ≥ 36 (AUC = 0.91, AUC = 0.90, respectively). The sensitivity and specificity of TAPSE/PASP at the optimal threshold exceeded 0.85 for both parameters. CONCLUSIONS TAPSE/PASP may be a feasible echocardiographic indicator for evaluating exercise tolerance.
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Affiliation(s)
- Lifang Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China
| | - Dongling Luo
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China
| | - Taoran Huang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China
- Shantou University Medical College, Shantou, Guangdong Province, China
| | - Xiaoshan Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China
- Guangdong Medical University, Zhanjiang, Guangdong Province, China
| | - Guolin Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China.
| | - Caojin Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China.
| | - Hongwen Fei
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, Guangdong Province, 510100, China.
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Sun N, Fan Y, Wu B. Timely identification for long-term impairment: a step further for postpulmonary embolism patients. J Thromb Haemost 2024; 22:50-52. [PMID: 38171701 DOI: 10.1016/j.jtha.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Na Sun
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry Education, Harbin Medical University, Harbin, China
| | - Youli Fan
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry Education, Harbin Medical University, Harbin, China
| | - Bingxiang Wu
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry Education, Harbin Medical University, Harbin, China.
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Plunkett MJ, Sayegh ALC, McWilliams TJ, Sithamparanathan S, Paton JFR, Fisher JP. The skeletal muscle metaboreflex: a novel driver of ventilation, dyspnoea and pulmonary haemodynamics during exercise in pulmonary arterial hypertension. Eur Respir J 2024; 63:2300952. [PMID: 37678950 PMCID: PMC10764981 DOI: 10.1183/13993003.00952-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
Impairment of exercise capacity, predominantly limited symptomatically by dyspnoea [1], affects most patients with pulmonary arterial hypertension (PAH) despite current therapies [2], with significant implication for patients, adversely impairing health-related quality of life [3] and clinical prognosis [4]. However, the underpinning physiological mechanisms behind dyspnoea and exercise limitation remain incompletely understood. Skeletal muscle metabolic and microcirculatory deficits are present in PAH [2], and likely lead to earlier and more pronounced accumulation of metabolites during exercise. We hypothesised that this would augment the activation of group III/IV afferents responsive to metabolites present in exercising limb muscles (i.e. muscle metaboreflex), and provide a novel driver for hyperventilation [5], pulmonary arterial pressure [6] and sensations of dyspnoea [7] in PAH. During exercise, the skeletal muscle metaboreflex is enhanced in pulmonary arterial hypertension, and drives excess ventilation and increased pulmonary artery pressure, and increases the perception of dyspnoea https://bit.ly/3OG46f6
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Affiliation(s)
- Michael J Plunkett
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Respiratory Medicine, Te Toka Tumai Auckland, Te Whatu Ora Health New Zealand, Auckland, New Zealand
| | - Ana Luiza C Sayegh
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tanya J McWilliams
- Respiratory Medicine, Te Toka Tumai Auckland, Te Whatu Ora Health New Zealand, Auckland, New Zealand
| | | | - Julian F R Paton
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - James P Fisher
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Merrill RM, Gibbons IS, Barker CJ. Upper Airway-Related Symptoms According to Mental Illness and Sleep Disorders among Workers Employed by a Large Non-Profit Organization in the Mountain West Region of the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7173. [PMID: 38131725 PMCID: PMC10743120 DOI: 10.3390/ijerph20247173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
The relationships between selected upper airway-related symptoms (speech disturbances, voice disorders, cough, and breathing abnormalities) and mental illness and sleep disorders have been previously demonstrated. However, these relationships have not been compared in a single study with consideration of potential confounding variables. The current research incorporates a descriptive study design of medical claims data for employees (~21,362 per year 2017-2021) with corporate insurance to evaluate the strength of these relationships, adjusting for demographic variables and other important confounders. The upper airway-related symptoms are each significantly and positively associated with several mental illnesses and sleep disorders, after adjusting for demographic and other potential confounders. The rate of any mental illness is 138% (95% CI 93-195%) higher for speech disturbances, 55% (95% CI 28-88%) higher for voice disorders, 28% (95% CI 22-34%) higher for cough, and 58% (95% CI 50-66%) higher for breathing abnormalities, after adjustment for the confounding variables. Confounding had significant effects on the rate ratios involving cough and breathing abnormalities. The rate of any sleep disorder is 78% (95% CI 34-136%) higher for speech disturbances, 52% (95% CI 21-89%) higher for voice disorders, 34% (95% CI 27-41%) higher for cough, and 172% (95% CI 161-184%) higher for breathing abnormalities, after adjustment for the confounding variables. Confounding had significant effects on each of the upper airway-related symptoms. Rates of mental illness and sleep disorders are positively associated with the number of claims filed for each of the upper airway-related symptoms. The comorbid nature of these conditions should guide clinicians in providing more effective treatment plans that ultimately yield the best outcome for patients.
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Affiliation(s)
- Ray M. Merrill
- Department of Public Health, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA; (I.S.G.); (C.J.B.)
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6
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Vézina FA, Bouchard PA, Breton-Gagnon É, Dion G, Viglino D, Roy P, Bilodeau L, Provencher S, Denault MH, Saey D, Lellouche F, Maltais F. Automated O 2 Titration Alone or With High-Flow Nasal Cannula During Walking Exercise in Chronic Lung Diseases. Respir Care 2023; 69:respcare.10810. [PMID: 37491073 PMCID: PMC10753602 DOI: 10.4187/respcare.10810] [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: 07/27/2023]
Abstract
BACKGROUND Exercise-induced O2 desaturation contributes to dyspnea and exercise intolerance in various respiratory diseases. This study assessed whether automated O2 titration was superior to fixed-flow O2 to improve exertional dyspnea and walking exercise endurance. We also aimed at evaluating possible additive effects of high-flow nasal cannula coupled with automated O2 titration on these outcomes. METHODS Subjects with chronic respiratory diseases and exercise-induced desaturation performed a 3-min constant-speed shuttle test (CSST) and an endurance shuttle walking test (ESWT) with either (1) fixed-flow O2, (2) automated O2 titration targeting an SpO2 of 94% (± 2%), and (3) automated O2 titration + high-flow nasal cannula according to a randomized sequence. The main outcome was Borg dyspnea score at the end of the 3-min CSST. Secondary outcomes included endurance time and dyspnea during ESWT and oxygenation status during exercise. RESULTS Ten subjects with COPD, 10 with interstitial lung disease, 5 with pulmonary hypertension, and 3 with cystic fibrosis completed the study. Compared to fixed-flow O2, automated O2 titration did not reduce dyspnea at the end of the 3-min CSST. Endurance time during the ESWT was prolonged with automated O2 titration (mean difference 298 [95% CI 205-391] s, P < .001), and dyspnea at isotime was reduced. No further improvement was noted when high-flow nasal cannula was added to automated O2 titration. Compared to fixed-flow O2, O2 flows were higher with automated O2 titration, resulting in better oxygenation. CONCLUSIONS Automated O2 titration was superior to fixed-flow O2 to alleviate dyspnea and improve exercise endurance during the ESWT in subjects with a variety of chronic respiratory diseases. Adding high-flow nasal cannula to automated O2 titration provided no further benefits.
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Affiliation(s)
- Felix-Antoine Vézina
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada; and Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec City, Québec, Canada
| | - Pierre-Alexandre Bouchard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Émilie Breton-Gagnon
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Geneviève Dion
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Damien Viglino
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada; and Université Grenoble Alpes, Laboratoire Hypoxie-Physiopathologie HP2 INSERM U1300, Grenoble, France
| | - Pascalin Roy
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Lara Bilodeau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Marie-Hélène Denault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Didier Saey
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - François Lellouche
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada.
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7
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Farmakis IT, Valerio L, Barco S, Alsheimer E, Ewert R, Giannakoulas G, Hobohm L, Keller K, Mavromanoli AC, Rosenkranz S, Morris TA, Konstantinides SV, Held M, Dumitrescu D. Cardiopulmonary exercise testing during follow-up after acute pulmonary embolism. Eur Respir J 2023; 61:2300059. [PMID: 36958742 PMCID: PMC10249018 DOI: 10.1183/13993003.00059-2023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/03/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) may provide prognostically valuable information during follow-up after pulmonary embolism (PE). Our objective was to investigate the association of patterns and degree of exercise limitation, as assessed by CPET, with clinical, echocardiographic and laboratory abnormalities and quality of life (QoL) after PE. METHODS In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3- and 12-month follow-ups, including CPET. We defined cardiopulmonary limitation as ventilatory inefficiency or insufficient cardiocirculatory reserve. Deconditioning was defined as peak O2 uptake (V'O2 ) <80% with no other abnormality. RESULTS Overall, 396 patients were included. At 3 months, prevalence of cardiopulmonary limitation and deconditioning was 50.1% (34.7% mild/moderate; 15.4% severe) and 12.1%, respectively; at 12 months, it was 44.8% (29.1% mild/moderate; 15.7% severe) and 14.9%, respectively. Cardiopulmonary limitation and its severity were associated with age (OR per decade 2.05, 95% CI 1.65-2.55), history of chronic lung disease (OR 2.72, 95% CI 1.06-6.97), smoking (OR 5.87, 95% CI 2.44-14.15) and intermediate- or high-risk acute PE (OR 4.36, 95% CI 1.92-9.94). Severe cardiopulmonary limitation at 3 months was associated with the prospectively defined, combined clinical-haemodynamic end-point of "post-PE impairment" (OR 6.40, 95% CI 2.35-18.45) and with poor disease-specific and generic health-related QoL. CONCLUSIONS Abnormal exercise capacity of cardiopulmonary origin is frequent after PE, being associated with clinical and haemodynamic impairment as well as long-term QoL reduction. CPET can be considered for selected patients with persisting symptoms after acute PE to identify candidates for closer follow-up and possible therapeutic interventions.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Eva Alsheimer
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ralf Ewert
- Clinic for Internal Medicine, Greifswald University Hospital, Greifswald, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Matthias Held
- Department of Pulmonary Medicine, KWM Missio Clinic, Würzburg, Germany
- These authors contributed equally and share last authorship
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
- These authors contributed equally and share last authorship
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Aitken CR, Stewart GM, Walsh JR, Palmer T, Adams L, Sabapathy S, Morris NR. Exertional dyspnea responses to the Dyspnea Challenge in heart failure: Comparison to chronic obstructive pulmonary disease. Heart Lung 2023; 58:108-115. [PMID: 36455422 DOI: 10.1016/j.hrtlng.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In heart failure (HF), exertional dyspnea is a common symptom, but validated field-based tests for its measurement are limited. The Dyspnea Challenge is a two-minute uphill treadmill walk designed to measure exertional dyspnea in cardiopulmonary disease. OBJECTIVES The purpose of this study was to establish the test-retest reliability of the Dyspnea Challenge in HF and to compare the exercise responses to a group with chronic obstructive pulmonary disease (COPD). METHODS The study was an experimental, single-blind, randomized, multi-site project that recruited individuals with HF (New York Heart Association I-III) and COPD (Global Initiative for Chronic Obstructive Lung Disease II-IV). Participants completed two visits. On the first visit, participants performed two six-minute walk tests (6MWT), followed by two to three Dyspnea Challenges to calculate treadmill speed and gradient. At Visit Two, participants performed two separate Dyspnea Challenges, with one including measures of pulmonary gas exchange and central hemodynamics. RESULTS Twenty-one individuals with HF (10 female; 66±11years; ejection fraction:45.3 ± 6.1%; six-minute distance(6MWD) 520 ± 97 m), and 25 COPD (11 female; 68 ± 10 yr; forced expiratory volume in 1 s:47.6 ± 11.5%; 6MWD: 430 ± 101 m). Intraclass correlation coefficients demonstrated excellent test-retest reliability for HF (0.94, P<.01) and COPD (0.95, P<.01). While achieving similar end-exercise exertional dyspnea intensities (P=.60), the HF group walked at a higher average speed (4.2 ± 0.8 vs. 3.5 ± 0.8km·h-1) and gradient (10.3 ± 2.8 vs. 9.6 ± 2.8%) and a greater oxygen uptake (P<.01) and ventilation (P<.01) than those with COPD. While achieving similar cardiac outputs (P=.98), stroke volumes (P=.97), and heart rates (P=.83), those with HF displayed a larger arteriovenous oxygen difference (P<.01), while those with COPD exhibited greater decreases in inspiratory capacity (P=.03), arterial oxygen saturation (P=.02), and breathing reserve (P<.01). CONCLUSIONS The Dyspnea Challenge is a reliable test-retest measure of exertional dyspnea in HF. Typical to their pathologies, HF seemed limited by an inadequate modulation of cardiac output, while ventilatory constraints hampered those with COPD.
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Affiliation(s)
- Craig R Aitken
- School of Health Sciences and Social Work, Southport, QLD. Australia; Allied Health Research Collaborative. The Prince Charles Hospital. Brisbane. QLD. Australia; Heart Lung Institute. The Prince Charles Hospital Brisbane. QLD. Australia.
| | - Glenn M Stewart
- School of Health Sciences and Social Work, Southport, QLD. Australia; Allied Health Research Collaborative. The Prince Charles Hospital. Brisbane. QLD. Australia; Heart Lung Institute. The Prince Charles Hospital Brisbane. QLD. Australia; Menzies Health Institute of Queensland, Griffith University, Southport, QLD. Australia
| | - James R Walsh
- School of Health Sciences and Social Work, Southport, QLD. Australia; Allied Health Research Collaborative. The Prince Charles Hospital. Brisbane. QLD. Australia; Heart Lung Institute. The Prince Charles Hospital Brisbane. QLD. Australia
| | - Tanya Palmer
- School of Health Sciences and Social Work, Southport, QLD. Australia
| | - Lewis Adams
- School of Health Sciences and Social Work, Southport, QLD. Australia
| | - Surendran Sabapathy
- School of Health Sciences and Social Work, Southport, QLD. Australia; Menzies Health Institute of Queensland, Griffith University, Southport, QLD. Australia
| | - Norman R Morris
- School of Health Sciences and Social Work, Southport, QLD. Australia; Allied Health Research Collaborative. The Prince Charles Hospital. Brisbane. QLD. Australia; Heart Lung Institute. The Prince Charles Hospital Brisbane. QLD. Australia; Menzies Health Institute of Queensland, Griffith University, Southport, QLD. Australia
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9
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Didden E, Lee E, Wyckmans J, Quinn D, Perchenet L. Time to diagnosis of pulmonary hypertension and diagnostic burden: A retrospective analysis of nationwide US healthcare data. Pulm Circ 2023; 13:e12188. [PMID: 36694845 PMCID: PMC9843478 DOI: 10.1002/pul2.12188] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 12/21/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023] Open
Abstract
The main aim of this analysis was to investigate time from symptom onset (chronic unexplained dyspnoea [CUD]) to diagnosis of Group 1 pulmonary hypertension (PH)-pulmonary arterial hypertension (PAH)-and to characterize healthcare resource utilization leading up to diagnosis using a nationwide US claims and an electronic health record (EHR) database from Optum©. Eligible patients were ≥18 years old at first CUD diagnosis (index event) and had a PAH diagnosis on or after index date. Based on administrative codes, PAH was defined as right heart catheterization (RHC), ≥ 2 PAH diagnoses (1 within a year of RHC), and ≥1 post-RHC prescription for PAH treatment. All values are median (1st quartile-3rd quartile) unless otherwise stated. Of 854,722 patients with CUD in the claims database, 582 (0.1%) had PAH. Time from CUD to PAH diagnosis was 2.26 (0.73-4.22) years. PAH patients experienced 3 (2-4) transthoracic echocardiograms (TTEs), 6 (3-12) specialist visits, and 2 (1-4) hospitalizations during the diagnostic interval. Almost one-third of patients (29%) waited 10 months or more to have a TTE. Findings from the EHR database were broadly similar. Resource utilization during the diagnostic interval was also analyzed in an overall PH cohort: findings were generally similar to the PAH cohort (2 [1-3] TTEs, 4 [2-9] specialist visits and 2 [1-4] hospitalizations). These data indicate a delay in the diagnostic pathway for PAH, and illustrate the burden associated with PAH diagnosis.
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Affiliation(s)
| | - Eileen Lee
- Janssen Research & DevelopmentSpring HousePennsylvaniaUSA
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Farmakis IT, Keller K, Barco S, Konstantinides SV, Hobohm L. From acute pulmonary embolism to post-pulmonary embolism sequelae. VASA 2023; 52:29-37. [PMID: 36444524 DOI: 10.1024/0301-1526/a001042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aim of this narrative review is to summarize the functional and hemodynamic implications of acute PE and PE sequelae, namely the post-PE syndrome. Briefly, we will first describe the epidemiology, diagnostic procedures, and therapeutic approaches of acute PE. Then, we will provide a definition of the post-PE syndrome and present the so far accumulated evidence regarding its epidemiology and the implications that arise for further diagnosis and treatment. Lastly, we will explore the most devastating long-term complication of PE, namely chronic thromboembolic pulmonary hypertension (CTEPH), and recent advances in its management.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center Mainz, Germany.,Department of Sports Medicine, Internal Medicine VII, Medical Clinic, University Hospital Heidelberg, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Department of Angiology, University Hospital Zurich, Switzerland
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center Mainz, Germany
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11
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Evaluation of primary and accessory respiratory muscles and their influence on exercise capacity and dyspnea in pulmonary arterial hypertension. Heart Lung 2023; 57:173-179. [PMID: 36219922 DOI: 10.1016/j.hrtlng.2022.09.015] [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: 07/08/2022] [Revised: 08/11/2022] [Accepted: 09/25/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Skeletal and respiratory muscle disfunction has been described in pulmonary arterial hypertension (PAH), however, involvement of accessory respiratory muscles and their association with symptomatology in PAH is unclear. OBJECTIVES To assess the primary and accessory respiratory muscles and their influence on exercise tolerance and dyspnea. METHODS 27 patients and 27 healthy controls were included. Serratus anterior (SA), pectoralis muscles (PM) and sternocleidomastoid (SCM) muscle strength were evaluated as accessory respiratory muscles, maximal inspiratory (MIP) and expiratory pressures (MEP) as primary respiratory muscles, and quadriceps as peripheral muscle. Exercise capacity was evaluated with 6-min walk test (6MWT), dyspnea with modified Medical Council Research (MMRC) and London Chest Activity of Daily Living (LCADL) scales. RESULTS All evaluated muscles, except SCM, and 6MWT were decreased in patient group (p < 0.01). SA was the most affected muscle among primary and accessory respiratory muscles (Cohen's-d = 1.35). All evaluated muscles significantly correlated to 6MWT (r = 0.428-0.525). A multivariate model including SA, SCM and MIP was the best model for predicting 6MWT (R = 0.606; R2 = 0.368; p = 0.013) and SA strength had the most impact on the 6MWT (B = 1.242; β = 0.340). None of the models including respiratory muscles were able to predict dyspnea, however PM and SA strength correlated to LCADL total (r = -0.493) and MMRC (r = -0.523), respectively. CONCLUSION SCM may be excessively used in PAH since it retains its strength. Considering the relationship of accessory respiratory muscles with exercise tolerance and dyspnea, monitoring the strength of these muscles in the clinical practice may help providing better management for PAH.
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12
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Mitrouska I, Bolaki M, Vaporidi K, Georgopoulos D. Respiratory system as the main determinant of dyspnea in patients with pulmonary hypertension. Pulm Circ 2022; 12:e12060. [PMID: 35506092 PMCID: PMC9053013 DOI: 10.1002/pul2.12060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/10/2022] Open
Abstract
Dyspnea on exertion is a devastating symptom, commonly observed in patients with pulmonary hypertension (PH). The pathophysiology of dyspnea in these patients has been mainly attributed to cardiovascular determinants and isolated abnormalities of the respiratory system during exercise, neglecting the contribution of the control of the breathing system. The aim of this review is to provide a novel approach to the interpretation of dyspnea in patients with PH, focused on the impact of the control of the breathing system during exercise. Exercise through multiple mechanisms affects the (1) ventilatory demands, as dictated by respiratory center activity, (2) actual ventilation, and (3) metabolic hyperbola. In patients with PH, exertional dyspnea can be explained by exercise-induced alterations in these variables. Compared to healthy subjects, at a given CO2 production during exercise, ventilatory demands in patients with PH are higher due to metabolic acidosis (early reaching the anaerobic threshold), hypoxemia, and excessive upward movement of metabolic hyperbola owing to abnormal exercise response of dead space to tidal volume ratio. Simultaneously, dynamic hyperinflation and respiratory muscles weakness decreases the actual ventilation for a given respiratory center activity, creating a dissociation between demands and ventilation. Consequently, a progressive increase in ventilatory demands and respiratory center activity occurs during exercise. The forebrain projection of high respiratory center activity causes exertional dyspnea despite the relatively low ventilation and significant ventilatory reserve. This type of analysis suggests that the respiratory system is the main determinant of exertional dyspnea in patients with PH, with the cardiovascular system being an indirect contributor.
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Affiliation(s)
- Ioanna Mitrouska
- Department of Pulmonary Medicine, University Hospital of Heraklion, Medical SchoolUniversity of CreteHeraklionCreteGreece
| | - Maria Bolaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical SchoolUniversity of CreteHeraklionCreteGreece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical SchoolUniversity of CreteHeraklionCreteGreece
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical SchoolUniversity of CreteHeraklionCreteGreece
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13
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Anand A, Sharma R, Srivastava N, Ramakrishnan S. J receptor activity in idiopathic pulmonary hypertension and its expected change in the presence of pulmonary bed vasodilators. Respir Physiol Neurobiol 2021; 294:103742. [PMID: 34298167 DOI: 10.1016/j.resp.2021.103742] [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: 04/19/2021] [Revised: 06/17/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022]
Abstract
Juxtapulmonary receptors (J) lying in the lung parenchyma are stimulated naturally by any condition that produces interstitial oedema, transient increases in interstitial volume and pressure or raised pulmonary capillary pressure. There is no information available about the level of their stimulation in patients with idiopathic pulmonary hypertension (IPH) who have high levels of pulmonary artery systolic pressures. The aim of the present study therefore was to find the level of these receptors activity in these patients at their prevailing pulmonary artery systolic pressures. This was done by the established method of determining the dose of i.v. lobeline that gives rise to threshold levels of sensations in the upper chest areas and accelerates respiration. In IPH patients it was found to be as high as 31.6 ± 5.6 μg/kg i.e., twice as much as that known for healthy individuals which is 15 μg/kg. This shows an enhanced stimulation of J receptors in IPH patients. Expectedly when pulmonary artery systolic pressure falls with pulmonary bed vasodilator medication given to IPH patients, a reduction in the natural stimulus of J receptors would also occur leading to a fall in their activity and hence that of the quantum of their reflexes of respiratory acceleration and inhibition of exercise. This finding provides the first insight of a neural mechanism that could be influenced to produce its effects when pulmonary artery systolic pressure falls by pulmonary vasodilator medication.
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Affiliation(s)
- Ashima Anand
- Exertional Breathlessness Studies Laboratory, Vallabhbhai Patel Chest Institute, Delhi, India.
| | - Rajeev Sharma
- Department of Cardiology, All India Institute of Medical Sciences, Delhi, India
| | - Niraj Srivastava
- Exertional Breathlessness Studies Laboratory, Vallabhbhai Patel Chest Institute, Delhi, India
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14
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Gelzinis TA. Pulmonary Hypertension in 2021: Part I-Definition, Classification, Pathophysiology, and Presentation. J Cardiothorac Vasc Anesth 2021; 36:1552-1564. [PMID: 34344595 DOI: 10.1053/j.jvca.2021.06.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022]
Abstract
The World Symposium on Pulmonary Hypertension (WSPH) was organized by the World Health Organization in 1973 in response to an increase in pulmonary arterial hypertension in Europe caused by aminorex, an appetite suppressant. The mandate of this meeting was to review the latest clinical and scientific research and to formulate recommendations to improve the diagnosis and management of pulmonary hypertension (PH).1 Since 1998, the WSPH has met every five years and in 2018, the sixth annual WSPH revised the hemodynamic definition of PH. This two-part series will review the updated definition, classification, pathophysiology, presentation, diagnosis, management, and perioperative management of patients with PH. In the first part of this series, the definition, classification, pathophysiology, and presentation will be reviewed.
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15
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Sree Raman K, Shah R, Stokes M, Walls A, Woodman RJ, Perry R, Walker JG, Proudman S, De Pasquale CG, Celermajer DS, Selvanayagam JB. Right ventricular myocardial deoxygenation in patients with pulmonary artery hypertension. J Cardiovasc Magn Reson 2021; 23:22. [PMID: 33678188 PMCID: PMC7938464 DOI: 10.1186/s12968-020-00694-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/09/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In pulmonary arterial hypertension (PAH), progressive right ventricular (RV) dysfunction is believed to be largely secondary to RV ischaemia. A recent pilot study has demonstrated the feasibility of Oxygen-sensitive (OS) cardiovascular magnetic resonance (CMR) to detect in-vivo RV myocardial oxygenation. The aims of the present study therefore, were to assess the prevalence of RV myocardial ischaemia and relationship with RV myocardial interstitial changes in PAH patients with non-obstructive coronaries, and corelate with functional and haemodynamic parameters. METHODS We prospectively recruited 42 patients with right heart catheter (RHC) proven PAH and 11 healthy age matched controls. The CMR examination involved standard functional imaging, OS-CMR imaging and native T1 mapping. An ΔOS-CMR signal intensity (SI) index (stress/rest signal intensity) was acquired at RV anterior, RV free-wall and RV inferior segments. T1 maps were acquired using Shortened Modified Look-Locker Inversion recovery (ShMOLLI) at the inferior RV segment. RESULTS The inferior RV ΔOS-CMR SI index was significantly lower in PAH patients compared with healthy controls (9.5 (- 7.4-42.8) vs 12.5 (9-24.6)%, p = 0.02). The inferior RV ΔOS-CMR SI had a significant correlation to RV inferior wall thickness (r = - 0.7, p < 0.001) and RHC mean pulmonary artery pressure (mPAP) (r = - 0.4, p = 0.02). Compared to healthy controls, patients with PAH had higher native T1 in the inferior RV wall: 1303 (1107-1612) vs 1232 (1159-1288)ms, p = 0.049. In addition, there was a significant difference in the inferior RV T1 values between the idiopathic PAH and systemic sclerosis associated PAH patients: 1242 (1107-1612) vs 1386 (1219-1552)ms, p = 0.007. CONCLUSION Blunted OS-CMR SI suggests the presence of in-vivo microvascular RV dysfunction in PAH patients. The native T1 in the inferior RV segments is significantly increased in the PAH patients, particularly among the systemic sclerosis associated PAH group.
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Affiliation(s)
- Karthigesh Sree Raman
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia
- Cardiac Imaging Research, South Australian Health & Medical Research Institute, Adelaide, Australia
- Department of Medicine (Northland Campus), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ranjit Shah
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia
- Cardiac Imaging Research, South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Michael Stokes
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Angela Walls
- Clinical Research and Imaging Centre, South Australian Health & Medical Research Institute, Auckland, Australia
| | - Richard J Woodman
- Flinders Centre of Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Rebecca Perry
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia
- Cardiac Imaging Research, South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Jennifer G Walker
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital and Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Carmine G De Pasquale
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Joseph B Selvanayagam
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia.
- Cardiac Imaging Research, South Australian Health & Medical Research Institute, Adelaide, Australia.
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16
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Matsuoka Y, Taniguchi Y, Miwa K, Sumimoto K, Tsuboi Y, Onishi H, Yanaka K, Emoto N, Hirata K. Assessment of oxygenation after balloon pulmonary angioplasty for patients with inoperable chronic thromboembolic pulmonary hypertension. Int J Cardiol 2021; 333:188-194. [PMID: 33684382 DOI: 10.1016/j.ijcard.2021.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension would be promising. However, some patients showed residual dyspnea or symptoms, despite normalized hemodynamics. We aimed to clarify the clinical impact of oxygenation parameters on BPA outcome. METHOD Ninety-nine consecutive patients who underwent BPA from September 2011 to December 2019 were enrolled. We evaluated hemodynamics with right heart catheterization, arterial blood gas examination, New York Heart Association functional class (NYHA-FC), respiratory function tests, nocturnal oximetry, and exercise capacity (6-min walk test and cardiopulmonary exercise testing) at baseline and after BPA. RESULT Nearly normal hemodynamics was achieved after BPA (mean pulmonary artery pressure (PAP): 37.5 ± 10.0 to 20.6 ± 4.9 mmHg, p < 0.01). Oxygenation slightly improved (partial pressure of arterial oxygen; 61.5 ± 12.3 to 67.7 ± 12.7 mmHg, p < 0.01). Exertional desaturation remained unchanged (-8.1 ± 4.8 to -7.8 ± 5.1, p = 0.59), and this was associated with residual symptom (NYHA-FC ≥ 2) after BPA (OR 0.591, 95% CI 0.416-0.840, p = 0.003) in multivariate regression analyses. Lower vital capacity (r2 = 0.03, p = 0.01), higher mean PAP (r2 = 0.08, p = 0.02), and higher minute ventilation/carbon dioxide production (VE/VCO2) slope (r2 = 0.18, p < 0.01), the marker of ventilatory inefficiency, were correlated with exertional desaturation after BPA in multivariate linear analyses. CONCLUSION Although hemodynamics nearly normalized, oxygenation did not. Moreover, exertional desaturation remained unchanged. This might cause residual symptom after BPA. Residual pulmonary hypertension suggesting incurable arteriopathy, and higher VE/VCO2 slope suggesting ventilation-perfusion mismatch might be related to exertional desaturation. Domiciliary oxygen therapy should be continued, if necessary.
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Affiliation(s)
- Yoichiro Matsuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Keisuke Miwa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Keiko Sumimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yasunori Tsuboi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Lewis RA, Armstrong I, Bergbaum C, Brewis MJ, Cannon J, Charalampopoulos A, Church AC, Coghlan JG, Davies RJ, Dimopoulos K, Elliot C, Gibbs JSR, Gin-Sing W, Haji G, Hameed AG, Howard LS, Johnson MK, Kempny A, Kiely DG, Lo Giudice F, McCabe C, Peacock AJ, Peleyeju O, Pepke-Zaba J, Polwarth G, Price L, Sabroe I, Schreiber BE, Sheares K, Taboada D, Thompson AAR, Toshner MR, Wanjiku I, Wort SJ, Yorke J, Condliffe R. EmPHasis-10 health-related quality of life score predicts outcomes in patients with idiopathic and connective tissue disease-associated pulmonary arterial hypertension: results from a UK multicentre study. Eur Respir J 2021; 57:13993003.00124-2020. [PMID: 32631835 PMCID: PMC7905834 DOI: 10.1183/13993003.00124-2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/28/2020] [Indexed: 01/09/2023]
Abstract
Health-related quality of life (HRQoL) scores assess symptom burden in pulmonary arterial hypertension (PAH) but data regarding their role in prognostication and risk stratification are limited. We assessed these relationships using the emPHasis-10 HRQoL measure.1745 patients with idiopathic PAH (IPAH), drug-induced PAH (DPAH), heritable PAH (HPAH) (collectively "(I/D/H)PAH"), or connective tissue disease-associated PAH (CTD-PAH), who had completed emPHasis-10 questionnaires at one of six UK referral centres between 2014 and 2017, were identified. Correlations with exercise capacity and World Health Organization (WHO) functional class were assessed, and exploratory risk stratification thresholds were tested.Moderate correlations were seen between emPHasis-10 scores and 6-min walk distance (r=-0.546), incremental shuttle walk distance (r=-0.504) and WHO functional class (r=0.497) (all p<0.0001). Distribution of emPHasis-10 score differed significantly between each WHO functional class (all p<0.0001). On multivariate analysis, emPHasis-10 score, but not WHO functional class, was an independent predictor of mortality. In a risk stratification approach, scores of 0-16, 17-33 and 34-50 identified incident patients with 1-year mortality of 5%, 10% and 23%, respectively. Survival of patients in WHO functional class III could be further stratified using an emPHasis-10 score ≥34 (p<0.01). At follow-up, patients with improved emPHasis-10 scores had improved exercise capacity (p<0.0001) and patients who transitioned between risk groups demonstrated similar survival to patients originally in those risk groups.The emPHasis-10 score is an independent prognostic marker in patients with (I/D/H)PAH or CTD-PAH. It has utility in risk stratification in addition to currently used parameters. Improvement in emPHasis-10 score is associated with improved exercise capacity.
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Affiliation(s)
- Robert A Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Iain Armstrong
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Carmel Bergbaum
- National Pulmonary Hypertension Service, Royal Brompton Hospital and Imperial College, London, UK
| | - Melanie J Brewis
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - John Cannon
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - A Colin Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - J Gerry Coghlan
- Pulmonary Hypertension Unit, Royal Free Hospital, London, UK
| | - Rachel J Davies
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton Hospital and Imperial College, London, UK
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - J Simon R Gibbs
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Wendy Gin-Sing
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Gulam Haji
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Abdul G Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Luke S Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Martin K Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Aleksander Kempny
- National Pulmonary Hypertension Service, Royal Brompton Hospital and Imperial College, London, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital and Imperial College, London, UK
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | | | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Gary Polwarth
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Laura Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital and Imperial College, London, UK
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Karen Sheares
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Mark R Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Ivy Wanjiku
- Pulmonary Hypertension Unit, Royal Free Hospital, London, UK
| | - S John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital and Imperial College, London, UK
| | - Janelle Yorke
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
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18
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Palliative Care in Pulmonary Arterial Hypertension. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Mantoo M, Makkar N, Mahidhar J, Karuru U, Kumar D, Seth S. Outcome of pulmonary hypertension in pregnancy in contemporary era: A case-based narrative review. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.4103/jpcs.jpcs_49_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Ross L, Stevens W, Wilson M, Strickland G, Walker J, Sahhar J, Ngian GS, Roddy J, Major G, Proudman S, Baron M, Nikpour M. Can Patient-Reported Symptoms Be Used to Measure Disease Activity in Systemic Sclerosis? Arthritis Care Res (Hoboken) 2020; 72:1459-1465. [PMID: 31421031 DOI: 10.1002/acr.24053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/13/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the association between patient-reported symptoms and changes in disease activity over time in systemic sclerosis (SSc). METHODS Using data from 1,636 patients enrolled in the Australian Scleroderma Cohort Study, we used generalized estimating equations to determine the relationship between patient-reported worsening of Raynaud's phenomenon (RP), skin involvement, and breathlessness in the month preceding each study visit and features of disease activity in the corresponding organ systems. The associations between the following parameters were analyzed: patient-reported worsening RP and the presence of new-onset digital pitting and digital ulcers; patient-reported worsening skin involvement and increasing modified Rodnan skin thickness score (MRSS); new areas of skin involvement and new-onset joint contractures; patient-reported worsening breathlessness and deteriorating respiratory functions test (RFT) results, indicated by a 10% decrease in forced vital capacity (FVC) and a 15% decrease in diffusing capacity for carbon monoxide (DLco), new-onset interstitial lung disease (ILD), and new-onset pulmonary arterial hypertension (PAH). RESULTS We found a significant association between patient-reported worsening RP and the presence of digital ulcers (odds ratio [OR] 1.53 [95% confidence interval (95% CI) 0.60-0.93]), patient-reported worsening skin involvement and increasing MRSS (OR 2.10 [95% CI 1.54-2.86]), and worsening patient breathlessness and deteriorating RFTs (FVC OR 2.12 [95% CI 1.70-2.65]; DLco OR 1.97 [95% CI 1.34-2.02]), new-onset ILD (OR 1.91 [95% CI 1.40-2.61]), and new-onset PAH (OR 5.08 [95% CI 3.59-7.19]). CONCLUSION These results demonstrate that patient-reported symptoms are associated with clinically meaningful changes in disease activity in patients with SSc. This suggests that when objective measures of change in disease status are unavailable, patient-reported symptoms could be used to indicate a change in SSc disease activity.
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Affiliation(s)
- Laura Ross
- St. Vincent's Hospital Melbourne and the University of Melbourne, Fitzroy, Victoria, Australia
| | - Wendy Stevens
- St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Michelle Wilson
- St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | | | - Jennifer Walker
- Flinders Medical Centre, Bedford Park, South Australia, Australia, and Royal Adelaide Hospital and Flinders University, Adelaide, South Australia, Australia
| | - Joanne Sahhar
- Monash Health and Monash University, Clayton, Victoria, Australia
| | - Gene-Siew Ngian
- Monash Health and Monash University, Clayton, Victoria, Australia
| | - Janet Roddy
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Gabor Major
- Royal Newcastle Centre, New Lambton Heights, New South Wales, Australia
| | - Susanna Proudman
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Murray Baron
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Mandana Nikpour
- St. Vincent's Hospital Melbourne and the University of Melbourne, Fitzroy, Victoria, Australia
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21
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McCabe C. Therapeutic use of oxygen in pulmonary arterial hypertension: a forgotten friend. Eur J Prev Cardiol 2020; 28:124-126. [PMID: 33624038 DOI: 10.1093/eurjpc/zwaa020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Colm McCabe
- Department of Pulmonary Vascular Disease, Royal Brompton Hospital, London SW3 6NP, UK.,National Heart and Lung Institute, Imperial College, London, UK
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22
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Sree Raman K, Shah R, Stokes M, Walls A, Woodman RJ, Ananthakrishna R, Walker JG, Proudman S, Steele PM, De Pasquale CG, Celermajer DS, Selvanayagam JB. Left ventricular ischemia in pre-capillary pulmonary hypertension: a cardiovascular magnetic resonance study. Cardiovasc Diagn Ther 2020; 10:1280-1292. [PMID: 33224752 DOI: 10.21037/cdt-20-698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Prognosis in pulmonary arterial hypertension (PAH) is largely dependent on right ventricular (RV) function. However, recent studies have suggested the presence of left ventricular (LV) dysfunction in PAH patients. The potential role of LV ischemia, as a contributor to progressive LV dysfunction, has not been systematically studied in PAH. We aim to assess the presence and extent of LV myocardial ischemia in patients with known PH and without obstructive coronary artery disease (CAD), using oxygen-sensitive (OS) cardiovascular magnetic resonance (CMR) and stress/rest CMR T1 mapping. Methods We prospectively recruited 28 patients with right heart catheter-proven PH and no significant CAD, 8 patients with known CAD and 11 normal age-matched controls (NC). OS-CMR images were acquired using a T2* sequence and T1 maps were acquired using Shortened Modified Look-Locker Inversion recovery (ShMOLLI) at rest and adenosine-induced stress vasodilatation; ΔOS-CMR signal intensity (SI) index (stress/rest SI) and ΔT1 reactivity (stress-rest/rest T1 mapping) were calculated. Results Global LV ΔOS SI index was significantly lower in PH patients compared with controls (11.1%±6.7% vs. 20.5%±10.5%, P=0.016), as was ΔT1 reactivity (5.2%±4.5% vs. 8.0%±2.9%, P=0.047). The ischemic segments of CAD patients had comparable ΔOS SI (10.3%±6.4% vs. 11.1%±6.7%, P=0.773) to PH patients, but lower ΔT1 reactivity (1.1%±4.2% vs. 5.2%±4.5%, P=0.036). Conclusions Decreased OS-CMR SI and T1 reactivity signify the presence of impaired myocardial oxygenation and vasodilatory response in PH patients. Given their unobstructed epicardial coronary arteries, this is likely secondary to coronary microvascular dysfunction (CMD).
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Affiliation(s)
- Karthigesh Sree Raman
- College of Medicine and Public Health, Flinders University, Flinders, Australia.,Flinders Medical Centre, Flinders, Australia.,Cardiac Imaging Research, South Australian Health & Medical Research Institute, Australia.,Whangarei Hospital, Northland District Health Board, Whangarei, New Zealand.,Department of Medicine (Northland Campus), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ranjit Shah
- College of Medicine and Public Health, Flinders University, Flinders, Australia.,Flinders Medical Centre, Flinders, Australia.,Cardiac Imaging Research, South Australian Health & Medical Research Institute, Australia
| | - Michael Stokes
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Angela Walls
- Clinical Research and Imaging Centre, South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
| | - Richard J Woodman
- Flinders Centre of Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Flinders, Australia
| | - Rajiv Ananthakrishna
- College of Medicine and Public Health, Flinders University, Flinders, Australia.,Flinders Medical Centre, Flinders, Australia.,Cardiac Imaging Research, South Australian Health & Medical Research Institute, Australia
| | | | - Susanna Proudman
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Peter M Steele
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Carmine G De Pasquale
- College of Medicine and Public Health, Flinders University, Flinders, Australia.,Flinders Medical Centre, Flinders, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Joseph B Selvanayagam
- College of Medicine and Public Health, Flinders University, Flinders, Australia.,Flinders Medical Centre, Flinders, Australia.,Cardiac Imaging Research, South Australian Health & Medical Research Institute, Australia
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23
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Tello K, Dalmer A, Vanderpool R, Ghofrani HA, Naeije R, Roller F, Seeger W, Dumitrescu D, Sommer N, Brunst A, Gall H, Richter MJ. Impaired right ventricular lusitropy is associated with ventilatory inefficiency in pulmonary arterial hypertension. Eur Respir J 2019; 54:13993003.00342-2019. [PMID: 31515402 DOI: 10.1183/13993003.00342-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/15/2019] [Indexed: 12/18/2022]
Abstract
Cardiopulmonary exercise testing (CPET) is an important tool for assessing functional capacity and prognosis in pulmonary arterial hypertension (PAH). However, the associations of CPET parameters with the adaptation of right ventricular (RV) function to afterload remain incompletely understood.In this study, 37 patients with PAH (idiopathic in 31 cases) underwent single-beat pressure-volume loop measurements of RV end-systolic elastance (Ees), arterial elastance (Ea) and diastolic elastance (Eed). Pulmonary arterial stiffness was assessed by magnetic resonance imaging. The results were correlated to CPET variables. The predictive relevance of RV function parameters for clinically relevant ventilatory inefficiency, defined as minute ventilation/carbon dioxide production (V' E/V' CO2 ) slope >48, was evaluated using logistic regression analysis.The median (interquartile range) of the V' E/V' CO2 slope was 42 (32-52) and the V' E/V' CO2 nadir was 40 (31-44). The mean±sd of peak end-tidal carbon dioxide tension (P ETCO2 ) was 23±8 mmHg. Ea, Eed and parameters reflecting pulmonary arterial stiffness (capacitance and distensibility) correlated with the V' E/V' CO2 slope, V' E/V' CO2 nadir, P ETCO2 and peak oxygen pulse. RV Ees and RV-arterial coupling as assessed by the Ees/Ea ratio showed no correlations with CPET parameters. Ea (univariate OR 7.28, 95% CI 1.20-44.04) and Eed (univariate OR 2.21, 95% CI 0.93-5.26) were significantly associated with ventilatory inefficiency (p<0.10).Our data suggest that impaired RV lusitropy and increased afterload are associated with ventilatory inefficiency in PAH.
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Affiliation(s)
- Khodr Tello
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Antonia Dalmer
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | | | - Hossein A Ghofrani
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,Dept of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Dept of Medicine, Imperial College London, London, UK
| | | | - Fritz Roller
- Dept of Radiology, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Daniel Dumitrescu
- Dept of Cardiology, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Natascha Sommer
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Anne Brunst
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel J Richter
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
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24
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Lungenbeteiligung bei Herzkrankheiten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-0296-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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