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Kaemmerer H, Diller GP, Achenbach S, Dähnert I, Eichstaedt CA, Eicken A, Freiberger A, Freilinger S, Geiger R, Gorenflo M, Grünig E, Hager A, Huntgeburth M, Kaemmerer-Suleiman AS, Kozlik-Feldmann R, Lammers AE, Nagdyman N, Michel S, Schmidt KH, Uebing A, von Scheidt F, Apitz C. [Pulmonary hypertension in adults with congenital heart disease in light of the 2022-ESC-PAH guidelines - Part II: Supportive therapy, special situations (pregnancy, contraception, non-cardiac surgery), targeted pharmacotherapy, organ transplantation, special management (shunt lesions, left ventricular disorders, univentricular hearts), interventions, intensive care, follow-up, future perspectives]. Pneumologie 2024; 78:566-577. [PMID: 38788761 DOI: 10.1055/a-2274-1025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
The number of adults with congenital heart defects (CHD) is steadily rising and amounts to approximately 360,000 in Germany. CHD is often associated with pulmonary hypertension (PH), which may develop early in untreated CHD. Despite timely treatment of CHD, PH not infrequently persists or recurs in older age and is associated with significant morbidity and mortality.The revised European Society of Cardiology/European Respiratory Society 2022 guidelines for the diagnosis and treatment of PH represent a significant contribution to the optimized care of those affected. However, the topic of "adults with congenital heart disease" is addressed only relatively superficial in these guidelines. Therefore, in the present article, this topic is commented in detail from the perspective of congenital cardiology.
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Affiliation(s)
- Harald Kaemmerer
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Gerhard Paul Diller
- Klinik für Kardiologie III: angeborene Herzfehler (EMAH) und Klappenerkrankungen, Universitätsklinikum Münster, Münster, Deutschland
| | - Stephan Achenbach
- Universitätsklinik Erlangen, Medizinische Klinik 2 - Kardiologie und Angiologie, Erlangen, Deutschland
| | - Ingo Dähnert
- Universitätsklinik für Kinderkardiologie, Herzzentrum Leipzig, Leipzig, Deutschland
| | - Christina A Eichstaedt
- Zentrum für Pulmonale Hypertonie, Thoraxklinik Heidelberg am Universitätsklinikum Heidelberg, Heidelberg, Deutschland; Institut für Humangenetik, Universität Heidelberg, INF 366, TLRC am DZL Heidelberg, Deutschland
| | - Andreas Eicken
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Annika Freiberger
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Sebastian Freilinger
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Ralf Geiger
- Univ.-Klinik für Pädiatrie III, Kardiologie, Pneumologie, Allergologie, Cystische Fibrose, Innsbruck, Österreich
| | - Matthias Gorenflo
- Klinik für Kinderkardiologie und angeborene Herzfehler, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Ekkehard Grünig
- Zentrum für Pulmonale Hypertonie, Thoraxklinik Heidelberg am Universitätsklinikum Heidelberg, Heidelberg, Deutschland; Institut für Humangenetik, Universität Heidelberg, INF 366, TLRC am DZL Heidelberg, Deutschland
| | - Alfred Hager
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Michael Huntgeburth
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | | | - Rainer Kozlik-Feldmann
- Klinik und Poliklinik für Kinderkardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Klinik und Poliklinik für Kinderherzmedizin und Erwachsene mit angeborenen Herzfehlern, Hamburg, Deutschland
| | - Astrid E Lammers
- Klinik für Pädiatrische Kardiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Münster, Deutschland
| | - Nicole Nagdyman
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Sebastian Michel
- LMU Klinikum, Herzchirurgische Klinik und Poliklinik, Sektion für Chirurgie angeborener Herzfehler und Kinderherzchirurgie, Campus Großhadern, München, Deutschland
| | - Kai Helge Schmidt
- Universitätsmedizin Mainz, Zentrum für Kardiologie - Kardiologie I, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Anselm Uebing
- Universitätsklinikum Schleswig-Holstein, Klinik für angeborene Herzfehler und Kinderkardiologie, Kiel, Deutschland
| | - Fabian von Scheidt
- Internationales Zentrum für Erwachsene mit angeborenen Herzfehlern (EMAH), Klinik für angeborene Herzfehler und Kinderkardiologie, Deutsches Herzzentrum München, Deutschland
| | - Christian Apitz
- Sektion Pädiatrische Kardiologie, Universitätsklinik für Kinder- und Jugendmedizin Ulm, Ulm, Deutschland
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Mathai SC. Pulmonary Hypertension Associated with Connective Tissue Disease. Rheum Dis Clin North Am 2024; 50:359-379. [PMID: 38942575 DOI: 10.1016/j.rdc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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3
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Avitabile CM, Mota JP, Yeaman KM, Andrieux SJ, Lechtenberg L, Escobar E, Chuo J, Xanthopoulos MS, Faig W, O'Malley SM, Ford E, McBride MG, Paridon SM, Mitchell JA, Zemel BS. Creating a digital approach for promoting physical activity in pediatric pulmonary hypertension: A framework for future interventions. Pulm Circ 2024; 14:e12402. [PMID: 38962181 PMCID: PMC11219287 DOI: 10.1002/pul2.12402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 07/05/2024] Open
Abstract
Children with pulmonary hypertension (PH) often demonstrate limited exercise capacity. Data support exercise as an effective nonpharmacologic intervention among adults with PH. However, data on exercise training in children and adolescents are limited, and characteristics of the optimal exercise program in pediatric PH have not been identified. Exercise programs may have multiple targets, including muscle deficits which are associated with exercise limitations in both adult and pediatric PH. Wearable accelerometer sensors measure physical activity volume and intensity in the naturalistic setting and can facilitate near continuous data transfer and bidirectional communication between patients and the study team when paired with informatics tools during exercise interventions. To address the knowledge gaps in exercise training in pediatric PH, we designed a prospective, single arm, nonrandomized pilot study to determine feasibility and preliminary estimates of efficacy of a 16-week home exercise intervention, targeting lower extremity muscle mass and enriched by wearable mobile health technology. The exercIse Training in pulmONary hypertEnsion (iTONE) trial includes (1) semistructured exercise prescriptions tailored to the participant's baseline level of activity and access to resources; (2) interval goal setting fostering self-efficacy; (3) real time monitoring of activity via wearable devices; (4) a digital platform enabling communication and feedback between participant and study team; (5) multiple avenues to assess participant safety. This pilot intervention will provide information on the digital infrastructure needed to conduct home-based exercise interventions in PH and will generate important preliminary data on the effect of exercise interventions in youth with chronic cardiorespiratory conditions to power larger studies in the future.
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Affiliation(s)
- Catherine M. Avitabile
- Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Jena P. Mota
- Division of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Kiley M. Yeaman
- Research InstituteChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Sybil J. Andrieux
- Research InstituteChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Lara Lechtenberg
- Research InstituteChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Emma Escobar
- Research InstituteChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - John Chuo
- Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of NeonatologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Melissa S. Xanthopoulos
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Division of Pulmonary and Sleep MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of Psychiatry, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Walter Faig
- Biostatistics and Data Management CoreChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Shannon M. O'Malley
- Division of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Elizabeth Ford
- Division of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Michael G. McBride
- Division of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Stephen M. Paridon
- Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Jonathan A. Mitchell
- Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of Gastroenterology, Hepatology, and NutritionChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Babette S. Zemel
- Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of Gastroenterology, Hepatology, and NutritionChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
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Budhram B, Weatherald J, Humbert M. Pulmonary Hypertension in Connective Tissue Diseases Other than Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:419-434. [PMID: 38499196 DOI: 10.1055/s-0044-1782217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Pulmonary hypertension (PH) is a known complication of certain connective tissue diseases (CTDs), with systemic sclerosis (SSc) being the most common in the Western world. However, PH in association with non-SSc CTD such as systemic lupus erythematous, mixed connective tissue disease, and primary Sjögren's syndrome constitutes a distinct subset of patients with inherently different epidemiologic profiles, pathophysiologic mechanisms, clinical features, therapeutic options, and prognostic implications. The purpose of this review is to inform a practical approach for clinicians evaluating patients with non-SSc CTD-associated PH.The development of PH in these patients involves a complex interplay between genetic factors, immune-mediated mechanisms, and endothelial cell dysfunction. Furthermore, the broad spectrum of CTD manifestations can contribute to the development of PH through various pathophysiologic mechanisms, including intrinsic pulmonary arteriolar vasculopathy (pulmonary arterial hypertension, Group 1 PH), left-heart disease (Group 2), chronic lung disease (Group 3), chronic pulmonary artery obstruction (Group 4), and unclear and/or multifactorial mechanisms (Group 5). The importance of diagnosing PH early in symptomatic patients with non-SSc CTD is highlighted, with a review of the relevant biomarkers, imaging, and diagnostic procedures required to establish a diagnosis.Therapeutic strategies for non-SSc PH associated with CTD are explored with an in-depth review of the medical, interventional, and surgical options available to these patients, emphasizing the CTD-specific considerations that guide treatment and aid in prognosis. By identifying gaps in the current literature, we offer insights into future research priorities that may prove valuable for patients with PH associated with non-SSc CTD.
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Affiliation(s)
- Brandon Budhram
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marc Humbert
- Université Paris-Saclay, Inserm UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, European Reference Network for Rare Respiratory Diseases (ERN-LUNG), Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Le Kremlin-Bicêtre, France
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Barret T, Degano B, Bouvaist H, Pison C, Noirclerc M, Vanzetto G, Rocca C. Routine Rehabilitation as a Treatment Component for Patients With Pulmonary Arterial or Chronic Thromboembolic Pulmonary Hypertensions. J Cardiopulm Rehabil Prev 2023; 43:354-360. [PMID: 36939648 DOI: 10.1097/hcr.0000000000000755] [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: 03/21/2023]
Abstract
PURPOSE Patients with pulmonary hypertension (PH) have long been advised to avoid exercise in fear of deterioration in right-sided heart function. Since the 2009 European Society of Cardiology guidelines, rehabilitation in expert centers is considered to have a specific role in care of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We report routine rehabilitation effects in patients with PH as a component of real-life multimodal treatment. METHODS Patients with PAH or CTEPH were recommended for either in- or outpatient rehabilitation in addition to their usual care, unless there were practical problems or the patient declined. Assessment was conducted according to New York Heart Association classes, adverse events, 6 min-walk test, hemodynamics, and risk stratification after rehabilitation. RESULTS Forty-one patients, 61% female, age 60 ±18 yr were included between March 2010 and May 2019. No major adverse events or deaths related to progression of right-sided heart failure were reported. Nevertheless, 22% of participants suffered adverse events in most cases not linked with physical activity. Rehabilitation as add-on to medical therapy and/or arterial deobstruction improved New York Heart Association class: mean difference, -0.39 (95% CI, -0.68 to -0.10), 6-min walk test: mean difference, 80 m (95% CI, 46-114), and was associated with improved right-sided heart hemodynamics. The risk assessment grade improved by -0.25 points (95% CI, -0.44 to -0.06) after rehabilitation. CONCLUSIONS For patients with PAH or CTEPH, supervised rehabilitation as add-on to medical therapy and/or arterial deobstruction is safe and effective in improving patient and clinically related outcomes.
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Affiliation(s)
- Thomas Barret
- Service de Rééducation Cardiaque, Institut de Rééducation Sud, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France (Drs Barret, Noirclerc, and Rocca); Service de Cardiologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France (Drs Bouvaist and Vanzetto); Université Grenoble Alpes, Saint-Martin-d'Hères, France (Drs Degano, Pison, and Vanzetto); and Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France (Drs Degano and Pison)
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Morris NR, Kermeen FD, Jones AW, Lee JY, Holland AE. Exercise-based rehabilitation programmes for pulmonary hypertension. Cochrane Database Syst Rev 2023; 3:CD011285. [PMID: 36947725 PMCID: PMC10032353 DOI: 10.1002/14651858.cd011285.pub3] [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: 03/24/2023]
Abstract
BACKGROUND Individuals with pulmonary hypertension (PH) have reduced exercise capacity and quality of life. Despite initial concerns that exercise training may worsen symptoms in this group, several studies have reported improvements in functional capacity and well-being following exercise-based rehabilitation. OBJECTIVES To evaluate the benefits and harms of exercise-based rehabilitation for people with PH compared with usual care or no exercise-based rehabilitation. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 June 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in people with PH comparing supervised exercise-based rehabilitation programmes with usual care or no exercise-based rehabilitation. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. exercise capacity, 2. serious adverse events during the intervention period and 3. health-related quality of life (HRQoL). Our secondary outcomes were 4. cardiopulmonary haemodynamics, 5. Functional Class, 6. clinical worsening during follow-up, 7. mortality and 8. changes in B-type natriuretic peptide. We used GRADE to assess certainty of evidence. MAIN RESULTS We included eight new studies in the current review, which now includes 14 RCTs. We extracted data from 11 studies. The studies had low- to moderate-certainty evidence with evidence downgraded due to inconsistencies in the data and performance bias. The total number of participants in meta-analyses comparing exercise-based rehabilitation to control groups was 462. The mean age of the participants in the 14 RCTs ranged from 35 to 68 years. Most participants were women and classified as Group I pulmonary arterial hypertension (PAH). Study durations ranged from 3 to 25 weeks. Exercise-based programmes included both inpatient- and outpatient-based rehabilitation that incorporated both upper and lower limb exercise. The mean six-minute walk distance following exercise-based rehabilitation was 48.52 metres higher than control (95% confidence interval (CI) 33.42 to 63.62; I² = 72%; 11 studies, 418 participants; low-certainty evidence), the mean peak oxygen uptake was 2.07 mL/kg/min higher than control (95% CI 1.57 to 2.57; I² = 67%; 7 studies, 314 participants; low-certainty evidence) and the mean peak power was 9.69 W higher than control (95% CI 5.52 to 13.85; I² = 71%; 5 studies, 226 participants; low-certainty evidence). Three studies reported five serious adverse events; however, exercise-based rehabilitation was not associated with an increased risk of serious adverse event (risk difference 0, 95% CI -0.03 to 0.03; I² = 0%; 11 studies, 439 participants; moderate-certainty evidence). The mean change in HRQoL for the 36-item Short Form (SF-36) Physical Component Score was 3.98 points higher (95% CI 1.89 to 6.07; I² = 38%; 5 studies, 187 participants; moderate-certainty evidence) and for the SF-36 Mental Component Score was 3.60 points higher (95% CI 1.21 to 5.98 points; I² = 0%; 5 RCTs, 186 participants; moderate-certainty evidence). There were similar effects in the subgroup analyses for participants with Group 1 PH versus studies of groups with mixed PH. Two studies reported mean reduction in mean pulmonary arterial pressure following exercise-based rehabilitation (mean reduction: 9.29 mmHg, 95% CI -12.96 to -5.61; I² = 0%; 2 studies, 133 participants; low-certainty evidence). AUTHORS' CONCLUSIONS In people with PH, supervised exercise-based rehabilitation may result in a large increase in exercise capacity. Changes in exercise capacity remain heterogeneous and cannot be explained by subgroup analysis. It is likely that exercise-based rehabilitation increases HRQoL and is probably not associated with an increased risk of a serious adverse events. Exercise training may result in a large reduction in mean pulmonary arterial pressure. Overall, we assessed the certainty of the evidence to be low for exercise capacity and mean pulmonary arterial pressure, and moderate for HRQoL and adverse events. Future RCTs are needed to inform the application of exercise-based rehabilitation across the spectrum of people with PH, including those with chronic thromboembolic PH, PH with left-sided heart disease and those with more severe disease.
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Affiliation(s)
- Norman R Morris
- Allied Health Research Collaborative, The Prince Charles Hospital, Chermside, Australia
- School of Allied Health Sciences and Social Work and Menzies Health Institute, Griffith University, Gold Coast Campus, Southport, Australia
| | - Fiona D Kermeen
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia
| | - Arwel W Jones
- Central Clinical School, Monash University, Melbourne, Australia
| | - Joanna Yt Lee
- Central Clinical School, Monash University, Melbourne, Australia
| | - Anne E Holland
- Central Clinical School, Monash University, Melbourne, Australia
- Physiotherapy, Alfred Health, Melbourne, Australia
- Institute for Breathing and Sleep, Melbourne, Australia
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7
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Exercise Training in Pulmonary Hypertension: AN UPDATED SYSTEMATIC REVIEW WITH META-ANALYSIS. J Cardiopulm Rehabil Prev 2023:01273116-990000000-00061. [PMID: 36655898 DOI: 10.1097/hcr.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Given that previous reviews on exercise training in pulmonary hypertension (PH) were largely based on a small number of randomized controlled trials (RCT), their conclusions are subject to bias. This review sought to identify the impact of exercise training on functional capacity and health-related quality of life (HRQoL) in PH using advanced statistical approaches such as meta-analysis by stratification according to study design. REVIEW METHODS Five databases were searched from January 2015 to April 2020 to update a previous review. Included articles had data extracted, risk of bias (ROB) assessed, and quality rating performed. Data were analyzed using meta-analysis with a random-effects model for 6-min walk test (6MWT) distance and HRQoL. Heterogeneity was explored using stratified meta-analysis, within patient correlation and meta-regression. RESULTS A total of 28 studies (11 RCT, 12 pre-/post-studies, 2 two-group non-RCT, and three case series) consisting of 1264 patients were included. Meta-analysis of six RCT demonstrated an improved 6MWT distance by 49.5 m (95% CI, 27.2-71.8: I2 = 73%; 254 participants; low-moderate ROB) with a low correlation coefficient of 0.34, while the 12 pre-/post-non-RCT showed an improvement of 68.36 m (95% CI, -86.78 to -49.94: I2 = 37%; 746 participants; high ROB) along with improvements in V˙ o2peak (weighted mean difference [WMD] = 3.03 mL/kg/min, 95% CI, 2.17-3.90: I2 = 0%, P = .82), and HRQoL (WMD = 2.74: 95% CI, -0.82 to 6.30). Metaregression showed that the benefit of exercise on 6MWT distance did not significantly vary across the trial study characteristics. CONCLUSION This updated review identified an additional body of evidence supporting the efficacy of exercise training on 6MWT distance and HRQoL in stable PH patients. These benefits appeared to be consistent across models of delivery.
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Chennakesavulu PV, Uppaluri S, Koyi J, Jhaveri S, Avanthika C, Sakhamuri LT, Ashokbhai PK, Singh P. Pulmonary Hypertension in Scleroderma- Evaluation and Management. Dis Mon 2022:101468. [PMID: 36163292 DOI: 10.1016/j.disamonth.2022.101468] [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: 11/25/2022]
Abstract
Pulmonary Arterial Hypertension (PAH) is a clinical syndrome consisting of physiologic/hemodynamic criteria that are a consequence of several etiologies. Systemic Sclerosis (SSc), one of the most common causes of PAH, is an autoimmune disorder of the connective tissue leading to fibrosis that involves the skin, gastrointestinal tract, lungs, heart, kidney etc. SSc has an annual prevalence of one to five cases for every 1000 individuals and nearly 15 percent of all cases develop PAH. At its core, Pulmonary hypertension (PH) in SSc is an obliterative vasculopathy in small to medium-sized pulmonary arterioles. A host of other local and systemic mechanisms operate in concert to gradually alter the hemodynamics resulting in elevated pulmonary vascular resistance and thus right ventricular afterload. A diagnosis of PAH in SSc is virtually a death sentence, with studies reporting a mortality rate of 50 per cent in the 3 years of diagnosis. Therefore, developing and implementing a robust screening and diagnosis protocol is crucial in the fight against this pervasive disease. This review aims to summarize the current literature of PAH in SSc, with a special focus on the screening and diagnosis protocols, newer treatment options and prognostic indicators for the same.
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Affiliation(s)
| | - Srikar Uppaluri
- Kamineni Academy of medical sciences and research centre, Hyderabad, India.
| | | | | | | | | | | | - Priyanka Singh
- United health services hospital, Wilson medical center, New York
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9
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Dong C, Li Y. Exercise Rehabilitation Training in Patients with Pulmonary Hypertension: A Review. Heart Lung Circ 2022; 31:1341-1348. [PMID: 35840511 DOI: 10.1016/j.hlc.2022.06.660] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
Abstract
Pulmonary hypertension (PH) has a high morbidity and mortality. Despite the existing disease-targeted therapy, most patients with PH continue to suffer from difficulty in breathing, exercise intolerance, and reduced quality of life. Recently, a large body of research results has suggested that exercise rehabilitation training (ERT) seems to be a beneficial, safe, and cost-effective treatment for patients with PH. However, knowledge gaps still exist for a uniformly accepted ERT protocol, the modality, duration, intensity, and frequency of ERT in PH. The purpose of this review is to summarise the existing research evidence and knowledge, aiming to strengthen clinicians' awareness of the application of ERT in patients with PH. PubMed databases were systematically searched for eligible studies. Twelve (12) randomised controlled trials and other important studies documenting effectiveness, safety, and adverse events of ERT are summarised. Additionally, the modality, duration, intensity, and frequency of various types of ERT and future research directions are discussed. In summary, ERT is generally effective and safe for PH patients as an adjuvant treatment to disease-specific therapy. It can improve the exercise capacity and tolerance, skeletal and respiratory muscle performance, cardiopulmonary function, and quality of life of PH patients. In view of the occurrence of a small number of adverse events, we currently recommend a combination of in-hospital and home-based ERT under close supervision. In the future, more multi-centre randomised controlled studies are needed to evaluate the effectiveness and feasibility of long-term, community, or home-based ERT, as well as to explore the molecular mechanism behind it.
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Affiliation(s)
- Chang Dong
- Pulmonary and Critical Care Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Yanxia Li
- Pulmonary and Critical Care Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
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Jiang R, Wang L, Yuan P, Zhao QH, Gong SG, He J, Qiu HL, Luo CJ, Zhang R, Shen T, Zhan MY, Jiang YM, Chen FD, Liu JM, Shen YQ. A Study of the Efficacy and Safety of Aerobic Exercise Training in Pulmonary Arterial Hypertension (the Saturday Study): Protocol for a Prospective, Randomized, and Controlled Trial. Front Med (Lausanne) 2022; 9:835272. [PMID: 35449803 PMCID: PMC9016180 DOI: 10.3389/fmed.2022.835272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patients with pulmonary arterial hypertension (PAH) have reduced exercise capacity and poor quality of life. Exercise-based rehabilitation in PAH results in clinically relevant improvements in exercise capacity and hemodynamics. To clarify the mechanism, we will evaluate the effect of aerobic exercise training rehabilitation on right ventricular (RV) remodeling and function as determined measured by cardiac magnetic resonance imaging (CMR). Methods We will conduct a 26-week multicenter randomized controlled trial. Patients on stable and unchanged PAH-targeted medication are randomly assigned (1:1) to the control and training groups. The primary endpoint is the RV stroke volume (RVSV) change from baseline to Week 26, determined by CMR. Comprehensive RV function is also performed using CMR. Other characteristics of the RV and left ventricle, World Health Organization functional class, 6-min walk distance, and N-terminal pro-B-type natriuretic peptide are included in secondary endpoints. We also investigate the proteomic, metabolomic, and transcriptomic changes after exercise training as exploratory endpoints. Ethics and Dissemination The study and protocol were approved by the Ethics Committee of Shanghai Pulmonary Hospital (Approved No. of ethics committee: L20-17). The results will be disseminated at medical conferences and in journal publications. All participants will sign written informed consent. Trial Registration Number ChiCTR2000031650.
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Affiliation(s)
- Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ting Shen
- Department of Cardiac Rehabilitation, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Meng-Yi Zhan
- Department of Cardiac Rehabilitation, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu-Mei Jiang
- Department of Cardiac Rehabilitation, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fa-Dong Chen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu-Qin Shen
- Department of Cardiac Rehabilitation, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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11
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Chia KSW, Shiner C, Brown K, Holloway C, Moreyra C, Bart N, Wong PKK, Faux SG, Kotlyar E. The exercise in pulmonary arterial hypertension (ExPAH) study: A randomized controlled pilot of exercise training and multidisciplinary rehabilitation in pulmonary arterial hypertension. Pulm Circ 2022; 12:e12069. [PMID: 35795491 PMCID: PMC9248794 DOI: 10.1002/pul2.12069] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 11/09/2022] Open
Abstract
Pulmonary hypertension (PH) is characterized by progressive dyspnea, fatigue, and reduced exercise capacity. Despite medical treatment, outcomes remain poor. While exercise training is well established in patients with heart failure, it is less established in patients with PH. This single-blind, randomized controlled pilot study examined the feasibility and effect of 12-week outpatient exercise (multidisciplinary rehabilitation or home walking program) on hemodynamics using cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) in patients with pulmonary arterial hypertension (PAH), a subset of PH. Sixteen participants were randomized to either multidisciplinary outpatient rehabilitation or a home walking program for 12 weeks. Primary outcome measures were changes in right ventricular ejection fraction and stroke volume index on cMRI. Secondary outcome measures included hemodynamics on RHC, quality of life (QOL), muscle strength (handgrip and vital capacity) and 6-min walk test. This preliminary, pilot study suggests that outpatient exercise interventions may be associated with improved hemodynamic function (mean pulmonary artery wedge pressure, stroke volume, and stroke volume index), QOL (PH symptoms, depression, and anxiety), and muscular strength (vital capacity and handgrip strength) for people with PAH, but was not adequately powered to make any formal conclusions. However, our outpatient programs were feasible, safe, and acceptable to participants. Future studies are required to further explore the potential hemodynamic benefits of exercise in PAH.
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Affiliation(s)
- Karen S. W. Chia
- Department of Medicine, St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia
- Department of Rehabiliation MedicineSt Vincent's HospitalSydneyNew South WalesAustralia
- UNSW Rural Clinical SchoolCoffs HarbourNew South WalesAustralia
| | - Christine T. Shiner
- Department of Medicine, St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia
- Department of Rehabiliation MedicineSt Vincent's HospitalSydneyNew South WalesAustralia
| | - Karen Brown
- Department of CardiologySt Vincent's HospitalSydneyNew South WalesAustralia
| | | | - Camila Moreyra
- Department of CardiologySt Vincent's HospitalSydneyNew South WalesAustralia
| | - Nicole Bart
- Department of CardiologySt Vincent's HospitalSydneyNew South WalesAustralia
| | | | - Steven G. Faux
- Department of Medicine, St Vincent's Clinical SchoolUniversity of New South WalesSydneyAustralia
- Department of Rehabiliation MedicineSt Vincent's HospitalSydneyNew South WalesAustralia
| | - Eugene Kotlyar
- Department of CardiologySt Vincent's HospitalSydneyNew South WalesAustralia
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12
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Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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13
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Siaplaouras J, Frerix M, Apitz A, Zöller D, Apitz C. Effects of exercise training on heart rate variability in children and adolescents with pulmonary arterial hypertension: a pilot study. Cardiovasc Diagn Ther 2021; 11:1028-1036. [PMID: 34527528 DOI: 10.21037/cdt-20-263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
Background Pulmonary arterial hypertension (PAH) is often associated with cardiac autonomic dysfunction, and heart rate variability (HRV) as marker of cardiac autonomic function is even related to disease severity. Knowledge about the effects of physical activity on HRV is limited in these patients. We aimed to assess whether HRV parameters can be influenced by a supervised exercise training program and whether respective changes are related to levels of activity. Methods Six children and adolescents with moderate PAH (3 female, mean age 15.0±4.4 years; mean pulmonary to systemic arterial pressure ratio 0.5±0.2) performed supervised endurance and resistance training for 16 weeks. PAH-specific targeted medication remained unchanged during the study period. HRV was assessed before training and after 16 weeks of training by the use of ECG Move accelerometers. HRV indices included: standard deviation of normal-to-normal (NN) intervals (SDNN), square root of the mean of the sum of the squares of differences between successive NN-intervals (RMSSD), proportion of the number of pairs of successive normal-to-normal intervals that differ by more than 50 ms divided by total number of normal-to-normal interval (pNN50), and the Baevsky stress index (BSI) calculated by the histogram method. Results Before and after the training program, SDNN, RMSSD and pNN50 correlated with the level of physical activity. Mean values of SDNN, RMSSD and pNN50 did not change significantly due to the training program. Notably, activity level depending SDNN increased markedly after the exercise program (during activity +12.4%, at rest +6.6% and reclining +8.1%, Hedge's g of 0.28, 0.14 and 0.27, respectively). BSI decreased during activity due to the training program reflecting a reduction of stress level (Hedge's g -0.87 indicating an effect of clinical relevance). Conclusions According to the experience of this pilot study a workout program of 16 weeks revealed an activity level dependent effect on parameters of autonomic cardiac function in children and adolescents with PAH. This mechanism might contribute to the positive effects of exercise training in patients with PAH.
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Affiliation(s)
- Jannos Siaplaouras
- Division of Pediatric Cardiology, University Childrens Hospital Ulm, Ulm, Germany
| | - Marc Frerix
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Anita Apitz
- Division of Pediatric Cardiology, University Childrens Hospital Ulm, Ulm, Germany
| | - David Zöller
- Pediatric Heart Center, Justus-Liebig-University Giessen, Giessen, Germany
| | - Christian Apitz
- Division of Pediatric Cardiology, University Childrens Hospital Ulm, Ulm, Germany.,Pediatric Heart Center, Justus-Liebig-University Giessen, Giessen, Germany
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14
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Seo YG, Oh S, Park WH, Jang M, Kim HY, Chang SA, Park IK, Sung J. Optimal aerobic exercise intensity and its influence on the effectiveness of exercise therapy in patients with pulmonary arterial hypertension: a systematic review. J Thorac Dis 2021; 13:4530-4540. [PMID: 34422379 PMCID: PMC8339761 DOI: 10.21037/jtd-20-3296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/12/2021] [Indexed: 01/21/2023]
Abstract
Background Exercise intensity in exercise training programs is an important determinant of program efficacy, such as improvement in exercise capacity and quality of life (QOL). It is not well known whether differently applied exercise intensities are efficacious when used in exercise-based cardiac rehabilitation programs for patients with pulmonary arterial hypertension (PAH). Methods Three databases (PubMed, EMBASE, and CINAHL) were searched with the following inclusion criteria: comparative study of exercise interventions for patients with pulmonary arterial hypertension. Three clinical specialists (a physician, nurse, and exercise physiologist) selected the included articles using the process of systematic review. Included articles were grouped according to aerobic exercise intensity: low, moderate-to-vigorous, and vigorous. The level of evidence for each study was rated using Sackett’s levels of evidence. Results Of 1,452 studies reviewed, 8 were included according to the inclusion criteria (3 randomized controlled trials (RCTs), 3 prospective studies, and 2 case series). Exercise capacity for a six-minute walk distance (mean: 57.7 m) and QOL improved in the above moderate intensity group, while the low intensity group did not show improvement after intervention. For termination criteria, data obtained from the reviewed articles were not sufficient to suggest any exercise intensity recommendations for patients with pulmonary arterial hypertension. Discussion The findings in this study suggest that at least moderate aerobic exercise intensity is needed to significantly improve six-minute walk distance and QOL in individuals diagnosed with World Health Organization Group 1 of pulmonary arterial hypertension. There is a need for prospective RCTs comparing different exercise intensities in this patient population.
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Affiliation(s)
- Yong-Gon Seo
- Division of Sports Medicine, Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Suki Oh
- Division of Sports Medicine, Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Won-Hah Park
- Division of Sports Medicine, Department of Orthopedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Mija Jang
- Department of Nursing, Rehabilitation & Prevention Center, Cardiac Center, Heart Stroke & Vascular Institute, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ho-Young Kim
- Cardiac Rehabilitation and Prevention Center, Heart Stroke & Vascular Institute, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Stroke & Vascular Institute, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - In-Kyung Park
- Division of Cardiology, Department of Internal Medicine, Rehabilitation & Prevention Center, Heart Stroke & Vascular Institute, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Jidong Sung
- Division of Cardiology, Department of Internal Medicine, Rehabilitation & Prevention Center, Heart Stroke & Vascular Institute, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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15
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Abstract
Rationale: The evidence base for rehabilitation in pulmonary hypertension is expanding, but adoption in clinical practice is limited.Objectives: The World Health Organization International Classification for Functioning, Disability and Health identifies three health domains: Body Functions/Structures, Activity and Participation in society. To ensure that the wider impact of rehabilitation in pulmonary hypertension is accurately assessed, it is important that study endpoints reflect all three domains.Methods: A systematic review of the literature was conducted to identify studies of rehabilitation in patients with pulmonary hypertension from 2006 to 2019.Results: Searches across five databases yielded 2,564 articles, of which 34 met eligibility criteria; 50 different outcome measures (mean = 5, minimum = 1, maximum = 9) were identified. When mapped onto the World Health Organization International Classification for Functioning, Disability and Health, 48% of instances of outcome usage were measures of Body Functions/Structure, 33% were measures of Activity, and 18% were measures of Participation. Measures of Participation were not included in seven studies (21%).Conclusions: Studies of rehabilitation in pulmonary hypertension have focused primarily on measures of Body Functions/Structure; the impact in other health domains is not well characterized. Greater inclusion of outcome measures reflecting Activity and Participation in society is needed to allow assessment of the wider impact of rehabilitation in patients with pulmonary hypertension.
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16
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Malenfant S, Lebret M, Breton-Gagnon É, Potus F, Paulin R, Bonnet S, Provencher S. Exercise intolerance in pulmonary arterial hypertension: insight into central and peripheral pathophysiological mechanisms. Eur Respir Rev 2021; 30:200284. [PMID: 33853885 PMCID: PMC9488698 DOI: 10.1183/16000617.0284-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 12/08/2020] [Indexed: 11/05/2022] Open
Abstract
Exercise intolerance is a cardinal symptom of pulmonary arterial hypertension (PAH) and strongly impacts patients' quality of life (QoL). Although central cardiopulmonary impairments limit peak oxygen consumption (V' O2peak ) in patients with PAH, several peripheral abnormalities have been described over the recent decade as key determinants in exercise intolerance, including impaired skeletal muscle (SKM) morphology, convective O2 transport, capillarity and metabolism indicating that peripheral abnormalities play a greater role in limiting exercise capacity than previously thought. More recently, cerebrovascular alterations potentially contributing to exercise intolerance in patients with PAH were also documented. Currently, only cardiopulmonary rehabilitation has been shown to efficiently improve the peripheral components of exercise intolerance in patients with PAH. However, more extensive studies are needed to identify targeted interventions that would ultimately improve patients' exercise tolerance and QoL. The present review offers a broad and comprehensive analysis of the present literature about the complex mechanisms and their interactions limiting exercise in patients and suggests several gaps in knowledge that need to be addressed in the future for a better understanding of exercise intolerance in patients with PAH.
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Affiliation(s)
- Simon Malenfant
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Marius Lebret
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Émilie Breton-Gagnon
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - François Potus
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
| | - Roxane Paulin
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Steeve Provencher
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
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17
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Zhao YL, Yuan P, Zhao QH, Gong SG, Zhang R, He J, Luo CJ, Qiu HL, Liu JM, Wang L, Jiang R. Comparative Effectiveness of Exercise Training for Patients With Chronic Thromboembolic Pulmonary Hypertension After Pulmonary Endarterectomy: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:664984. [PMID: 34222365 PMCID: PMC8245692 DOI: 10.3389/fcvm.2021.664984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/24/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients with chronic thromboembolic pulmonary hypertension (CTEPH) still experience reduced exercise capacity despite pulmonary endarterectomy (PEA). Exercise training improves the exercise capacity and quality of life (QoL) in patients with PH, but data on the effects of exercise training on these patients are scarce. The aim of this meta-analysis and systematic review was to evaluate the effectiveness and safety of exercise training in CTEPH after PEA. Methods: We searched the relevant literature published before January 2020 for the systematic review and meta-analysis using the PubMed, EMBASE, and Cochrane Library databases. The primary outcome was a change in the 6-min walking distance (6 MWD). We also assessed the effect of exercise on the peak oxygen uptake (VO2) or peak VO2/kg, oxygen uptake anaerobic threshold, workload, oxygen pulse, hemodynamics, arterial blood gases, oxygen saturation, N-terminal pro-brain-type natriuretic peptide (NT-proBNP), quality of life (QoL) and pulmonary function tests. Results: We included 4 studies with 208 exercise-training participants. In the pooled analysis, short-term exercise training can improve the 6 MWD of 58.89 m (95% CI: 46.26-71.52 m, P < 0.0001). There was a significant increase in the peak VO2/kg or peak VO2 after exercise training (3.15 ml/min/kg, 95% CI: 0.82-5.48, P = 0.008; 292.69 ml/min, 95% CI: 24.62-560.75, P = 0.032, respectively). After exercise training, the maximal workload and O2 pulse significantly improved. Three months of exercise training increased the right ventricular ejection fraction by 3.53% (95% CI: 6.31-11.94, P < 0.00001, I 2 = 0) independently of PEA surgery. In addition, NT-proBNP plasma levels significantly improved with exercise training after PEA [weighted mean difference (WMD): -524.79 ng/L, 95% CI: 705.16 to -344.42, P < 0.0001, I 2 = 0]. The partial pressure of oxygen and pH improved progressively over 12 weeks of exercise training (WMD: 4 mmHg, 95% CI: 1.01-8.33, P = 0.01; WMD: 0.03, 95% CI: 0.02-0.04, P < 0.0001, respectively). Subscales of the QoL measured by the SF-36 questionnaire had also improved. In addition, exercise training was well-tolerated with a low dropout rate, and no major adverse events occurred during exercise training. Conclusion: Exercise training may be associated with a significant improvement in the exercise capacity and QoL among CTEPH patients after PEA and was proven to be safe. However, more large-scale multicentre studies are needed to confirm the effectiveness and safety of exercise training in CTEPH patients after PEA. PROSPERO registration number: CRD42021235275.
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Affiliation(s)
- Ya-Lin Zhao
- Department of Respiratory Critical Care Medicine, The First Hospital of Kunming, Kunming, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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18
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Palevičiūtė E, Gumbienė L, Jurevičienė E, Šimbelytė T, Laucevičienė I, Laucevičius A, Barysienė J, Eichstaedt CA, Benjamin N, Grünig E, Čelutkienė J. The Experience, Prerequisites, and the Barriers in Organizing a Specialized Rehabilitation Program for Patients with Pulmonary Hypertension. Respiration 2021; 100:949-957. [PMID: 34044412 DOI: 10.1159/000516331] [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: 01/18/2021] [Accepted: 03/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a severe progressive disease, associated with reduced exercise capacity and poor quality of life. Although scientific evidence supports the incorporation of specialized training in the treatment of PH, it is only available in a few countries. OBJECTIVES AND METHODS This article aims to share the experience of implementing a PH rehabilitation program, to summarize the barriers and prerequisites for launching this service, and to assess its early effect. We retrospectively analyzed our pathway in organizing this program, by singling out essential steps. RESULTS The preparation phase took about 14 months. Establishing and running of a PH rehabilitation program required dedicated rehabilitation specialists to join the multidisciplinary PH expert team. Team members needed to gain special knowledge on exercise training in severely compromised patients; thus, supervision and education by experienced consultants was crucial. The main eligibility criteria for patients were stable status, optimal medical treatment, and motivation to undergo the training. The first results evaluating the effect of a specialized PH training program in 9 patients are promising. Seven of them improved their functional capacity over the period of 15 weeks. CONCLUSIONS Despite a number of challenges and barriers, the implementation of a specialized rehabilitation program should be encouraged in a few dedicated PH expert centers per country, who are capable to fulfill all prerequisites and organizational aspects. Local PH experts, supervision by an experienced center, in-patient rehabilitation facilities, dedicated personnel, equipment, and patient motivation are essential.
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Affiliation(s)
- Eglė Palevičiūtė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros Klinikos, ERN-LUNG, Vilnius, Lithuania
| | - Lina Gumbienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros Klinikos, ERN-LUNG, Vilnius, Lithuania
| | - Elena Jurevičienė
- Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros Klinikos, ERN-LUNG, Vilnius, Lithuania.,Centre of Pulmonology and Allergology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Toma Šimbelytė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ieva Laucevičienė
- Department of Rehabilitation, Physical and Sports Medicine, Vilnius University, Vilnius, Lithuania
| | - Aleksandras Laucevičius
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jūratė Barysienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany.,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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19
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Zhou Y, Feng Y, Zhang W, Li H, Zhang K, Wu Z. Physical Exercise in Managing Takayasu Arteritis Patients Complicated With Cardiovascular Diseases. Front Cardiovasc Med 2021; 8:603354. [PMID: 34055922 PMCID: PMC8149735 DOI: 10.3389/fcvm.2021.603354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Takayasu arteritis (TA) is a kind of large-vessel vasculitis that mainly affects the aorta and its branches, and the patients are usually women at a relatively young age. The chronic inflammation of arteries in TA patients leads to stenosis, occlusion, dilatation, or aneurysm formation. Patients with TA thereby have a high risk of cardiovascular disease (CVD) complications, which are the most common cause of mortality. This review summarizes the main cardiovascular complications and the risk factors of cardiovascular complications in patients with TA. Here, we discuss the benefits and potential risks of physical exercise in patients with TA and give recommendations about exercise prescription for TA patients to decrease the risks of CVD and facilitate rehabilitation of cardiovascular complications, which might maximally improve the outcomes.
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Affiliation(s)
- Yaxin Zhou
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Yuan Feng
- Department of Rheumatology and Immunology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Wei Zhang
- Department of Rheumatology and Immunology, Xi'an No.5 Hospital, Xi'an, China
| | - Hongxia Li
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Department of Rheumatology and Immunology, Air Force Medical Center, Air Force Medical University (Fourth Military Medical University), Beijing, China
| | - Kui Zhang
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Zhenbiao Wu
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
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20
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Albanaqi AL, Rahimi GRM, Smart NA. Exercise Training for Pulmonary Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Biol Res Nurs 2020; 23:442-454. [PMID: 33371736 DOI: 10.1177/1099800420982376] [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: 11/16/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a chronic disease with a notable health burden; regular exercise may improve specific health outcome measures. OBJECTIVE The objective of this meta-analysis was to estimate the effectiveness of exercise training for PH patients. DATA SOURCES PubMed, CINAHL, SportDiscuss and Google Scholar databases and reference lists of included studies were searched. STUDY SELECTION The selection criteria were randomized controlled trials (RCTs) employing an exercise training intervention. Data were extracted from the entered studies for analysis. The primary outcomes were peak oxygen uptake (VO2peak), anaerobic threshold (AT), 6-minute walk distance (6-MWD), and quality of life (QoL) measures (physical component score and mental component score). The analysis included 9 articles with a total of 302 participants: intervention (n = 154), and control (n = 148). RESULTS In the pooled analysis, improvements were seen in: VO2peak, mean difference (MD) 2.79 ml/kg/min (95% CI 2.00 to 3.59, p < 0.00001); AT, MD 107.83 ml/min (95% CI 39.64 to 176.00, p = 0.002); and 6-MWD, MD 46.67 meters (95% CI 32.39 to 60.96, p < 0.00001). Differences were found in the SF-36 physical component score MD 3.57 (95% CI 2.04 to 5.10, p < 0.00001) and the SF-36 mental component score MD 3.92 (95% CI 1.92 to 5.91, p = 0.001). CONCLUSION This meta-analysis demonstrates exercise training has a beneficial effect on fitness, walking performance, and self-reported QoL in PH patients.
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Affiliation(s)
- Alsaeedi L Albanaqi
- Turaif General Hospital, Ministry of Health, Kingdom of Saudi Arabia.,School of Science and Technology, 1319University of New England, Armidale, New South Wales, Australia
| | | | - Neil A Smart
- School of Science and Technology, 1319University of New England, Armidale, New South Wales, Australia
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21
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Zhang X, Xu D. Effects of exercise rehabilitation training on patients with pulmonary hypertension. Pulm Circ 2020; 10:2045894020937129. [PMID: 32685130 PMCID: PMC7343373 DOI: 10.1177/2045894020937129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/01/2020] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension (PH) comprises a group of pathophysiological syndromes characterized by elevated pulmonary artery pressure and pulmonary vascular resistance, which lead to right ventricular overload, and even right heart failure. PH has a poor prognosis and severely leads to a decline in quality of life. Historically, patients with PH were advised to limit their physical activity. However, an increasing number of studies have reported the safety and efficacy of exercise rehabilitation training in PH. This review briefly examined and summarized the effects of exercise rehabilitation training on PH patients reported in the recent literature. The findings of the reviewed studies indicate that exercise rehabilitation training in PH patients has beneficial effects in terms of exercise capacity and quality of life, vascular and right ventricle remodelling, inflammatory response, muscular function and oxidative stress. However, the underlying mechanisms and appropriate exercise strategies (e.g. the duration and intensity of exercise) still need to be explored. In conclusion, exercise rehabilitation training of the appropriate intensity and frequency can improve the prognosis and quality of life of PH patients. The training should be monitored by professional staff and be provided as an adjunct to pharmacological treatment. Larger clinical trials are required to confirm the safety and efficacy of exercise rehabilitation training in PH.
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Affiliation(s)
- Xiaojun Zhang
- Department of Internal Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Danyan Xu
- Department of Internal Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
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22
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Waller L, Krüger K, Conrad K, Weiss A, Alack K. Effects of Different Types of Exercise Training on Pulmonary Arterial Hypertension: A Systematic Review. J Clin Med 2020; 9:jcm9061689. [PMID: 32498263 PMCID: PMC7356848 DOI: 10.3390/jcm9061689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/13/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) represents a chronic progressive disease characterized by high blood pressure in the pulmonary arteries leading to right heart failure. The disease has been a focus of medical research for many years due to its worse prognosis and limited treatment options. The aim of this study was to systematically assess the effects of different types of exercise interventions on PAH. Electronic databases were searched until July 2019. MEDLINE database was used as the predominant source for this paper. Studies with regards to chronic physical activity in adult PAH patients are compared on retrieving evidence on cellular, physiological, and psychological alterations in the PAH setting. Twenty human studies and 12 rat trials were identified. Amongst all studies, a total of 628 human subjects and 614 rats were examined. Regular physical activity affects the production of nitric oxygen and attenuates right ventricular hypertrophy. A combination of aerobic, anaerobic, and respiratory muscle training induces the strongest improvement in functional capacity indicated by an increase of 6 MWD and VO2peak. In human studies, an increase of quality of life was found. Exercise training has an overall positive effect on the physiological and psychological components of PAH. Consequently, PAH patients should be encouraged to take part in regular exercise training programs.
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Affiliation(s)
- Lena Waller
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
- Correspondence: ; Tel.: +49-641-99-25212
| | - Karsten Krüger
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| | - Kerstin Conrad
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| | - Astrid Weiss
- Department of Internal Medicine, Institute of Pulmonary Pharmacotherapy, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany;
| | - Katharina Alack
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
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23
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Yılmaz BC, Güçlü MB, Keleş MN, Taçoy GA, Çengel A. Effects of upper extremity aerobic exercise training on oxygen consumption, exercise capacity, dyspnea and quality of life in patients with pulmonary arterial hypertension. Heart Lung 2020; 49:564-571. [PMID: 32457004 DOI: 10.1016/j.hrtlng.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 03/29/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pulmonary and extrapulmonary impairments are prevalent in pulmonary arterial hypertension (PAH) which is a rare, chronic and progressive disease. OBJECTIVES To investigate the effects of upper extremity aerobic exercise training on exercise capacity, oxygen consumption, dyspnea and quality of life in patients with PAH. METHODS In a prospective, randomized controlled, double-blinded study, eleven patients in training group applied upper extremity aerobic exercise training (50-80% of maximal heart rate), 15-45 min/day, 3 days a week for 6 weeks and 11 patients in control group alternating active upper extremity exercises for the same period. Exercise capacity evaluated using six minute walk test (6MWT), oxygen consumption simultaneously measured during 6MWT using a portable instrument, dyspnea modified Borg scale and Modified Medical Research Council dyspnea scale and quality of life Short Form 36 Health Survey, before and after the exercise training. RESULTS Baseline characteristics of groups were similar (p>0.05). Dyspnea (p<0.001) and peak oxygen consumption (p = 0.031) were significantly improved in training group compared the controls. Dyspnea, exercise capacity, peak oxygen consumption, minute ventilation, tidal volume, end tidal carbon-dioxide pressure, and vitality, social functioning and role-physical were significantly improved within training group (p<0.05). Oxygen consumption at anaerobic threshold were significantly decreased within control group (p<0.05). CONCLUSIONS Upper extremity aerobic exercise training improves oxygen consumption, and decreases dyspnea perception. It is a safe and effective intervention in patients with PAH. (ClinicalTrials.gov registration: NCT02371733).
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Affiliation(s)
- Burcu Camcıoğlu Yılmaz
- Muğla Sıtkı Koçman University Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Kötekli Mah., Muğla 48000, Turkey.
| | - Meral Boşnak Güçlü
- Gazi University Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ankara, Turkey
| | - Müşerrefe Nur Keleş
- Gazi University Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ankara, Turkey
| | | | - Atiye Çengel
- Gazi University Faculty of Medicine, Department of Cardiology, Ankara, Turkey
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24
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Chia KSW, Wong PKK, Gonzalez S, Kotlyar E, Faux SG, Shiner CT. Attitudes towards exercise among medical specialists who manage patients with pulmonary hypertension. Pulm Circ 2020; 10:2045894020922806. [PMID: 32489642 PMCID: PMC7238796 DOI: 10.1177/2045894020922806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/07/2020] [Indexed: 11/16/2022] Open
Abstract
Exercise training was not traditionally recommended for patients with pulmonary hypertension. However, recent work has demonstrated that exercise improves endurance and quality-of-life in patients with pulmonary hypertension. Unfortunately, patients with pulmonary hypertension are often sedentary. While some studies have examined patient attitudes to exercise, none have investigated physician perspectives on exercise in patients with pulmonary hypertension. This multinational survey of physicians involved in treating patients with pulmonary hypertension sought to ascertain physician attitudes to exercise and physician-identified barriers and enablers of exercise in this patient population. We collected cross-sectional survey data from a cohort of 280 physicians, including rehabilitation physicians, cardiologists, respiratory physicians and rheumatologists. We found that overall, 86% physicians recommended exercise, in line with current guidelines, although there were differences in the rationale for prescribing exercise and in the type of exercise prescription. Barriers to exercise included patient-related factors, such as patient ill health preventing exercise; poor patient motivation and lack of understanding regarding the benefits of exercise. Systemic barriers included cost/funding issues and limited availability of appropriate services. Perceived enablers of exercise included access to appropriate programmes, provision of education and supportive treating clinicians. Further research is required to identify and implement interventions to promote physical activity in patients with pulmonary hypertension.
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Affiliation(s)
- Karen S W Chia
- Department of Rehabilitation Medicine, St Vincent's Hospital Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Peter K K Wong
- Department of Rheumatology, Westmead Hospital, Sydney, Australia.,Rural Clinical School, Coffs Harbour, University of New South Wales, Sydney, Australia
| | - Senen Gonzalez
- Royal Talbot Rehabilitation Centre, Melbourne, Australia
| | - Eugene Kotlyar
- Department of Rehabilitation Medicine, St Vincent's Hospital Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,Department of Cardiology, St Vincent's Hospital, Sydney, Australia
| | - Steven G Faux
- Department of Rehabilitation Medicine, St Vincent's Hospital Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Christine T Shiner
- Department of Rehabilitation Medicine, St Vincent's Hospital Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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25
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Zeng X, Chen H, Ruan H, Ye X, Li J, Hong C. Effectiveness and safety of exercise training and rehabilitation in pulmonary hypertension: a systematic review and meta-analysis. J Thorac Dis 2020; 12:2691-2705. [PMID: 32642177 PMCID: PMC7330286 DOI: 10.21037/jtd.2020.03.69] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Pulmonary hypertension (PH) is a chronic progressive disease characterized by increasing pulmonary vascular resistance, poor prognosis and high disability rate. Although many targeted drugs for PH have been put to clinical use, most patients still have poor exercise tolerance and quality of life. Exercise training is considered to further improve exercise capacity and quality of life in patients with PH, but it has not been fully studied and utilized. The aim of this systematic review and meta-analysis is to evaluate the effectiveness and safety of exercise training in patients with PH. Methods A search was conducted for the meta-analysis using the databases PubMed, Embase, Cochrane Library, including literature published before December 2018. The primary outcome of this meta-analysis was a change in the 6-minute walk distance (6MWD). In addition, peak oxygen uptake (PeakVO2), resting pulmonary arterial systolic pressure (PASPrest), resting heart rate (HRrest), peak exercise heart rate (HRpeak), oxygen uptake anaerobic threshold (VO2 at AT), maximum workload and quality of life (QoL) were also assessed. Results A total of 651 patients in 17 studies were included. A meta-analysis showed that exercise training was associated with significant improvement in the 6MWD [weighted mean difference (WMD): 64.75 m (95% CI: 53.19–76.31 m, P<0.001)], peakVO2 [WMD: 1.78 mL/min/kg (95% CI: 1.27–2.29 mL/min/kg, P<0.001)], HRpeak [WMD: 11.07 beats/min (95% CI: 8.04–14.11 beats/min, P<0.001)] and QoL measured by SF-36 questionnaire subscale scores. Furthermore, exercise training is well tolerated, and no major adverse event occurred related to exercise training. Conclusions Exercise training is associated with a significant improvement in exercise capacity, cardiorespiratory fitness and quality of life among patients with PH and proved to be safe for stable PH patients with optimization of medical therapy. However, more large-scale multicenter studies are needed to confirm the effectiveness and safety of exercise training in patients with PH.
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Affiliation(s)
- Xiaomei Zeng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,General practice Department, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen 518035, China
| | - Haiming Chen
- First Clinical Medical Institute of Guangzhou Medical University, Guangzhou 510182, China
| | - Honglian Ruan
- School of Public Health, Guangzhou Medical University, Guangzhou 511436, China
| | - Xiaojuan Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,General practice Department, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen 518035, China
| | - Jieying Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Cheng Hong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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26
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Almaaitah S, Highland KB, Tonelli AR. Management of Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Integr Blood Press Control 2020; 13:15-29. [PMID: 32280271 PMCID: PMC7125406 DOI: 10.2147/ibpc.s232038] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/05/2020] [Indexed: 12/25/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare and complex immune-mediated connective tissue disease characterized by multi-organ fibrosis and dysfunction. Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a leading cause of death in this population. Pulmonary arterial hypertension (PAH) can coexist with other forms of pulmonary hypertension in SSc, including pulmonary hypertension related to left heart disease, interstitial lung disease, chronic thromboembolism and pulmonary venous occlusive disease, which further complicates diagnosis and management. Available pulmonary arterial hypertension therapies target the nitric oxide, endothelin and prostacyclin pathways. These therapies have been studied in SSc-PAH in addition to idiopathic PAH, often with different treatment responses. In this article, we discuss the management as well as the treatment options for patients with SSc-PAH.
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Affiliation(s)
- Saja Almaaitah
- Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kristin B Highland
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
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27
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Dasgupta A, Wu D, Tian L, Xiong PY, Dunham-Snary KJ, Chen KH, Alizadeh E, Motamed M, Potus F, Hindmarch CCT, Archer SL. Mitochondria in the Pulmonary Vasculature in Health and Disease: Oxygen-Sensing, Metabolism, and Dynamics. Compr Physiol 2020; 10:713-765. [PMID: 32163206 DOI: 10.1002/cphy.c190027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In lung vascular cells, mitochondria serve a canonical metabolic role, governing energy homeostasis. In addition, mitochondria exist in dynamic networks, which serve noncanonical functions, including regulation of redox signaling, cell cycle, apoptosis, and mitochondrial quality control. Mitochondria in pulmonary artery smooth muscle cells (PASMC) are oxygen sensors and initiate hypoxic pulmonary vasoconstriction. Acquired dysfunction of mitochondrial metabolism and dynamics contribute to a cancer-like phenotype in pulmonary arterial hypertension (PAH). Acquired mitochondrial abnormalities, such as increased pyruvate dehydrogenase kinase (PDK) and pyruvate kinase muscle isoform 2 (PKM2) expression, which increase uncoupled glycolysis (the Warburg phenomenon), are implicated in PAH. Warburg metabolism sustains energy homeostasis by the inhibition of oxidative metabolism that reduces mitochondrial apoptosis, allowing unchecked cell accumulation. Warburg metabolism is initiated by the induction of a pseudohypoxic state, in which DNA methyltransferase (DNMT)-mediated changes in redox signaling cause normoxic activation of HIF-1α and increase PDK expression. Furthermore, mitochondrial division is coordinated with nuclear division through a process called mitotic fission. Increased mitotic fission in PAH, driven by increased fission and reduced fusion favors rapid cell cycle progression and apoptosis resistance. Downregulation of the mitochondrial calcium uniporter complex (MCUC) occurs in PAH and is one potential unifying mechanism linking Warburg metabolism and mitochondrial fission. Mitochondrial metabolic and dynamic disorders combine to promote the hyperproliferative, apoptosis-resistant, phenotype in PAH PASMC, endothelial cells, and fibroblasts. Understanding the molecular mechanism regulating mitochondrial metabolism and dynamics has permitted identification of new biomarkers, nuclear and CT imaging modalities, and new therapeutic targets for PAH. © 2020 American Physiological Society. Compr Physiol 10:713-765, 2020.
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Affiliation(s)
- Asish Dasgupta
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Danchen Wu
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lian Tian
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ping Yu Xiong
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Kuang-Hueih Chen
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Elahe Alizadeh
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Mehras Motamed
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - François Potus
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Charles C T Hindmarch
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Providence Care Hospital, Kingston, Ontario, Canada
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28
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Rafikova O, Al Ghouleh I, Rafikov R. Focus on Early Events: Pathogenesis of Pulmonary Arterial Hypertension Development. Antioxid Redox Signal 2019; 31:933-953. [PMID: 31169021 PMCID: PMC6765063 DOI: 10.1089/ars.2018.7673] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022]
Abstract
Significance: Pulmonary arterial hypertension (PAH) is a progressive disease of the lung vasculature characterized by the proliferation of all vascular wall cell types, including endothelial, smooth muscle, and fibroblasts. The disease rapidly advances into a form with extensive pulmonary vascular remodeling, leading to a rapid increase in pulmonary vascular resistance, which results in right heart failure. Recent Advances: Most current research in the PAH field has been focused on the late stage of the disease, largely due to an urgent need for patient treatment options in clinics. Further, the pathobiology of PAH is multifaceted in the advanced disease, and there has been promising recent progress in identifying various pathological pathways related to the late clinical picture. Critical Issues: Early stage PAH still requires additional attention from the scientific community, and although the survival of patients with early diagnosis is comparatively higher, the disease develops in patients asymptomatically, making it difficult to identify and treat early. Future Directions: There are several reasons to focus on the early stage of PAH. First, the complexity of late stage disease, owing to multiple pathways being activated in a complex system with intra- and intercellular signaling, leads to an unclear picture of the key contributors to the pathobiology. Second, an understanding of early pathophysiological events can increase the ability to identify PAH patients earlier than what is currently possible. Third, the prompt diagnosis of PAH would allow for the therapy to start earlier, which has proved to be a more successful strategy, and it ensures better survival in PAH patients.
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Affiliation(s)
- Olga Rafikova
- Division of Endocrinology, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Imad Al Ghouleh
- Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ruslan Rafikov
- Division of Endocrinology, Department of Medicine, University of Arizona, Tucson, Arizona
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29
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Vasilyeva LI, Egudina ED, Kalashnikova OS, Zhivilo IA, Sapozhnichenko LV. [Physical rehabilitation of patients with pulmonary hypertension]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2019; 96:51-60. [PMID: 31626160 DOI: 10.17116/kurort20199605151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by characterized by a continuous increase in precapillary pulmonary vascular resistance with a progressive decrease in cardiac output, which leads to progressive dyspnea, fatigue, and deterioration of exercise capacity. Traditionally, the patients have been advised to limit physical exercises. Recent studies suggest that there are improvements in exercise capacity, quality of life, muscle function, and pulmonary circulation when cardiovascular and pulmonary rehabilitation programs are implemented. According to the 2015 European Society of Cardiology guidelines for the management of patients with PAH, physical rehabilitation is indicated for clinically stable patients who receive drug therapy for this disease. There are various physical rehabilitation programs, but there is no generally accepted protocol for physical exercises in patients with PAH. The review highlights the pathophysiological mechanisms for reducing exercise capacity in patients with PAH; methods for assessing the right ventricular contractile reserve, the effect of physical stress on the cardiovascular system, lungs, and muscles; the existing physical rehabilitation programs, complications and ways to overcome them are considered. Clinical trials studies are also briefly analyzed; promising areas for further development and improvement of rehabilitation programs are considered.
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Affiliation(s)
- L I Vasilyeva
- Dnipropetrovsk Medical Academy, Ministry of Health of Ukraine, Dnipro, Ukraine
| | - E D Egudina
- Dnipropetrovsk Medical Academy, Ministry of Health of Ukraine, Dnipro, Ukraine
| | - O S Kalashnikova
- Dnipropetrovsk Medical Academy, Ministry of Health of Ukraine, Dnipro, Ukraine
| | - I A Zhivilo
- Academician M.D. Strazhesko National Research Center 'Institute of Cardiology', Kiev, Ukraine
| | - L V Sapozhnichenko
- Dnipropetrovsk Medical Academy, Ministry of Health of Ukraine, Dnipro, Ukraine
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30
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Eichstaedt CA, Benjamin N, Xanthouli P, Marra AM, Grünig E. The role of rehabilitation in patients with pulmonary arterial hypertension. Curr Opin Pulm Med 2019; 25:398-404. [PMID: 31365372 DOI: 10.1097/mcp.0000000000000609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current review summarizes the latest evidence of the effects of exercise training for pulmonary hypertension patients demonstrated by six randomized controlled trails and 20 further studies. As the availability of exercise training is still limited it is important to raise awareness of the body of evidence showing the benefit for the patients and the limitations. RECENT FINDINGS The effects of exercise training on exercise capacity, hemodynamics as well as quality of life are described as well as different settings and components of exercise training. Associated adverse events are critically reviewed and strategies for avoidance of these events discussed. Lastly, the most important issues of availability and reimbursement of a specialized exercise training program are examined and the future path is outlined to improve patient access. SUMMARY The latest publications on this topic strengthen the call for international multicenter randomized controlled trials to establish the feasibility of exercise training in different healthcare systems and to enhance patient access to these programs.
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Affiliation(s)
- Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
- Institute of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL)
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31
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Huston JH, Frantz RP, Brittain EL. Early intervention: should we conduct therapeutic trials for mild pulmonary hypertension before onset of symptoms? Pulm Circ 2019; 9:2045894019845615. [PMID: 30931829 PMCID: PMC6469279 DOI: 10.1177/2045894019844994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease that carries a poor
prognosis. For 45 years, the definition of pulmonary hypertension (PH) has been
a mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg, based on expert opinion.
Recent data indicate that the mortality risk starts in the mPAP range of
21–24 mmHg, which has recently been reflected in the World Symposium on PH
consensus document defining PH as a mPAP > 20 mmHg. The mortality associated
with these lower levels of pulmonary pressures suggests that these values
reflect a more advanced disease stage than previously recognized. It is unknown
whether interventions targeting patients with mPAP values in the range of
21–24 mmHg in the absence of left ventricular or hypoxic lung disease are of
clinical benefit. Here we present historical perspective on the hemodynamic
definition of PH, discuss recent epidemiologic data, and outline obstacles to
enrolling and evaluating response to therapy in mild PAH patients, as well as
potentially useful study designs.
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Affiliation(s)
- Jessica H Huston
- 1 Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert P Frantz
- 2 Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Evan L Brittain
- 1 Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,3 Vanderbilt Translational and Clinical Research Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Grünig E, Eichstaedt C, Barberà JA, Benjamin N, Blanco I, Bossone E, Cittadini A, Coghlan G, Corris P, D'Alto M, D'Andrea A, Delcroix M, de Man F, Gaine S, Ghio S, Gibbs S, Gumbiene L, Howard LS, Johnson M, Jurevičienė E, Kiely DG, Kovacs G, MacKenzie A, Marra AM, McCaffrey N, McCaughey P, Naeije R, Olschewski H, Pepke-Zaba J, Reis A, Santos M, Saxer S, Tulloh RM, Ulrich S, Vonk Noordegraaf A, Peacock AJ. ERS statement on exercise training and rehabilitation in patients with severe chronic pulmonary hypertension. Eur Respir J 2018; 53:13993003.00332-2018. [DOI: 10.1183/13993003.00332-2018] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022]
Abstract
Objectives of this European Respiratory Society task force were to summarise current studies, to develop strategies for future research and to increase availability and awareness of exercise training for pulmonary hypertension (PH) patients.An evidence-based approach with clinical expertise of the task force members, based on both literature search and face-to-face meetings was conducted. The statement summarises current knowledge and open questions regarding clinical effects of exercise training in PH, training modalities, implementation strategies and pathophysiological mechanisms.In studies (784 PH patients in total, including six randomised controlled trials, three controlled trials, 10 prospective cohort studies and four meta-analyses), exercise training has been shown to improve exercise capacity, muscular function, quality of life and possibly right ventricular function and pulmonary haemodynamics. Nevertheless, further studies are needed to confirm these data, to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.As exercise training appears to be effective, cost-efficient and safe, but is scarcely reimbursed, support from healthcare institutions, commissioners of healthcare and research funding institutions is greatly needed. There is a strong need to establish specialised rehabilitation programmes for PH patients to enhance patient access to this treatment intervention.
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Benjamin N, Marra AM, Eichstaedt C, Grünig E. Exercise Training and Rehabilitation in Pulmonary Hypertension. Heart Fail Clin 2018; 14:425-430. [PMID: 29966639 DOI: 10.1016/j.hfc.2018.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Within the last years, exercise training and rehabilitation as add-on to medical treatment has become an emerging field in pulmonary hypertension. Owing to the beneficial effects of exercise training in pulmonary hypertension, the new European Respiratory Society/European Society of Cardiology guidelines for pulmonary hypertension recommended a supervised and closely monitored exercise and respiratory training/rehabilitation as add-on to medical therapy (class IIa, level of evidence B). In this article, different training modalities, effects of exercise training, possible pathobiological mechanisms of action, and future research questions are discussed.
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Affiliation(s)
- Nicola Benjamin
- Department of Pneumology, Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, Heidelberg 69126, Germany; German Center of Lung Research (DZL), TLRC Heidelberg, Germany
| | | | - Christina Eichstaedt
- Department of Pneumology, Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, Heidelberg 69126, Germany; German Center of Lung Research (DZL), TLRC Heidelberg, Germany
| | - Ekkehard Grünig
- Department of Pneumology, Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, Heidelberg 69126, Germany; German Center of Lung Research (DZL), TLRC Heidelberg, Germany.
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McGregor G, Powell R, Finnegan S, Nichols S, Underwood M. Exercise rehabilitation programmes for pulmonary hypertension: a systematic review of intervention components and reporting quality. BMJ Open Sport Exerc Med 2018; 4:e000400. [PMID: 30364456 PMCID: PMC6196941 DOI: 10.1136/bmjsem-2018-000400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 02/02/2023] Open
Abstract
Objectives To identify the components, and assess the reporting quality, of exercise training interventions for people living with pulmonary hypertension. Design Systematic review with analysis of intervention reporting quality using the Consensus on Exercise Reporting Template (CERT). Data sources Eligible studies in the Cochrane Systematic Review of exercise-based rehabilitation for pulmonary hypertension, updated with a new search of relevant databases from 1 August 2016 to 15 January 2018. Eligibility criteria Peer-reviewed journal articles of randomised and non-randomised controlled trials, and non-controlled prospective observational studies, investigating dynamic exercise training interventions in adult humans with diagnosed pulmonary hypertension, reporting on at least one physiological and/or psychosocial outcome. Results Interventions typically involved cycle ergometry and walking. They were delivered as 3-week inpatient, or outpatient and/or home-based programmes, lasting for 4–15 weeks. Components relating specifically to exercise prescription were described satisfactorily and in more detail than motivational/behavioural change strategies, adherence and fidelity. Mean CERT score was 13.1 (range 8–17) out of a possible maximum score of 19. No studies fully reported every aspect of an exercise intervention to the standard recommended by CERT. Summary/conclusion Considerable variability was evident in the components and reporting quality of interventions for exercise rehabilitation studies in pulmonary hypertension. Interventional studies using exercise training should pay greater attention to describing motivational/behavioural change strategies, adherence and fidelity. Detailed description of these parameters is essential for the safe and effective replication of exercise rehabilitation interventions for pulmonary hypertension in clinical practice. Trial registration number CRD42018085558.
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Affiliation(s)
- Gordon McGregor
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital, Coventry, UK.,School of Health & Life Sciences, Coventry University, Coventry, UK
| | - Richard Powell
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital, Coventry, UK
| | - Susanne Finnegan
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Martin Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Lavender M, Chia KS, Dwyer N, Corte TJ, Spencer L, Thakkar V, McWilliams T, Kotlyar E, Whitford H. Safe and effective exercise training for patients with pulmonary arterial hypertension: putting current evidence into clinical practice. Expert Rev Respir Med 2018; 12:965-977. [PMID: 30251562 DOI: 10.1080/17476348.2018.1527687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION While there have been significant advances in the medical treatment of pulmonary arterial hypertension (PAH), life expectancy, and quality of life remain reduced in this disease. Strenuous exercise may be hazardous for PAH patients; however, several relatively small trials have confirmed that exercise training programs can be used safely and effectively as adjunctive treatment for selected patients. The use of exercise training is now recommended in consensus international PAH treatment algorithms; however, there is no published guideline detailing how this intervention should be carried out. Areas covered: This review describes the evidence available and evaluates its applicability to 'real life' clinical practice. The limitations of current evidence are acknowledged, and we discuss how the existing data can be applied to management of PAH patients in Australia, New Zealand, and countries with similar healthcare systems. Recommendations for PAH exercise training are proposed including patient selection, program structure and duration, training modalities, training intensity, supervision, monitoring, safety precautions, and outcome assessments. Expert commentary: It is recognized that knowledge gaps remain and further research is required into physiological mechanisms associated with improved exercise capacity, optimal outpatient exercise regimen, durability of benefit, and whether there is any disease-modifying effect or impact on long-term prognosis.
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Affiliation(s)
- Melanie Lavender
- a Department of Respiratory Medicine , Fiona Stanley Hospital , Clayton , Australia.,b University of New South Wales Rural Clinical School , Clayton , Australia
| | - Karen Sw Chia
- b University of New South Wales Rural Clinical School , Clayton , Australia.,c Coffs Harbour Health Campus , Coffs Harbour , Australia.,d Department of Medicine , University of New South Wales Rural Clinical School , Coffs Harbour , New South Wales , Australia
| | - Nathan Dwyer
- e Cardiology Department, Royal Hobart Hospital , Hobart , Australia.,f School of Medicine, University of Tasmania , Hobart , Australia
| | - Tamera J Corte
- g Department of Respiratory Medicine , Royal Prince Alfred Hospital and University of Sydney , Camperdown , Australia
| | - Lissa Spencer
- h Physiotherapy Department , Royal Prince Alfred Hospital , Camperdown , Australia
| | - Vivek Thakkar
- i Department of Rheumatology , Liverpool Hospital , Liverpool BC , Australia.,j Faculty of Medicine and Health Sciences , Macquarie University , Campbelltown , Australia.,k School of Medicine , Western Sydney University , Campbelltown , Australia
| | | | - Eugene Kotlyar
- m Heart and Lung Transplant unit and Cardiology department , St Vincent's Hospital , Darlinghurst , Australia
| | - Helen Whitford
- n Department of Respiratory Medicine , The Alfred Hospital , Melbourne , Australia
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Vinke P, Jansen SM, Witkamp RF, van Norren K. Increasing quality of life in pulmonary arterial hypertension: is there a role for nutrition? Heart Fail Rev 2018; 23:711-722. [PMID: 29909553 PMCID: PMC6096781 DOI: 10.1007/s10741-018-9717-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease primarily affecting the pulmonary vasculature and heart. PAH patients suffer from exercise intolerance and fatigue, negatively affecting their quality of life. This review summarizes current insights in the pathophysiological mechanisms underlying PAH. It zooms in on the potential involvement of nutritional status and micronutrient deficiencies on PAH exercise intolerance and fatigue, also summarizing the potential benefits of exercise and nutritional interventions. Pubmed/Medline, Scopus, and Web of Science were searched for publications on pathophysiological mechanisms of PAH negatively affecting physical activity potential and nutritional status, and for potential effects of interventions involving exercise or nutritional measures known to improve exercise intolerance. Pathophysiological processes that contribute to exercise intolerance and impaired quality of life of PAH patients include right ventricular dysfunction, inflammation, skeletal muscle alterations, and dysfunctional energy metabolism. PAH-related nutritional deficiencies and metabolic alterations have been linked to fatigue, exercise intolerance, and endothelial dysfunction. Available evidence suggests that exercise interventions can be effective in PAH patients to improve exercise tolerance and decrease fatigue. By contrast, knowledge on the prevalence of micronutrient deficiencies and the possible effects of nutritional interventions in PAH patients is limited. Although data on nutritional status and micronutrient deficiencies in PAH are scarce, the available knowledge, including that from adjacent fields, suggests that nutritional intervention to correct deficiencies and metabolic alterations may contribute to a reduction of disease burden.
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Affiliation(s)
- Paulien Vinke
- Nutrition and Pharmacology Group, Division of Human Nutrition and Health, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Suzanne M Jansen
- Actelion Pharmaceuticals Nederland B.V., Woerden, the Netherlands
| | - Renger F Witkamp
- Nutrition and Pharmacology Group, Division of Human Nutrition and Health, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands
| | - Klaske van Norren
- Nutrition and Pharmacology Group, Division of Human Nutrition and Health, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands
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Rothbard N, Agrawal A, Fischer C, Talwar A, Sahni S. Pulmonary arterial hypertension in the elderly: Clinical perspectives. Cardiol J 2018; 27:184-193. [PMID: 30155860 DOI: 10.5603/cj.a2018.0096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 08/24/2018] [Accepted: 07/11/2018] [Indexed: 01/25/2023] Open
Abstract
Pulmonary hypertension (PH) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, which eventually leads to right ventric-ular failure and death. Pulmonary arterial hypertension (PAH) (World Health Organization Group I), a subset of PH, and may be idiopathic in nature or associated with other systemic conditions and is thought to most commonly effect women, the majority of whom are of childbearing age. However, PAH in the elderly population is being increasingly diagnosed creating clinical considerations that had once not been considered. Often in an elderly population the diagnosis of PAH may be delayed due to chronic comorbid conditions such as coronary artery disease or other dyspneic conditions. Though survival and clinical outcomes have improved, the elderly population continues to have disproportionately lower survival rates. High clinical suspicion of PAH warrants a complete diagnostic workup with right heart catheterization. Upon diagnosis, PAH specific therapy should be initiated with possible drug interactions in mind. Adjuvant pulmonary rehabilitation should be considered as a conservative measure with definitive results. Finally, psychosomatic aspects of the disease should also be considered in elderly populations.
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Affiliation(s)
- Nicholas Rothbard
- Department of Primary Care, Touro College of Osteopathic Medicine, 230 West 125th Street, Suite 220, 10027 New York, United States
| | - Abhinav Agrawal
- Department of Pulmonary, Northwell Health System, Critical Care and Sleep Medicine, 410 Lakeville Rd., Suite 107, 11040 New Hyde Park, United States
| | - Conrad Fischer
- Department of Primary Care, Touro College of Osteopathic Medicine, 230 West 125th Street, Suite 220, 10027 New York, United States.,Department of Medicine, Brookdale University Hospital Medical Center, Brooklyn, NY, United States
| | - Arunabh Talwar
- Department of Pulmonary, Northwell Health System, Critical Care and Sleep Medicine, 410 Lakeville Rd., Suite 107, 11040 New Hyde Park, United States
| | - Sonu Sahni
- Department of Primary Care, Touro College of Osteopathic Medicine, 230 West 125th Street, Suite 220, 10027 New York, United States. .,Department of Medicine, Brookdale University Hospital Medical Center, Brooklyn, NY, United States.
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Grünig E, Benjamin N, Krüger U, Kaemmerer H, Harutyunova S, Olsson KM, Ulrich S, Gerhardt F, Neurohr C, Sablotzki A, Halank M, Marra AM, Kabitz HJ, Thimm G, Fliegel KG, Klose H. General measures and supportive therapy for pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:30-36. [PMID: 30190156 DOI: 10.1016/j.ijcard.2018.08.085] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to general measures (i.e. physical activity/supervised rehabilitation, pregnancy/contraception, elective surgery, infection prevention, psychological support, travel) and supportive therapy (i.e. anticoagulants, diuretics, oxygen, cardiovascular medications, anaemia/iron deficiency, arrhythmias) for PAH. While the European guidelines provide detailed recommendations for the use of targeted PAH therapies as well as supportive care, detailed treatment decisions in routine clinical care may be challenging, and the relevance of supportive care is often not sufficiently considered. In addition, new evidence became available, thus requiring a thorough reevaluation of specific recommendations. The detailed results and recommendations of the working group on general measures and supportive therapy for PAH, which were last updated in the spring of 2018, are summarized in this article.
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Affiliation(s)
- Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany.
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Ulrich Krüger
- Department of Cardiology, Heart Centre Duisburg, Germany
| | - Harald Kaemmerer
- Department of Paediatric Cardiology and Congenital Heart Disease Munich, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, German Centre for Lung Research (DZL), Hannover, Germany
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital Zurich, Switzerland
| | - Felix Gerhardt
- Department of Cardiology, University Hospital Cologne, Germany
| | - Claus Neurohr
- Dept. of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Armin Sablotzki
- Clinic for Anesthesiology St. Georg Hospital, Leipzig, Germany
| | - Michael Halank
- Department of Pneumology, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany; IRCCS S.D.N., Via Gianturco 113, 80143 Naples, Italy
| | - Hans-Joachim Kabitz
- Department of Pneumology and Intensive Care Medicine, Academic Teaching Hospital, Klinikum Konstanz, Germany
| | - Günther Thimm
- Patientenvereinigung Pulmonale Hypertonie e.V., Rheinstetten, Germany
| | | | - Hans Klose
- Department of Pneumology, University Hospital Hamburg-Eppendorf, Germany
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Kaemmerer H, Apitz C, Brockmeier K, Eicken A, Gorenflo M, Hager A, de Haan F, Huntgeburth M, Kozlik-Feldmann RG, Miera O, Diller GP. Pulmonary hypertension in adults with congenital heart disease: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:79-88. [PMID: 30195841 DOI: 10.1016/j.ijcard.2018.08.078] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/24/2018] [Indexed: 01/03/2023]
Abstract
In the summer of 2016, delegates from the German Respiratory Society (DGP), the German Society of Cardiology (DGK) and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH in adults associated with congenital heart disease (CHD). As such patients are often complex and require special attention, and the general PAH treatment algorithm in the ESC/ERS guidelines appears too unspecific for CHD, the working group proposes an analogous algorithm for the management of PH-CHD which takes the special features of this patient group into consideration, and includes general measures, supportive therapy, targeted PAH drug therapy as well as interventional and surgical procedures. The detailed results and recommendations of the working group on PH in adults with CHD, which were last updated in the spring of 2018, are summarized in this article.
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Affiliation(s)
- Harald Kaemmerer
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich, Germany.
| | - Christian Apitz
- Department of Paediatric Cardiology, University Hospital for Paediatric and Adolescent Medicine, Ulm, Germany
| | - Konrad Brockmeier
- Department for Paediatric Cardiology, Heart Centre, University of Cologne, Germany
| | - Andreas Eicken
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich, Germany
| | - Matthias Gorenflo
- Department for Congenital Heart Defects/Paediatric Cardiology, Heidelberg University Hospital, Germany
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich, Germany
| | | | - Michael Huntgeburth
- Clinic for Internal Medicine III, Department of Cardiology, Heart Centre, University of Cologne, Germany
| | - Rainer G Kozlik-Feldmann
- Department for Paediatric Cardiology, University Heart Centre, University Hospital Eppendorf, Hamburg, Germany
| | - Oliver Miera
- Department for Congenital Heart Disease/Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Gerhard P Diller
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
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Grunig G, Eichstaedt CA, Verweyen J, Durmus N, Saxer S, Krafsur G, Stenmark K, Ulrich S, Grünig E, Pylawka S. Circulating MicroRNA Markers for Pulmonary Hypertension in Supervised Exercise Intervention and Nightly Oxygen Intervention. Front Physiol 2018; 9:955. [PMID: 30090067 PMCID: PMC6068281 DOI: 10.3389/fphys.2018.00955] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022] Open
Abstract
Rationale: Therapeutic exercise training has been shown to significantly improve pulmonary hypertension (PH), including 6-min walking distance and right heart function. Supplemental nightly oxygen also has therapeutic effects. A biomarker tool that could query critical gene networks would aid in understanding the molecular effects of the interventions. Methods: Paired bio-banked serum (n = 31) or plasma (n = 21) samples from the exercise or oxygen intervention studies, respectively, and bio-banked plasma samples (n = 20) from high altitude induced PH in cattle were tested. MicroRNAs (miRNAs) markers were chosen for study because they regulate gene expression, control the function of specific gene networks, and are conserved across species. Results: miRNAs that control muscle (miR-22-3p, miR-21-5p) or erythrocyte function (miR-451a) were chosen based on pilot experiments. Plasma samples from cattle that developed PH in high altitude had significantly higher miR-22-3p/(relative to) miR-451a values when compared to control cattle tolerant to high altitude. Measurements of miR-22-3p/miR-451a values in serum from patients receiving exercise training showed that the values were significantly decreased in 74.2% of the samples following intervention and significantly increased in the remainder (25.8%). In samples obtained after exercise intervention, a higher composite miRNA value, made of miR-22-3p and miR-21-5p/miR-451a and spike RNA, was significantly decreased in 65% of the samples and significantly increased in 35% of the samples. In the study of nightly oxygen intervention, when comparing placebo and oxygen, half of the samples showed a significant down-ward change and the other half a significant up-ward change measuring either of the miRNA markers. Samples that had a downward change in the miRNA marker following either intervention originated from patients who had a significantly higher 6-min-walking-distance at baseline (mean difference of 90 m or 80 m following exercise or oxygen intervention, respectively) when compared to samples that had an upward change in the miRNA marker. Conclusion: These natural animal model and human sample studies further highlight the utility of miRNAs as future biomarkers. The different directional changes of the miRNA markers following supervised exercise training or nightly oxygen intervention could indicate different PAH molecular pathomechanisms (endotypes). Further studies are needed to test this idea.
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Affiliation(s)
- Gabriele Grunig
- Department of Environmental Medicine and Division of Pulmonary Medicine, Department of Medicine, New York University School of Medicine, New York, NY, United States.,Mirna Analytics LLC, New York, NY, United States
| | | | | | - Nedim Durmus
- Department of Environmental Medicine and Division of Pulmonary Medicine, Department of Medicine, New York University School of Medicine, New York, NY, United States
| | - Stephanie Saxer
- Clinic for Pulmonology, University Hospital Zürich, Zurich, Switzerland
| | - Greta Krafsur
- Department of Medicine, University of Colorado, Aurora, CO, United States
| | - Kurt Stenmark
- Department of Medicine, University of Colorado, Aurora, CO, United States
| | - Silvia Ulrich
- Clinic for Pulmonology, University Hospital Zürich, Zurich, Switzerland
| | - Ekkehard Grünig
- Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
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Babu AS, Morris NR, Arena R, Myers J. Exercise-based evaluations and interventions for pulmonary hypertension with connective tissue disorders. Expert Rev Respir Med 2018; 12:615-622. [PMID: 29798690 DOI: 10.1080/17476348.2018.1481393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Exercise intolerance is a common and often significant limitation in pulmonary arterial hypertension (PAH). This intolerance greatly affects the quality of life and function of the individual with PAH, irrespective of its etiology. In PAH associated with connective tissue disorders (PAH-CTD), exercise intolerance is further amplified by the presence of coexisting musculoskeletal manifestations of CTD. The evaluation of exercise capacity and prescription for exercise training therefore becomes a challenge to the clinician. Areas covered: This review highlights factors contributing to exercise intolerance in PAH-CTD, evaluation methods of exercise capacity and an overview on exercise training and a roadmap for future research. Expert commentary: Exercise intolerance is a complex interplay of cardiovascular, pulmonary, and musculoskeletal systems. Data from cardiopulmonary exercise tests have shown predictive abilities for both diagnosis and prognosis. In its absence, the 6-min walk test can be used to provide similar information thereby making the role of exercise testing an invaluable evaluation method in PAH-CTD. Exercise training data in PAH-CTD are still sparse, though, data from PAH studies suggest potential benefit. However, more research is required in this area of testing and training for greater understanding on exercise hemodynamic, phenotypes, and training benefits.
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Affiliation(s)
- Abraham Samuel Babu
- a Department of Physiotherapy , School of Allied Health Sciences, Manipal Academy of Higher Education , Manipal , Karnataka , India.,b Department of Cardiology/Medicine, Austin Health, Faculty of Medicine, Dentistry & Health Sciences , University of Melbourne , Melbourne , Australia
| | - Norman R Morris
- c Allied Health Research Collaborative , The Prince Charles Hospital , Brisbane , Queensland , Australia.,d School of Allied Health Sciences and Menzies Health Institute , Griffith University , Brisbane , Queensland , Australia
| | - Ross Arena
- e Department of Physical Therapy , College of Applied Science, University of Illinois at Chicago , Chicago , USA
| | - Jonathan Myers
- f Department of Cardiology , Veterans Affairs/Stanford University , Palo Alto , CA , USA
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Bei Y, Tao L, Cretoiu D, Cretoiu SM, Xiao J. MicroRNAs Mediate Beneficial Effects of Exercise in Heart. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1000:261-280. [PMID: 29098626 DOI: 10.1007/978-981-10-4304-8_15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
MicroRNAs (miRNAs, miRs), a group of small non-coding RNAs, repress gene expressions at posttranscriptional level in most cases and are involved in cardiovascular physiology and disease pathogenesis. Increasing evidence has proved that miRNAs are potential regulators of exercise induced cardiac growth and mediate the benefits of exercise in a variety of cardiovascular diseases. In this chapter, we will review the regulatory effects of miRNAs in cardiac adaptations to exercise, and summarize their cardioprotective effects against myocardial infarction, ischemia/reperfusion injury, heart failure, diabetic cardiomyopathy, atherosclerosis, hypertension, and pulmonary hypertension. Also, we will introduce circulating miRNAs in response to acute and chronic exercise. Therefore, miRNAs may serve as novel therapeutic targets and potential biomarkers for cardiovascular diseases.
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Affiliation(s)
- Yihua Bei
- Cardiac Regeneration and Ageing Lab, School of Life Science, Shanghai University, Shanghai, 200444, China
| | - Lichan Tao
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Dragos Cretoiu
- Victor Babes National Institute of Pathology, Bucharest, 050096, Romania.,Division of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania
| | - Sanda Maria Cretoiu
- Victor Babes National Institute of Pathology, Bucharest, 050096, Romania.,Division of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, Bucharest, 050474, Romania
| | - Junjie Xiao
- Cardiac Regeneration and Ageing Lab, School of Life Science, Shanghai University, Shanghai, 200444, China.
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New insights into the recognition, classification and management of systemic sclerosis-associated pulmonary hypertension. Curr Opin Rheumatol 2018; 29:561-567. [PMID: 28817465 DOI: 10.1097/bor.0000000000000440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Pulmonary hypertension is a common complication of systemic sclerosis (SSc), and remains a leading cause of morbidity and mortality. We will review recent developments in the recognition, classification and treatment of pulmonary hypertension in SSc. RECENT FINDINGS Advances in screening for pulmonary arterial hypertension (PAH) and use of exercise haemodynamics may help to identify pulmonary vascular disease earlier in SSc. Recent studies have led to changes in recommendations for adjunct therapy and selection of pulmonary vasodilators for the treatment of SSc-associated PAH. SUMMARY Recent advances in the diagnosis, classification and management of pulmonary hypertension in SSc have continued to improve our understanding of this challenging disease. Ongoing investigation in the pathogenesis of this disease will afford the opportunity to develop targeted therapies to improve outcomes for SSc patients with pulmonary hypertension.
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Comorbidities in Patients With Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation Outcomes. J Cardiopulm Rehabil Prev 2018; 37:283-289. [PMID: 28410285 DOI: 10.1097/hcr.0000000000000236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE The objective of this study was to evaluate the impact of comorbidities as potential predictors of the response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). METHODS The study included 165 patients with COPD with exercise limitations. Comorbidity was classified as cardiac, metabolic, orthopedic, behavioral health problems, or other diseases. Number of comorbidities was grouped as 0, 1, or ≥2. Outcomes were defined as improvement in exercise capacity (maximal exercise capacity, 6-minute walk test, and constant workload cycle exercise duration) and quality of life (Chronic Respiratory Questionnaire). We assessed the effect of comorbidities on improvement in outcomes and the impact of the number of comorbidities on the percentage of patients reaching the minimal clinically important difference for each outcome. RESULTS Most patients (n = 160; 96%) were elderly males (mean age 70 years) with COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages II to IV. Sixty-four percent of patients had at least 1 comorbidity. The ≥2 comorbidity group (n = 29) had a higher modified Charlson index and more patients required continuous supplemental oxygen. Absolute differences in dyspnea scores in patients with cardiac disease and orthopedic problems compared with those without these comorbidities were 2.6 ± 0.87; 95% CI 0.89 to 4.32; p = .003, and -3.25 ± 1.23; 95% CI -5.69 to -0.82; p = .009, respectively. Comorbidities had no significant effect on other exercise outcomes or quality of life. CONCLUSION Patients with cardiac disease experienced greater improvement in the dyspnea score compared with patients with no cardiac disease, whereas patients with orthopedic problems had a smaller but also clinically significant improvement in dyspnea after pulmonary rehabilitation.
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Sundaram SM, Chung L. An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature. Curr Rheumatol Rep 2018; 20:10. [PMID: 29488016 DOI: 10.1007/s11926-018-0709-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc). RECENT FINDINGS PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor. Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.
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Affiliation(s)
- Sneha M Sundaram
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University, 1000 Welch Road, Suite 201, Palo Alto, CA, 94304, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA.
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46
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Mechanisms underlying the impact of exercise training in pulmonary arterial hypertension. Respir Med 2018; 134:70-78. [DOI: 10.1016/j.rmed.2017.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/10/2017] [Accepted: 11/28/2017] [Indexed: 11/23/2022]
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Abstract
Pulmonary arterial hypertension (PAH) is characterized by a continuous increase in pre-capillary pulmonary vascular resistance (PVR) with a progressive reduction of cardiac output (CO). Similar to what occurs in left heart failure (HF), this represents the initial phase of a syndrome characterized by the progressive development of dyspnea and fatigue with increasing deterioration of exercise tolerance. Although the therapies introduced in the last two decades have determined a significant improvement of the clinical conditions of PAH patients, they have a little impact on exercise capacity and prognosis. However, as previously demonstrated for HF, recent pilot studies have reported that physical and respiratory rehabilitation may have a specific role in the management of PAH. Despite potential risks, so far all studies agree that exercise training (ET) improves exercise capacity, quality of life (QoL), muscle function and pulmonary circulation. We will review the pathophysiological mechanisms underlying the functional incompetence of PAH patients, the effects of ET on clinical and functional parameters, the selection criteria for inclusion of patients in a training program, the suggested monitoring of beneficial effects or possible side effects induced by ET. Finally, we discuss of the possible exercise induced amelioration of prognosis in PAH.
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Affiliation(s)
| | - Maurizio Bussotti
- Department of Cardiology, Istituti Clinici Scientifici Maugeri SpA SB, Istituto di Milano-IRCCS, Milan, Italy
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Brown MB, Kempf A, Collins CM, Long GM, Owens M, Gupta S, Hellman Y, Wong V, Farber M, Lahm T. A prescribed walking regimen plus arginine supplementation improves function and quality of life for patients with pulmonary arterial hypertension: a pilot study. Pulm Circ 2017; 8:2045893217743966. [PMID: 29199900 PMCID: PMC5731727 DOI: 10.1177/2045893217743966] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Current evidence suggests that exercise training is beneficial in pulmonary arterial hypertension (PAH). Unfortunately, the standard supervised, hospital-based programs limit patient accessibility to this important intervention. Our proof-of-concept study aimed to provide insight into the usefulness of a prescribed walking regimen along with arginine supplementation to improve outcomes for patients with PAH. Twelve PAH patients (all women) in New York Heart Association (NYHA) functional class (FC) II (n = 7) or III (n = 5) and in stable condition for ≥ 3 months were enrolled. Patients performed home- and fitness-center- based walking at 65-75% heart rate (HR) reserve for 45 min, six sessions/week for 12 weeks. Concomitant L-arginine supplementation (6000 mg/day) was provided to maximize beneficial endothelial training adaptations. Cardiopulmonary exercise testing, 6-min walk testing (6MWT), echocardiography, laboratory studies, and quality of life (QoL) survey (SF-36) were performed at baseline and 12 weeks. Eleven patients completed the study (72 session adherence rate = 96 ± 3%). Objective improvement was demonstrated by the 6MWT distance (increased by 40 ± 13 m, P = 0.01), VO2max (increased by 2 ± 0.7 mL/kg/min, P = 0.02), time-to-VO2max (increased by 2.5 ± 0.6 min, P = 0.001), VO2 at anaerobic threshold (increased by 1.3 ± 0.5 mL/kg/min, P = 0.04), HR recovery (reduced by 68 ± 23% in slope, P = 0.01), and SF-36 subscales of Physical Functioning and Energy/Fatigue (increased by 70 ± 34% and 74 ± 34%, respectively, P < 0.05). No adverse events occurred, and right ventricular function and brain natriuretic peptide levels remained stable, suggesting safety of the intervention. This proof-of-concept study indicates that a simple walking regimen with arginine supplementation is a safe and efficacious intervention for clinically stable PAH patients, with gains in objective function and QoL measures. Further investigation in a randomized controlled trial is warranted.
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Affiliation(s)
- Mary Beth Brown
- 1 Department of Physical Therapy, Indiana University School of Health and Rehabilitation Sciences, Indianapolis, IN, USA.,2 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attie Kempf
- 1 Department of Physical Therapy, Indiana University School of Health and Rehabilitation Sciences, Indianapolis, IN, USA
| | - Catherine M Collins
- 1 Department of Physical Therapy, Indiana University School of Health and Rehabilitation Sciences, Indianapolis, IN, USA
| | - Gary M Long
- 1 Department of Physical Therapy, Indiana University School of Health and Rehabilitation Sciences, Indianapolis, IN, USA
| | - Matthew Owens
- 1 Department of Physical Therapy, Indiana University School of Health and Rehabilitation Sciences, Indianapolis, IN, USA
| | - Shikha Gupta
- 2 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yaron Hellman
- 3 12250 Division of Cardiology, Department of Medicine, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Vincent Wong
- 3 12250 Division of Cardiology, Department of Medicine, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Mark Farber
- 2 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- 2 Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,4 Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
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Chia KSW, Wong PKK, Faux SG, McLachlan CS, Kotlyar E. The benefit of exercise training in pulmonary hypertension: a clinical review. Intern Med J 2017; 47:361-369. [DOI: 10.1111/imj.13159] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/27/2016] [Accepted: 06/08/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Karen S. W. Chia
- Department of Medicine; University of New South Wales Rural Clinical School; Coffs Harbour New South Wales Australia
- Department of Medicine; Coffs Harbour Health Campus; Coffs Harbour New South Wales Australia
| | - Peter K. K. Wong
- Department of Medicine; University of New South Wales Rural Clinical School; Coffs Harbour New South Wales Australia
- Department of Medicine; Coffs Harbour Health Campus; Coffs Harbour New South Wales Australia
- Mid-North Coast Arthritis Clinic; Coffs Harbour New South Wales Australia
| | - Steven G. Faux
- Department of Rehabilitation, Sacred Heart Rehabilitation; St Vincent's Health; Sydney New South Wales Australia
- Department of Medicine; University of New South Wales; Sydney New South Wales Australia
- Department of Medicine; St Vincent's Hospital; Sydney New South Wales Australia
| | - Craig S. McLachlan
- Department of Medicine; University of New South Wales Rural Clinical School; Coffs Harbour New South Wales Australia
| | - Eugene Kotlyar
- Department of Medicine; University of New South Wales; Sydney New South Wales Australia
- Department of Medicine; St Vincent's Hospital; Sydney New South Wales Australia
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Richter MJ, Grimminger J, Krüger B, Ghofrani HA, Mooren FC, Gall H, Pilat C, Krüger K. Effects of exercise training on pulmonary hemodynamics, functional capacity and inflammation in pulmonary hypertension. Pulm Circ 2017; 7:20-37. [PMID: 28680563 PMCID: PMC5448538 DOI: 10.1086/690553] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension (PH) is characterized by severe exercise limitation mainly attributed to the impairment of right ventricular function resulting from a concomitant elevation of pulmonary vascular resistance and pressure. The unquestioned cornerstone in the management of patients with pulmonary arterial hypertension (PAH) is specific vasoactive medical therapy to improve pulmonary hemodynamics and strengthen right ventricular function. Nevertheless, evidence for a beneficial effect of exercise training (ET) on pulmonary hemodynamics and functional capacity in patients with PH has been growing during the past decade. Beneficial effects of ET on regulating factors, inflammation, and metabolism have also been described. Small case-control studies and randomized clinical trials in larger populations of patients with PH demonstrated substantial improvements in functional capacity after ET. These findings were accompanied by several studies that suggested an effect of ET on inflammation, although a direct link between this effect and the therapeutic benefit of ET in PH has not yet been demonstrated. On this background, the aim of the present review is to describe current concepts regarding the effects of exercise on the pulmonary circulation and pathophysiological limitations, as well as the clinical and mechanistic effects of exercise in patients with PH.
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Affiliation(s)
- Manuel J. Richter
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
| | - Jan Grimminger
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
- Department of Internal Medicine, University Clinic Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Britta Krüger
- Institute of Sport Science, Justus Liebig-University Giessen, Giessen, Germany
| | - Hossein A. Ghofrani
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - Frank C. Mooren
- Department of Sports Medicine, Justus Liebig-University Giessen, Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
| | - Christian Pilat
- Department of Sports Medicine, Justus Liebig-University Giessen, Giessen, Germany
| | - Karsten Krüger
- Department of Sports Medicine, Justus Liebig-University Giessen, Giessen, Germany
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