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Smith JR, Senefeld JW, Larson KF, Joyner MJ. Consequences of group III/IV afferent feedback and respiratory muscle work on exercise tolerance in heart failure with reduced ejection fraction. Exp Physiol 2023; 108:1351-1365. [PMID: 37735814 PMCID: PMC10900130 DOI: 10.1113/ep090755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
Exercise intolerance and exertional dyspnoea are the cardinal symptoms of heart failure with reduced ejection fraction (HFrEF). In HFrEF, abnormal autonomic and cardiopulmonary responses arising from locomotor muscle group III/IV afferent feedback is one of the primary mechanisms contributing to exercise intolerance. HFrEF patients also have pulmonary system and respiratory muscle abnormalities that impair exercise tolerance. Thus, the primary impetus for this review was to describe the mechanistic consequences of locomotor muscle group III/IV afferent feedback and respiratory muscle work in HFrEF. To address this, we first discuss the abnormal autonomic and cardiopulmonary responses mediated by locomotor muscle afferent feedback in HFrEF. Next, we outline how respiratory muscle work impairs exercise tolerance in HFrEF through its effects on locomotor muscle O2 delivery. We then discuss the direct and indirect evidence supporting an interaction between locomotor muscle group III/IV afferent feedback and respiratory muscle work during exercise in HFrEF. Last, we outline future research directions related to locomotor and respiratory muscle abnormalities to progress the field forward in understanding the pathophysiology of exercise intolerance in HFrEF. NEW FINDINGS: What is the topic of this review? This review is focused on understanding the role that locomotor muscle group III/IV afferent feedback and respiratory muscle work play in the pathophysiology of exercise intolerance in patients with heart failure. What advances does it highlight? This review proposes that the concomitant effects of locomotor muscle afferent feedback and respiratory muscle work worsen exercise tolerance and exacerbate exertional dyspnoea in patients with heart failure.
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Affiliation(s)
- Joshua R. Smith
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Jonathon W. Senefeld
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMNUSA
- Department of Kinesiology and Community HealthUniversity of Illinois at Urbana‐ChampaignUrbanaILUSA
| | | | - Michael J. Joyner
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMNUSA
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Analysis of Reasonable Respiratory Efficiency in Tennis Competition and Training Environment Based on Cloud Computing. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4289667. [PMID: 35480156 PMCID: PMC9038377 DOI: 10.1155/2022/4289667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/19/2022] [Accepted: 03/11/2022] [Indexed: 11/23/2022]
Abstract
Competitive tennis is developing in the direction of quantification. How to use and give full play to all positive factors, in order to attack actively and give full play to the limits of body and psychology, breathing, as the basic metabolic function of human body, also plays a vital role in tennis. This paper studies that it plays an important role in the rationality and explosiveness of sports and the psychological and physiological regulation in competition. The characteristics of tennis events determine the importance of scientific and rational breathing. Reasonable breathing during exercise is conducive to maintaining the basic stability of the internal environment, improving the training effect, and giving full play to the functional ability of the human body, so as to create excellent sports results. First, reduce respiratory resistance. Second, there are two methods to improve alveolar ventilation efficiency and pulmonary ventilation: increasing respiratory rate and increasing respiratory depth. When the inhalation volume is constant, the alveolar gas freshness rate depends on the functional residual volume in the alveolar cavity at the end of expiratory or before inhalation. The less functional the residual air, the more fresh air inhaled, and the higher the oxygen partial pressure in alveolar gas. An effective way to reduce the functional residual volume in the alveolar cavity is to exhale as deeply as possible, so as to ensure that more oxygen enters the body. Reasonable breathing methods can not only accelerate the excitation of the body, increase movement strength, reduce fatigue, and promote recovery but also play a vital role in the rational allocation of physical fitness and the improvement of sports performance. The purpose of this study is to provide a theoretical basis for scientific tennis training by analyzing the characteristics of tennis events, the form of breathing in tennis and the efficiency of reasonable breathing in tennis.
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Taylor JL, Bonikowske AR, Olson TP. Optimizing Outcomes in Cardiac Rehabilitation: The Importance of Exercise Intensity. Front Cardiovasc Med 2021; 8:734278. [PMID: 34540924 PMCID: PMC8446279 DOI: 10.3389/fcvm.2021.734278] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 01/04/2023] Open
Abstract
Exercise based cardiac rehabilitation (CR) is recognized internationally as a class 1 clinical practice recommendation for patients with select cardiovascular diseases and heart failure with reduced ejection fraction. Over the past decade, several meta-analyses have generated debate regarding the effectiveness of exercise-based CR for reducing all-cause and cardiovascular mortality. A common theme highlighted in these meta-analyses is the heterogeneity and/or lack of detail regarding exercise prescription methodology within CR programs. Currently there is no international consensus on exercise prescription for CR, and exercise intensity recommendations vary considerably between countries from light-moderate intensity to moderate intensity to moderate-vigorous intensity. As cardiorespiratory fitness [peak oxygen uptake (VO2peak)] is a strong predictor of mortality in patients with coronary heart disease and heart failure, exercise prescription that optimizes improvement in cardiorespiratory fitness and exercise capacity is a critical consideration for the efficacy of CR programming. This review will examine the evidence for prescribing higher-intensity aerobic exercise in CR, including the role of high-intensity interval training. This discussion will highlight the beneficial physiological adaptations to pulmonary, cardiac, vascular, and skeletal muscle systems associated with moderate-vigorous exercise training in patients with coronary heart disease and heart failure. Moreover, this review will propose how varying interval exercise protocols (such as short-duration or long-duration interval training) and exercise progression models may influence central and peripheral physiological adaptations. Importantly, a key focus of this review is to provide clinically-relevant recommendations and strategies to optimize prescription of exercise intensity while maximizing safety in patients attending CR programs.
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Affiliation(s)
- Jenna L Taylor
- Division of Preventative Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Amanda R Bonikowske
- Division of Preventative Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Thomas P Olson
- Division of Preventative Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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Smith JR, Berg JD, Curry TB, Joyner MJ, Olson TP. Respiratory muscle work influences locomotor convective and diffusive oxygen transport in human heart failure during exercise. Physiol Rep 2021; 8:e14484. [PMID: 32562374 PMCID: PMC7305241 DOI: 10.14814/phy2.14484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction It remains unclear if naturally occurring respiratory muscle (RM) work influences leg diffusive O2 transport during exercise in heart failure patients with reduced ejection fraction (HFrEF). In this retrospective study, we hypothesized that RM unloading during submaximal exercise will lead to increases in locomotor muscle O2 diffusion capacity (DMO2) contributing to the greater leg VO2. Methods Ten HFrEF patients and 10 healthy control matched participants performed two submaximal exercise bouts (i.e., with and without RM unloading). During exercise, leg blood flow was measured via constant infusion thermodilution. Intrathoracic pressure was measured via esophageal balloon. Radial arterial and femoral venous blood gases were measured and used to calculate leg arterial and venous content (CaO2 and CvO2, respectively), VO2, O2 delivery, and DMO2. Results From CTL to RM unloading, leg VO2, O2 delivery, and DMO2 were not different in healthy participants during submaximal exercise (all, p > .15). In HFrEF, leg VO2 (CTL: 0.7 ± 0.3 vs. RM unloading: 1.0 ± 0.4 L/min, p < .01), leg O2 delivery (CTL: 0.9 ± 0.4 vs. RM unloading: 1.4 ± 0.5 L/min, p < .01), and leg DMO2 (CTL: 31.5 ± 11.4 vs. RM unloading: 49.7 ± 18.6 ml min−1 mmHg−1) increased from CTL to RM unloading during submaximal exercise (all, p < .01), whereas CaO2‐CvO2 was not different (p = .51). The degree of RM unloading (i.e., % decrease in esophageal pressure‐time integral during inspiration) was related to the % increase in leg DMO2 with RM unloading (r = −.76, p = .01). Conclusion Our data suggest RM unloading leads to increased leg VO2 due to greater convective and diffusive O2 transport during submaximal exercise in HFrEF patients.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jessica D Berg
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy B Curry
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael J Joyner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Smith JR, Hirai DM, Copp SW, Ferguson SK, Holdsworth CT, Hageman KS, Poole DC, Musch TI. Exercise training decreases intercostal and transversus abdominis muscle blood flows in heart failure rats during submaximal exercise. Respir Physiol Neurobiol 2021; 292:103710. [PMID: 34091075 DOI: 10.1016/j.resp.2021.103710] [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: 02/25/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022]
Abstract
Diaphragm muscle blood flow (BF) and vascular conductance (VC) are elevated with chronic heart failure (HF) during exercise. Exercise training (ExT) elicits beneficial respiratory muscle and pulmonary system adaptations in HF. We hypothesized that diaphragm BF and VC would be lower in HF rats following ExT than their sedentary counterparts (Sed). Respiratory muscle BFs and mean arterial pressure were measured via radiolabeled microspheres and carotid artery catheter, respectively, during submaximal treadmill exercise (20 m/min, 5 % grade). During exercise, no differences were present between HF + ExT and HF + Sed in diaphragm BFs (201 ± 36 vs. 227 ± 44 mL/min/100 g) or VCs (both, p > 0.05). HF + ExT compared to HF + Sed had lower intercostal BF (27 ± 3 vs. 41 ± 5 mL/min/100 g) and VC (0.21 ± 0.02 vs. 0.31 ± 0.04 mL/min/mmHg/100 g) during exercise (both, p < 0.05). Further, HF + ExT compared to HF + Sed had lower transversus abdominis BF (20 ± 1 vs. 35 ± 6 mL/min/100 g) and VC (0.14 ± 0.02 vs. 0.27 ± 0.05 mL/min/mmHg/100 g) during exercise (both, p < 0.05). These data suggest that exercise training lowers the intercostal and transversus abdominis BF responses in HF rats during submaximal treadmill exercise.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Daniel M Hirai
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Steven W Copp
- Department of Kinesiology, Kansas State University, Manhattan, KS, United States
| | - Scott K Ferguson
- Department of Kinesiology and Exercise Sciences, University of Hawaii, Hilo, HI, United States
| | - Clark T Holdsworth
- Department of Kinesiology, Kansas State University, Manhattan, KS, United States; Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, United States
| | - K Sue Hageman
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, United States
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, KS, United States; Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, United States
| | - Timothy I Musch
- Department of Kinesiology, Kansas State University, Manhattan, KS, United States; Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, United States
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Kipp S, Leahy MG, Hanna JA, Sheel AW. Partitioning the work of breathing during running and cycling using optoelectronic plethysmography. J Appl Physiol (1985) 2021; 130:1460-1469. [PMID: 33703946 DOI: 10.1152/japplphysiol.00945.2020] [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: 11/22/2022] Open
Abstract
Work of breathing ([Formula: see text]) derived from a single lung volume and pleural pressure is limited and does not fully characterize the mechanical work done by the respiratory musculature. It has long been known that abdominal activation increases with increasing exercise intensity, yet the mechanical work done by these muscles is not reflected in [Formula: see text]. Using optoelectronic plethysmography (OEP), we sought to show first that the volumes obtained from OEP (VCW) were comparable to volumes obtained from flow integration (Vt) during cycling and running, and second, to show that partitioned volume from OEP could be utilized to quantify the mechanical work done by the rib cage ([Formula: see text]RC) and abdomen ([Formula: see text]AB) during exercise. We fit 11 subjects (6 males/5 females) with reflective markers and balloon catheters. Subjects completed an incremental ramp cycling test to exhaustion and a series of submaximal running trials. We found good agreement between VCW versus Vt during cycling (bias = 0.002; P > 0.05) and running (bias = 0.016; P > 0.05). From rest to maximal exercise,[Formula: see text]AB increased by 84% (range: 30%-99%; [Formula: see text]AB: 1 ± 1 J/min to 61 ± 52 J/min). The relative contribution of the abdomen increased from 17 ± 9% at rest to 26 ± 16% during maximal exercise. Our study highlights and provides a quantitative measure of the role of the abdominal muscles during exercise. Incorporating the work done by the abdomen allows for a greater understanding of the mechanical tasks required by the respiratory muscles and could provide further insight into how the respiratory system functions during disease and injury.NEW & NOTEWORTHY We demonstrated that optoelectronic plethysmography (OEP) is a reliable tool to determine ventilatory volume changes during cycling and running, without restricting natural upper arm movements. Second, using OEP volumes coupled with pressure-derived measures, we calculated the work done by the rib cage and abdomen, respectively, during exercise. Collectively, our findings indicate that pulmonary mechanics can be accurately quantified using OEP, and abdominal work performed during ventilation contributes substantially to the overall work of the respiratory musculature.
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Affiliation(s)
- Shalaya Kipp
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael G Leahy
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacob A Hanna
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
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Chen SM, Wang LY, Wu PJ, Liaw MY, Chen YL, Chen AN, Tsai TH, Hang CL, Lin MC. The Interrelationship between Ventilatory Inefficiency and Left Ventricular Ejection Fraction in Terms of Cardiovascular Outcomes in Heart Failure Outpatients. Diagnostics (Basel) 2020; 10:E469. [PMID: 32664450 PMCID: PMC7399946 DOI: 10.3390/diagnostics10070469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/28/2022] Open
Abstract
The relationship between left ventricular ejection fraction (LVEF) and cardiovascular (CV) outcome is documented in patients with low LVEF. Ventilatory inefficiency is an important prognostic predictor. We hypothesized that the presence of ventilatory inefficiency influences the prognostic predictability of LVEF in heart failure (HF) outpatients. In total, 169 HF outpatients underwent the cardiopulmonary exercise test (CPET) and were followed up for a median of 9.25 years. Subjects were divided into five groups of similar size according to baseline LVEF (≤39%, 40-58%, 59-68%, 69-74%, and ≥75%). The primary endpoints were CV mortality and first HF hospitalization. The Cox proportional hazard model was used for simple and multiple regression analyses to evaluate the interrelationship between LVEF and ventilatory inefficiency (ventilatory equivalent for carbon dioxide (VE/VCO2) at anaerobic threshold (AT) >34.3, optimized cut-point). Only LVEF and VE/VCO2 at AT were significant predictors of major CV events. The lower LVEF subgroup (LVEF ≤ 39%) was associated with an increased risk of CV events, relative to the LVEF ≥75% subgroup, except for patients with ventilatory inefficiency (p = 0.400). In conclusion, ventilatory inefficiency influenced the prognostic predictability of LVEF in reduced LVEF outpatients. Ventilatory inefficiency can be used as a therapeutic target in HF management.
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Affiliation(s)
- Shyh-Ming Chen
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Lin-Yi Wang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (L.-Y.W.); (M.-Y.L.)
| | - Po-Jui Wu
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Mei-Yun Liaw
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (L.-Y.W.); (M.-Y.L.)
| | - Yung-Lung Chen
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - An-Ni Chen
- Department of Physical Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | - Tzu-Hsien Tsai
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Chi-Ling Hang
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (Y.-L.C.); (T.-H.T.); (C.-L.H.)
| | - Meng-Chih Lin
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
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Abstract
The heart and lungs are intimately linked. Hence, impaired function of one organ may lead to changes in the other. Accordingly, heart failure is associated with airway obstruction, loss of lung volume, impaired gas exchange, and abnormal ventilatory control. Cardiopulmonary exercise testing is an excellent tool for evaluation of gas exchange and ventilatory control. Indeed, many parameters routinely measured during cardiopulmonary exercise testing, including the level of minute ventilation per unit of carbon dioxide production and the presence of exercise oscillatory ventilation, have been found to be strongly associated with prognosis in patients with heart failure.
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Affiliation(s)
- Ivan Cundrle
- Department of Anesthesiology and Intensive Care, St. Anne's University Hospital, Pekarska 53, Brno 65691, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Lyle J Olson
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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9
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Smith JR, Olson TP. Ventilatory constraints influence physiological dead space in heart failure. Exp Physiol 2018; 104:70-80. [PMID: 30298957 PMCID: PMC6312456 DOI: 10.1113/ep087183] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/08/2018] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? The goal of this study was to investigate the effect of alterations in tidal volume and alveolar volume on the elevated physiological dead space and the contribution of ventilatory constraints thereof in heart failure patients during submaximal exercise. What is the main finding and its importance? We found that physiological dead space was elevated in heart failure via reduced tidal volume and alveolar volume. Furthermore, the degree of ventilatory constraints was associated with physiological dead space and alveolar volume. ABSTRACT Patients who have heart failure with reduced ejection fraction (HFrEF) exhibit impaired ventilatory efficiency [i.e. greater ventilatory equivalent for carbon dioxide ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:mrow> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> <mml:mo>/</mml:mo> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mrow><mml:mi>C</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:mrow> </mml:msub> </mml:mrow> </mml:math> ) slope] and elevated physiological dead space (VD /VT ). However, the impact of breathing strategy on VD /VT during submaximal exercise in HFrEF is unclear. The HFrEF (n = 9) and control (CTL, n = 9) participants performed constant-load cycling exercise at similar ventilation ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> </mml:math> ). Inspiratory capacity, operating lung volumes and arterial blood gases were measured during submaximal exercise. Arterial blood gases were used to derive VD /VT , alveolar volume, dead space volume, alveolar ventilation and dead space ventilation. During submaximal exercise, HFrEF patients had greater <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:mrow> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> <mml:mo>/</mml:mo> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mrow><mml:mi>C</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:mrow> </mml:msub> </mml:mrow> </mml:math> slope and VD /VT than CTL subjects (P = 0.01). At similar <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> </mml:math> , HFrEF patients had smaller tidal volumes and alveolar volumes (HFrEF 1.11 ± 0.33 litres versus CTL 1.66 ± 0.37 litres; both P ≤ 0.01), whereas dead space volume was not different (P = 0.47). The augmented breathing frequency in HFrEF patients resulted in greater dead space ventilation compared with CTL subjects (HFrEF 15 ± 4 l min-1 versus CTL 10 ± 5 l min-1 ; P = 0.048). The HFrEF patients exhibited greater increases in expiratory reserve volume and lower inspiratory capacity (as a percentage of predicted) than CTL subjects (both P < 0.05), which were significantly related to VD /VT and alveolar volume in HFrEF patients (all P < 0.03). In HFrEF, the reduced tidal volume and alveolar volume elevate physiological dead space during submaximal exercise, which is worsened in those with the greatest ventilatory constraints. These findings highlight the negative consequences of ventilatory constraints on physiological dead space during submaximal exercise in HFrEF.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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10
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Smith JR, Van Iterson EH, Johnson BD, Borlaug BA, Olson TP. Exercise ventilatory inefficiency in heart failure and chronic obstructive pulmonary disease. Int J Cardiol 2018; 274:232-236. [PMID: 30201380 DOI: 10.1016/j.ijcard.2018.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 08/13/2018] [Accepted: 09/03/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dyspnea on exertion is common to both heart failure (HF) and chronic obstructive pulmonary disease (COPD), and it is important to discriminate whether symptoms are caused by HF or COPD in clinical practice. The ventilatory equivalent for carbon dioxide (V̇E/V̇CO2) slope and V̇E intercept (a reflection of pulmonary dead space) are two candidate non-invasive indices that could be used for this purpose. Thus, we compared non-invasive indexes of ventilatory efficiency in patients with HF and preserved or reduced ejection fraction (HFpEF and HFrEF, respectively) or COPD. METHODS Patients with HFpEF (n = 21), HFrEF (n = 20), and COPD (n = 22) patients performed cardiopulmonary exercise testing to volitional fatigue. V̇E and gas exchange were measured via breath-by-breath open circuit spirometry. All data from rest to peak exercise were used to calculate V̇E/V̇CO2 slope and V̇E intercept using linear regression. Receiver operating characteristic (ROC) curves were constructed to determine optimized cutoffs for V̇E/V̇CO2 slope and V̇E intercept to discriminate HFpEF and HFrEF from COPD. RESULTS HFrEF patients had a greater V̇E/V̇CO2 slope than HFpEF and COPD patients (HFrEF: 40 ± 9; HFpEF: 32 ± 7; COPD: 32 ± 7) (p < 0.01). COPD patients had a greater V̇E intercept than HFpEF and HFrEF patients (COPD: 3.32 ± 1.66; HFpEF: 0.77 ± 1.23; HFrEF: 1.28 ± 1.19 L/min) (p < 0.01). A V̇E intercept of 2.64 L/min discriminated COPD from HF patients (AUC: 0.88, p < 0.01), while V̇E/V̇CO2 slope did not (p = 0.11). CONCLUSION These findings demonstrate that V̇E intercept, not V̇E/V̇CO2 slope, may discriminate COPD from both HFpEF and HFrEF patients.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Erik H Van Iterson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Bruce D Johnson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
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11
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Obokata M, Olson TP, Reddy YNV, Melenovsky V, Kane GC, Borlaug BA. Haemodynamics, dyspnoea, and pulmonary reserve in heart failure with preserved ejection fraction. Eur Heart J 2018; 39:2810-2821. [PMID: 29788047 PMCID: PMC6658816 DOI: 10.1093/eurheartj/ehy268] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/14/2018] [Accepted: 04/30/2018] [Indexed: 02/06/2023] Open
Abstract
Aims Increases in left ventricular filling pressure are a fundamental haemodynamic abnormality in heart failure with preserved ejection fraction (HFpEF). However, very little is known regarding how elevated filling pressures cause pulmonary abnormalities or symptoms of dyspnoea. We sought to determine the relationships between simultaneously measured central haemodynamics, symptoms, and lung ventilatory and gas exchange abnormalities during exercise in HFpEF. Methods and results Subjects with invasively-proven HFpEF (n = 50) and non-cardiac causes of dyspnoea (controls, n = 24) underwent cardiac catheterization at rest and during exercise with simultaneous expired gas analysis. During submaximal (20 W) exercise, subjects with HFpEF displayed higher pulmonary capillary wedge pressures (PCWP) and pulmonary artery pressures, higher Borg perceived dyspnoea scores, and increased ventilatory drive and respiratory rate. At peak exercise, ventilation reserve was reduced in HFpEF compared with controls, with greater dead space ventilation (higher VD/VT). Increasing exercise PCWP was directly correlated with higher perceived dyspnoea scores, lower peak exercise capacity, greater ventilatory drive, worse New York Heart Association (NYHA) functional class, and impaired pulmonary ventilation reserve. Conclusion This study provides the first evidence linking altered exercise haemodynamics to pulmonary abnormalities and symptoms of dyspnoea in patients with HFpEF. Further study is required to identify the mechanisms by which haemodynamic derangements affect lung function and symptoms and to test novel therapies targeting exercise haemodynamics in HFpEF.
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Affiliation(s)
- Masaru Obokata
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Thomas P Olson
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Yogesh N V Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Vojtech Melenovsky
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Garvan C Kane
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Barry A Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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Van Iterson EH, Smith JR, Olson TP. Exercise on-transition uncoupling of ventilatory, gas exchange and cardiac hemodynamic kinetics accompany pulmonary oxygen stores depletion to impact exercise intolerance in human heart failure. Acta Physiol (Oxf) 2018; 223:e13063. [PMID: 29575588 DOI: 10.1111/apha.13063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 03/04/2018] [Accepted: 03/08/2018] [Indexed: 12/16/2022]
Abstract
AIM In contrast to knowledge that heart failure (HF) patients demonstrate peak exercise uncoupling across ventilation, gas exchange and cardiac haemodynamics, whether this dyssynchrony follows that at the exercise on-transition is unclear. This study tested whether exercise on-transition temporal lag for ventilation relative to gas exchange and oxygen pulse (O2 pulse) couples with effects from abnormal pulmonary gaseous oxygen store (O2store ) contributions to V˙O2 to interdependently precipitate persistently elevated ventilatory demand and low oxidative metabolic capacity in HF. METHODS Beat-to-beat HR and breath-to-breath ventilation and gas exchange were continuously acquired in HF (N = 9, ejection fraction = 30 ± 9%) and matched controls (N = 10) during square-wave ergometry at 60% V˙O2peak (46 ± 14 vs 125 ± 54-W, P < .001). Temporal responses across V˙E , V˙O2 and O2 pulse were assessed for the exercise on-transition using single exponential model Phase II on-kinetic time constants (τ = time to reach 63% steady-state rise). Breath-to-breath gas fractions and respiratory flows were used to determine O2stores . RESULTS HF vs controls: τ for V˙E (137 ± 93 vs 74 ± 40-seconds, P = .03), V˙O2 (60 ± 40 vs 23 ± 5-seconds, P = .03) and O2 pulse (28 ± 18 vs 23 ± 15-seconds, P = .59). Within HF, τ for V˙E differed from O2 pulse (P < .02), but not V˙O2 . Exercise V˙E rise (workload indexed) differed in HF vs controls (545 ± 139 vs 309 ± 88-mL min-1 W-1 , P < .001). Exercise on-transition O2store depletion in HF exceeded controls, generally persisting to end-exercise. CONCLUSION These data suggest HF demonstrated exercise on-transition O2store depletion (high O2store contribution to V˙O2 ) coupled with dyssynchronous V˙E , V˙O2 and O2 pulse kinetics-not attributable to prolonged cardiac haemodynamics. Persistent high ventilatory demand and low oxidative metabolic capacity in HF may be precipitated by physiological uncoupling occurring within the exercise on-transition.
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Affiliation(s)
- E. H. Van Iterson
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester MN USA
| | - J. R. Smith
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester MN USA
| | - T. P. Olson
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester MN USA
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13
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Olson TP, Johnson BD, Borlaug BA. Impaired Pulmonary Diffusion in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2016; 4:490-8. [PMID: 27256752 PMCID: PMC4893169 DOI: 10.1016/j.jchf.2016.03.001] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/29/2016] [Accepted: 03/02/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The purpose of this study was to compare measures of gas exchange at rest and during exercise in patients with heart failure and preserved ejection fraction (HFpEF) with age- and sex-matched control subjects. BACKGROUND Patients with HFpEF display elevation in left heart pressures, but it is unclear how this affects pulmonary gas transfer or its determinants at rest and during exercise. METHODS Patients with HFpEF (n = 20) and control subjects (n = 26) completed a recumbent cycle ergometry exercise test with simultaneous measurement of ventilation and gas exchange. Diffusion of the lungs for carbon monoxide (DLCO) and its subcomponents, pulmonary capillary blood volume (VC) and alveolar-capillary membrane conductance (DM), were measured at rest, and matched for low-intensity (20 W) and peak exercise. Stroke volume was measured by transthoracic echocardiography to calculate cardiac output. RESULTS Compared with control subjects, patients with HFpEF displayed impaired diastolic function and reduced exercise capacity. Patients with HFpEF demonstrated a 24% lower DLCO at rest (11.0 ± 2.3 ml/mm Hg/min vs. 14.4 ± 3.3 ml/mm Hg/min; p < 0.01) related to reductions in both DM (18.1 ± 4.9 ml/mm Hg/min vs. 23.1 ± 9.1 ml/mm Hg/min; p = 0.04), and VC (45.9 ± 15.2. ml vs. 58.9 ± 16.2 ml; p = 0.01). DLCO was lower in patients with HFpEF compared with control subjects in all stages of exercise, yet its determinants showed variable responses. With low-level exercise, patients with HFpEF demonstrated greater relative increases in VC, coupled with heightened ventilatory drive and more severe symptoms of dyspnea compared with control subjects. At 20-W exercise, DM was markedly reduced in patients with HFpEF compared with control subjects. From 20 W to peak exercise, there was no further increase in VC in patients with HFpEF, which in tandem with reduced DM, led to a 30% reduction in DLCO at peak exercise (17.3 ± 4.2 ml/mm Hg/min vs. 24.7 ± 7.1 ml/mm Hg/min; p < 0.01). CONCLUSIONS Subjects with HFpEF display altered pulmonary function and gas exchange at rest and especially during exercise, which contributes to exercise intolerance. Novel therapies that improve gas diffusion may be effective to improve exercise tolerance in patients with HFpEF.
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Affiliation(s)
- Thomas P Olson
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota.
| | - Bruce D Johnson
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
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14
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Keller-Ross ML, Johnson BD, Carter RE, Joyner MJ, Eisenach JH, Curry TB, Olson TP. Improved Ventilatory Efficiency with Locomotor Muscle Afferent Inhibition is Strongly Associated with Leg Composition in Heart Failure. Int J Cardiol 2015; 202:159-66. [PMID: 26397403 DOI: 10.1016/j.ijcard.2015.08.212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/26/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Skeletal muscle atrophy contributes to increased afferent feedback (group III and IV) and may influence ventilatory control (high VE/VCO2 slope) in heart failure (HF). OBJECTIVE This study examined the influence of muscle mass on the change in VE/VCO2 with afferent neural block during exercise in HF. METHODS 17 participants [9 HF (60±6 yrs) and 8 controls (CTL) (63±7 yrs, mean±SD)] completed 3 sessions. Session 1: dual energy x-ray absorptiometry and graded cycle exercise to volitional fatigue. Sessions 2 and 3: 5 min of constant-work cycle exercise (65% of peak power) randomized to lumbar intrathecal injection of fentanyl (afferent blockade) or placebo. Ventilation (VE) and gas exchange (oxygen consumption, VO2; carbon dioxide production, VCO2) were measured. RESULTS Peak work and VO2 were lower in HF (p<0.05). Leg fat was greater in HF (34.4±3.0 and 26.3±1.8%) and leg muscle mass was lower in HF (63.0±2.8 and 70.4±1.8%, respectively, p<0.05). VE/VCO2 slope was reduced in HF during afferent blockade compared with CTL (-18.8±2.7 and -1.4±2.0%, respectively, p=0.02) and was positively associated with leg muscle mass (r2=0.58, p<0.01) and negatively associated with leg fat mass (r2=0.73, p<0.01) in HF only. CONCLUSIONS HF patients with the highest fat mass and the least leg muscle mass had the greatest improvement in VE/VCO2 with afferent blockade with leg fat mass being the only predictor for the improvement in VE/VCO2 slope. Both leg muscle mass and fat mass are important contributors to ventilatory abnormalities and strongly associated to improvements in VE/VCO2 slope with locomotor afferent inhibition in HF.
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Affiliation(s)
- Manda L Keller-Ross
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN 55905.
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN 55905
| | - Rickey E Carter
- Department of Health Sciences Research, Mayo College of Medicine, Rochester, MN 55905
| | - Michael J Joyner
- Department of Anesthesiology, Mayo College of Medicine, Rochester, MN 55905
| | - John H Eisenach
- Department of Anesthesiology, Mayo College of Medicine, Rochester, MN 55905
| | - Timothy B Curry
- Department of Anesthesiology, Mayo College of Medicine, Rochester, MN 55905
| | - Thomas P Olson
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN 55905
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15
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Kim CH, Cha YM, Shen WK, Maccarter DJ, Taylor BJ, Johnson BD. Effects of atrioventricular and interventricular delays on gas exchange during exercise in patients with heart failure. J Heart Lung Transplant 2014; 33:397-403. [PMID: 24594137 DOI: 10.1016/j.healun.2014.01.855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/22/2013] [Accepted: 01/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been an important treatment for heart failure. However, it is controversial as to whether an individualized approach to altering AV and VV timing intervals would improve outcomes. Changes in respiratory patterns and gas exchange are dynamic and may be influenced by timing delays. Light exercise enhances the heart and lung interactions. Thus, in this study we investigated changes in non-invasive gas exchange by altering AV and VV timing intervals during light exercise. METHODS Patients (n = 20, age 66 ± 9 years) performed two walking tests post-implantation. The protocol evaluated AV delays (100, 120, 140, 160 and 180 milliseconds), followed by VV delays (0, -20 and -40 milliseconds) while gas exchange was assessed. RESULTS There was no consistent group pattern of change in gas exchange variables across AV and VV delays (p > 0.05). However, there were modest changes in these variables on an individual basis with variations in VE/VCO2 averaging 10%; O2 pulse 11% and PETCO2 5% across AV delays, and 4%, 8% and 2%, respectively, across VV delays. Delays that resulted in the most improved gas exchange differed from nominal in 17 of 20 subjects. CONCLUSION Gas exchange measures can be improved by optimization of AV and VV delays and thus could be used to individualize the approach to CRT optimization.
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Affiliation(s)
- Chul-Ho Kim
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
| | | | - Bryan J Taylor
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Bruce D Johnson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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16
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Olson TP, Joyner MJ, Eisenach JH, Curry TB, Johnson BD. Influence of locomotor muscle afferent inhibition on the ventilatory response to exercise in heart failure. Exp Physiol 2013; 99:414-26. [DOI: 10.1113/expphysiol.2013.075937] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Thomas P. Olson
- Departments of Internal Medicine; Division of Cardiovascular Diseases
| | | | | | | | - Bruce D. Johnson
- Departments of Internal Medicine; Division of Cardiovascular Diseases
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17
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Abstract
During dynamic exercise, the healthy pulmonary system faces several major challenges, including decreases in mixed venous oxygen content and increases in mixed venous carbon dioxide. As such, the ventilatory demand is increased, while the rising cardiac output means that blood will have considerably less time in the pulmonary capillaries to accomplish gas exchange. Blood gas homeostasis must be accomplished by precise regulation of alveolar ventilation via medullary neural networks and sensory reflex mechanisms. It is equally important that cardiovascular and pulmonary system responses to exercise be precisely matched to the increase in metabolic requirements, and that the substantial gas transport needs of both respiratory and locomotor muscles be considered. Our article addresses each of these topics with emphasis on the healthy, young adult exercising in normoxia. We review recent evidence concerning how exercise hyperpnea influences sympathetic vasoconstrictor outflow and the effect this might have on the ability to perform muscular work. We also review sex-based differences in lung mechanics.
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Affiliation(s)
- Andrew William Sheel
- The School of Kinesiology, The University of British Columbia, Vancouver, Canada.
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18
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Quantifying oscillatory ventilation during exercise in patients with heart failure. Respir Physiol Neurobiol 2013; 190:25-32. [PMID: 24121091 DOI: 10.1016/j.resp.2013.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 09/06/2013] [Accepted: 09/18/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study examined the validity of a novel software application to quantify measures of periodic breathing rest (PB) and oscillatory ventilation during exercise (EOV) in heart failure patients (HF). METHODS Eleven male HF patients (age=53±8yrs, ejection fraction=17±4, New York Heart Association Class=III(7)/IV(4)) were recruited. Ventilation and gas exchange were collected breath-by-breath. Amplitude and period of oscillations in ventilation (V˙E), tidal volume (VT), end-tidal carbon dioxide [Formula: see text] , and oxygen consumption [Formula: see text] were measured manually (MAN) and using novel software which included a peak detection algorithm (PK), sine wave fitting algorithm (SINE), and Fourier analysis (FOUR). RESULTS During PB, there were no differences between MAN and PK for amplitude of V˙E, VT, [Formula: see text] , or [Formula: see text] . Similarly, there were no differences between MAN and SINE for amplitude of V˙E or VT although [Formula: see text] and [Formula: see text] were lower with SINE (p<0.05). In contrast, the PK demonstrated significantly shorter periods for V˙E, VT, [Formula: see text] , and [Formula: see text] compared to MAN (p<0.05) whereas there were no differences in periods of oscillations between MAN and SINE or FOUR for all variables. During EOV, there were no differences between MAN and PK for amplitude of V˙E, VT, [Formula: see text] , and [Formula: see text] . SINE demonstrated significantly lower amplitudes for VT, [Formula: see text] , and [Formula: see text] (p<0.05) although V˙E was not different. PK demonstrated shorter periods for all variables (p<0.05) whereas there were no differences between MAN and SINE or FOUR for all variables. CONCLUSION These data suggest PK consistently captures amplitudes while underestimating period. In contrast, SINE and FOUR consistently capture period although SINE underestimates amplitude. Thus, an optimal algorithm for the quantification of PB and/or EOV in patients with HF might combine multiple analysis methods.
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A multivariable index for grading exercise gas exchange severity in patients with pulmonary arterial hypertension and heart failure. Pulm Med 2012; 2012:962598. [PMID: 23346397 PMCID: PMC3549363 DOI: 10.1155/2012/962598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/27/2012] [Indexed: 11/21/2022] Open
Abstract
Patients with pulmonary arterial hypertension (PAH) and heart failure (HF) display many abnormalities in respiratory gas exchange. These abnormalities are accentuated with exercise and track with disease severity. However, use of gas exchange measures in day-to-day clinical practice is limited by several issues, including the large number of variables available and difficulty in data interpretation. Moreover, maximal exercise testing has limitations in clinical populations due to their complexity, patient anxiety and variability in protocols and cost. Therefore, a multivariable gas exchange index (MVI) that integrates key gas exchange variables obtained during submaximal exercise into a severity score that ranges from normal to severe-very-severe is proposed. To demonstrate the usefulness of this index, we applied this to 2 groups (PAH, n = 42 and HF, n = 47) as well as to age matched healthy controls (n = 25). We demonstrate that this score tracks WHO classification and right ventricular systolic pressure in PAH (r = 0.53 and 0.73, P ≤ 0.01) and NYHA and cardiac index in HF (r = 0.49 and 0.74, P ≤ 0.01). This index demonstrates a stronger relationship than any single gas exchange variable alone. In conclusion, MVI obtained from light, submaximal exercise gas exchange is a useful approach to simplify data interpretation in PAH and HF populations.
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20
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Lalande S, Luoma CE, Miller AD, Johnson BD. Effect of changes in intrathoracic pressure on cardiac function at rest and during moderate exercise in health and heart failure. Exp Physiol 2011; 97:248-56. [PMID: 22080485 DOI: 10.1113/expphysiol.2011.061945] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study investigated the effect of changes in inspiratory intrathoracic pressure on stroke volume at rest and during moderate exercise in patients with heart failure and reduced ejection fraction (HFREF) as well as healthy individuals. Stroke volume was obtained by echocardiography during 2 min of spontaneous breathing (S), two progressive levels of inspiratory unloading (UL1 and UL2) using a ventilator, and two progressive levels of inspiratory loading using resistors in 11 patients with HFREF (61 ± 9 years old; ejection fraction 32 ± 4%; NYHA class I-II) and 11 age-matched healthy individuals at rest and during exercise at 60% of maximal aerobic capacity on a semi-recumbent cycle ergometer. At rest, inspiratory unloading progressively decreased stroke volume index (SVI; S, 35.2 ± 5.4 ml m(-2); UL1, 33.3 ± 5.1 ml m(-2); and UL2, 32.2 ± 4.4 ml m(-2)) in healthy individuals, while it increased SVI (S, 31.4 ± 4.6 ml m(-2); UL1, 32.0 ± 5.9 ml m(-2); and UL2, 34.0 ± 7.2 ml m(-2)) in patients with HFREF (P = 0.04). During moderate exercise, inspiratory unloading decreased SVI in a similar manner (S, 43.9 ± 7.1 ml m(-2); UL1, 40.7 ± 4.7 ml m(-2); and UL2, 39.9 ± 3.7 ml m(-1)) in healthy individuals, while it increased SVI (S, 40.8 ± 6.5 ml m(-2); UL1, 42.8 ± 6.9 ml m(-2); and UL2, 44.1 ± 4. ml m(-2)) in patients with HFREF (P = 0.02). Inspiratory loading did not significantly change SVI at rest or during moderate exercise in both groups. It is concluded that inspiratory unloading improved SVI at rest and during moderate exercise in patients with HFREF, possibly due to a reduction in left ventricular afterload.
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Affiliation(s)
- Sophie Lalande
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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21
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Arena R, Sietsema KE. Cardiopulmonary exercise testing in the clinical evaluation of patients with heart and lung disease. Circulation 2011; 123:668-80. [PMID: 21321183 DOI: 10.1161/circulationaha.109.914788] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ross Arena
- Department of Physical Therapy, Virginia Commonwealth University, Richmond Virginia 23298-0224, USA.
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TOMCZAK SIMONEE, GUENETTE JORDANA, REID WDARLENE, MCKENZIE DONALDC, SHEEL AWILLIAM. Diaphragm Fatigue after Submaximal Exercise with Chest Wall Restriction. Med Sci Sports Exerc 2011; 43:416-24. [DOI: 10.1249/mss.0b013e3181ef5e67] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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23
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Olson TP, Johnson BD. Influence of cardiomegaly on disordered breathing during exercise in chronic heart failure. Eur J Heart Fail 2010; 13:311-8. [PMID: 20952768 DOI: 10.1093/eurjhf/hfq177] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Heart failure (HF) patients breathe with a rapid shallow pattern during exercise. This study examined the relationship between cardiac size and tachypnoeic breathing in HF patients during exercise. METHODS AND RESULTS Thirty-seven HF patients [age = 55 ± 13 years, ejection fraction (EF) = 27 ± 10%, New York Heart Association (NYHA) class = 2.3 ± 1.2] and 42 controls (CTL) (age = 56 ± 14 years, EF = 63 ± 8%) were recruited. Participants underwent maximal exercise testing, pulmonary function testing, and chest radiography for calculation of total thoracic cavity volume (TTCV), diaphragm, heart, and lung volumes. Heart failure patients were divided into two groups: Group A = cardiac volume < median (n = 18) and Group B = cardiac volume ≥ median of the HF patients (n = 19). There was no difference between groups for TTCV (CTL = 8203 ± 1489 vs. Group A = 8694 ± 1249 vs. Group B = 8195 ± 1823 cm(3)). Cardiac volume was different between groups for both absolute (CTL = 630 ± 181 vs. Group A = 894 ± 186 vs. Group B = 1401 ± 382 cm(3), P< 0.001 for all comparisons) and %TTCV (CTL = 8 ± 2 vs. Group A = 10 ± 1 vs. Group A = 18 ± 5%, P< 0.001 for all comparisons). Similarly, total lung volume as a %TTCV was significantly different among the groups (CTL = 70 ± 4 vs. Group A = 65 ± 5 vs. Group A = 58 ± 7%, P< 0.01 for all comparisons). In HF patients, there was a trend (P = 0.10) towards an independent association between cardiac size and tidal volume (V(T)) at 75% of VO(2) peak whereas this relationship was statistically significant at VO(2) peak (P = 0.02) as patients with larger cardiac size had reduced V(T). CONCLUSION This study demonstrates the close relationship between cardiac size and breathing pattern during exercise in HF patients. These results suggest cardiac size may pose a significant constraint on the lungs during exercise and may contribute to tachypnoeic breathing.
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Affiliation(s)
- Thomas P Olson
- Division of Cardiovascular Diseases, Department of Internal Medicine, Joseph 4-221, Mayo Clinic and Foundation, Rochester, MN 55905, USA.
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Woods PR, Olson TP, Frantz RP, Johnson BD. Causes of breathing inefficiency during exercise in heart failure. J Card Fail 2010; 16:835-42. [PMID: 20932466 DOI: 10.1016/j.cardfail.2010.05.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 05/04/2010] [Accepted: 05/06/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with heart failure (HF) develop abnormal pulmonary gas exchange; specifically, they have abnormal ventilation relative to metabolic demand (ventilatory efficiency/minute ventilation in relation to carbon dioxide production [V(E)/VCO₂]) during exercise. The purpose of this investigation was to examine the factors that underlie the abnormal breathing efficiency in this population. METHODS AND RESULTS Fourteen controls and 33 moderate-severe HF patients, ages 52 ± 12 and 54 ± 8 years, respectively, performed submaximal exercise (∼65% of maximum) on a cycle ergometer. Gas exchange and blood gas measurements were made at rest and during exercise. Submaximal exercise data were used to quantify the influence of hyperventilation (PaCO₂) and dead space ventilation (V(D)) on V(E)/VCO₂. The V(E)/VCO₂ relationship was lower in controls (30 ± 4) than HF (45 ± 9, P < .01). This was the result of hyperventilation (lower PaCO₂) and higher V(D)/V(T) that contributed 40% and 47%, respectively, to the increased V(E)/VCO₂ (P < .01). The elevated V(D)/V(T) in the HF patients was the result of a tachypneic breathing pattern (lower V(T), 1086 ± 366 versus 2003 ± 504 mL, P < .01) in the presence of a normal V(D) (11.5 ± 4.0 versus 11.9 ± 5.7 L/min, P = .095). CONCLUSIONS The abnormal ventilation in relation to metabolic demand in HF patients during exercise was due primarily to alterations in breathing pattern (reduced V(T)) and excessive hyperventilation.
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Affiliation(s)
- Paul R Woods
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55902, USA.
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25
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Olson TP, Joyner MJ, Dietz NM, Eisenach JH, Curry TB, Johnson BD. Effects of respiratory muscle work on blood flow distribution during exercise in heart failure. J Physiol 2010; 588:2487-501. [PMID: 20457736 DOI: 10.1113/jphysiol.2009.186056] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Heart failure (HF) patients have a reduced cardiac reserve and increased work of breathing. Increased locomotor muscle blood flow demand may result in competition between respiratory and locomotor vascular beds. We hypothesized that HF patients would demonstrate improved locomotor blood flow with respiratory muscle unloading during activity. Ten patients (ejection fraction = 31 +/- 3%) and 10 controls (CTL) underwent two cycling sessions (60% peak work). Session 1 (S1): 5 min of normal breathing (NB), 5 min respiratory muscle unloading with a ventilator, and 5 min of NB. Session 2 (S2): 5 min NB, 5 min of respiratory muscle loading with inspiratory resistance, and 5 min of NB. Measurements included: leg blood flow (LBF, thermodilution), cardiac output (Q), and oesophageal pressure (P(pl), index of pleural pressure). S1: P(pl) was reduced in both groups (HF: 73 +/- 8%; CTL: 60 +/- 13%, P < 0.01). HF: Q increased (9.6 +/- 0.4 vs. 11.3 +/- 0.8 l min(-1), P < 0.05) and LBF increased (4.8 +/- 0.8 vs. 7.3 +/- 1.1 l min(-1), P < 0.01); CTL: no changes in Q (14.7 +/- 1.0 vs. 14.8 +/- 1.6 l min(-1)) or LBF (10.9 +/- 1.8 vs. 10.3 +/- 1.7 l min(-1)). S2: P(pl) increased in both groups (HF: 172 +/- 16%, CTL: 220 +/- 40%, P < 0.01). HF: no change was observed in Q(10.0 +/- 0.4 vs. 10.3 +/- 0.8 l min(-1)) or LBF (5.0 +/- 0.6 vs. 4.7 +/- 0.5 l min(-1)); CTL: increased (15.4 +/- 1.4 vs. 16.9 +/- 1.5 l min(-1), P < 0.01) and LBF remained unchanged (10.7 +/- 1.5 vs. 10.3 +/- 1.8 l min(-1)). These data suggest HF patients preferentially steal blood flow from locomotor muscles to accommodate the work of breathing during activity. Further, HF patients are unable to vasoconstrict locomotor vascular beds beyond NB when presented with a respiratory load.
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Affiliation(s)
- Thomas P Olson
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Clinical Role of Exercise Training in the Management of Patients With Chronic Heart Failure. J Cardiopulm Rehabil Prev 2010; 30:67-76. [DOI: 10.1097/hcr.0b013e3181d0c1c1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ceridon ML, Snyder EM, Strom NA, Tschirren J, Johnson BD. Influence of rapid fluid loading on airway structure and function in healthy humans. J Card Fail 2009; 16:175-85. [PMID: 20142030 DOI: 10.1016/j.cardfail.2009.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 08/12/2009] [Accepted: 08/17/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The present study examined the influence of rapid intravenous fluid loading (RFL) on airway structure and pulmonary vascular volumes using computed tomography imaging and the subsequent impact on pulmonary function in healthy adults (n = 16). METHODS AND RESULTS Total lung capacity (DeltaTLC = -6%), forced vital capacity (DeltaFVC = -14%), and peak expiratory flow (DeltaPEF = -19%) decreased, and residual volume (DeltaRV = +38%) increased post-RFL (P < .05). Airway luminal cross-sectional area (CSA) decreased at the trachea, and at airway generation 3 (P < .05), wall thickness changed minimally with a tendency for increasing in generation five (P = .13). Baseline pulmonary function was positively associated with airway luminal CSA; however, this relationship deteriorated after RFL. Lung tissue volume and pulmonary vascular volumes increased 28% (P < .001) post-RFL, but did not fully account for the decline in TLC. CONCLUSIONS These data suggest that RFL results in obstructive/restrictive PF changes that are most likely related to structural changes in smaller airways or changes in extrapulmonary vascular beds.
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Affiliation(s)
- Maile L Ceridon
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
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Lalande S, Johnson BD. Breathing strategy to preserve exercising cardiac function in patients with heart failure. Med Hypotheses 2009; 74:416-21. [PMID: 19800746 DOI: 10.1016/j.mehy.2009.09.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 09/11/2009] [Indexed: 11/30/2022]
Abstract
The heart and lungs are closely linked as they lie in series, share a common surface area and compete for space within the thoracic cavity. The heart and lungs are exposed to the similar changes in intrathoracic pressure, and reflexes within one organ can influence the other (i.e. vagal influence of lung inflation on heart rate). In patients with heart failure, these cardiopulmonary interactions may be altered due to decreased lung and left ventricular compliance, increased cardiac size, high cardiac filling pressure and altered receptor sensitivity to neural activation. Exercise further affects the cardiopulmonary interactions by stimulating an increase in the depth and frequency of breathing which accentuates the fluctuations in intrathoracic pressure, and by requiring large increases in stroke volume and heart rate in order to respond to the increased metabolic demand. Previous work from our laboratory suggested that patients with heart failure avoid high lung volumes during exercise, often at the expense of unnecessary large positive expiratory intrathoracic pressures resulting in significant wasted effort. Moreover, we also observed that voluntarily increases in lung volume in patients with heart failure induced a mild relative bradycardia, a response not observed in similar aged healthy individuals. Thus, we hypothesized that the rapid shallow low lung volume breathing, in combination with positive expiratory intrathoracic pressure, often adopted by patients with heart failure during exercise is an attempt to preserve, or even enhance, the cardiac response to exercise.
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Affiliation(s)
- S Lalande
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Pianosi PT, Johnson JN, Turchetta A, Johnson BD. Pulmonary function and ventilatory limitation to exercise in congenital heart disease. CONGENIT HEART DIS 2009; 4:2-11. [PMID: 19207396 DOI: 10.1111/j.1747-0803.2008.00244.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pulmonary function in older children and adolescents following surgical repair of congenital heart disease is often abnormal for various reasons. Many of these patients report symptoms of exercise intolerance although the reason(s) for this symptom can be complicated and sometimes interrelated. Is it simply deconditioning due to inactive lifestyle, chronotropic or inotropic insufficiency? or could there indeed be ventilatory limitation to exercise? These are the questions facing the clinician with the increasing frequency of patients undergoing repair early in life and growing into adulthood. Understanding pulmonary functional outcomes and means of determining ventilatory limitation to exercise is essential to thoroughly address the problem. This article reviews pulmonary function in patients with congenital heart disease and then describes a newer technique that should be applied to determine ventilatory limitation to exercise.
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Affiliation(s)
- Paolo T Pianosi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicne, Rochester, MN, USA.
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Abstract
Chronic heart failure (CHF) is a common and debilitating condition characterized by reduced exercise tolerance. While exercise training was once thought to be contraindicated for patients with CHF, a substantial body of data has been published over the last two decades to support the use of exercise programs for these patients. Improvements in exercise capacity, quality of life, and mortality have been demonstrated among patients with CHF who have participated in formal exercise programs. Exercise prescription is a means of assessing and interpreting clinical information and applying the principles of training to develop an appropriate regimen so that these benefits are achieved. The major principles of the exercise prescription are the mode, frequency, duration, and intensity. Importantly, safe and effective exercise prescription for patients with CHF requires more than the application of these principles; it also requires careful consideration of the individual patients' functional status, comorbid conditions, medications, contraindications, and personal goals and preferences. Recent studies have demonstrated that a wide spectrum of patients with CHF benefit from appropriately applied exercise training, including those with both systolic and diastolic dysfunction, atrial fibrillation, pacemakers, implantable cardioversion devices, and post-cardiac transplantation. Increasingly, the principles of exercise prescription are included as a component of comprehensive CHF management programs. Evidence has accumulated that CHF patients who participate in rehabilitation programs have better health outcomes in terms of reduced morbidity and mortality, as well as lower hospitalization rates and lower overall health care costs.
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Arruda ALM, Pellikka PA, Olson TP, Johnson BD. Exercise Capacity, Breathing Pattern, and Gas Exchange During Exercise for Patients with Isolated Diastolic Dysfunction. J Am Soc Echocardiogr 2007; 20:838-46. [PMID: 17617310 DOI: 10.1016/j.echo.2006.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Left ventricular diastolic dysfunction (DiaD) is as common as left ventricular systolic dysfunction. Whether these causes of heart failure lead to similar breathing pattern and gas exchange responses to exercise remains unclear. METHODS Participants (control subjects [n = 47], systolic dysfunction [n = 46], and DiaD [n = 40]) underwent resting echocardiograms and cardiopulmonary exercise testing. RESULTS Patients demonstrated lower peak oxygen consumption and tidal volume than control subjects (P < .05). Ventilation tended to be highest in DiaD. The submaximal ventilatory equivalent for carbon dioxide was highest in DiaD. Left atrial volume (all groups) was correlated with peak oxygen consumption (r = -0.38) whereas the ratio of early mitral inflow velocity to early mitral annular velocity was related to peak oxygen consumption (r = -0.36) and treadmill time (r = -0.35). CONCLUSION Isolated DiaD is associated with altered breathing pattern and gas exchange similar to systolic dysfunction. Elevated left atrial volume, higher early mitral inflow velocity to early mitral annular velocity ratio, or both are predictive of exercise capacity and elevated ventilatory responses in patients with DiaD suggesting a role for dysfunctional ventricular relaxation.
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Affiliation(s)
- Ana Lucia M Arruda
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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