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Gonzalez-Garcia M, Conde-Camacho R, Díaz K, Rodríguez-Cortes C, Rincon-Alvarez E. Differences in Exercise Capacity, Ventilatory Efficiency, and Gas Exchange between Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension Residing at High Altitude. Rev Cardiovasc Med 2024; 25:247. [PMID: 39139420 PMCID: PMC11317340 DOI: 10.31083/j.rcm2507247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/21/2024] [Accepted: 05/07/2024] [Indexed: 08/15/2024] Open
Abstract
Background Cardiopulmonary exercise testing (CPET) assesses exercise capacity and causes of exercise limitation in patients with pulmonary hypertension (PH). At altitude, changes occur in the ventilatory pattern and a decrease in arterial oxygen pressure in healthy; these changes are increased in patients with cardiopulmonary disease. Our objective was to compare the response to exercise and gas exchange between patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) residing at the altitude of Bogotá (2640 m). Methods All patients performed an incremental CPET with measurement of oxygen consumption ( VO 2 ), dead space (VD/VT), ventilatory equivalents (VE/ VCO 2 ), and alveolar-arterial oxygen gradient ( PA-aO 2 ). X 2 test and one-way analysis of variance were used for comparisons between PAH and CTEPH. Results We included 53 patients, 29 with PAH, 24 with CTEPH, and 102 controls as a reference of the normal response to exercise at altitude. CTEPH patients had a higher New York Health Association (NYHA) functional class than PAH (p = 0.037). There were no differences between patients with PAH and CTEPH in hemodynamics and VO 2 % of predicted (67.8 ± 18.7 vs. 66.0 ± 19.8, p < 0.05), but those with CTEPH had higher dyspnea, VD/VT (0.36 ± 0.09 vs. 0.23 ± 0.9, p < 0.001), VE/ VCO 2 (45.8 ± 7.1 vs. 39.3 ± 5.6, p < 0.001), and PA-aO 2 (19.9 ± 7.6 vs. 13.5 ± 7.6, p < 0.001) than PAH patients. Conclusions At altitude, patients with PH present severe alterations in gas exchange during exercise. There were no differences in exercise capacity between PAH and CTEPH, but patients with CTEPH had more dyspnea and greater alterations in gas exchange during exercise. CPET made it possible to identify alterations related to the pathophysiology of CTEPH that could explain the functional class and dyspnea in these patients.
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Affiliation(s)
- Mauricio Gonzalez-Garcia
- Fundación Neumológica Colombiana, 110131 Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, 250001 Chía, Colombia
- Postgraduate Program in Sports Medicine, Universidad El Bosque, 110121 Bogotá, Colombia
| | - Rafael Conde-Camacho
- Fundación Neumológica Colombiana, 110131 Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, 250001 Chía, Colombia
| | - Katherine Díaz
- Fundación Neumológica Colombiana, 110131 Bogotá, Colombia
| | - Camilo Rodríguez-Cortes
- Fundación Neumológica Colombiana, 110131 Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, 250001 Chía, Colombia
| | - Emily Rincon-Alvarez
- Fundación Neumológica Colombiana, 110131 Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, 250001 Chía, Colombia
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Forbes LM, Bull TM, Lahm T, Make BJ, Cornwell WK. Exercise Testing in the Risk Assessment of Pulmonary Hypertension. Chest 2023; 164:736-746. [PMID: 37061028 PMCID: PMC10504600 DOI: 10.1016/j.chest.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023] Open
Abstract
TOPIC IMPORTANCE Right ventricular dysfunction in pulmonary hypertension (PH) contributes to reduced exercise capacity, morbidity, and mortality. Exercise can unmask right ventricular dysfunction not apparent at rest, with negative implications for prognosis. REVIEW FINDINGS Among patients with pulmonary vascular disease, right ventricular afterload may increase during exercise out of proportion to increases observed among healthy individuals. Right ventricular contractility must increase to match the demands of increased afterload to maintain ventricular-arterial coupling (the relationship between contractility and afterload) and ultimately cardiac output. Impaired right ventricular contractile reserve leads to ventricular-arterial uncoupling, preventing cardiac output from increasing during exercise and limiting exercise capacity. Abnormal pulmonary vascular response to exercise can signify early pulmonary vascular disease and is associated with increased mortality. Impaired right ventricular contractile reserve similarly predicts poor outcomes, including reduced exercise capacity and death. Exercise provocation can be used to assess pulmonary vascular response to exercise and right ventricular contractile reserve. Noninvasive techniques (including cardiopulmonary exercise testing, transthoracic echocardiography, and cardiac MRI) as well as invasive techniques (including right heart catheterization and pressure-volume analysis) may be applied selectively to the screening, diagnosis, and risk stratification of patients with suspected or established PH. Further research is required to determine the role of exercise stress testing in the management of pulmonary vascular disease. SUMMARY This review describes the current understanding of clinical applications of exercise testing in the risk assessment of patients with suspected or established PH.
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Affiliation(s)
- Lindsay M Forbes
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd M Bull
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Barry J Make
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Pezzuto B, Agostoni P. The Current Role of Cardiopulmonary Exercise Test in the Diagnosis and Management of Pulmonary Hypertension. J Clin Med 2023; 12:5465. [PMID: 37685532 PMCID: PMC10487723 DOI: 10.3390/jcm12175465] [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: 06/26/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis if left untreated. Despite remarkable achievements in understanding disease pathophysiology, specific treatments, and therapeutic strategies, we are still far from a definitive cure for the disease, and numerous evidences have underlined the importance of early diagnosis and treatment to improve the prognosis. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity and evaluating the pathophysiological mechanisms underlying exercise limitation. As effort dyspnea is the earliest and one of the main clinical manifestations of PAH, CPET has been shown to provide valid support in early detection, differential diagnosis, and prognostic stratification of PAH patients, being a useful tool in both the first approach to patients and follow-up. The purpose of this review is to present the current applications of CPET in pulmonary hypertension and to propose possible future utilization to be further investigated.
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Affiliation(s)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Batista KS, Cézar ID, Benedetto IG, C da Silva RM, Wagner LE, Pereira da Silva D, Sanches PR, Gazzana MB, Knorst MM, de-Torres JP, Neder JA, Berton DC. Continuous Monitoring of Pulse Oximetry During the 6-Minute Walk Test Improves Clinical Outcomes Prediction in COPD. Respir Care 2023; 68:92-100. [PMID: 36167849 PMCID: PMC9993518 DOI: 10.4187/respcare.10091] [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: 01/31/2023]
Abstract
BACKGROUND Continuous monitoring of SpO2 throughout the 6-min walk test (6MWT) unveiled that some patients with respiratory diseases may present values across the test lower than SpO2 measured at the end of the test. Nevertheless, it remains unclear whether this approach improves the yield of walk-induced desaturation detection in predicting mortality and hospitalizations in patients with COPD. METHODS Four hundred twenty-one subjects (51% males) with mild-very severe COPD underwent a 6MWT with continuous measurement of SpO2 . Exercise desaturation was defined as a fall in SpO2 ≥ 4%. All-cause mortality was assessed up to 6 y of follow-up and the rate of hospitalizations in the year succeeding the 6MWT. RESULTS One hundred forty-nine subjects (35.4%) died during a mean (interquartile) follow-up of 55.5 (30.2-64.1) months. Desaturation was observed in 299/421 (71.0%). SpO2 along the test was < end SpO2 (88 [82-92]% vs 90 [84-93]%, P < .001). Desaturation detected only during (but not at the end of) the test was found in 81/421 (19.2%) participants. Multivariate Cox regression model adjusted for sex, body composition, FEV1, residual volume/total lung capacity ratio, walk distance, O2 supplementation during the test, and comorbidities retained the presence of desaturation either at the end (1.85 [95% CI 1.02-3.36]) or only along the test (2.08 [95% CI 1.09-4.01]) as significant predictors of mortality. The rate of hospitalizations was higher in those presenting with any kind of desaturation compared to those without exercise desaturation. Logistic regression analysis revealed that walking interruption and diffusing capacity of the lung for carbon monoxide predicted desaturation observed only during the test. CONCLUSIONS O2 desaturation missed by end-exercise SpO2 but exposed by measurements during the test was independently associated with all-cause mortality and hospitalizations in subjects with COPD.
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Affiliation(s)
- Kellen S Batista
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Igor Dossin Cézar
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Igor G Benedetto
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Ravena M C da Silva
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Litiele Evelin Wagner
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Danton Pereira da Silva
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Paulo R Sanches
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Marcelo B Gazzana
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Marli M Knorst
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Juan P de-Torres
- Division of Respirology and Sleep Medicine, Kingston Health Science Center and Queen's University, Kingston, Ontario, Canada
| | - J Alberto Neder
- Division of Respirology and Sleep Medicine, Kingston Health Science Center and Queen's University, Kingston, Ontario, Canada
| | - Danilo C Berton
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil.
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Joseph P, Savarimuthu S, Zhao J, Yan X, Oakland HT, Cullinan M, Heerdt PM, Singh I. Noninvasive determinants of pulmonary hypertension in interstitial lung disease. Pulm Circ 2023; 13:e12197. [PMID: 36814586 PMCID: PMC9939578 DOI: 10.1002/pul2.12197] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/04/2022] [Accepted: 01/23/2023] [Indexed: 01/30/2023] Open
Abstract
Pulmonary hypertension (PH) in interstitial lung disease (ILD) is associated with increased mortality and impaired exertional capacity. Right heart catheterization is the diagnostic standard for PH but is invasive and not readily available. Noninvasive physiologic evaluation may predict PH in ILD. Forty-four patients with PH and ILD (PH-ILD) were compared with 22 with ILD alone (non-PH ILD). Six-min walk distance (6MWD, 223 ± 131 vs. 331 ± 125 m, p = 0.02) and diffusing capacity for carbon monoxide (DLCO, 33 ± 14% vs. 55 ± 21%, p < 0.001) were lower in patients with PH-ILD. PH-ILD patients exhibited a lower gas-exchange derived pulmonary vascular capacitance (GXCAP, 251 ± 132 vs. 465 ± 282 mL × mmHg, p < 0.0001) and extrapolated maximum oxygen uptake (VO2max) (56 ± 32% vs. 84 ± 37%, p = 0.003). Multivariate analysis was performed to determine predictors of VO2 max. GXCAP was the only variable that predicted extrapolated VO2 max among PH-ILD and non-PH ILD patients. Receiver operating characteristic curve analysis assessed the ability of individual noninvasive variables to distinguish between PH-ILD and non-PH ILD patients. GXCAP (area under the curve [AUC] 0.85 ± 0.04, p < 0.0001) and delta ETCO2 (AUC 0.84 ± 0.04, p < 0.0001) were the strongest predictors of PH-ILD. A CART analysis selected GXCAP, estimated right ventricular systolic pressure (eRVSP) by echocardiogram, and FVC/DLCO ratio as predictive variables for PH-ILD. With this analysis, the AUC improved to 0.94 (sensitivity of 0.86 and sensitivity of 0.93). Patients with a GXCAP ≤ 416 mL × mmHg had an 82% probability of PH-ILD. Patients with GXCAP ≤ 416 mL × mmHg and high FVC/DLCO ratio >1.7 had an 80% probability of PH-ILD. Patients with GXCAP ≤ 416 mL × mmHg and an elevated eRVSP by echocardiogram >43 mmHg had 100% probability of PH-ILD. The incorporation of GXCAP with either eRVSP or FVC/DLCO ratio distinguishes between PH-ILD and non-PH-ILD with high probability and may therefore assist in determining the need to proceed with a diagnostic right heart catheterization and potential initiation of pulmonary arterial hypertension-directed therapy in PH-ILD patients.
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Affiliation(s)
- Phillip Joseph
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Stella Savarimuthu
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Jiayi Zhao
- Department of BiostatisticsYale School of Public HealthNew HavenConnecticutUSA
| | - Xiting Yan
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Hannah T. Oakland
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Marjorie Cullinan
- Department of Respiratory CareYale New Haven HospitalNew HavenConnecticutUSA
| | - Paul M. Heerdt
- Department of AnaesthesiologyYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
| | - Inderjit Singh
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineYale New Haven Hospital and Yale School of MedicineNew HavenConnecticutUSA
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Li X, Duan A, Jin Q, Zhang Y, Luo Q, Zhao Q, Yan L, Huang Z, Hu M, Xiong C, Zhao Z, Liu Z. Exercise feature and predictor of prognosis in patients with pulmonary artery stenosis-associated pulmonary hypertension. ESC Heart Fail 2022; 9:4198-4208. [PMID: 36101502 PMCID: PMC9773706 DOI: 10.1002/ehf2.14154] [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: 05/28/2022] [Revised: 08/23/2022] [Accepted: 09/04/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS The prognosis is poor for patients with pulmonary artery stenosis-associated pulmonary hypertension (PAS-PH). Identifying predictors of prognosis in PAS-PH is crucial to preventing premature death, which has rarely been investigated. We aimed to explore the cardiopulmonary exercise testing (CPET) parameters to predict the prognosis of these patients. METHODS We prospectively included all patients with PAS-PH who underwent CPET between September 2014 and June 2021 in Fuwai Hospital (ClinicalTrials.gov ID: NCT02061787). The primary outcome was clinical worsening, including death, rehospitalization for heart failure, or deterioration of PH. RESULTS Seventy-two patients were included in this study. A median of 2-year follow-up revealed that 18 (25%) patients experienced clinical worsening. The 1-year, 3-year, and 5-year event-free survival rates were 92.5%, 81.7%, and 62.7%, respectively. Patients with clinical worsening demonstrated significantly worse baseline haemodynamics and poorer exercise capacity than their counterparts. Multivariable Cox regression identified that peak O2 pulse could independently predict clinical worsening [hazard ratio: 0.344, 95% confidence interval (CI) 0.188-0.631, P < 0.001], outperforming other parameters. Peak O2 pulse correlated with PH severity. Incorporating peak O2 pulse into the simplified 2015 European Society of Cardiology/European Respiratory Society risk stratification improved the accuracy for predicting clinical worsening (pre vs. post area under the curve: 0.727 vs. 0.846, P < 0.001; net reclassification index: 0.852, 95% CI 0.372-1.332, P < 0.001; integrated discrimination index 0.133, 95% CI 0.031-0.235, P = 0.011). CONCLUSIONS The prognosis is poor for PAS-PH, and exercise intolerance and ventilation inefficiency are commonly observed. Peak O2 pulse independently predicted the prognosis of these patients. A low peak O2 pulse identified patients at high risk of clinical deterioration and served for risk stratification of PAS-PH.
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Affiliation(s)
- Xin Li
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Anqi Duan
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qi Jin
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina,Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Yi Zhang
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qin Luo
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qing Zhao
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Lu Yan
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhihua Huang
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Meixi Hu
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Changming Xiong
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhihui Zhao
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhihong Liu
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Shmalts AA. Dynamics of 6-Minute Walk Distance as a Predictor of Efficiency Specific Pulmonary Vasodilators. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-06-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension is a severe and often rapidly progressive disease with a fatal outcome. Approved specific therapy with five classes of drugs – prostanoids, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, soluble guanylate cyclase stimulators and prostacyclin receptor agonists has significantly improved the prognosis of patients. An accessible and reproducible criterion of exercise tolerance – a distance walked in six-minute walk test (6MXD) – occupies one of the central places among the performance indicators (clinical, echocardiographic and hemodynamic) of specific pulmonary vasodilators. Reflecting the clinical severity of pulmonary hypertension and, according to some data, its long-term prognosis, the dynamics of 6MXD is an integral component of the combined primary endpoints of randomized controlled trials. In the CHEST-2019 recommendations, the dynamics of the 6MXD was used to standardize the randomized controlled trials. The 6MXD is indispensable for dynamic observation and decisionmaking on further treatment tactics
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Affiliation(s)
- A. A. Shmalts
- A.N. Bakoulev National Medical Research Center for Cardiovascular Surgery; Russian State Medical Postgraduate Academy
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Badagliacca R, Rischard F, Giudice FL, Howard L, Papa S, Valli G, Manzi G, Sciomer S, Palange P, Garcia JG, Vanderpool R, Rinaldo R, Vigo B, Insel M, Fedele F, Vizza CD. INCREMENTAL VALUE OF CARDIOPULMONARY EXERCISE TESTING IN INTERMEDIATE-RISK PULMONARY ARTERIAL HYPERTENSION. J Heart Lung Transplant 2022; 41:780-790. [DOI: 10.1016/j.healun.2022.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 02/02/2022] [Accepted: 02/28/2022] [Indexed: 01/29/2023] Open
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Weatherald J, Philipenko B, Montani D, Laveneziana P. Ventilatory efficiency in pulmonary vascular diseases. Eur Respir Rev 2021; 30:30/161/200214. [PMID: 34289981 PMCID: PMC9488923 DOI: 10.1183/16000617.0214-2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is a frequently used tool in the differential diagnosis of dyspnoea. Ventilatory inefficiency, defined as high minute ventilation (V′E) relative to carbon dioxide output (V′CO2), is a hallmark characteristic of pulmonary vascular diseases, which contributes to exercise intolerance and disability in these patients. The mechanisms of ventilatory inefficiency are multiple and include high physiologic dead space, abnormal chemosensitivity and an altered carbon dioxide (CO2) set-point. A normal V′E/V′CO2 makes a pulmonary vascular disease such as pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) unlikely. The finding of high V′E/V′CO2 without an alternative explanation should prompt further diagnostic testing to exclude PAH or CTEPH, particularly in patients with risk factors, such as prior venous thromboembolism, systemic sclerosis or a family history of PAH. In patients with established PAH or CTEPH, the V′E/V′CO2 may improve with interventions and is a prognostic marker. However, further studies are needed to clarify the added value of assessing ventilatory inefficiency in the longitudinal follow-up of patients. Ventilatory inefficiency is a hallmark feature of PH that reflects abnormal ventilation/perfusion matching, chemosensitivity and an altered CO2 set-point. Minute ventilation/CO2 production is useful in the diagnosis, management and prognostication of PH.https://bit.ly/3jnNdUG
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Affiliation(s)
- Jason Weatherald
- Dept of Medicine, Division of Respirology, University of Calgary, Cumming School of Medicine, Calgary, Canada.,Libin Cardiovascular Institute, Calgary, Canada
| | - Brianne Philipenko
- Dept of Medicine, Division of Respirology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Dept of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France .,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Hôpitaux Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
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10
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Zhao D, Abbasi A, Casaburi R, Adami A, Tiller NB, Yuan W, Yee C, Jendzjowsky NG, MacDonald DM, Kunisaki KM, Stringer WW, Porszasz J, Make BJ, Bowler RP, Rossiter HB. Identifying a Heart Rate Recovery Criterion After a 6-Minute Walk Test in COPD. Int J Chron Obstruct Pulmon Dis 2021; 16:2545-2560. [PMID: 34511898 PMCID: PMC8427685 DOI: 10.2147/copd.s311572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/16/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Slow heart rate recovery (HRR) after exercise is associated with autonomic dysfunction and increased mortality. What HRR criterion at 1-minute after a 6-minute walk test (6MWT) best defines pulmonary impairment?. STUDY DESIGN AND METHODS A total of 5008 phase 2 COPDGene (NCT00608764) participants with smoking history were included. A total of 2127 had COPD and, of these, 385 were followed-up 5-years later. Lung surgery, transplant, bronchiectasis, atrial fibrillation, heart failure and pacemakers were exclusionary. HR was measured from pulse oximetry at end-walk and after 1-min seated recovery. A receiver operator characteristic (ROC) identified optimal HRR cut-off. Generalized linear regression determined HRR association with spirometry, chest CT, symptoms and exacerbations. RESULTS HRR after 6MWT (bt/min) was categorized in quintiles: ≤5 (23.0% of participants), 6-10 (20.7%), 11-15 (18.9%), 16-22 (18.5%) and ≥23 (18.9%). Compared to HRR≤5, HRR≥11 was associated with (p<0.001): lower pre-walk HR and 1-min post HR; greater end-walk HR; greater 6MWD; greater FEV1%pred; lower airway wall area and wall thickness. HRR was positively associated with FEV1%pred and negatively associated with airway wall thickness. An optimal HRR ≤10 bt/min yielded an area under the ROC curve of 0.62 (95% CI 0.58-0.66) for identifying FEV1<30%pred. HRR≥11 bt/min was the lowest HRR associated with consistently less impairment in 6MWT, spirometry and CT variables. In COPD, HRR≤10 bt/min was associated with (p<0.001): ≥2 exacerbations in the previous year (OR=1.76[1.33-2.34]); CAT≥10 (OR=1.42[1.18-1.71]); mMRC≥2 (OR=1.42[1.19-1.69]); GOLD 4 (OR=1.98[1.44-2.73]) and GOLD D (OR=1.51[1.18-1.95]). HRR≤10 bt/min was predicted COPD exacerbations at 5-year follow-up (RR=1.83[1.07-3.12], P=0.027). CONCLUSION HRR≤10 bt/min after 6MWT in COPD is associated with more severe expiratory flow limitation, airway wall thickening, worse dyspnoea and quality of life, and future exacerbations, suggesting that an abnormal HRR≤10 bt/min after a 6MWT may be used in a comprehensive assessment in COPD for risk of severity, symptoms and future exacerbations.
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Affiliation(s)
- Dongxing Zhao
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- 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, Guangdong, 510120, People’s Republic of China
| | - Asghar Abbasi
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Alessandra Adami
- Department of Kinesiology, University of Rhode Island, Kingston, RI, USA
| | - Nicholas B Tiller
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Wei Yuan
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- Respiratory Medicine Department, Beijing Friendship Hospital Affiliated of Capital Medical University, Beijing, 100050, People’s Republic of China
| | | | - Nicholas G Jendzjowsky
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David M MacDonald
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Ken M Kunisaki
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - William W Stringer
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Janos Porszasz
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | | | - Harry B Rossiter
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - On behalf of the COPDGene Investigators
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- 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, Guangdong, 510120, People’s Republic of China
- Department of Kinesiology, University of Rhode Island, Kingston, RI, USA
- Respiratory Medicine Department, Beijing Friendship Hospital Affiliated of Capital Medical University, Beijing, 100050, People’s Republic of China
- MemorialCare Long Beach Medical Center, Long Beach, CA, USA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Health Care System, Minneapolis, MN, USA
- National Jewish Health, Denver, CO, USA
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11
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Westhoff M, Litterst P, Ewert R. Cardiopulmonary Exercise Testing in Combined Pulmonary Fibrosis and Emphysema. Respiration 2021; 100:395-403. [PMID: 33657565 DOI: 10.1159/000513848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Combined pulmonary fibrosis and emphysema (CPFE) is a distinct entity among fibrosing lung diseases with a high risk for lung cancer and pulmonary hypertension (PH). Notably, concomitant PH was identified as a negative prognostic indicator that could help with early diagnosis to provide important information regarding prognosis. OBJECTIVES The current study aimed to determine whether cardiopulmonary exercise testing (CPET) can be helpful in differentiating patients having CPFE with and without PH. METHODS Patients diagnosed with CPFE in 2 German cities (Hemer and Greifswald) over a period of 10 years were included herein. CPET parameters, such as peak oxygen uptake (peak VO2), functional dead space ventilation (VDf/VT), alveolar-arterial oxygen difference (AaDO2), arterial-end-tidal CO2 difference [P(a-ET)CO2] at peak exercise, and the minute ventilation-carbon dioxide production relationship (VE/VCO2 slope), were compared between patients with and without PH. RESULTS A total of 41 patients with CPET (22 with PH, 19 without PH) were analyzed. Right heart catheterization was performed in 15 of 41 patients without clinically relevant complications. Significant differences in peak VO2 (861 ± 190 vs. 1,397 ± 439 mL), VO2/kg body weight/min (10.8 ± 2.6 vs. 17.4 ± 5.2 mL), peak AaDO2 (72.3 ± 7.3 vs. 46.3 ± 14.2 mm Hg), VE/VCO2 slope (70.1 ± 31.5 vs. 39.6 ± 9.6), and peak P(a-ET)tCO2 (13.9 ± 3.5 vs. 8.1 ± 3.6 mm Hg) were observed between patients with and without PH (p < 0.001). Patients with PH had significantly higher VDf/VT at rest, VT1, and at peak exercise (65.6 ± 16.8% vs. 47.2 ± 11.6%; p < 0.001) than those without PH. A cutoff value of 44 for VE/VCO2 slope had a sensitivity and specificity of 94.7 and 72.7%, while a cutoff value of 11 mm Hg for P(a-ET)CO2 in combination with peak AaDO2 >60 mm Hg had a specificity and sensitivity of 95.5 and 84.2%, respectively. Combining peak AaDO2 >60 mm Hg with peak VO2/body weight/min <16.5 mL/kg/min provided a sensitivity and specificity of 100 and 95.5%, respectively. CONCLUSION This study provided initial data on CPET among patients having CPFE with and without PH. CPET can help noninvasively detect PH and identify patients at risk. AaDO2 at peak exercise, VE/VCO2 slope, peak P(a-ET)CO2, and peak VO2 were parameters that had high sensitivity and, when combined, high specificity.
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Affiliation(s)
- Michael Westhoff
- Department of Pneumology, Sleep and Respiratory Medicine, Hemer Lung Clinic, Hemer, Germany, .,University Witten/Herdecke, Witten, Germany,
| | - Patric Litterst
- Department of Pneumology, Sleep and Respiratory Medicine, Hemer Lung Clinic, Hemer, Germany
| | - Ralf Ewert
- Department of Internal Medicine, University Medicine, Greifswald, Germany
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12
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Chen LW, Chen SY, Hsu HH, Wu YW, Lai YM, Chien MY. Exercise Capacity and Quality of Life in Pulmonary Arterial Hypertension. ACTA CARDIOLOGICA SINICA 2021; 37:74-85. [PMID: 33488030 PMCID: PMC7814335 DOI: 10.6515/acs.202101_37(1).20200720a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/20/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive pulmonary vascular disease with a high mortality rate that can be divided into different groups according to etiology and prognosis. Few studies have investigated differences in the exercise capacity and quality of life (QOL) among the different groups of PAH patients. Therefore, we aimed to (1) compare the hemodynamic exercise responses between patients with idiopathic pulmonary arterial hypertension (IPAH) and PAH associated with other diseases (APAH), and (2) determine the factors associated with exercise capacity in patients with PAH. METHODS Six patients diagnosed with IPAH and eight with APAH [congenital heart disease (CHD)-dominant PAH] were included in this study. The main outcome measures included body composition, exercise capacity, hemodynamic measurements, physical activity levels, fatigue severity, and QOL. RESULTS The CHD-dominant PAH group had a significantly lower predicted peak oxygen consumption (VO2pred %), pressure of end-tidal carbon dioxide at the peak and at anaerobic threshold (PETCO2peak and PETCO2@AT), and significantly elevated ventilatory equivalent (VE/VCO2slope and VE/VCO2@AT) compared with the IPAH group. Multiple regression analysis indicated that PETCO2@AT was significantly associated with either VO2peak (β = 0.805, adjusted R2 = 0.619, p = 0.001) or 6-minute walk distance (β = 0.816, adjusted R2 = 0.638, p < 0.001). CONCLUSIONS Patients with CHD-dominant PAH had poor exercise capacity and exercise responses compared to those with IPAH. Evaluating exercise capacity and the patient response to exercise using cardiopulmonary exercise testing is increasingly important in view of the etiology of PAH.
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Affiliation(s)
- Ling-Wei Chen
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University
- Department of Rehabilitation, Central Clinics and Hospital, Taipei
| | - Ssu-Yuan Chen
- Department of Rehabilitation, Fu-Jen Catholic University Hospital, New Taipei City
- Department of Physical Medicine and Rehabilitation
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei
| | - Yen-Wen Wu
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yu-Mei Lai
- Department of Surgery, National Taiwan University Hospital, Taipei
| | - Meng-Yueh Chien
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University
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13
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Patterson AJ, Sarode A, Al-Kindi S, Shaver L, Thomas R, Watson E, Alaiti MA, Liu Y, Hamilton J, Seiberlich N, Rashid I, Gilkeson R, Schilz R, Hoit B, Jenkins T, Zullo M, Bossone E, Longenecker C, Simonetti O, Rajagopalan S. Evaluation of dyspnea of unknown etiology in HIV patients with cardiopulmonary exercise testing and cardiovascular magnetic resonance imaging. J Cardiovasc Magn Reson 2020; 22:74. [PMID: 33040733 PMCID: PMC7549205 DOI: 10.1186/s12968-020-00664-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 08/25/2020] [Indexed: 11/15/2022] Open
Abstract
AIM Human Immunodeficiency Virus (HIV) patients commonly experience dyspnea for which an immediate cause may not be always apparent. In this prospective cohort study of HIV patients with exercise limitation, we use cardiopulmonary exercise testing (CPET) coupled with exercise cardiovascular magnetic resonance (CMR) to elucidate etiologies of dyspnea. METHODS AND RESULTS Thirty-four HIV patients on antiretroviral therapy with dyspnea and exercise limitation (49.7 years, 65% male, mean absolute CD4 count 700) underwent comprehensive evaluation with combined rest and maximal exercise treadmill CMR and CPET. The overall mean oxygen consumption (VO2) peak was reduced at 23.2 ± 6.9 ml/kg/min with 20 patients (58.8% of overall cohort) achieving a respiratory exchange ratio > 1. The ventilatory efficiency (VE)/VCO2 slope was elevated at 36 ± 7.92, while ventilatory reserve (VE: maximal voluntary ventilation (MVV)) was within normal limits. The mean absolute right ventricular (RV) and left ventricular (LV) contractile reserves were preserved at 9.0% ± 11.2 and 9.4% ± 9.4, respectively. The average resting and post-exercise mean average pulmonary artery velocities were 12.2 ± 3.9 cm/s and 18.9 ± 8.3 respectively, which suggested lack of exercise induced pulmonary artery hypertension (PAH). LV but not RV delayed enhancement were identified in five patients. Correlation analysis found no relationship between peak VO2 measures of contractile RV or LV reserve, but LV and RV stroke volume correlated with PET CO2 (p = 0.02, p = 0.03). CONCLUSION Well treated patients with HIV appear to have conserved RV and LV function, contractile reserve and no evidence of exercise induced PAH. However, we found evidence of impaired ventilation suggesting a non-cardiopulmonary etiology for dyspnea.
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Affiliation(s)
- Andrew J Patterson
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Anuja Sarode
- Kent State University, College of Public Health, Kent, OH, USA
| | - Sadeer Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Lauren Shaver
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Rahul Thomas
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Evelyn Watson
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Mohamad Amer Alaiti
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Yuchi Liu
- Michigan University, Department of Biomedical Engineering, Ann Arbor, MI, USA
| | - Jessie Hamilton
- Michigan University, Department of Biomedical Engineering, Ann Arbor, MI, USA
| | - Nicole Seiberlich
- Michigan University, Department of Biomedical Engineering, Ann Arbor, MI, USA
| | - Imran Rashid
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Robert Gilkeson
- University Hospitals Cleveland Medical Center, Department of Radiology, Cleveland, OH, USA
| | - Robert Schilz
- University Hospitals Cleveland Medical Center, Department of Pulmonology, Cleveland, OH, USA
| | - Brian Hoit
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Trevor Jenkins
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Melissa Zullo
- Kent State University, College of Public Health, Kent, OH, USA
| | | | | | - Orlando Simonetti
- Ohio State University Department of Cardiovascular Medicine, Columbus, OH, USA
| | - Sanjay Rajagopalan
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA.
- University Hospitals Cleveland Medical Center, Department of Radiology, Cleveland, OH, USA.
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14
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Gas Exchange and Ventilatory Efficiency During Exercise in Pulmonary Vascular Diseases. Arch Bronconeumol 2020; 56:578-585. [DOI: 10.1016/j.arbres.2019.12.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 12/16/2019] [Accepted: 12/22/2019] [Indexed: 12/31/2022]
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15
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Laveneziana P, Weatherald J. Pulmonary Vascular Disease and Cardiopulmonary Exercise Testing. Front Physiol 2020; 11:964. [PMID: 32848882 PMCID: PMC7425313 DOI: 10.3389/fphys.2020.00964] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is of great interest and utility for clinicians dealing Pulmonary Hypertension (PH) in several ways, including: helping with differential diagnosis, evaluating exercise intolerance and its underpinning mechanisms, accurately assessing exertional dyspnea and unmasking its underlying often non-straightforward mechanisms, generating prognostic indicators. Pathophysiologic anomalies in PH can range from reduced cardiac output and aerobic capacity, to inefficient ventilation, dyspnea, dynamic hyperinflation, and locomotor muscle dysfunction. CPET can magnify the PH-related pathophysiologic anomalies and has a major role in the management of PH patients.
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Affiliation(s)
- Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMR S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Sites Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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16
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Tran D, Munoz P, Lau EMT, Alison JA, Brown M, Zheng Y, Corkery P, Wong K, Lindstrom S, Celermajer DS, Davis GM, Cordina R. Inspiratory Muscle Training Improves Inspiratory Muscle Strength and Functional Exercise Capacity in Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension: A Pilot Randomised Controlled Study. Heart Lung Circ 2020; 30:388-395. [PMID: 32736963 DOI: 10.1016/j.hlc.2020.06.006] [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: 03/24/2020] [Revised: 05/20/2020] [Accepted: 06/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Exercise intolerance is present even in the early stages of pulmonary arterial hypertension (PAH) and is associated with poorer prognosis. Respiratory muscle dysfunction is common and may contribute to exercise limitation. We sought to investigate the effects of inspiratory muscle training (IMT) to improve exercise capacity in PAH. METHODS Adults with PAH were prospectively recruited and randomly assigned to either IMT or a control group. At baseline and after 8 weeks, assessment of respiratory muscle function, pulmonary function, neurohormonal activation, 6-minute walk distance and cardiopulmonary exercise testing variables were conducted. Inspiratory muscle strength was assessed by maximal static inspiratory pressure (PImax). The IMT group performed two cycles of 30 breaths at 30-40% of their PImax 5 days a week for 8 weeks. RESULTS Twelve (12) PAH patients (60±14 years, 10 females) were recruited and randomised (six in the IMT group and six in the control group). After 8 weeks, the IMT group improved PImax by 31 cmH2O compared with 10 cmH2O in controls, p=0.02. Following IMT, 6-minute walk distance improved by 24.5 m in the IMT group and declined by 12 m in the controls (mean difference 36.5 m, 95% CI 3.5-69.5, p=0.03). There was no difference in peak oxygen uptake between-groups (mean difference 0.4 mL/kg/min, 95% CI -2.6 to 3.4, p=0.77). There was no difference in the mean change between-groups in neurohormonal activation or pulmonary function. CONCLUSION In this pilot randomised controlled study, IMT improved PImax and 6-minute walk distance in PAH patients.
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Affiliation(s)
- Derek Tran
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Phillip Munoz
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Edmund M T Lau
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jennifer A Alison
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Brown
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Yizhong Zheng
- Department of Respiratory and Sleep Medicine, St George Hospital, Sydney, NSW, Australia
| | - Patricia Corkery
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Keith Wong
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Steven Lindstrom
- Department of Respiratory and Sleep Medicine, St George Hospital, Sydney, NSW, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Glen M Davis
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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17
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Ruigrok D, Meijboom LJ, Nossent EJ, Boonstra A, Braams NJ, van Wezenbeek J, de Man FS, Marcus JT, Vonk Noordegraaf A, Symersky P, Bogaard HJ. Persistent exercise intolerance after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Eur Respir J 2020; 55:13993003.00109-2020. [DOI: 10.1183/13993003.00109-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/09/2020] [Indexed: 11/05/2022]
Abstract
AimHaemodynamic normalisation is the ultimate goal of pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). However, whether normalisation of haemodynamics translates into normalisation of exercise capacity is unknown. The incidence, determinants and clinical implications of exercise intolerance after PEA are unknown. We performed a prospective analysis to determine the incidence of exercise intolerance after PEA, assess the relationship between exercise capacity and (resting) haemodynamics and search for preoperative predictors of exercise intolerance after PEA.MethodsAccording to clinical protocol all patients underwent cardiopulmonary exercise testing (CPET), right heart catheterisation and cardiac magnetic resonance (CMR) imaging before and 6 months after PEA. Exercise intolerance was defined as a peak oxygen consumption (V′O2) <80% predicted. CPET parameters were judged to determine the cause of exercise limitation. Relationships were analysed between exercise intolerance and resting haemodynamics and CMR-derived right ventricular function. Potential preoperative predictors of exercise intolerance were analysed using logistic regression analysis.Results68 patients were included in the final analysis. 45 (66%) patients had exercise intolerance 6 months after PEA; in 20 patients this was primarily caused by a cardiovascular limitation. The incidence of residual pulmonary hypertension was significantly higher in patients with persistent exercise intolerance (p=0.001). However, 27 out of 45 patients with persistent exercise intolerance had no residual pulmonary hypertension. In the multivariate analysis, preoperative transfer factor of the lung for carbon monoxide (TLCO) was the only predictor of exercise intolerance after PEA.ConclusionsThe majority of CTEPH patients have exercise intolerance after PEA, often despite normalisation of resting haemodynamics. Not all exercise intolerance after PEA is explained by the presence of residual pulmonary hypertension, and lower preoperative TLCO was a strong predictor of exercise intolerance 6 months after PEA.
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18
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Pöhler GH, Klimes F, Voskrebenzev A, Behrendt L, Czerner C, Gutberlet M, Cebotari S, Ius F, Fegbeutel C, Schoenfeld C, Kaireit TF, Hauck EF, Olsson KM, Hoeper MM, Wacker F, Vogel‐Claussen J. Chronic Thromboembolic Pulmonary Hypertension Perioperative Monitoring Using Phase‐Resolved Functional Lung (PREFUL)‐MRI. J Magn Reson Imaging 2020; 52:610-619. [DOI: 10.1002/jmri.27097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Gesa H. Pöhler
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Filip Klimes
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Andreas Voskrebenzev
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Lea Behrendt
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Christoph Czerner
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Marcel Gutberlet
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Serghei Cebotari
- Department of CardiothoracicTransplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Fabio Ius
- Department of CardiothoracicTransplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Christine Fegbeutel
- Department of CardiothoracicTransplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Christian Schoenfeld
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Till F. Kaireit
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Erik F. Hauck
- Department of NeurosurgeryDuke Hospital Durham North Carolina USA
| | - Karen M. Olsson
- Department of Respiratory MedicineHannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Marius M. Hoeper
- Department of Respiratory MedicineHannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Frank Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
| | - Jens Vogel‐Claussen
- Department of Diagnostic and Interventional Radiology, Hannover Medical School Hannover Germany
- German Centre for Lung Research, BREATH Hannover Germany
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19
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Tello K, Dalmer A, Vanderpool R, Ghofrani HA, Naeije R, Roller F, Seeger W, Dumitrescu D, Sommer N, Brunst A, Gall H, Richter MJ. Impaired right ventricular lusitropy is associated with ventilatory inefficiency in pulmonary arterial hypertension. Eur Respir J 2019; 54:13993003.00342-2019. [PMID: 31515402 DOI: 10.1183/13993003.00342-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/15/2019] [Indexed: 12/18/2022]
Abstract
Cardiopulmonary exercise testing (CPET) is an important tool for assessing functional capacity and prognosis in pulmonary arterial hypertension (PAH). However, the associations of CPET parameters with the adaptation of right ventricular (RV) function to afterload remain incompletely understood.In this study, 37 patients with PAH (idiopathic in 31 cases) underwent single-beat pressure-volume loop measurements of RV end-systolic elastance (Ees), arterial elastance (Ea) and diastolic elastance (Eed). Pulmonary arterial stiffness was assessed by magnetic resonance imaging. The results were correlated to CPET variables. The predictive relevance of RV function parameters for clinically relevant ventilatory inefficiency, defined as minute ventilation/carbon dioxide production (V' E/V' CO2 ) slope >48, was evaluated using logistic regression analysis.The median (interquartile range) of the V' E/V' CO2 slope was 42 (32-52) and the V' E/V' CO2 nadir was 40 (31-44). The mean±sd of peak end-tidal carbon dioxide tension (P ETCO2 ) was 23±8 mmHg. Ea, Eed and parameters reflecting pulmonary arterial stiffness (capacitance and distensibility) correlated with the V' E/V' CO2 slope, V' E/V' CO2 nadir, P ETCO2 and peak oxygen pulse. RV Ees and RV-arterial coupling as assessed by the Ees/Ea ratio showed no correlations with CPET parameters. Ea (univariate OR 7.28, 95% CI 1.20-44.04) and Eed (univariate OR 2.21, 95% CI 0.93-5.26) were significantly associated with ventilatory inefficiency (p<0.10).Our data suggest that impaired RV lusitropy and increased afterload are associated with ventilatory inefficiency in PAH.
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Affiliation(s)
- Khodr Tello
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Antonia Dalmer
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | | | - Hossein A Ghofrani
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,Dept of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Dept of Medicine, Imperial College London, London, UK
| | | | - Fritz Roller
- Dept of Radiology, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Daniel Dumitrescu
- Dept of Cardiology, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Natascha Sommer
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Anne Brunst
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel J Richter
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
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Vieira EB, Ota-Arakaki JS, Dal Corso S, Ivanaga I, Fonseca AXC, Oliveira RKF, Rodrigues-Júnior JC, Ferreira EVM, Nery LE, Ramos RP. Incremental step test in patients with pulmonary hypertension. Respir Physiol Neurobiol 2019; 271:103307. [PMID: 31557537 DOI: 10.1016/j.resp.2019.103307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/17/2019] [Accepted: 09/22/2019] [Indexed: 10/25/2022]
Abstract
Cardiopulmonary exercise testing (CPET) on a treadmill or cycle ergometer provides an integrated assessment of the cardiorespiratory system during exertion and is widely used in clinical practice. An incremental step test (IST) can be an alternative for eliciting maximal exercise responses. Therefore, 20 patients with pre-capillary PH (65% female, 41 ± 15 yrs) randomly performed a symptom-limited CPET on a cycle ergometer and IST. Metabolic, cardiovascular, ventilatory and gas exchange variables were recorded during both tests. There was a greater desaturation and higher V̇O2PEAK in IST compared to CPET. The V̇O2GET, HR PEAK (% pred), ΔV̇E/ΔV̇CO2 and ΔHR/ΔV̇O2 were similar in both IST and CPET. By linear regression analyses, the work performed on IST [W = (mass × 9,8 m/s2 x vertical distance)] was a predictor of peak V̇O2 independent of the gender and age (r2 = 077, p = 0001). In conclusion, IST elicited higher peak cardiopulmonary responses and has a good agreement with known severity markers in patients with pre-capillary PH.
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Affiliation(s)
- E B Vieira
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - J S Ota-Arakaki
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil.
| | - S Dal Corso
- Department of Physical Therapy, Universidade Nove de Julho (Uninove), São Paulo, SP, Brazil
| | - I Ivanaga
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - A X C Fonseca
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - R K F Oliveira
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - J C Rodrigues-Júnior
- Department of Physical Therapy, Universidade Nove de Julho (Uninove), São Paulo, SP, Brazil
| | - E V M Ferreira
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - L E Nery
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - R P Ramos
- Pulmonary Function and Exercise Physiology Unit. Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
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Rubin LJ. Assessing Prognosis of Pulmonary Arterial Hypertension in the Therapeutic Era: Importance of Serial Hemodynamic Measurements. Circulation 2019; 137:705-706. [PMID: 29440197 DOI: 10.1161/circulationaha.117.031499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
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Badagliacca R, Papa S, Poscia R, Valli G, Pezzuto B, Manzi G, Torre R, Gianfrilli D, Sciomer S, Palange P, Naeije R, Fedele F, Vizza CD. The added value of cardiopulmonary exercise testing in the follow-up of pulmonary arterial hypertension. J Heart Lung Transplant 2018; 38:306-314. [PMID: 30581051 DOI: 10.1016/j.healun.2018.11.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The added value of cardiopulmonary exercise testing (CPET) in the follow-up of patients with stable pulmonary arterial hypertension (PAH) remains undefined. METHODS Idiopathic, heritable, and drug-induced PAH patients free from clinical worsening (CW) after 1 year of treatment were enrolled in derivation (n = 80) and validation (n = 80) cohorts at an interval of 6 years and followed for 3 years. Prognostic models were constructed and validated in low-risk patients in World Health Organization (WHO) Functional Class I or II with cardiac index (CI) ≥2.5 liters/min/m2 and right atrial pressure (RAP) <8 mm Hg. Discrimination and calibration were assessed. RESULTS Forty-one derivation cohort patients had CW (51.2%) during 722 ± 349 days. Changes (∆) in WHO classification and CI and absolute value of RAP were independent predictors of CW. With addition of CPET variables, peak oxygen uptake (VO2 peak) and ∆CI independently improved the power of the prognostic model. Receiver operating characteristic (ROC)-derived cut-off values for ∆CI and VO2 peak were 0.40 liter/min/m2 and 15.7 ml/kg/min (≥60% predicted value), respectively. Twenty-nine validation cohort patients had CW (36.2%) during 710 ± 282 days. Different combinations of cut-off values of VO2 peak and ∆CI defined 4 groups. The event-free survival rates at 1, 2, and 3 years were 100%, 100%, and 100%, respectively, for the high ∆CI with high VO2 peak combination; 100%, 88%, and 71% for low ∆CI/high VO2 peak; 80%, 54%, and 40% for high ∆CI/low VO2 peak; and 72%, 54%, and 33% for low ∆CI/low VO2 peak. CONCLUSIONS The combinations of baseline VO2 peak and change in CI during follow-up is important in prognostication of low-risk patients with idiopathic, heritable, and drug-induced PAH.
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Affiliation(s)
- Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy.
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Poscia
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Gabriele Valli
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Beatrice Pezzuto
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Torre
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Susanna Sciomer
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
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Jaijee S, Quinlan M, Tokarczuk P, Clemence M, Howard LSGE, Gibbs JSR, O'Regan DP. Exercise cardiac MRI unmasks right ventricular dysfunction in acute hypoxia and chronic pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2018; 315:H950-H957. [PMID: 29775415 PMCID: PMC6230906 DOI: 10.1152/ajpheart.00146.2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Coupling of right ventricular (RV) contractility to afterload is maintained at rest in the early stages of pulmonary arterial hypertension (PAH), but exercise may unmask depleted contractile reserves. We assessed whether elevated afterload reduces RV contractile reserve despite compensated resting function using noninvasive exercise imaging. Fourteen patients with PAH (mean age: 39.1 yr, 10 women and 4 men) and 34 healthy control subjects (mean ageL 35.6 yr, 17 women and 17 men) completed real-time cardiac magnetic resonance imaging during submaximal exercise breathing room air. Control subjects were then also exercised during acute normobaric hypoxia (fraction of inspired O2: 12%). RV contractile reserve was assessed by the effect of exercise on ejection fraction. In control subjects, the increase in RV ejection fraction on exercise was less during hypoxia (P = 0.017), but the response of left ventricular ejection fraction to exercise did not change. Patients with PAH had an impaired RV reserve, with half demonstrating a fall in RV ejection fraction on exercise despite comparable resting function to controls (PAH: rest 53.6 ± 4.3% vs. exercise 51.4 ± 10.7%; controls: rest 57.1 ± 5.2% vs. exercise 69.6 ± 6.1%, P < 0.0001). In control subjects, the increase in stroke volume index on exercise was driven by reduced RV end-systolic volume, whereas patients with PAH did not augment the stroke volume index, with increases in both end-diastolic and end-systolic volumes. From baseline hemodynamic and exercise capacity variables, only the minute ventilation-to-CO2 output ratio was an independent predictor of RV functional reserve (P = 0.021). In conclusion, noninvasive cardiac imaging during exercise unmasks depleted RV contractile reserves in healthy adults under hypoxic conditions and patients with PAH under normoxic conditions despite preserved ejection fraction at rest. NEW & NOTEWORTHY Right ventricular (RV) reserve was assessed using real-time cardiac magnetic resonance imaging in patients with pulmonary arterial hypertension and in healthy control subjects under normobaric hypoxia, which has been previously associated with acute pulmonary hypertension. Hypoxia caused a mild reduction in RV reserve, whereas chronic pulmonary arterial hypertension was associated with a marked reduction in RV reserve.
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Affiliation(s)
- Shareen Jaijee
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
| | - Marina Quinlan
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
| | - Pawel Tokarczuk
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
| | | | - Luke S G E Howard
- Department of Cardiology, National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust , London , United Kingdom
| | - J Simon R Gibbs
- Department of Cardiology, National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust , London , United Kingdom.,National Heart and Lung Institute, Imperial College London , London , United Kingdom
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
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Farina S, Correale M, Bruno N, Paolillo S, Salvioni E, Badagliacca R, Agostoni P. The role of cardiopulmonary exercise tests in pulmonary arterial hypertension. Eur Respir Rev 2018; 27:27/148/170134. [PMID: 29720508 DOI: 10.1183/16000617.0134-2017] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/19/2018] [Indexed: 11/05/2022] Open
Abstract
Despite recent advances in the therapeutic management of patients affected by pulmonary arterial hypertension (PAH), survival remains poor. Prompt identification of the disease, especially in subjects at increased risk of developing PAH, and prognostic stratification of patients are a necessary target of clinical practice but remain challenging. Cardiopulmonary exercise test (CPET) parameters, particularly peak oxygen uptake, end-tidal carbon dioxide tension and the minute ventilation/carbon dioxide production relationship, emerged as new prognostic tools for PAH patients. Moreover, CPET provides a comprehensive pathophysiological evaluation of patients' exercise limitation and dyspnoea, which are the main and early symptoms of the disease. This review focuses on the role of CPET in the management of PAH patients, reporting guideline recommendations for CPET and discussing the pathophysiology of exercise limitation and the most recent use of CPET in the diagnosis, prognosis and therapeutic targeting of PAH.
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Affiliation(s)
| | | | - Noemi Bruno
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,AOR S.Carlo, Dipartimento Cardiovascolare, Potenza, Italy
| | - Stefania Paolillo
- IRCCS SDN, Istituto di ricerca diagnostica e nucleare, Naples, Italy
| | | | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "La Sapienza" University of Rome, Rome, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dept of Clinical Sciences and Community Health (Cardiovascular Section), University of Milan, Milan, Italy
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Peak circulatory power is a strong prognostic factor in patients with idiopathic pulmonary arterial hypertension. Respir Med 2018; 135:29-34. [PMID: 29414450 DOI: 10.1016/j.rmed.2018.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/06/2018] [Accepted: 01/08/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies have shown that peak circulatory power (peak CircP; peak oxygen uptake × peak systolic blood pressure) is a variable predictor of prognosis in patients with left heart failure. It remains unknown whether peak CircP also predicts outcome in patients with idiopathic pulmonary arterial hypertension (IPAH). METHODS Patients with newly diagnosed IPAH who underwent symptom-limited cardiopulmonary exercise testing (CPET) from 1 January 2011 to 1 January 2014 in Fuwai Hospital were prospectively enrolled and followed for up to 66 months for cardiac events (mortality and lung transplantation). RESULTS One hundred forty patients with IPAH (104 female, mean age: 33 ± 11 years) were studied. During follow-up (mean: 42 ± 14 months), 24 patients died and 1 patient underwent lung transplantation. In the univariate analysis, peak oxygen uptake(VO2), oxygen uptake at anaerobic threshold, ventilation (VE)/carbon dioxide output (VCO2) slope, end-tidal partial pressure of carbon dioxide at anaerobic threshold, peak systolic blood pressure (SBP), the change of SBP, the change of heart rate, peak work rate, peak CircP, pulmonary vascular resistance, cardiac index and World Health Organization functional class were predictive of cardiac events (all P < .05).In the multivariate analysis, Peak CircP in the fourth model had the highest significance compared with peak VO2 and VE/VCO2 slope in the second and third model (chi-square = 5.26, P < .02, HR: 0.99, 95% CI: 0.99 to 1.00). CONCLUSIONS Peak CircP, better than peak VO2 and VE/VCO2slope, was a strong predictor of cardiac events among exercise parameters in patients with IPAH.
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Predicting Peak Oxygen Uptake From the 6-Minute Walk Test in Patients With Pulmonary Hypertension. J Cardiopulm Rehabil Prev 2017; 36:203-8. [PMID: 26959496 DOI: 10.1097/hcr.0000000000000174] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To determine whether the 6-minute walk test (6MWT) is a predictor of peak oxygen uptake ((Equation is included in full-text article.)O2) in patients with idiopathic pulmonary arterial hypertension (IPAH). METHODS A total of 157 patients treated for IPAH completed a 6MWT in accordance with American Thoracic Society standards. Heart rate, pulse oximetry, and Borg rating of perceived exertion were determined at baseline and posttest. A cardiopulmonary exercise test (CPET) was performed on a cycle ergometer using a ramp protocol. Participants were stratified post hoc by age into 3 groups: children (n = 26), adolescents (n = 49), and adults (n = 82). Multiple linear regression analysis was performed to predict peak (Equation is included in full-text article.)O2 from the 6MWT. RESULTS The regression equation generated for the children was the only model to strongly predict peak (Equation is included in full-text article.)O2 (r = 0.87; P < .001). Similar models for adolescent (r = 0.59; P < .001) and adult groups (r = 0.68; P < .001) did not achieve the same level of correlation. CONCLUSION Six-Minute Walk Test was able to accurately predict peak (Equation is included in full-text article.)O2 in children (6-12 years) with IPAH; however, the model was weaker for predicting peak (Equation is included in full-text article.)O2 in older populations. These findings suggest that 6MWT may be as valid a test for predicting peak (Equation is included in full-text article.)O2 in children with IPAH as CPET measured peak (Equation is included in full-text article.)O2. In older IPAH populations, CPET is the only reliable method for the evaluation of peak (Equation is included in full-text article.)O2.
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Castleberry A, Mulvihill MS, Yerokun BA, Gulack BC, Englum B, Snyder L, Worni M, Osho A, Palmer S, Davis RD, Hartwig MG. The utility of 6-minute walk distance in predicting waitlist mortality for lung transplant candidates. J Heart Lung Transplant 2016; 36:780-786. [PMID: 28131666 DOI: 10.1016/j.healun.2016.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The lung allocation score (LAS) has led to improved organ allocation for transplant candidates. At present, the 6-minute walk distance (6MWD) is treated as a binary categorical variable of whether or not a candidate can walk more than 150 feet in 6 minutes. In this study, we tested the hypothesis that 6MWD is presently under-utilized with respect to discriminatory power, and that, as a continuous variable, could better prognosticate risk of waitlist mortality. METHODS A retrospective cohort analysis was performed using the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) transplant database. Candidates listed for isolated lung transplant between May 2005 and December 2011 were included. The population was stratified by 6MWD quartiles and unadjusted survival rates were estimated. Multivariable Cox proportional hazards modeling was used to assess the effect of 6MWD on risk of death. The Scientific Registry of Transplant Recipients (SRTR) Waitlist Risk Model was used to adjust for confounders. The optimal 6MWD for discriminative accuracy in predicting waitlist mortality was assessed by receiver-operating characteristic (ROC) curves. RESULTS Analysis was performed on 12,298 recipients. Recipients were segregated into quartiles by distance walked. Waitlist mortality decreased as 6MWD increased. In the multivariable model, significant variables included 6MWD, male gender, non-white ethnicity and restrictive lung diseases. ROC curves discriminated 6-month mortality was best at 655 feet. CONCLUSIONS The 6MWD is a significant predictor of waitlist mortality. A cut-off of 150 feet sub-optimally identifies candidates with increased risk of mortality. A cut-off between 550 and 655 feet is more optimal if 6MWD is to be treated as a dichotomous variable. Utilization of the LAS as a continuous variable could further enhance predictive capabilities.
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Affiliation(s)
- Anthony Castleberry
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael S Mulvihill
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
| | - Babatunde A Yerokun
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian C Gulack
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian Englum
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Laurie Snyder
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Mathias Worni
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, Berne, Switzerland
| | - Asishana Osho
- Department of General Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - R Duane Davis
- Cardiovascular Institute, Florida Hospital, Orlando, Florida, USA
| | - Matthew G Hartwig
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Ramos RP, Ferreira EVM, Valois FM, Cepeda A, Messina CMS, Oliveira RK, Araújo ATV, Teles CA, Neder JA, Nery LE, Ota-Arakaki JS. Clinical usefulness of end-tidal CO 2 profiles during incremental exercise in patients with chronic thromboembolic pulmonary hypertension. Respir Med 2016; 120:70-77. [PMID: 27817818 DOI: 10.1016/j.rmed.2016.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Great ventilation to carbon dioxide output (ΔV˙E/ΔV˙CO2) and reduced end-tidal partial pressures for CO2 (PetCO2) during incremental exercise are hallmarks of chronic thromboembolic pulmonary hypertension (CTEPH) and idiopathic pulmonary arterial hypertension (IPAH). However, CTEPH is more likely to involve proximal arteries, which may lead to poorer right ventricle-pulmonary vascular coupling and worse gas exchange abnormalities. Therefore, abnormal PetCO2 profiles during exercise may be more prominent in patients with CTEPH and could be helpful to indicate disease severity. METHODS Seventy patients with CTEPH and 34 with IPAH underwent right heart catheterization and cardiopulmonary exercise testing. According to PetCO2 pattern during exercise, patients were classified as having an increase or stabilization in PetCO2 up to the gas exchange threshold (GET), an abrupt decrease in the rest-exercise transition or a progressive and slow decrease throughout exercise. A subgroup of patients with CTEPH underwent a constant work rate exercise test to obtain arterial blood samples during steady-state exercise. RESULTS Multivariate logistic regression analyses showed that progressive decreases in PetCO2 and SpO2 were better discriminative parameters than ΔV˙E/ΔV˙CO2 to distinguish CTEPH from IPAH. This pattern of PetCO2 was associated with worse functional impairment and greater reduction in PaCO2 during exercise. CONCLUSION Compared to patients with IPAH, patients with CTEPH present more impaired gas exchange during exercise, and PetCO2 abnormalities may be used to identify more clinically and hemodynamically severe cases.
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Affiliation(s)
- R P Ramos
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - E V M Ferreira
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - F M Valois
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - A Cepeda
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - C M S Messina
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - R K Oliveira
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - A T V Araújo
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - C A Teles
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - J A Neder
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - L E Nery
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - J S Ota-Arakaki
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Schoenfeld C, Cebotari S, Hinrichs J, Renne J, Kaireit T, Olsson KM, Voskrebenzev A, Gutberlet M, Hoeper MM, Welte T, Haverich A, Wacker F, Vogel-Claussen J. MR Imaging–derived Regional Pulmonary Parenchymal Perfusion and Cardiac Function for Monitoring Patients with Chronic Thromboembolic Pulmonary Hypertension before and after Pulmonary Endarterectomy. Radiology 2016; 279:925-34. [DOI: 10.1148/radiol.2015150765] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Pinkstaff SO, Burger CD, Daugherty J, Bond S, Arena R. Cardiopulmonary exercise testing in patients with pulmonary hypertension: clinical recommendations based on a review of the evidence. Expert Rev Respir Med 2016; 10:279-95. [DOI: 10.1586/17476348.2016.1144475] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Puente-Maestu L, Palange P, Casaburi R, Laveneziana P, Maltais F, Neder JA, O'Donnell DE, Onorati P, Porszasz J, Rabinovich R, Rossiter HB, Singh S, Troosters T, Ward S. Use of exercise testing in the evaluation of interventional efficacy: an official ERS statement. Eur Respir J 2016; 47:429-60. [DOI: 10.1183/13993003.00745-2015] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/14/2015] [Indexed: 12/20/2022]
Abstract
This document reviews 1) the measurement properties of commonly used exercise tests in patients with chronic respiratory diseases and 2) published studies on their utilty and/or evaluation obtained from MEDLINE and Cochrane Library searches between 1990 and March 2015.Exercise tests are reliable and consistently responsive to rehabilitative and pharmacological interventions. Thresholds for clinically important changes in performance are available for several tests. In pulmonary arterial hypertension, the 6-min walk test (6MWT), peak oxygen uptake and ventilation/carbon dioxide output indices appear to be the variables most responsive to vasodilators. While bronchodilators do not always show clinically relevant effects in chronic obstructive pulmonary disease, high-intensity constant work-rate (endurance) tests (CWRET) are considerably more responsive than incremental exercise tests and 6MWTs. High-intensity CWRETs need to be standardised to reduce interindividual variability. Additional physiological information and responsiveness can be obtained from isotime measurements, particularly of inspiratory capacity and dyspnoea. Less evidence is available for the endurance shuttle walk test. Although the incremental shuttle walk test and 6MWT are reliable and less expensive than cardiopulmonary exercise testing, two repetitions are needed at baseline. All exercise tests are safe when recommended precautions are followed, with evidence suggesting that no test is safer than others.
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ACAR S, SAVCI S, KARDİBAK D, ÖZCAN KAHRAMAN B, AKDENİZ B, ÖZPELİT E, SEVİNÇ C. Clinical correlation between the 6-min walk test andcardiopulmonary exercise testing in patients with pulmonary arterial hypertension. Turk J Med Sci 2016; 46:1658-1664. [DOI: 10.3906/sag-1505-96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 02/14/2016] [Indexed: 11/03/2022] Open
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Howard LS, Ferrari P, Mehta S. Physicians' and patients' expectations of therapies for pulmonary arterial hypertension: where do they meet? Eur Respir Rev 2015; 23:458-68. [PMID: 25445944 DOI: 10.1183/09059180.00007514] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
In recent years, many new, effective therapies for pulmonary arterial hypertension (PAH) have become available and are widely used, yet the long-term prognosis for patients with PAH remains poor. In the absence of a cure, physicians' expectations of PAH-specific therapies are to: 1) improve patients' symptoms and functional capacity; 2) slow disease progression; and 3) improve survival. However, patients with PAH may prioritise other more tangible needs, such as improvements in their ability to carry out their daily tasks and increase their quality of life. Patients with PAH have also called out for social and emotional support from their physicians, caregivers, families and patient associations. Therefore, it is necessary that clinical trials of PAH-specific treatments include end-points that are meaningful to both patients and physicians, and that a multidisciplinary approach to the management of patients with PAH takes into consideration the broader aspects of patients' and caregivers' needs and wishes beyond simple physiological measurements.
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Affiliation(s)
- Luke S Howard
- Dept of Cardiac Sciences, National Pulmonary Hypertension Service, Hammersmith Hospital and Imperial College London, London, UK. Pulmonary Hypertension Association Europe, Vienna, Austria. Pulmonary Hypertension Association of Canada, Vancouver, BC, Canada. Dept of Medicine, Division of Respirology, Southwest Ontario PH Clinic, London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada.
| | - Pisana Ferrari
- Dept of Cardiac Sciences, National Pulmonary Hypertension Service, Hammersmith Hospital and Imperial College London, London, UK. Pulmonary Hypertension Association Europe, Vienna, Austria. Pulmonary Hypertension Association of Canada, Vancouver, BC, Canada. Dept of Medicine, Division of Respirology, Southwest Ontario PH Clinic, London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada
| | - Sanjay Mehta
- Dept of Cardiac Sciences, National Pulmonary Hypertension Service, Hammersmith Hospital and Imperial College London, London, UK. Pulmonary Hypertension Association Europe, Vienna, Austria. Pulmonary Hypertension Association of Canada, Vancouver, BC, Canada. Dept of Medicine, Division of Respirology, Southwest Ontario PH Clinic, London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada. Dept of Cardiac Sciences, National Pulmonary Hypertension Service, Hammersmith Hospital and Imperial College London, London, UK. Pulmonary Hypertension Association Europe, Vienna, Austria. Pulmonary Hypertension Association of Canada, Vancouver, BC, Canada. Dept of Medicine, Division of Respirology, Southwest Ontario PH Clinic, London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada
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Vonk Noordegraaf A, Haddad F, Bogaard HJ, Hassoun PM. Noninvasive imaging in the assessment of the cardiopulmonary vascular unit. Circulation 2015; 131:899-913. [PMID: 25753343 DOI: 10.1161/circulationaha.114.006972] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anton Vonk Noordegraaf
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.).
| | - Francois Haddad
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
| | - Harm J Bogaard
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
| | - Paul M Hassoun
- From Pulmonary Diseases (A.V.N., J.H.B.) and Physics and Medical Technology (A.V.N.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Division of Cardiovascular Medicine, Department of Medicine and Stanford Cardiovascular Institute, Stanford University, Palo Alto, CA (F.H.); and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
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MacKenzie AM, Peacock AJ. Medical Therapies for the Treatment of Pulmonary Arterial Hypertension: How Do We Choose? Curr Hypertens Rep 2015; 17:56. [DOI: 10.1007/s11906-015-0560-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Spruijt OA, de Man FS, Groepenhoff H, Oosterveer F, Westerhof N, Vonk-Noordegraaf A, Bogaard HJ. The Effects of Exercise on Right Ventricular Contractility and Right Ventricular–Arterial Coupling in Pulmonary Hypertension. Am J Respir Crit Care Med 2015; 191:1050-7. [DOI: 10.1164/rccm.201412-2271oc] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Buys R, Avila A, Cornelissen VA. Exercise training improves physical fitness in patients with pulmonary arterial hypertension: a systematic review and meta-analysis of controlled trials. BMC Pulm Med 2015; 15:40. [PMID: 25896259 PMCID: PMC4423624 DOI: 10.1186/s12890-015-0031-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disorder characterized by hypertension in the pulmonary arteries. PAH leads to symptoms such as shortness of breath, dizziness, leg edema and chest pain, impacting heavily on quality of life. The aim of this systematic review and meta-analysis was to determine the effect of exercise training to improve physical fitness and functionality in patients with PAH. METHODS A search was conducted for controlled trials using the databases Medline, Embase, SPORT Discus and Cochrane Central Register of Controlled Trials. Studies were included if at least 80% of the participants presented with group 1 PAH and if the intervention consisted of an exercise training program of at least 3 weeks duration. Data were extracted on study quality, participant and exercise intervention characteristics, and outcomes. Data were pooled by the generic inverse variance method using random effect models and were expressed as weighted means and 95% confidence intervals (CI). RESULTS Of 110 identified abstracts, 5 studies with 106 patients (exercise: 53; control: 53; mean age 49.7 years) were included. Disease severity ranged from mild to severe; 96 patients suffered from PAH, 10 patients had chronic thromboembolic pulmonary hypertension. Exercise training led to an increase in 6 minute walk distance (72.5 m; 95% CI 46.0 m to 99.1 m; p < 0.0001) and peak oxygen uptake (2.16 mL/kg/min; 95% CI 2.16 to 3.93; p = 0.02). No severe adverse events during exercise were reported. CONCLUSIONS Our findings suggest that an exercise training program positively influences exercise tolerance and functional capacity in patients with PAH.
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Affiliation(s)
- Roselien Buys
- Department of Rehabilitation Sciences, Tervuursevest 101, B 1501, B-3001, Leuven, Belgium.
| | - Andrea Avila
- Department of Rehabilitation Sciences, Tervuursevest 101, B 1501, B-3001, Leuven, Belgium.
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Demir R, Küçükoğlu MS. Six-minute walk test in pulmonary arterial hypertension. Anatol J Cardiol 2015; 15:249-54. [PMID: 25880178 PMCID: PMC5337064 DOI: 10.5152/akd.2015.5834] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2014] [Indexed: 02/02/2023] Open
Abstract
Exercise intolerance is the main characteristic of pulmonary arterial hypertension (PAH). The six-minute walk test (6MWT) and cardiopulmonary exercise test are widely used in assessing exercise capacity of PAH patients. Six-minute walk distance (6MWD) has been specified as the main clinical outcome in PAH and has been used as the primary end-point in many studies conducted for new PAH treatments. Using 6MWD as the end-point in clinical studies has many advantages. 6MWT is an inexpensive, easily applicable, and repeatable standardized test that is well-tolerated by PAH patients. Moreover, it is a valid measure of symptomatic improvement. It is correlated with variables of maximal cardiopulmonary exercise test as a measure of submaximal exercise capacity and disease severity markers such as functional class and pulmonary hemodynamics. It is widely used in clinical practice together with other invasive and non-invasive disease markers in assessing disease progression and response to treatment. In addition, it has prognostic importance and is a good prognostic marker. On the other hand, there are limitations to the use of 6MWD as the primary end-point in PAH treatment. It has decreased sensitivity in individuals with less severe disease and high 6MWD at baseline and decreased adequacy in assessing the effects of treatment in patients who are still under PAH treatment. Despite the limitations, 6MWD plays a key role in the evaluation and management of PAH patients.
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Affiliation(s)
- Rengin Demir
- Department of Cardiology, Cardiology Institute, İstanbul University; İstanbul-Turkey.
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Serra AJ, de Carvalho PDTC, Lanza F, de Amorim Flandes C, Silva SC, Suzuki FS, Bocalini DS, Andrade E, Casarin C, Silva JA. Correlation of six-minute walking performance with quality of life is domain- and gender-specific in healthy older adults. PLoS One 2015; 10:e0117359. [PMID: 25695668 PMCID: PMC4335060 DOI: 10.1371/journal.pone.0117359] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/22/2014] [Indexed: 11/19/2022] Open
Abstract
We analyzed the relationship between performance on the 6-min walk test (6MWT) and health-related quality of life (HRQoL) in older subjects. Our secondary aim was to determine the distance to be completed on the 6MWT for the subject to achieve a score of 50 on the Short Form (36) Health Survey (SF-36). Associations were tested using linear correlation and multivariate linear regression. Participants were 130 healthy older individuals. The predictive performance of the 6MWT based on an SF-36 score of 50 was assessed using a receiver operating characteristic curve and its area under curve (AUC). Associations were observed between physical functioning, role-emotional, social functioning, vitality, general health score, and 6MWT performance in women, after adjusting for confounding variables (coefficients: 0.57, 0.38, 0.40, and 0.46, respectively; p < 0.05). No association was found for men. The distance for the 6MWT to predict an SF-36 score of 50 was 481 m for men in the physical functioning (AUC: 0.79) and role-physical (AUC: 0.84) domains, and 420 m for women in role-emotional (AUC: 0.75), role-physical (AUC: 0.80), and general health (AUC: 0.80) domains. Our results indicate that superior 6MWT performance may be associated with better HRQoL in several domains in only healthy older women. No association between 6MWT performance and role-emotional, mental health, or vitality domains was found. We suggest that a score of 50 is represented by a 6MWT distance of 481 m for men and 420 m for women, at least in the role-physical domain.
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Affiliation(s)
- Andrey Jorge Serra
- Post-Graduation at Biophotonic Applied to Health Science, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | | | - Fernanda Lanza
- Post-graduation Program in Rehabilitation Sciences, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | - Camila de Amorim Flandes
- Post-Graduation at Biophotonic Applied to Health Science, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | - Shirley Cardoso Silva
- Post-Graduation at Biophotonic Applied to Health Science, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | - Frank Shiguemitsu Suzuki
- Post-Graduation at Biophotonic Applied to Health Science, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | - Danilo Sales Bocalini
- Post-Graduation at Physical Education, São Judas Tadeu University (USJT), São Paulo, SP, Brazil
| | - Erinaldo Andrade
- Post-Graduation at Biophotonic Applied to Health Science, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | - Cezar Casarin
- Post-Graduation at Biophotonic Applied to Health Science, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
| | - José Antonio Silva
- Post-Graduation at Medicine, Nove de Julho University (UNINOVE), São Paulo, SP, Brazil
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Prognostication in Pulmonary Arterial Hypertension with Submaximal Exercise Testing. Diseases 2015; 3:15-23. [PMID: 28943605 PMCID: PMC5548231 DOI: 10.3390/diseases3010015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 12/26/2014] [Accepted: 01/27/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction: The submaximal exercise test (SET), which gives both a measure of exercise tolerance, as well as disease severity, should be a more robust functional and prognostic marker than the six-minute walk test (6MWT). This study aimed to determine the prognostic value of SET as predicted by the validated REVEAL (Registry to Evaluate Early and Long-Term Pulmonary Artery Hypertension Disease Management) registry risk score (RRRS). Methods: Sixty-five consecutive patients with idiopathic and associated pulmonary arterial hypertension (PAH) underwent right-heart catheterization, echocardiogram, 6MWT and a three-minute SET (Shape-HF™). Analyses explored the association between SET variables and prognosis predicted by the RRRS. Results: Although multiple SET variables correlated with the RRRS on univariate analyses, only VE/VCO2 (ρ = 0.57, p < 0.0001) remained an independent predictor in multivariate analysis (β = 0.05, p = 0.0371). Additionally, the VE/VCO2 was the most discriminatory (area under receiver operating characteristic curve, 0.84) in identifying the highest-risk category (RRRS ≥ 10), with an optimal cut-off of 40.6, resulting in a high sensitivity (92%) and negative-predictive value (97%), but a lower specificity (67%). Conclusion: SETs, particularly the VE/VCO2, appear to have prognostic value when compared to the RRRS. If validated in prospective trials, SET should prove superior to the 6MWT or the RRRS, with significant implications for both future clinical trials and clinical practice.
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The Role of Exercise Testing in the Modern Management of Pulmonary Arterial Hypertension. Diseases 2014. [DOI: 10.3390/diseases2020120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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