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Slavich M, Ricchetti G, Demarchi B, Cavalli G, Spoladore R, Federico A, Federico F, Bezzi C, Margonato A, Fragasso G. Clinical and functional effects of beta-blocker therapy discontinuation in patients with biventricular heart failure. J Cardiovasc Med (Hagerstown) 2024; 25:141-148. [PMID: 38149700 DOI: 10.2459/jcm.0000000000001571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Nearly two-thirds of patients with heart failure with reduced ejection fraction (HFrEF) have right ventricular dysfunction, previously identified as an independent predictor of reduced functional capacity and poor prognosis. Beta-blocker therapy (β-BT) reduces mortality and hospitalizations in patients with HFrEF and is approved as first-line therapy regardless of concomitant right ventricular function. However, the exact role of sympathetic nervous system activation in right ventricular dysfunction and the potential usefulness (or harmfulness) of β-BT in these patients are still unclear. OBJECTIVES The aim of the study is to evaluate the medium-term effect of β-BT discontinuation on functional capacity and right ventricular remodelling based on cardiopulmonary exercise testing (CPET), echocardiography and serum biomarkers in patients with clinically stable biventricular dysfunction. METHODS In this single-centre, open-label, prospective trial, 16 patients were enrolled using the following criteria: patients were clinically stable without signs of peripheral congestion; NYHA II-III while on optimal medical therapy (including β-BT); LVEF 40% or less; echocardiographic criteria of right ventricular dysfunction. Patients were randomized 1 : 1 either to withdraw (group 0) or continue (group 1) β-BT. In group 0, optimal heart rate was obtained with alternative rate-control drugs. Echo and serum biomarkers were performed at baseline, after 3 and 6 months; CPET was performed at baseline and 6 months. Mann--Whitney U test was adopted to determine the relationships between β-BT discontinuation and effects on right ventricular dysfunction. RESULTS At 6 months' follow up, S' DTI improved (ΔS': 1.01 vs. -0.92 cm/s; P = 0.03), while estimated PAPs (ΔPAPs: 0.8 vs. -7.5 mmHg; P = 0.04) and echo left ventricular-remodelling (ΔEDVi: 19.55 vs. -0.96 ml/mq; P = 0.03) worsened in group 0. In absolute terms, the only variables significantly affected by β-BT withdrawal were left ventricular EDV and ESV, appearing worse in group 0 (mean EDVi 115 vs. 84 ml/mq; mean ESVi 79 vs. 53.9 ml/mq, P = 0.03). No significant changes in terms of functional capacity were observed after β-BT withdrawal. CONCLUSION In HFrEF patients with concomitant right ventricular dysfunction, β-BT discontinuation did not produce any beneficial effects. In addition, despite maintenance of optimal heart rate control, β-BT discontinuation induced worsening of left ventricular remodelling. Our study corroborates the hypothesis that improvement in left ventricular function may likewise be a major determinant for improvement in right ventricular function, reducing pulmonary wedge pressure and right ventricular afterload, with only a marginal action of its negative inotropic effect. In conclusion, β-BT appears beneficial also in heart failure patients with biventricular dysfunction.
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Affiliation(s)
- Massimo Slavich
- Department of Cardiology, IRCCS San Raffaele Scientific Institute
| | | | - Barbara Demarchi
- Department of Cardiology, IRCCS San Raffaele Scientific Institute
| | - Giulio Cavalli
- Immunology, Rheumatology, Allergology and Rare Diseases Unit, IRCCS Ospedale San Raffaele
| | | | - Anna Federico
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Carolina Bezzi
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute
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2
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Campodonico J, Contini M, Alimento M, Mapelli M, Salvioni E, Mattavelli I, Bonomi A, Agostoni P. Physiology of exercise and heart failure treatments: cardiopulmonary exercise testing as a tool for choosing the optimal therapeutic strategy. Eur J Prev Cardiol 2023; 30:ii54-ii62. [PMID: 37819227 DOI: 10.1093/eurjpc/zwad189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 10/13/2023]
Abstract
In the last decades, the pharmacological treatment of heart failure (HF) become more complex due to the availability of new highly effective drugs. Although the cardiovascular effects of HF therapies have been extensively described, less known are their effects on cardiopulmonary function considered as a whole, both at rest and in response to exercise. This is a 'holistic' approach to disease treatment that can be accurately evaluated by a cardiopulmonary exercise test. The aim of this paper is to assess the main differences in the effects of different drugs [angiotensin-converting enzyme (ACE)-inhibitors, Angiotensin II receptor blockers, β-blockers, Angiotensin receptor-neprilysin inhibitors, renal sodium-glucose co-transporter 2 inhibitors, iron supplementation] on cardiopulmonary function in patients with HF, both at rest and during exercise, and to understand how these differences can be taken into account when choosing the most appropriate treatment protocol for each individual patient leading to a precision medicine approach.
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Affiliation(s)
- Jeness Campodonico
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea 4, 20138 Milan, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Marina Alimento
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea 4, 20138 Milan, Italy
| | | | - Irene Mattavelli
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Via Parea 4, 20138 Milan, Italy
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3
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Beavers CJ, Ambrosy AP, Butler J, Davidson BT, Gale SE, Piña IL, Mastoris I, Reza N, Mentz RJ, Lewis GD. Iron Deficiency in Heart Failure: A Scientific Statement from the Heart Failure Society of America. J Card Fail 2023; 29:1059-1077. [PMID: 37137386 DOI: 10.1016/j.cardfail.2023.03.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/10/2023] [Accepted: 03/23/2023] [Indexed: 05/05/2023]
Abstract
Iron deficiency is present in approximately 50% of patients with symptomatic heart failure and is independently associated with worse functional capacity, lower quality of, life and increased mortality. The purpose of this document is to summarize current knowledge of how iron deficiency is defined in heart failure and its epidemiology and pathophysiology, as well as pharmacological considerations for repletion strategies. This document also summarizes the rapidly expanding array of clinical trial evidence informing when, how, and in whom to consider iron repletion.
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Affiliation(s)
- Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky.
| | - Andrew P Ambrosy
- Kaiser Permanente Northern California - Division of Research (DOR), Oakland, CA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, Mississippi
| | - Beth T Davidson
- Centennial Heart Cardiovascular Consultants, Nashville, Tennessee
| | - Stormi E Gale
- Novant Health Matthews Medical Center, Matthews, North Carolina
| | - Ileana L Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Nosheen Reza
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina
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4
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Belli-Marin JFC, Bocchi EA, Ayub-Ferreira S, Junior NC, Guimarães GV. Effects of β-blocker therapy on exercise oscillatory ventilation in reduced ejection fraction heart failure patients: A case series study. Biomed Pharmacother 2022; 152:113106. [PMID: 35665667 DOI: 10.1016/j.biopha.2022.113106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is an abnormal breathing pattern that occurs in ~20% of patients with heart failure (HF) and is associated with poor prognosis and exercise intolerance. β-blockers (βb) are prescribed for most HF patients; however, their effect on EOV remains unclear. We evaluated the effect of βb on EOV in HF patients with reduced ejection fraction (HFrEF). METHODS Fifteen patients diagnosed with HF, ejection fraction < 45%, aged from 18 to 65 years, were included before starting βb therapy. Patients underwent clinical evaluation, cardiopulmonary exercise testing, echocardiography, laboratory exams (norepinephrine levels, B type natriuretic peptide) at baseline and after βb therapy optimized for six months. Presence of exercise oscillatory breathing was determined by two experienced observers who were blinded to the moment of the test (pre or post). RESULTS Fifteen patients (1 female), aged 49.5 ± 2.5 years, with HFrEF, NYHA I-III enrolled in the study. The etiologies of the HFrEF were idiopathic (n = 8) and hypertensive (n = 7). LVEF increased after βb therapy from 25.9 ± 2.5% to 33 ± 2.6%, P = 0.02; peak VO2 did not significantly change (21.8 ± 1.7 vs 24.7 ± 1.9, P = 0.4); VE/VCO2 slope changed from 32.1 ± 10.6-27.5 ± 9.1, P = 0.03. Before βb initiation, nine patients (60%) had EOV, but only two (13%) did after optimized therapy. McNemar test was used to evaluate the significance of the association between the two moments (P = 0.02). CONCLUSION In patients with HF, medical therapy with βb can reverse EOV. This may explain why these patients experience symptom improvement after βb therapy.
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Affiliation(s)
| | - Edimar Alcides Bocchi
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Silvia Ayub-Ferreira
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Nelson Carvas Junior
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Guilherme Veiga Guimarães
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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Lewis GD, Docherty KF, Voors AA, Cohen-Solal A, Metra M, Whellan DJ, Ezekowitz JA, Ponikowski P, Böhm M, Teerlink JR, Heitner SB, Kupfer S, Malik FI, Meng L, Felker GM. Developments in Exercise Capacity Assessment in Heart Failure Clinical Trials and the Rationale for the Design of METEORIC-HF. Circ Heart Fail 2022; 15:e008970. [PMID: 35236099 DOI: 10.1161/circheartfailure.121.008970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a highly morbid condition for which exercise intolerance is a major manifestation. However, methods to assess exercise capacity in HFrEF vary widely in clinical practice and in trials. We describe advances in exercise capacity assessment in HFrEF and a comparative analysis of how various therapies available for HFrEF impact exercise capacity. Current guideline-directed medical therapy has indirect effects on cardiac performance with minimal impact on measured functional capacity. Omecamtiv mecarbil is a novel selective cardiac myosin activator that directly increases cardiac contractility and in a phase 3 cardiovascular outcomes study significantly reduced the primary composite end point of time to first heart failure event or cardiovascular death in patients with HFrEF. The objective of the METEORIC-HF trial (Multicenter Exercise Tolerance Evaluation of Omecamtiv Mecarbil Related to Increased Contractility in Heart Failure) is to assess the effect of omecamtiv mecarbil versus placebo on multiple components of functional capacity in HFrEF. The primary end point is to test the effect of omecamtiv mecarbil compared with placebo on peak oxygen uptake as measured by cardiopulmonary exercise testing after 20 weeks of treatment. METEORIC-HF will provide state-of-the-art assessment of functional capacity by measuring ventilatory efficiency, circulatory power, ventilatory anaerobic threshold, oxygen uptake recovery kinetics, daily activity, and quality-of-life assessment. Thus, the METEORIC-HF trial will evaluate the potential impact of increased myocardial contractility with omecamtiv mecarbil on multiple important measures of functional capacity in ambulatory patients with symptomatic HFrEF. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT03759392.
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Affiliation(s)
- Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston (G.D.L.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (K.F.D.)
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, the Netherlands (A.A.V.)
| | - Alain Cohen-Solal
- Paris University, UMR-S 942, Department of Cardiology, Lariboisiere Hospital, Assistance Publique Hopitaux de Paris, France (A.C.-S.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.M.)
| | - David J Whellan
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA (D.J.W.)
| | | | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Poland (P.P.)
| | - Michael Böhm
- Department of Internal Medicine, Saarland University, Homburg, Germany. (M.B.).,Department of Cardiology, Saarland University, Homburg, Germany. (M.B.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and University of California San Francisco (J.R.T.)
| | - Stephen B Heitner
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Stuart Kupfer
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Fady I Malik
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Lisa Meng
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - G Michael Felker
- Division of Cardiology, School of Medicine, Duke University Medical Center, Durham, NC (G.M.F.)
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Peters EL, van Campen JS, Groepenhoff H, de Man FS, Vonk Noordegraaf A, Bogaard HJ. Bisoprolol and/or hyperoxic breathing do not reduce hyperventilation in pulmonary arterial hypertension patients. Pulm Circ 2021; 11:20458940211057890. [PMID: 34925761 PMCID: PMC8671678 DOI: 10.1177/20458940211057890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/19/2021] [Indexed: 11/17/2022] Open
Abstract
Hyperventilation is common in pulmonary arterial hypertension and may be related to autonomic imbalance. Patients underwent exercise testing and hyperoxic breathing before and after bisoprolol treatment. We found that neither beta blocker treatment nor hyperoxic breathing in patients reduced hyperventilation at rest and during exercise, although it reduced heart rate.
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Affiliation(s)
- Eva L. Peters
- Department of Pulmonary MedicineAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of PhysiologyAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Jasmijn S.J.A van Campen
- Department of Pulmonary MedicineAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Herman Groepenhoff
- Department of Pulmonary MedicineAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Frances S. de Man
- Department of Pulmonary MedicineAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary MedicineAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Harm J. Bogaard
- Department of Pulmonary MedicineAmsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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7
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Cardiopulmonary exercise testing in chronic heart failure patients treated with beta-blockers: Still a valid prognostic tool. Int J Cardiol 2020; 317:128-132. [DOI: 10.1016/j.ijcard.2020.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
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8
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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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9
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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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10
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Contini M, Spadafora E, Barbieri S, Gugliandolo P, Salvioni E, Magini A, Apostolo A, Palermo P, Alimento M, Agostoni P. Effects of β 2-receptor stimulation by indacaterol in chronic heart failure treated with selective or non-selective β-blockers: a randomized trial. Sci Rep 2020; 10:7101. [PMID: 32345990 PMCID: PMC7188807 DOI: 10.1038/s41598-020-62644-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/24/2020] [Indexed: 11/09/2022] Open
Abstract
Alveolar β2-receptor blockade worsens lung diffusion in heart failure (HF). This effect could be mitigated by stimulating alveolar β2-receptors. We investigated the safety and the effects of indacaterol on lung diffusion, lung mechanics, sleep respiratory behavior, cardiac rhythm, welfare, and exercise performance in HF patients treated with a selective (bisoprolol) or a non-selective (carvedilol) β-blocker. Study procedures were performed before and after indacaterol and placebo treatments according to a cross-over, randomized, double-blind protocol in forty-four patients (27 on bisoprolol and 17 on carvedilol). No differences between indacaterol and placebo were observed in the whole population except for a significantly higher VE/VCO2 slope and lower maximal PETCO2 during exercise with indacaterol, entirely due to the difference in the bisoprolol group (VE/VCO2 31.8 ± 5.9 vs. 28.5 ± 5.6, p < 0.0001 and maximal PETCO2 36.7 ± 5.5 vs. 37.7 ± 5.8 mmHg, p < 0.02 with indacaterol and placebo, respectively). In carvedilol, indacaterol was associated with a higher peak heart rate (119 ± 34 vs. 113 ± 30 bpm, with indacaterol and placebo) and a lower prevalence of hypopnea during sleep (3.8 [0.0;6.3] vs. 5.8 [2.9;10.5] events/hour, with indacaterol and placebo). Inhaled indacaterol is well tolerated in HF patients, it does not influence lung diffusion, and, in bisoprolol, it increases ventilation response to exercise.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy. .,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy.
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11
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Sinagra G, Corrà U, Contini M, Magrì D, Paolillo S, Perrone Filardi P, Sciomer S, Badagliacca R, Agostoni P. Choosing among β-blockers in heart failure patients according to β-receptors' location and functions in the cardiopulmonary system. Pharmacol Res 2020; 156:104785. [PMID: 32224252 DOI: 10.1016/j.phrs.2020.104785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/05/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
Several large clinical trials showed a favorable effect of β-blocker treatment in patients with chronic heart failure (HF) as regards overall mortality, cardiovascular mortality, and hospitalizations. Indeed, the use of β-blockers is strongly recommended by current international guidelines, and it remains a cornerstone in the pharmacological treatment of HF. Although different types of β-blockers are currently approved for HF therapy, possible criteria to choose the best β-blocking agent according to HF patients' characteristics and to β-receptors' location and functions in the cardiopulmonary system are still lacking. In such a context, a growing body of literature shows remarkable differences between β-blocker types (β1-selective blockers versus β1-β2 blockers) with respect to alveolar-capillary gas diffusion and chemoreceptor response in HF patients, both factors able to impact on quality of life and, most likely, on prognosis. This review suggests an original algorithm for choosing among the currently available β-blocking agents based on the knowledge of cardiopulmonary pathophysiology. Particularly, starting from lung physiology and from some experimental models, it focuses on the mechanisms underlying lung mechanics, chemoreceptors, and alveolar-capillary unit impairment in HF. This paper also remarks the significant benefit deriving from the correct use of the different β-blockers in HF patients through a brief overview of the most important clinical trials.
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Affiliation(s)
- Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, Veruno Institute, Veruno, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | | | - Susanna Sciomer
- Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Roberto Badagliacca
- Dipartimento Di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Università Degli Studi Di Roma, Roma, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy.
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12
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Huang D, Guo J, Yang W, Liu J. Exercise Capacity and Ventilatory Efficiency in Patients With Pulmonary Embolism After Short Duration of Anticoagulation Therapy. Am J Med Sci 2020; 359:140-146. [DOI: 10.1016/j.amjms.2019.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 10/25/2022]
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13
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Chobola M, Homolka P, Benej M, Chovanec Z, Brat K, Sramek V, Olson LJ, Cundrle I. Ventilatory Efficiency Identifies Patients Prone to Hypoxemia During One-Lung Ventilation. J Cardiothorac Vasc Anesth 2019; 33:1956-1962. [DOI: 10.1053/j.jvca.2019.01.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/23/2019] [Accepted: 01/25/2019] [Indexed: 01/29/2023]
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14
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Wagner J, Agostoni P, Arena R, Belardinelli R, Dumitrescu D, Hager A, Myers J, Rauramaa R, Riley M, Takken T, Schmidt-Trucksäss A. The Role of Gas Exchange Variables in Cardiopulmonary Exercise Testing for Risk Stratification and Management of Heart Failure with Reduced Ejection Fraction. Am Heart J 2018; 202:116-126. [PMID: 29933148 DOI: 10.1016/j.ahj.2018.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/18/2018] [Indexed: 01/14/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in the developed world and results in significant morbidity and mortality. Accurate risk assessment methods and prognostic variables are therefore needed to guide clinical decision making for medical therapy and surgical interventions with the ultimate goal of decreasing risk and improving health outcomes. The purpose of this review is to examine the role of cardiopulmonary exercise testing (CPET) and its most commonly used ventilatory gas exchange variables for the purpose of risk stratification and management of HFrEF. We evaluated five widely studied gas exchange variables from CPET in HFrEF patients based on nine previously used systematic criteria for biomarkers. This paper provides clinicians with a comprehensive and critical overview, class recommendations and evidence levels. Although some CPET variables met more criteria than others, evidence supporting the clinical assessment of variables beyond peak V̇O2 is well-established. A multi-variable approach also including the V̇E-V̇CO2 slope and EOV is therefore recommended.
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Affiliation(s)
- Jonathan Wagner
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy & Department of Clinical sciences and Community health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL
| | - Romualdo Belardinelli
- Department of Cardiovascular Sciences, Cardiac Rehabilitation Lancisi, Ancona, Italy
| | - Daniel Dumitrescu
- Herzzentrum der Universitaet zu Koeln, Klinik III fuer Innere Medizin, Cologne, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technical University of Munich, Germany
| | - Jonathan Myers
- Cardiology Division, VA Palo Alto Health Care System and Stanford University, Palo Alto, CA
| | - Rainer Rauramaa
- Foundation for Research in Health, Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
| | - Marshall Riley
- Department of Medicine, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Tim Takken
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
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15
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Abstract
Heart failure treatment depends on several drugs, all providing improvement in outcome, but that cannot be realistically used all together in the same patient. It would be useful to have a tool that allows the arrangement of the most appropriate therapy cocktail for each patient. The aim of this article is to show the main differences in the effects of several drugs on cardiopulmonary function in patients with heart failure, both while resting and during exercise, and to discuss how these differences can be taken into account when choosing the most appropriate therapeutic protocol. In summary, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers act synergistically to increase exercise capacity and peak oxygen uptake, but through different mechanisms: the former improving lung diffusion and exercise ventilatory efficiency, an action that is counteracted by concomitant aspirin therapy, and the latter probably by improving muscle perfusion. As for β-blockers, nonselective compounds, such as carvedilol, improve ventilation efficiency on the one hand, but interfere with lung diffusion on the other, and they are probably less tolerated under hypoxic conditions. On the contrary, β1-selective compounds, such as bisoprolol or nebivolol, have a neutral effect on both lung diffusion and ventilation efficiency. These observations could be the basis for the choice of pharmacological therapy in patients with heart failure.
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MONTERO DAVID, FLAMMER ANDREASJ. Effect of Beta-blocker Treatment on V˙O2peak in Patients with Heart Failure. Med Sci Sports Exerc 2018; 50:889-896. [DOI: 10.1249/mss.0000000000001513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Montero D, Diaz-Cañestro C. Determinants of exercise intolerance in heart failure with preserved ejection fraction: A systematic review and meta-analysis. Int J Cardiol 2018; 254:224-229. [PMID: 29407095 DOI: 10.1016/j.ijcard.2017.10.114] [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: 06/09/2017] [Revised: 10/08/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Severe exercise intolerance (EI), demonstrated by impaired peak oxygen consumption, intrinsically characterizes heart failure with preserved ejection fraction (HFpEF). Controversy exists on the determinants of EI in patients with HFpEF according to case-control studies. The purpose of this study is to systematically review and clarify the main (Fick) determinants of EI in HFpEF. METHODS We conducted a systematic search of MEDLINE, Scopus and Web of Science since their inceptions until January 2017 for articles assessing peak cardiac output and/or arteriovenous oxygen difference (a-vO2diffpeak) with incremental exercise in patients diagnosed with HFpEF and age-matched control individuals. Meta-analyses were performed to determine the standardized mean difference (SMD) in peak cardiac index (CIpeak) and a-vO2diffpeak between HFpEF and control groups. Subgroup and meta-regression analyses were used to evaluate potential moderating factors. RESULTS Ten studies were included after systematic review, comprising a total of 213 HFpEF patients and 179 age-matched control individuals (mean age=51-73years). After data pooling, CIpeak (n=392, SMD=-1.42; P<0.001) and a-vO2diffpeak (n=228, SMD=-0.52; P=0.002) were impaired in HFpEF patients. In subgroup analyses, a-vO2diffpeak was reduced in HFpEF versus healthy individuals (n=114, SMD=-0.85; P<0.001) but not compared with control patients without heart failure (n=92, SMD=-0.12; P=0.57). The SMD in a-vO2diffpeak was negatively associated with age (B=-0.05, P=0.046), difference in % females (B=-0.01, P=0.026) and prevalence of hypertension (B=-0.01, P=0.015) between HFpEF and control groups. CONCLUSIONS HFpEF is associated with a predominant impairment of CIpeak, accompanied by sex- and comorbidity-dependent reduced oxygen extraction at peak exercise.
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Affiliation(s)
- David Montero
- Department of Cardiology, University Hospital Zurich, Switzerland.
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18
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Quality of life assessment in heart failure interventions: a 10-year (1996–2005) review. ACTA ACUST UNITED AC 2016; 14:589-607. [DOI: 10.1097/hjr.0b013e32828622c3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The increasing prevalence and poor prognosis associated with heart failure have prompted research to focus on improving quality of life (QoL) for heart failure patients. Research from 1996–2005 was systematically reviewed to identify randomized controlled trials that assessed QoL in heart failure. In 120 studies, 44 were medication trials; 19 surgical/procedural interventions; and 57 patient care/service delivery interventions. Studies were summarized in terms of aim, population, QoL measures used and QoL findings. Studies used 47 different measures of QoL-generic, health-related, condition-specific, domain-specific and utility measures. Most used a single QoL measure. In 87%, a condition specific QoL measure was used, with the Minnesota Living with Heart Failure Questionnaire being the favoured assessment tool. The range of QoL measures in use poses challenges for development of cumulative knowledge. Although comparability across studies is important, this must be informed by the responsiveness of the instrument selected. As carried out in other cardiac groups, comparative evaluations of instrument responsiveness are needed in heart failure. Eur J Cardiovasc Prev Rehabil 14:589-607 © 2007 The European Society of Cardiology
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Nedeljkovic I, Banovic M, Stepanovic J, Giga V, Djordjevic-Dikic A, Trifunovic D, Nedeljkovic M, Petrovic M, Dobric M, Dikic N, Zlatar M, Beleslin B. The combined exercise stress echocardiography and cardiopulmonary exercise test for identification of masked heart failure with preserved ejection fraction in patients with hypertension. Eur J Prev Cardiol 2015; 23:71-7. [PMID: 26358991 DOI: 10.1177/2047487315604836] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is commonly associated with hypertension (HTN). However, resting echocardiography (ECHO) can underestimate the severity of disease. Exercise stress echocardiography (ESE) and the cardiopulmonary exercise testing (CPX) appeared to be useful tests in dynamic assessment of HFpEF. The value of combined exercise stress echocardiography cardiopulmonary testing (ESE-CPX) in the identification of masked HFpEF is still undetermined. OBJECTIVE The purpose of this study was to analyse the value of the combined ESE-CPX in the identification of masked HFpEF in patients with HTN, dyspnoea and normal resting left ventricular (LV) systolic and diastolic function. METHODOLOGY We studied 87 patients with HTN, exertional dyspnoea and normal resting LV function. They all underwent ESE-CPX testing (supine bicycle, ramp protocol, 15 W/min). ECHO measurements were performed at rest, and at peak load. Achievement of peak E/e' ratio>15 was a marker for masked HFpEF. RESULTS Increase of E/e'>15 occurred in 8/87 patients (9.2%) during ESE-CPX. Those patients had the lower peak VO2 (p = 0.012), the lower VO2 at anaerobic threshold (p = 0.025), the lower workload (p = 0.026), the lower peak partial pressure end tidal carbon dioxide (PetCO2) (p < 0.0001), and the higher VE/VCO2 slope (p < 0.0001) which was an independent multivariate predictor of HFpEF (p = 0.021), with the cut-off value of 32.95 according to the receiver-operator characteristic (ROC) curve (sensitivity (Sn) 100%, specificity (Sp) 90%). CONCLUSION The combined ESE-CPX test is feasible and reliable test that can unmask HFpEF and may become an important aid in the early diagnosis of HFpEF, excluding the other causes of exertional dyspnoea.
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Affiliation(s)
- Ivana Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Marko Banovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Jelena Stepanovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Danijela Trifunovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Petrovic
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Milan Dobric
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
| | - Nenad Dikic
- Outpatient Clonoc for Sport Medicine 'Vita Maxima', Belgrade, Serbia
| | - Milan Zlatar
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Serbia School of Medicine, University of Belgrade, Serbia
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Mushtaq S, Andreini D, Farina S, Salvioni E, Pontone G, Sciomer S, Volpato V, Agostoni P. Levosimendan improves exercise performance in patients with advanced chronic heart failure. ESC Heart Fail 2015; 2:133-141. [PMID: 27708855 PMCID: PMC5042087 DOI: 10.1002/ehf2.12047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/15/2015] [Accepted: 06/02/2015] [Indexed: 11/06/2022] Open
Abstract
AIMS Cardiopulmonary exercise test (CPET) provides parameters such as peak VO2 and ventilation/CO2 production (VE/VCO2) slope, which are strong prognostic predictors in patients with stable advanced chronic heart failure (ADHF). The study aim was to evaluate the effects of the inodilator levosimendan on CPET in patients with ADHF under stable clinical conditions. METHODS AND RESULTS We enrolled patients with ADHF (peak VO2 < 12 mL/min/kg) in a double-blind, placebo-controlled protocol. Patients were randomly assigned to i.v. infusion of placebo (500 mL 5% glucose; n = 19) or levosimendan (in 500 mL 5% glucose; n = 23). Before and 24 h after the end of the infusion, patients underwent determination of New York Heart Association class, B-type natriuretic peptide (BNP), haemoglobin, serum creatinine, and blood urea nitrogen levels, as well as CPET, standard spirometry, and alveolar capillary gas diffusion. BNP showed no change with placebo (1042 ± 811 to 1043 ± 867 pg/mL), but it was decreased with levosimendan (1163 ± 897 to 509 ± 543 pg/mL, P < 0.001). No changes were observed for haemoglobin, creatinine, and blood urea nitrogen in either group. With levosimendan, a minor improvement was observed in spirometry measurements, but not in alveolar capillary gas diffusion. Peak VO2 showed a small, non-significant increase with placebo (9.5 ± 1.7 to 10.0 ± 2.1 mL/kg/min, P = 0.12), and a greater increase with levosimendan (9.8 ± 1.7 to 11.0 ± 1.9 mL/kg/min, P < 0.005). The VE/VCO2 slope showed no change (44.0 ± 11 vs. 43.4 ± 10.3, P = 0.44), and a decrease (41.9 ± 10 vs. 36.6 ± 6.4, P < 0.001) in the placebo and in the levosimendan group, respectively. CONCLUSION Levosimendan treatment significantly improves peak VO2 and reduces VE/VCO2 slope and BNP in patients with ADHF.
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Affiliation(s)
- Saima Mushtaq
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Daniele Andreini
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
- Cardiovascular Section, Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
| | - Stefania Farina
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Elisabetta Salvioni
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Gianluca Pontone
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Susanna Sciomer
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthesiological and Geriatric Sciences‘La Sapienza’ University of RomeRomeItaly
| | - Valentina Volpato
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Piergiuseppe Agostoni
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
- Cardiovascular Section, Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
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21
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Imamura T, Kinugawa K, Nitta D, Inaba T, Maki H, Hatano M, Komuro I. Novel Scoring System Using Cardiopulmonary Exercise Testing Predicts Prognosis in Heart Failure Patients Receiving Guideline-Directed Medical Therapy. Circ J 2015; 79:1068-75. [DOI: 10.1253/circj.cj-14-1249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | - Koichiro Kinugawa
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | - Daisuke Nitta
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Toshiro Inaba
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Hisataka Maki
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
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Güder G, Brenner S, Störk S, Hoes A, Rutten FH. Chronic obstructive pulmonary disease in heart failure: accurate diagnosis and treatment. Eur J Heart Fail 2014; 16:1273-82. [DOI: 10.1002/ejhf.183] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/08/2014] [Accepted: 09/12/2014] [Indexed: 01/08/2023] Open
Affiliation(s)
- Gülmisal Güder
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Susanne Brenner
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Arno Hoes
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Frans H. Rutten
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
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23
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Corrà U, Piepoli MF, Adamopoulos S, Agostoni P, Coats AJ, Conraads V, Lambrinou E, Pieske B, Piotrowicz E, Schmid JP, Seferović PM, Anker SD, Filippatos G, Ponikowski PP. Cardiopulmonary exercise testing in systolic heart failure in 2014: the evolving prognostic role. Eur J Heart Fail 2014; 16:929-41. [DOI: 10.1002/ejhf.156] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 06/23/2014] [Accepted: 06/27/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ugo Corrà
- Cardiology Division, IRCCS Fondazione ‘S. Maugeri’; Centro Medico e di Riabilitazione di Veruno; Veruno Novara Italy
| | - Massimo F. Piepoli
- Heart Failure Unit, Cardiac Department; G Da Saliceto Hospital; Piacenza Italy
| | | | | | - Andrew J.S. Coats
- Monash University, Melbourne, Australia and University of Warwick; Coventry UK
| | - Viviane Conraads
- Department of Cardiology; Antwerp University Hospital; Edegem Antwerpen Belgium
| | | | - Burkert Pieske
- Department of Cardiology Medical University Graz; Austria
| | - Ewa Piotrowicz
- Telecardiology Center; Institute of Cardiology; Warsaw Poland
| | - Jean-Paul Schmid
- Department of Cardiology, Cardiovascular Prevention, Rehabilitation & Sports Medicine; Bern University Hospital and University of Bern; Switzerland
| | - Petar M. Seferović
- Polyclinic of the Clinical Centre of Serbia, and Department of Internal Medicine Belgrade University School of Medicine; Belgrade Serbia
| | - Stefan D. Anker
- Applied Cachexia Research; Department of Cardiology, Charitè, Campus Virchow Klinikum; Berlin Germany
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology; University Hospital Attikon; Athens Greece
| | - Piotr P. Ponikowski
- Department of Heart Diseases, Faculty of Health Sciences; Wroclaw Medical University Military Hospital; Wroclaw Poland
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Pardaens S, Vanderheyden M, Calders P, Willems AM, Bartunek J, de Sutter J. Activation of the ergoreceptors in cardiac patients with and without heart failure. J Card Fail 2014; 20:747-754. [PMID: 25079301 DOI: 10.1016/j.cardfail.2014.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 07/14/2014] [Accepted: 07/16/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND The presence of ergoreflex activity and its current relationship to hyperventilation and prognosis in cardiac patients is unclear. Therefore, we evaluated ergoreflex activity in cardiac patients with and without heart failure (CHF) as well as in healthy subjects, and we examined how ergoreceptor activity was related to a mortality risk score in CHF (MAGGIC). METHODS AND RESULTS Twenty-five healthy subjects and 76 patients were included, among whom were 25 with ischemic heart disease (IHD), 24 with stable CHF, and 27 with unstable CHF. Ergoreflex activity was measured with a dynamic handgrip exercise, followed by post-handgrip regional circulatory occlusion (PH-RCO). Ergoreflex activity contributed significantly to ventilation (median [interquartile range] %V) in unstable CHF (81 [73-91] %V without PH-RCO, 92 [82-107] %V with PH-RCO, and 11 [6-20] difference in %V; P < .001) and was positively correlated with the MAGGIC risk score (Spearman ρ = 0.431; P = .002). No ergoreflex activity was observed in healthy subjects (-4 [-10 to 5] difference in %V), IHD (0 [-8 to 3] Diff in %V) and stable CHF (-3 [-11 to 6] difference in %V). CONCLUSIONS Ergoreflex activity contributes to hyperventilation, but only in CHF patients with persistent symptoms, and is closely related to the MAGGIC risk score. Ergoreflex activity was not present in patients with IHD or stable CHF, suggesting other reasons for the increased ventilatory drive in those patients.
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Affiliation(s)
- Sofie Pardaens
- Department of Internal Medicine, Ghent University, Ghent, Belgium.
| | | | - Patrick Calders
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | | | - Jozef Bartunek
- Cardiovascular Center, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Johan de Sutter
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Department of Cardiology, AZ Maria Middelares, Ghent, Belgium
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25
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Ingle L. Prognostic value and diagnostic potential of cardiopulmonary exercise testing in patients with chronic heart failure. Eur J Heart Fail 2014; 10:112-8. [DOI: 10.1016/j.ejheart.2007.12.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 11/16/2007] [Accepted: 12/19/2007] [Indexed: 10/22/2022] Open
Affiliation(s)
- Lee Ingle
- Carnegie Faculty of Sport and Education; Leeds Metropolitan University; Beckett's Park, Headingley Leeds LS6 3QS UK
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26
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Guazzi M. Abnormalities in Cardiopulmonary Exercise Testing Ventilatory Parameters in Heart Failure: Pathophysiology and Clinical Usefulness. Curr Heart Fail Rep 2014; 11:80-7. [DOI: 10.1007/s11897-013-0183-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Rausch CM, Taylor AL, Ross H, Sillau S, Ivy DD. Ventilatory efficiency slope correlates with functional capacity, outcomes, and disease severity in pediatric patients with pulmonary hypertension. Int J Cardiol 2013; 169:445-8. [PMID: 24144928 DOI: 10.1016/j.ijcard.2013.10.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 08/04/2013] [Accepted: 10/05/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing is widely used in a variety of cardiovascular conditions. Ventilatory efficiency slope can be derived from submaximal exercise testing. The present study sought to evaluate the relationship between ventilatory efficiency slope and functional capacity, outcomes, and disease severity in pediatric patients with pulmonary hypertension. METHODS Seventy six children and young adults with a diagnosis of pulmonary hypertension (PH) performed 258 cardiopulmonary exercise tests from 2001 to 2011. Each individual PH test was matched to a control test. Ventilatory efficiency slope was compared to traditional measures of functional capacity and disease severity including WHO functional classification, peak oxygen consumption, and invasive measures of pulmonary arterial pressures and pulmonary vascular resistance. RESULTS Ventilatory efficiency slope was significantly higher in patients with pulmonary arterial hypertension, with an estimated increase of 7.2 for each increase in WHO class (p<0.0001), compared with normal control subjects (38.9 vs. 30.9, p<0.001). Ventilatory efficiency slope correlated strongly with invasive measures of disease severity including pulmonary vascular resistance index (r =0.61), pulmonary artery pressure (r =0.58), mean pulmonary artery pressure/mean aortic pressure ratio (r =0.52), and peak VO2 (r=-0.58). Ventilatory efficiency slope in 12 patients with poor outcomes (9 death, 3 lung transplant), was significantly elevated compared to patients who did not (51.1 vs. 37.9, p<0.001). CONCLUSIONS Ventilatory efficiency slope correlates well with invasive and noninvasive markers of disease severity including peak VO2, WHO functional class, and catheterization variables in pediatric patients with PH. Ventilatory efficiency slope may be a useful noninvasive marker for disease severity.
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Affiliation(s)
- Christopher M Rausch
- University of Colorado School of Medicine, Department of Pediatrics CO, USA; Children's Hospital Colorado, Division of Pediatric Cardiology, CO, USA.
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28
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Agostoni P. Considerations on Safety and Treatment of Patients with Chronic Heart Failure at High Altitude. High Alt Med Biol 2013; 14:96-100. [DOI: 10.1089/ham.2012.1117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Dipartimento di scienze cliniche e di comunità, Università di Milano, Milan Italy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Ramos RP, Alencar MCN, Treptow E, Arbex F, Ferreira EMV, Neder JA. Clinical usefulness of response profiles to rapidly incremental cardiopulmonary exercise testing. Pulm Med 2013; 2013:359021. [PMID: 23766901 PMCID: PMC3666297 DOI: 10.1155/2013/359021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 12/17/2012] [Accepted: 01/15/2013] [Indexed: 02/06/2023] Open
Abstract
The advent of microprocessed "metabolic carts" and rapidly incremental protocols greatly expanded the clinical applications of cardiopulmonary exercise testing (CPET). The response normalcy to CPET is more commonly appreciated at discrete time points, for example, at the estimated lactate threshold and at peak exercise. Analysis of the response profiles of cardiopulmonary responses at submaximal exercise and recovery, however, might show abnormal physiologic functioning which would not be otherwise unraveled. Although this approach has long been advocated as a key element of the investigational strategy, it remains largely neglected in practice. The purpose of this paper, therefore, is to highlight the usefulness of selected submaximal metabolic, ventilatory, and cardiovascular variables in different clinical scenarios and patient populations. Special care is taken to physiologically justify their use to answer pertinent clinical questions and to the technical aspects that should be observed to improve responses' reproducibility and reliability. The most recent evidence in favor of (and against) these variables for diagnosis, impairment evaluation, and prognosis in systemic diseases is also critically discussed.
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Affiliation(s)
- Roberta P. Ramos
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Maria Clara N. Alencar
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Erika Treptow
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Flávio Arbex
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Eloara M. V. Ferreira
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - J. Alberto Neder
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University and Kingston General Hospital, Richardson House, 102 Stuart Street, Kingston, ON, Canada K7L 2V6
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Paolillo S, Pellegrino R, Salvioni E, Contini M, Iorio A, Bovis F, Antonelli A, Torchio R, Gulotta C, Locatelli A, Agostoni P. Role of alveolar β2-adrenergic receptors on lung fluid clearance and exercise ventilation in healthy humans. PLoS One 2013; 8:e61877. [PMID: 23613962 PMCID: PMC3627811 DOI: 10.1371/journal.pone.0061877] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 03/14/2013] [Indexed: 11/19/2022] Open
Abstract
Background In experimental conditions alveolar fluid clearance is controlled by alveolar β2-adrenergic receptors. We hypothesized that if this occurs in humans, then non-selective β-blockers should reduce the membrane diffusing capacity (DM), an index of lung interstitial fluid homeostasis. Moreover, we wondered whether this effect is potentiated by saline solution infusion, an intervention expected to cause interstitial lung edema. Since fluid retention within the lungs might trigger excessive ventilation during exercise, we also hypothesized that after the β2-blockade ventilation increased in excess to CO2 output and this was further enhanced by interstitial edema. Methods and Results 22 healthy males took part in the study. On day 1, spirometry, lung diffusion for carbon monoxide (DLCO) including its subcomponents DM and capillary volume (VCap), and cardiopulmonary exercise test were performed. On day 2, these tests were repeated after rapid 25 ml/kg saline infusion. Then, in random order 11 subjects were assigned to oral treatment with Carvedilol (CARV) and 11 to Bisoprolol (BISOPR). When heart rate fell at least by 10 beats·min−1, the tests were repeated before (day 3) and after saline infusion (day 4). CARV but not BISOPR, decreased DM (−13±7%, p = 0.001) and increased VCap (+20±22%, p = 0.016) and VE/VCO2 slope (+12±8%, p<0.01). These changes further increased after saline: −18±13% for DM (p<0.01), +44±28% for VCap (p<0.001), and +20±10% for VE/VCO2 slope (p<0.001). Conclusions These findings support the hypothesis that in humans in vivo the β2-alveolar receptors contribute to control alveolar fluid clearance and that interstitial lung fluid may trigger exercise hyperventilation.
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Affiliation(s)
- Stefania Paolillo
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
- Dipartimento di Medicina Interna, Scienze cardiovascolari ed immunologiche, Università Federico II, Napoli, Italy
| | - Riccardo Pellegrino
- Allergologia e Fisiopatologia Respiratoria, ASO S. Croce e Carle, Cuneo, Italy
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Annamaria Iorio
- Dipartimento cardiovascolare, Ospedali Riuniti e Università di Trieste, Trieste, Italy
| | - Francesca Bovis
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Andrea Antonelli
- Allergologia e Fisiopatologia Respiratoria, ASO S. Croce e Carle, Cuneo, Italy
| | - Roberto Torchio
- Pneumologia-Fisiopatologia Respiratoria, AOU S. Luigi, Orbassano, Torino, Italy
| | - Carlo Gulotta
- Pneumologia-Fisiopatologia Respiratoria, AOU S. Luigi, Orbassano, Torino, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, Istituto Di Ricovero e Cura a Carattere Scientifico, Milano, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Milan, Italy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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31
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Ludka O, Trna J, Galkova L, Musil V, Spinar J. Usefulness of exercise tissue doppler echocardiography for prognostic stratification of congestive heart failure patients with left ventricular systolic dysfunction. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:27-34. [DOI: 10.5507/bp.2012.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 01/04/2012] [Indexed: 11/23/2022] Open
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Abstract
Lung function abnormalities both at rest and during exercise are frequently observed in patients with chronic heart failure, also in the absence of respiratory disease. Alterations of respiratory mechanics and of gas exchange capacity are strictly related to heart failure. Severe heart failure patients often show a restrictive respiratory pattern, secondary to heart enlargement and increased lung fluids, and impairment of alveolar-capillary gas diffusion, mainly due to an increased resistance to molecular diffusion across the alveolar capillary membrane. Reduced gas diffusion contributes to exercise intolerance and to a worse prognosis. Cardiopulmonary exercise test is considered the “gold standard” when studying the cardiovascular, pulmonary, and metabolic adaptations to exercise in cardiac patients. During exercise, hyperventilation and consequent reduction of ventilation efficiency are often observed in heart failure patients, resulting in an increased slope of ventilation/carbon dioxide (VE/VCO2) relationship. Ventilatory efficiency is as strong prognostic and an important stratification marker. This paper describes the pulmonary abnormalities at rest and during exercise in the patients with heart failure, highlighting the principal diagnostic tools for evaluation of lungs function, the possible pharmacological interventions, and the parameters that could be useful in prognostic assessment of heart failure patients.
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Cameron P, Ellis PM, Pond GR, Goffin JR. Do beta-blockers alter dyspnea and fatigue in advanced lung cancer? A retrospective analysis. Palliat Med 2012; 26:797-803. [PMID: 21844136 DOI: 10.1177/0269216311415454] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Dyspnea is common in lung cancer and may be partially attributable to increased ventilatory drive due to muscle weakness. The sympathetic component of this pathway might be mitigated by β-blockers. METHODS A retrospective review of new patients with stage III-IV non-small lung cancer or any small cell lung cancer was undertaken to assess the impact of β-blocker use on dyspnea and fatigue. Data were abstracted for clinical characteristics, β-blocker use, and pre-treatment Edmonton Symptom Assessment System dyspnea and fatigue scores. RESULTS Of 348 patients assessed, 202 met eligibility criteria. The median age was 67, 55.4% were female, 18.8% had chronic obstructive pulmonary disease (COPD), and 5.9% had active coronary artery disease. Over 60% of patients scored 4/10 or higher on their dyspnea and fatigue scores. While dyspnea and fatigue were moderately associated, no association was found between β-blocker use and either symptom. Recorded dosages of β-blockers were low. COPD was associated with dyspnea and fatigue, while anemia was associated with fatigue. CONCLUSIONS Dyspnea and fatigue are prevalent and increased in the presence of COPD and anemia. No association between β-blocker use and dyspnea or fatigue scores was observed. This may be attributable to inadequate dosing or to retrospective bias.
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Wessler BS, Kramer DG, Kelly JL, Trikalinos TA, Kent DM, Konstam MA, Udelson JE. Drug and Device Effects on Peak Oxygen Consumption, 6-Minute Walk Distance, and Natriuretic Peptides as Predictors of Therapeutic Effects on Mortality in Patients With Heart Failure and Reduced Ejection Fraction. Circ Heart Fail 2011; 4:578-88. [DOI: 10.1161/circheartfailure.111.961573] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Although peak oxygen consumption (peak V
o
2
), 6-minute walk distance (6MW), and natriuretic peptides (BNP and NT-proBNP) are predictors of mortality in heart failure (HF) patients, it is not known whether therapy-induced changes in these measures can predict therapeutic effect on mortality. The objective of this analysis is to quantitatively assess the relationship between therapeutic effects on commonly proposed short-term markers in HF trials and therapeutic effects on long-term outcome in patients with HF and left ventricular dysfunction.
Methods and Results—
We identified drug or device therapies for which there exists at least 1 randomized, controlled trial (RCT) assessing mortality over at least 6 months in at least 500 patients. For each of these therapies, we identified RCTs assessing the short-term changes in V
o
2
, 6MW, BNP, and NT-proBNP (few of the mortality RCTs assessed the short-term changes in markers). For each intervention, we calculated the odds ratio for mortality (using random effect meta-analysis when necessary), as well as the trial level average drug- or device-induced change in the markers. We assessed the correlation between the odds ratio for death with the placebo-corrected change in the functional parameter or biomarker across the interventions. We identified mortality RCTs of 27 distinct therapies (n=73 267 patients) with a median follow-up of 19 months, that directed the search for RCTs of the effect of those interventions on the functional markers and biomarkers. There were 54 peak V
o
2
trials (n=4646 patients), 34 6MW trials (n=6995 patients), 15 BNP trials (n=7233), and 6 NT-proBNP trials (n=1946) included in this analysis. There was no significant correlation between the average therapy-induced placebo-corrected change in peak V
o
2
and the odds ratio for mortality (
r
=0.158,
P
=0.26). Increased drug or device-induced average change in 6MW was correlated with increased odds ratio for mortality (
r
=0.373,
P
=0.036). There was no significant correlation between the average therapy-induced, placebo-corrected change in the natriuretic peptides and the odds ratio for mortality (BNP:
r
=−0.065,
P
=0.82, NT-proBNP:
r
=−0.667,
P
=0.15). There was no apparent relation between change in the functional parameter or biomarker and categorical effect on mortality.
Conclusions—
This analysis, limited to trial level data from different therapeutic eras, suggests that drug- or device-induced effects on peak V
o
2
, 6MW, and natriuretic peptides found in short-term trials do not predict the corresponding average long-term therapeutic effects on mortality for patients with HF and left ventricular dysfunction.
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Affiliation(s)
- Benjamin S. Wessler
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
| | - Daniel G. Kramer
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
| | - Jessica L. Kelly
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
| | - Thomas A. Trikalinos
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
| | - David M. Kent
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
| | - Marvin A. Konstam
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
| | - James E. Udelson
- From the Division of Cardiology, CardioVascular Center and the Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston MA
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Scardovi AB, De Maria R, Ferraironi A, Gatto L, Celestini A, Forte S, Parolini M, Sciarretta S, Ricci R, Guazzi M. A case for assessment of oscillatory breathing during cardiopulmonary exercise test in risk stratification of elderly patients with chronic heart failure. Int J Cardiol 2011; 155:115-9. [PMID: 21402422 DOI: 10.1016/j.ijcard.2011.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 02/10/2011] [Indexed: 01/26/2023]
Abstract
UNLABELLED The prognostic value of exercise oscillatory breathing (EOB) during cardiopulmonary test (CPX) has been described in young chronic heart failure (HF) patients. We assessed the prognostic role of EOB vs other clinical and ventilatory parameters in elderly HF patients performing a maximal CPX. METHODS AND RESULTS We prospectively followed-up 370 HF outpatients ≥ 65 years after a symptom limited CPX. We tested the predictive value of clinical and ventilatory parameters for all-cause mortality and a composite of all-cause mortality and HF hospitalizations. Median age was 74 years, 51% had ischemic heart disease, 25% NYHA class III; ejection fraction was 41% [34-50]. Peak oxygen consumption (PVO(2)) was 11.9 [9.9-14] mL/kg/min, the slope of the regression line relating ventilation to CO(2) output, (VE/VCO(2) slope) was 33.9 [29.8-39.2]. EOB was found in 58% of patients. At follow-up, 84 patients died and overall 158, using a time-to-first event approach, met the composite end-point. Independent predictors of all-cause mortality were CPX EOB and the ratio of VE/VCO(2) slope to peak VO(2), hemoglobin, creatinine and body mass index. The area under the ROC curve (AUC) of the Cox multivariable model was 0.80 (95% CI 0.73 to 0.87). Independent predictors of the composite end-point were EOB, VE/VCO(2) slope, hemoglobin and HF admissions in the previous year (Model AUC 0.75) (95% CI 0.69 to 0.81). CONCLUSIONS Among elderly HF patients, EOB prevalence is higher than middle-aged cohorts. EOB and the ratio of VE/VCO(2) slope to peak VO(2) resulted the strongest ventilatory predictor of all-cause mortality, independent of ventricular function.
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36
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Valentini M, Revera M, Bilo G, Caldara G, Savia G, Styczkiewicz K, Parati S, Gregorini F, Faini A, Branzi G, Malfatto G, Magrì D, Agostoni P, Parati G. Effects of Beta-Blockade on Exercise Performance at High Altitude: A Randomized, Placebo-Controlled Trial Comparing the Efficacy of Nebivolol versus Carvedilol in Healthy Subjects. Cardiovasc Ther 2011; 30:240-8. [DOI: 10.1111/j.1755-5922.2011.00261.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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37
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Karsten M, Contini M, Cefalù C, Cattadori G, Palermo P, Apostolo A, Bussotti M, Magrì D, Salvioni E, Farina S, Sciomer S, Catai AM, Agostoni P. Effects of carvedilol on oxygen uptake and heart rate kinetics in patients with chronic heart failure at simulated altitude. Eur J Prev Cardiol 2011; 19:444-51. [DOI: 10.1177/1741826711402736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The response to moderate exercise at altitude in heart failure (HF) is unknown. Methods and results: We evaluated 30 HF patients, (NYHA I-III, 25 M/5 F; 59 ± 10 years; LVEF = 39.6 ± 7.1%), in stable clinical conditions, treated with carvedilol at the maximal tolerated dose. We performed a maximal cardiopulmonary exercise test (CPET) with ramp protocol at sea level to evaluate patients’ performance and two moderate intensity constant workload CPETs (50% of peak workload) at sea level (normoxia) and simulated altitude (hypoxia). Oxygen uptake ([Formula: see text]) and heart rate (HR) on-kinetics at constant workload were assessed calculating the time constant (τ) with a monoexponential equation. [Formula: see text] and HR were higher in hypoxia (0.944 ± 0.233 vs 1.031 ± 0.264 l/min; 100 ± 23 vs 108 ± 22 bpm; p < 0.001). On-kinetics showed a different behavior of τ being [Formula: see text] faster in hypoxia (67.1 ± 23.0 vs. 56.3 ± 19.7 s; p = 0.026) and HR faster in normoxia (49.3 ± 19.4 vs. 62.2 ± 22.5 s; p = 0.018). Ten patients, who lowered oxygen kinetics in hypoxia, had greater HR increase during maximal CPET suggesting lower functional betablockade. The higher τ of [Formula: see text] in hypoxia is likely to be due to a peripheral effect of carvedilol mediated either by β- or α-receptor. Conclusion: HF patients performing moderate exercise at 2000 m simulated altitude have 20% [Formula: see text] increase without trouble at the beginning of exercise when treated with carvedilol.
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Affiliation(s)
- Marlus Karsten
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Laboratório de Fisioterapia Cardiovascular, Núcleo de Pesquisa em Exercício Físico, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | | | | | | | | | | | - Maurizio Bussotti
- Cardiologia Riabilitativa, Fondazione S Maugeri, IRCCS, Milan, Italy
| | - Damiano Magrì
- U.O. Cardiologia, S. Andrea Hospital, “Sapienza”, Rome University, Rome, Italy
| | | | | | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche e Geriatriche, ‘Sapienza’, Rome University, Rome, Italy
| | - Aparecida Maria Catai
- Laboratório de Fisioterapia Cardiovascular, Núcleo de Pesquisa em Exercício Físico, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Division of Critical Care and Respiratory Medicine, University of Washington, Seattle, USA
- Dipartimento di Scienze Cardiovascolari, Università di Milano, Milan, Italy
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38
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Corrà U, Mezzani A, Giordano A, Caruso R, Giannuzzi P. A new cardiopulmonary exercise testing prognosticating algorithm for heart failure patients treated with beta-blockers. Eur J Prev Cardiol 2011; 19:185-91. [DOI: 10.1177/1741826710396625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ugo Corrà
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
| | - Alessandro Mezzani
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
| | - Andrea Giordano
- Bioengineering Department, Salvatore Maugeri Foundation, IRCCS, Via per Revislate 13, 28010 Veruno, Italy
| | - Roberto Caruso
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
| | - Pantaleo Giannuzzi
- Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Veruno, Italy
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39
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The prognostic value of left ventricular filling pressure during exercise in heart failure patients. COR ET VASA 2011. [DOI: 10.33678/cor.2011.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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40
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Sue DY. Excess ventilation during exercise and prognosis in chronic heart failure. Am J Respir Crit Care Med 2011; 183:1302-10. [PMID: 21257789 DOI: 10.1164/rccm.201006-0965ci] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Excess ventilation during exercise with accompanying dyspnea is characteristic of chronic heart failure (CHF), and these patients often exhibit increased Ve relative to the Vco(2) compared with normal subjects. This can be measured in several ways, including using such variables as the slope of Ve versus Vco(2), the lowest ratio of Ve/Vco(2), and the ratio of Ve/Vco(2) at the lactic acidosis threshold or peak exercise. There is now considerable evidence that the degree of excess ventilation during exercise in patients with CHF is a robust predictor of outcome and identifies higher-risk patients requiring aggressive treatment, including heart transplantation. The mechanism of excess ventilation in patients with CHF during exercise is not completely understood. It may be related to enhanced output of chemoreceptors or peripheral muscle ergoreceptors, increased dead space/Vt ratio due to increased contribution of high ventilation-perfusion lung regions or rapid shallow breathing caused by earlier onset of lactic acidosis, or likely resulting from a combination of these causes.
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Affiliation(s)
- Darryl Y Sue
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509-2910, USA.
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41
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Suzuki JI, Ogawa M, Tamura N, Maejima Y, Takayama K, Maemura K, Honda K, Hirata Y, Nagai R, Isobe M. A critical role of sympathetic nerve regulation for the treatment of impaired daily rhythm in hypertensive Dahl rats. Hypertens Res 2010; 33:1060-5. [PMID: 20668456 DOI: 10.1038/hr.2010.125] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
There is a deep relationship between impaired circadian rhythm and hypertension. However, the detailed mechanisms between the daily sleep-wake rhythm and cardiovascular disorders have not yet been elucidated. To clarify the mechanism, we examined salt-sensitive Dahl rats that were fed normal chow (n=10), high-salt chow (n=10) and high-salt chow with bisoprolol (n=10). Simultaneous electroencephalogram, electromyogram and locomotor activity were examined to analyze the sleep-wake state. We also examined heart rate, blood pressure and echocardiographic findings to verify the presence of hypertension. Hypertension with impaired ventricular contraction was observed in the rats with high-salt-chow consumption whereas normal-chow rats did not show these disorders. Although rats with the normal diet showed a standard daily rhythm with normal rapid eye movement (REM) sleep duration and locomotor activity, the high-salt-diet group exhibited an impaired daily rhythm with suppressed REM sleep and significant abnormal locomotor activity. Bisoprolol significantly improved the daily sleep-wake rhythm and locomotor activity. We showed that an impaired daily rhythm was closely related to the development of hypertension. Regulation of sympathetic nerve alterations may have a key role in the treatment of hypertension and circadian rhythm disorder.
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Affiliation(s)
- Jun-ichi Suzuki
- Department of Advanced Clinical Science and Therapeutics, University of Tokyo, 7-3-1 Hongo, Tokyo, Japan.
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42
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Laveneziana P, Agostoni P, Mignatti A, Mushtaq S, Colombo P, Sims D, Uriel N, Jorde UP. Effect of Acute β-blocker Withholding on Ventilatory Efficiency in Patients With Advanced Chronic Heart Failure. J Card Fail 2010; 16:548-55. [DOI: 10.1016/j.cardfail.2010.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 02/08/2010] [Accepted: 02/10/2010] [Indexed: 11/30/2022]
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43
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Agostoni P, Apostolo A, Cattadori G, Salvioni E, Berna G, Antonioli L, Vignati C, Schina M, Sciomer S, Bussotti M, Palermo P, Fiorentini C, Contini M. Effects of beta-blockers on ventilation efficiency in heart failure. Am Heart J 2010; 159:1067-73. [PMID: 20569721 DOI: 10.1016/j.ahj.2010.03.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Accepted: 03/31/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hyperventilation and consequent reduction of ventilation (VE) efficiency are frequently observed during exercise in heart failure (HF) patients, resulting in an increased slope of VE/carbon dioxide (VE/Vco(2)) relationship. The latter is an independent predictor of HF prognosis. beta-Blockers improve the prognosis of HF patients. We evaluated the effect on the efficiency of VE of a beta(1)-beta(2) unselective (carvedilol) versus a beta(1) selective (bisoprolol) beta-blocker. METHODS We analyzed consecutive maximal cardiopulmonary exercise tests performed on 572 clinically stable HF patients (New York Heart Association class I-III, left ventricle ejection fraction < or =50%) categorized in 3 groups: 81 were not treated with beta-blocker, 304 were treated with carvedilol, and 187 were treated with bisoprolol. Clinical conditions were similar. RESULTS The VE/Vco(2) slope was lower in carvedilol- compared with bisoprolol-treated patients (29.7 +/- 0.4 vs 31.6 +/- 0.5, P = .023, peak oxygen consumption adjusted) and with patients not receiving beta-blockers (31.6 +/- 0.7, P = .036). Maximum end-tidal CO(2) pressure during the isocapnic buffering period was higher in patients treated with carvedilol (39.0 +/- 0.3 mm Hg) than with bisoprolol (37.2 +/- 0.4 mm Hg, P < .001) and in patients not receiving beta-blockers (37.2 +/- 0.5 mm Hg, P = .001). CONCLUSIONS Reduction of hyperventilation, with improvement of VE efficiency during exercise (reduction of VE/Vco(2) slope and increase of maximum end-tidal CO(2) pressure), is specific to carvedilol (beta(1)-beta(2) unselective blocker) and not to bisoprolol (beta(1)-selective blocker).
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44
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Arena R, Lavie CJ, Milani RV, Myers J, Guazzi M. Cardiopulmonary exercise testing in patients with pulmonary arterial hypertension: An evidence-based review. J Heart Lung Transplant 2010; 29:159-73. [DOI: 10.1016/j.healun.2009.09.003] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 09/08/2009] [Accepted: 09/08/2009] [Indexed: 11/17/2022] Open
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45
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Agostoni P, Palermo P, Contini M. Respiratory Effects of β-blocker Therapy in Heart Failure. Cardiovasc Drugs Ther 2009; 23:377-84. [DOI: 10.1007/s10557-009-6195-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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46
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Corra U, Mezzani A, Giordano A, Bosimini E, Giannuzzi P. Exercise haemodynamic variables rather than ventilatory efficiency indexes contribute to risk assessment in chronic heart failure patients treated with carvedilol. Eur Heart J 2009; 30:3000-6. [DOI: 10.1093/eurheartj/ehp138] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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47
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BELOKA SOFIA, GUJIC MARKO, DEBOECK GAEL, NISET GEORGES, CIARKA AGNIESZKA, ARGACHA JEANFRANÇOIS, ADAMOPOULOS DIONYSIOS, VAN DE BORNE PHILIPPE, NAEIJE ROBERT. β-Adrenergic Blockade and Metabo-Chemoreflex Contributions to ExerciseCapacity. Med Sci Sports Exerc 2008; 40:1932-8. [DOI: 10.1249/mss.0b013e31817fbe11] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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48
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Kataoka M, Satoh T, Yoshikawa T, Nakamura I, Kohno T, Yoshizawa A, Anzai T, Ogawa S. Comparison of the Effects of Carvedilol and Metoprolol on Exercise Ventilatory Efficiency in Patients With Congestive Heart Failure. Circ J 2008; 72:358-63. [DOI: 10.1253/circj.72.358] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masaharu Kataoka
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
| | - Toru Satoh
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
| | - Tsutomu Yoshikawa
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
| | | | - Takashi Kohno
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
| | - Akihiro Yoshizawa
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
| | - Toshihisa Anzai
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
| | - Satoshi Ogawa
- Cardiopulmonary Division, Department of Medicine, Keio University School of Medicine
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The clinical and research applications of aerobic capacity and ventilatory efficiency in heart failure: an evidence-based review. Heart Fail Rev 2007; 13:245-69. [PMID: 17987381 DOI: 10.1007/s10741-007-9067-5] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Accepted: 10/22/2007] [Indexed: 10/22/2022]
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50
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Agostoni P, Contini M, Cattadori G, Apostolo A, Sciomer S, Bussotti M, Palermo P, Fiorentini C. Lung function with carvedilol and bisoprolol in chronic heart failure: is beta selectivity relevant? Eur J Heart Fail 2007; 9:827-33. [PMID: 17561440 DOI: 10.1016/j.ejheart.2007.04.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Accepted: 04/26/2007] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Carvedilol is a beta-blocker with similar affinity for beta1- and beta2 receptors, while bisoprolol has higher beta1 affinity. The respiratory system is characterized by beta2-receptor prevalence. Airway beta receptors regulate bronchial tone and alveolar beta receptors regulate alveolar fluid re-absorption which influences gas diffusion. AIMS To compare the effects of carvedilol and bisoprolol on lung function in patients with chronic heart failure (CHF). METHODS AND RESULTS We performed a double-blind, cross-over study in 53 CHF patients. After 2 months of full dose treatment with either carvedilol or bisoprolol, we assessed lung function by salbutamol challenge, carbon monoxide lung diffusion (DLCO), including membrane conductance (DM), and gas exchange during exercise. FEV1 and FVC were similar; after salbutamol FEV1 was higher with bisoprolol (p<0.04). DLco was 82+/-21% of predicted with carvedilol and 90+/-20% with bisoprolol (p<0.01) due to DM changes. Peak VO2 was 17.8+/-4.5 mL/min/kg on bisoprolol and 17.0+/-4.6 on carvedilol, (p<0.05) with no differences in bronchial tone (same expiratory time) throughout exercise. Differences were greater in the 22 subjects with DLCO<80%. CONCLUSION Carvedilol and bisoprolol have different effects on DLCO and response to salbutamol. DLCO differences, being DM related, are due to changes in active membrane transport which is under alveolar beta2-receptor control. Peak VO2 was slightly higher with bisoprolol particularly in CHF patients with reduced DLCO.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Istituto di Cardiologia, Università di Milano, Milan, Italy.
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