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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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Nugara C, Giallauria F, Vitale G, Sarullo S, Gentile G, Clemenza F, Lo Voi A, Zarcone A, Venturini E, Iannuzzo G, Coats AJS, Sarullo FM. Effects of Sacubitril/Valsartan on Exercise Capacity in Patients with Heart Failure with Reduced Ejection Fraction and the Role of Percentage of Delayed Enhancement Measured by Cardiac Magnetic Resonance in Predicting Therapeutic Response: A Multicentre Study. Card Fail Rev 2023; 9:e07. [PMID: 37427008 PMCID: PMC10326660 DOI: 10.15420/cfr.2022.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/15/2022] [Indexed: 07/11/2023] Open
Abstract
Background: This study aims to evaluate the cardiopulmonary effects of sacubitril/valsartan therapy in patients with heart failure with reduced ejection fraction (HFrEF), investigating a possible correlation with the degree of myocardial fibrosis, as assessed by cardiac magnetic resonance. Methods: A total of 134 outpatients with HFrEF were enrolled. Results: After a mean follow-up of 13.3 ± 6.6 months, an improvement in ejection fraction and a reduction in E/A ratio, inferior vena cava size and N-terminal pro-B-type natriuretic peptide levels were observed. At follow-up, we observed an increase in VO2 peak of 16% (p<0.0001) and in O2 pulse of 13% (p=0.0002) as well as an improvement in ventilatory response associated with a 7% reduction in the VE/VCO2 slope (p=0.0001). An 8% increase in the ΔVO2/Δ work ratio and an 18% increase in exercise tolerance were also observed. Multivariate logistic regression analysis showed that the main predictors of events during follow-up were VE/VCO2 slope >34 (OR 3.98; 95% CI [1.59-10.54]; p=0.0028); ventilatory oscillatory pattern (OR 4.65; 95% CI [1.55-16.13]; p=0.0052); and haemoglobin level (OR 0.35; 95% CI [0.21-0.55]; p<0.0001). In patients who had cardiac magnetic resonance, when delayed enhancement >4.6% was detected, a lower response after sacubitril/valsartan therapy was observed as expressed by improvement in ΔVO2 peak, O2 pulse, LVEF and N-terminal pro-B-type natriuretic peptide. No significant differences were observed in ΔVO2/Δ work and VE/VCO2 slope. Conclusion:Sacubitril/valsartan improves cardiopulmonary functional capacity in HFrEF patients. The presence of myocardial fibrosis on cardiac magnetic resonance is a predictor of response to therapy.
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Affiliation(s)
- Cinzia Nugara
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli HospitalPalermo, Italy
| | - Francesco Giallauria
- Department of Translational Medical Sciences, Federico II University of NaplesNaples, Italy
| | - Giuseppe Vitale
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli HospitalPalermo, Italy
| | - Silvia Sarullo
- School of Sport Medicine and Physical Exercise Medicine, Department of Biomedicine, Neurosciences and Advances Diagnostic, University of PalermoPalermo, Italy
| | - Giovanni Gentile
- Diagnostic and Therapeutic Services, Radiology Unit, IRCCS-ISMETTPalermo, Italy
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETTPalermo, Italy
| | - Francesco Clemenza
- Diagnostic and Therapeutic Services, Radiology Unit, IRCCS-ISMETTPalermo, Italy
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETTPalermo, Italy
| | - Annamaria Lo Voi
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli HospitalPalermo, Italy
| | - Antonino Zarcone
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli HospitalPalermo, Italy
| | - Elio Venturini
- Cardiac Rehabilitation Unit, AUSL Toscana Nord-Ovest, Cecina Civil HospitalLivorno, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, Federico II University of NaplesNaples, Italy
| | - Andrew JS Coats
- Monash UniversityAustralia
- University of WarwickUK
- IRCCS San Raffaele PisanaRome, Italy
| | - Filippo M Sarullo
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli HospitalPalermo, Italy
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Agostoni P, Sciomer S, Palermo P, Contini M, Pezzuto B, Farina S, Magini A, De Martino F, Magrì D, Paolillo S, Cattadori G, Vignati C, Mapelli M, Apostolo A, Salvioni E. Minute ventilation/carbon dioxide production in chronic heart failure. Eur Respir Rev 2021; 30:30/159/200141. [PMID: 33536259 PMCID: PMC9489123 DOI: 10.1183/16000617.0141-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/21/2020] [Indexed: 11/05/2022] Open
Abstract
In chronic heart failure, minute ventilation (V'E) for a given carbon dioxide production (V'CO2 ) might be abnormally high during exercise due to increased dead space ventilation, lung stiffness, chemo- and metaboreflex sensitivity, early metabolic acidosis and abnormal pulmonary haemodynamics. The V'E versus V'CO2 relationship, analysed either as ratio or as slope, enables us to evaluate the causes and entity of the V'E/perfusion mismatch. Moreover, the V'E axis intercept, i.e. when V'CO2 is extrapolated to 0, embeds information on exercise-induced dead space changes, while the analysis of end-tidal and arterial CO2 pressures provides knowledge about reflex activities. The V'E versus V'CO2 relationship has a relevant prognostic power either alone or, better, when included within prognostic scores. The V'E versus V'CO2 slope is reported as an absolute number with a recognised cut-off prognostic value of 35, except for specific diseases such as hypertrophic cardiomyopathy and idiopathic cardiomyopathy, where a lower cut-off has been suggested. However, nowadays, it is more appropriate to report V'E versus V'CO2 slope as percentage of the predicted value, due to age and gender interferences. Relevant attention is needed in V'E versus V'CO2 analysis in the presence of heart failure comorbidities. Finally, V'E versus V'CO2 abnormalities are relevant targets for treatment in heart failure.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy .,Dept of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Susanna Sciomer
- Dept of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | | | | | | | | | | | - Damiano Magrì
- Dept of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefania Paolillo
- Dept of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, Multimedica IRCCS, Milan, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dept of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dept of Clinical Science and Community Health, University of Milan, Milan, Italy
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Malfatto G, Ravaro S, Caravita S, Baratto C, Sorropago A, Giglio A, Tomaselli M, Parati G, Villani A. Improvement of functional capacity in sacubitril-valsartan treated patients assessed by cardiopulmonary exercise test. Acta Cardiol 2020; 75:732-736. [PMID: 31577528 DOI: 10.1080/00015385.2019.1669317] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Neprilisin and angiotensin receptor inhibition (Sacubitril/Valsartan, i.e. ARNI) is recommended in heart failure guidelines for patients in NYHA class II-III with reduced left ventricular ejection fraction (LVEF). ARNI increase survival and quality of life; due to their hemodynamic effects, ARNI could also affect exercise tolerance. We studied the effects of ARNI on cardiopulmonary test (CPET) after six months of treatment in 35 patients [67 ± 11 years; LVEF 31 ± 6%; NT-proBNP 1822 ± 1651 pg/ml; ICD/CRT since at least 6 months in 26/35], treated with increasing doses of Sacubitril/Valsartan up to 318 ± 36 mg/die. In addition, levels of NT-proBNP, renal function, electrolytes, and echocardiocolorDoppler were assessed in the same time periods. No variations of renal function and/or potassium levels were observed; NT-proBNP decreased. Most CPET variables were improved by ARNI (p < .05): peak VO2 and O2 pulse increased (from 15.8 ± 3.4 to 17.0 ± 4.0 ml/kg/min and from 11.5 ± 2.5 to 12.6 ± 2.4 ml/beat, respectively), while VEVCO2 slope decreased from 35.2 ± 11.2 to 33.1 ± 12.3. A significant relationship (p < .05) was observed between the amount of increase in LVEF and that of O2 pulse in all patients, and between the amount of decrease in PAPs and that of VEVCO2 slope in patients showing pulmonary hypertension in baseline. In a subgroup of 22 patients who already completed A 1 year follow-up, overall CPET improvement was maintained. In conclusion, already in the short term ARNI favourably affect cardiopulmonary response to exercise in heart failure patients; such a change seems to be preserved on a longer period.
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Affiliation(s)
- Gabriella Malfatto
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
| | - Silvia Ravaro
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
- Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
| | - Sergio Caravita
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
| | - Claudia Baratto
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
- Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
| | - Antonio Sorropago
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
- Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
| | - Alessia Giglio
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
| | - Michele Tomaselli
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
- Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
- Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
| | - Alessandra Villani
- Istituto Auxologico Italiano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Milano, Italy
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Early Effects of Sacubitril/Valsartan on Exercise Tolerance in Patients with Heart Failure with Reduced Ejection Fraction. J Clin Med 2019; 8:jcm8020262. [PMID: 30791533 PMCID: PMC6406731 DOI: 10.3390/jcm8020262] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sacubitril/valsartan in heart failure (HF) with reduced ejection fraction (HFrEF) was shown to be superior to enalapril in reducing the risk of death and hospitalization for HF. Our aim was to evaluate the cardiopulmonary effects of sacubitril/valsartan in patients with HFrEF. METHODS We conducted an observational study. Ninety-nine ambulatory patients with HFrEF underwent serial cardiopulmonary exercise tests (CPET) after initiation of sacubitril/valsartan in addition to recommended therapy. RESULTS At baseline, 37% of patients had New York Heart Association (NYHA) class III. After a median follow-up of 6.2 months (range 3⁻14.9 months) systolic blood pressure decreased from 117 ± 14 to 101 ± 12 mmHg (p < 0.0001), left ventricular ejection fraction (LVEF) increased from 27 ± 6 to 29.7 ± 7% (p < 0.0001), peak oxygen consumption (VO₂) improved from 14.6 ± 3.3 (% of predicted = 53.8 ± 14.1) to 17.2 ± 4.7 mL/kg/min (% of predicted = 64.7 ± 17.8) (p < 0.0001), minute ventilation/carbon dioxide production relationship (VE/VCO₂ Slope) decreased from 34.1 ± 6.3 to 31.7 ± 6.1 (p = 0.006), VO₂ at anaerobic threshold increased from 11.3 ± 2.6 to 12.6 ± 3.5 mL/kg/min (p = 0.007), oxygen pulse increased from 11.5 ± 3.0 to 13.4 ± 4.3 mL/kg/min (p < 0.0001), and ∆VO₂/∆Work increased from 9.2 ± 1.5 to 10.1 ± 1.8 mL/min/watt (p = 0.0002). CONCLUSION Sacubitril/valsartan improved exercise tolerance, LVEF, peak VO₂, and ventilatory efficiency at 6.2 months follow-up. Further studies are necessary to better clarify underlying mechanisms of this functional improvement.
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