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Martínez-Meñaca A, Cruz-Utrilla A, Mora-Cuesta VM, Luna-López R, Segura-de la Cal T, Flox-Camacho Á, Alonso-Lecue P, Escribano-Subias P, Cifrián-Martínez JM. Simplified risk stratification based on cardiopulmonary exercise test: A Spanish two-center experience. Pulm Circ 2024; 14:e12342. [PMID: 38414916 PMCID: PMC10897871 DOI: 10.1002/pul2.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/21/2023] [Accepted: 01/22/2024] [Indexed: 02/29/2024] Open
Abstract
A simplified 4-strata risk stratification approach based on three variables is widespread in pulmonary arterial hypertension (PAH) at follow-up. This study aimed to assess the impact of replacing the 6-min walk test (6MWT) with the peak 02 uptake evaluated by the cardiopulmonary exercise test (CPET) on risk stratification by this scale. We included 180 prevalent patients with PAH from two reference hospitals in Spain, followed up between 2006 and 2022. Patients were included if all the variables of interest were available within a 3-month period on the Spanish Registry of Pulmonary Arterial Hypertension (REHAP): functional class (FC); NT-proBNP; 6MWT; and CPET. The original 4-strata model (NT-proBNP, 6MWT, FC) identified most patients at low or intermediate-low risk (36.7% and 51.1%, respectively). Notably, the modified scale (NT-proBNP, CPET, FC) improved the identification of patients at intermediate-high risk up to 18.9%, and at high risk up to 1.1% in comparison with the previous 12.2% and 0.0% in the original scale. This new model increased the number of patients correctly classified into higher-risk strata (positive NRI of 0.06), as well as classified more patients without events in lower-risk strata (negative NRI of 0.04). The proposed score showed a slightly superior prognostic capacity compared with the original model (Harrel's C-index 0.717 vs. 0.709). Using O2 uptake instead of distance walked in the 6MWT improves the identification of high-risk patients using the 4-strata scale. This change could have relevant prognostic implications and lead to changes in the specific treatment of PAH.
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Affiliation(s)
- Amaya Martínez-Meñaca
- Respiratory Department, ERN-LUNG (European Reference Network on rare respiratory diseases), Instituto de Investigación Valdecilla (IDIVAL) Hospital Universitario Marqués de Valdecilla Santander Spain
| | - Alejandro Cruz-Utrilla
- Cardiology Department, ERN-LUNG (European Reference Network on rare respiratory diseases) Hospital Universitario Doce de Octubre Madrid Spain
| | - Víctor Manuel Mora-Cuesta
- Respiratory Department, ERN-LUNG (European Reference Network on rare respiratory diseases), Instituto de Investigación Valdecilla (IDIVAL) Hospital Universitario Marqués de Valdecilla Santander Spain
| | - Raquel Luna-López
- Cardiology Department, ERN-LUNG (European Reference Network on rare respiratory diseases) Hospital Universitario Doce de Octubre Madrid Spain
| | - Teresa Segura-de la Cal
- Cardiology Department, ERN-LUNG (European Reference Network on rare respiratory diseases) Hospital Universitario Doce de Octubre Madrid Spain
| | - Ángela Flox-Camacho
- Cardiology Department, ERN-LUNG (European Reference Network on rare respiratory diseases) Hospital Universitario Doce de Octubre Madrid Spain
| | | | - Pilar Escribano-Subias
- Cardiology Department, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII) Hospital Universitario Doce de Octubre Madrid Spain
- ERN-LUNG (European Reference Network on rare respiratory diseases), Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
| | - José Manuel Cifrián-Martínez
- Respiratory Department, ERN-LUNG (European Reference Network on rare respiratory diseases), Instituto de Investigación Valdecilla (IDIVAL) Facultad de Medicina, Hospital Universitario Marqués de Valdecilla Universidad de Cantabria Santander Spain
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Dharmavaram N, Esmaeeli A, Jacobson K, Brailovsky Y, Raza F. Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism. Interv Cardiol Clin 2023; 12:349-365. [PMID: 37290839 DOI: 10.1016/j.iccl.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Long-term exercise intolerance and functional limitations are common after an episode of acute pulmonary embolism (PE), despite 3 to 6 months of anticoagulation. These persistent symptoms are reported in more than half of the patients with acute PE and are referred as "post-PE syndrome." Although these functional limitations can occur from persistent pulmonary vascular occlusion or pulmonary vascular remodeling, significant deconditioning can be a major contributing factor. Herein, the authors review the role of exercise testing to elucidate the mechanisms of exercise limitations to guide next steps in management and exercise training for musculoskeletal deconditioning.
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Affiliation(s)
- Naga Dharmavaram
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA
| | - Amir Esmaeeli
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA
| | - Kurt Jacobson
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Department of Medicine, Jefferson Heart Institute-Sidney Kimmel School of Medicine, Thomas Jefferson University, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Farhan Raza
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA.
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Raza F, Dharmavaram N, Hess T, Dhingra R, Runo J, Chybowski A, Kozitza C, Batra S, Horn EM, Chesler N, Eldridge M. Distinguishing exercise intolerance in early-stage pulmonary hypertension with invasive exercise hemodynamics: Rest V E /VCO 2 and ETCO 2 identify pulmonary vascular disease. Clin Cardiol 2022; 45:742-751. [PMID: 35419844 PMCID: PMC9286332 DOI: 10.1002/clc.23831] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Among subjects with exercise intolerance and suspected early-stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management. HYPOTHESIS Rest gas exchange parameters (minute ventilation to carbon dioxide production ratio: VE /VCO2 and end-tidal carbon dioxide: ETCO2 ) can identify PVD in early-stage PH. METHODS We conducted a retrospective review of 55 subjects with early-stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant. RESULTS The mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest VE /VCO2 and lower rest ETCO2 (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5-0.6*). On receiver-operating characteristic analysis to predict PVD (vs. non-PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest VE /VCO2 = 0.70* and ETCO2 = 0.73*. Based on this, optimal thresholds of rest VE /VCO2 > 40 mm Hg and rest ETCO2 < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group. CONCLUSIONS In a broad cohort of subjects with suspected early-stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (VE /VCO2 > 40 mm Hg and ETCO2 < 30 mm Hg) identify PVD.
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Affiliation(s)
- Farhan Raza
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Naga Dharmavaram
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Timothy Hess
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Ravi Dhingra
- Department of Medicine‐Division of CardiologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - James Runo
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Amy Chybowski
- Department of Medicine‐Division of Pulmonary and Critical CareUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Callyn Kozitza
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Supria Batra
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Evelyn M. Horn
- Department of Medicine‐Division of Cardiology Weill Cornell MedicineNew YorkNew YorkUSA
| | - Naomi Chesler
- University of California‐Irvine Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical EngineeringIrvineCaliforniaUSA
| | - Marlowe Eldridge
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of PediatricsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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Iwasawa T, Fukui S, Kawakami M, Kawakami T, Kataoka M, Yuasa S, Fukuda K, Fujiwara T, Tsuji T. Factors related to instrumental activities of daily living in persons with chronic thromboembolic pulmonary hypertension. Chron Respir Dis 2021; 18:14799731211046634. [PMID: 34592826 PMCID: PMC8489748 DOI: 10.1177/14799731211046634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Instrumental activities of daily living (IADL) are significantly related to quality of life and mortality among individuals with heart disease. However, few reports have examined IADL in persons with chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to clarify factors related to IADL in persons with CTEPH. This retrospective, observational study enrolled 163 persons with CTEPH (mean ± standard deviation age = 65 ± 13 years; 68% female) admitted to the Department of Cardiology at Keio University Hospital between January 2015 and July 2019. The Frenchay Activities Index (FAI) was used to assess IADL. Age, sex, body mass index, World Health Organization functional class (WHO-FC), cardiac function (mean pulmonary arterial pressure, mean right atrial pressure, pulmonary capillary wedge pressure, and cardiac index), pulmonary function (percentage vital capacity, percentage forced expiratory volume in 1 s, diffusion capacity of carbon monoxide (DLCO)/alveolar volume (VA)), physical function (knee extension strength and walking speed), and 6-min walking distance (6MWD) were assessed. Multiple regression analysis was performed to identify factors significantly associated with FAI. Mean FAI was 25 ± 8. Univariate analysis showed that sex, WHO-FC, DLCO/VA, walking speed, and 6MWD were correlated with FAI. Multiple regression analysis showed that 6MWD (sβ = 0.338, 95% CI 0.014–0.034, p < .001), sex (sβ = 0.268, 95% CI 2.238–7.165, p < .001), and DLCO/VA (sβ = 0.257, 95% CI 1.011–3.528, p < .001) were significantly correlated with FAI (R2 = 0.261). IADL were associated with exercise tolerance, sex, and DLCO/VA in persons with CTEPH. In the future, more details of IADL are expected to be clarified by analyzing individual components of IADL and investigating social background characteristics, including living environment.
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Affiliation(s)
- Tatsuya Iwasawa
- Department of Rehabilitation Medicine, 34787Keio University Hospital, Tokyo, Japan.,Department of Rehabilitation Medicine, 34787Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shogo Fukui
- Department of Rehabilitation Medicine, 34787Keio University Hospital, Tokyo, Japan.,Graduate School of Health Management, Keio University, Tokyo, Japan
| | - Michiyuki Kawakami
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kawakami
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshiyuki Fujiwara
- Department of Rehabilitation Medicine, 34787Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuya Tsuji
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
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Farkhooy A, Bellocchia M, Hedenström H, Libertucci D, Bucca C, Janson C, Solidoro P, Malinovschi A. Lung function in relation to six-minute walk test in pulmonary hypertension. Eur Clin Respir J 2020; 7:1745492. [PMID: 32363016 PMCID: PMC7178896 DOI: 10.1080/20018525.2020.1745492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/16/2020] [Indexed: 11/21/2022] Open
Abstract
Background: Pulmonary hypertension (PH) is a progressive disorder of the pulmonary circulation, associated with diverse medical conditions. Exercise limitation is the most prominent symptom in PH. Exercise capacity, commonly assessed through a six-minute walk test (6MWT), correlates with both functional status and survival in PH. Few studies have analysed the relation between respiratory function and exercise limitation. Therefore, we investigated the relationship between resting pulmonary function, exercise capacity, and exertional desaturation, assessed through the 6MWT, in unselected PH patients. Methods: Fifty consecutive patients with PH diagnosis, referred for pulmonary function testing (lung volume, spirometry, and diffusing capacity for carbon monoxide (DLCO)) and 6MWT, were recruited at Molinette University Hospital, Turin. Results: The majority of the patients (54%) had PH due to left heart disease. Airway obstruction (FEV1/VC-ratio < 0.7) was found in 46% of the patients and they performed significantly worse in the 6MWT than unobstructed patients (307 m vs. 377 m). Patients with PH due to left heart disease also performed significantly poorer 6MWT when airway obstruction was present (305 m vs. 389 m). Twenty-two patients (44%) presented exertional desaturation upon 6MWT. Lower DLCO divided by the alveolar volume (DLCO/VA), FEV1/VC-ratios and resting PaO2-values were significantly correlated with exertional desaturation after adjustments for age, sex, BMI, and smoking habits. DLCO/VA was the main determinant of exertional desaturation in a stepwise regression model. Conclusions: Spirometric parameters of airway obstruction were related to walk distance and exercise-induced desaturation in PH patients. This suggests a place for spirometry in clinical monitoring of PH patients.
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Affiliation(s)
- Amir Farkhooy
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Michaela Bellocchia
- Cardiovascular and Thoracic Department, Pneumology Unit, AOU Molinette, Città della Salute e della Scienza di Torino and University of Turin, Turin, Italy
| | - Hans Hedenström
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Daniela Libertucci
- Cardiovascular and Thoracic Department, Pneumology Unit, AOU Molinette, Città della Salute e della Scienza di Torino and University of Turin, Turin, Italy
| | - Caterina Bucca
- Cardiovascular and Thoracic Department, Pneumology Unit, AOU Molinette, Città della Salute e della Scienza di Torino and University of Turin, Turin, Italy
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Paolo Solidoro
- Cardiovascular and Thoracic Department, Pneumology Unit, AOU Molinette, Città della Salute e della Scienza di Torino and University of Turin, Turin, Italy
| | - Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
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Boucly A, Morélot-Panzini C, Garcia G, Weatherald J, Jaïs X, Savale L, Montani D, Humbert M, Similowski T, Sitbon O, Laveneziana P. Intensity and quality of exertional dyspnoea in patients with stable pulmonary hypertension. Eur Respir J 2019; 55:13993003.02108-2018. [DOI: 10.1183/13993003.02108-2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 10/28/2019] [Indexed: 11/05/2022]
Abstract
Dynamic hyperinflation is observed during exercise in 60% of patients with clinically stable pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), intensifying exertional dyspnoea. The impact of dynamic changes in respiratory mechanics during exercise on qualitative dimensions of dyspnoea in these patients has not been evaluated.26 patients (PAH n=17; CTEPH n=9) performed an incremental symptom-limited cycle exercise test. Minute ventilation (V′E), breathing pattern, operating lung volumes and dyspnoea intensity were assessed throughout exercise. Dyspnoea quality was serially assessed during exercise using a three-item questionnaire (dyspnoea descriptors). The inflection point of tidal volume (VT) relative to V′E was determined for each incremental test. Changes in inspiratory capacity during exercise defined two groups of patients: hyperinflators (65%) and non-hyperinflators (35%). Multidimensional characterisation of dyspnoea was performed after exercise using the Multidimensional Dyspnea Profile.In hyperinflators, inspiratory capacity decreased progressively throughout exercise by 0.36 L, while remaining stable in non-hyperinflators. The “work/effort” descriptor was most frequently selected throughout exercise in both types of patients (65% of all responses). At the VT/V′E inflection, work/effort plateaued while “unsatisfied inspiration” descriptors became selected predominantly only in hyperinflators (77% of all responses). In the affective domain, the emotion most frequently associated with dyspnoea was anxiety.In pulmonary hypertension patients who develop hyperinflation during exercise, dyspnoea descriptors referring to unsatisfied inspiration become predominant following the VT/V′E inflection. As these descriptors are generally associated with more negative emotional experiences, delaying or preventing the VT/V′E inflection may have important implications for symptom management in patients with pulmonary hypertension.
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Babu AS, Padmakumar R, Nayak K, Shetty R, Mohapatra AK, Maiya AG. Effects of home-based exercise training on functional outcomes and quality of life in patients with pulmonary hypertension: A randomized clinical trial. Indian Heart J 2019; 71:161-165. [PMID: 31280830 PMCID: PMC6620412 DOI: 10.1016/j.ihj.2019.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 01/15/2023] Open
Abstract
Objectives The objective of this study was to assess the effects of home-based exercise training (HBET) on function and quality of life (QoL) in patients with pulmonary hypertension (PH). Methods A prospective, nonblinded, randomized clinical trial was carried out on 84 medically stable patients with PH belonging to any functional class or etiology and of either sex. Patients were randomized to either standard care or HBET. Both groups also received education using the Pulmonary Hypertension Manual (PulHMan). Outcomes included functional capacity from 6-min walk distance (6MWD), QoL using the Medical Outcomes Survey Short Form – 36, functional class (FC), and right heart indices (right ventricular systolic pressure [RVSP] and tricuspid annular plane systolic excursion [TAPSE]) and were assessed at entry and after 12 weeks. Results HBET improved 6MWD by 48.5 m and 13 m in the experimental and control groups, respectively (p < 0.001). QoL showed statistical improvements after HBET between the groups for the physical and mental components and for the various subdomains (except body pain). Furthermore, FC improved by one grade with HBET (p < 0.001). Conclusion HBET program improved functional capacity, QoL, and FC in patients with PH.
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Affiliation(s)
- Abraham Samuel Babu
- Department of Physiotherapy, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Ramachandran Padmakumar
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
| | - Krishnanand Nayak
- Department of Cardiovascular Technology, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Ranjan Shetty
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India; Department of Cardiology, Manipal Hospital, Hal Airport Road, Bengaluru, 560017, Karnataka, India
| | - Aswini Kumar Mohapatra
- Department of Pulmonary Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Arun G Maiya
- Department of Physiotherapy, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
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8
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Jiang R, Liu H, Pudasaini B, Zhang R, Xu JL, Wang L, Zhao QH, Yuan P, Guo J, He J, Gong SG, Wu C, Wu WH, Luo CJ, Qiu HL, Jing ZC, Liu JM. Characteristics of cardiopulmonary exercise testing of patients with borderline mean pulmonary artery pressure. CLINICAL RESPIRATORY JOURNAL 2019; 13:148-158. [PMID: 30667180 DOI: 10.1111/crj.12996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/08/2019] [Accepted: 01/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary hypertension patients with mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg had impaired cardiopulmonary exercise testing (CPET). Borderline mean pulmonary pressures (boPAP; 21-24 mm Hg) represent early pulmonary vasculopathy. The CPET characteristics of boPAP are a matter of discussion. We aimed to determine the CPET profile of such borderline hemodynamics. METHODS A matched case-control study was conducted on consecutive boPAP patients at the Shanghai Pulmonary Hospital between Jan 2012 and Jan 2017. Hemodynamics, echocardiography, the pulmonary function test (PFT) and CPET parameters were compared between boPAP patients and normal mPAP patients which were matched 1:1 by sex and age. Conditional logistic regression analysis was performed to determine the efficacy of CPET in detecting boPAP. RESULTS A total of 48 patients underwent RHC and CPET (24 Normal, 24 boPAP). There were no differences in the demographics, echocardiography and PFT. BoPAP patients had significantly decreased VO2 at the anaerobic threshold and peak VO2 /kg (858.4 ± 246.5 mL/min vs 727.9 ± 228.0 mL/min, P = 0.037; 21.1 ± 6.4 mL/min/kg vs. 15.5 ± 5.6 mL/min/kg, P = 0.001, respectively). Significant differences were not observed in ventilation efficiency. A trend of impaired oxygen pulse and submaximal exercise tolerance were observed in boPAP patients. Conditional logistical regression analysis revealed the risk of boPAP increased by 2.493 (95% confident interval: 1.388 to 4.476, P = 0.002) with every 5 mL/min/kg decrease in peak VO2 /kg. CONCLUSIONS Patients with boPAP have a greater prevalence of exercise intolerance, a trend of impaired oxygen pulse and submaximal exercise tolerance.
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Affiliation(s)
- Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Respiratory and Clinical Care Medicine, Henan Provincial Peoples' Hospital of Zhengzhou University, Zhengzhou, China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian-Lin Xu
- The Second Department of Internal Medicine, Peoples' Hospital of Dongchuan District, Kunming, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cheng Wu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhi-Cheng Jing
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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9
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Lavie CJ, Shah SB, Arena R. Pulmonary hypertension in adults with and without congenital heart disease: Different strokes for different folks. Eur J Prev Cardiol 2018; 26:83-85. [PMID: 30379571 DOI: 10.1177/2047487318810868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carl J Lavie
- 1 John Ochsner Heart and Vascular Institute, the University of Queensland School of Medicine, USA
| | - Sangeeta B Shah
- 1 John Ochsner Heart and Vascular Institute, the University of Queensland School of Medicine, USA
| | - Ross Arena
- 2 Department of Physical Therapy, University of Illinois at Chicago, USA
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10
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Lavender M, Chia KS, Dwyer N, Corte TJ, Spencer L, Thakkar V, McWilliams T, Kotlyar E, Whitford H. Safe and effective exercise training for patients with pulmonary arterial hypertension: putting current evidence into clinical practice. Expert Rev Respir Med 2018; 12:965-977. [PMID: 30251562 DOI: 10.1080/17476348.2018.1527687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION While there have been significant advances in the medical treatment of pulmonary arterial hypertension (PAH), life expectancy, and quality of life remain reduced in this disease. Strenuous exercise may be hazardous for PAH patients; however, several relatively small trials have confirmed that exercise training programs can be used safely and effectively as adjunctive treatment for selected patients. The use of exercise training is now recommended in consensus international PAH treatment algorithms; however, there is no published guideline detailing how this intervention should be carried out. Areas covered: This review describes the evidence available and evaluates its applicability to 'real life' clinical practice. The limitations of current evidence are acknowledged, and we discuss how the existing data can be applied to management of PAH patients in Australia, New Zealand, and countries with similar healthcare systems. Recommendations for PAH exercise training are proposed including patient selection, program structure and duration, training modalities, training intensity, supervision, monitoring, safety precautions, and outcome assessments. Expert commentary: It is recognized that knowledge gaps remain and further research is required into physiological mechanisms associated with improved exercise capacity, optimal outpatient exercise regimen, durability of benefit, and whether there is any disease-modifying effect or impact on long-term prognosis.
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Affiliation(s)
- Melanie Lavender
- a Department of Respiratory Medicine , Fiona Stanley Hospital , Clayton , Australia.,b University of New South Wales Rural Clinical School , Clayton , Australia
| | - Karen Sw Chia
- b University of New South Wales Rural Clinical School , Clayton , Australia.,c Coffs Harbour Health Campus , Coffs Harbour , Australia.,d Department of Medicine , University of New South Wales Rural Clinical School , Coffs Harbour , New South Wales , Australia
| | - Nathan Dwyer
- e Cardiology Department, Royal Hobart Hospital , Hobart , Australia.,f School of Medicine, University of Tasmania , Hobart , Australia
| | - Tamera J Corte
- g Department of Respiratory Medicine , Royal Prince Alfred Hospital and University of Sydney , Camperdown , Australia
| | - Lissa Spencer
- h Physiotherapy Department , Royal Prince Alfred Hospital , Camperdown , Australia
| | - Vivek Thakkar
- i Department of Rheumatology , Liverpool Hospital , Liverpool BC , Australia.,j Faculty of Medicine and Health Sciences , Macquarie University , Campbelltown , Australia.,k School of Medicine , Western Sydney University , Campbelltown , Australia
| | | | - Eugene Kotlyar
- m Heart and Lung Transplant unit and Cardiology department , St Vincent's Hospital , Darlinghurst , Australia
| | - Helen Whitford
- n Department of Respiratory Medicine , The Alfred Hospital , Melbourne , Australia
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11
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Evaluation of end-tidal CO2 pressure at the anaerobic threshold for detecting and assessing pulmonary hypertension. Heart Vessels 2017; 32:1350-1357. [DOI: 10.1007/s00380-017-0999-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/26/2017] [Indexed: 11/25/2022]
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12
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Babu AS, Arena R, Myers J, Padmakumar R, Maiya AG, Cahalin LP, Waxman AB, Lavie CJ. Exercise intolerance in pulmonary hypertension: mechanism, evaluation and clinical implications. Expert Rev Respir Med 2016; 10:979-90. [PMID: 27192047 DOI: 10.1080/17476348.2016.1191353] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Exercise intolerance in pulmonary hypertension (PH) is a major factor affecting activities of daily living and quality of life. Evaluation strategies (i.e., non-invasive and invasive tests) are integral to providing a comprehensive assessment of clinical and functional status. Despite a growing body of literature on the clinical consequences of PH, there are limited studies discussing the contribution of various physiological systems to exercise intolerance in this patient population. AREAS COVERED This review, through a search of various databases, describes the physiological basis for exercise intolerance across the various PH etiologies, highlights the various exercise evaluation methods and discusses the rationale for exercise training amongst those diagnosed with PH. Expert commentary: With the growing importance of evaluating exercise capacity in PH (class 1, Level C recommendation), understanding why exercise performance is altered in PH is crucial. Thus, the further study is required for better quality evidence in this area.
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Affiliation(s)
- Abraham Samuel Babu
- a Department of Physiotherapy, School of Allied Health Sciences , Manipal University , Manipal , Karnataka , India
| | - Ross Arena
- b Department of Physical Therapy and Department of Kinesiology and Nutrition , University of Illinois at Chicago , Chicago , USA
| | - Jonathan Myers
- c Veterans Affairs Health Center , Stanford University , Palo Alto , CA , USA
| | | | - Arun G Maiya
- a Department of Physiotherapy, School of Allied Health Sciences , Manipal University , Manipal , Karnataka , India
| | - Lawrence P Cahalin
- e Department of Physical Therapy , Millers School of Medicine , Miami , FL , USA
| | - Aaron B Waxman
- f Pulmonary Vascular Disease Program, Dyspnea and Performance Evaluation Center, Pulmonary Critical Care Medicine, Cardiovascular Medicine , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - Carl J Lavie
- g Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School , The University of Queensland School of Medicine , New Orleans , LA , USA
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Babu AS, Padmakumar R, Maiya AG, Mohapatra AK, Kamath RL. Effects of Exercise Training on Exercise Capacity in Pulmonary Arterial Hypertension: A Systematic Review of Clinical Trials. Heart Lung Circ 2015; 25:333-41. [PMID: 26703447 DOI: 10.1016/j.hlc.2015.10.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/24/2015] [Accepted: 10/26/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) causes profound functional limitations and poor quality of life. Yet, there is only a limited literature available on the role of exercise training. This paper systematically reviews the effects of exercise training on exercise capacity in PAH. METHODS A systematic search of databases (PubMed, CINAHL, CENTRAL, Web of Science and PEDRo) was undertaken for English language articles published between 1(st) January 1980 and 31(st) March 2015. Quality rating for all articles was done using the Downs and Black scoring system. RESULTS Fifteen articles of good (n=4), moderate (n=6) and poor (n=5) quality were included in the review. Exercise interventions included aerobic, resistance, inspiratory muscle training or a combination, for 6-18 weeks. Improvements were seen in exercise capacity (six minute walk distance (6MWD) and peak VO2) by 17-96m and 1.1-2.1ml/Kg/min, functional class by one class and quality of life, with minimal adverse events. CONCLUSIONS There is evidence to recommend the use of exercise training as an adjunct to medical treatment in PAH. More clinical trials and research are required to assess the effects of different types of exercise programs in patients with PAH, while focussing on strong exercise endpoints to quantify the improvements seen with exercise training.
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Affiliation(s)
- Abraham Samuel Babu
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal - 576104, Karnataka, India.
| | - Ramachandran Padmakumar
- Department of Cardiology, Kasturba Medical College, Manipal University, Manipal-576104, Karnataka, India
| | - Arun G Maiya
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal - 576104, Karnataka, India
| | - Aswini Kumar Mohapatra
- Department of Pulmonary Medicine, Kasturba Medical College, Manipal University, Manipal-576104, Karnataka, India
| | - R L Kamath
- Department of Cardiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
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Update in Exercise Testing. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0095-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Torres DDFM, Zin WA, Lopes AJ, Vigário PDS, Garcia MI, Waetge D, Bandeira MLDS, Bessa LGP, Guimarães FS. Association Between Hemodynamic Profile, Physical Capacity and Quality of Life in Pulmonary Hypertension. Arq Bras Cardiol 2015; 104:387-93. [PMID: 25742419 PMCID: PMC4495453 DOI: 10.5935/abc.20150012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 10/02/2014] [Indexed: 01/19/2023] Open
Abstract
Background No studies have described and evaluated the association between hemodynamics,
physical limitations and quality of life in patients with pulmonary
hypertension (PH) without concomitant cardiovascular or respiratory
disease. Objective To describe the hemodynamic profile, quality of life and physical capacity of
patients with PH from groups I and IV and to study the association between
these outcomes. Methods Cross-sectional study of patients with PH from clinical groups I and IV and
functional classes II and III undergoing the following assessments:
hemodynamics, exercise tolerance and quality of life. Results This study assessed 20 patients with a mean age of 46.8 ± 14.3 years.
They had pulmonary capillary wedge pressure of 10.5 ± 3.7 mm Hg,
6-minute walk distance test (6MWDT) of 463 ± 78 m, oxygen consumption
at peak exercise of 12.9 ± 4.3 mLO2.kg-1.min-1 and scores of quality
of life domains < 60%. There were associations between cardiac index (CI)
and ventilatory equivalent for CO2 (r=-0.59, p <0.01), IC and ventilatory
equivalent for oxygen (r=-0.49, p<0.05), right atrial pressure (RAP) and
'general health perception' domain (r=-0.61, p<0.01), RAP and 6MWTD
(r=-0.49, p<0.05), pulmonary vascular resistance (PVR) and 'physical
functioning' domain (r=-0.56, p<0.01), PVR and 6MWTD (r=-0.49, p<0.05)
and PVR index and physical capacity (r=-0.51, p<0.01). Conclusion Patients with PH from groups I and IV and functional classes II and III
exhibit a reduction in physical capacity and in the physical and mental
components of quality of life. The hemodynamic variables CI, diastolic
pulmonary arterial pressure, RAP, PVR and PVR index are associated with
exercise tolerance and quality of life domains.
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Affiliation(s)
| | - Walter Araujo Zin
- Laboratório de Fisiologia da Respiração, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Agnaldo José Lopes
- Laboratório de Função Pulmonar, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Patrícia dos Santos Vigário
- Programa de Pós-Graduação em Ciências da Reabilitação, Centro Universitário Augusto Motta, Rio de Janeiro, RJ, Brazil
| | - Marcelo Iorio Garcia
- Serviço de Cardiologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Daniel Waetge
- Serviço de Pneumologia, Ambulatório de Hipertensão Pulmonar, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcelo Luiz da Silva Bandeira
- Serviço de Cardiologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Luiz Gustavo Pignataro Bessa
- Serviço de Cardiologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Fernando Silva Guimarães
- Laboratório de Fisiologia da Respiração, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Pulmonary hypertension: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases. Ann Am Thorac Soc 2015; 11 Suppl 3:S178-85. [PMID: 24754827 DOI: 10.1513/annalsats.201312-443ld] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Pulmonary vascular dysfunction (PVD) precedes the onset of clinical signs and symptoms of pulmonary arterial hypertension (PAH). PAH is defined by the elevation of pulmonary arterial pressure, which often progresses to right ventricular (RV) dysfunction and failure. PAH affects subjects of all ages, and is associated with diverse medical conditions, most of which are rare. Several factors pose immediate challenges to the development of strategies for primary prevention of PAH, including: (1) the idiopathic or primary form of the disease is extremely rare, limiting screening practicality; (2) methods for the detection of preclinical PVD are currently not established; (3) the understanding of determinants of pulmonary vascular growth, structure, and function in normal and PAH states is insufficient; (4) relatively small numbers of "at-risk" subjects are available for long-term studies to accurately assess disease development; and (5) preventative therapies for PVD are lacking. Despite these limitations, leveraging known at-risk patient populations for study, as well as growing progress across multiple disciplines, ranging from systems biology to advanced and more sensitive functional imaging modalities, may facilitate the opportunity to significantly improve primary prevention research and implementation over the next decade.
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Skoro-Sajer N, Lang I. Extended-release oral treprostinil for the treatment of pulmonary arterial hypertension. Expert Rev Cardiovasc Ther 2014; 12:1391-9. [PMID: 25363827 DOI: 10.1586/14779072.2014.975209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by an increase in pulmonary vascular resistance ultimately resulting in progressive right heart failure. Although new specific treatments have demonstrated improvements in various end points including morbidity/mortality, prognosis remains unfavorable with an on-treatment yearly mortality rate of 10%. Due to complex delivery systems, the use of parenteral prostanoids has been limited to patients with advanced disease. While inhaled prostanoids have had little effect, an oral prostacyclin analog is a desired initial treatment for PAH patients. To that end, UT-15C was synthesized as a sustained-release tablet. FREEDOM-M in treatment-naïve PAH patients resulted in significant improvements of 6-min walk distance supporting the use of oral treprostinil as initial monotherapy in PAH patients with class II or III symptoms. A further study targeting patients on combination treatments is currently exploring a morbidity/mortality end point in a large patient population.
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Affiliation(s)
- Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Arena R, Guazzi M, Cahalin LP, Myers J. Revisiting Cardiopulmonary Exercise Testing Applications in Heart Failure. Exerc Sport Sci Rev 2014; 42:153-60. [DOI: 10.1249/jes.0000000000000022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Armstrong HF, Schulze PC, Bacchetta M, Thirapatarapong W, Bartels MN. Impact of pulmonary hypertension on exercise performance in patients with interstitial lung disease undergoing evaluation for lung transplantation. Respirology 2014; 19:675-82. [PMID: 24797365 PMCID: PMC4065213 DOI: 10.1111/resp.12306] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 03/13/2014] [Accepted: 03/14/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary hypertension (PH) is a known complication in patients with interstitial lung disease (ILD). Cardiopulmonary exercise testing (CPET) is an essential tool for the assessment of patients with cardiac and pulmonary diseases due to its prognostic and therapeutic implications. Few studies have evaluated the relationship between CPET response and mean pulmonary artery pressures (mPAP) in ILD. The purpose of the present study was to determine and compare the potential correlations between CPET, 6-min walk test (6MWT), pulmonary function testing (PFT) and PH in patients with ILD being evaluated for lung transplantation. METHODS The present study reviewed patients with ILD who received lung transplantations and had CPETs within 2 years before transplantation, right heart catheterizations, PFTs and 6MWTs within 4 months of CPET. RESULTS A total of 72 patients with ILD were analysed; 36% had PH. There were significant correlations between mPAP and CPET parameters in patients with PH; but mPAP had no impact on percent of predicted diffusion capacity of the lung for carbon monoxide or 6-min walk distance (6MWD). CPET parameters were able to detect differences between levels of severity of PH through the use of the ratio of minute ventilation to rate of carbon dioxide production (VE/VCO2) and the partial pressure of end-tidal carbon dioxide. CONCLUSIONS This is the first study that analyses 6MWD, PFT and CPET in patients with ILD awaiting lung transplantation with and without PH. The present study demonstrates the significant impact of PH on exercise capacity and performance in patients with ILD awaiting lung transplantation.
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Affiliation(s)
- Hilary F. Armstrong
- Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center, NY, NY 10032
| | - P. Christian Schulze
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, NY, NY 10032
| | - Matthew Bacchetta
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia-Presbyterian Hospital, NY, NY 10032
| | - Wilawan Thirapatarapong
- Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center, NY, NY 10032
- Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
| | - Matthew N. Bartels
- Department of Rehabilitation and Regenerative Medicine, Columbia University Medical Center, NY, NY 10032
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Domingo E, Grignola JC, Aguilar R, Arredondo C, Bouteldja N, Messeguer ML, Roman A. Impairment of pulmonary vascular reserve and right ventricular systolic reserve in pulmonary arterial hypertension. BMC Pulm Med 2014; 14:69. [PMID: 24762000 PMCID: PMC4007147 DOI: 10.1186/1471-2466-14-69] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 04/04/2014] [Indexed: 11/12/2022] Open
Abstract
Background Exercise capacity is impaired in pulmonary arterial hypertension (PAH). We hypothesized that cardiovascular reserve abnormalities would be associated with impaired hemodynamic response to pharmacological stress and worse outcome in PAH. Methods Eighteen PAH patients (p) group 1 NYHA class II/III and ten controls underwent simultaneous right cardiac catheterization and intravascular ultrasound at rest and during low dose-dobutamine (10 mcg/kg/min) with trendelenburg (DST). We estimated cardiac output (CO), pulmonary vascular resistance (PVR) and capacitance (PC), and PA elastic modulus (EM). We concomitantly measured tricuspid annular plane systolic excursion (TAPSE), RV myocardial peak systolic velocity (Sm) and isovolumic myocardial acceleration (IVA) in PAH patients. Based on the rounded mean + 2 SD of the increase in mPAP in our healthy control group during DST (2.8 + 1.8 mm Hg), PAH p were divided into two groups according to mean PA pressure (mPAP) response during DST, 1: ΔmPAP > 5 mm Hg and 2: ΔmPAP ≤ 5 mm Hg. Cardiovascular reserve was estimated as the change (delta, Δ) during DST compared with rest, including ΔmPAP with respect to ΔCO (ΔmPAP/ΔCO). All patients were prospectively followed up for 2 years. Results PAH p showed significant lower heart rate and CO increase than controls during DST, with a significant mPAP and pulse PAP increase and higher ΔmPAP/ΔCO (p < 0.05). Neither hemodynamic, IVUS and echocardiographic data were different between both PAH groups at rest. In group 1, DST caused a higher ΔEM, ΔmPAP/ΔCO, ΔPVR, and ΔTAPSE than group 2, with a lower IVA increase and a negative ΔSV (p < 0.05). TAPSE correlated with mPAP and RVP (p < 0.05) and, IVA and Sm correlated with CO (p < 0.05). ΔEM correlated with ΔmPAP and ΔIVA with ΔCO (p < 0.05). There were two deaths/pulmonary transplantations in group 1 and one death in group 2 during the follow-up (p > 0.05). Conclusions Pulmonary vascular reserve and RV systolic reserve are significantly impaired in patients with PAH. The lower recruitable cardiovascular reserve is significantly related to a worse hemodynamic response to DST and it could be associated with a poor clinical outcome.
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Affiliation(s)
| | - Juan C Grignola
- Pathophysiology Department, School of Medicine, Hospital de Clínicas, Universidad de la República, Avda Italia 2870, PC 11600 Montevideo, Uruguay.
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Babu AS, Myers J, Arena R, Maiya AG, Padmakumar R. Evaluating exercise capacity in patients with pulmonary arterial hypertension. Expert Rev Cardiovasc Ther 2014; 11:729-37. [DOI: 10.1586/erc.13.33] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873-934. [PMID: 23877260 DOI: 10.1161/cir.0b013e31829b5b44] [Citation(s) in RCA: 1235] [Impact Index Per Article: 112.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Guazzi M, Cahalin LP, Arena R. Cardiopulmonary Exercise Testing as a Diagnostic Tool for the Detection of Left-sided Pulmonary Hypertension in Heart Failure. J Card Fail 2013; 19:461-7. [DOI: 10.1016/j.cardfail.2013.05.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 10/26/2022]
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Armstrong HF, Thirapatarapong W, Dussault NE, Bartels MN. Distinguishing Pulmonary Hypertension in Interstitial Lung Disease by Ventilation and Perfusion Defects Measured by Cardiopulmonary Exercise Testing. Respiration 2013; 86:407-13. [DOI: 10.1159/000350445] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 02/26/2013] [Indexed: 11/19/2022] Open
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Babu AS, Padmakumar R, Maiya AG. A review of ongoing trials in exercise based rehabilitation for pulmonary arterial hypertension. Indian J Med Res 2013; 137:900-6. [PMID: 23760374 PMCID: PMC3734680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Indexed: 11/04/2022] Open
Abstract
Exercise based rehabilitation for patients with pulmonary arterial hypertension (PAH) is a new treatment option for these patients to improve their functional capacity and quality of life. Despite the benefits seen in cardiopulmonary rehabilitation in various other conditions, it has been underutilized for the patients with PAH. A review of currently registered ongoing trials on exercise training for patients with PAH from the World Health Organization International Clinical Trial Registry Platform was done using the key words "rehabilitation", "exercise training", "pulmonary artery hypertension" and "pulmonary hypertension" for a period of 10 years (2002-2012). The search revealed 57 registered trials in various trial registries from which seven met the inclusion criteria. The current studies are being carried out in Germany (n=4), Brazil (n=1), Australia (n=1) and India (n=1). This indicates a shift in focus from the only medical management to the rehabilitation and long term care for patients with PAH.
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Affiliation(s)
- Abraham Samuel Babu
- Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal, India.
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Babu AS, Arena R, Maiya AG, Padmakumar R, Guazzi M. Should Cardiopulmonary Exercise Testing Become a Part of Regular Evaluation for Patients with a Family History of Pulmonary Hypertension? Pulm Circ 2013; 3:121-2. [PMID: 23662184 PMCID: PMC3641715 DOI: 10.4103/2045-8932.109927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Abraham Samuel Babu
- Department of PhysiotherapyManipal College of Allied Health SciencesManipal UniversityManipalKarnatakaIndia
| | - Ross Arena
- Division of Physical TherapyDepartment of Orthopaedics and RehabilitationDivision of CardiologyDepartment of Internal MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Arun G. Maiya
- Department of PhysiotherapyManipal College of Allied Health SciencesManipal UniversityManipalKarnatakaIndia
- Dr.TMA Pai Endowment Chair in Exercise and Health PromotionManipal UniversityManipal
| | | | - Marco Guazzi
- Cardiopulmonary Laboratory, Cardiology DivisionSan Paolo HospitalUniversity of MilanoMilanItaly
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Guazzi M, Adams V, Conraads V, Halle M, Mezzani A, Vanhees L, Arena R, Fletcher GF, Forman DE, Kitzman DW, Lavie CJ, Myers J. EACPR/AHA Scientific Statement. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Circulation 2012; 126:2261-74. [PMID: 22952317 PMCID: PMC4777325 DOI: 10.1161/cir.0b013e31826fb946] [Citation(s) in RCA: 546] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Guazzi M, Adams V, Conraads V, Halle M, Mezzani A, Vanhees L, Arena R, Fletcher GF, Forman DE, Kitzman DW, Lavie CJ, Myers J. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J 2012; 33:2917-27. [DOI: 10.1093/eurheartj/ehs221] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Marco Guazzi
- Department of Medical Sciences, Cardiology, I.R.C.C.S. San Donato Hospital, University of Milan, San Donato Milanese, P.za Malan, 2, 20097, Milan, Italy
| | - Volker Adams
- Department of Cardiology, University Leipzig–Heart Center Leipzig, Leipzig, Germany
| | - Viviane Conraads
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Martin Halle
- Department of Prevention and Sports Medicine, Technische Universität München, Munich, Germany
| | - Alessandro Mezzani
- Exercise Pathophysiology Laboratory, Cardiac Rehabilitation Division, S. Maugeri Foundation IRCCS, Scientific Institute of Veruno, Veruno (NO), Italy
| | - Luc Vanhees
- Research Centre for Cardiovascular and Respiratory Rehabilitation, Department of Rehabilitation Sciences, KU Leuven (University of Leuven), Leuven, Belgium
| | - Ross Arena
- Department of Orthopaedics and Rehabilitation – Division of Physical Therapy and Department of Internal Medicine – Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | | | - Daniel E. Forman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Dalane W. Kitzman
- Department of Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carl J. Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA, USA
| | - Jonathan Myers
- Division of Cardiology, VA Palo Alto Health Care System, Stanford University, Palo Alto, CA, USA
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Abstract
Right ventricular (RV) dysfunction arises in chronic lung disease when chronic hypoxemia and disruption of pulmonary vascular beds increase ventricular afterload. RV dysfunction is defined by hypertrophy with preserved myocardial contractility and cardiac output. RV hypertrophy seems to be a common complication of chronic and advanced lung disease. RV failure is rare, except during acute exacerbations of chronic lung disease or when multiple comorbidities are present. Treatment is targeted at correcting hypoxia and improving pulmonary gas exchange and mechanics. There are no data supporting the use of pulmonary hypertension-specific therapies for patients with RV dysfunction secondary to chronic lung disease.
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Affiliation(s)
- Todd M. Kolb
- Post-Doctoral Fellow, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Paul M. Hassoun
- Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
- Director, Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland
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Heart rate recovery in pulmonary arterial hypertension: relationship with exercise capacity and prognosis. Am Heart J 2012; 163:580-8. [PMID: 22520523 DOI: 10.1016/j.ahj.2012.01.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/26/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delayed postexercise heart rate recovery (HRR) has been associated with disability and poor prognosis in chronic cardiopulmonary diseases. The usefulness of HRR to predict exercise impairment and mortality in patients with pulmonary arterial hypertension (PAH), however, remains largely unexplored. METHODS Seventy-two patients with PAH of varied etiology (New York Heart Association classes I-IV) and 21 age- and gender-matched controls underwent a maximal incremental cardiopulmonary exercise test (CPET), with heart rate being recorded up to the fifth minute of recovery. RESULTS Heart rate recovery was consistently lower in the patients compared with the controls (P < .05). The best cutoff for HRR in 1 minute (HRR(1 min)) to discriminate the patients from the controls was 18 beats. Compared with patients with HRR(1 min) ≤ 18 (n = 40), those with HRR(1 min) >18 (n = 32) had better New York Heart Association scores, resting hemodynamics and 6-minute walking distance. In fact, HRR(1 min) >18 was associated with a range of maximal and submaximal CPET variables indicative of less severe exercise impairment (P < .05). The single independent predictor of HRR(1 min) ≤ 18 was the 6-minute walking distance (odds ratio [95% CI] 0.99 [0.98-1.00], P < .05). On a multiple regression analysis that considered only CPET-independent variables, HRR(1 min) ≤ 18 was the single predictor of mortality (hazard ratio [95% CI] 1.19 [1.03-1.37], P < .05). CONCLUSIONS Preserved HRR(1 min) (>18 beats) is associated with less impaired responses to incremental exercise in patients with PAH. Conversely, a delayed HRR(1 min) response has negative prognostic implications, a finding likely to be clinically useful when more sophisticated (and costlier) analyses provided by a full CPET are not available.
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Rubin LJ, Morrell NW. New frontiers in pulmonary hypertension. Expert Rev Respir Med 2011; 5:139-40. [DOI: 10.1586/ers.11.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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