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Meyer FJ, Opitz C. Post-Pulmonary Embolism Syndrome: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:128-134. [PMID: 38531395 DOI: 10.1055/a-2229-4190] [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: 03/28/2024] Open
Abstract
In survivors of acute pulmonary embolism (PE), the post-PE syndrome (PPES) may occur. In PPES, patients typically present with persisting or progressive dyspnea on exertion despite 3 months of therapeutic anticoagulation. Therefore, a structured follow-up is warranted to identify patients with chronic thromboembolic pulmonary disease (CTEPD) with normal pulmonary pressure or chronic thromboembolic pulmonary hypertension (CTEPH). Both are currently understood as a dual vasculopathy, that is, secondary arterio- and arteriolopathy, affecting the large and medium-sized pulmonary arteries as well as the peripheral vessels (diameter < 50 µm). The follow-up algorithm after acute PE commences with identification of clinical symptoms and risk factors for CTEPH. If indicated, a stepwise performance of echocardiography, ventilation-perfusion scan (or alternative imaging), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, cardiopulmonary exercise testing, and pulmonary artery catheterization with angiography should follow. CTEPH patients should be treated in a multidisciplinary center with adequate experience in the complex therapeutic options, comprising pulmonary endarterectomy, balloon pulmonary angioplasty, and pharmacological interventions.
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Affiliation(s)
- F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching) - München Klinik gGmbH, Sanatoriumsplatz 2 München, München, Bavaria, Germany
| | - Christian Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK Kliniken Berlin Westend, Berlin, Germany
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Alotaibi M, Yang JZ, Papamatheakis DG, McGuire WC, Fernandes TM, Morris TA. Cardiopulmonary exercise test to detect cardiac dysfunction from pulmonary vascular disease. Respir Res 2024; 25:121. [PMID: 38468264 PMCID: PMC10926602 DOI: 10.1186/s12931-024-02746-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cardiac dysfunction from pulmonary vascular disease causes characteristic findings on cardiopulmonary exercise testing (CPET). We tested the accuracy of CPET for detecting inadequate stroke volume (SV) augmentation during exercise, a pivotal manifestation of cardiac limitation in patients with pulmonary vascular disease. METHODS We reviewed patients with suspected pulmonary vascular disease in whom CPET and right heart catheterization (RHC) measurements were taken at rest and at anaerobic threshold (AT). We correlated CPET-determined O2·pulseAT/O2·pulserest with RHC-determined SVAT/SVrest. We evaluated the sensitivity and specificity of O2·pulseAT/O2·pulserest to detect SVAT/SVrest below the lower limit of normal (LLN). For comparison, we performed similar analyses comparing echocardiographically-measured peak tricuspid regurgitant velocity (TRVpeak) with SVAT/SVrest. RESULTS From July 2018 through February 2023, 83 simultaneous RHC and CPET were performed. Thirty-six studies measured O2·pulse and SV at rest and at AT. O2·pulseAT/O2·pulserest correlated highly with SVAT/SVrest (r = 0.72, 95% CI 0.52, 0.85; p < 0.0001), whereas TRVpeak did not (r = -0.09, 95% CI -0.47, 0.33; p = 0.69). The AUROC to detect SVAT/SVrest below the LLN was significantly higher for O2·pulseAT/O2·pulserest (0.92, SE 0.04; p = 0.0002) than for TRVpeak (0.69, SE 0.10; p = 0.12). O2·pulseAT/O2·pulserest of less than 2.6 was 92.6% sensitive (95% CI 76.6%, 98.7%) and 66.7% specific (95% CI 35.2%, 87.9%) for deficient SVAT/SVrest. CONCLUSIONS CPET detected deficient SV augmentation more accurately than echocardiography. CPET-determined O2·pulseAT/O2·pulserest may have a prominent role for noninvasive screening of patients at risk for pulmonary vascular disease, such as patients with persistent dyspnea after pulmonary embolism.
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Affiliation(s)
- Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Jenny Z Yang
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Demosthenes G Papamatheakis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Timothy A Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA.
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Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
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Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
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Meda NS, Sherner JH, Holley AB. Dyspnea and Post-Pulmonary Embolism Syndrome after a Mild COVID-19 Infection. Ann Am Thorac Soc 2024; 21:151-157. [PMID: 38156895 DOI: 10.1513/annalsats.202304-332cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/08/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
| | | | - Aaron B Holley
- Department of Pulmonary/Sleep and Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC
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van Kan C, Tramper J, Bresser P, J. Meijboom L, Symersky P, Winkelman JA, Nossent EJ, Aman J, Bogaard HJ, Vonk Noordegraaf A, van Es J. Patients with CTEPH and mild hemodynamic severity of disease improve to a similar level of exercise capacity after pulmonary endarterectomy compared to patients with severe hemodynamic disease. Pulm Circ 2024; 14:e12316. [PMID: 38274560 PMCID: PMC10808941 DOI: 10.1002/pul2.12316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 01/27/2024] Open
Abstract
The correlation between hemodynamics and degree of pulmonary vascular obstruction (PVO) is known to be poor in chronic thromboembolic pulmonary hypertension (CTEPH), which makes the selection of patients eligible for pulmonary endarterectomy (PEA) challenging. It can be postulated that patients with similar PVO but different hemodynamic severity have different postoperative hemodynamics and exercise capacity. Therefore, we aimed to assess the effects of PEA on hemodynamics and exercise physiology in mild and severe CTEPH patients. We retrospectively studied 18 CTEPH patients with a mild hemodynamic profile (mean pulmonary arterial pressure [mPAP] between 25 and 30 mmHg at rest) and CTEPH patients with a more severe hemodynamic profile (mPAP > 30 mmHg), matched by age, gender, and PVO. Cardiopulmonary exercise testing parameters were evaluated at baseline and 18 months following PEA. At baseline, exercise capacity, defined as oxygen uptake, was less severely impaired in the mild CTEPH group compared to the severe CTEPH group. After PEA, in the mild CTEPH group, ventilatory efficiency and oxygen pulse improved significantly (p < 0.05), however, the change in ventilatory efficiency and oxygen pulse was smaller compared to the severe CTEPH group. Only in the severe CTEPH group exercise capacity improved significantly (p < 0.001). Hence, in the present study, postoperative hemodynamic outcome and the CPET-determined recovery of exercise capacity in mild CTEPH patients did not differ from a matched group of severe CTEPH patients.
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Affiliation(s)
- Coen van Kan
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Respiratory MedicineOLVGAmsterdamThe Netherlands
| | - Jelco Tramper
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
| | - Paul Bresser
- Department of Respiratory MedicineOLVGAmsterdamThe Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear MedicineAmsterdam UMCAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Petr Symersky
- Department of Cardiothoracic SurgeryAmsterdam UMCAmsterdamThe Netherlands
- Department of Cardiothoracic SurgeryOLVGAmsterdamThe Netherlands
| | | | - Esther J. Nossent
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Josien van Es
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Respiratory MedicineOLVGAmsterdamThe Netherlands
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [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: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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7
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Mounsey LA, Witkin AS, Wong A, Kowal A, Hoenstine C, McGinnis S, Malhotra R, Lewis GD, Hardin CC, Rodriguez-Lopez J. Cardiopulmonary Exercise Testing in Patients with Persistent Dyspnea after Pulmonary Embolism. Ann Am Thorac Soc 2023; 20:1528-1530. [PMID: 37311210 DOI: 10.1513/annalsats.202302-108rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/12/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
| | | | | | - Alyssa Kowal
- Massachusetts General Hospital Boston, Massachusetts
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Morris TA, Fernandes TM, Chung J, Vintch JRE, McGuire WC, Thapamagar S, Alotaibi M, Aries S, Dakaeva K. Observational cohort study to validate SEARCH, a novel hierarchical algorithm to define long-term outcomes after pulmonary embolism. BMJ Open 2023; 13:e074470. [PMID: 37770267 PMCID: PMC10546166 DOI: 10.1136/bmjopen-2023-074470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Chronic dyspnoea and exercise impairment are common after acute pulmonary embolism (PE) but are not defined and quantified sufficiently to serve as outcomes in clinical trials. The planned project will clinically validate a novel method to determine discrete, clinically meaningful diagnoses after acute PE. The method uses an algorithm entitled SEARCH, for symptom screen, exercise testing, arterial perfusion, resting echocardiography, confirmatory imaging and haemodynamic measurements. SEARCH is a stepwise algorithm that sorts patients by a hierarchical series of dichotomous tests into discreet categories of long-term outcomes after PE: asymptomatic, post-PE deconditioning, symptoms from other causes, chronic thromboembolism with ventilatory inefficiency, chronic thromboembolism with small stroke volume augmentation, chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension. METHODS The project will test the inter-rater reliability of the SEARCH algorithm by determining whether it will yield concordant post-PE diagnoses when six independent reviewers review the same diagnostic data on 150 patients evaluated at two time points after PE. The project will also determine whether the post-PE diagnoses are stable, according to the SEARCH algorithm, between the first evaluation and the subsequent one 6 months later. IMPLICATIONS Validation of the SEARCH algorithm would offer clinicians a straightforward method to diagnose post-PE conditions that are rarely distinguished clinically. Their categorisation and definition will allow post-PE conditions to be used as endpoints in clinical trials of acute PE treatment. TRIAL REGISTRATION NUMBER NCT05568927.
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Affiliation(s)
- Timothy A Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Jina Chung
- Division of Cardiology, The Lundquist Institute, Torrance, California, USA
- Division of Cardiology, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Janine R E Vintch
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute, Torrance, California, USA
- Division of Respiratory and Critical Care Physiology and Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Suman Thapamagar
- Division of Pulmonary and Critical Care Medicine, Riverside University Health System, Moreno Valley, California, USA
- Division of Pulmonary and Critical Care Medicine, University of California Riverside, Riverside, California, USA
| | - Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Savannah Aries
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Khadizhat Dakaeva
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
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Kabadi A, Kerr K, Fernandes TM. Updates in the diagnosis and management of chronic thromboembolic disease. Curr Opin Pulm Med 2023; 29:340-347. [PMID: 37461845 DOI: 10.1097/mcp.0000000000000987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW Chronic thromboembolic disease (CTED) is distinct from chronic thromboembolic pulmonary hypertension (CTEPH) and is defined by dyspnea on exertion after acute pulmonary embolism with the presence of residual perfusion defects and absence of resting pulmonary hypertension. Here, we review clinical features and diagnostic criteria for CTED and summarize treatment options. RECENT FINDINGS The optimal management for CTED is unclear as the long-term outcomes of conservative vs. invasive treatment for this disease have not been reported. There are a few studies evaluating outcomes of pulmonary thromboendarterectomy and balloon pulmonary angioplasty (BPA) in CTED, concluding that these procedures are safe and effective in select patients. However, these trials are small nonrandomized observational studies, reporting outcomes only up to 1 year after the intervention. Conservative management of CTED with observation, pulmonary hypertension-targeted therapy, or cardiopulmonary rehabilitation has not been studied. It is unknown whether these treatments are as effective or superior to pulmonary thromboendarterectomy or BPA in CTED. SUMMARY The management of CTED is individualized and based on symptoms and exercise limitations. Early referral of patients with CTED to a specialized CTEPH center is recommended to determine if watchful waiting, BPA, or pulmonary thromboendarterectomy is most beneficial.
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Affiliation(s)
- Alisha Kabadi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, California, USA
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11
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Farmakis IT, Valerio L, Barco S, Alsheimer E, Ewert R, Giannakoulas G, Hobohm L, Keller K, Mavromanoli AC, Rosenkranz S, Morris TA, Konstantinides SV, Held M, Dumitrescu D. Cardiopulmonary exercise testing during follow-up after acute pulmonary embolism. Eur Respir J 2023; 61:2300059. [PMID: 36958742 PMCID: PMC10249018 DOI: 10.1183/13993003.00059-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/03/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) may provide prognostically valuable information during follow-up after pulmonary embolism (PE). Our objective was to investigate the association of patterns and degree of exercise limitation, as assessed by CPET, with clinical, echocardiographic and laboratory abnormalities and quality of life (QoL) after PE. METHODS In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3- and 12-month follow-ups, including CPET. We defined cardiopulmonary limitation as ventilatory inefficiency or insufficient cardiocirculatory reserve. Deconditioning was defined as peak O2 uptake (V'O2 ) <80% with no other abnormality. RESULTS Overall, 396 patients were included. At 3 months, prevalence of cardiopulmonary limitation and deconditioning was 50.1% (34.7% mild/moderate; 15.4% severe) and 12.1%, respectively; at 12 months, it was 44.8% (29.1% mild/moderate; 15.7% severe) and 14.9%, respectively. Cardiopulmonary limitation and its severity were associated with age (OR per decade 2.05, 95% CI 1.65-2.55), history of chronic lung disease (OR 2.72, 95% CI 1.06-6.97), smoking (OR 5.87, 95% CI 2.44-14.15) and intermediate- or high-risk acute PE (OR 4.36, 95% CI 1.92-9.94). Severe cardiopulmonary limitation at 3 months was associated with the prospectively defined, combined clinical-haemodynamic end-point of "post-PE impairment" (OR 6.40, 95% CI 2.35-18.45) and with poor disease-specific and generic health-related QoL. CONCLUSIONS Abnormal exercise capacity of cardiopulmonary origin is frequent after PE, being associated with clinical and haemodynamic impairment as well as long-term QoL reduction. CPET can be considered for selected patients with persisting symptoms after acute PE to identify candidates for closer follow-up and possible therapeutic interventions.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Eva Alsheimer
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ralf Ewert
- Clinic for Internal Medicine, Greifswald University Hospital, Greifswald, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Matthias Held
- Department of Pulmonary Medicine, KWM Missio Clinic, Würzburg, Germany
- These authors contributed equally and share last authorship
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
- These authors contributed equally and share last authorship
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Milne KM, James MD, Smyth RM, Vincent SG, Singh N, D'Arsigny CL, de-Torres JP, de Wit K, Johri A, Neder JA, O'Donnell DE, Phillips DB. Neurophysiological mechanisms of exertional dyspnea in post-pulmonary embolism syndrome. J Appl Physiol (1985) 2023; 134:667-677. [PMID: 36701483 DOI: 10.1152/japplphysiol.00677.2022] [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: 01/27/2023] Open
Abstract
Following pulmonary embolism (PE), a third of patients develop persistent dyspnea, which is commonly termed the post-PE syndrome. The neurophysiological underpinnings of exertional dyspnea in patients with post-PE syndrome without pulmonary hypertension (PH) are unclear. Thus, the current study determined if abnormally high inspiratory neural drive (IND) due, in part, to residual pulmonary gas-exchange abnormalities, was linked to heightened exertional dyspnea and exercise limitation, in such patients. Fourteen participants with post-PE syndrome (without resting PH) and 14 age-, sex-, and body mass index-matched healthy controls undertook pulmonary function testing and a symptom-limited cycle cardiopulmonary exercise test with measurements of IND (diaphragmatic electromyography), ventilatory requirements for CO2 (V̇e/V̇co2), and perceived dyspnea intensity (modified Borg 0-10 scale). Post-PE (vs. control) had a reduced resting transfer coefficient for carbon monoxide (KCO: 84 ± 15 vs. 104 ± 14%pred, P < 0.001) and peak oxygen uptake (V̇o2peak) (76 ± 14 vs. 124 ± 28%pred, P < 0.001). IND and V̇e/V̇co2 were higher in post-PE than controls at standardized submaximal work rates (P < 0.05). Dyspnea increased similarly in both groups as a function of increasing IND but was higher in post-PE at standardized submaximal work rates (P < 0.05). High IND was associated with low KCO (r = -0.484, P < 0.001), high V̇e/V̇co2 nadir (r = 0.453, P < 0.001), and low V̇o2peak (r = -0.523, P < 0.001). In patients with post-PE syndrome, exercise IND was higher than controls and was associated with greater dyspnea intensity. The heightened IND and dyspnea in post-PE, in turn, were strongly associated with low resting KCO and high exercise V̇e/V̇co2, which suggest important pulmonary gas-exchange abnormalities in this patient population.NEW & NOTEWORTHY This study is the first to show that increased exertional dyspnea in patients with post-pulmonary embolism (PE) syndrome, without overt pulmonary hypertension, was strongly associated with elevated inspiratory neural drive (IND) to the diaphragm during exercise, compared with healthy controls. The greater IND was associated with impairments in pulmonary gas exchange and significant deconditioning. Our results help to explain why many patients with post-PE syndrome report significant dyspnea at relatively low levels of physical activity.
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Affiliation(s)
- Kathryn M Milne
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada.,Centre for Heart Lung Innovation, Providence Health Care Research Institute, University of British Columbia St. Paul's Hospital, Vancouver, British Columbia, Canada.,Division of Respiratory Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Reginald M Smyth
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Namisha Singh
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Christine L D'Arsigny
- Department of Critical Care Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Juan P de-Torres
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Amer Johri
- Division of Cardiology, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada.,School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
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13
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Farmakis IT, Keller K, Barco S, Konstantinides SV, Hobohm L. From acute pulmonary embolism to post-pulmonary embolism sequelae. VASA 2023; 52:29-37. [PMID: 36444524 DOI: 10.1024/0301-1526/a001042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aim of this narrative review is to summarize the functional and hemodynamic implications of acute PE and PE sequelae, namely the post-PE syndrome. Briefly, we will first describe the epidemiology, diagnostic procedures, and therapeutic approaches of acute PE. Then, we will provide a definition of the post-PE syndrome and present the so far accumulated evidence regarding its epidemiology and the implications that arise for further diagnosis and treatment. Lastly, we will explore the most devastating long-term complication of PE, namely chronic thromboembolic pulmonary hypertension (CTEPH), and recent advances in its management.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center Mainz, Germany.,Department of Sports Medicine, Internal Medicine VII, Medical Clinic, University Hospital Heidelberg, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Department of Angiology, University Hospital Zurich, Switzerland
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center Mainz, Germany
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14
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Alblas H, van Kan C, van Het Westeinde SC, Emmering J, Niezen A, Al Butaihi IAM, Noordegraaf AV, van Es J. Persistent dyspnea after acute pulmonary embolism is related to perfusion defects and lower long-term quality of life. Thromb Res 2022; 219:89-94. [PMID: 36152460 DOI: 10.1016/j.thromres.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/01/2022] [Accepted: 09/12/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Heleen Alblas
- Department of Pulmonary Medicine, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Coen van Kan
- Department of Pulmonary Medicine, Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Department of Respiratory Medicine, OLVG, Amsterdam, the Netherlands.
| | | | - Jasper Emmering
- Department of Radiology and Nuclear Medicine, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - André Niezen
- Department of Radiology and Nuclear Medicine, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Ibrahim A M Al Butaihi
- Department of Radiology and Nuclear Medicine, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Josien van Es
- Department of Pulmonary Medicine, Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
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15
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Evaluation of Dyspnea and Exercise Intolerance After Acute Pulmonary Embolism. Chest 2022; 163:933-941. [PMID: 35792185 PMCID: PMC10107059 DOI: 10.1016/j.chest.2022.06.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 12/13/2022] Open
Abstract
Long-term dyspnea and exercise intolerance are common clinical problems after acute pulmonary embolism. Unfortunately, no single test can distinguish among the range of potential pathologic outcomes after pulmonary embolism. We illustrate a stepwise approach to post-pulmonary embolism evaluation that uses a hierarchic series of clinically validated diagnostic tests. The algorithm is represented by the acronym SEARCH, which stands for Symptom screening, Exercise testing, Arterial perfusion, Resting echocardiography, Confirmatory chest imaging, and Hemodynamics measured by right heart catheterization. We illustrate the algorithm with a patient whom we saw in our pulmonary embolism follow-up clinic. Patients are asked at least 6 months after pulmonary embolism whether they have returned to their baseline level of respiratory comfort and exercise tolerance. Patients with dyspnea and exercise intolerance undergo noninvasive cardiopulmonary exercise testing to identify elevated ventilatory dead space ratios, decreased stroke volume augmentation with exercise, and other physiologic abnormalities during exertion. Ventilation-perfusion scanning is performed on those patients with exercise-related physiologic findings to confirm the presence of residual pulmonary arterial obstruction or to suggest alternative diagnoses. Resting echocardiography may provide evidence of pulmonary hypertension; confirmatory imaging with pulmonary angiography or CT angiography may disclose findings characteristic of chronic pulmonary artery obstruction. Finally, right heart catheterization is performed to confirm chronic thromboembolic pulmonary hypertension; if resting pulmonary hemodynamics are normal, then invasive cardiopulmonary exercise testing may disclose exercise-induced defects.
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16
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Abstract
PURPOSE OF REVIEW In the past decades, the diagnostic and therapeutic management of chronic thromboembolic pulmonary hypertension (CTEPH) has been revolutionized. RECENT FINDINGS Advances in epidemiological knowledge and follow-up studies of pulmonary embolism patients have provided more insight in the incidence and prevalence. Improved diagnostic imaging techniques allow accurate assessment of the location and extend of the thromboembolic burden in the pulmonary artery tree, which is important for the determination of the optimal treatment strategy. Next to the pulmonary endarterectomy, the newly introduced technique percutaneous pulmonary balloon angioplasty and/or P(A)H-targeted medical therapy has been shown to be beneficial in selected patients with CTEPH and might also be of importance in patients with chronic thromboembolic pulmonary vascular disease. SUMMARY In this era of a comprehensive approach to CTEPH with different treatment modalities, a multidisciplinary approach guides management decisions leading to optimal treatment and follow-up of patients with CTEPH.
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17
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Boon GJAM, Janssen SMJ, Barco S, Bogaard HJ, Ghanima W, Kroft LJM, Meijboom LJ, Ninaber MK, Nossent EJ, Spruit MA, Symersky P, Vliegen HW, Noordegraaf AV, Huisman MV, Siegerink B, Abbink JJ, Klok FA. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res 2021; 206:66-75. [PMID: 34419865 DOI: 10.1016/j.thromres.2021.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Post-Pulmonary Embolism Syndrome (PPES) comprises heterogeneous entities, including chronic thromboembolic disease with/without pulmonary hypertension (CTEPH/CTEPD), and deconditioning. OBJECTIVES To assess underlying physiological determinants of PPES, and efficacy and safety of rehabilitation training in these patients. METHODS 56 consecutive PE patients with persistent dyspnea and/or functional limitations despite ≥3 months of anticoagulation underwent standardized diagnostic work-up including exercise testing as part of routine practice. All diagnostic (imaging and cardiopulmonary function) tests were interpreted by a core group of experienced clinicians. A subgroup of patients without CTEPH or other treatable conditions was referred for a 12-week personalized rehabilitation program, studying changes in physical condition and patient-reported outcome measures. RESULTS Persistent vascular occlusions were observed in 21/56 patients (38%) and CTEPH was confirmed in ten (18%). Regarding those without CTEPH, impaired cardiopulmonary responses were evident in 18/39 patients with available CPET data (46%), unrelated to chronic thrombi. Rehabilitation was completed by 27 patients after excluding 29 (patients with CTEPH or treatable comorbidities, refusal, ineligibility, or training elsewhere). Training intensity, PE-specific quality of life (PEmb-QoL) and fatigue (CIS) improved with a median difference of 20 W (p = 0.001), 3.9 points (p < 0.001) and 16 points (p = 0.003), respectively. Functional status (Post-VTE Functional Status Scale) improved ≥1 grade in 18 (67%) patients, and declined in one (3.7%). CONCLUSIONS Our findings suggest that abnormal cardiopulmonary responses to exercise are common in patients with PPES and are not limited to those with chronic thrombi. Offering pulmonary rehabilitation to patients not treated otherwise seems safe and promising.
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Affiliation(s)
- Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway; Institute of Clinical Research, University of Oslo, Oslo, Norway
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J Nossent
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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18
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Morris TA, Porszasz J, Stringer WW. Response. Chest 2021; 158:1781-1782. [PMID: 33036092 DOI: 10.1016/j.chest.2020.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego.
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19
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Stringer WW, Porszasz J, Cao M, Rossiter HB, Siddiqui S, Rennard S, Casaburi R. The effect of long-acting dual bronchodilator therapy on exercise tolerance, dynamic hyperinflation, and dead space during constant work rate exercise in COPD. J Appl Physiol (1985) 2021; 130:2009-2018. [PMID: 33914661 PMCID: PMC8526332 DOI: 10.1152/japplphysiol.00774.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We investigated whether dual bronchodilator therapy (glycopyrrolate/formoterol fumarate; GFF; Bevespi Aerosphere) would increase exercise tolerance during a high-intensity constant work rate exercise test (CWRET) and the relative contributions of dead space ventilation (VD/VT) and dynamic hyperinflation (change in inspiratory capacity) to exercise limitation in chronic obstructive pulmonary disease (COPD). In all, 48 patients with COPD (62.9 ± 7.6 yrs; 33 male; GOLD spirometry stage 1/2/3/4, n = 2/35/11/0) performed a randomized, double blind, placebo (PL) controlled, two-period crossover, single-center trial. Gas exchange and inspiratory capacity (IC) were assessed during cycle ergometry at 80% incremental exercise peak work rate. Transcutaneous [Formula: see text] (Tc[Formula: see text]) measurement was used for VD/VT estimation. Baseline postalbuterol forced expiratory volume in 1 s (FEV1) was 1.86 ± 0.58 L (63.6% ± 13.9 predicted). GFF increased FEV1 by 0.18 ± 0.21 L relative to placebo (PL; P < 0.001). CWRET endurance time was greater after GFF vs. PL (383 ± 184 s vs. 328 ± 115 s; difference 55 ± 125 s; P = 0.013; confidence interval: 20-90 s), a 17% increase. IC on GFF was above placebo IC at all time points and fell less with GFF vs. PL (P ≤ 0.0001). Isotime tidal volume (1.54 ± 0.50 vs. 1.47 ± 0.45 L; P = 0.022) and ventilation (52.9 ± 19.9 vs. 51.0 ± 18.9 L/min; P = 0.011) were greater, and respiratory rate was unchanged (34.9 ± 9.2 vs. 35.1 ± 8.0 br/min, P = 0.865). Isotime VD/VT did not differ between groups (GFF 0.28 ± 0.08 vs. PL 0.27 ± 0.09; P = 0.926). GFF increased exercise tolerance in patients with COPD, and the increase was accompanied by attenuated dynamic hyperinflation without altering VD/VT.NEW & NOTEWORTHY This study was a randomized clinical trial (NCT03081156) that collected detailed physiology data to investigate the effect of dual bronchodilator therapy on exercise tolerance in COPD, and additionally to determine the relative contributions of changes in dead space ventilation (VD/VT) and dynamic hyperinflation to alterations in exercise limitation. We utilized a unique noninvasive method to assess VD/VT (transcutaneous carbon dioxide, Tc[Formula: see text]) and found that dual bronchodilators yielded a moderate improvement in exercise tolerance. Importantly, attenuation of dynamic hyperinflation rather than change in dead space ventilation was the most important contributor to exercise tolerance improvement.
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Affiliation(s)
- William W Stringer
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Janos Porszasz
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Min Cao
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Harry B Rossiter
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California.,Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Stephen Rennard
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, United Kingdom.,Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Richard Casaburi
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
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20
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Leprat T, Ivanes F, Bernard A, Marchand-Adam S, Plantier L. Transcutaneous PCO 2 -based dead space ventilation at submaximal exercise accurately discriminates healthy controls from patients with chronic obstructive pulmonary disease. Clin Physiol Funct Imaging 2021; 41:253-261. [PMID: 33529433 DOI: 10.1111/cpf.12692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/14/2020] [Accepted: 01/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increased physiological dead space ventilation (VD /VT ) at exercise reflects pulmonary gas exchange impairment and is a sensitive marker of cardio-respiratory disease. VD /VT is typically not measured during routine cardiopulmonary exercise testing (CPET) because its calculation requires arterial blood gas analysis for determination of PaCO2 . Instead, dead space ventilation is indirectly evaluated as a determinant of the ventilation (VE)/VCO2 relationship, which also depends on the PaCO2 set point. We hypothesized that VD /VT calculations based on non-invasive transcutaneous PCO2 (PtcCO2 ) measurement had better diagnostic characteristics than the VE/VCO2 slope for the discrimination of healthy subjects from patients with COPD, a common disease associated with impaired pulmonary gas exchange. METHODS Retrospective study of 19 healthy controls and 24 COPD patients who underwent CPET with continuous PtcCO2 monitoring. Areas under receiver operating characteristics curves (AUC) were calculated to assess diagnostic accuracy of CPET measurement for the discrimination of COPD and Controls. RESULTS The AUC for PtcCO2 -based VD /VT at VT1 (0.977) was significantly higher than for the VE/VCO2 slope (0.660), SpO2 at peak exercise (0.913), decrease in inspiratory capacity (0.719), and ventilatory reserve (0.708). At a threshold of 0.24, the sensitivity and specificity of PtcCO2 -based VD /VT for the discrimination of COPD patients and healthy Controls were 100% and 84%, respectively. All Control subjects had PtcCO2 -based VD /VT ≤ 0.25. CONCLUSIONS PtcCO2 -based VD /VT was the most accurate measurement to discriminate healthy controls from subjects with COPD, a chronic lung disease associated with altered pulmonary gas exchange. Non-invasive monitoring of PtcCO2 may be useful for routine CPET.
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Affiliation(s)
- Thibault Leprat
- Service de Médecine Cardiovasculaire, CHRU de Tours, Tours, France.,Université de Tours, Tours, France
| | - Fabrice Ivanes
- Service de Médecine Cardiovasculaire, CHRU de Tours, Tours, France.,Université de Tours, Tours, France.,EA4245 Transplantation, Immunologie et Inflammation, Tours, France
| | - Anne Bernard
- Service de Médecine Cardiovasculaire, CHRU de Tours, Tours, France.,Université de Tours, Tours, France.,EA4245 Transplantation, Immunologie et Inflammation, Tours, France
| | - Sylvain Marchand-Adam
- Université de Tours, Tours, France.,Service de Pneumologie et Explorations Fonctionnelles Respiratoires, CHRU de Tours, Tours, France.,CEPR/INSERM UMR1100, Tours, France
| | - Laurent Plantier
- Université de Tours, Tours, France.,Service de Pneumologie et Explorations Fonctionnelles Respiratoires, CHRU de Tours, Tours, France.,CEPR/INSERM UMR1100, Tours, France
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21
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Jervan Ø, Gleditsch J, Tavoly M, Klok FA, Rashid D, Holst R, Steine K, Stavem K, Ghanima W. Pulmonary and cardiac variables associated with persistent dyspnea after pulmonary embolism. Thromb Res 2021; 201:90-99. [PMID: 33662800 DOI: 10.1016/j.thromres.2021.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Persistent dyspnea is common in follow-up after pulmonary embolism (PE), but the underlying mechanisms are poorly understood. MATERIAL AND METHODS This cross-sectional study included subjects aged 18-75 years with confirmed PE by computed tomography pulmonary angiography (CTPA) 6-72 months earlier. A total of 180 participants underwent clinical examination, incremental shuttle walk test, laboratory tests, transthoracic echocardiography, pulmonary function tests and ventilation/perfusion scintigraphy. In further analysis, we divided participants into two groups; "dyspnea" or "no dyspnea", based on interview and questionnaires at inclusion. The association of cardiac and pulmonary variables with persistent dyspnea was assessed using multiple logistic regression analysis. RESULTS In total, 44% (95% CI: 39%-51%) of the participants reported persistent dyspnea after PE. Age (adjusted odds ratio (aOR) 0.93 per year, 95% CI: 0.90-0.97, P = 0.001), body mass index (BMI) (aOR 1.14 per kg/m2, 95% CI: 1.04-1.25, P = 0.004), recurrent venous thromboembolism (VTE) (aOR 3.69, 95% CI: 1.45-9.38, P = 0.006) and diffusion capacity of the lung for carbon monoxide (DLCO) (aOR 0.95 per increase of 1%, 95% CI: 0.92-0.98, P = 0.001) were independently associated with persistent dyspnea. CONCLUSIONS Persistent dyspnea was prevalent after PE. Age, BMI and recurrent VTE were independently associated with dyspnea. Apart from reduced DLCO, no other cardiac or pulmonary variables were associated with persistent dyspnea.
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Affiliation(s)
- Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Diyar Rashid
- Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - René Holst
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Kjetil Steine
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Medicine, Østfold Hospital, Kalnes, Norway; Dept of hematology, Oslo University hospital, Oslo, Norway
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22
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Boon GJAM, Huisman MV, Klok FA. Determinants and Management of the Post-Pulmonary Embolism Syndrome. Semin Respir Crit Care Med 2021; 42:299-307. [PMID: 33548930 DOI: 10.1055/s-0041-1722964] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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23
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Cao M, Stringer WW, Corey S, Orogian A, Cao R, Calmelat R, Lin F, Casaburi R, Rossiter HB, Porszasz J. Transcutaneous PCO 2 for Exercise Gas Exchange Efficiency in Chronic Obstructive Pulmonary Disease. COPD 2021; 18:16-25. [PMID: 33455452 DOI: 10.1080/15412555.2020.1858403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Gas exchange inefficiency and dynamic hyperinflation contributes to exercise limitation in chronic obstructive pulmonary disease (COPD). It is also characterized by an elevated fraction of physiological dead space (VD/VT). Noninvasive methods for accurate VD/VT assessment during exercise in patients are lacking. The current study sought to compare transcutaneous PCO2 (TcPCO2) with the gold standard-arterial PCO2 (PaCO2)-and other available methods (end tidal CO2 and the Jones equation) for estimating VD/VT during incremental exercise in COPD. Ten COPD patients completed a symptom limited incremental cycle exercise. TcPCO2 was measured by a heated electrode on the ear-lobe. Radial artery blood was collected at rest, during unloaded cycling (UL) and every minute during exercise and recovery. Ventilation and gas exchange were measured breath-by-breath. Bland-Altman analysis examined agreement of PCO2 and VD/VT calculated using PaCO2, TcPCO2, end-tidal PCO2 (PETCO2) and estimated PaCO2 by the Jones equation (PaCO2-Jones). Lin's Concordance Correlation Coefficient (CCC) was assessed. 114 measurements were obtained from the 10 COPD subjects. The bias between TcPCO2 and PaCO2 was 0.86 mmHg with upper and lower limit of agreement ranging -2.28 mmHg to 3.99 mmHg. Correlation between TcPCO2 and PaCO2 during rest and exercise was r2=0.907 (p < 0.001; CCC = 0.941) and VD/VT using TcPCO2 vs. PaCO2 was r2=0.958 (p < 0.0001; CCC = 0.967). Correlation between PaCO2-Jones and PETCO2 vs. PaCO2 were r2=0.755, 0.755, (p < 0.001; CCC = 0.832, 0.718) and for VD/VT calculation (r2=0.793, 0.610; p < 0.0001; CCC = 0.760, 0.448), respectively. The results support the accuracy of TcPCO2 to reflect PaCO2 and calculate VD/VT during rest and exercise, but not in recovery, in COPD patients, enabling improved accuracy of noninvasive assessment of gas exchange inefficiency during incremental exercise testing.
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Affiliation(s)
- Min Cao
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA.,Department of Cardio-Pulmonary function, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - William W Stringer
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Susan Corey
- Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente, San Diego, CA, USA
| | - Arin Orogian
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Robert Cao
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Robert Calmelat
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Fang Lin
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA.,Department of Respiratory, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Richard Casaburi
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Harry B Rossiter
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA.,Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Janos Porszasz
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
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24
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Dyspnea Postpulmonary Embolism. Chest 2020; 158:1780-1781. [DOI: 10.1016/j.chest.2020.05.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/16/2020] [Indexed: 11/24/2022] Open
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25
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Klok FA, Couturaud F, Delcroix M, Humbert M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J 2020; 55:13993003.00189-2020. [PMID: 32184319 DOI: 10.1183/13993003.00189-2020] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). Untreated CTEPH is fatal, but, if diagnosed in time, successful surgical (pulmonary endarterectomy), medical (pulmonary hypertension drugs) and/or interventional (balloon pulmonary angioplasty) therapies have been shown to improve clinical outcomes, especially in case of successful pulmonary endarterectomy. Early diagnosis has however been demonstrated to be challenging. Poor awareness of the disease by patients and physicians, high prevalence of the post-PE syndrome (i.e. persistent dyspnoea, functional limitations and/or decreased quality of life following an acute PE diagnosis), lack of clear guideline recommendations as well as inefficient application of diagnostic tests in clinical practice lead to a reported staggering diagnostic delay >1 year. Hence, there is a great need to improve current clinical practice and diagnose CTEPH earlier. In this review, we will focus on the clinical presentation of and risk factors for CTEPH, and provide best practices for PE follow-up programmes from expert centres, based on a clinical case.
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Affiliation(s)
- Fredrikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Univ Brest, Brest, France
| | - Marion Delcroix
- Dept of Respiratory Diseases, University Hospitals and Respiratory Division, Dept of Chronic Diseases, Metabolism and Aging, KU Leuven - University of Leuven, Leuven, Belgium
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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