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Çınar C, Yıldızeli ŞO, Balcan B, Yıldızeli B, Mutlu B, Peker Y. Determinants of Severe Nocturnal Hypoxemia in Adults with Chronic Thromboembolic Pulmonary Hypertension and Sleep-Related Breathing Disorders. J Clin Med 2023; 12:4639. [PMID: 37510754 PMCID: PMC10380264 DOI: 10.3390/jcm12144639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVES We aimed to investigate the occurrence of sleep-related breathing disorders (SRBDs) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and addressed the effect of pulmonary hemodynamics and SRBD indices on the severity of nocturnal hypoxemia (NH). METHODS An overnight polysomnography (PSG) was conducted in patients with CTEPH, who were eligible for pulmonary endarterectomy. Pulmonary hemodynamics (mean pulmonary arterial pressure (mPAP), pulmonary arterial wedge pressure (PAWP), pulmonary vascular resistance (PVR) measured with right heart catheterization (RHC)), PSG variables (apnea-hypopnea index (AHI)), lung function and carbon monoxide diffusion capacity (DLCO) values, as well as demographics and comorbidities were entered into a logistic regression model to address the determinants of severe NH (nocturnal oxyhemoglobin saturation (SpO2) < 90% under >20% of total sleep time (TST)). SRBDs were defined as obstructive sleep apnea (OSA; as an AHI ≥ 15 events/h), central sleep apnea with Cheyne-Stokes respiration (CSA-CSR; CSR pattern ≥ 50% of TST), obesity hypoventilation syndrome (OHS), and isolated sleep-related hypoxemia (ISRH; SpO2 < 88% under >5 min without OSA, CSA, or OHS). RESULTS In all, 50 consecutive patients (34 men and 16 women; mean age 54.0 (SD 15.1) years) were included. The average mPAP was 43.8 (SD 16.8) mmHg. SRBD was observed in 40 (80%) patients, of whom 27 had OSA, 2 CSA-CSR, and 11 ISRH. None had OHS. Severe NH was observed in 31 (62%) patients. Among the variables tested, age (odds ratio (OR) 1.08, 95% confidence interval [CI] 1.01-1.15; p = 0.031), mPAP (OR 1.11 [95% CI 1.02-1.12; p = 0.012]), and AHI (OR 1.17 [95% CI 1.02-1.35; p = 0.031]) were independent determinants of severe NH. CONCLUSIONS Severe NH is highly prevalent in patients with CTEPH. Early screening for SRBDs and intervention with nocturnal supplemental oxygen and/or positive airway pressure as well as pulmonary endarterectomy may reduce adverse outcomes in patients with CTEPH.
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Affiliation(s)
- Caner Çınar
- Department of Pulmonary Medicine, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Şehnaz Olgun Yıldızeli
- Department of Pulmonary Medicine, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Baran Balcan
- Department of Pulmonary Medicine, School of Medicine, Koç University, Istanbul 34450, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Bülent Mutlu
- Department of Cardiology, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Yüksel Peker
- Department of Pulmonary Medicine, School of Medicine, Koç University, Istanbul 34450, Turkey
- Department of Molecular and Clinical Medicine, University of Gothenburg, 405 30 Gothenburg, Sweden
- Department of Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, 221 00 Lund, Sweden
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Johnson ZJ, Lestrud SO, Hauck A. Current understanding of the role of sleep-disordered breathing in pediatric pulmonary hypertension. Progress in Pediatric Cardiology 2022. [DOI: 10.1016/j.ppedcard.2022.101609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sharma S, Stansbury R, Hackett B, Fox H. Sleep apnea and pulmonary hypertension: A riddle waiting to be solved. Pharmacol Ther 2021; 227:107935. [PMID: 34171327 DOI: 10.1016/j.pharmthera.2021.107935] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023]
Abstract
Obstructive sleep apnea (OSA) is an under-recognized yet highly prevalent disease that has major implications to cardiovascular health. Pulmonary hypertension (pH) is less common but none the less a fatal condition. The association of OSA and PH is a known but not well understood phenomenon. Furthermore, the relationship appears to be bi-directional with limited understanding of the mechanism(s) driving the processes. PH in OSA has real time consequences as it has been shown to increase mortality. Limited data suggests that treatment with continuous positive pressure therapy may be beneficial and reduce pulmonary pressure. In this review, we discuss current data on prevalence of PH in OSA and vice versa. We also explore the pathophysiology of this relationship and a proposed mechanism for their connection. Finally, we address the treatment of OSA with CPAP and its impact on pulmonary pressures. Gaps in knowledge and future research potential are illustrated and discoursed.
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Adir Y, Humbert M, Chaouat A. Sleep-related breathing disorders and pulmonary hypertension. Eur Respir J 2020; 57:13993003.02258-2020. [PMID: 32747397 DOI: 10.1183/13993003.02258-2020] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022]
Abstract
Sleep-related breathing disorders (SBDs) include obstructive apnoea, central apnoea and sleep-related hypoventilation. These nocturnal events have the potential to increase pulmonary arterial pressure (PAP) during sleep but also in the waking state. "Pure" obstructive sleep apnoea syndrome (OSAS) is responsible for a small increase in PAP whose clinical impact has not been demonstrated. By contrast, in obesity hypoventilation syndrome (OHS) or overlap syndrome (the association of chronic obstructive pulmonary disease (COPD) with obstructive sleep apnoea (OSA)), nocturnal respiratory events contribute to the development of pulmonary hypertension (PH), which is often severe. In the latter circumstances, treatment of SBDs is essential in order to improve pulmonary haemodynamics.Patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) are at risk of developing SBDs. Obstructive and central apnoea, as well as a worsening of ventilation-perfusion mismatch, can be observed during sleep. There should be a strong suspicion of SBDs in such a patient population; however, the precise indications for sleep studies and the type of recording remain to be specified. The diagnosis of OSAS in patients with PAH or CTEPH should encourage treatment with continuous positive airway pressure (CPAP). The presence of isolated nocturnal hypoxaemia should also prompt the initiation of long-term oxygen therapy. These treatments are likely to avoid worsening of PH; however, it is prudent not to treat central apnoea and Cheyne-Stokes respiration (CSR) with adaptive servo-ventilation in patients with chronic right-heart failure because of a potential risk of serious adverse effects from such treatment.In this review we will consider the current knowledge of the consequences of SBDs on pulmonary haemodynamics in patients with and without chronic respiratory disease (group 3 of the clinical classification of PH) and the effect of treatments of respiratory events during sleep on PH. The prevalence and consequences of SBDs in PAH and CTEPH (groups 1 and 4 of the clinical classification of PH, respectively), as well as therapeutic options, will also be discussed.
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Affiliation(s)
- Yochai Adir
- Pulmonary Division, Lady Davis Carmel Medical Center, Haifa, Israel.,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Marc Humbert
- Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM, UMR_S 999 (Pulmonary Hypertension: Pathophysiology and Novel Therapies), Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Dept of Respiratory and Intensive Care Medicine, and the Pulmonary Hypertension National Referral Centre, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Ari Chaouat
- Dept of Pulmonology and the Multidisciplinary Sleep Disorders Centre, CHRU Nancy, Nancy, France.,INSERM, UMR_S 1116 (Acute and Chronic Cardiovascular Failure), Université de Lorraine, Nancy, France
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Kader MN, Moiz JA, Bhati P, Ali MS, Talwar D. Diagnostic Validity of Cardiopulmonary Exercise Testing for Screening Pulmonary Hypertension in Patients With Chronic Obstructive Pulmonary Disease. J Cardiopulm Rehabil Prev 2020; 40:189-94. [PMID: 31714394 DOI: 10.1097/HCR.0000000000000456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine diagnostic validity of cardiopulmonary exercise testing (CPX) parameters for detecting pulmonary hypertension (PH) in patients with chronic obstructive pulmonary disease (COPD) and to investigate association between CPX parameters and indices of PH. METHODS This cross-sectional study enrolled 48 moderate to very severe COPD patients in whom PH was confirmed by echocardiography. Symptom-limited CPX was performed using an incremental exercise protocol. Relevant CPX parameters were derived and were tested for their diagnostic ability for diagnosing PH. Logistic regression was applied to examine the effect of various clinical covariates on the diagnostic ability of exercise test variables for detecting PH. RESULTS Of the 48 patients, 29 were diagnosed with PH and 19 were negative for PH based on echocardiographic testing. CPX measures including peak oxygen uptake (% predicted (Equation is included in full-text article.)O2peak, (Equation is included in full-text article.)O2peak [mL/min], (Equation is included in full-text article.)O2/kg), oxygen pulse ((Equation is included in full-text article.)O2/HR % predicted, (Equation is included in full-text article.)O2/HR mL/beat), and peak minute ventilation ((Equation is included in full-text article.)Epeak [L/m]) were inversely correlated with mean pulmonary arterial pressure (mPAP). Peak (Equation is included in full-text article.)O2/HR and (Equation is included in full-text article.)O2peak were found to be significant predictors of PH in univariate analysis. (Equation is included in full-text article.)O2peak (%), (Equation is included in full-text article.)O2/HR (mL/beat), and desaturation (%) were identified as independent predictors of PH adjusted for age, forced expiratory volume in 1 sec (%), and forced vital capacity (L). CONCLUSION The present study validates the use of CPX parameters such as (Equation is included in full-text article.)O2peak and (Equation is included in full-text article.)O2/HR as a diagnostic tool for correctly identifying PH in COPD patients. Therefore, CPX may be used as an adjunct to echocardiographic measurement of PH where there is unavailability of equipment and expertise.
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Abstract
Patent foramen ovale has been associated with multiple pulmonary diseases, such as pulmonary hypertension, platypnea-orthodeoxia syndrome, and chronic obstructive pulmonary disease. A connection between patent foramen ovale and chronic pulmonary disease was first described more than 2 decades ago in case reports associating patent foramen ovale with more severe hypoxemia than that expected based on the severity of the primary pulmonary disease. It has been suggested that patients with both chronic pulmonary disease and patent foramen ovale are subject to severe hypoxemia because of the right-to-left shunt. Furthermore, investigators have reported improved systemic oxygenation after patent foramen ovale closure in some patients with chronic pulmonary disease. This review focuses on the association between chronic pulmonary disease and patent foramen ovale and on the dynamics of a right-to-left shunt, and it considers the potential benefit of patent foramen ovale closure in patients who have hypoxemia that is excessive in relation to the degree of their pulmonary disease.
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MESH Headings
- Coronary Circulation
- Disease Progression
- Echocardiography, Doppler, Color
- Echocardiography, Three-Dimensional
- Foramen Ovale, Patent/complications
- Foramen Ovale, Patent/diagnostic imaging
- Foramen Ovale, Patent/physiopathology
- Foramen Ovale, Patent/therapy
- Hemodynamics
- Humans
- Hypoxia/diagnosis
- Hypoxia/etiology
- Hypoxia/physiopathology
- Hypoxia/therapy
- Male
- Middle Aged
- Pulmonary Circulation
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Risk Factors
- Severity of Illness Index
- Treatment Outcome
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Thurnheer R, Ulrich S, Bloch KE. Precapillary Pulmonary Hypertension and Sleep-Disordered Breathing: Is There a Link? Respiration 2016; 93:65-77. [PMID: 27884004 DOI: 10.1159/000452957] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/28/2016] [Indexed: 12/19/2022] Open
Abstract
Among patients with sleep apnea the reported prevalence of precapillary pulmonary hypertension (PH) has varied largely, depending on patient selection, disease definition, and associated conditions, in particular chronic pulmonary disease. However, in the absence of comorbidities, PH seems to be rare in patients with sleep apnea. Conversely, sleep-related breathing disorders have been commonly found in patients with PH and they have been associated with an impaired quality of life. Since sleep-related breathing disorders may affect the pulmonary circulation and vice versa, patients with sleep-related breathing disorders should be evaluated for risk factors, symptoms and clinical signs of PH and right ventricular heart failure and patients with PH should be evaluated for sleep apnea. Therapeutic options for patients with sleep apnea and PH may include supplemental oxygen, drugs and positive pressure ventilation. Both nocturnal oxygen administration and acetazolamide have been shown to improve sleep apnea in patients with PH. In addition, oxygen therapy also improved exercise performance. Further studies are needed to corroborate the efficacy of these and other treatments.
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Affiliation(s)
- Robert Thurnheer
- Department of Internal Medicine, Pulmonary Division and Sleep Disorders Center, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
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Schiza S, Mermigkis C, Margaritopoulos GA, Daniil Z, Harari S, Poletti V, Renzoni EA, Torre O, Visca D, Bouloukaki I, Sourvinos G, Antoniou KM. Idiopathic pulmonary fibrosis and sleep disorders: no longer strangers in the night. Eur Respir Rev 2015; 24:327-39. [PMID: 26028644 PMCID: PMC9487812 DOI: 10.1183/16000617.00009114] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The prevalence of obstructive sleep apnoea (OSA) is continuously increasing in patients with idiopathic pulmonary fibrosis (IPF) and, for the first time, the recent IPF guidelines recognise OSA as an important associated comorbidity that can affect patient's survival. Thus, it becomes conceivable that clinicians should refer patients with newly diagnosed IPF to sleep centres for the diagnosis and treatment of OSA as well as for addressing issues regarding the reduced compliance of patients with continuous positive airway pressure therapy. The discovery of biomarkers common to both disorders may help early diagnosis, institution of the most appropriate treatment and follow-up of patients. Better understanding of epigenetic changes may provide useful information about pathogenesis and, possibly, development of new drugs for a dismal disease like IPF. It is now believed that IPF and sleep disorders can coexist in the same patienthttp://ow.ly/LXPSL
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Adir Y, Ollech JE, Vainshelboim B, Shostak Y, Laor A, Kramer MR. The Effect of Pulmonary Hypertension on Aerobic Exercise Capacity in Lung Transplant Candidates with Advanced Emphysema. Lung 2015; 193:223-9. [DOI: 10.1007/s00408-015-9698-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
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Shaikh ZF, Kelly JL, Shrikrishna D, de Villa M, Mullen MJ, Hopkinson NS, Morrell MJ, Polkey MI. Patent foramen ovale is not associated with hypoxemia in severe chronic obstructive pulmonary disease and does not impair exercise performance. Am J Respir Crit Care Med 2014; 189:540-7. [PMID: 24450410 DOI: 10.1164/rccm.201309-1618oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Patent foramen ovale (PFO) may be disadvantageous in chronic obstructive pulmonary disease (COPD). It is unknown whether right-to-left shunting through PFO increases during exercise impairing exercise performance. OBJECTIVES To determine whether (1) PFO prevalence is greater in hypoxemic versus less hypoxemic patients with COPD, (2) PFO is associated with clinically relevant impairment, and (3) right-to-left shunting increases during exercise and impairs exercise performance. METHODS Patients with COPD and age-matched control subjects underwent contrast transthoracic echocardiography and transcranial Doppler to identify PFO. Patients with COPD with no shunt and patients with large PFO underwent cardiopulmonary exercise tests with contrast transcranial Doppler, esophageal, and gastric balloon catheters. MEASUREMENTS AND MAIN RESULTS PFO prevalence was similar in 50 patients with COPD and 50 healthy control subjects (46% vs. 30%; P = 0.15). Large shunts were more common in patients with COPD (26% vs. 6%; P = 0.01). In an expanded COPD cohort, PFO prevalence was similar in 31 hypoxemic (Pao2 ≤ 7.3 kPa) and 63 less hypoxemic (Pao2 > 8.0 kPa) patients with COPD (39% vs. 52%; P = 0.27). Patients with intrapulmonary shunting had lower Pao2 than both patients with PFO and those with no right-to-left shunt (7.7 vs. 8.6 vs. 9.3 kPa, respectively; P = 0.002). Shunting significantly increased during exercise in patients with COPD with PFO. Endurance time at 60% Vo2max was 574 (178) seconds for patients with PFO and 534 (279) seconds for those without (P = ns). CONCLUSIONS Hypoxemic patients with COPD do not have a higher prevalence of PFO. Patients with COPD with PFO do not perform less well either on a 6-minute walk or submaximal exercise testing despite increased right-to-left shunting during exercise.
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Affiliation(s)
- Zarrin F Shaikh
- 1 Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, and
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Burns RM, Johnson MK, Church AC. How should we best determine the need for inflight oxygen in patients with pulmonary arterial hypertension? Thorax 2013; 68:680. [DOI: 10.1136/thoraxjnl-2013-203344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Baptista R, Serra S, Martins R, Salvador MJ, Castro G, Gomes M, Santos L, Monteiro P, da Silva JAP, Pêgo M. Exercise-Induced Pulmonary Hypertension in Scleroderma Patients: A Common Finding but with Elusive Pathophysiology. Echocardiography 2012; 30:378-84. [DOI: 10.1111/echo.12063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Sara Serra
- Department of Rheumatology; Coimbra University Hospital; Coimbra; Portugal
| | - Rui Martins
- Department of Cardiology; Coimbra University Hospital; Coimbra; Portugal
| | | | - Graça Castro
- Department of Cardiology; Coimbra University Hospital; Coimbra; Portugal
| | - Manuel Gomes
- Department of Internal Medicine; Coimbra University Hospital; Coimbra; Portugal
| | | | | | | | - Mariano Pêgo
- Department of Cardiology; Coimbra University Hospital; Coimbra; Portugal
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Burns RM, Peacock AJ, Johnson MK, Church AC. Hypoxaemia in patients with pulmonary arterial hypertension during simulated air travel. Respir Med 2012; 107:298-304. [PMID: 23127571 DOI: 10.1016/j.rmed.2012.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 10/02/2012] [Accepted: 10/15/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent air travel recommendations suggest patients with precapillary pulmonary hypertension (PCPH) in New York Heart Association (NYHA) functional class 3 and 4 should have in-flight oxygen without the need for pre-flight testing. However it remains unclear as to how best to determine patients fitness to fly. METHODS This study (i) investigates the effect of hypoxic challenge testing (HCT) on the arterial oxygen levels in a cohort of 36 patients with PCPH and (ii) compares the relative frequency with which FC and HCT predict the requirement for in-flight oxygen. RESULTS The degree of arterial hypoxaemia induced by HCT (fall in partial pressure of oxygen in arterial blood (PaO(2)) 2.36 kPa, 95% CI 2.06-2.66 kPa) was similar to the drop observed in other published studies of chronic respiratory diseases. Following current air travel recommendations based on FC, 25 patients of the cohort would require in-flight oxygen whilst 10 subjects failed the HCT. Fourteen subjects had flown post-diagnosis. Of these, nine subjects should have had in-flight oxygen based on FC but were asymptomatic without. Also one who passed the HCT had developed symptoms during the flight whilst three who failed the HCT were asymptomatic flying without in-flight oxygen. CONCLUSIONS Hypoxaemia induced by simulated air travel in patients with PCPH is similar to that seen in published studies of patients with other chronic respiratory diseases. HCT failed to predict correctly who had developed symptoms during an aircraft flight in a significant minority of the study subjects. Similarly guidelines based on functional class result in a major increase in the proportion of patients being advised to use oxygen, many of whom had been asymptomatic on previous flights without it. More work is required to improve prediction of need for in-flight oxygen in patients with PCPH.
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Affiliation(s)
- R M Burns
- Scottish Pulmonary Vascular Unit, Golden Jubilee Hospital, Agamemnon Street, Clydebank, Glasgow G81 4DY, UK
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Abstract
The development of pulmonary hypertension in COPD adversely affects survival and exercise capacity and is associated with an increased risk of severe acute exacerbations. Unfortunately not all patients with COPD who meet criteria for long term oxygen therapy benefit from it. Even in those who benefit from long term oxygen therapy, such therapy may reverse the elevated pulmonary artery pressure but cannot normalize it. Moreover, the recent discovery of the key roles of endothelial dysfunction and inflammation in the pathogenesis of PH provides the rationale for considering specific pulmonary vasodilators that also possess antiproliferative properties and statins.
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Schwaiblmair M, Faul C, von Scheidt W, Berghaus TM. Detection of exercise-induced pulmonary arterial hypertension by cardiopulmonary exercise testing. Clin Cardiol 2012; 35:548-53. [PMID: 22588968 DOI: 10.1002/clc.22009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 04/11/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pulmonary arterial pressure (PAP) response to exercise may provide a tool for the early detection of pulmonary arterial hypertension (PAH). Therefore, an accurate noninvasive method for evaluating exercise-induced PAH (EIPAH) is desirable. HYPOTHESIS We sought to examine if cardiopulmonary exercise testing (CPET) is able to indicate EIPAH. METHODS Fifty-three patients aged 67.1 ± 1.7 years (37 female, 16 male) with borderline PAH (resting mean PAP 21-24 mm Hg) performed CPET and right heart catheterization at rest and during handgrip testing. RESULTS When comparing patients with an exercise-induced mean PAP ≥ mm Hg (group A, n = 24) and subjects with an exercise-induced mean PAP <35 mm Hg (group B, n = 29), group A had a significantly lower mean aerobic capacity (15.2 ± 1.2 vs 19.7 ± 1.2 mL/min/kg; P = 0.02), higher ventilatory equivalents for oxygen at the anaerobic threshold (34.3 ± 1.5 vs 29.9 ± 1.1; P = 0.02), a widening of the mean alveolar-arterial oxygen difference (37.8 ± 3.0 vs 26.8 ± 2.4 mm Hg; P = 0.007), an elevated mean functional dead space ventilation (29.5 ± 2.7 vs 21.2 ± 1.7%; P = 0.008), and a higher mean arterial to end-tidal carbon dioxide gradient at peak exercise (3.7 ± 0.9 vs 0.4 ± 0.8 mm Hg; P = 0.007). CONCLUSIONS EIPAH is characterized by a decreased ventilatory efficiency due to ventilation to perfusion inequalities. CPET may be useful for the identification of EIPAH and serve to diagnose PAH at an early stage.
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Affiliation(s)
- Martin Schwaiblmair
- Department of Internal Medicine I, Klinikum Augsburg, Ludwig-Maximilians-University, Munich, Germany.
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Cuttica MJ, Kalhan R, Shlobin OA, Ahmad S, Gladwin M, Machado RF, Barnett SD, Nathan SD. Categorization and impact of pulmonary hypertension in patients with advanced COPD. Respir Med 2010; 104:1877-82. [PMID: 20547449 DOI: 10.1016/j.rmed.2010.05.009] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Revised: 05/11/2010] [Accepted: 05/13/2010] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The functional significance of pulmonary hypertension (PH) in COPD is unclear. The purpose of the study was to define the prevalence, severity and associated functional impact of PH in patients with severe COPD listed for lung transplant. METHODS A retrospective review of the Organ Procurement and Tissue Network (OPTN) database between 1997 and 2006 for patients with the primary diagnosis of COPD. Baseline demographics, hemodynamics, pulmonary function tests, six minute walk distance test (6MWD) and pre-transplant survival data was analyzed. RESULTS 4930 patients with COPD had evaluable right heart catheterization data (RHC). PH was present in 30.4%, with pulmonary venous hypertension (PVH) accounting for an additional 17.2% of patients. Patients with pulmonary hypertension walked an average of 28 m less than those with normal hemodynamics. Normal hemodynamics group: 261 ± 104 m, PH; 238 ± 106 m (p < 0.01), PVH: 228 ± 104 m (p < 0.05). In a multivariable analysis, the mean pulmonary artery pressure (β = -1.33; p = 0.01) was an independent predictor of a reduced 6MWD, as were forced vital capacity (β = 1.48; p < 0.001) and patient age (β = -1.91; p < 0.001). Both PH (HR 1.23 95%CI [1.01-1.50]) and PVH (HR 1.35 95%CI [1.11-1.65]) were shown to be independent risk factors for mortality on the waiting list, even after adjustment for age sex, race, BMI, lung function, severity of illness and diabetes (PH: HR 1.27; 95%CI [1.04-1.55], PVH: HR 1.40; 95%CI [1.13-1.73]). CONCLUSION PH is common in advanced COPD and is associated with functional impairment and an increased mortality risk. Stratification by RHC determined pulmonary hemodynamics appears important in distinguishing distinct clinical phenotypes.
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Affiliation(s)
- Michael J Cuttica
- Pulmonary Hypertension Program, Division of Pulmonary and Critical Care Medicine, Northwestern University, Suite 1400, Chicago, IL 60611, USA.
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Abstract
The term “cor pulmonale” is still popular but there is presently no consensual definition and it seems more appropriate to define the condition by the presence of pulmonary hypertension (PH) resulting from diseases affecting the structure and/or the function of the lungs: PH results in right ventricular enlargement and may lead with time to right heart failure (RHF). Chronic obstructive pulmonary disease (COPD) is the first cause of cor pulmonale, far before idiopathic pulmonary fibrosis and obesity–hypoventilation syndrome. In chronic respiratory disease (CRD) PH is “pre-capillary,” due to an increase of pulmonary vascular resistance (PVR). The first cause of increased PVR is chronic long-standing alveolar hypoxia which induces pulmonary vascular remodeling. The main characteristic of PH in CRD and particularly in COPD is its mild to moderate degree, resting pulmonary artery mean pressure (PAP) in a stable state of the disease usually ranging between 20 and 35 mmHg. However, PH may worsen during exercise, sleep, and exacerbations of the disease. These acute increases in afterload can favor the development of RHF. A minority (<5%) of COPD patients exhibit severe or “disproportionate” PH (PAP >40 mmHg), the mechanism of which is not well understood. At present long-term oxygen therapy (LTOT) is the logical treatment of PH since alveolar hypoxia is considered to be the major determinant of the elevation of PAP and PVR. LTOT stabilizes or at least attenuates and sometimes reverses the progression of PH, but PAP seldom returns to normal. Vasodilators (prostacyclin, endothelin receptor antagonists, sildenafil, nitric oxide) could be considered in patients with severe PH but controlled studies in this field are presently lacking.
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Abstract
Obstructive sleep apnea (OSA) is associated with repetitive nocturnal arterial oxygen desaturation and hypercapnia, large intrathoracic negative pressure swings, and acute increases in pulmonary artery pressure. Rodents when exposed to brief, intermittent hypoxia for several hours per day to mimic OSA developed pulmonary vascular remodeling and sustained pulmonary hypertension and right ventricular hypertrophy within a few weeks. Until recently, however, it was unclear whether episodic nocturnal hypoxemia associated with OSA was sufficient to cause similar changes in humans. This controversy appears to have been resolved by several recent studies that have shown (a) pulmonary hypertension in 20% to 40% of patients with OSA in the absence of other known cardiopulmonary disorders and (b) reductions in pulmonary artery pressure in patients with OSA after nocturnal continuous positive airway pressure (CPAP) treatment. The pulmonary hypertension associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors including pulmonary arteriolar remodeling and hyperreactivity to hypoxia and left ventricular diastolic dysfunction and left atrial enlargement. Although measurable changes in the structure and function of the right ventricle have been reported in association with OSA, the clinical significance of these changes is uncertain. Right ventricular failure in OSA appears to be uncommon and is more likely if there is coexisting left-sided heart disease or chronic hypoxic respiratory disease.
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Abstract
Although the prevalence of pulmonary hypertension (PH) in individuals with chronic obstructive pulmonary disease (COPD) is not known precisely, approximately 10%–30% of patients with moderate to severe COPD have elevated pulmonary pressures. The vast majority of PH associated with COPD is mild to moderate and severe PH occurs in <5% of patients. When COPD is associated with PH, both mortality and morbidity are increased. There are no clinical or physical examination findings that accurately identify patients with underlying PH. Radiographic imaging findings are specific but not sensitive indicators of PH. Echocardiography is the principle noninvasive diagnostic test but may be technically limited in a significant proportion of patients with COPD. Right heart catheterization is required for accurate measurement of pulmonary pressures. The combined effects of inflammation, endothelial cell dysfunction, and angiogenesis appear to contribute to the development of PH associated with COPD. Systemic vasodilators have not been found to be effective therapy. Selective pulmonary vasodilators including inhaled nitric oxide and phosphodiesterase inhibitors are promising treatments for patients with COPD associated PH but further evaluation of these medications is needed prior to their routine use.
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Affiliation(s)
- Jean Elwing
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, University of Cincinnati Medical School, Cincinnati, OH, USA
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Holverda S, Rietema H, Bogaard HJ, Westerhof N, Postmus PE, Boonstra A, Vonk-Noordegraaf A. Acute effects of sildenafil on exercise pulmonary hemodynamics and capacity in patients with COPD. Pulm Pharmacol Ther 2008; 21:558-64. [PMID: 18342559 DOI: 10.1016/j.pupt.2008.01.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 12/17/2007] [Accepted: 01/22/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND We investigated in chronic obstructive pulmonary disease (COPD) patients whether a single dose of sildenafil can attenuate the exercise-induced increase in pulmonary artery pressure, thereby allowing augmentation of stroke volume (SV), and improving maximal exercise capacity. METHODS Eighteen COPD patients (GOLD II-IV) underwent right heart catheterization at rest and submaximal exercise. Mean pulmonary artery pressure (mPpa) and cardiac output (CO) were assessed. Resting and exercise measurements were repeated 60 min after oral intake of 50mg sildenafil. Also, on different days, patients performed two maximal exercise tests (CPET) randomly, 1h after placebo and after 50mg sildenafil. RESULTS Five COPD patients had pulmonary hypertension (PH) at rest (mPpa >25 mmHg) and six developed PH during exercise (mPpa >30 mmHg). In all patients, mPpa increased from rest to submaximal exercise (23+/-10-35+/-14 mmHg). After sildenafil mPpa at rest was 20+/-10 mmHg, in exercise mPpa was increased less to 30+/-14 mmHg (p<0.01). The reduced augmentation in mPpa was not accompanied by an increased SV and CO. In COPD patients with PH the percentage increase in mPpa to submaximal exercise was 68% before, and 51% after oral intake of sildenafil (p=0.07). In COPD without PH, these values were 46% and 41% (ns), respectively. Maximal exercise capacity and CPET characteristics were unchanged after sildenafil. CONCLUSION Regardless of mPpa at rest, sildenafil attenuates the increase in mPpa during submaximal exercise in COPD. This attenuated increase is neither accompanied by enhanced SV and CO, nor by improved maximal exercise capacity.
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Affiliation(s)
- Sebastiaan Holverda
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands
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22
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Holverda S, Bogaard HJ, Groepenhoff H, Postmus PE, Boonstra A, Vonk-Noordegraaf A. Cardiopulmonary Exercise Test Characteristics in Patients with Chronic Obstructive Pulmonary Disease and Associated Pulmonary Hypertension. Respiration 2008; 76:160-7. [DOI: 10.1159/000110207] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 08/16/2007] [Indexed: 11/19/2022] Open
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Shujaat A, Minkin R, Eden E. Pulmonary hypertension and chronic cor pulmonale in COPD. Int J Chron Obstruct Pulmon Dis 2007; 2:273-82. [PMID: 18229565 PMCID: PMC2695205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hypoxia and endothelial dysfunction play a central role in the development of pulmonary hypertension. Cor pulmonale is a maladaptive response to pulmonary hypertension. The presence of peripheral edema in cor pulmonale is almost invariably associated with hypercapnia. Correction of abnormalities of gas exchange and ventilation can ameliorate pulmonary hypertension and improve survival. This review focuses on new information about the pathogenesis and treatment of pulmonary hypertension in COPD including information derived from lung volume reduction surgery, the role of brain natriuretic peptide, exhaled nitric oxide for diagnosis, and the treatment of cor pulmonale with recently available specific pulmonary vasodilators.
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Affiliation(s)
| | | | - Edward Eden
- Correspondence: Edward Eden Chief, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, St. Luke’s and Roosevelt Hospitals, Columbia University, New York, NY, USA, Tel +1 212 523 7341, Fax +1 212 523 8426, Email
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Mereles D, Ewert R, Lodziewski S, Borst MM, Benz A, Olschewski H, Grünig E. Effect of Inhaled Iloprost during Off-Medication Time in Patients with Pulmonary Arterial Hypertension. Respiration 2007; 74:498-502. [PMID: 17449958 DOI: 10.1159/000101953] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 01/17/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Iloprost is a stable prostacyclin analogue that is associated with a longer duration of vasodilatation and has been approved for inhalative use with 6 or 9 inhalations during the daytime and a night pause. It is not known if during the night pause rebound pulmonary hypertension occurs. The aim of this study was to assess the hemodynamics in iloprost-treated patients during the daytime and at night. METHODS We enrolled 5 adult patients (aged 45 +/- 10 years) with idiopathic pulmonary arterial hypertension (IPAH) and chronic inhaled iloprost therapy for at least 12 months. Further medication remained unchanged during the study period. Hemodynamics were monitored by right heart catheterization. RESULTS After 30-60 min of nebulized iloprost, mean pulmonary arterial pressures (PAP) decreased from 68 +/- 15 to 51 +/- 18 mm Hg (p = 0.004). After 6 h off-medication sleeping time, mean PAP initially increased until 2 a.m. and decreased subsequently until wake-up time at 6 a.m. Mean PAP, cardiac index and pulmonary vascular resistance at night were not significantly different from the values during the day. CONCLUSIONS In this study, patients with IPAH and chronic nebulized iloprost therapy did not reveal a rebound pulmonary hypertension during off-medication sleeping time.
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Affiliation(s)
- Derliz Mereles
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany.
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Abstract
Chronic Obstructive Pulmonary Disease (COPD) is an inflammatory disease, primarily caused by cigarette smoke, which will soon become the third leading cause of death globally. Despite the importance of the problem, our real understanding of the biological underpinnings of COPD remains incomplete. Consequently, our first-line therapies, while helpful, are not yet as effective as they need to be. In this review, we will focus on these challenges and more, including the role of impaired tissue repair and adaptive immunity in disease pathogenesis, determining who may be at risk, describing COPD phenotypes and potential biomarkers. New ideas for chronic disease management and prevention of exacerbations will also be discussed. While much remains to be accomplished, meeting these challenges will bring rewards because what we learn will have implications for the understanding and treatment of chronic inflammatory diseases beyond COPD.
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Affiliation(s)
- R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Health Sciences Center, 4200 E. Ninth Avenue, C272, Denver, Colorado 80220, USA.
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Mortimer HJ, Peacock AJ, Kirk A, Welsh DJ. p38 MAP kinase: essential role in hypoxia-mediated human pulmonary artery fibroblast proliferation. Pulm Pharmacol Ther 2006; 20:718-25. [PMID: 17055760 DOI: 10.1016/j.pupt.2006.08.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Revised: 08/26/2006] [Accepted: 08/30/2006] [Indexed: 10/24/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a disease that results in thickening of the vascular wall. Some of the most prominent changes are seen in the adventitia as a result of fibroblast proliferation and increased extracellular matrix deposition. Previous work from this laboratory using animal models has shown that pulmonary but not systemic artery fibroblasts proliferate to hypoxic exposure and that this response is dependent on activation of p38 mitogen-activated protein kinase (p38MAPK). In this study, we wished to determine whether human pulmonary artery fibroblasts (HPAFs) behaved similarly under conditions of acute hypoxic exposure (35 mmHg for 24 h). Fibroblast proliferation was assessed by [(3)H]thymidine uptake and protein assays performed using Western blotting techniques. HPAFs proliferated in response to acute hypoxic exposure, human systemic artery fibroblasts did not. This hypoxia-mediated proliferation was p38 MAPK dependent and could be blocked using a specific p38 MAPK inhibitor. Hypoxia-inducible factor-1 (HIF-1) expression was increased in hypoxic pulmonary but not systemic cells and could be partially abrogated with the p38 inhibitor. This work in man confirmed our previous findings in animals that significant differences exist between the pulmonary and systemic circulations in response to hypoxic exposure. This study highlights the importance of p38 MAPK and HIF-1 in hypoxia-mediated proliferation of pulmonary artery adventitial fibroblasts.
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Affiliation(s)
- Heather J Mortimer
- Scottish Pulmonary Vascular Unit, Level 8, Western Infirmary, Glasgow, G11 6NT, Scotland, UK
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Alkotob ML, Soltani P, Sheatt MA, Katsetos MC, Rothfield N, Hager WD, Foley RJ, Silverman DI. Reduced Exercise Capacity and Stress-Induced Pulmonary Hypertension in Patients With Scleroderma. Chest 2006; 130:176-81. [PMID: 16840399 DOI: 10.1378/chest.130.1.176] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES We sought to determine the incidence of stress-induced pulmonary artery (PA) systolic hypertension in a referral population of patients with scleroderma, and to examine the relation between stress-induced pulmonary systolic hypertension and exercise capacity in this population. BACKGROUND Early detection of patients with scleroderma at risk for pulmonary hypertension (PHTN) could lead to more timely intervention and thus reduce morbidity and improve mortality. The change in PA systolic pressure (PASP) with exercise provides a possible tool for such detection. METHODS Sixty-five patients with scleroderma (9 men and 56 women; mean age 51 +/- 12 years [SD]), normal resting PASP, and normal resting left ventricular function underwent exercise Doppler echocardiography using a standard Bruce protocol. Tricuspid regurgitation velocity was measured before and after exercise. Exercise variables including workload achieved in metabolic equivalents (METS), total exercise time, percentage of target heart rate achieved, and PASP at rest and within 60 s after exercise were recorded. RESULTS Thirty patients (46%) demonstrated an increase in PASP to > 35 mm Hg plus an estimated right atrial pressure of 5 mm Hg. Postexercise PASP inversely correlated to both the maximum workload achieved (r = - 0.34, p = 0.006) and exercise time (r = - 0.31, p = 0.01). In women, the correlation was more significant (r = - 0.38, p = 0.003). Patients in the lowest quartile of exercise time, with the least cardiac workload achieved, produced the highest postexercise PASP. CONCLUSION Stress-induced PHTN is common in patients with scleroderma, even when resting PASP is normal. Stress Doppler echocardiography identifies scleroderma patients with an abnormal rise in PASP during exertion. Peak PASP is linearly related to exercise time and maximum workload achieved. Measurement of PASP during exercise may prove to be a useful tool for the identification of future resting PHTN.
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Affiliation(s)
- M Luay Alkotob
- Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, USA
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Vonk-Noordegraaf A, Marcus JT, Holverda S, Roseboom B, Postmus PE. Early changes of cardiac structure and function in COPD patients with mild hypoxemia. Chest 2005; 127:1898-903. [PMID: 15947300 DOI: 10.1378/chest.127.6.1898] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND COPD is often associated with changes of the structure and the function of the heart. Although functional abnormalities of the right ventricle (RV) have been well described in COPD patients with severe hypoxemia, little is known about these changes in patients with normoxia and mild hypoxemia. STUDY OBJECTIVES To assess the structural and functional cardiac changes in COPD patients with normal Pa(O2) and without signs of RV failure. METHODS In 25 clinically stable COPD patients (FEV1, 1.23 +/- 0.51 L/s; Pa(O2), 82 +/- 10 mm Hg [mean +/- SD]) and 26 age-matched control subjects, the RV and left ventricular (LV) structure and function were measured by MRI. Pulmonary artery pressure (PAP) was estimated from right pulmonary artery distensibility. RESULTS RV mass divided by RV end-diastolic volume as a measure of RV adaptation was 0.72 +/- 0.18 g/mL in the COPD group and 0.41 +/- 0.09 g/mL in the control group (p < 0.01). LV and RV ejection fractions were 62 +/- 14% and 53 +/- 12% in the COPD patients, and 68 +/- 11% and 53 +/- 7% in the control subjects, respectively. PAP estimated from right pulmonary artery distensibility was not elevated in the COPD group. CONCLUSION From these results, we conclude that concentric RV hypertrophy is the earliest sign of RV pressure overload in patients with COPD. This structural adaptation of the heart does not alter RV and LV systolic function.
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Affiliation(s)
- Anton Vonk-Noordegraaf
- Department of Pulmonary Medicine, Institute for Cardiovascular Research, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB Amsterdam, Netherlands.
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Duchna HW, Grote L, Andreas S, Schulz R, Wessendorf TE, Becker HF, Clarenbach P, Fietze I, Hein H, Koehler U, Nachtmann A, Randerath W, Rasche K, Ruhle KH, Sanner B, Schafer H, Staats R, Topfer V. Sleep-Disordered Breathing and Cardio- and Cerebrovascular Diseases: 2003 Update of Clinical Significance and Future Perspectives. Schlafbezogene Atmungsstorungen und kardio- und zerebrovaskulare Erkrankungen: Update 2003 der klinischen Bedeutung und zukunftiger Entwicklungen. Somnologie 2003. [DOI: 10.1046/j.1439-054x.2003.03207.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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