Reduced exercise capacity is associated with left ventricular systolic dysfunction in long-term survivors of allogeneic hematopoietic stem-cell transplantation

PURPOSE

Exercise intolerance is a common complication in survivors of allogeneic hematopoietic stem-cell transplantation (allo-HSCT). The aim of this study was to determine if cardiac function measured with echocardiography is associated with exercise capacity measured with cardio-pulmonary exercise tests in long-term survivors treated in their youth with allo-HSCT.

METHODS

The study included 96 patients, of which 54.2% were female, aged 34.9 ± 11.6 years and 17.7 ± 9.3 years after allo-HSCT. Reduced exercise capacity was defined as <85% of predicted-peak oxygen uptake (VO_2peak ). Linear regression was used in the prediction of VO_2peak (ml/kg/min). Receiver operating characteristic evaluated the accuracy of predicting reduced exercise capacity.

RESULTS

VO_2peak was 36.2 ± 7.7 ml/kg/min and 43 (44.8%) had reduced exercise capacity. Left ventricular ejection fraction was 55.4 ± 5.9% and global longitudinal strain (GLS) was -17.6% ± 2.0%. Left and right ventricular functions were significantly lower in survivors with reduced exercise capacity. Increased body mass index, lower physical activity score, reduced pulmonary function (by forced expiratory volume in 1-s) and reduced left ventricular systolic function (by GLS) were significant independent predictors for reduced VO_2peak . GLS was superior to other echocardiographical indices for identifying reduced exercise capacity (area under curve = 0.64, p = 0.014).

CONCLUSIONS

Left ventricular systolic dysfunction measured by GLS is associated with reduced exercise capacity in long-term allo-HSCT survivors.

Impact of Exercise-Induced Pulmonary Hypertension on Right Ventricular Function and on Worsening of Cardiovascular Risk in HIV Patients

Background and Aim: Exercise-induced pulmonary hypertension (ExPH) predicts clinical outcomes, such as all-cause mortality and cardiovascular (CV) hospitalizations, in patients with dyspnea on effort. We investigated its prognostic significance in human immunodeficiency virus (HIV)-affected patients. Methods: In 52 consecutive HIV patients with either low (n = 47) or intermediate probability (n = 5) of PH at rest, we evaluated—at time 0 and after 2 years—the prognostic determinants of CV risk, according to the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) Guidelines. Patients were classified with or without ExPH at stress echocardiography (ESE) and cardiopulmonary exercise test (CPET). We then related ExPH at time 0 with clinical worsening (CV risk score increase >20% after 2 years). Results: Right ventricle (RV) systolic function was significantly reduced in patients with ExPH compared to those without ExPH at CPET. This also occurred in patients with intermediate/high probability compared to those with low probability of ExPH at ESE. The former exhibited worse values of TAPSE and FAC (p < 0.001 and p = 0.01, respectively). A significantly higher proportion of patients with ExPH (CPET) or with intermediate/high probability of ExPH (ESE) had higher sPAP (p < 0.001), mPAP (p = 0.004) and higher TRV (p = 0.006), as well as higher right atrial area (p < 0.001) and indexed right atrial volume (p = 0.004). Total pulmonary vascular resistance (expressed by the ratio between TRV and the velocity-time integral at the level of the right ventricular outflow tract) was higher both in patients with ExPH and in those with intermediate/high probability of ExPH (p < 0.001). Patients with intermediate/high probability of ExPH at ESE showed a trend (p = 0.137) towards clinical worsening compared to those with low probability of ExPH. No patients with low probability of ExPH had a >20% increased CV risk score after 2 years. We found an association between higher NT-proBNP and the presence or intermediate/high probability of ExPH after 2 years (p = 0.048 at CPET, p = 0.033 at ESE). Conclusions: The assessment of ExPH may predict a trend of increasing CV risk score over time. If confirmed at a longer follow-up, ExPH could contribute to better risk stratification in HIV patients.

Diagnostic tests and subtypes of dysfunctional breathing in children with unexplained exertional dyspnea

BACKGROUND

Inappropriate hyperventilation during exercise may be a specific subtype of dysfunctional breathing (DB).

OBJECTIVE

To assess whether Nijmegen questionnaire and hyperventilation provocation test (HVPT) are able to differentiate inappropriate hyperventilation from other DB subtypes in children with unexplained exertional dyspnea, and normal spirometry and echocardiography.

METHODS

The results were compared between a subgroup of 25 children with inappropriate hyperventilation (increased V'E/V'CO₂ slope during a cardiopulmonary exercise test (CPET)) and an age and sex matched subgroup of 25 children with DB without hyperventilation (median age, 13.5 years; 36 girls). Anxiety was evaluated using State-Trait Anxiety Inventory for Children questionnaire.

RESULTS

All children were normocapnic (at rest and peak exercise) and the children with hyperventilation had lower tidal volume/vital capacity on peak exercise (shallow breathing). The Nijmegen score correlated positively with dyspnea during the CPET and the HVPT (p = 0.001 and 0.010, respectively) and with anxiety score (p = 0.022). The proportion of children with a positive Nijmegen score (≥19) did not differ between hyperventilation (13/25) and no hyperventilation (14/25) groups (p = 0.777). Fractional end-tidal CO₂ (FETCO₂ ) at 5-min recovery of the HVPT was < 90% baseline in all children (25/25) of both subgroups. Likewise, there was no significant difference between the two subgroups for other indices of HVPT (FETCO₂ at 3-min recovery and symptoms during the test).

CONCLUSION

The validity of the Nijmegen questionnaire and the HVPT to discriminate specific subtypes of dysfunctional breathing, as well as the relevance of the inappropriate hyperventilation subtype itself may both be questioned.

Isolated Exercise-Induced Pulmonary Hypertension Associates with Higher Cardiovascular Risk in Scleroderma Patients

Background and Aim: Isolated exercise-induced pulmonary hypertension (ExPH) associates with cardiovascular (CV) events in patients with left heart disease. We investigated its prognostic significance in scleroderma patients at risk for pulmonary arterial hypertension (PAH). Methods: In 26 consecutive scleroderma female patients with either low (n = 13) or intermediate probability (n = 13) of pulmonary hypertension (PH) at rest, we evaluated, both at time 0 and 1 year, prognostic determinants of CV risk: onset or progression of heart failure/syncope; worsening of functional class; functional performance at the 6-minute walking test and at cardiopulmonary exercise test; right atrial area; and pericardial effusion. We assigned a severity score 1–3 to each prognostic determinant, derived an overall CV risk score, and its 0–1 year change. Isolated ExPH during the cardiopulmonary exercise test (CPET) was defined as absence of PH at rest, reduced peak VO₂, VE/VCO₂ >30 at anaerobic threshold, reduced O₂ pulse, and ΔVO₂/ΔW <9 mL/min/W. We then correlated ExPH at time 0 with clinical worsening (risk score increase >20% after 1 year). Results: ExPH was strongly associated with clinical worsening compared to patients without ExPH (p = 0.005). In patients without ExPH, none had > 20% increased CV risk score after 1 year. Conversely, about 50% of patients with ExPH had such an increase, suggesting a worsening of prognosis. Conclusions: Isolated ExPH associates with higher cardiovascular risk and thus clinical worsening in scleroderma patients. The assessment of ExPH by CPET can thus contribute to a better risk stratification and the planning of a more adequate follow-up.

Long-term observation of adults after successful repair of aortic coarctation

Introduction

Despite successful repair of aortic coarctation, cardiovascular complications occur.

Aim

To analyse type and frequency of late complications and their impact on exercise capacity in adults after aortic coarctation repair.

Material and methods

Fifty-eight adults after aortic coarctation repair, 36 male, median age 27.46 ±10.57, were compared to 30 healthy volunteers. Physical examination, transthoracic echocardiography, carotid intima-media thickness measurement, cardiopulmonary exercise test and 24-hour ambulatory blood pressure monitoring were performed.

Results

The main complications were: arterial hypertension 48.3%, myocardial hypertrophy in echocardiography 29.34%, recoarctation 25.86%, aortic dilation 13.79% and coronary artery disease 6.89%. Exercise tolerance was reduced in the cardiopulmonary exercise test. The VO₂/kg peak was lower, 29.01 ±8.79 vs. 49.16 ±7.38 ml/kg/min, p < 0.001, VE/VCO₂ peak higher 28.18 ±4.69 vs. 26.78 ±3.13, p = 0.017. The peak heart rate was reduced, 157.28 ±22.22 vs. 177.93 ±23.08 bpm, p < 0.001, peak systolic blood pressure was higher, 174.79 ±17.62 vs. 153.33 ±4.79 mm Hg, p < 0.001. Systolic blood pressure in 24-hour ambulatory monitoring correlated with left ventricle mass index, r = 0.29, p = 0.025, wall thickness, r = 0.31, p = 0.039. Age at operation was related to left ventricle wall thickness, r = 0.27, p = 0.041, and carotid intima-media thickness, r = 0.26, p = 0.046. There was no association of any cardio-pulmonary parameters with time from surgery, type of operation or echocardiography results.

Conclusions

Adults after aortic coarctation repair suffer from arterial hypertension, recurrent aortic stenosis, aortic aneurysms, and coronary artery disease. Reduced exercise capacity in cardio-pulmonary exercise test is related to hypertensive reaction and chronotropic incompetence.

Which field walking test should be used to assess functional exercise capacity in lung cancer? An observational study

BACKGROUND

There is emerging evidence regarding the efficacy of exercise training to improve exercise capacity for individuals with non-small cell lung cancer (NSCLC). Cardiopulmonary exercise testing (CPET) is the gold standard measure of exercise capacity; however this laboratory test has limitations for use in research and clinical practice. Alternative field walking tests are the six-minute walk test (6MWT), incremental-shuttle walk test (ISWT) and endurance-shuttle walk test (ESWT); however there is limited information about their clinimetric properties in NSCLC.

AIMS

In NSCLC to determine the 1) criterion validity of the 6MWT, ISWT and ESWT against CPET; 2) construct validity of the 6MWT, ISWT and ESWT against measures of function, strength, respiratory function and health-related quality of life (HRQoL); and 3) clinical applicability of the tests.

METHODS

Twenty participants (40 % male, mean ± SD age 66.1 ± 6.5 years) with stage I-IIIb NSCLC completed the 6MWT, ISWT, ESWT and CPET within six months of treatment. Testing order was randomised. Additional measures included Eastern Cooperative Oncology Group Performance-Status (ECOG-PS, function), respiratory function, hand-grip dynamometry and HRQoL. Correlations and regression analyses were used to assess relationships.

RESULTS

The ISWT demonstrated criterion validity with a moderate relationship between ISWT distance and CPET peak oxygen consumption (r = 0.61, p = 0.007). Relationships between CPET and six minute walk distance (6MWD) (r = 0.24, p = 0.329) or ESWT time (r = 0.02, p = 0.942) were poor. Moderate construct validity existed for the 6MWD and respiratory function (forced vital capacity % predicted r = 0.53, p = 0.019; forced expiratory volume in the first second % predicted r = 0.55, p = 0.015). There were no relationships between the walking tests and measures of function, strength or HRQoL. The ESWT had a ceiling effect with 18 % reaching maximum time. No floor effects were seen in the tests. The mean ± SD time required to perform the individual 6MWT, ISWT and ESWT was 12.8 ± 2.5, 14.7 ± 3.7 and 16.3 ± 5.0 min respectively; in comparison to CPET which was 51.2 ± 12.7 min. Only one assessor was required to perform all field walking tests and no adverse events occurred.

CONCLUSIONS

The ISWT is a promising measure of functional exercise capacity in lung cancer. Findings need to be confirmed in a larger sample prior to translation into practice.