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Pubblicazioni recenti - cardiopulmonary exercise
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The Influence of Atrial Strain on Functional Capacity in Patients with the Fontan Circulation.
Pediatr Cardiol2020 Aug;():. doi: 10.1007/s00246-020-02435-7.
Rato João, Mendes Susana Cordeiro, Sousa Ana, Lemos Mariana, Martins Duarte Saraiva, Anjos Rui,
Abstract
Speckle-tracking echocardiography has been used to assess atrial function. This analysis is feasible in univentricular hearts. The aim of this study was to characterize the relationship between atrial strain and functional capacity in the Fontan circulation. Apical four-chamber echocardiographic loops of 39 Fontan patients were reviewed. The dominant atrium was assessed for active (?), conduit (?), and reservoir (?) strain and ?/? ratio. Cardiopulmonary exercise test was performed on the same day and oxygen uptake (VO) at ventilatory threshold (VT) and peak VO were chosen as the dependent variables. Statistical analysis was performed using SPSS version 23. Unpaired t test was used for binomial and continuous variable correlation; single and multivariable linear regression were used for continuous variable correlation. Statistical significance was defined as p value < 0.05. VO at VT as a percentage of predicted VO was 36.8% (SD 10.7). Peak VO was 64.7% (SD 18.9) of the predicted value. In univariate analysis, both were associated with age, atrioventricular regurgitation, ejection fraction, ?, ?, and ?/?. In multivariate regression, higher VO at VT and peak VO were associated with younger age (p = 0.003 and p = 0.001, respectively) and higher ? (p = 0.026 and p = 0.020). Evaluation of heart function is difficult in the Fontan circulation, hindered by complex ventricular morphology and lack of normative data. VO provides a good surrogate. Atrial strain parameters are compromised in these patients and associated with VO. Therefore, whenever possible, atrial strain should be measured as it may provide a new method of risk stratification.
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Ventilatory efficiency during ramp exercise in relation to age and sex in a healthy Japanese population.
J Cardiol2020 Aug;():. doi: S0914-5087(20)30249-5.
Ashikaga Kohei, Itoh Haruki, Maeda Tomoko, Itoh Hidetaka, Ichikawa Yuri, Tanaka Shiori, Ajisaka Ryuichi, Koike Akira, Makita Shigeru, Omiya Kazuto, Kato Yuko, Adachi Hitoshi, Nagayama Masatoshi, Tajima Akihiko, Harada Naomi, Akashi Yoshihiro J, ,
Abstract
BACKGROUND:
The current understanding of ventilator efficiency variables during ramp exercise testing in the normal Japanese population is insufficient, and the responses of tidal volume (VT) and minute ventilation (V?E) to the ramp exercise test in the normal Japanese population are not known.
METHODS:
A total of 529 healthy Japanese subjects aged 20-78 years underwent cardiopulmonary exercise testing using a cycle ergometer with ramp protocols. VT and V?E at rest, at anaerobic threshold, and at peak exercise were determined. The slope of V?E versus carbon dioxide (V?CO) (V?E vs. V?CO slope), minimum V?E/V?CO, and oxygen uptake efficiency slope (OUES) were determined.
RESULTS:
For males and females in their 20 s, peak VT (VTpeak) was 2192 ± 376 and 1509 ± 260 mL (p < 0.001), peak V?E (V?Epeak) was 80.6 ± 18.7 and 57.7 ± 13.9 L/min (sex differences p < 0.001), the V?E vs. V?CO slope was 24.4 ± 3.2 and 25.7 ± 3.2 (p = 0.035), the minimum V?E/V?CO was 24.2 ± 2.3 and 27.0 ± 2.8 (p < 0.001), and the OUES was 2452 ± 519 and 1991 ± 315 (p < 0.001), respectively. VTpeak and V?Epeak decreased with age and increased with weight and height. The V?E vs. V?CO slope and minimum V?E/V?CO increased with age, while conversely, the OUES decreased with age.
CONCLUSIONS:
We have established the normal range of VT and V?E responses, the V?E vs. V?CO slope, the minimum V?E/V?CO, and the OUES for a healthy Japanese population. Some of these parameters were influenced by weight, height, sex, and age. These results provide useful reference values for interpreting the results of cardiopulmonary exercise testing in cardiac patients.
Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
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Confounded by obesity and modulated by urinary uric acid excretion, sleep-disordered breathing indirectly relates to hyperuricaemia in males: A structural equation model.
J Sleep Res2020 Aug;():e13108. doi: 10.1111/jsr.13108.
Lai Ching-Hsiang, Huang Ren-Jing, Wong James Kok-Suh, Chang Shen-Wen, Chung Ai-Hui, Chi Yung-Chun, Yu Yi-Chen, Lee Shin-Da, Ting Hua,
Abstract
Sleep-disordered breathing (SDB) causes hypoxic stress and can trigger uric acid (UA) overproduction. We comprehensively investigated whether SDB, interacting with components of metabolic syndrome, hepatic and renal dysfunctions, low physical fitness, sedentary lifestyle, disrupted sleep, and chronic systemic inflammation (CSI), is directly associated with hyperuricaemia. In 528 community-based males (mean [SD] age 46.2 [7.4] years), we cross-sectionally analysed measures of anthropometry; self-reported lifestyle habits; overnight sleep polysomnography data; cardiopulmonary exercise tests; and biomarkers of cardiometabolic, hepatic, and renal functions; and CSI, using structural equation modelling. Objective disrupted sleep, C-reactive protein, low physical fitness, and sedentary lifestyle were not related to UA levels in univariate analysis and were excluded. The latent variables (with corresponding manifest variables) obesity (body mass index, waist-hip ratio), hypertension (post-sleep systolic, diastolic blood pressure), dyslipidaemia (total cholesterol, triglyceride/high-density lipoprotein cholesterol), hepatic dysfunction (alanine aminotransferase, aspartate transaminase), and renal dysfunction (blood urea nitrogen, serum creatinine) were positively; and hyperglycaemia (fasting glucose, glycated haemoglobin) was negatively associated with hyperuricaemia (serum UA), except for SDB (Apnea-Hypopnea Index, percentage of oxygen saturation <90% period against total sleep time, oxygen desaturation index) in the one-stage influence model. In the two-stage model, SDB, closely interacting with obesity, was positively indirectly associated with hyperuricaemia through directly linked renal dysfunction and obesity-linked hypertension, inverse hyperglycaemia, dyslipidaemia, and hepatic dysfunction. In conclusion, structural equation modelling reveals that SDB closely interacts with obesity and is positively but indirectly related to hyperuricaemia in males. This suggests that urinary UA excretion modulates and obesity confounds the SDB-hyperuricaemia relationship.
© 2020 European Sleep Research Society.
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Evaluation of Exertional Ventilatory Parameters Using Oscillometry in COPD.
Int J Chron Obstruct Pulmon Dis2020 ;15():1697-1711. doi: 10.2147/COPD.S260735.
Yamamoto Yuji, Miki Keisuke, Matsuki Takanori, Fukushima Kiyoharu, Oshitani Yohei, Kagawa Hiroyuki, Tsujino Kazuyuki, Yoshimura Kenji, Miki Mari, Kida Hiroshi,
Abstract
Background:
Oscillometry is a tool to measure respiratory impedance that requires minimal patients' effort. In patients with chronic obstructive pulmonary disease (COPD), the correlation of respiratory impedance at rest with exertional ventilatory parameters, including exercise tolerance, has scarcely been reported. In addition, the utility of oscillometric parameters might differ between the inspiratory and expiratory phases due to airflow obstruction during expiration, but the hypothesis had not been validated. The aim of the present study was to investigate whether oscillometric parameters are associated with exertional ventilatory parameters in patients with COPD.
Methods:
Fifty-five subjects with COPD who attended clinics at the National Hospital Organization Osaka Toneyama Medical Center performed spirometry, oscillometry, and cardiopulmonary exercise testing (CPET) within 2 weeks. The correlations between parameters of spirometry, oscillometry, and CPET were analyzed using Spearman's rank correlation coefficient, univariate, and multivariate analyses.
Results:
Respiratory reactance had better correlations with the CPET parameters than respiratory resistance. Moreover, inspiratory reactance at rest correlated with the CPET parameters stronger than expiratory reactance. In particular, inspiratory resonant frequency (Fres-ins) correlated with peak oxygen uptake (r=-0.549, p<0.01) and dead space to tidal volume ratio at peak exercise (r=0.677, p<0.01) and the best predicted expiratory tidal volume (V ex) at peak exercise of all the oscillometric parameters (r=-0.679, p<0.01). However, the correlation between Fres-ins and ex at peak exercise became weak in subjects with severe and very severe COPD during exercise.
Conclusion:
Measurement of respiratory reactance is useful for the effortless evaluation of not only exertional ventilatory parameters but exercise tolerance in patients with COPD. The correlation of respiratory impedance with exertional ventilatory parameters can become weak in patients with advanced COPD; thus, the measurement of oscillometry might not be appropriate for evaluating exertional ventilatory parameters of patients with advanced COPD.
© 2020 Yamamoto et al.
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Adjuvant treatment with 5-FU and oxaliplatin does not influence cardiac function neurovascular control, and physical capacity in patients with colon cancer.
Oncologist2020 Aug;():. doi: 10.1634/theoncologist.2020-0225.
Groehs Raphaela V, Negrao Marcelo V, Hajjar Ludhmila A, Jordão Camila P, Carvalho Bruna P, Toschi-Dias Edgar, Andrade Ana C, Hodas Fabiana P, Alves Maria Jnn, Sarmento Adriana O, Testa Laura, Hoff Paulo M G, Negrão Carlos E, Filho Roberto Kalil,
Abstract
BACKGROUND:
Adjuvant chemotherapy with fluorouracil (5-FU) and oxaliplatin increases recurrence-free and overall survival in patients with colon adenocarcinoma. It is known that these drugs have been associated with cardio- and neurotoxicity. We investigated the effects of 5-FU+/-oxaliplatin on cardiac function, vascular responses, neurovascular control, and physical capacity in patients with colon cancer.
METHODS:
Twenty-nine patients with prior colectomy for stage II-III adenocarcinoma and clinical indication for adjuvant chemotherapy were allocated to receive 5-FU (n=12) or 5-FU+oxaliplatin (n=17), according to the oncologist's decision. All the analyses were performed just before and after the end of chemotherapy. Cardiac function was assessed by echocardiography and speckle-tracking and cardiac autonomic control by heart rate variability (HRV). Vascular endothelial function was assessed by flow-mediated dilation (FMD). Muscle sympathetic nerve activity (MSNA) was directly recorded by microneurography technique and muscle blood flow by venous occlusion plethysmography. Physical capacity was evaluated by cardiopulmonary exercise test.
RESULTS:
Chemotherapy (pooled data) did not significantly change left ventricular ejection fraction (58±1 vs 55±2%, P=0.14), longitudinal strain (-18±1 vs -18±1%, P=0.66) and HRV. Likewise, chemotherapy did not significantly change FMD and muscle blood flow, and MSNA (33±2 vs 32±1 bursts/min, P=0.31). Physical capacity was not significantly change in both groups. Similar findings were observed when the patients were subdivided in 5-FU and 5-FU+oxaliplatin. 5-FU and 5-FU+oxaliplatin did not significantly change cardiac function, HRV, vascular responses, MSNA and physical capacity.
CONCLUSION:
This study provides evidence that adjuvant treatment with 5-FU+/-oxaliplatin is well tolerated and does not promote changes compatible with long-term cardiotoxicity.
IMPLICATIONS FOR PRACTICE:
Adjuvant chemotherapy with fluorouracil (5-FU) and oxaliplatin increases recurrence-free and overall survival in patients with colon adenocarcinoma, however these drugs have been associated with cardio- and neurotoxicity. We investigated the effects of these drugs on cardiac function, vascular responses, neurovascular control, and physical capacity in patients with colon cancer. And we found that 5-FU and oxaliplatin did not significantly change cardiac function, cardiac autonomic control, vascular endothelial function, muscle sympathetic nerve activity and physical capacity. This study provides evidence that adjuvant treatment with 5-FU+/-oxaliplatin is well tolerated and does not promote changes compatible with long-term cardiotoxicity.
© AlphaMed Press 2020.
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Preoperative In-Hospital Rehabilitation Improves Physical Function in Patients with Pancreatic Cancer Scheduled for Surgery.
Tohoku J Exp Med2020 ;251(4):279-285. doi: 10.1620/tjem.251.279.
Mikami Yukio, Kouda Ken, Kawasaki Shinji, Okada Ken-Ichi, Kawai Manabu, Kitahata Yuji, Miyazawa Motoki, Hirono Seiko, Unno Michiaki, Tajima Fumihiro, Yamaue Hiroki,
Abstract
Low preoperative physical function in cancer patients is associated with postoperative complications; however, there have been no reports on the benefits of in-hospital preoperative rehabilitation on preoperative physical function in patients with pancreatic cancer. Therefore, the aim of this study was to quantitatively determine the effects of preoperative in-hospital rehabilitation provided under the supervision of a physiotherapist, on preoperative physical function in patients with pancreatic cancer. The study subjects were 26 patients (15 males, 11 females; age 71.2 ± 8.5 years, range: 51-87 years), including four patients with preoperative chemotherapy, scheduled for surgery for pancreatic cancer. Muscle strengthening exercises and aerobic exercises were conducted 11.9 ± 5.1 days prior to surgery. Cardiopulmonary exercise testing, 6-minute walk distance, and the Functional Independence Measure score were measured before and after the rehabilitation program. We also investigated the relation between the rehabilitation program and incidence of postoperative complications. All 26 study patients completed the preoperative rehabilitation program and no adverse events were noted. Peak oxygen uptake during cardiopulmonary exercise testing and 6-minute walk distance increased significantly after the rehabilitation program. The Functional Independence Measure score remained constant throughout the intervention. No wound infection, delirium, deep vein thrombosis, or respiratory complications were encountered postoperatively. In-hospital preoperative rehabilitation under the supervision of a physiotherapist significantly improved physical function and maintained physical activity in patients with pancreatic cancer. Such improvements may contribute toward preventing serious postoperative complications, resulting in better outcomes.
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Effect of closed loop stimulation versus accelerometer on outcomes with cardiac resynchronization therapy: the CLASS trial.
J Interv Card Electrophysiol2020 Aug;():. doi: 10.1007/s10840-020-00829-4.
Hsu Jonathan C, Darden Douglas, Alegre Maylene, Birgersdotter-Green Ulrika, Feld Gregory K, Hoffmayer Kurt S, Han Frederick, Krummen David, Raissi Farshad, Ho Gordon, Taub Pam R, Urey Marcus A, Adler Eric,
Abstract
PURPOSE:
Chronotropic incompetence (CI) in patients with heart failure is common and associated with impaired exercise intolerance and adverse outcomes. This study sought to determine the effects of closed loop stimulation (CLS) rate-adaptive pacing on functional capacity in patients with heart failure with reduced ejection fraction (HFrEF) and CI implanted with cardiac resynchronization therapy (CRT) devices.
METHODS:
A randomized, blinded, cross-over designed trial enrolled patients with HFrEF and CI implanted with a Biotronik CRT-D to complete a quality of life questionnaire, 6-min walk distance (6MWD), and cardiopulmonary exercise testing after two programmed periods: 1-week period of CLS and 1-week period of standard accelerometer (DDDR).
RESULTS:
Nine patients (6 males, mean age 71.4 years, 7 with New York Heart Association Class III, mean ejection fraction 39?±?8%) were enrolled. Quality of life trended higher in CLS as compared to DDDR (550.8?±?123.9 vs 489.3?±?164.9, p =?0.06). There were no differences between CLS and DDDR in 6MWD (293.1?±?90.2 m vs 315.1?±?95.5 m, p =?0.52), peak heart rate (HR) 110.7?±?14.7 bpm vs 109.7 bpm?±?14.1, p =?0.67), or peak VO2 (12.3?±?4.9 ml/kg/min vs 12.9?±?5.9, p =?0.47). As tests were submaximal as indicated by low respiratory exchange ratios (0.98?±?0.11 vs 1.0?±?0.8, p =?0.35), VE/VCO slope also showed no difference between CLS and DDDR (35.8?±?5.6 vs 35.4?±?5.7, p =?0.65). Five patients (56%) preferred CLS programming (p =?1.0).
CONCLUSIONS:
In patients with HFrEF and CI implanted with a CRT-D, peak HR, peak VO2, and 6MWD were equivalent, while there was a trend toward improved quality of life in CLS as compared to DDDR.
CLINICAL TRIAL REGISTRATION:
URL: https://www.clinicaltrials.gov . Unique identifier: NCT02693262.
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Effects of Yangxinshi tablet on exercise tolerance in patients with coronary heart disease: A protocol of randomized, double-blind, placebo-controlled, and multi-center trial.
Medicine (Baltimore)2020 Jul;99(31):e21485. doi: 10.1097/MD.0000000000021485.
Zhang Sisi, Liang Congying, Yang Yang, Zhao Zhijia, Li Jiaojiao, Meng Xiaoping,
Abstract
BACKGROUND:
Exercise intolerance is very common in patients with coronary heart disease (CHD). Although some researches confirming the validation of traditional Chinese medicine (TCM) on CHD treatment, the effect of TCM on improving the exercise tolerance of patients with CHD remains unclear so far. Our trial is to investigate whether the Yangxinshi (YXS) tablet can improve exercise tolerance as well as the quality of life among CHD patients.
METHODS:
It is a randomized, double-blind, placebo-controlled, multi-center trial. A total of 90 patients with CHD from 3 hospitals in China will be enrolled and randomly assigned to one of 2 groups: YXS group, N?=?45; placebo group, N?=?45. The 2 groups will simultaneously receive standardized western medicine and exercise-based cardiac rehabilitation program for 12 weeks. The primary outcome measure is the exercise capacity, which will be evaluated by the cardiopulmonary exercise test and 6-minute walking test. The 2nd outcomes include symptom improvement, psychologic issues, laboratory tests, side effects, and adverse events.
DISCUSSION:
To our knowledge, it is the 1st randomized controlled trial to evaluate the effect of TCM YXS tablet on exercise tolerance in patients with CHD. The results will provide more evidence for future studies in this area.
TRIAL REGISTRATION:
This study protocol was registered in Research Registry (researchregistry5752).
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Cardiopulmonary Exercise Testing in Patients With Interstitial Lung Disease.
Front Physiol2020 ;11():832. doi: 10.3389/fphys.2020.00832.
Molgat-Seon Yannick, Schaeffer Michele R, Ryerson Christopher J, Guenette Jordan A,
Abstract
Interstitial lung disease (ILD) is a heterogeneous group of conditions characterized by fibrosis and/or inflammation of the lung parenchyma. The pathogenesis of ILD consistently results in exertional dyspnea and exercise intolerance. Cardiopulmonary exercise testing (CPET) provides important information concerning the pathophysiology of ILD that can help inform patient management. Despite the purported benefits of CPET, its clinical utility in ILD is not well defined; however, there is a growing body of evidence that provides insight into the potential value of CPET in ILD. Characteristic responses to CPET in patients with ILD include exercise-induced arterial hypoxemia, an exaggerated ventilatory response, a rapid and shallow breathing pattern, critically low inspiratory reserve volume, and elevated sensations of dyspnea and leg discomfort. CPET is used in ILD to determine cause(s) of symptoms such as exertional dyspnea, evaluate functional capacity, inform exercise prescription, and determine the effects of pharmacological and non-pharmacological interventions on exercise capacity and exertional symptoms. However, preliminary evidence suggests that CPET in ILD may also provide valuable prognostic information and can be used to ascertain the degree of exercise-induced pulmonary hypertension. Despite these recent advances, additional research is required to confirm the utility of CPET in patients with ILD. This brief review outlines the clinical utility of CPET in patients with ILD. Typical patterns of response are described and practical issues concerning CPET interpretation in ILD are addressed. Additionally, important unanswered questions relating to the clinical utility of CPET in the assessment, prognostication, and management of patients with ILD are identified.
Copyright © 2020 Molgat-Seon, Schaeffer, Ryerson and Guenette.
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Pulmonary Vascular Pressures and Gas Exchange Response to Exercise in Heart Failure with Preserved Ejection Fraction.
J Card Fail2020 Aug;():. doi: S1071-9164(20)30891-5.
Fermoyle Caitlin C, Stewart Glenn M, Borlaug Barry A, Johnson Bruce D,
Abstract
Elevated left ventricular filling pressure (measured as mean pulmonary capillary wedge pressure, PCWPm) at rest or with exercise is diagnostic of heart failure with preserved ejection fraction (HFpEF). However, the capacity of the right ventricle to compensate for a high PCWPm and thus maintain an appropriate transpulmonary gradient (TPG) and perfusion of the pulmonary capillaries is likely an important contributor to gas exchange efficiency and exercise capacity. Therefore, this study aimed to determine whether a higher TPG at peak exercise is associated with superior exercise capacity and gas exchange. Gas exchange data from dyspneic patients referred for exercise right heart catheterization were retrospectively analyzed and patients were split into two groups based on TPG. Patients with a higher TPG at peak exercise had a higher peak VO (1025±227 vs.823±276, p=0.038), end-tidal partial pressure of CO (PETCO; 42.2±7.9 vs. 38.0±4.7, p=0.044), and gas exchange estimates of pulmonary vascular capacitance (GX; 408±90 vs. 268±108, p=0.001). A higher TPG at peak exercise correlated with a higher peak VO, O pulse, and stroke volume (R=0.42, 0.44 and 0.42, respectively, all p<0.05). These findings indicate that a greater TPG with exercise might be important for improving exercise capacity in HFpEF.
Copyright © 2020. Published by Elsevier Inc.
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Cardiopulmonary exercise testing - refining the clinical perspective by combining assessments.
Expert Rev Cardiovasc Ther2020 Aug;():. doi: 10.1080/14779072.2020.1806057.
Arena Ross, Canada Justin M, Popovic Dejana, Trankle Cory R, Del Buono Marco, Lucas Alexander, Abbate Antonio,
Abstract
INTRODUCTION:
Cardiorespiratory fitness (CRF) is now established as a vital sign. Cardiopulmonary exercise testing (CPX) is the gold-standard approach to assessing CRF.
AREAS COVERED:
A body of literature spanning several decades clearly supports the clinical utility of CPX in those who are apparently health and at risk for chronic disease as well as numerous patient populations. While CPX, in and of itself, is a valid and reliable clinical assessment, combining findings with other available assessments may provide a more comprehensive perspective that enhances clinical decision making and outcomes. The current review will accomplish the following: 1) Define key CPX measures based upon current evidence; and 2) Describe the current evidence addressing the relationships between CPX and echocardiography, serum biomarkers and cardiovascular magnetic resonance.
EXPERT OPINION:
Cardiopulmonary exercise testing provides prognostic and diagnostic information in apparently healthy individuals, those at risk for one or more chronic conditions, as well as numerous patient populations. Moreover, if the goal of an intervention is to improve one or more systems integral to the physiologic response to exercise, CPX should be considered as a central assessment to gauge therapeutic efficacy. To further refine the information obtained from CPX, combining other assessments have demonstrated promise.
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[Pectus excavatum: not just a cosmetic problem].
Ned Tijdschr Geneeskd2020 May;164():. doi: D4509.
de Loos E R, Höppener P F, Busari J O, Lenderink T, Hulsewé K W E, Vissers Y L J,
Abstract
Pectus excavatum is the most common deformity of the anterior chest wall. Nevertheless, awareness amongst physicians is lacking and consequences of the diagnosis are often underestimated. Symptoms include cardiopulmonary symptoms such as palpitations, fatigue and exercise intolerance. Moreover, patients often have psychosocial problems and suffer from poor body image and lower quality of life. A multidisciplinary approach is recommended for diagnostic work-up and treatment, involving dedicated paediatricians, cardiologists and surgeons. Treatment can be non-surgical or surgical. Conservative options include physiotherapy and vacuum bell therapy. In symptomatic patients, surgical treatment is warranted from the age of 12-14 years. Minimally invasive repair with the Nuss bar technique is considered the gold standard for adolescents. Patients who are unsuitable for minimally invasive repair can be treated with open surgical correction, for example, via a modified Ravitch procedure. Early referral to a specialised centre is recommended.
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Physiological performance and inflammatory markers as indicators of complications after oesophageal cancer surgery.
BJS Open2020 Aug;():. doi: 10.1002/bjs5.50328.
Powell A G M T, Eley C, Abdelrahman T, Coxon A H, Chin C, Appadurai I, Davies R, Bailey D M, Lewis W G,
Abstract
BACKGROUND:
The extent to which physiological factors influence outcome following oesophageal cancer surgery is poorly understood. This study aimed to evaluate the extent to which cardiorespiratory fitness and selected metabolic factors predicted complications after surgery for carcinoma.
METHODS:
Two hundred and twenty-five consecutive patients underwent preoperative cardiopulmonary exercise testing to determine peak oxygen uptake ( o ), anaerobic threshold and the ventilatory equivalent for carbon dioxide ( e/ co ). Cephalic venous blood was assayed for serum C-reactive protein (CRP) and albumin levels, and a full blood count was done. The primary outcome measure was the Morbidity Severity Score (MSS).
RESULTS:
One hundred and ninety-eight patients had anatomical resection. A high MSS (Clavien-Dindo grade III or above) was found in 48 patients (24·2 per cent) and was related to an increased CRP concentration (area under the receiver operating characteristic (ROC) curve (AUC) 0·62, P = 0·001) and lower o (AUC 0·36, P = 0·003). Dichotomization of CRP levels (above 10?mg/l) and o (below 18·6?ml per kg per min) yielded adjusted odds ratios (ORs) for a high MSS of 2·86 (P = 0·025) and 2·92 (P = 0·002) respectively. Compared with a cohort with a low Combined Inflammatory and Physiology Score (CIPS), the OR was 1·70 (95 per cent c.i. 0·85 to 3·39) for intermediate and 27·47 (3·12 to 241·69) for high CIPS (P?
CONCLUSION:
CRP and o were independently associated with major complications after potentially curative oesophagectomy for cancer. A composite risk score identified a group of patients with a high risk of developing complications.
© 2020 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of British Journal of Surgery Society.
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Physical effort of middle-aged women in a university hospital - Field tests in comparison to standardized cardiopulmonary exercise testing (CPET).
Arch Environ Occup Health2020 Aug;():1-10. doi: 10.1080/19338244.2020.1799181.
Schneider Joachim, Brückner Ulrike, Laux Sandra, Schneider-Lauteren Stephanie,
Abstract
Physical effort of workload of female employees in the healthcare system is perceived to rise. Research focused mainly on physical activity levels of registered nurses (RN). Therefore, we investigated physical strain during daily routine of other hospital workers next to RN. Ouptake, heart rate, breathing frequency and ventilation were measured in 33 female medical (associate) professionals (MAP) and Cleaners&Helpers (Cl&H) using Oxycon Mobile. Physical work load was compared to standardized CPET. Wilcoxon-test and ANOVA were calculated using SPSS 20.0. Cl&H performed heavy-lifting and had the lowest power during CPET. The O-uptake for heavy-lifting as strong effort, differed significantly from office work (?
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Ventilatory and chronotropic incompetence during incremental and constant load exercise in end-stage renal disease: a comparative physiology study.
Am J Physiol Renal Physiol2020 Aug;():. doi: 10.1152/ajprenal.00258.2020.
McGuire Scott, Horton Elizabeth Jane, Renshaw Derek, Chan Klaris, Krishnan Nithya, McGregor Gordon,
Abstract
BACKGROUND:
Aerobic capacity is impaired in end-stage renal disease (ESRD), reducing quality of life and longevity. Whilst determinants of maximal exercise intolerance are well defined, little is known of limitation during submaximal exercise. By comparing ESRD and healthy controls, the aim of this study was to characterise mechanisms of exercise intolerance in ESRD by assessing cardiopulmonary physiology at rest and during exercise.
METHODS:
Resting spirometry and echocardiography were performed in 20 ESRD participants and 20 healthy age and gender matched controls. Exercise tolerance was assessed with ventilatory gas exchange and central hemodynamics during a maximal cardiopulmonary exercise test (CPEX) and 30 minutes of submaximal constant load exercise (CLEX).
RESULTS:
Left ventricular mass (292 ± 102 vs. 185 ± 83 g; p = 0.01) and filling pressure (E/e': 6.48 ± 3.57 vs. 12.09 ± 6.50 m/s; p = 0.02) were higher in ESRD; forced vital capacity (3.44 ± 1 vs. 4.29 ± 0.95 L/min; p = 0.03) and peak VO (13.3 ± 2.7 vs. 24.6 ± 7.3 ml.kg.min; p < 0.001) were lower. During CLEX, the relative increase in (a-v) O difference (13 ± 18 vs. 74 ± 18%) and heart rate (32 ± 18 vs. 75 ± 29%) were less in ESRD despite exercise being performed at a higher percentage of maximum VE (48 ± 3 vs 39 ± 3%) and HR (82 ± 2 vs. 64 ± 2%).
CONCLUSION:
Ventilatory and chronotropic incompetence contribute to exercise intolerance in ESRD. Both are potential targets for medical and lifestyle interventions.
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Sacubitril/valsartan use in a real-world population of patients with heart failure and reduced ejection fraction.
J Cardiovasc Med (Hagerstown)2020 Jul;():. doi: 10.2459/JCM.0000000000001018.
Mapelli Massimo, Salvioni Elisabetta, de Martino Fabiana, Mattavelli Irene, Bonomi Alice, Sassi Valentina, Gugliandolo Paola, Vignati Carlo, Magini Alessandra, Rovai Sara, Paolillo Stefania, Agostoni Piergiuseppe,
Abstract
AIMS:
Practice guidelines recommend sacubitril/valsartan for heart failure with reduced ejection fraction. The aim of our study was to describe the use of sacubitril/valsartan in real-world clinical practice to help identify patients best able to tolerate titration to higher doses.
METHODS:
We retrospectively analyzed clinical data for 201 patients with heart failure with reduced ejection fraction prescribed sacubitril/valsartan at our heart failure clinic (Centro Cardiologico Monzino) between September 2016/December 2018. Patients had a mean age of 67.2 years, mean left ventricular ejection fraction of 30.1%, New York Heart Association class II (65%), class III (35%), and poor cardiopulmonary exercise capacity. Median 2-year risk of death/urgent cardiac transplantation was 8.9% [Metabolic Exercise Cardiac Kidney Index (MECKI) score].
RESULTS:
After a median follow-up of 230 (interquartile interval: 105-366) days, 57 patients achieved higher-dose sacubitril/valsartan, 103 tolerated medium/low doses, nine died, and 20 interrupted treatment. The highest dose of sacubitril/valsartan was reached by younger patients with better hemoglobin (Hb) levels, renal function, and blood pressure (BP). Patients continuing on sacubitril/valsartan had significantly higher serum Hb and sodium, better BP, and lower MECKI scores than patients who discontinued treatment or died during follow-up. Our patients were older and frailer than those in the pivotal PARADIGM-HF trial.
CONCLUSION:
In our experience, more than one-third of the patients were able to tolerate the higher dose of sacubitril/valsartan, and these patients were younger, had higher Hb, and better BP and renal function. MECKI score stratification was useful to discriminate patients who continued treatment from those who did not. Future prospective studies should test if these clinical variables can guide the up-titration of sacubitril/valsartan.
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Association Between Neurohormone Levels and Exercise Testing Measures in Patients with Mechanical Circulatory Supports.
ASAIO J2020 Aug;66(8):875-880. doi: 10.1097/MAT.0000000000001082.
Grosman-Rimon Liza, Kachel Erez, McDonald Michael A, Lalonde Spencer D, Yip Paul, Ribeiro Roberto V P, Adamson Mitchell B, Cherney David Z, Rao Vivek,
Abstract
Continuous-flow left ventricular assist device (CF-LVAD) recipients exhibit impaired exercise capacity. Long-term continuous blood flow also elevates norepinephrine (NE) and aldosterone (Aldo) levels. However, the relationship between exercise capacity and neurohormonal activation has not been elucidated. Our study objective was to assess the association between cardiopulmonary exercise testing (CPT) measures and neurohormonal levels in CF-LVAD recipients. Symptom-limited CPT on a treadmill, using the modified Bruce protocol was performed in 15 CF-LVAD recipients. Norepinephrine and Aldo levels were measured, and the association between their levels and CPT measures were assessed. Peak VO2 (13.6 ml/kg/min) and percent age, sex predicted VO2 max (49.4%), and oxygen pulse (O2 pulse) (9.0 ± 4.0 ml/beat) were low, whereas minute ventilation/carbon dioxide output (VE/VCO2) slope (35) was elevated. In addition, VO2 at anaerobic threshold (VO2 AT), and O2 pulse values negatively correlated with NE levels. Norepinephrine levels positively correlated with chronotropic responses and heart rate (HR) recovery. Aldo levels in CF-LVAD recipients were not related to any CPT measures. Continuous-flow left ventricular assist device recipients exhibited impaired exercise capacity and chronotropic incompetence (CI). Despite the association of NE levels with chronotropic responses at peak exercise, neither NE levels nor chronotropic responses predicted peak VO2. This suggests that CI may not be the primary factor responsible for the low peak VO2. O2 pulse, which is a combined measure for stroke volume and peripheral oxygen extraction during exercise, was an independent predictor of peak VO2. Future studies should examine the contribution of peripheral factors to exercise capacity limitations.
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Heart, lungs, and muscle interplay in worsening activity-related breathlessness in advanced cardiopulmonary disease.
Curr Opin Support Palliat Care2020 Sep;14(3):157-166. doi: 10.1097/SPC.0000000000000516.
Alberto Neder J, O'Donnell Denis E,
Abstract
PURPOSE OF REVIEW:
Activity-related breathlessness is a key determinant of poor quality of life in patients with advanced cardiorespiratory disease. Accordingly, palliative care has assumed a prominent role in their care. The severity of breathlessness depends on a complex combination of negative cardiopulmonary interactions and increased afferent stimulation from systemic sources. We review recent data exposing the seeds and consequences of these abnormalities in combined heart failure and chronic obstructive pulmonary disease (COPD).
RECENT FINDINGS:
The drive to breathe increases ('excessive breathing') secondary to an enlarged dead space and hypoxemia (largely COPD-related) and heightened afferent stimuli, for example, sympathetic overexcitation, muscle ergorreceptor activation, and anaerobic metabolism (largely heart failure-related). Increased ventilatory drive might not be fully translated into the expected lung-chest wall displacement because of the mechanical derangements brought by COPD ('inappropriate breathing'). The latter abnormalities, in turn, negatively affect the central hemodynamics which are already compromised by heart failure. Physical activity then decreases, worsening muscle atrophy and dysfunction.
SUMMARY:
Beyond the imperative of optimal pharmacological treatment of each disease, strategies to lessen ventilation (e.g., walking aids, oxygen, opiates and anxiolytics, and cardiopulmonary rehabilitation) and improve mechanics (heliox, noninvasive ventilation, and inspiratory muscle training) might mitigate the burden of this devastating symptom in advanced heart failure-COPD.
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Exercise Training in Patients With Heart Failure With Preserved Ejection Fraction: A Community Hospital Pilot Study.
J Cardiovasc Nurs2020 Jul;():. doi: 10.1097/JCN.0000000000000737.
Bean Glenn, Mou Jin, Pflugeisen Bethann, Olsen Lindsay, Hoag Stephanie, Silva Angela, Ball Andrea L, Lee Tobias,
Abstract
BACKGROUND:
Patients with heart failure with preserved ejection fraction (HFpEF) experience poor exercise tolerance and quality of life. Little is known about the feasibility or effects of HFpEF exercise training (ET) in a community hospital setting.
OBJECTIVE:
The aim of this study was to examine the feasibility and pilot data of a community-based HFpEF ET intervention.
METHODS:
This was a single-group (n = 16), pretest-posttest, 9-week ET intervention. The Minnesota Living With Heart Failure Questionnaire, Patient Health Questionnaire-9, cardiopulmonary exercise test (peak VO2), and 6-minute walk test were used for evaluation.
RESULTS:
Participants (n = 16) attended 88% of prescribed ET sessions and 94% completed all pretest-posttest assessments. Significant improvements in Minnesota Living With Heart Failure Questionnaire (P = .01), Patient Health Questionnaire-9 (P ? .01), exercise test time (P = .01) and 6-minute walk test (P = .001), but not in peak VO2 (P = .16), were found.
CONCLUSIONS:
The ET intervention was feasible and safe, and findings support improved quality of life, depressive symptoms, and exercise tolerance. Larger controlled trials are warranted.
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Association of Hospice Care Services with the Utilisation of Life-sustaining Treatments during End-of-life Care among Cancer Patients: A Nationwide 11-year Cohort Study.
J Pain Symptom Manage2020 Jul;():. doi: S0885-3924(20)30640-0.
Yen Yung-Feng, Lai Yun-Ju, Ko Ming-Chung, Chen Yu-Yen, Chen Yi-Tui, Chou Yi-Sheng, Huang Chun-Teng, Chen Chu-Chieh,
Abstract
CONTEXT:
The impact of hospice care services on the utilisation of life-sustaining treatments during end-of-life care in terminally ill patients has not been extensively studied.
OBJECTIVES:
To determine the impact of hospice care services on the utilisation of life-sustaining treatments during the last three months of life among cancer patients.
METHODS:
This nationwide population-based cohort study identified adults with cancer diagnosis from the Taiwan Registry for Catastrophic Illness, 2006-2016. Life-sustaining treatments included cardiopulmonary resuscitation, intubation, mechanical ventilation support, nasogastric tube feeding, and total parenteral nutrition. Hospice care services consisted of hospice inpatient care, hospice-shared care, and hospice home care. The association of hospice care services with the utilisation of life-sustaining treatments was determined using multiple logistic regression.
RESULTS:
Of 516,409 cancer patients, 310,722 (60.2%) patients utilised life-sustaining treatments during the last three months of life. After adjusting for covariates, patients with hospice care services were less likely to receive life-sustaining treatments during the last 3 months of life than those without the services (adjusted odds ratio [AOR]=0.70, 95% confidence interval [CI]: 0.69-0.71). While type of life-sustaining treatments considered, hospice care services were associated with a lower likelihood of receiving cardiopulmonary resuscitation (AOR=0.125, 95% CI: 0.118-0.131), endotracheal intubation (AOR=0.204, 95% CI: 0.199-0.210), mechanical ventilation support (AOR=0.265, 95% CI: 0.260-0.270), nasogastric tube feeding (AOR=0.736, 95% CI: 0.727-0.744), and total parenteral nutrition (AOR=0.86, 95% CI: 0.84-0.88).
CONCLUSION:
Hospice care services were associated with a lower likelihood of receiving life-sustaining treatments during the last three months of life in cancer patients.
Copyright © 2020. Published by Elsevier Inc.
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