Abstract Background Peak oxygen uptake ( V ˙ O2 peak) is a well-established prognostic marker in chronic heart failure (CHF). Cardiopulmonary exercise testing (CPET) provides physiological parameters ...other than V ˙ O2 peak that might have prognostic value. We aimed at determining whether exercise recovery data kinetics have prognostic implications over V ˙ O2 peak and Heart Failure Survival Score. Methods Exercise data from 200 consecutive CHF patients evaluated for possible heart transplantation and received CPET at our institution between 2004 and 2011 were analyzed. The rate of recovery of oxygen uptake ( V ˙ O2 ) at 2 minutes after exercise ( V ˙ O2 -REC2 ) was calculated using the difference between V ˙ O2 peak and V ˙ O2 at minute 2 of recovery and expressed as a percentage of V ˙ O2 peak. The composite primary end point was the time from CPET to the first event including death, heart transplant, or mechanical heart implantation. Results Mean follow-up period was 1271 ± 61 days during which there were 108 first events including 35 deaths, 66 heart transplants, and 7 mechanical heart implantations. The strongest prognostic factors in the univariate analysis were V ˙ O2 -REC2 , V ˙ O2 peak, V ˙ O2 efficiency slope, and ventilation to carbon dioxide excretion ratio slope (all P < 0.0001). Multivariate analysis showed that V ˙ O2 -REC2 ( P < 0.0001), ventilation to carbon dioxide excretion ratio slope ( P = 0.0022), use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers ( P = 0.0042), presence of a defibrillator ( P = 0.0127), and mean arterial pressure ( P = 0.0151) were independent predictors of event-free survival time. Conclusions V ˙ O2 -REC2 was the strongest prognostic marker of death, heart transplantation, and mechanical heart implantation in severe CHF. This finding should be confirmed prospectively.
Abstract Background Asthma with incomplete reversibility of airway obstruction (IRAO) may often be associated to smoking-induced changes. Nevertheless, a high proportion of patients showing IRAO have ...never smoked. These patients with IRAO often share features of patients with chronic obstructive pulmonary disease (COPD). Although IRAO is still a poorly defined condition, it has been associated with a higher morbidity and mortality than asthma with complete reversibility of airway obstruction (CRAO) or even COPD alone. A high prevalence of comorbidities could contribute to the reported poorer clinical outcome in IRAO, in comparison to CRAO or COPD alone. Aim To determine the prevalence of past and current comorbidities in IRAO patients compared to patients with CRAO or COPD. Methods This was a retrospective, cross-sectional study. Demographic data, clinical characteristics and 36 predetermined comorbidities documented from self-report and chart review, were recorded from smoking-associated IRAO (S-IRAO), non-smoking IRAO (NS-IRAO), CRAO and COPD patients. Results A total of 199 patients were included in the final analysis (111F/88M, mean (±SD) age of 63 ± 10 years). The CRAO group had more comorbidities than the three other groups, but this difference was significant only with the NS-IRAO group ( P = 0.04). For most comorbidities, the prevalence of comorbidities in both IRAO sub-groups was intermediate between CRAO and COPD, with significant differences between S-IRAO and NS-IRAO only for hypertension ( P = 0.03), nasal polyps ( P = 0.002) and pneumonia ( P = 0.04). Typical asthma-associated comorbidities tended to be more prevalent in NS-IRAO patients and COPD-associated comorbidities in S-IRAO patients. Conclusion In this study, the prevalence of comorbidities was not superior in patients with IRAO, compared to those with CRAO or COPD alone. The prevalence of comorbidities in the two main types of IRAO patients reflects exposure to cigarette smoke and asthma-related mechanisms.
Cardioselective β blockers are considered to have little impact on lung function at rest in patients with chronic obstructive pulmonary disease (COPD). However, their effects on dynamic ...hyperinflation, an important mechanism contributing to symptoms and exercise tolerance in patients with COPD, have not been evaluated. Twenty-seven patients with moderate to severe COPD (forced expiratory volume in 1 second 52 ± 13% predicted) completed pulmonary function tests, echocardiography, maximal exercise tests, and cycle endurance tests at baseline. Inspiratory capacity was measured at 2-minute intervals during the cycle endurance test to quantify dynamic hyperinflation. Pulmonary function and cycle endurance testing were repeated after 14 days of bisoprolol 10 mg/day and 14 days of placebo in a randomized, double-blind, placebo-controlled, crossover trial. The extent of dynamic hyperinflation at peak isotime exercise with bisoprolol and placebo was compared. Peak isotime was defined as the latest time point that was reached during the 2 cycle endurance tests. Changes in inspiratory capacity from rest to peak isotime were different with bisoprolol compared to placebo (−0.50 ± 0.35 vs −0.41 ± 0.33 L, p = 0.01). Exercise duration tended to be lower with bisoprolol compared to placebo (305 ± 125 vs 353 ± 172 seconds, p = 0.11). The magnitude of change in exercise duration between the bisoprolol and placebo conditions was correlated with the magnitude of change in inspiratory capacity (r = 0.57, p <0.01). In conclusion, bisoprolol was associated with modest worsening dynamic hyperinflation, whereas exercise duration remained unchanged in patients with moderate to severe COPD. The magnitude of these effects was small and should not contraindicate the use of bisoprolol in patients with COPD.
The COPD Assessment Test Gupta, Nisha, MSc; Pinto, Lancelot, MD; Benedetti, Andrea, PhD ...
Chest,
November 2016, Letnik:
150, Številka:
5
Journal Article
Recenzirano
Background The COPD Assessment Test (CAT) is a valid disease-specific questionnaire measuring health status. However, knowledge concerning its use regarding patient and disease characteristics ...remains limited. Our main objective was to assess the degree to which the CAT score varies and can discriminate between specific patient population groups. Methods The Canadian Cohort Obstructive Lung Disease (CanCOLD) is a random-sampled, population-based, multicenter, prospective cohort that includes subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease GOLD classifications 1 to 3). The CAT questionnaire was administered at three visits (baseline, 1.5 years, and 3 years). The CAT total score was determined for sex, age groups, smoking status, GOLD classification, exacerbations, and comorbidities. Results A total of 716 subjects with COPD were included in the analysis. The majority of subjects (72.5%) were not previously diagnosed with COPD. The mean FEV1 /FVC ratio was 61.1 ± 8.1%, with a mean FEV1 % predicted of 82.3 ± 19.3%. The mean CAT scores were 5.8 ± 5.0, 9.6 ± 6.7, and 16.1 ± 10.0 for GOLD 1, 2, and 3+ classifications, respectively. Higher CAT scores were observed in women, current smokers, ever-smokers, and subjects with a previous diagnosis of COPD. The CAT was also able to distinguish between subjects who experience exacerbations vs those who had no exacerbation. Conclusions These results suggest that the CAT, originally designed for use in clinically symptomatic patients with COPD, can also be used in individuals with mild airflow obstruction and newly diagnosed COPD. In addition, the CAT was able to discriminate between sexes and subjects who experience frequent and infrequent exacerbations. Trial Registry ClinicalTrials.gov; No.: NCT00920348 ; Study ID No.: IRO-93326.
Objectives This study sought to determine the effects of chronic obstructive pulmonary disease (COPD) on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and to ...determine the factors associated with worse outcomes in COPD patients. Background No data exist on the factors determining poorer outcomes in COPD patients undergoing TAVI. Methods A total of 319 consecutive patients (29.5% with COPD) who underwent TAVI were studied. Functional status was evaluated by New York Heart Association (NYHA) functional class, Duke Activity Status Index, and the 6-min walk test (6MWT) at baseline and at 6 to 12 months. The TAVI treatment was considered futile if the patient either died or did not improve in NYHA functional class at 6-month follow-up. Results Survival rates at 1 year were 70.6% in COPD patients and 84.5% in patients without COPD (p = 0.008). COPD was an independent predictor of cumulative mortality after TAVI (hazard ratio: 1.84; 95% confidence interval: 1.08 to 3.13; p = 0.026). Improvement in functional status was observed after TAVI (p < 0.001 for NYHA functional class, Duke Activity Status Index, and 6MWT), but COPD patients exhibited less (p = 0.036) improvement in NYHA functional class. Among COPD patients, a shorter 6MWT distance predicted cumulative mortality (p = 0.013), whereas poorer baseline spirometry results (FEV1 forced expiratory volume in the first second of expiration) determined a higher rate of periprocedural pulmonary complications (p = 0.040). The TAVI treatment was futile in 40 COPD patients (42.5%) and a baseline 6MWT distance <170 m best determined the lack of benefit after TAVI (p = 0.002). Conclusions COPD was associated with a higher rate of mortality at mid-term follow-up. Among COPD patients, a higher degree of airway obstruction and a lower exercise capacity determined a higher risk of pulmonary complications and mortality, respectively. TAVI was futile in more than one-third of the COPD patients, and a shorter distance walked at the 6MWT predicted the lack of benefit after TAVI. These results may help to improve the clinical decision-making process in this challenging group of patients.
Background To better understand the interrelationships among disease severity, inspiratory capacity (IC), breathing pattern, and dyspnea, we studied responses to symptom-limited cycle exercise in a ...large cohort with COPD. Methods Analysis was conducted on data from two previously published replicate clinical trials in 427 hyperinflated patients with COPD. Patients were divided into disease severity quartiles based on FEV1 % predicted. Spirometry, plethysmographic lung volumes, and physiologic and perceptual responses to constant work rate (CWR) cycle exercise at 75% of the peak incremental work rate were compared. Results Age, body size, and COPD duration were similar across quartiles. As the FEV1 quartile worsened (mean, 62%, 49%, 39%, and 27% predicted), functional residual capacity increased (144%, 151%, 164%, and 185% predicted), IC decreased (86%, 81%, 69%, and 60% predicted), and peak incremental cycle work rate decreased (66%, 55%, 50%, and 44% predicted); CWR endurance time was 9.7, 9.3, 8.2, and 7.3 min, respectively. During CWR exercise, as FEV1 quartile worsened, peak minute ventilation ( e ) and tidal volume (V t ) decreased, whereas an inflection or plateau of the V t response occurred at a progressively lower e ( P < .0005), similar percentage of peak e (82%–86%), and similar V t /IC ratio (73%–77%). Dyspnea intensity at this inflection point was also similar across quartiles (3.1-3.7 Borg units) but accelerated steeply to intolerable levels thereafter. Conclusion Progressive reduction of the resting IC with increasing disease severity was associated with the appearance of critical constraints on V t expansion and a sharp increase in dyspnea to intolerable levels at a progressively lower ventilation during exercise.
Background The mechanisms through which neuromuscular electrical stimulation (NMES) training may improve limb muscle function and exercise tolerance in COPD are poorly understood. We investigated the ...functional and muscular effects of NMES in advanced COPD. Methods Twenty of 22 patients with COPD were randomly assigned to NMES (n = 12) or sham (n = 8) training in a double-blind controlled study. NMES was performed on quadriceps and calf muscles, at home, 5 days per week for 6 weeks. Quadriceps and calf muscle cross-sectional area (CSA), quadriceps force and endurance, and the shuttle-walking distance with cardiorespiratory measurements were assessed before and after training. Quadriceps biopsy specimens were obtained to explore the insulin-like growth factor-1/AKT signaling pathway (70-kDa ribosomal S6 kinase p70S6K, atrogin-1). Results NMES training improved muscle CSA ( P < .05), force, and endurance ( P < .03) when compared with sham training. Phosphorylated p70S6K levels (anabolism) were increased after NMES as compared with sham ( P = .03), whereas atrogin-1 levels (catabolism) were reduced ( P = .01). Changes in quadriceps strength and ventilation during walking contributed independently to variations in walking distance after training (r = 0.77, P < .001). Gains in walking distance were related to the ability to tolerate increasing current intensities during training (r = 0.95, P < .001). Conclusions In patients with severe COPD, NMES improved muscle CSA. This was associated with a more favorable muscle anabolic to catabolic balance. Improvement in walking distance after NMES training was associated with gains in muscle strength, reduced ventilation during walking, and the ability to tolerate higher stimulation intensity. Trial registry ClinicalTrials.gov ; No.: NCT00874965 ; URL: www.clinicaltrials.gov
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