Akazawa Y; Fujioka T; Kühn A; Hui W; Slorach C; Roehlig C; Mertens L; Vogt M; Friedberg MK;

The Canadian Journal Of Cardiology [Can J Cardiol] 2019 Jun 12. Date of Electronic Publication: 2019 Jun 12.

Background: Right ventricular (RV) diastolic function and right atrial (RA) function are poorly characterized in patients with Ebstein anomaly (EA) but may influence functional capacity. We aimed to evaluate RV diastolic function and RA function in EA and study their relationship with biventricular systolic function and exercise capacity.
Methods: Seventy-two patients with EA and 69 controls prospectively underwent echocardiography, cardiovascular magnetic resonance imaging, and cardiopulmonary exercise testing to investigate RV systolic and diastolic function, RA function, and exercise capacity.
Results: Altered RV diastolic function was indicated by the reduced tricuspid valve E/A ratio, percentage RV filling time, and early and late diastolic strain rate; and by the increased tricuspid valve E/E’, isovolumic relaxation time, and RV myocardial performance index. The average of 6-RV-segment early diastolic strain rate correlated modestly with peak VO2 (r = 0.38, P < 0.01), RV ejection fraction (r = 0.41, P < 0.01), and left ventricular ejection fraction (r = 0.33, P < 0.05). Patients with EA had impaired RA reservoir, conduit, and pump function, which were associated with peak VO2 (r = 0.54, P < 0.001 for reservoir function).
Conclusions: Altered RV diastolic function and RA function in patients with EA are associated with impaired biventricular systolic function and exercise capacity. The stronger correlation of RA vs RV function with exercise capacity suggests that it may be important to evaluate RA function in this population.

Chuang ML; Lin IF; Hsieh MJ;

Journal Of Clinical Medicine [J Clin Med] 2019 Oct 07; Vol. 8 (10). Date of Electronic Publication: 2019 Oct 07.

Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) often have dyspnea. Despite differences in primary organ derangement and similarities in secondary skeletal muscle changes, both patient groups have prominent functional impairment. With similar daily exercise performance in patients with CHF and COPD, we hypothesized that patients with CHF would have worse ventilatory muscle oxygenation than patients with COPD. This study aimed to compare differences in tissue oxygenation and blood capacity between ventilatory muscles and leg muscles and between the two patient groups. Demographic data, lung function, and maximal cardiopulmonary exercise tests were performed in 134 subjects without acute illnesses. Muscle oxygenation and blood capacity were measured using frequency-domain near-infrared spectroscopy (fd-NIRS). We enrolled normal subjects and patients with COPD and CHF. The two patient groups were matched by oxygen-cost diagram scores, New York Heart Association functional classification scores, and modified Medical Research Council scores. COPD was defined as forced expired volume in one second and forced expired vital capacity ratio ≤0.7. CHF was defined as stable heart failure with an ejection fraction ≤49%. The healthy subjects were defined as those with no obvious history of chronic disease. Age, body mass index, cigarette consumption, lung function, and exercise capacity were different across the three groups. Muscle oxygenation and blood capacity were adjusted accordingly. Leg muscles had higher deoxygenation (HHb) and oxygenation (HbO2) and lower oxygen saturation (SmO2) than ventilatory muscles in all participants. The SmO2 of leg muscles was lower than that of ventilatory muscles because SmO2 was calculated as HbO2/(HHb+HbO2), and the HHb of leg muscles was relatively higher than the HbO2 of leg muscles. The healthy subjects had higher SmO2, the patients with COPD had higher HHb, and the patients with CHF had lower HbO2 in both muscle groups throughout the tests. The patients with CHF had lower SmO2 of ventilatory muscles than the patients with COPD at peak exercise (p < 0.01). We conclud that fd-NIRS can be used to discriminate tissue oxygenation of different musculatures and disease entities. More studies on interventions on ventilatory muscle oxygenation in patients with CHF and COPD are warranted

Shiraishi Y; Katsumata Y; Sadahiro T; Azuma K; Akita K; Isobe S; Yashima
F; Miyamoto K; Nishiyama T; Tamura Y; Kimura T; Nishiyama N; Aizawa Y;
Fukuda K; Takatsuki S.

Journal of the American Heart Association. 7(1), 2018 01 07.
VI 1

BACKGROUND: It has never been possible to immediately evaluate heart rate
variability (HRV) during exercise. We aimed to visualize the real-time
changes in the power spectrum of HRV during exercise and to investigate
its relationship to the ventilatory threshold (VT).

METHODS AND RESULTS: Thirty healthy subjects (29.1+/-5.7 years of age)
and 35 consecutive patients (59.0+/-13.2 years of age) with myocardial
infarctions underwent cardiopulmonary exercise tests with an RAMP protocol
ergometer. The HRV was continuously assessed with power spectral analyses
using the maximum entropy method and projected on a screen without delay.
During exercise, a significant decrease in the high frequency (HF) was
followed by a drastic shift in the power spectrum of the HRV with a
periodic augmentation in the low frequency/HF (L/H) and steady low HF.
When the HRV threshold (HRVT) was defined as conversion from a predominant
high frequency (HF) to a predominant low frequency/HF (L/H), the VO2 at
the HRVT (HRVT-VO2) was substantially correlated with the VO2 at the
lactate threshold and VT) in the healthy subjects (r=0.853 and 0.921,
respectively). The mean difference between each threshold (0.65 mL/kg per
minute for lactate threshold and HRVT, 0.53 mL/kg per minute for VT and
HRVT) was nonsignificant (P>0.05). Furthermore, the HRVT-VO2 was also
correlated with the VT-VO2 in these myocardial infarction patients
(r=0.867), and the mean difference was -0.72 mL/kg per minute and was
nonsignificant (P>0.05).

CONCLUSIONS: A HRV analysis with our method enabled real-time
visualization of the changes in the power spectrum during exercise. This
can provide additional information for detecting the VT.

Sima CA; Lau BC; Taylor CM; van Eeden SF; Reid WD; Sheel AW; Kirkham AR;
Camp PG.

2018 American Academy of
Physical Medicine and Rehabilitation.

BACKGROUND: Myocardial infarction (MI) remains under-recognized in chronic
lung disease (CLD) patients. Rehabilitation health professionals need
accessible clinical measurements to identify the presence of prior MI in
order to determine appropriate training prescription.

OBJECTIVES: To estimate prior MI in CLD patients entering a pulmonary
rehabilitation program, as well as its association with heart rate
parameters such as resting heart rate and chronotropic response index.

DESIGN: Retrospective cohort design.

SETTING: Pulmonary rehabilitation outpatient clinic in a tertiary care
university-affiliated hospital.

PATIENTS: Eighty-five CLD patients were studied.

METHODS: Electrocardiograms at rest and peak cardiopulmonary exercise
testing, performed before pulmonary rehabilitation, were analyzed.
Electrocardiographic evidence of prior MI, quantified by the Cardiac
Infarction Injury Score (CIIS), was contrasted with reported myocardial
events and then correlated with resting heart rate and chronotropic
response index parameters.

MAIN OUTCOME MEASUREMENTS: CIIS, resting heart rate, and chronotropic
response index.

RESULTS: Sixteen CLD patients (19%) demonstrated electrocardiographic
evidence of prior MI, but less than half (8%) had a reported MI history (P
< .05). The Cohen’s kappa test revealed poor level of agreement between
CIIS and medical records (kappa = 0.165), indicating that prior MI
diagnosis was under-reported in the medical records. Simple and multiple
regression analyses showed that resting heart rate but not chronotropic
response index was positively associated with CIIS in our population (R2 =
0.29, P < .001). CLD patients with a resting heart rate higher than 80
beats/min had approximately 5 times higher odds of having prior MI, as
evidenced by a CIIS >= 20.

CONCLUSIONS: CLD patients entering pulmonary rehabilitation are at risk
of unreported prior MI. Elevated resting heart rate appears to be an
indicator of prior MI in CLD patients; therefore, careful adjustment of
training intensity is recommended under these circumstances.

Dawkins C, Hollingsworth AC, Walker P, Milburn S, Danjoux G,Cheesman M, Mofidi R

J Cardiovasc Surg (Torino). 2019 Oct 4. doi: 10.23736/S0021-9509.19.11052-X.
[Epub ahead of print]

BACKGROUND: The aim of this study was to examine the value preoperative AT as
predictor of postoperative survival in patients who underwent elective EVAR for
repair of asymptomatic AAA.
METHODS: Consecutive patients who underwent elective EVAR between 2008 and 2018
were analysed. Cardiopulmonary exercise testing was performed. Perioperative/30
day mortality was compared between patients who had AT ≥8 ml kg-1 min-1 and those
with AT<8 ml kg-1 min-1. Risk factors for postoperative survival following EVAR
were examined using Cox’s regression analysis.
RESULTS: Between 1st January 2008 and 31st December 2017, 430 patients underwent
elective EVAR (standard device: 374, fenestrated/ branched: 56), [Median age: 76
years (range: 53-91)]. Median AT was 9.3 (range: 5.4-16.1). 30-day mortality was
0.9%. These patients were followed up for a median of 1630 days. There was no
significant difference in perioperative/30 day mortality between patients who had
AT≥8 and those who had AT<8 (χ2=1.56, P=0.22). Age [HR:1.51 (CI: 1.07-1.99),
(P<0.05)] and AT [HR: 0.59 (0.45-0.76), (P=0.0003)] were predictors of reduced
postoperative survival following elective EVAR whereas gender [HR: 0.75
(0.4-0.1.4), P=0.37)], AAA diameter [HR: 0.95 (0.77-0.1.16), (P=0.6)], AAA
morphology [HR: 1.23 (0.68-1.76), (P=0.95)] were not.
CONCLUSIONS: Anaerobic threshold is an independent predictor of prolonged
survival following elective EVAR and can be used to identify patients who receive
most benefit from elective EVAR.

Kristofer Hedman, Nicholas Cauwenberghs,
Jeffrey W Christle, Tatiana Kuznetsova, Francois Haddad,
Jonathan Myers

European Journal of Preventive Cardiology 0(00) 1–10

Aims: The association between peak systolic blood pressure (SBP) during exercise testing and outcome remains
controversial, possibly due to the confounding effect of external workload (metabolic equivalents of task (METs)) on
peak SBP as well as on survival. Indexing the increase in SBP to the increase in workload (SBP/MET-slope) could provide a more clinically relevant measure of the SBP response to exercise.We aimed to characterize the SBP/MET-slope in a large cohort referred for clinical exercise testing and to determine its relation to all-cause mortality.
Methods and results: Survival status for male Veterans who underwent a maximal treadmill exercise test between the years 1987 and 2007 were retrieved in 2018. We defined a subgroup of non-smoking 10-year survivors with fewer risk factors as a lower-risk reference group. Survival analyses for all-cause mortality were performed using Kaplan–Meier curves and Cox proportional hazard ratios (HRs (95% confidence interval)) adjusted for baseline age, test year, cardiovascular risk factors, medications and comorbidities. A total of 7542 subjects were followed over 18.4 (interquartile range 16.3) years. In lower-risk subjects (n¼709), the median (95th percentile) of the SBP/MET-slope was 4.9 (10.0) mmHg/MET. Lower peak SBP (<210 mmHg) and higher SBP/MET-slope (>10 mmHg/MET) were both associated with 20% higher mortality (adjusted HRs 1.20 (1.08–1.32) and 1.20 (1.10–1.31), respectively). In subjects with high fitness, a SBP/MET-slope>6.2 mmHg/MET was associated with a 27% higher risk of mortality (adjusted HR 1.27 (1.12–1.45)).
Conclusion: In contrast to peak SBP, having a higher SBP/MET-slope was associated with increased risk of mortality.
This simple, novel metric can be considered in clinical exercise testing reports.

Dear all

The attachment is the 2020 Milan Course. Click on ‘2020Cardiopulmonary’; then click on the displayed .pdf.

2020Cardiopulmonary

My best regards

Paul Older

Dear all

CPOC RCoA Bulletin September 2019

The attachment is the CPOC RCoA Bulletin.

It is of importance to many specialities, not just anaesthetists.

My regards

Paul

Ackland GL; Abbott TEF; Minto G; Owen T; Prabhu P; May SM; Reynolds JA; Cuthbertson BH; Wijesundera D; Pearse RM;

Plos One [PLoS One] 2019 Aug 21; Vol. 14 (8), pp. e0221277. Date of Electronic Publication: 20190821 (Print Publication: 2019).

Background: Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery.
Methods: In two prospective, blinded, observational cohort studies, we established the definition of impaired vagal function in terms of the HRR threshold that is associated with perioperative myocardial injury (HRR ≤ 12 beats min-1 (bpm), 60 seconds after cessation of cardiopulmonary exercise testing. The primary outcome of this secondary analysis was all-cause morbidity three and five days after surgery, defined using the Post-Operative Morbidity Survey. Secondary outcomes of this analysis were type of morbidity and time to become morbidity-free. Logistic regression and Cox regression tested for the association between HRR and morbidity. Results are presented as odds/hazard ratios [OR or HR; (95% confidence intervals).
Results: 882/1941 (45.4%) patients had HRR≤12bpm. All-cause morbidity within 5 days of surgery was more common in 585/822 (71.2%) patients with HRR≤12bpm, compared to 718/1119 (64.2%) patients with HRR>12bpm (OR:1.38 (1.14-1.67); p = 0.001). HRR≤12bpm was associated with more frequent episodes of pulmonary (OR:1.31 (1.05-1.62);p = 0.02)), infective (OR:1.38 (1.10-1.72); p = 0.006), renal (OR:1.91 (1.30-2.79); p = 0.02)), cardiovascular (OR:1.39 (1.15-1.69); p<0.001)), neurological (OR:1.73 (1.11-2.70); p = 0.02)) and pain morbidity (OR:1.38 (1.14-1.68); p = 0.001) within 5 days of surgery.
Conclusions: Multi-organ dysfunction is more common in surgical patients with cardiac vagal dysfunction, defined as HRR ≤ 12 bpm after preoperative cardiopulmonary exercise testing.

Hornsby WE; Departments of Internal Medicine, Division of Cardiovascular Medicine (Drs Hornsby, Saberi, Brook, Willer, Eagle, and Rubenfire and Ms Fink) and Cardiac Surgery (Drs Wu, Patel, and Yang), University of Michigan, Michigan Medicine, Ann Arbor; Creighton University School of Medicine, Omaha, Nebraska (Ms Norton); Department of Kinesiology, University of Windsor, Windsor, Ontario, Canada (Dr McGowan); Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York (Dr Jones); Departments of Computational Medicine and Bioinformatics and Human Genetics, University of Michigan, Ann Arbor (Dr Willer); and Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana (Dr Lavie).

Journal Of Cardiopulmonary Rehabilitation And Prevention [J Cardiopulm Rehabil Prev] 2019 Aug 29. Date of Electronic Publication: 2019 Aug 29.

Purpose: There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, Vo2peak), and blood pressure.
Methods: Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection.
Results: Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured Vo2peak was <36% predicted normative values (19.2 mL·kgmin vs 29.3 mL·kg·min, P < .0001); the most marked impairment in Vo2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups.
Conclusions: We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. Vo2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.