Effects of body position during cardiopulmonary exercise testing with right heart catheterization

Introduction: Supine resting right heart catheterization (srRHC) is the standard method to differentiate pulmonary arterial hypertension (PAH) and heart failure with preserved ejection fraction (HFpEF), but most such patients complain of symptoms during exercise. We hypothesized that the upright invasive exercise phenotype of patients with unexplained exertional intolerance provides a distinct and additive perspective compared with supine resting RHC in the diagnosis of PAH and HFpEF. Methods: We reviewed results of consecutive patients with unexplained effort intolerance who underwent same day sequential srRHC and invasive cardiopulmonary exercise testing (iCPET) between March 2011 and October 2013. At rest, patients were classified with PAH if mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg and pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg; as HFpEF if PAWP > 15 mmHg; and as normal if none of the above hemodynamic criteria were met. At peak exercise, patients were categorized as exercise-induced PAH (eiPAH), exercise HFpEF (eHFpEF), normal (eNormal), or peripheral limitation according to the criteria displayed in the table. Results: Of 255 patients, 212 (83%) had normal srRHC. Of these, 46 (22%) had an abnormal iCPET result: eiPAH (n=24), eHFpEF (n=22). A resting mPAP > 18 mmHg discriminated eiPAH reasonably well (ROC AUC: 0.75; 95%CI: 0.67-0.83). Of those with abnormal srRHC, iCPET reclassified diagnosis for 16/43 (37%). Of the 30 patients who had HFpEF by srRHC, 12 (40%) had a normal cardiac hemodynamic profile during upright maximum exercise. 4 (31%) of the 13 patients with PAH at rest had no suggestion of intrinsic pulmonary vascular disease during exercise (3 eHFpEF and 1 non-cardiac limitation) with iCPET. Conclusions: In patients with exertional intolerance, iCPET reveals hemodynamic abnormalities which are overlooked with resting RHC and reclassifies a significant subset of apparent PAH and HFpEF patients by srRHC.

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Cardiopulmonary Exercise Testing with Right-heart Catheterization in Patients with Systemic Sclerosis

The Journal of Rheumatology ◽

10.3899/jrheum.091424 ◽

2010 ◽

Vol 37 (9) ◽

pp. 1871-1877 ◽

Cited By ~ 10

Author(s):

ALLAN J. WALKEY ◽

MICHAEL IEONG ◽

MIR ALIKHAN ◽

HARRISON W. FARBER

Keyword(s):

Systemic Sclerosis ◽

Exercise Testing ◽

Lupus Erythematosus ◽

Cardiopulmonary Exercise Testing ◽

Right Heart Catheterization ◽

Left Ventricular ◽

Arterial Oxygen ◽

Heart Catheterization ◽

Right Heart ◽

Cardiopulmonary Exercise

Objective.To examine the role of cardiopulmonary exercise testing with right-heart catheterization (CPET/RHC) in patients with systemic sclerosis (SSc) with potentially multifactorial exertional limitation.Methods.This was a single-center retrospective cohort study of patients with SSc referred for CPET/RHC.Results.A total of 19 patients with SSc [subtypes: 10 limited, 5 diffuse, 1 systemic lupus erythematosus (SLE)/SSc overlap, and 3 with no subtype specified in the medical record] underwent CPET/RHC testing from February 2003 to February 2008. Of these patients, the primary limitations to exercise were found to be ventilatory (n = 6), deconditioning/cardiovascular (n = 6), pulmonary vascular (PVL; n = 3), and exercise-induced left ventricular diastolic dysfunction (exercise-LVDD; n = 4). No prior physical examination, pulmonary function test, imaging, or echocardiographic data reliably predicted the etiology of exercise limitation determined by CPET/RHC. Vital capacity and ventilatory equivalent for CO2 did not differ during CPET testing between PVL and exercise–LVDD, limiting the utility of CPET alone for discriminating these etiologies of dyspnea. Exercise alveolar-arterial oxygen gradient was elevated in subjects shown to have PVL [median 48 mm Hg (interquartile range 45.3, 62.0)] compared to those with exercise-LVDD [26.0 (IQR 10.6, 36.0)] and deconditioning [13.9 (IQR 4.0, 16.4); p = 0.02]. Major therapeutic changes occurred in 11/19 (58%) subjects after CPET/RHC testing.Conclusion.CPET/RHC testing in subjects with SSc and potentially multifactorial dyspnea adds potentially useful diagnostic information unavailable from noninvasive testing.

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Cardiopulmonary exercise testing in a combined screening approach to individuate pulmonary arterial hypertension in systemic sclerosis

Rheumatology ◽

10.1093/rheumatology/kez473 ◽

2019 ◽

Vol 59 (7) ◽

pp. 1581-1586 ◽

Cited By ~ 2

Author(s):

Alessandro Santaniello ◽

Rosa Casella ◽

Marco Vicenzi ◽

Irene Rota ◽

Gaia Montanelli ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Pulmonary Arterial Hypertension ◽

Positive Predictive Value ◽

Predictive Value ◽

Cardiopulmonary Exercise Testing ◽

Right Heart Catheterization ◽

Heart Catheterization ◽

Right Heart ◽

Cardiopulmonary Exercise ◽

Pulmonary Arterial

Abstract Objectives The DETECT algorithm has been developed to identify SSc patients at risk for pulmonary arterial hypertension (PAH) yielding high sensitivity but low specificity, and positive predictive value. We tested whether cardiopulmonary exercise testing (CPET) could improve the performance of the DETECT screening strategy. Methods Consecutive SSc patients over a 30-month period were screened with the DETECT algorithm and positive subjects were referred for CPET before the execution of right-heart catheterization. The predictive performance of CPET on top of DETECT was evaluated and internally validated via bootstrap replicates. Results Out of 314 patients, 96 satisfied the DETECT application criteria and 54 were positive. PAH was ascertained in 17 (31.5%) and pre-capillary pulmonary hypertension in 23 (42.6%) patients. Within CPET variables, the slope of the minute ventilation to carbon dioxide production relationship (VE/VCO2 slope) had the best performance to predict PAH at right-heart catheterization [median (interquartile range) of specificity 0.778 (0.714–0.846), positive predictive value 0.636 (0.556–0.750)]; exploratory analysis on pre-capillary yielded a specificity of 0.714 (0.636–0.8) and positive predictive value of 0.714 (0.636–0.8). Conclusion In association with the DETECT algorithm, CPET may be considered as a useful tool in the workup of SSc-related pulmonary hypertension. The sequential determination of the VE/VCO2 slope in DETECT-positive subjects may reduce the number of unnecessary invasive procedures without any loss in the capability to capture PAH. This strategy had also a remarkable performance in highlighting the presence of pre-capillary pulmonary hypertension.

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Cardiopulmonary exercise test predicts right heart catheterization

European Journal of Clinical Investigation ◽

10.1111/eci.12851 ◽

2017 ◽

Vol 47 (12) ◽

pp. e12851 ◽

Cited By ~ 3

Author(s):

Michele Correale ◽

Lucia Tricarico ◽

Armando Ferraretti ◽

Ilenia Monaco ◽

Morena Concilio ◽

...

Keyword(s):

Exercise Test ◽

Cardiopulmonary Exercise Test ◽

Right Heart Catheterization ◽

Heart Catheterization ◽

Right Heart ◽

Cardiopulmonary Exercise

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Limited Exercise Capacity in Patients with Systemic Sclerosis: Identifying Contributing Factors with Cardiopulmonary Exercise Testing

The Journal of Rheumatology ◽

10.3899/jrheum.161349 ◽

2017 ◽

Vol 45 (1) ◽

pp. 95-102 ◽

Cited By ~ 3

Author(s):

Nihal Martis ◽

Viviane Queyrel-Moranne ◽

David Launay ◽

Rémi Neviere ◽

Jean-Gabriel Fuzibet ◽

...

Keyword(s):

Systemic Sclerosis ◽

Exercise Testing ◽

Cardiopulmonary Exercise Testing ◽

Volume Ratio ◽

Significant Negative Correlation ◽

Left Ventricular ◽

Heart Catheterization ◽

Contributing Factors ◽

Exercise Limitation ◽

Cardiopulmonary Exercise

Objective.Exercise limitation in patients with systemic sclerosis (SSc) is often multifactorial and related to complications such as interstitial lung disease (ILD), pulmonary vasculopathy (PV), left ventricular dysfunction (LVD), and/or peripheral/muscular limitation (PML). We hypothesized that cardiopulmonary exercise testing (CPET) could not only suggest and rank competing etiologies, but also highlight peripheral impairment.Methods.Clinical, resting pulmonary function testing, and CPET data from patients with SSc referred for exercise limitation between October 2009 and November 2015 were retrospectively analyzed in this bi-center study. Patients were categorized as having ILD, PV, LVD, and/or PML based on CPET response patterns and the diagnoses were matched with results from the reference investigations. The latter consisted of transthoracic echocardiography, chest computed tomography scan, and right heart catheterization (RHC).Results.Twenty-seven patients presented with CPET profiles consistent with ILD (n = 16), PV (n = 15), LVD (n = 5), and PML (n = 19). None of the subjects had a normal CPET profile. There was a statistically significant negative correlation between resting DLCO, on the one hand, and dead space to tidal volume ratio and alveolar–arterial gradient [P(Ai-a)O2] on the other (p < 0.005). CPET identified 90% of patients with a mean pulmonary arterial pressure at rest ≥ 21 mmHg measured by RHC (n = 10). Peak P(Ai-a)O2, taken independently from other variables, was crucial in distinguishing subjects with ILD from those without ILD (p < 0.05).Conclusion.CPET is useful for the characterization of multifactorial exercise limitation in patients with SSc and in identifying SSc-related complications such as ILD and PV. This study also identifies PML as an underestimated cause of exercise limitation.

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