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Restrictive ventilatory dysfunction and dyspnea in elderly subjects
The American Journal of Medicine (2005) 118, 1300-1309
LETTERS Restrictive ventilatory dysfunction and dyspnea in elderly subjects To the Editor: We read with interest the study by Pedersen et al about the possible causes of chronic dyspnea in 129 elderly subjects.1 The authors found an impaired lung function in 69 patients and an “obvious” cardiac cause in 12 subjects. Another 32 patients had cardiac or noncardiac alterations (mostly obesity, observed in 23 patients) that could potentially account for dyspnea, but in 16 patients this symptom remained unexplained. The authors conclude that diastolic dysfunction is infrequent as a cause of dyspnea in elderly subjects. Patients with chronic obstructive pulmonary disease (COPD, observed in 43 patients), diagnosed according to the presence of forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio lower than 0.70, and nonCOPD patients with altered carbon monoxide lung diffusion capacity (26 subjects) were considered as having “lung disease.” Among the lung abnormalities, however, the authors did not mention the restrictive ventilatory syndrome, which may be a frequent cause of dyspnea, and this may have limited the conclusions of the study. A pure restrictive syndrome can be diagnosed in patients showing FVC⬍80% predicted and FEV1/ FVC⬎0.70.2 Excluding classic interstitial lung diseases, the restrictive pattern may have many etiologies, including muscular weakness, congestive heart failure, diabetes mellitus, and obesity. These subjects often report respiratory symptoms and functional impairment.2 Levels of chronic inflammation (increased fibrinogen and C-reactive protein blood values) similar to those observed in moderate COPD have also been detected.3 Furthermore, restricted subjects are more likely to develop type 2 diabetes mellitus than healthy subjects and patients with COPD, thus suggesting that undetermined metabolic abnormalities may add to, or account for, the ventilatory impairment.4 More importantly, a generic “poor lung function,” as indicated by low FVC or FEV1, is a well recognized independent risk factor for cardiovascular disease.5 A recent study found the restrictive syndrome to be relatively frequent in the elderly, with a prevalence of about 10%-12% after the age of 65.2 We analyzed a population of 131 consecutive elderly subjects enrolled 0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved.
from 2 social centers. Pulmonary function was studied by a Medical International Research (Rome, Italy) spirometer Spirolab based on a turbine flow sensor and complying with the American Thoracic Society 24/26 waveforms. According to the above-mentioned definitions,2 20 subjects (15.3%) were affected by restrictive syndrome, 24 had obstructive disease (18.3%), and 87 (66.4%) showed normal lung function (FVC ⬎80% predicted and FEV1/FVC ratio higher than 0.70). COPD patients (76.6 ⫾ 6.9 years) were older than both normal (71.4 ⫾ 8, P ⫽ .005) and restrictive subjects (69.3 ⫾ 7.3, P ⫽ .001); the number of male subjects was also higher in the obstructive group (62.5%), as compared with the normal (36.7%, P ⫽ .04) and the restrictive groups (30%, P ⫽ .06). Variables describing smoking (pack-years, years of smoking, cigarettes smoked) were significantly increased in COPD compared with the normal group (P ⬍.05), whereas no difference was found comparing restrictive with normal subjects. The 3 groups were comparable with regard to the prevalence of hypertension, coronary artery disease, cerebrovascular disease, heart failure and nonvalvular atrial fibrillation. Type 2 diabetes mellitus was significantly more prevalent in the restrictive group (40%) compared with the normal subjects (9.1%, P ⫽ .002) but not to the COPD subjects (20.8%, P ⫽ .2). Body mass index was also increased in restrictive (32.5 ⫾ 5 kg/m2) with respect to normal (27.8 ⫾ 5, P ⫽ .001) and obstructive subjects (27.5 ⫾ 3.4, P ⫽ .005). However, waist circumference was comparable in the 3 groups, a finding questioning the concept that restrictive syndrome may simply depend on the negative ventilatory effect of visceral obesity. These data stress the potential importance of subclinic restrictive syndrome in the elderly, a poorly defined condition deserving further investigation. In this regard, the study sample of Pedersen et al1 provides a precious tool for investigating whether restrictive syndrome concurs to cause dyspnea. In addition, the potential relationships among restrictive syndrome, impaired lung diffusion capacity, and the presence of dyspnea could also be tested by the authors. Filippo Luca Fimognari, MD Chair of Geriatrics Division of Internal Medicine ASL Roma G/Leopoldo Parodi-Delfino Hospital
Letters
1301 Colleferro, Rome, Italy University Campus Biomedico of Rome Rome, Italy Ruggero Pastorelli, MD Division of Internal Medicine ASL Roma G/Leopoldo Parodi-Delfino Hospital Colleferro, Rome, Italy Simone Scarlata, MD Raffaele Antonelli Incalzi, MD Chair of Geriatrics University Campus Biomedico of Rome Rome, Italy
had forced vital capacity ⬍80% and of these 14 subjects, 13 had a reduced lung diffusion capacity. Although the issue of restrictive ventilatory syndrome as a cause of dyspnea is interesting, it does not change the conclusions of our study, because the majority of subjects with possible restrictive syndrome, based on spirometric criteria as proposed by Fimognari et al, were also found to have a reduced lung diffusion capacity and thus categorized as having a possible pulmonary cause of dyspnea. Frants Pedersen, MD, PhD Per R. Hildebrandt, MD, DMSci Department of Cardiology and Endocrinology Frederiksberg University Hospital Copenhagen, Denmark
doi:10.1016/j.amjmed.2005.04.037
doi:10.1016/j.amjmed.2005.07.035 References 1. Pedersen F, Raymond I, Mehlsen J, et al. Prevalence of diastolic dysfunction as a possible cause of dyspnea in the elderly. Am J Med. 2005;118:25-31. 2. Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and functional limitation: data from the Third National Health and Nutrition Examination. J Intern Med. 2003;114:758-762. 3. Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and markers of inflammation: data from the Third National Health and Nutrition Examination. Am J Med. 2003;114:758-762. 4. Ford ES, Mannino DM. Prospective association between lung function and the incidence of diabetes: findings from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Diabetes Care 2004;27:2966-2970. 5. Hole DJ, Watt GC, Davey-Smith G, et al. Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study. BMJ 1996;313:711-715.
The Reply: We thank Fimognari et al for their interest in our article.1 Fimognari et al commented that among subjects with lung abnormalities, the restrictive ventilatory syndrome was not mentioned as a cause of dyspnea, which may have limited the conclusions of our study. The authors suggest that a pure restrictive syndrome can be diagnosed in patients showing forced vital capacity ⬍80% of predicted value and forced expiratory volume in 1 second/forced vital capacity ⬎70%. The main purpose of our study was to assess the prevalence of diastolic dysfunction as a potential cause of dyspnea in a sample of elderly subjects. The frequency of diastolic dysfunction was assessed in all subjects with dyspnea, excluding those with atrial fibrillation, as well as in a subgroup of 48 subjects without obvious cardiac causes of dyspnea or lung disease. Impaired lung function was defined as a forced expiratory volume in 1 second/forced vital capacity ⬍70% or impaired lung diffusion capacity. Measurement of a reduced total lung capacity is required for a final diagnosis of restrictive ventilatory insufficiency, although the proposed dynamic spirometric criteria by Fimognari et al may support the diagnosis. We found that 14 of 86 subjects with forced expiratory volume in 1 second/forced vital capacity ⬎70%
Reference 1. Pedersen F, Raymond I, Mehlsen J, et al. Prevalence of diastolic dysfunction as a possible cause of dyspnea in the elderly. Am J Med. 2005;118:25-31.
Dyspnea in the elderly To the Editor: Dyspnea is a cardinal symptom of heart failure. Both pulmonary venous distention and congestion may cause dyspnea in patients with left ventricular systolic failure. Data suggest that muscle weakness, in particular inspiratory muscle weakness, is common in patients with heart failure and may account, in part, for this symptom. We have shown that patients with diastolic dysfunction have diminished maximal subatmospheric static inspiratory muscle weakness; adopt a rapid, shallow breathing pattern during exercise; and experience dyspnea at low work loads when compared with matched control subjects.1 The study by Pedersen et al2 and the accompanying editorial by Vedantham and Fleischmann3 do not discuss other mechanisms of dyspnea in the elderly. In addition, clinical and occult coronary artery disease (CAD) is common in the elderly,4,5 and although 2 patients were excluded from the cohort, the study does not exclude most patients with CAD, based on the low sensitivity of electrocardiographic exercise tests and lack of maximal exercise protocol. Vagaries in diastolic and systolic noninvasive parameters also may be predicted by cardiotonic medications, status of hypertension control, baseline blood pressure, and heart rate. In addition, age-related changes in diastolic dysfunction might be an epi-phenomemona of presbycardia rather than an association of other disease conditions.4 These concerns, and the absence of age-matched control, weaken the conclusion of this otherwise meticulous study.
LETTERS Restrictive ventilatory dysfunction and dyspnea in elderly subjects To the Editor: We read with interest the study by Pedersen et al about the possible causes of chronic dyspnea in 129 elderly subjects.1 The authors found an impaired lung function in 69 patients and an “obvious” cardiac cause in 12 subjects. Another 32 patients had cardiac or noncardiac alterations (mostly obesity, observed in 23 patients) that could potentially account for dyspnea, but in 16 patients this symptom remained unexplained. The authors conclude that diastolic dysfunction is infrequent as a cause of dyspnea in elderly subjects. Patients with chronic obstructive pulmonary disease (COPD, observed in 43 patients), diagnosed according to the presence of forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio lower than 0.70, and nonCOPD patients with altered carbon monoxide lung diffusion capacity (26 subjects) were considered as having “lung disease.” Among the lung abnormalities, however, the authors did not mention the restrictive ventilatory syndrome, which may be a frequent cause of dyspnea, and this may have limited the conclusions of the study. A pure restrictive syndrome can be diagnosed in patients showing FVC⬍80% predicted and FEV1/ FVC⬎0.70.2 Excluding classic interstitial lung diseases, the restrictive pattern may have many etiologies, including muscular weakness, congestive heart failure, diabetes mellitus, and obesity. These subjects often report respiratory symptoms and functional impairment.2 Levels of chronic inflammation (increased fibrinogen and C-reactive protein blood values) similar to those observed in moderate COPD have also been detected.3 Furthermore, restricted subjects are more likely to develop type 2 diabetes mellitus than healthy subjects and patients with COPD, thus suggesting that undetermined metabolic abnormalities may add to, or account for, the ventilatory impairment.4 More importantly, a generic “poor lung function,” as indicated by low FVC or FEV1, is a well recognized independent risk factor for cardiovascular disease.5 A recent study found the restrictive syndrome to be relatively frequent in the elderly, with a prevalence of about 10%-12% after the age of 65.2 We analyzed a population of 131 consecutive elderly subjects enrolled 0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved.
from 2 social centers. Pulmonary function was studied by a Medical International Research (Rome, Italy) spirometer Spirolab based on a turbine flow sensor and complying with the American Thoracic Society 24/26 waveforms. According to the above-mentioned definitions,2 20 subjects (15.3%) were affected by restrictive syndrome, 24 had obstructive disease (18.3%), and 87 (66.4%) showed normal lung function (FVC ⬎80% predicted and FEV1/FVC ratio higher than 0.70). COPD patients (76.6 ⫾ 6.9 years) were older than both normal (71.4 ⫾ 8, P ⫽ .005) and restrictive subjects (69.3 ⫾ 7.3, P ⫽ .001); the number of male subjects was also higher in the obstructive group (62.5%), as compared with the normal (36.7%, P ⫽ .04) and the restrictive groups (30%, P ⫽ .06). Variables describing smoking (pack-years, years of smoking, cigarettes smoked) were significantly increased in COPD compared with the normal group (P ⬍.05), whereas no difference was found comparing restrictive with normal subjects. The 3 groups were comparable with regard to the prevalence of hypertension, coronary artery disease, cerebrovascular disease, heart failure and nonvalvular atrial fibrillation. Type 2 diabetes mellitus was significantly more prevalent in the restrictive group (40%) compared with the normal subjects (9.1%, P ⫽ .002) but not to the COPD subjects (20.8%, P ⫽ .2). Body mass index was also increased in restrictive (32.5 ⫾ 5 kg/m2) with respect to normal (27.8 ⫾ 5, P ⫽ .001) and obstructive subjects (27.5 ⫾ 3.4, P ⫽ .005). However, waist circumference was comparable in the 3 groups, a finding questioning the concept that restrictive syndrome may simply depend on the negative ventilatory effect of visceral obesity. These data stress the potential importance of subclinic restrictive syndrome in the elderly, a poorly defined condition deserving further investigation. In this regard, the study sample of Pedersen et al1 provides a precious tool for investigating whether restrictive syndrome concurs to cause dyspnea. In addition, the potential relationships among restrictive syndrome, impaired lung diffusion capacity, and the presence of dyspnea could also be tested by the authors. Filippo Luca Fimognari, MD Chair of Geriatrics Division of Internal Medicine ASL Roma G/Leopoldo Parodi-Delfino Hospital
Letters
1301 Colleferro, Rome, Italy University Campus Biomedico of Rome Rome, Italy Ruggero Pastorelli, MD Division of Internal Medicine ASL Roma G/Leopoldo Parodi-Delfino Hospital Colleferro, Rome, Italy Simone Scarlata, MD Raffaele Antonelli Incalzi, MD Chair of Geriatrics University Campus Biomedico of Rome Rome, Italy
had forced vital capacity ⬍80% and of these 14 subjects, 13 had a reduced lung diffusion capacity. Although the issue of restrictive ventilatory syndrome as a cause of dyspnea is interesting, it does not change the conclusions of our study, because the majority of subjects with possible restrictive syndrome, based on spirometric criteria as proposed by Fimognari et al, were also found to have a reduced lung diffusion capacity and thus categorized as having a possible pulmonary cause of dyspnea. Frants Pedersen, MD, PhD Per R. Hildebrandt, MD, DMSci Department of Cardiology and Endocrinology Frederiksberg University Hospital Copenhagen, Denmark
doi:10.1016/j.amjmed.2005.04.037
doi:10.1016/j.amjmed.2005.07.035 References 1. Pedersen F, Raymond I, Mehlsen J, et al. Prevalence of diastolic dysfunction as a possible cause of dyspnea in the elderly. Am J Med. 2005;118:25-31. 2. Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and functional limitation: data from the Third National Health and Nutrition Examination. J Intern Med. 2003;114:758-762. 3. Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and markers of inflammation: data from the Third National Health and Nutrition Examination. Am J Med. 2003;114:758-762. 4. Ford ES, Mannino DM. Prospective association between lung function and the incidence of diabetes: findings from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Diabetes Care 2004;27:2966-2970. 5. Hole DJ, Watt GC, Davey-Smith G, et al. Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study. BMJ 1996;313:711-715.
The Reply: We thank Fimognari et al for their interest in our article.1 Fimognari et al commented that among subjects with lung abnormalities, the restrictive ventilatory syndrome was not mentioned as a cause of dyspnea, which may have limited the conclusions of our study. The authors suggest that a pure restrictive syndrome can be diagnosed in patients showing forced vital capacity ⬍80% of predicted value and forced expiratory volume in 1 second/forced vital capacity ⬎70%. The main purpose of our study was to assess the prevalence of diastolic dysfunction as a potential cause of dyspnea in a sample of elderly subjects. The frequency of diastolic dysfunction was assessed in all subjects with dyspnea, excluding those with atrial fibrillation, as well as in a subgroup of 48 subjects without obvious cardiac causes of dyspnea or lung disease. Impaired lung function was defined as a forced expiratory volume in 1 second/forced vital capacity ⬍70% or impaired lung diffusion capacity. Measurement of a reduced total lung capacity is required for a final diagnosis of restrictive ventilatory insufficiency, although the proposed dynamic spirometric criteria by Fimognari et al may support the diagnosis. We found that 14 of 86 subjects with forced expiratory volume in 1 second/forced vital capacity ⬎70%
Reference 1. Pedersen F, Raymond I, Mehlsen J, et al. Prevalence of diastolic dysfunction as a possible cause of dyspnea in the elderly. Am J Med. 2005;118:25-31.
Dyspnea in the elderly To the Editor: Dyspnea is a cardinal symptom of heart failure. Both pulmonary venous distention and congestion may cause dyspnea in patients with left ventricular systolic failure. Data suggest that muscle weakness, in particular inspiratory muscle weakness, is common in patients with heart failure and may account, in part, for this symptom. We have shown that patients with diastolic dysfunction have diminished maximal subatmospheric static inspiratory muscle weakness; adopt a rapid, shallow breathing pattern during exercise; and experience dyspnea at low work loads when compared with matched control subjects.1 The study by Pedersen et al2 and the accompanying editorial by Vedantham and Fleischmann3 do not discuss other mechanisms of dyspnea in the elderly. In addition, clinical and occult coronary artery disease (CAD) is common in the elderly,4,5 and although 2 patients were excluded from the cohort, the study does not exclude most patients with CAD, based on the low sensitivity of electrocardiographic exercise tests and lack of maximal exercise protocol. Vagaries in diastolic and systolic noninvasive parameters also may be predicted by cardiotonic medications, status of hypertension control, baseline blood pressure, and heart rate. In addition, age-related changes in diastolic dysfunction might be an epi-phenomemona of presbycardia rather than an association of other disease conditions.4 These concerns, and the absence of age-matched control, weaken the conclusion of this otherwise meticulous study.