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Detection of Developing Pulmonary Vasculopathy in the Early Stage of Pulmonary Arterial Hypertension with Non- invasive Cardiopulmonary Exercise Testing
The 17th Annual Scientific Meeting collected information of emergency admissions in the Tokyo metropolitan area. We obtained records of 796 AHF patients transported via emergency medical services from 2009 to 2010. The patients were divided into 2 groups; early (those who took #60 minutes from onset to arrival) and late presenters (O60 minutes). Patients with ACS and cardiogenic shock were excluded. Result: A majority of the patients were elderly (77.2611.8 years old) and male (52.3%). The overall in-hospital mortality rate was 3.8%. The median time interval between symptom onset and hospital arrival was 95 minutes (IQR 56-202 minutes). The two groups had similar background characteristics and in-hospital mortality. In early presenters, classic risk factors such as systolic blood pressure (OR 0.962, P50.019) or BNP (OR 1.001, P50.020) had a significant impact on in-hospital mortality, whereas signs of respiratory distress such as decreased SpO2 had stronger association in late presenters (OR 0.950, P50.030). Conclusion: Recognizing the onset of symptoms seems to be important for accurate risk assessment of AHF.
O-066 Independent Prognostic Value of Right Atrial Pressure in Patients with Congestive Heart Disease YOSHIHARU SADA, HIROKI KINOSHITA, TOMOHIKO KISAKA, YOSHIHIRO DOHI, YASUKI KIHARA Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Science When significant pulmonary hypertension (PH) develops in association with leftsided heart disease (LHD), it leads to poor prognosis. Up to the present, mean pulmonary arterial pressure (mPAP) and right ventricular (RV) ejection fraction are reported as a predictor of survival. We sought a better understanding of the hemodynamic parameters in the patients with pulmonary arterial wedge pressure (PCW) $ 15 mmHg. It might improve the accuracy of the prognostic stratification of patients with congestive heart failure. This study enrolled 1169 consecutive patients received right heat catheterization (RHC) from January 2000 through December 2012. Among them, we analyzed 354 patients with a pulmonary capillary wedge pressure (PCW) $15 mmHg. During a follow-up period of 36 month, 56 patients died. Among baseline variables, right atrial pressure (RAP)$11mmHg were significantly related to outcome. Meanwhile, cardiac index (CI)$2.5ml/min, transpulmonary pressure gradient (TPG)$12mmHg, mPAP$25mmHg, and PCW$20mmHg were not significantly related to outcome when analyzed in the univariate model (HR for RAP 1.82, 95%CI 1.19-2.79; p!0.006). In the multivariate model, only RAP remained statistically significant (HR for RAP 1.60, 95%CI 1.02-2.54; p! 0.04). Our observation suggested that RV dysfunction is greatly important for prognosis of LHD.
O-067 Effect of Bosentan on Exercise Capacity in Patients with Pulmonary Arterial Hypertension or Inoperable Chronic Thromboembolic Pulmonary Hypertension AKIHIRO HIRASHIKI1, TAKAHISA KONDO1, YOSHIHISA NAKANO2, SHIRO ADACHI2, TAKAHIRO OKUMURA2, TOYOAKI MUROHARA2 1 Advanced Medicine in Cardiopulmonary Disease, Nagoya Graduate School of Medicine, 2Cardiology, Nagoya Graduate School of Medicine Background: Endothelin receptor antagonists (ERA) improve the prognosis of patients with pulmonary arterial hypertension (PAH). However, only limited data are available on the effect of treatment with the ERA bosentan on exercise capacity assessed with cardiopulmonary exercise testing (CPX) in patients with PAH or inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Purpose: To investigate the effect of the oral, dual-ERA bosentan on exercise capacity in patients with PAH or inoperable CTEPH by means of CPX. Methods: Fifteen consecutive PAH and 9 consecutive inoperable CTEPH patients were treated with bosentan. All patients underwent cardiac catheterization and echocardiography. CPX was performed both prior to initiation of bosentan therapy and after 6 months. Results: In PAH patients, peak VO2 significantly increased from 13.8 6 6.8 mL/kg/min at baseline to 16.8 6 7.2 mL/kg/min after 6 months (P ! 0.01). Similarly, VE/VCO2 slope also significantly decreased from 56.8 6 22.5 to 48.9 6 17.5 (P ! 0.05). However, in CTEPH patients, there were no significant differences in peak VO2 or VE/VCO2 slope between the before and after bosentan therapy values (P 5 0.35, P 5 0.67, respectively). Conclusions: Bosentan therapy improves exercise capacity in patients with PAH within a relatively short period. However, the effect is not seen in patients with CTEPH.
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O-068 Detection of Developing Pulmonary Vasculopathy in the Early Stage of Pulmonary Arterial Hypertension with Non- invasive Cardiopulmonary Exercise Testing HIROKI KINOSHITA, YOSHIHIRO DOHI, YOSHIHARU SADA, TOMOHIKO KISAKA, TOSHIRO KITAGAWA, HIDEYA YAMAMOTO, YASUKI KIHARA Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences In contrast to chronic thromboembolic pulmonary hypertension (CTEPH), patients with pulmonary arterial hypertension (PAH) have pulmonary vasculopathy which leads to impaired dilatation of affected pulmonary vessels, impeding the increase of cardiac output (CO) and stroke volume during exercise. Peak O2 uptake shows CO, and peak O2-pulse shows stroke volume during cardiopulmonary exercise testing (CPX). To investigate the exertional CO increase, we performed CPX in 12 patients with PAH and 7 with CTEPH. Predicted peak O2 uptake (45.5 6 8.0 vs. 60.6 6 13.4 %) and predicted peak O2-pulse (55.6 6 7.6 vs. 69.1 6 6.9 %) were significant higher in CTEPH than PAH. Diffusion capacity for carbon monoxide (% DLco: 40.3 6 13.7 vs. 62.2 6 13.9 %) was also significant higher in CTEPH than PAH, however there was no correlation between %DLco and peak O2 uptake or peak O2-pulse. While, there was no difference in mean pulmonary arterial pressure (31 6 6.8 vs. 30.1 6 7.0 mmHg), CO (4.1 6 0.6 vs. 4.4 6 0.4 L/min), and pulmonary vascular resistance (5.2 6 2.0 vs. 5.2 6 2.8 wood-units) at rest. Our data indicate that, regardless of hemodynamic, both lower peak O2 uptake and peak O2-pulse show pulmonary vasculopathy impeding the increase of CO during exercise. CPX can predict the onset of PAH by detection of pulmonary vasculopathy in early stage.
O-069 The Comparison of the WHO Functional Classification and Exercise Capacity in Patients with Pulmonary Arterial Hypertension HIROSHI IRISAWA, HIROSHI WATANABE Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine Background: In almost all clinical trials to date, the severity in patients with pulmonary arterial hypertension (PAH) has been evaluated using the WHO functional classification. However, the WHO functional classification is a subjective evaluation. We aimed to compare the WHO classification and exercise capacity which is an objective evaluation, of patients with PAH. Methods and Results: To estimate exercise capacity, 6-minutes walking test (6MWT), shuttle walking test (SWT) and ergometer for measurement of peak oxygen consumption were performed in 19 clinically stable-PAH patients (6 WHO class II patients and 13 WHO class III patients). The average walk distance of WHO class II patients in 6MWT and SWT was significantly longer than that of WHO class III patients. The peak oxygen consumption of WHO class II patients was significantly higher than that of WHO class III patients.A few WHO class III patients walked longer than WHO class II patient in 6MWT. The walk distance in SWT and peak oxygen consumption of WHO class III patients did not exceed those of WHO class II patients. Conclusions: WHO functional classification of PAH patients should reflect their exercise capacity. In SWT and peak oxygen consumption, the results were clearly divided according to the WHO functional classification. These tests may be useful at a PAH patient’s functional prediction.
O-070 Pulmonary Hypertension in Patients with Left Heart Disease: The Relationship with Left Ventricular Systolic Function TATSURO IBE, HIROSHI WADA, KENICHI SAKAKURA, NAHOKO IKEDA, YOSHITAKA SUGAWARA, JUNYA AKO, SHIN-ICHI MOMOMURA Division Of Cardiology, Saitama Medical Center, Jichi Medical University Background: The clinical picture of pulmonary hypertension in patients with left heart disease (PH-LHD) is largely uninvestigated. Methods: We analyzed consecutive 198 patients who were diagnosed with symptomatic (NYHA$2) heart failure and underwent right-side catheterization at compensated stage before discharge. Patients with mean pulmonary artery pressure (mPAP)$25mmHg and PCWPO15mmHg were defined as PHLHD. Results: PH-LHD was observed in 43% of the patients with left heart disease. The clinical characteristics between non-PH and PH-LHD are shown in Table. Age, systolic blood pressure, LAD, E/e’, TPPG but not LVEF were significantly different between the
O-066 Independent Prognostic Value of Right Atrial Pressure in Patients with Congestive Heart Disease YOSHIHARU SADA, HIROKI KINOSHITA, TOMOHIKO KISAKA, YOSHIHIRO DOHI, YASUKI KIHARA Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Science When significant pulmonary hypertension (PH) develops in association with leftsided heart disease (LHD), it leads to poor prognosis. Up to the present, mean pulmonary arterial pressure (mPAP) and right ventricular (RV) ejection fraction are reported as a predictor of survival. We sought a better understanding of the hemodynamic parameters in the patients with pulmonary arterial wedge pressure (PCW) $ 15 mmHg. It might improve the accuracy of the prognostic stratification of patients with congestive heart failure. This study enrolled 1169 consecutive patients received right heat catheterization (RHC) from January 2000 through December 2012. Among them, we analyzed 354 patients with a pulmonary capillary wedge pressure (PCW) $15 mmHg. During a follow-up period of 36 month, 56 patients died. Among baseline variables, right atrial pressure (RAP)$11mmHg were significantly related to outcome. Meanwhile, cardiac index (CI)$2.5ml/min, transpulmonary pressure gradient (TPG)$12mmHg, mPAP$25mmHg, and PCW$20mmHg were not significantly related to outcome when analyzed in the univariate model (HR for RAP 1.82, 95%CI 1.19-2.79; p!0.006). In the multivariate model, only RAP remained statistically significant (HR for RAP 1.60, 95%CI 1.02-2.54; p! 0.04). Our observation suggested that RV dysfunction is greatly important for prognosis of LHD.
O-067 Effect of Bosentan on Exercise Capacity in Patients with Pulmonary Arterial Hypertension or Inoperable Chronic Thromboembolic Pulmonary Hypertension AKIHIRO HIRASHIKI1, TAKAHISA KONDO1, YOSHIHISA NAKANO2, SHIRO ADACHI2, TAKAHIRO OKUMURA2, TOYOAKI MUROHARA2 1 Advanced Medicine in Cardiopulmonary Disease, Nagoya Graduate School of Medicine, 2Cardiology, Nagoya Graduate School of Medicine Background: Endothelin receptor antagonists (ERA) improve the prognosis of patients with pulmonary arterial hypertension (PAH). However, only limited data are available on the effect of treatment with the ERA bosentan on exercise capacity assessed with cardiopulmonary exercise testing (CPX) in patients with PAH or inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Purpose: To investigate the effect of the oral, dual-ERA bosentan on exercise capacity in patients with PAH or inoperable CTEPH by means of CPX. Methods: Fifteen consecutive PAH and 9 consecutive inoperable CTEPH patients were treated with bosentan. All patients underwent cardiac catheterization and echocardiography. CPX was performed both prior to initiation of bosentan therapy and after 6 months. Results: In PAH patients, peak VO2 significantly increased from 13.8 6 6.8 mL/kg/min at baseline to 16.8 6 7.2 mL/kg/min after 6 months (P ! 0.01). Similarly, VE/VCO2 slope also significantly decreased from 56.8 6 22.5 to 48.9 6 17.5 (P ! 0.05). However, in CTEPH patients, there were no significant differences in peak VO2 or VE/VCO2 slope between the before and after bosentan therapy values (P 5 0.35, P 5 0.67, respectively). Conclusions: Bosentan therapy improves exercise capacity in patients with PAH within a relatively short period. However, the effect is not seen in patients with CTEPH.
JHFS
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O-068 Detection of Developing Pulmonary Vasculopathy in the Early Stage of Pulmonary Arterial Hypertension with Non- invasive Cardiopulmonary Exercise Testing HIROKI KINOSHITA, YOSHIHIRO DOHI, YOSHIHARU SADA, TOMOHIKO KISAKA, TOSHIRO KITAGAWA, HIDEYA YAMAMOTO, YASUKI KIHARA Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences In contrast to chronic thromboembolic pulmonary hypertension (CTEPH), patients with pulmonary arterial hypertension (PAH) have pulmonary vasculopathy which leads to impaired dilatation of affected pulmonary vessels, impeding the increase of cardiac output (CO) and stroke volume during exercise. Peak O2 uptake shows CO, and peak O2-pulse shows stroke volume during cardiopulmonary exercise testing (CPX). To investigate the exertional CO increase, we performed CPX in 12 patients with PAH and 7 with CTEPH. Predicted peak O2 uptake (45.5 6 8.0 vs. 60.6 6 13.4 %) and predicted peak O2-pulse (55.6 6 7.6 vs. 69.1 6 6.9 %) were significant higher in CTEPH than PAH. Diffusion capacity for carbon monoxide (% DLco: 40.3 6 13.7 vs. 62.2 6 13.9 %) was also significant higher in CTEPH than PAH, however there was no correlation between %DLco and peak O2 uptake or peak O2-pulse. While, there was no difference in mean pulmonary arterial pressure (31 6 6.8 vs. 30.1 6 7.0 mmHg), CO (4.1 6 0.6 vs. 4.4 6 0.4 L/min), and pulmonary vascular resistance (5.2 6 2.0 vs. 5.2 6 2.8 wood-units) at rest. Our data indicate that, regardless of hemodynamic, both lower peak O2 uptake and peak O2-pulse show pulmonary vasculopathy impeding the increase of CO during exercise. CPX can predict the onset of PAH by detection of pulmonary vasculopathy in early stage.
O-069 The Comparison of the WHO Functional Classification and Exercise Capacity in Patients with Pulmonary Arterial Hypertension HIROSHI IRISAWA, HIROSHI WATANABE Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine Background: In almost all clinical trials to date, the severity in patients with pulmonary arterial hypertension (PAH) has been evaluated using the WHO functional classification. However, the WHO functional classification is a subjective evaluation. We aimed to compare the WHO classification and exercise capacity which is an objective evaluation, of patients with PAH. Methods and Results: To estimate exercise capacity, 6-minutes walking test (6MWT), shuttle walking test (SWT) and ergometer for measurement of peak oxygen consumption were performed in 19 clinically stable-PAH patients (6 WHO class II patients and 13 WHO class III patients). The average walk distance of WHO class II patients in 6MWT and SWT was significantly longer than that of WHO class III patients. The peak oxygen consumption of WHO class II patients was significantly higher than that of WHO class III patients.A few WHO class III patients walked longer than WHO class II patient in 6MWT. The walk distance in SWT and peak oxygen consumption of WHO class III patients did not exceed those of WHO class II patients. Conclusions: WHO functional classification of PAH patients should reflect their exercise capacity. In SWT and peak oxygen consumption, the results were clearly divided according to the WHO functional classification. These tests may be useful at a PAH patient’s functional prediction.
O-070 Pulmonary Hypertension in Patients with Left Heart Disease: The Relationship with Left Ventricular Systolic Function TATSURO IBE, HIROSHI WADA, KENICHI SAKAKURA, NAHOKO IKEDA, YOSHITAKA SUGAWARA, JUNYA AKO, SHIN-ICHI MOMOMURA Division Of Cardiology, Saitama Medical Center, Jichi Medical University Background: The clinical picture of pulmonary hypertension in patients with left heart disease (PH-LHD) is largely uninvestigated. Methods: We analyzed consecutive 198 patients who were diagnosed with symptomatic (NYHA$2) heart failure and underwent right-side catheterization at compensated stage before discharge. Patients with mean pulmonary artery pressure (mPAP)$25mmHg and PCWPO15mmHg were defined as PHLHD. Results: PH-LHD was observed in 43% of the patients with left heart disease. The clinical characteristics between non-PH and PH-LHD are shown in Table. Age, systolic blood pressure, LAD, E/e’, TPPG but not LVEF were significantly different between the