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Effect of Steady State Exercise on Right and Left Ventricular Performance in Chronic Obstructive Pulmonary Disease
fu:FERENCES 1 Bates DV, Macklem PT, Christie RV: Respiratory Function in Disease. Philadelphia, Saunders, 1971, pp 122,
150 2 Rudolph M, Banks RA, Semple SJG: Hypercapnia during oxygen therapy in acute exacerbations of chronic respira-
tory failure. Lancet 483-486, 1977 3 West JB, Ventilation-perfusion and diffusion disturbances in asthma. In Bronchial Asthma, Mechanisms and Therapeutics. Weiss EB, Segal MS. Boston, Little Brown and Co. 1976, pp 195-316 4 West JB: Respiratory Physiology. Baltimore, Williams and Wilkins 1974, pp 66-67 5 West JB: Pulmonary Pathophysiology-The essentials. Baltimore, Williams and Wilkins, 1977, p 27 6 Laks, MM, Juratsch CE, Garner D et al: Acute pulmonary hypertension produced by distention of the main pulmonary artery in the conscious dog. Chest 68: 807-813, 1975 7 Juratsch CE, Jengo JA, Laks MM: The role of the autonomic nervous system and pulmonary artery receptors in the production of experimental pulmonary hypertension. Chest 71:265-268, 1977 8 Whipp BJ, Wasserman K: Carotid bodies and ventilatory control dynamics in man. Fed Proc (in press) 9 Whipp BJ, Drysdale DB, Cunningham DJC et al: The interaction of peripheral and intracranial chemoreceptor and respiratory drive in man studied by transients. Bull Europ Physiopathol Resp 12:254-255, 1976
Effect of Steady State Exercise on Right and Left Ventricular Performance in Chronic Obstructive Pulmonary Disease* Noninvasive Assessment by Radionuclide Angiocardiography R. A. Matthay, M.D., F.C.C.P.;• H.]. Berget', M.D.; R A. Dtroies, M.D.;]. Loke, M.D.; B. L. Ztwet, M.D.; and A. Gottachallc, M.D.
R
ight and left ventricular response to exercise in patients with chronic obstructive pulmonary disease ( COPD) remains to be defined fully. Consequently, exercise cardiac performance was evaluated in 24 patients with COPD and the results compared to data obtained in 20 normal control subjects. In patients with COPD, forced expiratory volume in one-second ( FEV1 ) averaged ( ± SEM) 51± 5 percent predicted. Right ventricular (RV) and left v«mbicular (LV) ejection fractions (EF) were determined noninvasively by first-pass radionuclide angiocardiography at rest and during exercise using a computerized multicrystal scintillation camera and intravenous injections of 88 •technetium. 1 •2 The normal cardiac response to exercise in controls was an absolute increase of ~ 5 percent in RVEF and LVEF. 8·• In patients with COPD, cardiac performance was measured during relatively steady state •From Yale University School of Medicine, New Haven. Supported in part by NIH Grant No. HL-21690-02.
CHEST, 77: 2, FEBRUARY, 1980 SUPPLEMENT
upright bicycle exercise at approximately 50 percent maximal workload (range, 25 to 75 watts). In patients with COPD, RVEF was abnormal at rest ( < 45 percent) 2 in 8/24 patients. Mean RVEF at rest and exercise was not different (rest, 48±1 percent; exercise 45±2 percent, P-NS). In contrast, LVEF rose from 62±3 percent to 68±3 percent (P<.05). An abnormal RV response to exercise occurred in 20/24 patients, including 12 with normal resting RVEF and all eight with an abnormal resting RVEF. Furthermore, RVEF fell by at least 5 percent with exercise in seven of these 20 patients. Mean arterial oxygen saturation did not change significantly with exercise. FEV1 was significantly lower in patients with an abnormal RV response to exercise than in those with normal response ( 49 ± 5 vs 68 ± 5 percent predicted, P<.05); a similar but not significant difference was demonstrated for resting arterial oxygen tension (65±3 vs 76±5 mm Hg, P NS). Seven patients had an abnormal LV response to exercise, which was unrelated to severity of COPD and probably was due to latent coronary artery disease. RV dysfunction in COPD may not be present in the resting state, but may become manifest only under physiologic stress such as mild upright exercise. Abnormal exercise RV reserve in COPD occurs most frequently in patients with high degrees of resting obstructive ventilatory impairment.
fu:FERENCES 1 Marshall RC, Berger HJ, Costin JC, et al: Assessment of cardiac performance with quantitative radionuclide angiocardiography: sequential left ventricular ejection fraction, normalized left ventricular ejection rate, and regional wall motion. Circulation 56:820-829, 1977 2 Berger HJ, Matthay RA, Lo1ce J, et al: Assessment of cardiac performance with quantitative radionuclide angiocardiography: Right ventricular ejection fraction with reference to 6ndings in chronic obstructive pulmonary disease. Am J Cardiol41:897-905, 1978 3 Berger HJ, Johnstone DE, Sands MJ, et al: Response of right ventricular ejection fraction to upright bicycle exercise in coronary artery disease. Circolation, In Press 4 Berger HJ, Reduto LA, Johnstone DE, et al: Global and regional left ventricular response to bicycle exercise in coronary artery disease: Assessment by quantitative radionuclide angiocardiography. Am J Med 66:13-21, 1979 Q. (Woolcock): Did you give your patients oxygen? A. (Matthay): We are planning to do this. It is obviously very important. Q. (Edelman): Are your data explained by changes in afterload? A. (Matthay): At this point I cannot answer this question for certain, although afterload augmentation by one of several potential mechanisms likely played a significant role in the observed abnormal RV exercise responses in patients with COPD. Q. (Permutt): I think it is a beautiful piece of work-good correlation with mechanical factors. Is lung hyperinflation increased during exercise? A. (Matthay): Although we did not address this in our exercising patients, we think it likely that lung hyperinflation increases with exercise, causing an increase in RV afterload.
CHRONIC OBSTRUCTIVE LUNG DISEASE 303
150 2 Rudolph M, Banks RA, Semple SJG: Hypercapnia during oxygen therapy in acute exacerbations of chronic respira-
tory failure. Lancet 483-486, 1977 3 West JB, Ventilation-perfusion and diffusion disturbances in asthma. In Bronchial Asthma, Mechanisms and Therapeutics. Weiss EB, Segal MS. Boston, Little Brown and Co. 1976, pp 195-316 4 West JB: Respiratory Physiology. Baltimore, Williams and Wilkins 1974, pp 66-67 5 West JB: Pulmonary Pathophysiology-The essentials. Baltimore, Williams and Wilkins, 1977, p 27 6 Laks, MM, Juratsch CE, Garner D et al: Acute pulmonary hypertension produced by distention of the main pulmonary artery in the conscious dog. Chest 68: 807-813, 1975 7 Juratsch CE, Jengo JA, Laks MM: The role of the autonomic nervous system and pulmonary artery receptors in the production of experimental pulmonary hypertension. Chest 71:265-268, 1977 8 Whipp BJ, Wasserman K: Carotid bodies and ventilatory control dynamics in man. Fed Proc (in press) 9 Whipp BJ, Drysdale DB, Cunningham DJC et al: The interaction of peripheral and intracranial chemoreceptor and respiratory drive in man studied by transients. Bull Europ Physiopathol Resp 12:254-255, 1976
Effect of Steady State Exercise on Right and Left Ventricular Performance in Chronic Obstructive Pulmonary Disease* Noninvasive Assessment by Radionuclide Angiocardiography R. A. Matthay, M.D., F.C.C.P.;• H.]. Berget', M.D.; R A. Dtroies, M.D.;]. Loke, M.D.; B. L. Ztwet, M.D.; and A. Gottachallc, M.D.
R
ight and left ventricular response to exercise in patients with chronic obstructive pulmonary disease ( COPD) remains to be defined fully. Consequently, exercise cardiac performance was evaluated in 24 patients with COPD and the results compared to data obtained in 20 normal control subjects. In patients with COPD, forced expiratory volume in one-second ( FEV1 ) averaged ( ± SEM) 51± 5 percent predicted. Right ventricular (RV) and left v«mbicular (LV) ejection fractions (EF) were determined noninvasively by first-pass radionuclide angiocardiography at rest and during exercise using a computerized multicrystal scintillation camera and intravenous injections of 88 •technetium. 1 •2 The normal cardiac response to exercise in controls was an absolute increase of ~ 5 percent in RVEF and LVEF. 8·• In patients with COPD, cardiac performance was measured during relatively steady state •From Yale University School of Medicine, New Haven. Supported in part by NIH Grant No. HL-21690-02.
CHEST, 77: 2, FEBRUARY, 1980 SUPPLEMENT
upright bicycle exercise at approximately 50 percent maximal workload (range, 25 to 75 watts). In patients with COPD, RVEF was abnormal at rest ( < 45 percent) 2 in 8/24 patients. Mean RVEF at rest and exercise was not different (rest, 48±1 percent; exercise 45±2 percent, P-NS). In contrast, LVEF rose from 62±3 percent to 68±3 percent (P<.05). An abnormal RV response to exercise occurred in 20/24 patients, including 12 with normal resting RVEF and all eight with an abnormal resting RVEF. Furthermore, RVEF fell by at least 5 percent with exercise in seven of these 20 patients. Mean arterial oxygen saturation did not change significantly with exercise. FEV1 was significantly lower in patients with an abnormal RV response to exercise than in those with normal response ( 49 ± 5 vs 68 ± 5 percent predicted, P<.05); a similar but not significant difference was demonstrated for resting arterial oxygen tension (65±3 vs 76±5 mm Hg, P NS). Seven patients had an abnormal LV response to exercise, which was unrelated to severity of COPD and probably was due to latent coronary artery disease. RV dysfunction in COPD may not be present in the resting state, but may become manifest only under physiologic stress such as mild upright exercise. Abnormal exercise RV reserve in COPD occurs most frequently in patients with high degrees of resting obstructive ventilatory impairment.
fu:FERENCES 1 Marshall RC, Berger HJ, Costin JC, et al: Assessment of cardiac performance with quantitative radionuclide angiocardiography: sequential left ventricular ejection fraction, normalized left ventricular ejection rate, and regional wall motion. Circulation 56:820-829, 1977 2 Berger HJ, Matthay RA, Lo1ce J, et al: Assessment of cardiac performance with quantitative radionuclide angiocardiography: Right ventricular ejection fraction with reference to 6ndings in chronic obstructive pulmonary disease. Am J Cardiol41:897-905, 1978 3 Berger HJ, Johnstone DE, Sands MJ, et al: Response of right ventricular ejection fraction to upright bicycle exercise in coronary artery disease. Circolation, In Press 4 Berger HJ, Reduto LA, Johnstone DE, et al: Global and regional left ventricular response to bicycle exercise in coronary artery disease: Assessment by quantitative radionuclide angiocardiography. Am J Med 66:13-21, 1979 Q. (Woolcock): Did you give your patients oxygen? A. (Matthay): We are planning to do this. It is obviously very important. Q. (Edelman): Are your data explained by changes in afterload? A. (Matthay): At this point I cannot answer this question for certain, although afterload augmentation by one of several potential mechanisms likely played a significant role in the observed abnormal RV exercise responses in patients with COPD. Q. (Permutt): I think it is a beautiful piece of work-good correlation with mechanical factors. Is lung hyperinflation increased during exercise? A. (Matthay): Although we did not address this in our exercising patients, we think it likely that lung hyperinflation increases with exercise, causing an increase in RV afterload.
CHRONIC OBSTRUCTIVE LUNG DISEASE 303