Meet the expert ME6 Heart failure-copd overlap and cardiovascular responses to exercise: a cardiologist s perspective

Transcription

1 ERS Annual Congress Milan September 2017 Meet the expert ME6 Heart failure-copd overlap and cardiovascular responses to exercise: a cardiologist s perspective Monday, 11 September :00-14:00 Amber (South) MICO

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3 Meet the expert : ME6 Heart failure-copd overlap and cardiovascular responses to exercise: a cardiologist s perspective Aims : COPD and chronic heart failure (CHF) coexist in approximately one of three elderly patients with a primary diagnosis of either disease. Despite this, the pathophysiological consequences of the COPD-CHF overlap remain to be clarified. The aim of this Meet the Expert session is to provide a comprehensive understanding of the pathophysiological consequences of this overlap. Tracks: Chronic airway diseases - Exercise, rehabilitation and physiology Tags: Clinical Target audience: Cardiologist - Clinician - Physiologist - Physiotherapist - Pulmonologist - Respiratory physician - Respiratory therapist 13:00 Heart failure-copd overlap and cardiovascular responses to exercise: a cardiologist s perspective Piergiuseppe Agostoni (Milan, Italy)

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6 Piergiuseppe Agostoni, MD, PhD Centro Cardiologico Monzino, Dept. Of Clinical sciences and Community health, Cardiovascular Section, University of Milano, Milano Division of Respiratory Disease, University of Washington, Seattle, WA 1

7 Conflict of interest disclosure I have no real or perceived conflicts of interest that relate to this presentation. I have the following real or perceived conflicts of interest that relate to this presentation: Affiliation / Financial interest Commercial Company Grants/research support: Honoraria or consultation fees: Participation in a company sponsored bureau: Stock shareholder: Spouse / partner: Other support / potential conflict of interest: This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker s presentation. Drug or device advertisement is forbidden.

8 The comorbidome is a graphic expression of comorbidities with >10% prevalence and those comorbidities with the strongest association with mortality The area of the circle relates to the prevalence of the disease The proximity to the center (mortality) expresses the strength of the association between the disease and risk of death CAD = coronary artery disease; CHF = congestive heart failure; CRF = chronic renal failure; CVA = cerebrovascular accident; DJD = degenerative joint disease; GERD = gastroesophageal reflux Disease; OSA = obstructive sleep apnea; PAD = peripheral artery disease; HTN/RHF = pulmonary hypertension and right heart failure Divo M, et al. Am J Respir Crit Care Med

9 1-year survival 1-year survival free of MI, stroke or rehospitalization for CHF HR 1.42 ( ) HR 1.26 ( ) 1-year survival free of rehospitalization for CHF HR 1.35 ( ) Survival-free rehospitalization for CHF for any cause HR 1.14 ( ) Thick black line = patients without COPD; dotted black line = patients with COPD. CHF = chronic heart failure; HR = hazard ratio; MI = myocardial infarction Macchia A, et al. Eur J Heart Fail

10 * * Muscles activity Dead space Alveolar capillary gas diffusion VE = k x VCO 2 /[PaCO 2 x (1-Vd/Vt)] * Reflexes: Chemo,metabo CO 2 set-point * Sympathetic domain

11 * Cardiac output C(A-V)O 2 Alveolar capillary gas diffusion, PO2 atmopheric partial pressure Dead space Alveolar capillary gas diffusion VE = k x VO 2 /[PaO 2 x (1-Vd/Vt)] * Reflexes: Chemo,metabo O 2 set-point * Sympathetic domain

12 VE = k x VCO 2 /[PaCO 2 x (1-Vd/Vt)]

13 V D /V T 0,8 0,7 0,6 0,5 0,4 V D /V T = 1-863/PaCO2 (V E /VCO 2 ) PaCO 2 0,3 0,2 V E /VCO 2 0,

14 V D /V T 0,8 0,7 0,6 0,5 0,4 0,3 V D /V T = 1-863/PaCO2 (V E /VCO 2 ) HF COPD NORMAL PPH PaCO 2 0,2 V E /VCO 2 0,

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16 % Liters ml/kg/min ml/kg/min This one not quite right curves too high 20 Peak VO 2 18 VO 2 AT VE Max Day VT Max Day Day *p<0.001 vs Day 1. Peak VO 2 = oxygen consumption at peak exercise; AT = anaerobic threshold; VE max = maximal ventilation (percent of predicted value); VT max = maximal tidal volume Day Patients who underwent ultrafiltration Control group Agostoni PG, et al. J Am Coll Cardiol

17 Agostoni PG, et al. Am J Cardiol

18 Tidal volume (L) A1 patients: Before ultrafiltration 3 months after ultrafiltration Esophageal swing pressure (mmhg) Data are mean over 30 seconds (measurements of the last 30 seconds of each minute of exercise are reported). Vt = tidal volume; Pes =esophageal pressure Agostoni PG, et al. Am J Cardiol

19 CI (L/min/m 2 ) CI (L/min/m 2 ) Ppaw (mmhg) Pra (mmhg) Baseline 3 months after ultrafiltration *p<0.01 versus baseline (same level of exercise); vertical bars are SEM. CI = cardiac index; Ppaw = pulmonary artery wedge pressure; Pra = right atrial pressure Agostoni PG, et al. Am J Cardiol

20 Pra (mmhg) Ppaw (mmhg) Baseline 3 months after ultrafiltration *p<0.01 versus baseline (same level of exercise). Solid line = 1:3 slope of right atrial to pulmonary artery wedge pressure. Broken line = 1:1 slope of the same relation. Vertical bars are SEM. Ppaw = pulmonary artery wedge pressure; Pra = right atrial pressure Agostoni PG, et al. Am J Cardiol

21 Heart Heart Systole Diastole Modified from Butler J, et al. Circulation

22 % of predicted 190 patients with heart failure o o o o o o o o o O = p<0.01 DLCO = lung diffusion for carbon monoxide (alveolar gas diffusion); FEV 1 = forced expiratory volume in 1 second; FVC = forced vital capacity; VO 2 = oxygen consumption Agostoni PG, et al. Eur Heart J

23 Horizontal and vertical bars are the standard deviation of the normal population for VC and FEV 1, respectively. CHF = chronic heart failure; FEV 1 = forced expiratory volume in 1 second; VC = vital capacity Wasserman K, et al. Circulation

24 VC (ml/min) VA (L) DLCO (ml/mmhg/min) DM (ml/mmhg/min) * * * < >20 < > * * * # < >20 < >20 *p<0.01 vs <12; p<0.05 vs 12 16; p<0.01 vs 12 16; # p<0.02 vs <12; ǁ p<0.02 vs groups 12 16, and >20 combined. DLCO = lung diffusion for carbon monoxide (alveolar gas diffusion); DM = membrane diffusion; VA = alveolar ventilation; VC = capillary volume Agostoni P, et al. Eur Heart J

25 FEV 1 = forced expiratory volume in 1 second; VC = vital capacity Agostoni P, et al. Am Heart J 2000;140:e24 20

26 VE = expired volume per unit time (minute ventilation); VO 2 = oxygen consumption; VT = tidal volume Wasserman K, et al. Circulation

27 CHF = chronic heart failure; ex = exercise; HF = heart failure; Ptp = transpulmonary pressure Agostoni P, et al. J Appl Physiol

28 RQ = respiratory quotient; VCO 2 = carbon dioxide production; VO 2 = oxygen consumption; Vt = tidal volume 23

29 DS = dead space; Vt = tidal volume; W = workload Agostoni P, et al. Chest

30 Unavailable volume Available volume Vt = tidal volume; W = workload Apostolo A, et al. J Card Fail

31 N= N=1807 >33 FU_total (days) FU = follow-up; VCO 2 = carbon dioxide production; VE = expired volume per unit time (minute ventilation) Corrà U, et al. Int J Cardiol

32 Total population (6082 pts) peak VO2<12 ml/min/kg (1799 pts) VE/VCO2>34 VE/VCO2<34 VE/VCO2>34 VE/VCO2<34 p< p< VE/VCO2

33 HF = heart failure 28

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35 VE (L/min) 50 VEVCO 2 slope=29,78 ± 4,35 40 VEVCO 2 slope=28,56 ± 5,16 30 VEVCO 2 slope=27,57 ± 3, Y intercept 13,26±3,18 9,69±2,91 4,98±1,63 Added dead space ml +250 ml + 0 ml VCO 2 (L/min) VCO 2 = carbon dioxide production; VE = expired volume per unit time (minute ventilation) Gargiulo P, et al. PLoS One

36 VE/VCO 2 is a linear relationship where VE = avc0 2 +b with a= slope b= intercept with the Y axis b a VE=aVCO2+b VD does not contribute to gas exchanges, so the dead space of VE is the ventilation with VCO 2 equal to 0 Therefore, when VCO 2 = 0, VE related to VD is = b, that is = VE/VCO 2 Y intercept value The estimated measure of VD can be calculated measuring VE with VCO 2 = 0, that is Y intercept, divided by dead space respiratory rate (RR), that is RR with VCO 2 = 0 Y intercept / RR of VD The RR of VD can be calculated from the Y intercept value of the RR/VCO 2 relationship. 31

37 VD EVALUATION CALCULATED AS Y INTERCEPT OF I VE/VCO 2 WITH BLOOD GAS ANALYSIS (ABG) VD (L) intercetta ABG basal Added dead space VD Y intercept (L) +0 ml 0,39±0, ml 0,61±0, ml 0,83±0,12 32

38 Anthropometric and demographic characteristics HF n=108 HF-COPD n=106 COPD n=95 PAH n=85 Healthy n=56 ANOVA Age (years) 63±10* 66±5* 67±8* 54±18 # 50±16 # < Weight (kg) 79.7±15* 77±13* 72.7± ±12 # 77.9±13* < Height (cm) 171±8* 170±7* 168±8 166±8 # 175±8* # < Male (%) 88* (81%) 93* (88%) 83* (87%) 38 # (45%) 48* (86%) < *p 0.05 vs PAH, p 0.05 vs. healthy subjects, p 0.05 vs COPD, p 0.05 vs HF; # p 0.05 vs COPD-HF HF = heart failure; PAH = pulmonary arterial hypertension Apostolo A, et al. Int J Cardiol, in press 33

39 VE/VCO 2 slope VE INT (L/min) * * * * * * * * * HF HF-COPD COPD PAH Healthy * HF HF-COPD COPD PAH Healthy * * CO 2 = carbon dioxide; HF = heart failure; PAH = pulmonary arterial hypertension; VCO 2 = carbon dioxide production; VE = expired volume per unit time (minute ventilation) VE INT = VE intercept Apostolo A, et al. Int J Cardiol, in press 34

40 HF = heart failure; PAH = pulmonary arterial hypertension; VCO 2 = carbon dioxide production; VE = expired volume per unit time (minute ventilation) Apostolo A, et al. Int J Cardiol, in press 35

41 VE VE VE VE DS VE DS VE DS VE DS VE DS VE Alv VE Alv VE Alv VE Alv VE DS VE Alv VE Alv VCO 2 VCO 2 VCO 2 VE VE VE DS VE DS VE DS VE DS VE Alv VE Alv VE Alv VE Alv VCO 2 VCO 2 Dotted lines are extrapolation to the Y axis (VE intercepts) VCO 2 = carbon dioxide production; VE = expired volume per unit time (minute ventilation); Alv = alveolar ventilation; DS = dead space Apostolo A, et al. Int J Cardiol, in press 36

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