L esercizio fisico e le patologie cardiorespiratorie: dalla valutazione funzionale alla prescrizione. M. Guazzi
|
|
- Alfred Hoover
- 5 years ago
- Views:
Transcription
1 La Riabilitazione Interdisciplinare L esercizio fisico e le patologie cardiorespiratorie: dalla valutazione funzionale alla prescrizione M. Guazzi Università di Milano Dipartimento Cardiologia Universitaria IRCCS Policlinico San Donato Milano
2 Functional Evaluation and Exercise Prescription In Cardiac Patients Background and Key Questions Background: Exercise is a Mainstay Physiological Stressor and VO 2 is a Key Measure of CV Health Questions: O 2 Transport and Utilization Chain: What The Wrong Pathways in HF? Gas Exchange Analysis and Exercise Prescription
3 Articles per annum Functional Evaluation in Heart Failure Applications of CPET in Cardiology CPX and Oscillatory Breathing CPET Statements Single variable CPX pathophysiol/clinical (Peak VO2) CPX and Ventilation (VE/VCO2 slope OUES, PETCO2) Pubmed search analysis: CPET/CPX cardiac patients, heart disease, cardiopulmonary disease,exercise gas exchange 60% of papers looking at prognosis 70% on HFrEF Multiparametric approach Cardiopulmonary Imaging/Reappraisal of Invasive CPET
4 From 9 plots to Score Risk Tables Universal Report Color-Coded Score Tables..the ultimate goal is to increase awareness of the value of CPET and to increase the number of healthcare professionals who are able to perform clinically meaningful interpretation.
5 Applications of NonInvasive Echo Combined Approach in the CPX Lab Diagnosis Instrumental Clinical follow-up Valvular heart disease HFrEF HFpEF Others Coronary Artery Disease (HCM, congenital ) Rest Echo MRI Pulmonary hemodynamics Rest Echo MRI Pulmonary Hemodyamics Ergometry Stress Echo Nuclear test Stress MRI Angio CT Rest Echo MRI Pulmonary hemodynamics Exercise Gas Exchange +Echo Angiography Medical LVAD HTx Surgery PCI Medical Surgery Medical post Surgery
6 Cardiopulmonary Imaging
7 Measurement Baseline Unloaded Effort Anaerobic Threshold Maximal Effort P Value for Each Group Within Group Between Groups Time-Group Interaction Stroke volume, ml Normal HFpEF HFrEF Cardiac output, l/min Normal HFpEF HFrEF Vo 2, l/min Normal HFpEF HFrEF Mitral regurgitation, ml Normal HFpEF HFrEF Avo 2 diff, l/l Normal HFpEF HFrEF 77.3 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± * 67.5 ± ± ± ± ± ± ± ± ± 3.4* 24.0 ± 27.0* 105 ± ± ± ± ± 3.5* 7.0 ± ± ± ± 0.34* 0.4 ± ± ± ± ± 19,0* 70.7 ± ± 2.9* 9.6 ± ± ± ± ± 0.56 AVO2 diff estimation by CO estim and VO ± ± ± 0.02* 0.10 ± ± ± 0.02* Values are mean ± SD, or n (%). *p< 0.01, p <0.001 AVo 2 Diff = arterial-venous oxygen content difference; EDV = end-diastolic volume; other abbreviations as in Table ± ± ± ± ± ± 0.01* < < < < < < < < < < < < < <
8 Determinants of the O 2 Transport and Utilization Chain Framed on the Fick Principle Signs and Symptoms HFpEF HFrEF Exercise Intolerance Dyspnea and Fatigue Organ limiting steps in O 2 uptake [convection (delivery), release, diffusion and use] VO 2 = C.O. x C (a-v) O 2 Low Pcap O 2 High PvO 2
9 Fick Principle: Determinants. Delivery or convection Extraction 2.5 times VO 2 = C.O. x c (a-v) O times 1.2 times C.O. = HR x SV Mixed Venous C = 1.34 x Sat O 2 x [Hb] Ventilation Gas diffusion Perfusion HYPOXIA ANEMIA
10 Cardiac Output (L/min) C.O. X C (a-v)o 2 = VO 2 2,525 AT Peak VO 2 (L/min) 4.0 Anemia Normal 3.5 1,515 COPD ,55 0 Rest C (a-v)o 2 (ml %)
11 Cardiac Output and O 2 Extraction at Maximum Exe. in Normal Individuals Stringer et al J Appl Physiol 1997;83: Normal A-V diff range
12 Cardiac Output and O 2 Extraction at Peak Exe. in HFrEF normals
13 Cardiac Output (L/min) C.O. X C (a-v)o 2 = VO 2 2,525 AT Peak VO 2 (L/min) 4.0 Normal 3.5 1, CHF 2.0 0,55 Rest Anemia C (a-v)o 2 (ml %)
14 Partitioning C (a-v) O 2 Contribution to VO 2 Increase in Severe HFrEF To define the C(a-v)O 2 phenotypes (high vs low) by estimating extraction from the CO/VO 2 ratio 104 HFrEF patients (mean age 64±11 y, male %, ischemic etiology 68%, mean LVEF 34±9%) Population divided by CO/VO 2 median value Group A (<0.49) vs Group B (>0.49) In preparation
15 Functional and Echocardiographic Characteristics According to the Extent of C (a-v) O 2 Extent Variables Group A (n=52) Group B (n=52) p value Rest Peak Rest Peak Rest Peak CPET VO 2, L/min 0.26± ± ± ± ns Peak VO 2, 11.8±4 12.6±3.1 ns ml O 2 *Kg -1 *min -1 C(a-v)O 2, ml/100ml 9±3 19±5 7±1 12± VE/VCO 2, slope 36±11 31±7.01 ECHO LVEDVi, ml/m 2 101±33 91±23.09 MR ERO, mm 2 22±10 33±13 16±9 25± E/e 28±15 22±11.02 CO, l/min 3.1± ± ± ±
16 Good Extractor (peak exercise CO/VO 2 <0.49) CO, L/min: Rest 2.9; Peak 3.72 VO 2 : L/min Rest 0.27; Peak 0.65 C(a-v)O 2 ml/100 ml Rest 9; Peak 17 Bad Extractor (peak exercise CO/VO ) CO, L/min: Rest 3.3; Peak 5.2 VO 2 : L/min Rest 0.19 ; Peak 0.61 C(a-v)O 2 ml/100 ml Rest 6; Peak Impaired ventilatory efficiency Preserved ventilatory efficiency
17 Effects of Exe. Central Blood Flow Distribution on Fick Principle in HFrEF To define the role of mitral regurgitation on C(a-v)O 2, CO and related functional phenotype 110 HFrEF patients (mean age 65±11 y, male %, ischemic etiology 64%, mean LVEF 32±8%) divided by severe MR 33 Controls In preparation
18 CO (L/min) 10 peak VO ± 0.6 L/min CONTROLS peak VO ± 0.32 L/min -% no MR % rest VO ± 0.08 ml/min MR 4 3 rest VO ± 0.06 ml/min peak VO ± 0.26 ml/min 2 1 rest VO ± 0.09 ml/min +% C (a-v)o 2 (ml/100ml)
19 Functional and Echocardiographic Characteristics According to MR Variables CPET Group A (n=24) Group B (n=80) p value Rest Peak Rest Peak Rest Peak Peak VO 2, ml O 2 *Kg -1 *min ±4 13.3±3.01 C(a-v)O 2, ml/100ml 8±3 19±4 7.5±1 14± VE/VCO 2, slope 37±10 31±6.01 ECHO LVEDVi, ml/m 2 111±30 89±22.07 E/e 28±15 22±11.02 CO, l/min 3.5± ± ± ±
20 Good Extractor Bad Extractor Severe mitral insufficiency (ERO=37 mm 2 ) and LV dilatation (LVEDVi= 117 ml/m 2 ) Mild mitral insufficiency (ERO=11 mm 2 ) and LV dilatation (LVEDVi= 86 ml/m 2 )
21 Determinants of mpap in HFrEF pump load mpap = Q x PVR + PCWP RV Function Compliance Mitral Insuff In the systemic circulation, downstream hydraulic pressure (in the right atrium) contributes little (<5%) to systemic arterial pressure. In the lung, downstream pressure (ie, LAP) is a much more important contributor to mean PAP ( 50%), and this proportion can become even greater in HF Vascular tone and remodeling resistive Increased LV filling pressure stiffness pulsatile
22 Mitral Regurgitation Induces PH and RV Dysfunction 1. MR (primary or secondary) in both HFrEF and HFpEF is prognostically relevant 1,2 especially when detected during exercise 3,4 2. Exercise-induced MR triggers PH and portends a severe outcome ò significance especially when RV dysfunction/failure coexists 5-7 Rest watt 40 watt peak 1: Tumminello G et al 2: Guazzi M et al Circulation 12; 3: Lancellotti P et al. Circulation 03;108: ; 4: Lancellotti P Eur Heart J 05;26: ; 5: Kusunose K Circ Cardiovasc Imaging. 13;6: : Bandera F et al Eur J Cardiov Imag 16 PASP: 50 mmhg PASP: 85 mmhg
23 Right Ventricular Contractile Reserve and Pulmonary Circulation Uncoupling During Exercise Challenge in Heart Failure: Pathophysiology and Clinical Phenotypes JACC HF 16; 4(8): HFrEF pts undergoing Echo stress test and CPX Group A (TAPSE > 16 mm) n= 60 Average TAPSE: 21 mm (TAPSE < 16 mm) n=37 Average TAPSE= 13 mm Rest Median TAPSE at peak exe 15.5 mm Group B (TAPSE > 15.5 mm) n=19 Group C (TAPSE < 15.5 mm) n=18 Peak Exe B C
24 Right Ventricular Contractile Reserve and Pulmonary Circulation Uncoupling During Exercise Challenge in Heart Failure: Pathophysiology and Clinical Phenotypes 97 HFrEF pts undergoing Echo stress test and CPX, divided according to TAPSE > 16 mm Group A or < 16 mmhg at rest with recovery (Group B) or not during exercise (Group C) Results- RV to PC Coupling PASP (mmhg) 80 PASP (mmhg) y = 13,721x + 4,5659 R² = 0,9953 y = 6,2162x + 16,495 R² = 0, y = 72,5x - 896,5 R² = 0,7758 y = 4,4426x - 26,23 R² = y = 5,7934x + 9,679 R² = 0, y = 5,5x - 82,833 R² = 0, Cardiac Output (ml/min) TAPSE (mm) Group A Group B Group C
25 LENGTH TAPSE (mm) TAPSE (mm) 293 HF patients (247 HFrEF; 46 HFpEF) Echocardiographic evaluation of RV function, PH, LV function and biomarkers y=-0,1407x+23,645 R 2 =0, y=-0,0277x+,579 R 2 =0, Survivors (n=246) Non-survivors (n=47) y=-0,1107x+19,897 R 2 =0, PASP, FORCE mmhg TAPSE > 16 mm (n=176) TAPSE 16 mm (n=117) y=-0,0473x+16,589 R 2 =0, PASP (mmhg)
26 Right Ventricular Contractile Reserve and Pulmonary Circulation Uncoupling During Exercise Challenge in Heart Failure: Pathophysiology and Clinical Phenotypes Results- RV Contractile Reserve (TAPSE vs PASP relationship at rest and peak exe) Group A Group B Group C TAPSE (mm) 30 y = -0,0151x + 23,32 TAPSE (mm) 30 TAPSE (mm) y = 0,0081x + 17, y = -0,0344x + 14, y = -0,0321x + 21, y = -0,0002x + 14,008 5 y = -0,0136x + 13, PASP (mmhg) PASP (mmhg) PASP (mmhg) Full simbols: Rest Empty symbols: Peak exercise
27 Right Ventricular Contractile Reserve and Pulmonary Circulation Uncoupling During Exercise Challenge in Heart Failure: Pathophysiology and Clinical Phenotype Clinical Characteristics Group A (n=60) Group B (n=19) Group C (n=18) P Age, y 62±10 65±8 64± BMI 26±4 26±4 27± Female gender, % BNP, pg/dl 1879 ± ± ± * LV Cardiac Data *:Group B and C vs Group A Group A (n=60) Group B (n=19) Group C (n=18) P Rest Peak Rest Peak Rest Peak Rest Peak LV ejection fraction, % 33±8 37±10 34±9 37±14 32±11 35±10 ns ns LV end diastolic vol. indexed, ml/m 2 90±23 95±28 113±47 ns LV mass indexed, g/m 2 126±30 121±22 154± Left atrial volume indexed, ml/m 2 47±18 52±24 80± E/e 22±11 25±16 38± Cardiac output, l*min ± ± ± ± ± ± Severe MR, %
28 Right Ventricular Contractile Reserve and Pulmonary Circulation Uncoupling During Exercise Challenge in Heart Failure: Pathophysiology and Clinical Phenotypes CPET Data HF (n= 97) Group A (n=60) Group B (n=19) Group C (n=18) P Value Maximal work, W 65 ± ± ± ± 18ⱡ Peak VO 2, ml/kg/min 13.0 ± ± ± ± 2.3ⱡ Predicted peak VO 2, % 53 ± ± ± ± Peak RER 1.17 ± ± ± ± Peak O 2 pulse, ml/beat 9.0 ± ± ± ± VE/VCO 2 slope 34 ± ± 7 35 ± ± End-tidal CO 2, mmhg 33 ± 6 35 ± 5 33 ± 6 28 ± Exercise Oscillatory Ventilation * Circulatory power, mmhg ml O 2 1,886 ± 672 2,144 ± 627 1,734 ± 508 1,182 ± kg -1 min -1 Ventilatory power, mmhg 4.8 ± ± ± ± 1.2 < Values are mean ± SD or %. *Chi-square test. Kruskal-Wallis test. p < 0.025, group B versus group C. BP= blood pressure; EOV= exercise oscillatory ventilation; HF= heart failure; RER= respiratory exchange ratio; VCO2= carbon dioxide output; VE= minute ventilation; VO2 = oxygen uptake. *:Group B and C vs Group A peak
29 HR (beats/min) HR (bpm) VE (L/min) VCO 2 (L/min) VO 2 (L/min) VO 2 /HR V T (L) VE (L/min) RR P ET O 2 (mmhg) VE (L/min) VO 2 (ml/min) VO 2 (ml/min) P ET CO 2 (mmhg) The 9-plot Analysis peak VO 2 : 8 ml/min/kg Ramp protocol (8 watt/min) Max workload: 45 watt Work Symptom-limited test 100 terminated because of DYSPNEA and Significant RV-PA UNCOUPLING Work VO 2 (L/min) Time (sec) VE/VCO0.8 2 : slope: VE/VO 2 0 VCO VCO 2 (L/min) Time (sec) Time (sec) VE/VCO Time (sec) VE (L/min) Time (sec) Guazzi M et al JACC 17 in press
30 Group B Rest Peak Rest TAPSE 13 mm Peak TAPSE 18 mm Rest Peak Rest PASP 30 mmhg Peak PASP 50 mmhg ERO 9 mm 2 ERO 13 mm 2 Peak VO ml/kg/min; VE/VCO 2 Slope 32; EOV no Group C Rest Peak Rest Peak Rest TAPSE 12 mm Peak TAPSE 13 mm Rest PASP 66 mmhg Peak PASP 78 mmhg ERO 41 mm 2 ERO 51 mm 2 Peak VO ml/kg/min; VE/VCO 2 Slope 42; EOV yes
31 Exercise Training in Heart Failure 1. Training Intensity (% of VO2 max or max HR) 2. Type of training (endurance, resistance, combined) 3. Methods of training (continuous or steady state, intermittent, interval) 4. Training modality (concentric vs eccentric) 5. Training target (systemic vs regional training, e.g. respiratory training) 6. Training control (supervised/non supervised) 7. Training location (hospital based, outpatient, home based) Moderate intensity endurance training has been proven prognostic benefits reduced hospitalization rate 1, mortality 2,3 1 O Connor CM et al, JAMA 09;301: Keteyan SJ et al JACC 12;60: Piepoli MF et al BMJ 04;328:189
32 Conclusions and Outlook CPET imaging seems now an evolving step to better phenotyping advanced HFrEF. Mitral regurgitation is a sort of central redistributor of O 2 delivery whose mechanistic implications on exercise are of novel interest for either extraction (exhaustion at maximum), RV to PC uncoupuling (increased load) and exercise ventilation inefficiency RV pump failure comes up as an early and quite underestimated mechanical cause of impaired performance and exhaustion. ET training in HF: the evidence is just for continuous, moderate intensity, supervised modalities
The role of CPX testing in the rehabilitation of cardiac patients.
Cardiopulmonary exercise testing (CPX) for comprehensive cardiac evaluations The role of CPX testing in the rehabilitation of cardiac patients. Viviane M Conraads, MD, PhD Department of Cardiology Cardiac
More information11/12/2018. Prof. Steven S. Saliterman. Options. Prof. Paul Iaizzo s Physiology Lab, PHSL 3701
Department of Biomedical Engineering, University of Minnesota http://saliterman.umn.edu/ Prof. Paul Iaizzo s Physiology Lab, PHSL 3701 Options University of Minnesota Bricker, E. Compass, 5 Types of Cardiac
More informationBasics of Cardiopulmonary Exercise Test Interpretation. Robert Kempainen, MD Hennepin County Medical Center
Basics of Cardiopulmonary Exercise Test Interpretation Robert Kempainen, MD Hennepin County Medical Center None Conflicts of Interest Objectives Explain what normally limits exercise Summarize basic protocol
More informationExercise PHT in valvular heart disease. Julien Magne CHU Limoges, France
Exercise PHT in valvular heart disease Julien Magne CHU Limoges, France Faculty disclosure Julien Magne I disclose the following financial relationships: I have no financial relationships to disclose.
More informationHFPEF Echo with Strain vs. MRI T1 Mapping
HFPEF Echo with Strain vs. MRI T1 Mapping Erik Schelbert, MD MS Director, Cardiovascular Magnetic Resonance Assistant Professor of Medicine Heart & Vascular Institute University of Pittsburgh Disclosures
More informationIvana Nedeljkovic, M Ostojic, V Giga, V Stojanov, J Stepanovic, A Djordjevic Dikic, B Beleslin, M Nikolic, M Petrovic, D Popovic
Combined cardiopulmonary exercise stress echocardiography test: New test for assessment of diastolic dysfunction in patients with hypertension Ivana Nedeljkovic, M Ostojic, V Giga, V Stojanov, J Stepanovic,
More informationCPX and Prognosis in Cardiovascular Disease
CPX and Prognosis in Cardiovascular Disease Anselm K. Gitt, Piergiuseppe Agostoni Herzzentrum Ludwigshafen, Germany Instituto di Cardiologia Università di Milano, Milan, Italy Cardiopulmonary exercise
More informationPeripheral Contributions to HFpEF
Peripheral Contributions to HFpEF Greg Lewis MD Heart Failure Section Head MGH Cardiology Division and Pulmonary Critical Care Unit Harvard Medical School March 12, 2018 Pathophysiology of HFpEF vs. HFrEF
More informationDiastolic Heart Failure Uri Elkayam, MD
Diastolic Heart Failure Uri Elkayam, MD Professor of Medicine University of Southern California School of Medicine Los Angeles, California elkayam@usc.edu Diastolic Heart Failure Clinical Definition A
More informationΜαρία Μπόνου Διευθύντρια ΕΣΥ, ΓΝΑ Λαϊκό
Μαρία Μπόνου Διευθύντρια ΕΣΥ, ΓΝΑ Λαϊκό Diastolic HF DD: Diastolic Dysfunction DHF: Diastolic HF HFpEF: HF with preserved EF DD Pathophysiologic condition: impaired relaxation, LV compliance, LV filling
More informationDr.Fayez EL Shaer Consultant cardiologist Assistant professor of cardiology KKUH
Pulmonary Hypertension in patients with Heart Failure with Preserved Ejection Fraction Dr.Fayez EL Shaer Consultant cardiologist Assistant professor of cardiology KKUH Recent evaluation of available data
More informationDiagnosis is it really Heart Failure?
ESC Congress Munich - 25-29 August 2012 Heart Failure with Preserved Ejection Fraction From Bench to Bedside Diagnosis is it really Heart Failure? Prof. Burkert Pieske Department of Cardiology Med.University
More informationAtrial dysfunction and chronotropic incompetence
Pathophysiology of heart failure with preserved ejection fraction Atrial dysfunction and chronotropic incompetence Vojtech Melenovsky IKEM, Prague, Czech Republic DECLARATION OF CONFLICT OF INTEREST :
More informationClinical implication of exercise pulmonary hypertension: when should we measure it?
Clinical implication of exercise pulmonary hypertension: when should we measure it? Jang-Young, Kim Wonju College of Medicine, Yonsei Univ. Exercise pulmonary hypertension (EPH) Introduction of pulmonary
More informationWhat is established? Risk of Benefit complica comp tion
What s new in exercise training in CHF? Jean-Paul Schmid, MD, FESC Consultant Cardiologist, SpitalNetzBern Tiefenau Hospital, Dept. of Internal Medicine, Cardiology, Bern, Switzerland What is established?
More informationExercise Stress Testing: Cardiovascular or Respiratory Limitation?
Exercise Stress Testing: Cardiovascular or Respiratory Limitation? Marshall B. Dunning III, Ph.D., M.S. Professor of Medicine & Physiology Medical College of Wisconsin What is exercise? Physical activity
More informationThe right ventricle in chronic heart failure
The right ventricle in chronic heart failure ESC 2012 Christian Opitz, Berlin There are no conflicts of interest relevant to this presentation Percent of Population Prevalence of Heart Failure by Age and
More informationThe REDUCE LAP Heart Failure Trial. David M Kaye MD, PhD on behalf of the REDUCE LAP HF Investigators
Transcatheter Intracardiac Shunt Device Provides Sustained Clinical Benefit at One Year in Heart Failure with Preserved or Mildly Reduced Ejection Fraction: The REDUCE LAP Heart Failure Trial David M Kaye
More informationDECLARATION OF CONFLICT OF INTEREST
DECLARATION OF CONFLICT OF INTEREST ESC Congress 2011 Pathophysiology of HFPEF Vascular Remodeling & Pulmonary Hypertension Carolyn S.P. Lam MBBS, MRCP, MS Case Presentation 81 yo woman with dyspnoea &
More informationGuide to the interpretation of Cardiopulmonary Exercise Testing
Guide to the interpretation of Cardiopulmonary Exercise Testing Dr. Ines Frederix December 2014 Copyright: Ines Frederix 1 Ergospirometry: parameter description... 5 1.1 Cardiovascular parameters... 5
More informationCTED and the Value of Exercise Testing
CTED and the Value of Exercise Testing leveraging cardiopulmonary physiology to uncover a disease even more elusive than CTEPH Paul Forfia, MD Professor of Medicine Director, PH, RHF, and PTE Programs
More informationΚαθετηριασμός δεξιάς κοιλίας. Σ. Χατζημιλτιάδης Καθηγητής Καρδιολογίας ΑΠΘ
Καθετηριασμός δεξιάς κοιλίας Σ. Χατζημιλτιάδης Καθηγητής Καρδιολογίας ΑΠΘ The increasing interest in pulmonary arterial hypertension (PAH), the increasing interest in implantation of LVADs, and the evolution
More informationAnnual Congress of the European Society of Cardiology Munich, August
Annual Congress of the European Society of Cardiology Munich, August 26 2012 Gas exchange measurements during exercise show early pulmonary arterial hypertension in scleroderma patients Daniel Dumitrescu,
More informationThe Role of Cardiac Rehabilitation. The Role of Cardiac Rehabilitation. in Heart Failure. in Heart Failure. History of Cardiac Rehab.
The Role of Cardiac Rehabilitation The Role of Cardiac Rehabilitation in Heart Failure in Heart Failure Kate Traynor RN MS FAACVPR Financial Disclosures No relevant financial relationship exists. History
More informationFUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART
FUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART CINDY BITHER, MSN, ANP, ANP, AACC, CHFN CHIEF NP, ADV HF PROGRAM MEDSTAR WASHINGTON HOSPITAL CENTER CONFLICTS OF INTEREST NONE
More informationPHYSICAL AND SEXUAL ACTIVITIES
Forgotten problems in HF PHYSICAL AND SEXUAL ACTIVITIES Massimo F Piepoli, MD, PhD, FESC, FACC Heart Failure Unit, Guglielmo da Saliceto Hospital, Piacenza m.piepoli@alice.it No disclosures Massimo Speaker
More informationRight Heart Catheterization. Franz R. Eberli MD Chief of Cardiology Stadtspital Triemli, Zurich
Right Heart Catheterization Franz R. Eberli MD Chief of Cardiology Stadtspital Triemli, Zurich Right Heart Catheterization Pressure measurements Oxygen saturation measurements Cardiac output, Vascular
More informationtodays practice of cardiopulmonary medicine
todays practice of cardiopulmonary medicine Concepts and Applications of Cardiopulmonary Exercise Testing* Karl T. Weber, M.D.; Joseph S. Janicki, Ph.D.; Patricia A. McElroy, M.D.; and Hanumanth K. Reddy,
More informationBrief View of Calculation and Measurement of Cardiac Hemodynamics
Cronicon OPEN ACCESS EC CARDIOLOGY Review Article Brief View of Calculation and Measurement of Cardiac Hemodynamics Samah Alasrawi* Pediatric Cardiologist, Al Jalila Children Heart Center, Dubai, UAE *
More informationTesting Clinical Implications
Cardiopulmonary Exercise Testing Clinical Implications Dr Sahajal Dhooria Outline Basic concepts Case studies Recent advances in clinical applications of CPET Basic Concepts Exercise Any physical activity
More informationEvolutionary origins of the right ventricle. S Magder Department of Critical Care, McGill University Health Centre
Evolutionary origins of the right ventricle S Magder Department of Critical Care, McGill University Health Centre Fully separated four chamber heart only evolved in birds and mammals What are the evolutionary
More informationAtrial dyssynchrony syndrome: An overlooked cause of heart failure with normal ejection fraction
Atrial dyssynchrony syndrome: An overlooked cause of heart failure with normal ejection fraction JC Eicher, G Laurent, O Barthez, A Mathé, G Bertaux, JE Wolf Heart Failure Treatment Unit, Rhythmology and
More informationCardiac Rehabilitation Program for LVAD Patients. Dr Katherine Fan Consultant Cardiologist Grantham Hospital, Hong Kong SAR
Cardiac Rehabilitation Program for LVAD Patients Dr Katherine Fan Consultant Cardiologist Grantham Hospital, Hong Kong SAR Left Ventricular Assist Devices (LVAD) Improved Survival Following LVAD Implantations
More informationCardiopulmonary Exercise Testing Cases
Canadian Respiratory Conference - 217 Cardiopulmonary Exercise Testing Cases Darcy D Marciniuk, MD FRCPC FCCP Associate Vice-President Research, University of Saskatchewan Professor, Respirology, Critical
More informationDyspnea is a common exercise-induced
MK pg 214 Mædica - a Journal of Clinical Medicine STATE-OF-THE-ART Cardiopulmonary exercise testing in differential diagnosis of dyspnea Nora TOMA, MD; Gabriela BICESCU, MD, PhD; Raluca ENACHE, MD; Ruxandra
More informationImaging in Heart Failure: A Multimodality Approach. Thomas Ryan, MD
Imaging in Heart Failure: A Multimodality Approach Thomas Ryan, MD Heart Failure HFrEF HFpEF EF50% Lifetime risk 20% Prevalence 6M Americans Societal costs - $30B 50% 5-year survival 1 Systolic
More informationJosh Stanton and Michael Epton Respiratory Physiology Laboratory, Canterbury Respiratory Research Group Christchurch Hospital
Josh Stanton and Michael Epton Respiratory Physiology Laboratory, Canterbury Respiratory Research Group Christchurch Hospital Setting Scene Advancements in neonatal care over past 30 years has resulted
More informationHFpEF. April 26, 2018
HFpEF April 26, 2018 (J Am Coll Cardiol 2017;70:2476 86) HFpEF 50% or more (40-71%) of patients with CHF have preserved LV systolic function. HFpEF is an increasingly frequent hospital discharge. Outcomes
More informationHFpEF: Pathophysiology & Treatment
HFpEF: Pathophysiology & Treatment Barry A. Borlaug, MD Mayo Clinic, Rochester, MN borlaug.barry@mayo.edu Disclosure Financial Relationships Research Support: Aires Pharmaceuticals, Medtronic, GSK Consulting/Advisory
More informationCHRONIC HEART FAILURE : WHAT ELSE COULD WE OFFER TO OUR PATIENTS? Cardiac Rehabilitation Society of Thailand
CHRONIC HEART FAILURE : WHAT ELSE COULD WE OFFER TO OUR PATIENTS? Cardiac Rehabilitation Society of Thailand ENHANCED EXTERNAL COUNTER PULSATION Piyanuj Ruckpanich, MD. Cardiac Rehabilitation Center Perfect
More informationValue of echocardiography in chronic dyspnea
Value of echocardiography in chronic dyspnea Jahrestagung Schweizerische Gesellschaft für /Schweizerische Gesellschaft für Pneumologie B. Kaufmann 16.06.2016 Chronic dyspnea Shortness of breath lasting
More informationApproach to CPET. CPET Cases. Case 1 4/4/2018. Impaired? Cardiac factors? Ventilatory factors?
Approach to CPET CPET Cases Neil MacIntyre MD Duke University Medical Center Durham NC Impaired? Work,, /kg Cardiac factors?, /, BP, Rhythm Ventilatory factors? Ve/MVV (incl EIB, trapping), PaCO2 Gas exchange
More informationThe Who, How and When of Advanced Heart Failure Therapies. Disclosures. What is Advanced Heart Failure?
The Who, How and When of Advanced Heart Failure Therapies 9 th Annual Dartmouth Conference on Advances in Heart Failure Therapies Dartmouth-Hitchcock Medical Center Lebanon, NH May 20, 2013 Joseph G. Rogers,
More informationTranscatheter InterAtrial Shunt Device for the Treatment of Heart Failure: Results From the REDUCE LAP-HF I Randomized Controlled Trial
A M E R I C A N H E A R T A S S O C I A T I O N S C I E N T I F I C S E S S I O N S 2 0 1 7 Transcatheter InterAtrial Shunt Device for the Treatment of Heart Failure: Results From the REDUCE LAP-HF I Randomized
More informationTHE DIASTOLIC STRESS TEST: A NEW CLINICAL TOOL? THE CONCEPT OF DIASTOLIC RESERVE
Thierry C. Gillebert University of Ghent ESC Education Committee THE DIASTOLIC STRESS TEST: A NEW CLINICAL TOOL? THE CONCEPT OF DIASTOLIC RESERVE 1 Case: Ann, 63 years Suffered from metabolic syndrome
More informationHeart failure is one of the most important
Mædica - a Journal of Clinical Medicine MAEDICA a Journal of Clinical Medicine 2013; 8(2): 124-128 ORIGINAL PAPERS Worsening of Heart Failure after Abdominal Surgery Can we predict it? Nora TOMA; Ruxandra
More informationEjection across stenotic aortic valve requires a systolic pressure gradient between the LV and aorta. This places a pressure load on the LV.
Valvular Heart Disease Etiology General Principles Cellular and molecular mechanism of valve damage Structural pathology Functional pathology - stenosis/regurgitation Loading conditions - pressure/volume
More informationCardiopulmonary Stress Testing: Beyond Transplant Evaluation
Cardiopulmonary Stress Testing: Beyond Transplant Evaluation Ross Arena, PhD, PT, FAHA, FESC, FACSM Professor and Head College of Applied Health Sciences University of Illinois at Chicago Cardio- Pulmonary
More informationLV geometric and functional changes in VHD: How to assess? Mi-Seung Shin M.D., Ph.D. Gachon University Gil Hospital
LV geometric and functional changes in VHD: How to assess? Mi-Seung Shin M.D., Ph.D. Gachon University Gil Hospital LV inflow across MV LV LV outflow across AV LV LV geometric changes Pressure overload
More informationCardiac Rehabilitation for Heart Failure Patients. Jia Shen MD, MPH Assistant Professor of Medicine UC San Diego Health System
Cardiac Rehabilitation for Heart Failure Patients Jia Shen MD, MPH Assistant Professor of Medicine UC San Diego Health System Disclosures There are no conflict of interests related to this presentation.
More informationQUIZ 1. Tuesday, March 2, 2004
Harvard-MIT Division of Health Sciences and Technology HST.542J: Quantitative Physiology: Organ Transport Systems Instructors: Roger Mark and Jose Venegas MASSACHUSETTS INSTITUTE OF TECHNOLOGY Departments
More informationHemodynamics of Exercise
Hemodynamics of Exercise Joe M. Moody, Jr, MD UTHSCSA and ALMMVAH, STVAHCS Exercise Physiology - Acute Effects Cardiac Output (Stroke volume, Heart Rate ) Oxygen Extraction (Arteriovenous O 2 difference,
More informationBenefits of Combined Aerobic/Resistance/Inspiratory Muscle Training in Patients with Chronic Heart Failure. The Ideal Exercise Program for CHF?
Benefits of Combined Aerobic/Resistance/Inspiratory Muscle Training in Patients with Chronic Heart Failure. The Ideal Exercise Program for CHF? I D. Laoutaris, S Adamopoulos, A Manginas, D B. Panagiotakos,
More informationHeart Failure with Preserved Ejection Fraction (HFpEF): Natural History and Contemporary Management
Heart Failure with Preserved Ejection Fraction (HFpEF): Natural History and Contemporary Management Jason L. Guichard, MD, PhD Greenville Health System Department of Medicine, Carolina Cardiology Consultants
More informationHeart Failure with Preserved Left Ventricular Ejection Fraction. (HFpEF)
Thessaloniki, May 27, 2017 Heart Failure with Preserved Left Ventricular Ejection Fraction Filippos Triposkiadis, MD, FESC, FACC Professor of Cardiology Director, Department of Cardiology Larissa University
More informationEjection across stenotic aortic valve requires a systolic pressure gradient between the LV and aorta. This places a pressure load on the LV.
Valvular Heart Disease General Principles Etiology Cellular and molecular mechanism of valve damage Structural pathology Functional pathology - stenosis/regurgitation Loading conditions - pressure/volume
More informationΔυναμική υπερηχοκαρδιογραφία στις μυοκαρδιοπάθειες : έχει θέση και ποια ;
Ελληνική Καρδιολογική Εταιρεία Σεμινάρια ομάδων εργασίας Θεσσαλονίκη, 8-10 Φεβρουαρίου 2018 Ομάδα εργασίας Ηχωκαρδιολογίας Δυναμική υπερηχοκαρδιογραφία στις μυοκαρδιοπάθειες : έχει θέση και ποια ; ΑΓΑΘΗ-ΡΟΖΑ
More informationContent Display. - Introduction to Unit 4. Unit 4 - Cardiorespiratory Response to Exercise : Lesson 1. KINE xxxx Exercise Physiology
Content Display Unit 4 - Cardiorespiratory Response to Exercise : Lesson KINE xxxx Exercise Physiology 5 Unit 4 - Cardiorespiratory Response to Exercise Lesson U4LP - Introduction to Unit 4 The specific
More informationFOLLOW-UP MEDICAL CARE OF SERVICE MEMBERS AND VETERANS CARDIOPULMONARY EXERCISE TESTING
Cardiopulmonary Exercise Testing Chapter 13 FOLLOW-UP MEDICAL CARE OF SERVICE MEMBERS AND VETERANS CARDIOPULMONARY EXERCISE TESTING WILLIAM ESCHENBACHER, MD* INTRODUCTION AEROBIC METABOLISM ANAEROBIC METABOLISM
More informationHeart Failure with preserved ejection fraction (HFpEF)
Heart Failure with preserved ejection fraction (HFpEF) Dr. Pierpaolo Pellicori Hull York Medical School Kingston-upon-Hull United Kingdom Conflict of interest: none Heart failure is a contemporary problem
More informationThe right heart: the Cinderella of heart failure
The right heart: the Cinderella of heart failure Piotr Ponikowski, MD, PhD, FESC Medical University, Centre for Heart Disease Clinical Military Hospital Wroclaw, Poland none Disclosure Look into the Heart
More informationTHE PROPER APPROACH TO DIAGNOSING HEART FAILURE WITH PRESERVED EJECTION FRACTION
THE PROPER APPROACH TO DIAGNOSING HEART FAILURE WITH PRESERVED EJECTION FRACTION James C. Fang, MD, FACC Professor and Chief Cardiovascular Division University of Utah School of Medicine Disclosures Data
More informationCardiopulmonary Exercise Testing: its principles, interpretation & application. DM Seminar Harshith
Cardiopulmonary Exercise Testing: its principles, interpretation & application DM Seminar Harshith Outline Physiology of exercise Introduction Equipment and working Principles Interpretation and variables
More informationDiastology State of The Art Assessment
Diastology State of The Art Assessment Dr. Mohammad AlGhamdi Assistant professor, KSAU-HS Consultant Cardiologist King AbdulAziz Cardiac Center Ministry of National Guard Health Affairs Diagnostic Clinical
More informationLEFT BUNDLE BRANCH BLOCK- BENIGN OR A HARBINGER OF HEART FAILURE? PROGNOSTIC INDICATOR?
LEFT BUNDLE BRANCH BLOCK- BENIGN OR A HARBINGER OF HEART FAILURE? PROGNOSTIC INDICATOR? Juan Cinca Department and Chair of Cardiology Hospital de la Santa Creu i Sant Pau Universitat Autònoma de Barcelona
More informationECHO HAWAII. Role of Stress Echo in Valvular Heart Disease. Not only ischemia! Cardiomyopathy. Prosthetic Valve. Diastolic Dysfunction
Role of Stress Echo in Valvular Heart Disease ECHO HAWAII January 15 19, 2018 Kenya Kusunose, MD, PhD, FASE Tokushima University Hospital Japan Not only ischemia! Cardiomyopathy Prosthetic Valve Diastolic
More informationChapter 21 Training for Anaerobic and Aerobic Power
Section 06: Exercise Training to Improve Performance Chapter 21 Training for Anaerobic and Aerobic Power Chapter 22 Muscular Strength: Training Muscles to Become Stronger Chapter 23 Special Aids to Exercise
More informationHEMODYNAMIC ASSESSMENT
HEMODYNAMIC ASSESSMENT INTRODUCTION Conventionally hemodynamics were obtained by cardiac catheterization. It is possible to determine the same by echocardiography. Methods M-mode & 2D echo alone can provide
More informationHeart Failure. Cardiac Anatomy. Functions of the Heart. Cardiac Cycle/Hemodynamics. Determinants of Cardiac Output. Cardiac Output
Cardiac Anatomy Heart Failure Professor Qing ZHANG Department of Cardiology, West China Hospital www.blaufuss.org Cardiac Cycle/Hemodynamics Functions of the Heart Essential functions of the heart to cover
More informationPulmonary Hypertension: Another Use for Viagra
Pulmonary Hypertension: Another Use for Viagra Kathleen Tong, MD Director, Heart Failure Program Assistant Clinical Professor University of California, Davis Disclosures I have no financial conflicts A
More informationAssessing the Impact on the Right Ventricle
Advances in Tricuspid Regurgitation Congress of the European Society of Cardiology (ESC) Munich, August 25-29, 2012 Assessing the Impact on the Right Ventricle Stephan Rosenkranz, MD Clinic III for Internal
More informationThe new Guidelines: Focus on Chronic Heart Failure
The new Guidelines: Focus on Chronic Heart Failure Petros Nihoyannopoulos MD, FRCP, FESC Professor of Cardiology Imperial College London and National & Kapodistrian University of Athens 2 3 4 The principal
More informationInterest of PVO2 assesment in HFpEF patients
Interest of PVO2 assesment in HFpEF patients Jean Yves TABET CRCB, Villeneuve Saint Denis Institut Jacques Cartier, Massy Conflits of interest none Interest of PVO2 in HFr EF Evaluation of exercise tolerance
More informationHow does Pulmonary Hypertension Affect the Decision to Intervene in Mitral Valve Disease? NO DISCLOSURE
How does Pulmonary Hypertension Affect the Decision to Intervene in Mitral Valve Disease? Prof. Patrizio LANCELLOTTI, MD, PhD GIGA Cardiovascular Sciences, Heart Valve Clinic, University of Liège, CHU
More informationCardiopulmonary Exercise Testing in Cystic Fibrosis
Cardiopulmonary Exercise Testing in Cystic Fibrosis Owen Tomlinson MSc, AFHEA Children s Health & Exercise Research Centre University of Exeter James Shelley MSc Physical Activity Exchange Liverpool John
More informationConstrictive/Restrictive Cardiomyopathies: Diagnosis and Management Update; Radiation Induced Heart Disease. Alexander (Sandy) Dick, MD
Constrictive/Restrictive Cardiomyopathies: Diagnosis and Management Update; Radiation Induced Heart Disease Alexander (Sandy) Dick, MD Outline Pericardial Constriction Diagnosis: Imaging, Hemodynamics
More informationEjection Fraction in Heart Failure: A Redefinition. Tarek Kashour King Fahad Cardiac Center King Saud University Riyadh, KSA
Ejection Fraction in Heart Failure: A Redefinition Tarek Kashour King Fahad Cardiac Center King Saud University Riyadh, KSA Word of caution!!! Incomplete understanding of a disease process may lead to
More informationThe Pathophysiology of Cardiogenic Shock Knowledge Gaps & Opportunities
The Pathophysiology of Cardiogenic Shock Knowledge Gaps & Opportunities Navin K. Kapur, MD, FACC, FSCAI, FAHA Associate Professor, Department of Medicine Interventional Cardiology & Advanced Heart Failure
More informationRest and Exercise Echocardiography in Hypertrophic Cardiomyopathy: Determinants of Exercise Peak Gradient and Predictors of Outcome
Rest and Exercise Echocardiography in Hypertrophic Cardiomyopathy: Determinants of Exercise Peak Gradient and Predictors of Outcome G. Deswarte, AS. Polge, N. Lamblin, A. Millaire, M. Richardson, C. Bauters,
More informationOriginal Article. Role of Right Ventricle and Dynamic Pulmonary Hypertension on Determining ΔVO 2
Original Article Role of Right Ventricle and Dynamic Pulmonary Hypertension on Determining /ΔWork Rate Flattening Insights From Cardiopulmonary Exercise Test Combined With Exercise Echocardiography Francesco
More informationImaging in dilated cardiomyopathy : factors associated with a poor outcome
Imaging in dilated cardiomyopathy : factors associated with a poor outcome Johan De Sutter, MD, PhD, FESC AZ Maria Middelares Gent and University Gent - Belgium Dilated cardiomyopathy Cardiomyopathy with
More informationJohn G Lainchbury, A Mark Richards
538 * Heart failure EXERCISE TESTING IN THE ASSESSMENT OF CHRONIC CONGESTIVE HEART FAILURE John G Lainchbury, A Mark Richards Heart 22;88:538 543 See end of article for authors affiliations c PRACTICAL
More informationPulmonary Hypertension Due to Left Heart Disease
ACC Middle East Conference 2018 Pulmonary Hypertension Due to Left Heart Disease Ammar Chaudhary, MBChB, FRCPC Advanced Heart Failure & Transplantation King Faisal Specialist Hospital and Research Center
More informationAcute Coronary Syndrome. Sonny Achtchi, DO
Acute Coronary Syndrome Sonny Achtchi, DO Objectives Understand evidence based and practice based treatments for stabilization and initial management of ACS Become familiar with ACS risk stratification
More informationAdvanced imaging of the left atrium - strain, CT, 3D, MRI -
Advanced imaging of the left atrium - strain, CT, 3D, MRI - Monica Rosca, MD Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Declaration of interest: I have nothing to declare Case
More informationPathophysiology: Heart Failure
Pathophysiology: Heart Failure Mat Maurer, MD Irving Assistant Professor of Medicine Outline Definitions and Classifications Epidemiology Muscle and Chamber Function Pathophysiology Heart Failure: Definitions
More informationHeFSSA Practitioners Program 2017 Theme The Patient Journey: Feel Good and Live Long. Case Study 2
HeFSSA Practitioners Program 2017 Theme The Patient Journey: Feel Good and Live Long Case Study 2 HEART FAILURE WITH MID-RANGE EJECTION FRACTION TREATMENT OPTIONS CLINICAL CASE MEDICAL HISTORY 59-year-old
More informationValvular Guidelines: The Past, the Present, the Future
Valvular Guidelines: The Past, the Present, the Future Robert O. Bonow, MD, MS Northwestern University Feinberg School of Medicine Bluhm Cardiovascular Institute Northwestern Memorial Hospital Editor-in-Chief,
More informationQATs. VCE Physical Education SCHOOL-ASSESSED COURSEWORK UNIT 3 OUTCOME 2. Introduction. Quality Assessment Tasks
QATs Quality Assessment s Introduction UNIT 3 OUTCOME 2 VCE Physical Education SCHOOL-ASSESSED COURSEWORK Outcome 2 Use data collected in practical activities to analyse how the major body and energy systems
More informationMASSACHUSETTS INSTITUTE OF TECHNOLOGY
Harvard-MIT Division of Health Sciences and Technology HST.542J: Quantitative Physiology: Organ Transport Systems Instructors: Roger Mark and Jose Venegas MASSACHUSETTS INSTITUTE OF TECHNOLOGY Departments
More informationCardiopulmonary Exercise Testing: Relevant But Underused
Global reprints distributed only by Postgraduate Medicine USA. No part of Postgraduate Medicine may be reproduced or transmitted in any form without written permission from the publisher. All permission
More informationDisclosure. RV is not the innocent bystander 10/1/16. Assessment and Management of Pulmonary Heart Disease in the Female Patient
Assessment and Management of Pulmonary Heart Disease in the Female Patient Oct 1, 2016 Deborah Women s Heart Center Susan E Wiegers, MD, FASE, FACC Professor of Medicine Senior Associate Dean of Faculty
More informationCor pulmonale. Dr hamid reza javadi
1 Cor pulmonale Dr hamid reza javadi 2 Definition Cor pulmonale ;pulmonary heart disease; is defined as dilation and hypertrophy of the right ventricle (RV) in response to diseases of the pulmonary vasculature
More informationRevision of 10/27/2017 Form #280 Page 1 of 12 PVDOMICS STUDY Clinical Center Right Heart Catheterization (RHC) Results Form #280
Revision of 10/27/2017 Form #280 Page 1 of 12 PVDOMICS STUDY Clinical Center Right Heart Catheterization (RHC) Results Form #280 Instructions: Review PVDOMICS MOP Chapter 100 prior to completing right
More informationSurgery and device intervention for the elderly with heart failure: assessing the need. Devices and Technology for heart failure in 2011
Surgery and device intervention for the elderly with heart failure: assessing the need Devices and Technology for heart failure in 2011 Assessing cardiovascular function / prognosis (in the elderly): composite
More informationEcho assessment of the failing heart
Echo assessment of the failing heart Mark K. Friedberg, MD The Labatt Family Heart Center The Hospital for Sick Children Toronto, Ontario, Canada Cardiac function- definitions Cardiovascular function:
More informationTopics to be Covered. Cardiac Measurements. Distribution of Blood Volume. Distribution of Pulmonary Ventilation & Blood Flow
Topics to be Covered MODULE F HEMODYNAMIC MONITORING Cardiac Output Determinants of Stroke Volume Hemodynamic Measurements Pulmonary Artery Catheterization Control of Blood Pressure Heart Failure Cardiac
More informationLessons From An Advanced Dyspnea Center: New Approaches to An Old Problem. Robert Schilz DO, PhD
Lessons From An Advanced Dyspnea Center: New Approaches to An Old Problem Robert Schilz DO, PhD Conflict of Interest Statement Robert Schilz DO, PhD No conflicts relevant to this talk Introduction, Definitions,
More informationEvalua&on)of)Le-)Ventricular)Diastolic) Dysfunc&on)by)Echocardiography:) Role)of)Ejec&on)Frac&on)
Evalua&on)of)Le-)Ventricular)Diastolic) Dysfunc&on)by)Echocardiography:) Role)of)Ejec&on)Frac&on) N.Koutsogiannis) Department)of)Cardiology) University)Hospital)of)Patras)! I have no conflicts of interest
More informationPathophysiology Department
UNIVERSITY OF MEDICINE - PLOVDIV Pathophysiology Department 15A Vasil Aprilov Blvd. Tel. +359 32 602311 Algorithm for interpretation of submaximal exercise tests in children S. Kostianev 1, B. Marinov
More information