Effect of tiotropium bromide on the cardiovascular response to exercise in COPD

Respiratory Medicine (27) 11, 217 224 Effect of tiotropium bromide on the cardiovascular response to exercise in COPD J. Travers a, P. Laveneziana a, K.A. Webb a, S. Kesten b, D.E. O Donnell a, a Respiratory Investigation Unit, Department of Medicine, Queen s University, Kingston, Ont., Canada b Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA Received 9 January 27; accepted 16 March 27 Available online 1 May 27 KEYWORDS Dyspnea; Placebo; Heart rate; Blood pressure Summary Introduction: Exercise limitation and exertional dyspnea are important symptoms of chronic obstructive pulmonary disease (COPD), which may be partially relieved by tiotropium. Although the mechanism of relief is multifactorial, improved dynamic ventilatory mechanics appear to be important. It is not however known whether tiotropium may also act by improving cardiovascular function during exercise. Methods: We conducted a randomized, placebo-controlled crossover study in 18 COPD subjects with a FEV 1 473% predicted (mean7sem). Subjects inhaled either tiotropium 18 mg or placebo once daily for 7 1 days then the other intervention for a further 7 1 days after a 35-day washout period. Subjects performed constant work rate cycle exercise at 75% of maximum after each treatment period. Heart rate, blood pressure, oxygen uptake, operating lung volumes and breathing pattern were measured. Results: Heart rate was 7 beats/min lower at rest and throughout exercise with tiotropium compared to placebo (p ¼.1). Oxygen uptake was unchanged throughout exercise. Oxygen pulse on exercise was greater by 7.4% (po.1) and systolic blood pressure was lower by 7 mmhg (p ¼.3). The cardiac rate pressure product was reduced by 7.6% (po.1) with tiotropium. Exercise endurance tended to be greater with tiotropium. Reduction in heart rate on exercise correlated with an increase in inspiratory reserve volume (r ¼.5, p ¼.4). Conclusion: Tiotropium may improve cardiac as well as pulmonary function during exercise in COPD. We suggest that this effect may be due, in part, to improved cardiopulmonary interaction as a result of mechanical unloading of the ventilatory muscles however further study is required. ClinicalTrials.gov Identifier: NCT27427. & 27 Elsevier Ltd. All rights reserved. Corresponding author. Tel.: +1 613 5482342; fax: +1 613 5491459. E-mail address: odonnell@post.queensu.ca (D.E. O Donnell). 954-6111/$ - see front matter & 27 Elsevier Ltd. All rights reserved. doi:1.116/j.rmed.27.3.8

218 Introduction Exercise limitation and exertional dyspnea are often the most important symptoms experienced by individuals with chronic obstructive pulmonary disease (COPD). The cause of exercise limitation is multifactorial. Dynamic pulmonary hyperinflation during exercise with resulting neuromechanical dissociation is likely to be important in individuals with moderate to severe COPD. 1 Abnormalities of cardiovascular function, pulmonary gas exchange, peripheral muscle function, and perception of symptoms may also contribute. 2 4 Tiotropium bromide is a long acting anticholinergic agent that has demonstrated efficacy as inhaled therapy for COPD in improving exertional dyspnea, health status, spirometry, exercise tolerance and exacerbation frequency. 5 7 It is as effective or more effective than the short acting anticholinergic agent ipratropium and the long-acting b-adrenoreceptor agonist salmeterol. 8,9 Tiotropium therapy produces a reduction in dynamic hyperinflation and neuromechanical dissociation during exercise in COPD patients, 1 a potential explanation for the improvements in exertional dyspnea and exercise capacity. What is not known is whether the beneficial effect of tiotropium on exercise capacity may be due in part to improvements in the cardiovascular response to exercise. No study to date has examined the cardiovascular effects of tiotropium during exercise. Tiotropium could affect the cardiovascular system either directly or through its pulmonary effects via a cardiopulmonary interaction. A direct cardiac action is plausible as other anticholinergic agents are known to exert direct effects on the cardiovascular system. Atropine is a nonselective anticholinergic that increases heart rate and myocardial work at rest and during exercise. 11 In contrast, when the anticholinergic agents ipratropium and oxitropium are inhaled, resting heart rate may be slightly reduced. 12,13 Oxitropium has also been shown to slightly attenuate the exercise-induced rise in pulmonary artery pressure in COPD patients. 13 Like ipratropium and oxitropium, tiotropium has not been associated with classic anticholinergic effects such as tachycardia and may also slightly reduce resting heart rate. 14 Tiotropium however differs from traditional anticholinergic agents in its relative kinetic selectivity for M1 and M3 airway muscarinic receptor subtypes over the M2 cardiac muscarinic receptor subtype 15 and its direct cardiac effects during exercise are unknown. Another possibility is that tiotropium may affect the cardiovascular response to exercise by improving expiratory airflow and pulmonary mechanics via a cardiopulmonary interaction. Tiotropium improves dynamic hyperinflation during exercise. 7,16 This allows tidal breathing to occur on the more favorable, linear portion of the respiratory pressure volume curve and allows tidal breaths to be generated using less negative inspiratory pleural pressures. 1 Negative pleural pressures increase cardiac afterload as the ventricles must overcome the transmural pressure, the difference between thoracic and ventricular pressure, in addition to arterial pressure. 17,18 This cardiopulmonary interaction may be a limiting factor for exercise in individuals with severe COPD 19 and other cardiopulmonary interactions may also be relevant. We recently conducted a controlled clinical study designed to assess the effect of tiotropium on the sensory and pulmonary responses to exercise in COPD patients. 1 In the current study, we assessed cardiovascular data obtained at the time of this study to determine the effect of tiotropium on the cardiovascular response to exercise in COPD. Methods Subjects Subjects were eligible for inclusion if they had COPD, 2 were clinically stable, had a X2 pack-year cigarette smoke exposure, a forced expiratory volume in 1 s (FEV 1 ) p65% predicted, a functional residual capacity (FRC) X12% predicted and a modified baseline dyspnea index score p6. 21 Subjects were excluded if they had comorbid disease that could contribute to dyspnea and exercise limitation, a contraindication to exercise testing, 22 daytime oxygen use or had participated in a pulmonary rehabilitation program in the 6 weeks prior to the study. Study design J. Travers et al. The study incorporated a randomized, double-blind, placebo-controlled crossover design. Approval was obtained from the local hospital and university research ethics board. After giving written informed consent, subjects completed a screening assessment to determine eligibility where medical history, physical examination, chronic dyspnea evaluation, pulmonary function testing and a symptom-limited incremental cycle exercise test were performed. Eligible subjects entered a baseline period during which further pulmonary function tests and a constant load exercise test were performed to familiarize subjects with testing procedures in order to avoid possible learning effects. These tests were performed again both prior to and at the end of each of two 7 1 day treatment periods separated by a 35 day washout period. During each treatment period, subjects inhaled visually identical study medication, either tiotropium 18 mg or placebo, once daily in addition to other regular medication. Subjects were randomized in blocks of four using commercial software (ClinPro/LBL Version 5.2, Clinical Systems Inc.) to have an equal chance of being allocated to receive tiotropium during the first treatment period followed by placebo during the second treatment period or placebo during the first treatment period followed by tiotropium during the second treatment period. Subjects completed a follow up visit 1 week after completion of the second treatment period consisting of a physical examination and pulmonary function tests. Subjects avoided oral and long-acting b-agonists for 1 week before the screening visit and throughout the study and short-acting anticholinergics for 1 day before and throughout the study. Tiotropium or other long-acting anticholinergics were avoided apart from the study medication. Salbutamol was provided as an aerosol inhaler as rescue medication during the study. Concomitant regular corticosteroids and theophylline were permitted throughout the study except that before each study visit, short-acting

Cardiovascular effects of tiotropium during exercise 219 theophylline and long-acting theophylline were withheld for at least 24 and 48 h, respectively. Subjects avoided b-agonist use, caffeine, alcohol, heavy meals and major physical exertion before study visits which were all held in the morning. Post treatment assessments were performed 8 12 min after the last study medication dose. Procedures Pulmonary function measurements were collected according to recommended standards 23 25 by use of automated equipment (Vmax 229d with Autobox 62 D L, SensorMedics, Yorba Linda, CA) and expressed as percentages of predicted normal values as previously described. 1 Predicted inspiratory capacity (IC) was calculated as predicted total lung capacity (TLC) minus predicted FRC. Symptom-limited exercise tests were conducted on an electronically braked cycle ergometer (Ergometrics8S, SensorMedics) by use of a cardiopulmonary exercise testing system (Vmax 229d, SensorMedics) as previously described. 7,26 28 Incremental exercise testing was performed using 1 min increments of 1 W each following a 1 min warm up of unloaded pedaling. Constant-load tests were performed at 75% of the maximal incremental work rate for each subject. Endurance time was defined as the duration of loaded pedaling. Measurements were collected while subjects breathed through a mouthpiece with a low-resistance flow transducer while nose clips were worn. Standard cardiopulmonary exercise test parameters 29 were collected on a breath-bybreath basis. Intensity of dyspnea and leg discomfort was recorded using the 1-point Borg scale 3 at rest, during the last 3 s period of every 1 min interval during exercise and at end exercise. Operating lung volumes were derived from IC manoeuvres 1,28 performed at rest, within the last 3 s period of every 2 min interval during exercise and at end exercise. Blood pressure was measured by auscultation of the right brachial artery, using a sphygmomanometer with an arm cuff, at rest, within the first 3 s period of every 2 min interval, at end exercise and every 5 min during recovery until blood pressure measurements returned to near baseline. Oxyhemoglobin saturation was recorded continuously via a pulse oximeter. Analysis of exercise endpoints All breath-by-breath measurements were averaged in 3 s intervals throughout each test stage, rest, exercise and recovery. To avoid contamination of breath-by-breath data by the artifact of the IC maneuver, symptom ratings and IC measurements collected in a 3 s period that included an IC maneuver were linked to breath-by-breath data collected in the previous 3 s period. Systolic and diastolic blood pressure measurements were linearly extrapolated where necessary to give an estimated blood pressure that was linked to breath-by-breath data and symptom ratings obtained in between blood pressure measurements. Preexercise rest was defined as the steady-state period after at least 3 min of quiet breathing on the mouthpiece while seated at rest before exercise. Cardiopulmonary parameters were averaged over the last 3 s of this period and IC measurements at rest were collected while breathing on the same system immediately after completion of the quiet breathing period. A standardized time near end exercise (isotime) was defined as the highest common exercise time achieved during post treatment constant-load tests performed by a given subject, rounded down to the nearest whole minute. Peak exercise was defined as the last 3 s of loaded pedaling, cardiopulmonary parameters were averaged over this period, symptom ratings and IC measurements were collected immediately at the end of this period. The rate pressure product, a noninvasive marker of myocardial oxygen consumption 31 was calculated as heart rate multiplied by systolic blood pressure. Statistical analysis The sample size was chosen to have adequate power to detect a 3 ml difference in IC at isotime. po.5 significance level was used for all analyses. Treatment responses were compared by two-tailed paired t-tests. Pearson correlations were used to establish associations between cardiopulmonary variables. Data are shown as mean plus or minus the standard error of the mean. Results Eighteen subjects completed the study (Table 1). No subject experienced oxyhemoglobin desaturation below 88% or a significant elevation of end-tidal carbon dioxide tension during incremental exercise. No sequence or carryover effects were found with respect to cardiovascular variables, pulmonary variables or symptoms. The work rate for constant load exercise was 575 W. Effect of tiotropium at rest Heart rate was lower at rest following tiotropium treatment compared to placebo by 6.771.8 beats/min (95% confidence interval 3.2 1.1, p ¼.1). Diastolic blood pressure and the rate pressure product were also lower by 4.71.5 mmhg (95% confidence interval 1. 7., p ¼.14) and 972 mmhg beats/min (95% confidence interval 4 13, p ¼.1), respectively (Table 2). Other cardiovascular variables were not significantly changed. FEV 1 and FVC increased at rest following tiotropium treatment compared to placebo (Table 2). There was no significant change in the FEV 1 /FVC ratio. Lung hyperinflation and airway resistance decreased and airway conductance increased with tiotropium. Breathing pattern during preexercise rest was unchanged except that the ratio of inspiratory time to total breath time increased with tiotropium (p ¼.3). Effect of tiotropium on the response to exercise Post-treatment exercise endurance time was greater by.97.8 min or 14% after tiotropium compared to placebo, not a statistically significant difference. Selected mean cardiovascular and pulmonary responses to exercise are shown in Fig. 1. Heart rate was significantly lower with tiotropium throughout exercise. Oxygen uptake (VO 2 ) was

22 J. Travers et al. Table 1 Subject characteristics. Study subjects n ¼ 18 Male gender, % 72 Age, yr 672 Body mass index, kg/m 2 26.871.2 Cigarette smoke exposure, pack-years 5878 Baseline Dyspnea Index Focal score 5.27.3 Symptom limited peak incremental 6577 (41) work rate, W Systolic blood pressure, mmhg 12773 Diastolic blood pressure, mmhg 8371 Heart rate, beats/min 7372 FEV 1, l 1.137.9 (4) FEV 1 /FVC, % 4472 (62) FEF 5, l/s.457.6 (11) SVC, l 2.977.17 (75) IC, l 1.947.12 (67) TLC, l 7.457.25 (122) RV, l 4.487.19 (216) FRC, l 5.517.2 (171) MIP at FRC, cmh 2 O 675 (71) MEP at TLC, cmh 2 O 1871 (58) DL CO, ml/min/mmhg 14.271.2 (64) Values are means7se (percent of predicted normal values are given in parentheses). FEV 1, forced expiratory volume in 1 s. FVC, forced vital capacity. FEF 5, forced expiratory flow at 5% of FVC. SVC, slow vital capacity. IC, inspiratory capacity. TLC, total lung capacity. RV, residual volume. FRC, functional residual capacity. MIP, maximal inspiratory mouth pressure. MEP, maximal expiratory mouth pressure. DL CO, diffusing capacity of the lung for carbon monoxide. no different and oxygen pulse tended to be higher with tiotropium, significantly so at isotime and at peak exercise. Systolic and diastolic blood pressures were lower with tiotropium at all stages of exercise however the statistical significance of these differences was marginal. The rate pressure product was significantly lower with tiotropium at rest and at isotime. Inspiratory reserve volume (IRV) was significantly greater at rest and throughout exercise. Cardiovascular and pulmonary variables at isotime near peak exercise after tiotropium and placebo treatment are given in Table 3. Correlates of reduced heart rate on exercise The difference in heart rate at isotime with tiotropium compared to placebo correlated with the difference in endinspiratory lung volume (EILV) as a percent of TLC (partial multiple r ¼.53, p ¼.2) and the difference in IRV (partial multiple r ¼.5, p ¼.4) more strongly than with any other measured cardiopulmonary variables. Table 2 Post dose resting cardiovascular variables, pulmonary function and breathing pattern measurements at the end of each treatment period. Placebo Tiotropium Cardiovascular variables Heart rate, 7972 7272 beats/min VO 2, l/min.327.2.317.2 Oxygen pulse, 4.137.32 4.377.35 ml/beat Systolic blood 124.472.7 123.673. pressure, mmhg Diastolic blood 82.472. 78.471.1 pressure, mmhg Oxyhemoglobin 95.77.3 95.57.3 saturation, % Rate pressure product, mmhg.beats/min 9874 8973 Pulmonary function FEV 1, l 1.187.1 (42) 1.387.11 (49) FEV 1 /FVC, % 4472 (62) 4572 (63) FEF5, l/s.527.7 (53).577.6 (14) SVC, l 3.57.19 (77) 3.317.2 (84) TLC, l 7.367.17 (121) 7.277.25 (119) RV, l 4.317.23 (28) 3.977.2 (192) FRC, l 5.387.24 (167) 5.97.22 (158) Steady-state breathing pattern IC, l 2.27.12 2.257.13 IRV, l 1.357.13 1.577.13 EELV, l 5.337.23 5.7.2 V T, l.687.3.687.4 Respiratory rate, 18.67.9 18.871. breaths/min V T /T I, l/s.587.3.587.3 V T /T E, l/s.357.2.357.2 T I, s 1.27.6 1.337.8 T I /T tot.367.1.47.1 Values are means7se (percent of predicted normal values are given in parentheses). po.1 tiotropium versus placebo. VO 2, oxygen uptake. FEV 1, forced expiratory volume in 1 s. FVC, forced vital capacity. FEF 5, forced expiratory flow at 5% of FVC. SVC, slow vital capacity. TLC, total lung capacity. RV, residual volume. FRC, functional residual capacity. IC, inspiratory capacity. IRV, inspiratory reserve volume. EELV, end-expiratory lung volume. V T, tidal volume. T I, inspiratory time. T E, expiratory time. T tot, total breath time.

Cardiovascular effects of tiotropium during exercise 221 Heart rate (beats/min) 12 11 1 9 8 7 6 VO 2 (l/min) 1.4 1.2 1..8.6 Tiotropium Placebo.4.2. O 2 pulse (ml/beat) 14 12 1 8 6 4 2 RPP (x1 mmhg.beats/mn) 2 18 16 14 12 1 8 17 95 SBP (mmhg) 16 15 14 13 DBP (mmhg) 9 85 8 12 75 IRV (l) 2. 1. 5 1.. 5. Dyspnea (Borg) 7 6 5 4 3 2 1 Figure 1 Cardiovascular, IRV and dyspnea response to exercise. Open circles, placebo. Filled circles, tiotropium. Data points are means of all subjects. po.5 tiotropium versus placebo. po.1 tiotropium versus placebo. VO 2, oxygen uptake, RPP, rate pressure product, SBP, systolic blood pressure, DBP, diastolic blood pressure, IRV, inspiratory reserve volume. Discussion The novel finding of this study is a consistent, statistically significant and potentially clinically important effect of tiotropium on the cardiovascular response to exercise in subjects with COPD. Heart rate was lower with tiotropium at rest and throughout exercise by 7 beats/min with a corresponding increase in oxygen pulse, a surrogate measure of cardiac stroke volume, and a reduction in the rate pressure product, a surrogate measure of myocardial work at isotime during exercise. The reduction in heart rate at isotime during exercise correlated best with indices of dynamic hyperinflation, suggesting an association between the cardiac effects of tiotropium and improved pulmonary mechanics. These results suggest that either tiotropium exerts a direct effect on the cardiovascular system or that

222 J. Travers et al. Table 3 Post dose cardiovascular and pulmonary measurements at isotime near peak exercise. Placebo Tiotropium Heart rate, beats/min 11274 1574 VO 2, l/min 1.127.1 1.147.11 Oxygen pulse, ml/beat 1.17.9 1.971. Systolic blood pressure, 15676 14875 mmhg Diastolic blood pressure, 8872 8571 mmhg Oxyhemoglobin saturation, % 94.17.4 93.57.6 Rate pressure product, mmhg 17379 15679 beats/min V E, l/min 35.873.1 35.473.2 V E /VCO 2 34.371.7 34.871.7 Respiratory rate, breaths/min 29.871.6 27.671.2 V T, l 1.27.8 1.267.9 IC, l 1.637.9 1.867.13 IRV, l.447.7.67.11 EILV, %TLC 9471 9271 Dyspnea, Borg scale 4.47.6 3.67.4 Leg discomfort, Borg scale 4.27.5 4.27.5 Values are means7se. po.5 tiotropium versus placebo. VO 2, oxygen uptake. V E, minute ventilation. VCO 2, carbon dioxide production. V T, tidal volume. IC, inspiratory capacity. IRV, inspiratory reserve volume. EILV, end-inspiratory lung volume. TLC, total lung capacity. the bronchodilating and lung deflating actions of tiotropium result in improved cardiac function via a cardiopulmonary interaction. Potential direct cardiovascular effects of tiotropium Tiotropium administered by inhalation is mostly swallowed, very little of which is absorbed systemically. 32 The fraction that reaches the lung has a high bioavailability giving peak plasma concentrations approximately 6% of that achieved by intravenous administration and persisting in plasma for longer. 32 Although systemically available, the current results cannot be explained by tiotropium antagonism at cardiac M2 muscarinic receptors as this effect would produce an increase rather than a decrease in heart rate. Tiotropium antagonism of the M3 receptors of the pulmonary vasculature may result in both inhibition of vasoconstriction and inhibition of endothelial-dependent vasodilatation. It is possible that the net effect of these actions may reduce resting or exercise-induced pulmonary vascular tone and pulmonary arterial pressure. Studies of the cardiovascular effects of tiotropium at rest have reported few clinically significant effects. 33 A recent meta-analysis 34 suggests that there is an increased rate of cardiac arrhythmias, primarily atrial fibrillation, with tiotropium although this increase was statistically significant only after one study responsible for significant heterogeneity was excluded. An increased rate of cardiac death with ipratropium was noted in the Lung Health study 35 but this finding was not replicated in other studies 36 and has not been reported with tiotropium. Potential cardiopulmonary interactions Tiotropium significantly improved measures of dynamic hyperinflation during exercise, confirming the findings of other studies. 7,16 As described above, this effect could result in reduced cardiac afterload which may explain the observed improvement in cardiac function. The association of improvement in EILV and IRV, both measures of dynamic hyperinflation, with improvement in heart rate is consistent with this hypothesis but the association does not imply causation. Other potential interactions mediating the effect of tiotropium include improved pulmonary blood flow associated with reduced air trapping, 13 reduction in heart rate due to reduced discharge from slowly adapting pulmonary stretch receptors, 37 reduction in left ventricular compression from right ventricular overfilling 38 and reduction in positive pleural pressure during expiration. 39 Relation to other research We are not aware of any other study that has examined the effect of tiotropium on the cardiovascular response to exercise. The reduction in heart rate during exercise that we observed with tiotropium was not seen with either the short-acting anticholinergic oxitropium or the short-acting b-agonist fenoterol in a study of exercise hemodynamics. 13 A study of the effects of the long-acting b-agonist salmeterol during exercise also showed no reduction in heart rate despite a similar degree of improvement in dynamic hyperinflation to that observed with tiotropium. 26 The apparent difference between tiotropium and salmeterol is suggestive of a direct cardiovascular effect of tiotropium. The alternative explanation is that both agents act to reduce heart rate during exercise via improved cardiopulmonary interactions but in the case of salmeterol the effect is obscured by the tachycardia resulting from systemic b-adrenergic stimulation. Clinically and statistically significant differences in exercise endurance time with tiotropium have been previously reported in large trials. 7,16 In the present study, mean exercise endurance time was increased with tiotropium however the study was not powered to detect a statistically significant difference. Limitations of this study The data presented here were derived from a study primarily designed to assess the pulmonary and symptomatic response to exercise in COPD so a full range of hemodynamic measurements was not undertaken. Oxygen pulse and rate pressure product are only surrogate measures of stroke volume and myocardial work, respectively. We have no reason to suspect that the changes in these measures observed with tiotropium do not reflect similar changes in

Cardiovascular effects of tiotropium during exercise 223 stroke volume and myocardial work, but further study utilizing invasive hemodynamic measurement is required to conclusively determine this. Likewise, we were not able to directly measure cardiac output, ejection fraction or pulmonary artery pressure to help explain the mechanism or mechanisms by which tiotropium affects the cardiac response to exercise and determine whether the effect of tiotropium on the cardiovascular system is physiologically beneficial or not. From our data, we observed that exercise endurance was at least as good with tiotropium while measures of myocardial work were reduced suggesting that the effect of tiotropium is more likely to be beneficial than not. As the current analysis was performed post hoc, the chance that the results presented here represent a type I error is increased. The consistency of the effect throughout exercise suggests that the effect is real however prospective validation is required. Conclusion Tiotropium may improve cardiac as well as pulmonary function during exercise in COPD. We hypothesize that this is due to a reduction in negative inspiratory pressure brought about by alleviation of dynamic hyperinflation through bronchodilation rather than a direct effect of tiotropium on the heart. Further study is required to determine the mechanism of this effect. Conflict of interest statement This research was supported by the Ontario Ministry of Health, Boehringer Ingelheim (Canada) and Pfizer Canada. Steven Kesten is an employee of Boehringer Ingelheim Pharmaceuticals, Inc. References 1. O Donnell DE, Revill SM, Webb KA. Dynamic hyperinflation and exercise intolerance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 21;164(5):77 7. 2. Adams L, Chronos N, Lane R, Guz A. The measurement of breathlessness induced in normal subjects: individual differences. Clin Sci (London) 1986;7(2):131 4. 3. Barbera JA, Roca J, Ramirez J, Wagner PD, Ussetti P, Rodriguez- Roisin R. Gas exchange during exercise in mild chronic obstructive pulmonary disease. Correlation with lung structure. Am Rev Respir Dis 1991;144(3 Pt 1):52 5. 4. Oelberg DA, Kacmarek RM, Pappagianopoulos PP, Ginns LC, Systrom DM. Ventilatory and cardiovascular responses to inspired He-O 2 during exercise in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;158(6):1876 82. 5. Casaburi R, Mahler DA, Jones PW, et al. A long-term evaluation of once-daily inhaled tiotropium in chronic obstructive pulmonary disease. Eur Respir J 22;19(2):217 24. 6. Niewoehner DE, Rice K, Cote C, et al. Prevention of exacerbations of chronic obstructive pulmonary disease with tiotropium, a once-daily inhaled anticholinergic bronchodilator: a randomized trial. Ann Intern Med 25;143(5):317 26. 7. O Donnell DE, Fluge T, Gerken F, et al. Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD. Eur Respir J 24;23(6):832 4. 8. van Noord JA, Bantje TA, Eland ME, Korducki L, Cornelissen PJG. A randomised controlled comparison of tiotropium and ipratropium in the treatment of chronic obstructive pulmonary disease. Thorax 2;55(4):289 94. 9. Donohue JF, van Noord JA, Bateman ED, et al. A 6-month, placebo-controlled study comparing lung function and health status changes in COPD patients treated with tiotropium or salmeterol. Chest 22;122(1):47 55. 1. O Donnell DE, Hamilton AL, Webb KA. Sensory-mechanical relationships during high-intensity, constant-work-rate exercise in COPD. J Appl Physiol 26;11(4):125 35. 11. Chamberlain DA, Turner P, Sneddon JM. Effects of atropine on heart-rate in healthy man. Lancet 1967;29(755):12 5. 12. Chapman KR, Smith DL, Rebuck AS, Leenen FH. Hemodynamic effects of inhaled ipratropium bromide, alone and combined with an inhaled beta 2-agonist. Am Rev Respir Dis 1985;132(4): 845 7. 13. Saito S, Miyamoto K, Nishimura M, et al. Effects of inhaled bronchodilators on pulmonary hemodynamics at rest and during exercise in patients with COPD. Chest 1999;115(2):376 82. 14. Kesten S, Jara M, Wentworth C, Lanes S. Pooled clinical trial analysis of the safety of tiotropium. Chest Meet Abst 25; 128(4):257S c. 15. Takahashi T, Belvisi MG, Patel H, et al. Effect of Ba 679 BR, a novel long-acting anticholinergic agent, on cholinergic neurotransmission in guinea pig and human airways. Am J Respir Crit Care Med 1994;15(6 Pt 1):164 5. 16. Maltais F, Hamilton A, Marciniuk D, et al. Improvements in symptom-limited exercise performance over 8 h with once-daily tiotropium in patients with COPD. Chest 25;128(3):1168 78. 17. Buda AJ, Pinsky MR, Ingels NB, Daughters GT, Stinson EB, Alderman EL. Effect of intrathoracic pressure on left ventricular performance. N Engl J Med 1979;31(9):453 9. 18. Matthay RA, Berger HJ, Davies RA, et al. Right and left ventricular exercise performance in chronic obstructive pulmonary disease: radionuclide assessment. Ann Intern Med 198; 93(2):234 9. 19. Montes de Oca M, Rassulo J, Celli BR. Respiratory muscle and cardiopulmonary function during exercise in very severe COPD. Am J Respir Crit Care Med 1996;154(5):1284 9. 2. O Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease 23. Can Respir J 23;1(Suppl A): 11A 65A. 21. Stoller JK, Ferranti R, Feinstein AR. Further specification and evaluation of a new clinical index for dyspnea. Am Rev Respir Dis 1986;134(6):1129 34. 22. ERS Task Force on Standardization of Clinical Exercise Testing. Clinical exercise testing with reference to lung diseases: indications, standardization and interpretation strategies. Eur Respir J 1997;1(11):2662 89. 23. American Thoracic Society. Standardization of spirometry, 1994 update. Am J Respir Crit Care Med 1995;152(3):117 36. 24. American Thoracic Society. Single-breath carbon monoxide diffusing capacity (transfer factor). Recommendations for a standard technique 1995 update. Am J Respir Crit Care Med 1995;152(6 Pt 1):2185 98. 25. American Thoracic Society/European Respiratory Society. ATS/ ERS statement on respiratory muscle testing. Am J Respir Crit Care Med 22;166(4):518 624. 26. O Donnell DE, Voduc N, Fitzpatrick M, Webb KA. Effect of salmeterol on the ventilatory response to exercise in chronic obstructive pulmonary disease. Eur Respir J 24;24(1): 86 94. 27. O Donnell DE, D Arsigny C, Webb KA. Effects of hyperoxia on ventilatory limitation during exercise in advanced chronic obstructive pulmonary disease. Am J Respir Crit Care Med 21;163(4):892 8. 28. O Donnell DE, Lam M, Webb KA. Measurement of symptoms, lung hyperinflation, and endurance during exercise in chronic

224 J. Travers et al. obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158(5 Pt 1):1557 65. 29. Jones NL. Clinical exercise testing, 3rd ed. Phiadelphia, PA: Saunders; 1988. 3. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14(5):377 81. 31. Baller D, Bretschneider HJ, Hellige G. A critical look at currently used indirect indices of myocardial oxygen consumption. Basic Res Cardiol 1981;76(2):163 81. 32. Leusch A, Eichhorn B, Muller G, Rominger KL. Pharmacokinetics and tissue distribution of the anticholinergics tiotropium and ipratropium in the rat and dog. Biopharm Drug Dispos 21; 22(5):199 212. 33. Morganroth J, Golisch W, Kesten S. Eletrocardiographic monitoring in COPD patients receiving tiotropium. COPD: J Chronic Obstruct Pulmon Dis 24;1(2):181 9. 34. Barr RG, Bourbeau J, Camargo CA, Ram FSF. Tiotropium for stable chronic obstructive pulmonary disease: a meta-analysis. Thorax 26;61(1):854 62. 35. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV 1. The Lung Health Study. JAMA 1994;272(19):1497 55. 36. Ringbaek T, Viskum K. Is there any association between inhaled ipratropium and mortality in patients with COPD and asthma? Respir Med 23;97(3):264 72. 37. Schelegle ES, Green JF. An overview of the anatomy and physiology of slowly adapting pulmonary stretch receptors. Respir Physiol 21;125(1 2):17 31. 38. Boussuges A, Pinet C, Molenat F, et al. Left atrial and ventricular filling in chronic obstructive pulmonary disease. An echocardiographic and doppler study. Am J Respir Crit Care Med 2;162(2):67 5. 39. Miller JD, Hemauer SJ, Smith CA, Stickland MK, Dempsey JA. Expiratory threshold loading impairs cardiovascular function in health and chronic heart failure during submaximal exercise. J Appl Physiol 26;11(1):213 27.