Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure?
Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure?
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DOI：
10.1161/circulationaha.122.061828
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发表时间：
2023-01-31
期刊：
影响因子：
37.8
通讯作者：
Levine, Benjamin D.
中科院分区：
文献类型：
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作者：
Sarma, Satyam;MacNamara, James P.;Levine, Benjamin D.
背景：运动不耐受是射血分数保留性心力衰竭（HFpEF）的一个定义特征。运动时肺毛细血管楔压（PCWP）显著升高是HFpEF的特异性表现，被认为是运动不耐受的关键原因。如果是真的，急性降低PCWP应该提高运动能力。为了检验这一假设，我们评估了峰值运动能力与硝酸甘油和不与急性降低PCWP在运动中HFpEF.Methods患者：30例HFpEF（706岁，63%的女性）进行了2回合的直立，坐着周期运动剂量与舌下硝酸甘油或安慰剂对照，每15分钟在一个单盲，随机，交叉设计。PCWP（右心导管插入术），摄氧量（呼吸x呼吸气体交换），和心输出量（直接菲克）进行了评估，在休息，20瓦（W），并在安慰剂和硝酸甘油conditions.Results峰值运动：PCWP从84增加到35 +/- 9毫米汞柱从休息到峰值运动与安慰剂。与安慰剂相比，硝酸甘油组在静息（-1 +/- 2 mmHg）、20 W（-5 +/- 5 mmHg）和运动峰值（-7 +/- 6 mmHg;药物x运动阶段P=0.004）时的PCWP分级降低。硝酸甘油不影响静息、20 W或峰值时的摄氧量（安慰剂，1.34 +/- 0.48 vs硝酸甘油，1.32 +/- 0.46 L/min;药物x运动P=0.984）。与安慰剂相比，硝酸甘油降低了静息时（-8 +/- 13 mL）和20 W时（-7 +/- 11 mL）的每搏输出量，但未降低峰值运动时（0 +/- 10 mL）的每搏输出量。尽管PCWP降低，但峰值摄氧量没有改变。这些结果表明，急性减少PCWP不足以提高运动能力，并进一步认为，运动期间高PCWP本身并不是HFpEF患者运动能力的限制因素。
Background: Exercise intolerance is a defining characteristic of heart failure with preserved ejection fraction (HFpEF). A marked rise in pulmonary capillary wedge pressure (PCWP) during exertion is pathognomonic for HFpEF and is thought to be a key cause of exercise intolerance. If true, acutely lowering PCWP should improve exercise capacity. To test this hypothesis, we evaluated peak exercise capacity with and without nitroglycerin to acutely lower PCWP during exercise in patients with HFpEF.Methods: Thirty patients with HFpEF (706 years of age; 63% female) underwent 2 bouts of upright, seated cycle exercise dosed with sublingual nitroglycerin or placebo control every 15 minutes in a single-blind, randomized, crossover design. PCWP (right heart catheterization), oxygen uptake (breath x breath gas exchange), and cardiac output (direct Fick) were assessed at rest, 20 Watts (W), and peak exercise during both placebo and nitroglycerin conditions.Results: PCWP increased from 84 to 35 +/- 9 mmHg from rest to peak exercise with placebo. With nitroglycerin, there was a graded decrease in PCWP compared with placebo at rest (-1 +/- 2 mmHg), 20W (-5 +/- 5 mmHg), and peak exercise (-7 +/- 6 mmHg; drug x exercise stage P=0.004). Nitroglycerin did not affect oxygen uptake at rest, 20W, or peak (placebo, 1.34 +/- 0.48 versus nitroglycerin, 1.32 +/- 0.46 L/min; drug x exercise P=0.984). Compared with placebo, nitroglycerin lowered stroke volume at rest (-8 +/- 13 mL) and 20W (-7 +/- 11 mL), but not peak exercise (0 +/- 10 mL).Conclusions: Sublingual nitroglycerin lowered PCWP during submaximal and maximal exercise. Despite reduction in PCWP, peak oxygen uptake was not changed. These results suggest that acute reductions in PCWP are insufficient to improve exercise capacity, and further argue that high PCWP during exercise is not by itself a limiting factor for exercise performance in patients with HFpEF.