Advertisement

Respiratory Gas Analysis in Patients with Chronic Heart Failure

  • H. Drexler
Conference paper

Abstract

Traditionally, the clinical severity of chronic heart failure has been assessed by clinical symptoms and was graded according to the criteria of the New York Heart Association (NYHA). These criteria are by their nature subjective with a low reproducibility [16]. In order to detect any change in the functional state of patients with heart failure, e.g. improvement over time with specific treatment, it appears crucial to apply an objective, reproducible, and sensitive method. Except for advanced, severe chronic heart failure, symptoms occur with physical activity only. Therefore, exercise testing with determination of variables unaffected by patient motivation and the supervising physician, should be useful in the assessment of functional capacity of patients with chronic heart failure (Table 1). It is important to recognize that the determination of LV-function, although of major prognostic value, correlates poorly with functional classes [2, 12, 14, 18, 34]. Thus, among patients with similar degrees of LV-dysfunction, clinical symptoms may vary considerably and normal exercise capacity may be almost preserved despite substantial LV-dysfunction. Two patients with identical cardiac lesions will have different symptoms during exercise if the peripheral circulation of one adapts to the exercise better than that of the other. Heart failure during exercise occurs when the peripheral circulation does not adequately adjust to an inadequate cardiac output to keep pace with the metabolic requirements of the exercising muscle. Thus, although the primary defect is due to myocardial failure, the symptoms are not solely dependent on the behavior of the heart. Similarly, exercise hemodynamics do not relate closely to exercise capacity in patients with chronic heart failure; in addition, it remains an invasive procedure which cannot be repeated unlimitedly.

Keywords

Chronic Heart Failure Anaerobic Threshold Maximal Oxygen Consumption Isosorbide Dinitrate Arterial Lactate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Beaver WL, Wasserman K, Whipp BJ (1986) A new method for detecting anaerobic threshold by gas exchange. J Appl Physiol 60: 2020–2027PubMedGoogle Scholar
  2. 2.
    Benge W, Litchfield RL, Marcus ML (1980) Exercise capacity in patients with severe left ventricular dysfunction. Circulation 61: 955–959PubMedGoogle Scholar
  3. 3.
    Buchfuhrer MJ, Hansen JE, Robinson TE, Sue DY, Wasserman K, Whipp BJ (1983) Optimizing the exercise protocol for cardiopulmonary assessment. J Appl Physiol 55: 1558–1564PubMedGoogle Scholar
  4. 4.
    Buller NP, Poole-Wilson PA (1988) Extrapolated maximal oxygen consumption: a new method for the objective analysis of respiratory gas exchange during exercise. Br Heart J 59: 212–217PubMedCrossRefGoogle Scholar
  5. 5.
    Buller NP, Poole-Wilson PA (1990) Mechanism of the increased ventilatory response to exercise in patients with chronic heart failure. Br Heart J 63: 281–283PubMedCrossRefGoogle Scholar
  6. 6.
    Cohn JN et al. (1987) Veterans administration cooperative study on vasodilator therapy of heart failure: influence of prerandomization variables on the reduction of mortality by treatment with hydralazine and isosorbide dinitrate. Circulation 75: IV - 49Google Scholar
  7. 7.
    Dickstein K, Barvik S, Aarsland T, Snapinn S, Karlsson J (1990) A comparison of methodologies in detection of the anaerobic threshold. Circulation 81: II-38-II-46Google Scholar
  8. 8.
    Drexler H, Faude F, Hönig S, Jut H (1987) Blood flow distribution within skeletal muscle during exercise in the presence of chronic heart failure: effect of milrinone. Circulation 76: 1344–1352PubMedCrossRefGoogle Scholar
  9. 9.
    Drexler H, Riede U, Schäfer H (1987) Reduced oxidative capacity of skeletal muscle in patients with severe heart failure. Circulation 76: IV - 178CrossRefGoogle Scholar
  10. 10.
    Drexler H, Banhardt U, Meinertz T, Wollschläger H, Lehmann M, Just H (1989) Contrasting peripheral short-term and long-term effects of converting enzyme inhibition in patients with congestive heart failure. A double-blind, placebo-controlled trial. Circulation 79: 491–502Google Scholar
  11. 11.
    Drexler H, Münzel T, Riede U, König H, Just H (1990) Effect of chronic heart failure on skeletal muscle: ultrastructural analysis of 55 cases. Europ Heart J (in press)Google Scholar
  12. 12.
    Franciosa JA, Ziesche S, Wilen M (1979) Functional capacity in patients with chronic left ventricular failure. Relationship of bicycle exercise performance to clinical and hemodynamic characterization. Am J Med 67: 460–466PubMedCrossRefGoogle Scholar
  13. 13.
    Franciosa JA, Cohn JN (1979) Effect of isosorbide dinitrate on response to submaximal and maximal exercise in patients with congestive heart failure. Am J Cardiol 43: 1009–1014PubMedCrossRefGoogle Scholar
  14. 14.
    Franciosa JA, Park M, Levine TB (1981) Lack of correlation between exercise capacity and indexes of resting left ventricular performance in heart failure. Am J Cardiol 47: 33–39PubMedCrossRefGoogle Scholar
  15. 15.
    Franciosa JA (1987) Why patients with heart failure die: hemodynamic and functional determinants of survival. Circulation 75: IV-20-IV-27Google Scholar
  16. 16.
    Goldman L, Hasmoto B, Cook F, Lascalzo A (1981) Comparative reproducibility and validity of systems for assessing cardiovascular functional class. Circulation 64: 1227–1234PubMedCrossRefGoogle Scholar
  17. 17.
    Hagberg JM, Coyle EF, Carroll JE, Miller JM, Martin WH, Brooke MH (1982) Exercise hyperventilation in patients with McArdle disease. J Appl Physiol 52: 991–994PubMedGoogle Scholar
  18. 18.
    Higginbotham MB, Morris KG, Conn EH, Coleman RE, Cobb FR (1983) Determinants of variable exercise performance among patients with severe left ventricular dysfunction. Am J Cardiol 51: 52–60PubMedCrossRefGoogle Scholar
  19. 19.
    Janicki JS, Gupta S, Ferris ST, McElroy PA (1990) Long-term reproducibility of respiratory gas exchange measurements during exercise in patients with stable cardiac failure. Chest 97: 1217CrossRefGoogle Scholar
  20. 20.
    Koike A, Itoh H, Taniguchi K, Hiroe M (1989) Detecting abnormalities in left-ventricular function during exercise by respiratory measurement. Circulation 80: 1737–1746PubMedCrossRefGoogle Scholar
  21. 21.
    Lipkin DP (1987) The role of exercise testing in chronic heart failure. Br Heart J 58: 559–566PubMedCrossRefGoogle Scholar
  22. 22.
    Mancini DM, Ferraro N, Tuchler M, Chance B, Wilson JR (1988) Detection of abnormal calf muscle metabolism in patients with heart failure using phosphorus-31 nuclear magnetic resonance. Am J Cardiol 62: 1234–1240PubMedCrossRefGoogle Scholar
  23. 23.
    Massie BM, Conway M, Yonge R et al. (1987) 31P nuclear magnetic resonance evidence of abnormal skeletal muscle metabolism in patients with congestive heart failure. Am J Cardiol 60: 309–315PubMedCrossRefGoogle Scholar
  24. 24.
    Massie BM, Conway M, Yonge R et al. (1987) Skeletal muscle metabolism in patients with congestive heart failure: relation to clinical severity and blood flow. Circulation 76: 1009–1019PubMedCrossRefGoogle Scholar
  25. 25.
    Matthews JI, Bush BA, Morales FM (1987) Microprocessor exercise physiology systems vs a nonautomated system. A comparison of data output. Chest 92: 696–703Google Scholar
  26. 26.
    Münzel T, Drexel H, Kurz S, Dickhut H (1989) Anaerobic threshold determination by serial lactate measurements: a simple means to assess aerobic capacity in heart failure. Circulation 80: II - 56Google Scholar
  27. 27.
    Myers J, Walsh D, Sullivan M, Froelicher V (1990) Effect of sampling on variability and plateau in oxygen uptake. J Appl Physiol 68: 404–410PubMedCrossRefGoogle Scholar
  28. 28.
    Simonton CA, Higginbotham MB, Cobb FR (1988) The ventilatory threshold: quantitative analysis of reproducibility and relation to arterial lactate concentration in normal subjects and in patients with chronic congestive heart failure. Am J Cardiol 62: 100–107PubMedCrossRefGoogle Scholar
  29. 29.
    Solal AC, Chabernaud JM, Gourgon R (1990) Comparison of oxygen uptake during bicycle exercise in patients with chronic heart failure and in normal subjects. J Am Coll Cardiol 16: 80–85PubMedCrossRefGoogle Scholar
  30. 30.
    Sullivan MJ, Higginbotham MB, Cobb FR (1989) Exercise training in patients with chronic heart failure delays ventilatory anderobie treshould and imperoves submaximal exercise performance. Circulation 79: 324–329PubMedCrossRefGoogle Scholar
  31. 31.
    Sullivan MJ, Knight JD, Higginbotham MB, Cobb FR (1989) Relation between central and peripheral hemodynamics during exercise in patients with chronic heart failure. Muscle blood flow is reduced with maintenance of arterial perfusion pressure. Circulation 80: 769–781Google Scholar
  32. 32.
    Sullivan MJ, Cobb FR (1990) The anaerobic threshold in chronic heart failure. Relation to blood lactate, ventilatory basis, reproducibility, and response to exercise training. Circulation 81: II47—II-58Google Scholar
  33. 33.
    Systrom DM, Kanarek DJ, Kohler SJ, Kazemi H (1990) 31P nuclear magnetic resonance spectroscopy study of the anerobic threshold in humans. J Appl Physiol 68: 2060–2066Google Scholar
  34. 34.
    Szlachcic J, Massie BM, Kramer BL, Topic N, Tabau J (1985) Correlates and prognostic implication of exercise capacity in chronic congestive heart failure. Am J Cardiol 55: 1037–1042PubMedCrossRefGoogle Scholar
  35. 35.
    Tandon PK, Stander H, Dyke SH, Massey TJ, DiBianco R, Schwarz RP (1988) Assessment of the quality of life of patients with heart failure: a randomized, controlled drug trial. Heart failure 4: 3)-54Google Scholar
  36. 36.
    Wasserman K (1987) Determinants and detection of anaerobic threshold and consequences of exercise above it. Circulation 76: IV - 29Google Scholar
  37. 37.
    Weber KT, Kinasewitz LGT, Janicki JS, Fishman AP (1982) Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure. Circulation 65: 1213–1223PubMedCrossRefGoogle Scholar
  38. 38.
    Weber KT, Janicki JS (1985) Lactate production during maximal and submaximal exercise in patients with chronic heart failure. J Am Coll Cardiol 6: 717–724PubMedCrossRefGoogle Scholar
  39. 39.
    Weber KT, Janicki JS (1986) Cardiopulmonary exercise testing. WB Saunders Company, PhiladelphiaGoogle Scholar
  40. 40.
    Wilson JR, Untereker W, Hirshfeld J, Ferraro N (1981) Effects of isosorbide dinitrate and hydralazine on regional metabolic responses to arm exercise in patients with heart failure. Am J Cardiol 48: 934–938PubMedCrossRefGoogle Scholar
  41. 41.
    Wilson JR, Martin JL, Ferraro N; Weber KT (1983) Effect of hydralazine on perfusion and metabolism in the leg during upright bicycle exercise in patients with heart failure. Circulation 68: 425–432PubMedCrossRefGoogle Scholar
  42. 42.
    Wilson JR, Martin JL, Ferraro N (1984) Impaired skeletal muscle nutritive flow during exercise in patients with congestive heart failure: role of cardiac pump dysfunction as determined by the effect of dobutamine. Am J Cardiol 53: 1308–1315PubMedCrossRefGoogle Scholar
  43. 43.
    Yeh MP, Gardner RM, Adams TD, Yanowitz FG, Crapo RO (1983) “Anaerobic threshold”: problems of determination and validation. J Appl Physiol 55: 1178–1186PubMedGoogle Scholar
  44. 44.
    Zelis R, Mason DT, Braunwald E, Winterhalter M, King C (1968) A comparison of the effects of vasodilator stimuli on peripheral resistance vessels in normal subjects and in patients with congestive heart failure. J Clin Invest 47: 960–970PubMedCrossRefGoogle Scholar
  45. 45.
    Zelis R, Mason DT, Braunwald E (1969) Partition of blood flow to the cutaneous and muscular beds of the forearm at rest and during leg exercise in normal subjects and in patients with heart failure. Circ Res 24: 799–806PubMedGoogle Scholar
  46. 46.
    Zelis R, Longhurst J, Capone RJ, Mason DT (1974) A comparison of regional blood flow and oxygen utilization during dynamic forearm exercise in normal subjects and patients with congestive heart failure. Circulation 50: 137–143PubMedGoogle Scholar
  47. 47.
    Zelis R, Nellis SH, Longhurst J, Lee G, Mason DT (1975) Abnormalities in the regional circulations accompanying congestive heart failure. Prog Cardiovasc Dis 18: 181–199PubMedCrossRefGoogle Scholar

Copyright information

© Dr. Dietrich Steinkopff Verlag GmbH & Co. KG, Darmstadt 1991

Authors and Affiliations

  • H. Drexler
    • 1
  1. 1.Medizinische Klinik IIIUniversity of FreiburgFreiburg i. Br.Germany

Personalised recommendations