Cardiopulmonary exercise testing provides prognostic information in patients with hypertrophic cardiomyopathy. Submaximal exercise parameters, such as ventilatory efficiency and anaerobic threshold, measured alone or in combination with peak oxygen consumption, predict death from heart failure.
Background: Autonomic dysfunction promotes organ injury after major surgery through numerous pathological mechanisms. Vagal withdrawal is a key feature of autonomic dysfunction, and it may increase the severity of pain. We systematically evaluated studies that examined whether vagal neuromodulation can reduce perioperative complications and pain. Methods: Two independent reviewers searched PubMed, EMBASE, and the Cochrane Register of Controlled Clinical Trials for studies of vagal neuromodulation in humans. Risk of bias was assessed; I 2 index quantified heterogeneity. Primary outcomes were organ dysfunction (assessed by measures of cognition, cardiovascular function, and inflammation) and pain. Secondary outcomes were autonomic measures. Standardised mean difference (SMD) using the inverse variance random-effects model with 95% confidence interval (CI) summarised effect sizes for continuous outcomes. Results: From 1258 records, 166 full-text articles were retrieved, of which 31 studies involving patients (n¼721) or volunteers (n¼679) met the inclusion criteria. Six studies involved interventional cardiology or surgical patients. Indirect stimulation modalities (auricular [n¼23] or cervical transcutaneous [n¼5]) were most common. Vagal neuromodulation reduced pain (n¼10 studies; SMD¼2.29 [95% CI, 1.08e3.50]; P¼0.0002; I 2 ¼97%) and inflammation (n¼6 studies; SMD¼1.31 [0.45e2.18]; P¼0.003; I 2 ¼91%), and improved cognition (n¼11 studies; SMD¼1.74 [0.96e2.52]; P<0.0001; I 2 ¼94%) and cardiovascular function (n¼6 studies; SMD¼3.28 [1.96e4.59]; P<0.00001; I 2 ¼96%). Five of six studies demonstrated autonomic changes after vagal neuromodulation by measuring heart rate variability, muscle sympathetic nerve activity, or both. Conclusions: Indirect vagal neuromodulation improves physiological measures associated with limiting organ dysfunction, although studies are of low quality, are susceptible to bias and lack specific focus on perioperative patients.
Background Exercise testing is commonly performed in patients with hypertrophic cardiomyopathy (HCM) to evaluate blood pressure response, a conventional risk factor for sudden cardiac death. The 2011 ACCF/AHA guidelines state “the role of metabolic stress testing in the evaluation of patients with HCM remains to be decided, particularly with regard to clinical outcome. Methods and results Between 1998 and 2010, 1,898 patients (age 47 ± 15 years, 67% male) with HCM underwent cardiopulmonary exercise testing (CPX). During a mean follow-up of 5.8 ± 4 years, 178 (9.4%) patients reached the primary endpoint of all-cause mortality or orthotropic heart transplant. Peak oxygen consumption, V˙O2 (HR 0.91 95% CI 0.89–0.93, p < 0.001), ventilatory efficiency, V˙EV˙CO2 (HR 1.08 95% CI 1.06–1.09), and ventilatory anaerobic threshold V˙AT (HR 0.88 95% CI 0.84–0.92) were predictors of the primary outcome. A progressively worse prognosis was associated with higher ventilatory class (Figure 1). V˙EV˙CO2 was a good predictor of heart failure death or transplantation (HR 1.1 95% CI 1.07–1.14 p < 0.001) outcome but not sudden cardiac death (HR 1.01 95% CI 0.97–0.96 p = 0.54). Abstract 88 Figure 1 Kaplan Kaplan Meier plot showing survival rates in 1898 patients with HCM stratified by ventilatory class. Table shows population at risk at 5 year time points Conclusions CPX provides important prognostic information in patients with HCM. Sub-maximal exercise parameters are potentially more useful than peak VO2 alone. Patients with an enhanced ventilatory response have a substantially higher risk of death or transplantation. Reference 1 Gersh, et al. JACC 2011;58(25):212–60
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