Arterial vasodilatory and ventricular diastolic reserves determine the stroke volume response to exercise in elderly female hypertensive patients

Sahlén, Anders; Abdula, Goran; Norman, Mikael; Manouras, Aristomenis; Brodin, Lars‐Åke; Lund, Lars H.; Shahgaldi, Kambiz; Winter, Reidar

doi:10.1152/ajpheart.00555.2011

Cited by 14 publications

(18 citation statements)

References 57 publications

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“…Disturbances in effort testing in HFrEF have been well characterized, and V O 2 max is a key prognostic factor in the management of severe HFrEF (12). Much less is known regarding exercise response in HFpEF (1,22), but undoubtedly HFpEF is characterized by a rigid LV and impaired preload reserve. Indeed, invasively assessed LV chamber stiffness seems to be one of the main pathophysiological mechanisms underlying exertional dyspnea (23).…”

Section: Discussionmentioning

confidence: 99%

Echocardiography and invasive hemodynamics during stress testing for diagnosis of heart failure with preserved ejection fraction: an experimental study

Leite

Oliveira‐Pinto

Tavares-Silva

et al. 2015

American Journal of Physiology-Heart and Circulatory Physiology

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Leite S, Oliveira-Pinto J, Tavares-Silva M, Abdellatif M, Fontoura D, Falcão-Pires I, Leite-Moreira AF, Lourenço AP. Echocardiography and invasive hemodynamics during stress testing for diagnosis of heart failure with preserved ejection fraction: an experimental study. Am J Physiol Heart Circ Physiol 308: H1556 -H1563, 2015. First published April 11, 2015; doi:10.1152/ajpheart.00076.2015.-Inclusion of exercise testing in diagnostic guidelines for heart failure with preserved ejection fraction (HFpEF) has been advocated, but the target population, technical challenges, and underlying pathophysiological complexity raise difficulties to implementation. Hemodynamic stress tests may be feasible alternatives. Our aim was to test Trendelenburg positioning, phenylephrine, and dobutamine in the ZSF1 obese rat model to find echocardiographic surrogates for end-diastolic pressure (EDP) elevation and HFpEF. Seventeen-week-old WistarKyoto, ZSF1 lean, and obese rats (n ϭ 7 each) randomly and sequentially underwent (crossover) Trendelenburg (30°), 5 g·Kg Ϫ1 ·min Ϫ1 dobutamine, and 7.5 g·Kg Ϫ1 ·min Ϫ1 phenylephrine with simultaneous left ventricular (LV) pressure-volume loop and echocardiography evaluation under halogenate anesthesia. Effort testing with maximum O2 consumption (V O2 max) determination was performed 1 wk later. Obese ZSF1 showed lower effort tolerance and V O2 max along with higher resting EDP. Both Trendelenburg and phenylephrine increased EDP, whereas dobutamine decreased it. Significant correlations were found between EDP and 1) peak early filling Doppler velocity of transmitral flow (E) to corresponding myocardial tissue Doppler velocity (E=) ratio, 2) E to E-wave deceleration time (E/DT) ratio, and 3) left atrial area (LAA). Diagnostic efficiency of E/DT*LAA by receiver-operating characteristic curve analysis for elevation of EDP above a cut-off of 13 mmHg during hemodynamic stress was high (area under curve, AUC ϭ 0.95) but not higher than that of E/E= (AUC ϭ 0.77, P ϭ 0.15). Results in ZSF1 obese rats suggest that noninvasive echocardiography after hemodynamic stress induced by phenylephrine or Trendelenburg can enhance diagnosis of stable HFpEF and constitute an alternative to effort testing. heart failure with preserved

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Section: Discussionmentioning

confidence: 99%

Echocardiography and invasive hemodynamics during stress testing for diagnosis of heart failure with preserved ejection fraction: an experimental study

Leite

Oliveira‐Pinto

Tavares-Silva

et al. 2015

American Journal of Physiology-Heart and Circulatory Physiology

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“…Based on reports from our group (52) and others (45,47,58), dynamic afterload elevation appears to occur during exercise in elderly women. As principles of vascular-ventricular coupling posit that primary afterload elevation may produce secondary SV failure, we investigated in isolation the respective impacts of tachycardia and sympathoexcitation on SV regulation during circulatory stress in elderly women.…”

Section: Discussionmentioning

confidence: 87%

“…Measurement variability for Simpson's biplane method at our laboratory have been previously published as intraobserver and interobserver coefficients of variability of 2.3-3.8 and 7.5-8.4%, respectively (53). LV end-diastolic volume (LVEDV) was obtained as LVEDV ϭ SV ⁄ LVEF (1) as done elsewhere (2,3,20,52). Dimensions, flows, and velocities were analyzed in triplicate.…”

Section: Patientsmentioning

confidence: 99%

“…In the present study, we recorded compliance at endsystolic pressure which will henceforth be referred to as C ES (52). Statistics.…”

Section: Patientsmentioning

confidence: 99%

“…Afterload is a key determinant of LV output (12), and afterload mismatch may be particularly important for stroke volume (SV) regulation in this group (1,21) as, after menopause, there is a rapid increase in arterial stiffness that is much greater in women than in men (49,51,57). Interestingly, dynamic alterations of arterial function have been found during exercise in elderly women, including increased blood pressure, increased systemic vascular resistance (SVR), and decreased arterial compliance (16,18,43,45,47,52,58). This may be important as animal research has shown that an increase in afterload can produce an immediate alteration of LV relaxation (32).…”

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confidence: 99%

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Impact of tachycardia and sympathetic stimulation by cold pressor test on cardiac diastology and arterial function in elderly females

Johnson

Håkansson

Shahgaldi

et al. 2013

American Journal of Physiology-Heart and Circulatory Physiology

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Abnormal vascular-ventricular coupling has been suggested to contribute to heart failure with preserved ejection fraction in elderly females. Failure to increase stroke volume (SV) during exercise occurs in parallel with dynamic changes in arterial physiology leading to increased afterload. Such adverse vascular reactivity during stress may reflect either sympathoexcitation or be due to tachycardia. We hypothesized that afterload elevation induces SV failure by transiently attenuating left ventricular relaxation, a phenomenon described in animal research. The respective roles of tachycardia and sympathoexcitation were investigated in n = 28 elderly females (70 ± 4 yr) carrying permanent pacemakers. At rest, during atrial tachycardia pacing (ATP; 100 min(-1)) and during cold pressor test (hand immersed in ice water), we performed Doppler echocardiography (maximal untwist rate analyzed by speckle tracking imaging of rotational mechanics) and arterial tonometry (arterial stiffness estimated as augmentation index). Estimation of arterial compliance was based on an exponential relationship between arterial pressure and volume. We found that ATP produced central hypovolemia and a reduction in SV which was larger in patients with stiffer arteries (higher augmentation index). There was an associated adverse response of arterial compliance and vascular resistance during ATP and cold pressor test, causing an overall increase in afterload, but nonetheless enhanced maximal rate of untwist and no evidence of afterload-dependent failure of relaxation. In conclusion, tachycardia and cold provocation in elderly females produces greater vascular reactivity and SV failure in the presence of arterial stiffening, but SV failure does not arise secondary to afterload-dependent attenuation of relaxation.

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A systematic review of diastolic stress tests in heart failure with preserved ejection fraction, with proposals from the EU‐FP7 MEDIA study group

Erdei

Smiseth

Marino

et al. 2014

European J of Heart Fail

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Aims Cardiac function should be assessed during stress in patients with suspected heart failure with preserved ejection fraction (HFPEF), but it is unclear how to define impaired diastolic reserve. Methods and results We conducted a systematic review to identify which pathophysiological changes serve as appropriate targets for diagnostic imaging. We identified 38 studies of 1111 patients with HFPEF (mean age 65 years), 744 control patients without HFPEF, and 458 healthy subjects. Qualifying EF was >45–55%; diastolic dysfunction at rest was a required criterion in 45% of studies. The initial workload during bicycle exercise (25 studies) varied from 12.5 to 30 W (mean 23.1 ± 4.6), with increments of 10–25 W (mean 19.9 ± 6) and stage duration 1–5 min (mean 2.5 ± 1); targets were submaximal (n = 8) or maximal (n = 17). Other protocols used treadmill exercise, handgrip, dobutamine, lower body negative pressure, nitroprusside, fluid challenge, leg raising, or atrial pacing. Reproducibility of echocardiographic variables during stress and validation against independent reference criteria were assessed in few studies. Change in E/e' was the most frequent measurement, but there is insufficient evidence to establish this or other tests for routine use when evaluating patients with HFPEF. Conclusions To meet the clinical requirements of performing stress testing in elderly subjects, we propose a ramped exercise protocol on a semi‐supine bicycle, starting at 15 W, with increments of 5 W/min to a submaximal target (heart rate 100–110 b.p.m., or symptoms). Measurements during submaximal and recovery stages should include changes from baseline in LV long‐axis function and indirect echocardiographic indices of LV diastolic pressure.

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Arterial vasodilatory and ventricular diastolic reserves determine the stroke volume response to exercise in elderly female hypertensive patients

Abstract: Sahlén A, Abdula G, Norman M, Manouras A, Brodin LÅ, Lund LH, Shahgaldi K, Winter R. Arterial vasodilatory and ventricular diastolic reserves determine the stroke volume response to exercise in elderly female hypertensive patients.

Cited by 14 publications

References 57 publications

Echocardiography and invasive hemodynamics during stress testing for diagnosis of heart failure with preserved ejection fraction: an experimental study

Echocardiography and invasive hemodynamics during stress testing for diagnosis of heart failure with preserved ejection fraction: an experimental study

Impact of tachycardia and sympathetic stimulation by cold pressor test on cardiac diastology and arterial function in elderly females

A systematic review of diastolic stress tests in heart failure with preserved ejection fraction, with proposals from the EU‐FP7 MEDIA study group

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