Pulmonary circulation in the aged.

The mean pulmonary artery pressure (Ppa) achieved on mild-to-moderate exercise is age related and its haemodynamic correlates remain to be documented in patients free of pulmonary hypertension (PH).Our retrospective study involved patients free of PH investigated in our centre for possible pulmonary vascular disease between January 1, 2007 and October 31, 2009 who underwent right heart catheterisation at rest and during supine exercise up to 60 W. The 38 out of 99 patients aged ,50 yrs were included and a Ppa of 30 mmHg was considered the upper limit of normal on exercise.The 24 subjects who developed Ppa.30 mmHg on exercise had higher resting Ppa (19¡3 versus 15¡4 mmHg) and indexed pulmonary vascular resistance (PVRi; 3.4¡1.5 versus 2.2¡1.1 WU?m 2 ; p,0.05) than the remaining 14 subjects. Resting Ppa .15 mmHg predicted exercise Ppa .30 mmHg with 88% sensitivity and 57% specificity. The eight patients with resting Ppa 22-24 mmHg all had exercise Ppa .30 mmHg.In subjects aged ,50 yrs investigated for possible pulmonary vascular disease and free of PH, patients with mild-to-moderate exercise Ppa .30 mmHg had higher resting PVRi and higher resting Ppa, although there was no resting Ppa threshold value that could predict normal response on mild-to-moderate exercise. The clinical relevance of such findings deserves further long-term follow-up studies.KEYWORDS: Cardiac output, pulmonary hypertension, pulmonary vascular disease, right heart catheterisation F or the last 30 yrs, the diagnosis of pulmonary hypertension (PH) depended on either a resting mean pulmonary artery pressure (P pa) of .25 mmHg or an increase in P pa on exercise to .30 mmHg, with the pulmonary capillary wedge pressure f15 mmHg in the subgroup of pre-capillary PH. Since the 4th World Conference on PH, new guidelines have recommended that the exercise criterion should be eliminated [1,2], given both the marked age-dependency of ''normal'' P pa threshold on exercise [3] and the paucity of robust data supporting its clinical relevance [1,2]. The agedependency of P pa is much less at rest [3][4][5][6][7], such that a common 20.6 mmHg upper limit of normal (ULN) was suggested in supine healthy subjects [3]. Though a P pa of o21 mmHg is beyond the normal range (mean +2 standard deviations) and may be suspicious of pulmonary vascular disease, a small but significant proportion of apparently normal individuals will have a P pa o21 mmHg and they will outnumber the previously documented proportion of patients with PH [3]. As a result, new guidelines have defined pulmonary hypertension by a P pa at rest o25 mmHg (mean +3 standard deviations), and have also highlighted the fact that studies focusing on patients with resting P pa of 21-24 mmHg are especially needed [1][2][3].Numerous studies have documented the high percentage of patients at high risk for PH exhibiting elevation of P pa on exercise .30 mmHg while their P pa was normal at rest [8][9][10][11][12][13][14][15][16], and this may be considered as an early manifestation of pulmonary vasculop...

Section: Resultsmentioning

confidence: 70%

mentioning

confidence: 99%

The association between resting and mild-to-moderate exercise pulmonary artery pressure

Whyte

Hoette²,

Hervé³

et al. 2011

“…1) [8][9][10][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. After the exclusion of individuals with prospectively defined implausible data, 222 subjects (147 males, 33 females, 42 sex not available) were analysed.…”

Section: Resultsmentioning

confidence: 99%

Pulmonary vascular resistances during exercise in normal subjects: a systematic review

Kovàcs

Olschewski²,

Berghold³

et al. 2011

205

161

The physiological range of pulmonary vascular resistance (PVR) and total pulmonary resistance (TPR), and the impact of exercise, age and posture have been a matter of debate for many years.We performed a systematic literature review including all right heart catheterisation data where individual PVR and TPR of healthy subjects both at rest and exercise were available. Data were stratified according to age, exercise level and posture.Supine resting PVR in subjects aged ,24 yrs, 24-50 yrs, 51-69 yrs and o70 yrs was 61¡23, 69¡28, 86¡15 and 90¡39 dyn?s?cm -5 , respectively. Corresponding TPR was 165¡50, 164¡46, 226¡64 and 223¡45 dyn?s?cm -5, respectively. During moderate exercise in subjects aged f50 yrs, an 85% increase in cardiac output was associated with a 25% decrease in TPR (p,0.0001) and a 12% decrease in PVR (p,0.01). At 51-69 yrs of age there was no significant decrease in TPR and PVR. In individuals aged o70 yrs TPR even increased by 17% (p50.01), while PVR did not change significantly. At higher exercise levels, TPR decreased in all age groups. In the upright position, based on a limited number of data, resting TPR and PVR were higher than in the supine position and decreased more prominently during exercise, suggesting the release of resting pulmonary vasoconstriction.These data may form a basis to define normal PVR at rest and exercise.

“…Influence of sex, geographical origin, exercise method and position on Ppa Sex and the geographical origin of the data did not significantly influence resting and exercise P pa values (online data supplement, tables G-I) [13,14,16,18,19,29,35,39,43,47].…”

Section: Pulmonary Arterial Pressure During Exercisementioning

confidence: 99%

Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review

Kovàcs

Berghold²,

Scheidl³

et al. 2009

890

639

According to current guidelines, pulmonary arterial hypertension (PAH) is diagnosed when mean pulmonary arterial pressure (Ppa) exceeds 25 mmHg at rest or 30 mmHg during exercise. Issues that remain unclear are the classification of Ppa values ,25mmHg and whether Ppa .30 mmHg during exercise is always pathological.We performed a comprehensive literature review and analysed all accessible data obtained by right heart catheter studies from healthy individuals to determine normal Ppa at rest and during exercise. Data on 1,187 individuals from 47 studies in 13 countries were included. Data were stratified for sex, age, geographical origin, body position and exercise level.Ppa at rest was 14.0¡3.3 mmHg and this value was independent of sex and ethnicity. Resting Ppa was slightly influenced by posture (supine 14.0¡3.3 mmHg, upright 13.6¡3.1 mmHg) and age (,30 yrs: 12.8¡ 3.1mmHg; 30-50 yrs: 12.9¡3.0 mmHg; o50 yrs: 14.7¡4.0 mmHg). Ppa during exercise was dependent on exercise level and age. During mild exercise, Ppa was 19.4¡4.8 mmHg in subjects aged ,50 yrs compared with 29.4¡8.4 mmHg in subjects o50 yrs (p,0.001).In conclusion, while Ppa at rest is virtually independent of age and rarely exceeds 20 mmHg, exercise Ppa is age-related and frequently exceeds 30 mmHg, especially in elderly individuals, which makes it difficult to define normal Ppa values during exercise.