Chronotropic Incompetence As Pathophysiological Mechanism Reduction of Exercise Tolerance in Patients with Arterial Hypertension and Clinical Signs of Heart Failure with Preserved Left Ventricular Ejection Fraction
The objective: to determine the contribution of chronotropic incompetence (CI) , as one of the mechanisms for reducing exercise tolerance (ET) in patients with heart failure and preserved ejection fraction (HFpEF) of the left ventricle (LV).
Materials and methods. AT prospective study we consistently enrolled 39 patients with hypertension in conjunction with clinical signs and symptoms of heart failure, left ventricular ejection fraction ≥ 50% and symptoms of DD according to Doppler ECG, and compared with 30 patients with heart failure and LVEF 40–49%. Patients were determined level of NTproBNP, except standard laboratory indicators. Pulsed wave velocity (carotid-femoral) was determined using aplanation tonometry Using ECG, standard indicators were determined, and a diastolic stress test was performed when determining the E/e’ index in the range of 9–13. According to the levels of NTproBNP and LVEF patients were divided into three groups. Group 1 with NTproBNP level less than 125 pg/ml included 11 to group 2 (NTproBNP ≥125 pg/ml) – 28 to a group of 3–30 patients.
Results. According to the test results of diastolic stress test, 72,7% of patients group 1 achieved submaximal heart rate compared to 39,2% in group 2 and 10% in group 3 (p<0,05 and p<0,01). Time of work and executed load in patients of group 1 were higher compared to groups 2 and 3 (p<0,05 and p<0,01). Assessing the heart rate at an intermediate stage (50 W), there was a statistical difference between patients in groups 1 and 2 (p<0,01). CI and double product at the peak of exercise in patients of group 1 higher than in patients of groups 2 and 3 (p<0,01), according to comparable values of 2 and 3 groups. According to the results of the correlation analysis, these indicators in patients of group 2 correlated directly with the load performed (r=0,665; p<0,01 and r=0,665; p<0,02) and the load time (r=0,587; p<0,01 and r=0,477; p<0,01) and DT – with the time of the work performed (r=0,435; p<0,01). E/e’ with exercise inversely correlated with the load performed (r=–0,419; p<0.01).Conclusions. In patients with hypertension signs of HF and preserved LV EF with a NTproBNP level ≥125 pg/ml, the value of chronotropic reserve and double work at maximum exercise is less than those with NTproBNP level <125 pg/ml and comparable to those in patients with HF with intermediate (40–49%) LV EF. Patients with hypertension symptoms of heart failure with preserved ejection fraction with a level NTproBNP ≥125 pg/ml value of chronotropic reserve and double product at peak of exercise directly proportionally correlated to the applied load and operating time, and E/E’ at exercise inversely correlated with the performance of the load.
Full Text:PDF (Українська)
AHA Scientific Statement. Exercise standart for testing and training / G. F. Fletcher, G. J. Balady, A. Ezra // Cir. – 2001. – Vol. 104. – P. 1694–1740. https://doi.org/10.1161/hc3901.095960
ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002 Jul 1;166(1):111–7. doi: 10.1164/ajrccm.166.1.at1102 https://doi.org/10.1164/ajrccm.166.1.at1102
Aurigemma GP, Gaasch WH. Clinical practice: diastolic heart failure. N Engl J Med. 2004;351:1097–1105. https://doi.org/10.1056/NEJMcp022709
Baicu CF, Zile MR, Aurigemma GP, Gaasch WH. Left ventricular systolic performance, function, and contractility in patients with diastolic heart failure. Circulation. 2005;111:2306–2312. https://doi.org/10.1161/01.CIR.0000164273.57823.26
Borlaug BA, Melenovsky V, Russell SD, et al. Impaired chronotropic and vasodilator reserves limit exercise capacity in patients with heart failure and a preserved ejection fraction. Circulation. 2006; 114:2138 –47. https://doi.org/10.1161/CIRCULATIONAHA.106.632745
Borlaug BA, Olson TP, Lam CS, et al. Global cardiovascular reserve dysfunction in heart failure with preserved ejection fraction. J Am Coll Cardiol.2010; 56: 845–54. doi: 10.1016/j.jacc.2010.03.077. https://doi.org/10.1016/j.jacc.2010.03.077
Borlaug BA, Jaber WA, Ommen SR, et al. Diastolic relaxation and compliance reserve during dynamic exercise in heart failure with preserved ejection fraction. Heart. 2011; 97: 964–9. https://doi.org/10.1136/hrt.2010.212787
Brubacker PH and Kitzman DW. Chronotropic incompetence: Causes, consequences, and management. Circulation. 2011; 123: 1010–20. https://dx.doi.org/10.1161%2FCIRCULATIONAHA.110.940577
Clark AL, Coats AJ. Chronotropic incompetence in chronic heart failure. Int J Cardiol 1995;49: 225–231.
Fonarow GC, Stough WG, Abraham WT, Albert NM, Gheorghiade M, Greenberg BH, O’Connor CM, Sun JL, Yancy CW, Young JB. Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry. J Am Coll Cardiol 2007; 50:768–777. https://doi.org/10.1016/j.jacc.2007.04.064
Kawaguchi M, Hay I, Fetics B, Kass DA. Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations. Circulation. 2003;107:714–720. https://doi.org/10.1161/01.CIR.0000048123.22359.A0
Kitzman DW, Higginbotham MB, Cobb FR, Sheikh KH, Sullivan MJ. Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism. J Am Coll Cardiol. 1991;17:1065–1072. https://doi.org/10.1016/0735-1097(91)90832-T
Lauer MS, Francis GS, Okin PM, Pashkow FJ, Snader CE, Marwick TH. Impaired chronotropic response to exercise stress testing as a predictor of mortality. JAMA 1999;281:524–529. https://doi.org/10.1001/jama.281.6.524
Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, et al. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J. 2006 Nov;27(21):2588–605. https://doi.org/10.1093/eurheartj/ehl254
Liu CP, Ting CT, Lawrence W, Maughan WL, Chang MS, Kass DA. Diminished contractile response to increased heart rate in intact human left ventricular hypertrophy: systolic versus diastolic determinants. Circulation. 1993;88:1893–1906. https://doi.org/10.1161/01.CIR.88.4.1893
Myers J, Arena R, Dewey F, et al. A cardiopulmonary exercise testing score for predicting outcome in patients with heart Failure. Am Heart J 2008;156:1177–1183. https://doi.org/10.1016/j.ahj.2008.07.010
Nagueh S.F., Smiseth O.A., Appleton C.P., et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2016;17(12):1321–60 Epub 2017 Oct 27. https://doi.org/10.1093/ehjci/jew082
Orso F, Baldasseroni S, Maggioni A. Heart rate in coronary syndromes and heart failure. Prog Cardiovasc Dis 2009;52:38–45. https://doi.org/10.1016/j.pcad.2009.05.006
Owan TE, Redfield MM. Epidemiology of diastolic heart failure. Prog Cardiovasc Dis. 2005;47:320–332. https://doi.org/10.1016/j.pcad.2005.02.010
Pina IL, Apstein CS, Balady GJ, Belardinelli R, Chaitman BR, Duscha BD, Fletcher BJ, Fleg JL, Myers JN, Sullivan MJ. Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation 2003;107:1210–1225. https://doi.org/10.1161/01.CIR.0000055013.92097.40
Ponikowski P., Voors A.A., Anker S.D., Bueno H., Cleland J.G., et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016 Jul 14;37(27):2129–2200. https://doi.org/10.1093/eurheartj/ehw128
Robbins M, Francis G, Pashkow FJ, Snader CE, Hoercher K, Young JB, Lauer MS. Ventilatory and heart rate responses to exercise: Better predictors of heart failure mortality than peak oxygen consumption. Circulation 1999;100: 2411–2417. https://doi.org/10.1161/01.CIR.100.24.2411
Wasserman K, Hansen JE, Sue DY, Stringer WW. Principles of Exercise Testing and Interpretation. 3rd ed. Baltimore, Md: Lippincott Williams &Wilkins; 1999
Zile MR, Baicu CF, Gaasch WH. Diastolic heart failure–abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med.2004;350:1953–1959. doi: 10.1056/NEJMoa032566 https://doi.org/10.1056/NEJMoa032566
Copyright (c) 2020 К. М. Амосова, О. В. Василенко, Ю. В. Руденко, А. Б. Безродний, Г. В. Мостбауер, К. І. Черняєва, К. П. Лазарєва, І. В. Прудкий, І. І. Бурлаченко, Ю. О. Сиченко, А. В. Саблін, Н. В. Мельніченко
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
ISSN 2412-8708 (Online), ISSN 2307-5112 (Print)
ISSN (print): 2307-5112.