BRIEF REPORT
Right Ventricular Systolic Dysfunction Is Related to Exercise Intolerance in Patients With Chronic Obstructive Pulmonary Disease Giuseppe Caminiti, MD; Vittorio Cardaci, MD; Vittoria Conti, MD; Valentino D’Antoni; Jeganath Murugesan; Daniela Battaglia, MD; Maurizio Volterrani, MD
■ PURPOSE: To evaluate the impact of right ventricular dysfunction on exercise tolerance and potential changes resulting from exercise training in patients with chronic obstructive pulmonary disease (COPD) undergoing pulmonary rehabilitation. ■ METHODS: Subjects were 44 patients with a history of symptomatic (Global Initiative for Chronic Obstructive Lung Disease classes 2-4) COPD attending a 4-week aerobic exercise training program. Right ventricle dysfunction was evaluated by echocardiography at admission using tricuspid annular plane systolic excursion (TAPSE). Exercise tolerance was evaluated at admission and discharge using the 6-minute walk test (6MWT). Change in distance walked (Δ6MWT) was defined as the difference between 6MWT distance at discharge minus distance at admission. Patients were divided into 2 groups according to the presence of right ventricle dysfunction (TAPSE ≤16 mm). ■ RESULTS: Median age and left ventricular ejection fraction was 70.2 ± 5.2 years and 54.4 ± 9.1%, respectively. Of the 44 patients, 14 (31.8%) had TAPSE ≤16 mm. Baseline 6MWT distance was less in the group with TAPSE ≤16 mm compared with TAPSE >16 mm (110.2 ± 34 vs 185.7 ± 41, respectively; P = .02). After the training program, 6MWT distance increased in both groups, but there was less increase in the group with TAPSE ≤16 mm compared with TAPSE >16 mm (+24.3% vs +32.8%, respectively; P < .001). Tricuspid annular plane systolic excursion was significantly correlated to distance walked at the baseline 6MWT (r = 0.44; P = .002) and to Δ6MWT (r = .36; P = .006). ■ CONCLUSIONS: Tricuspid annular plane systolic excursion ≤16 mm was an indicator of decreased 6MWT distance at baseline and 6MWT distance change in COPD patients undergoing pulmonary rehabilitation. This relationship seems to be independent of pulmonary function.
70 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:70-74
K E Y
W O R D S
chronic obstructive pulmonary disease exercise tolerance right ventricular function
Author Affiliation: Department of Medical Sciences, Cardiovascular Research Unit, San Raffaele IRCCS, Rome, Italy (Dr Caminiti); Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy (Dr Cardaci, Dr Conti, Dr Battaglia, Mr D’Antoni, and Dr Volterrani); and Dipartimento di Medicina Fisica e Riabilitazione, Università Tor Vergata, Rome, Italy (Mr Murugesan). The authors declare no conflicts of interest. Correspondence: Giuseppe Caminiti, MD, Department of Medical Sciences, Cardiovascular Research Unit, IRCCS San Raffaele – Roma, via della Pisana 235, 00163 Rome, Italy (giuseppe.caminiti@ sanraffaele.it). DOI: 10.1097/HCR.0000000000000086
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 70
08/12/14 1:54 PM
Exercise intolerance causes disability and profoundly affects quality of life and survival of patients with chronic obstructive pulmonary disease (COPD).1 Several factors including pulmonary dysfunction, skeletal muscle fatigue, and pulmonary hypertension significantly contribute to the onset of exercise intolerance in these patients.2,3 Right ventricular dysfunction (RVD) is often observed in COPD patients, sometimes before the onset of pulmonary hypertension,3,4 and it seems to be related to poor physical status and survival.5 Recently, a growing number of echocardiographic markers of RVD have been evaluated as possible predictors of poor exercise tolerance in COPD. However, there is no general agreement on which are the most useful in clinical practice.5,6 The evaluation of tricuspid annular plane systolic excursion (TAPSE) by echocardiography provides a simple, rapid, quantitative tool for noninvasively assessing right ventricular systolic function.7 Given its proprieties, TAPSE assessment seems to be particularly useful in clinical practice, especially in the setting of pulmonary rehabilitation, where a combination of factors affecting exercise tolerance is important. To our knowledge, the possibility that TAPSE is related to exercise tolerance and to the response to exercise training (ET) has not been previously explored. In this study, we hypothesized that TAPSE would be correlated with exercise tolerance as evaluated by 6-minute walk test (6MWT) distance and the change in 6MWT distance following an ET program in patients with COPD.
METHODS Subjects were recruited from the pulmonary rehabilitation department at San Raffaele IRCCS, Rome, Italy. Forty-four patients (median age: 70.2 ± 5.2 years; male/female: 29/15) with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease classes 2-4) were enrolled. All subjects had a previous diagnosis of symptomatic COPD, no history of left ventricular disease, and preserved left ventricle ejection fraction (LVEF) of 54.4 ± 9.1%. Before starting the ET program, each patient underwent echocardiography evaluation and 6MWT. The rehabilitation program consisted of 2 sessions each day for 6 days per week for a total of 4 weeks. Each session lasted 30 minutes and included symptoms-limited ET (walking or cycling). Change in 6MWT (Δ6MWT) distance was defined as the difference between the distance walked at the end of ET program minus 6MWT distance performed at baseline. According to the American Society of Echocardiography guidelines,8 a www.jcrpjournal.com
TAPSE cutoff of ≤16 mm was chosen to identify RVD. Patients were divided into the following 2 groups on the basis of their right ventricular systolic function: reduced (TAPSE ≤16 mm) or normal (TAPSE >16 mm). Results were expressed as median ± standard deviation (SD) or percentages where appropriate. Withingroup changes in the reported variables were evaluated by a paired t test or the Wilcoxon signed rank test for nonnormally distributed variables. Betweengroups comparisons were performed using the unpaired t test and the Mann-Whitney rank sum test. Relationship between variables was assessed by the Pearson correlation or the Spearman rank test for nonnormally distributed data.
RESULTS Forty-four patients (median age: 70.2 ± 5.2 years; male/female: 29/15) with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease classes 2-4) were enrolled. All subjects had a diagnosis of symptomatic COPD, no history of left ventricular disease, and a preserved LVEF of 54.4 ± 9.1%. Fourteen patients (31.8%) had TAPSE ≤16 mm. At baseline patients with TAPSE ≤16 mm had similar LVEF compared with patients with TAPSE >16 mm (54.6 ± 4.9% vs 54.0 ± 7.1, respectively) and forced expiratory volume in 1 second (FEV1) percentage of predicted (48.7 ± 5.8 vs 49.3 ± 4.2, respectively) (Table 1). Baseline 6MWT distance was significantly less in the TAPSE ≤16 mm group compared with the TAPSE >16 mm group (110.2 ± 34 vs 185.7 ± 41; P = .02). After the ET program, 6MWT distance increased in both groups but there was less of an increase in the group with TAPSE ≤16 mm compared with TAPSE >16 mm (+24.3% vs +32.8%, respectively; P = .001). Tricuspid annular plane systolic excursion was directly related to distance walked at baseline 6MWT (r = 0.44; P = .002) (Figure 1) and to Δ6MWT (r = 0.36; P = .006) (Figure 2). Forced expiratory volume in 1 second and LVEF were poorly related to the performance of the 6MWT.
DISCUSSION This study found that TAPSE was strongly related to baseline 6MWT distance in COPD patients with moderate to severe disease and participating in an ET program. Our data are in agreement with those reported by Tanaka et al,5 who demonstrated that right ventricular function, evaluated through total ejection isovolume index, was strongly correlated with scores Right Ventricular Dysfunction in COPD / 71
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 71
08/12/14 1:54 PM
T a b l e 1 • Baseline Characteristics in Subjects With (TAPSE ≤16 mm) or Without (TAPSE >16 mm) Right Ventricular Dysfunctiona All Patients (n = 44)
TAPSE ≤16 mm (n = 14)
TAPSE >16 mm (n = 30)
70.2 ± 5.2
71.2 ± 8.4
69.5 ± 11.0
29:15
9:5
20:10
Body mass index, kg/m
27.7 ± 6.3
27.4 ± 8.5
28.1 ± 11.6
GOLD classes 2/3/4, n
25/14/5
9/4/1
16/10/4
LVEF, %
54.4 ± 9.1
54.6 ± 4.9
54.0 ± 7.1
LVDD, mm
47.5 ± 9.2
47.6 ± 7.5
47.1 ± 8.3
LVSD, mm
23.1 ± 7.1
23.4 ± 6.3
22.9 ± 8.1
E, cm/s
79.5 ± 11.3
78.9 ± 8.0
79.8 ± 14.8
A, cm/s
88.7 ± 13.5
89.1 ± 10.1
88.4 ± 9.0
E/A ratio
0.89 ± 0.4
0.88 ± 0.5
0.90 ± 0.2
RVDD, mm
33 ± 11.4
35 ± 7.1
32 ± 8.4
E, cm/s
52.6 ± 9.0
53.3 ± 11.4
52.1 ± 7.7
A, cm/s
47.5 ± 13.4
47.3 ± 13.0
47.8 ± 13.2
E/A ratio
1.11 ± 0.3
1.12 ± 0.2
1.08 ± 0.3
FEV1, % predicted
49.1 ± 7.3
48.7 ± 5.8
49.3 ± 4.2
FVC, % predicted
68.2 ± 11.0
67.6 ± 13.1
68.8 ± 9.2
IC, % predicted
54.5 ± 8.0
54.7 ± 6.5
54.3 ± 8.5
RV, % predicted
180 ± 32.7
178.4 ± 36.1
180.9 ± 29.3
TLC, % predicted
115 ± 28.4
117.1 ± 21.8
116.6 ± 29.0
Age, y Sex (male:female), n 2
Echocardiography data Left ventricle
Right ventricle
Spirometry data
Abbreviations: A, late ventricular filling velocity; E, early ventricular filling velocity; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease; IC, inspiratory capacity; LVDD, left ventricular diastolic diameter; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic diameter; RV, residual volume; RVDD, right ventricle diastolic diameter; TLC, total lung capacity. a Continuous data expressed as median ± SD.
reflecting daily living activity. Interestingly in our sample, we found similar values for FEV1 and other functional lung parameters in subjects with or without RVD. This result suggests that the relation between RVD and poor exercise tolerance is independent from the degree of pulmonary dysfunction. Similarly, Cuttica et al6 found that RVD, assessed with echocardiography, was related to exercise capacity but independently from the results of lung function tests. We also observed that TAPSE was significantly related to the improvement of 6MWT distance after ET. A similar finding has been recently described by our group in patients with heart failure.9 This is a new finding in COPD patients, and, in our opinion, it underscores the importance of assessing TAPSE before
starting an ET program. The assessment of TAPSE in this context could help physicians have a more complete understanding of the parameters affecting exercise tolerance in COPD and to realistically anticipate the individual response to ET in these patients.
CONCLUSIONS Our results confirm the association between RVD and poor exercise tolerance in COPD, regardless of functional lung parameters. They also demonstrate the utility of TAPSE for evaluating this relationship in the context of pulmonary rehabilitation programs. The assessment TAPSE is a simple and effective tool that can
72 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:70-74
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 72
08/12/14 1:54 PM
Figure 1. Scatterplot showing the relation between TAPSE and baseline 6MWT distance. Abbreviations: 6MWT, 6-minute walk test; TAPSE, tricuspid annular plane systolic excursion.
Figure 2. Scatterplot showing the relation between TAPSE and delta in 6MWT distance. Abbreviations: 6MWT, 6-minute walk test; TAPSE, tricuspid annular plane systolic excursion. www.jcrpjournal.com
Right Ventricular Dysfunction in COPD / 73
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 73
08/12/14 1:54 PM
be adopted in the routine clinical assessment of patients with COPD to explore the relationship between right ventricular function and exercise tolerance. This could give physicians, in the setting of pulmonary rehabilitation, the opportunity to better understand which patients will have a lower 6MWT performance upon admission to pulmonary rehabilitation and how 6MWT distance will change after an ET program.
References 1. Calverley PM, Walker P. Chronic obstructive pulmonary disease. Lancet. 2003;362:1053-1061. 2. Saey D, Debigare R, LeBlanc P, et al. Contractile leg fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2003;168:425-430. 3. Sims MW, Margolis DJ, Localio AR, Panettieri RA, Kawut SM, Christie JD. Impact of pulmonary artery pressure on exercise function in severe COPD. Chest. 2009;136:412-419.
4. Hilde JM, Skjorten I, Grotta J, et al. Right ventricle dysfunction and remodeling in chronic obstructive pulmonary disease without hypertension. J Am Coll Cardiol. 2013;62:1103-1111. 5. Tanaka Y, Hino M, Mizuno K, Gemma A. Evaluation of right ventricular function in patients with COPD. Respir Care. 2013; 58:816-823. 6. Cuttica MJ, Shah SJ, Rosenberg SR, et al. Right heart structural changes are independently associated with exercise capacity in non-severe COPD. PLoS ONE. 2011;6:e29069. 7. Meluzin J, Spinarova L, Bakala J, et al. Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion. A new, rapid, and non-invasive method of evaluating right ventricular systolic function. Eur Heart J. 2001;22:340-348. 8. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713. 9. Caminiti G, Volterrani M, Murugesan J, et al. Tricuspid annular plane systolic excursion is related to performance at six minute walking test in patients with heart failure undergoing exercise training. Int J Cardiol. 2013;169:91-92.
74 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:70-74
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 74
08/12/14 1:54 PM
Right Ventricular Systolic Dysfunction Is Related to Exercise Intolerance in Patients With Chronic Obstructive Pulmonary Disease Giuseppe Caminiti, MD; Vittorio Cardaci, MD; Vittoria Conti, MD; Valentino D’Antoni; Jeganath Murugesan; Daniela Battaglia, MD; Maurizio Volterrani, MD
■ PURPOSE: To evaluate the impact of right ventricular dysfunction on exercise tolerance and potential changes resulting from exercise training in patients with chronic obstructive pulmonary disease (COPD) undergoing pulmonary rehabilitation. ■ METHODS: Subjects were 44 patients with a history of symptomatic (Global Initiative for Chronic Obstructive Lung Disease classes 2-4) COPD attending a 4-week aerobic exercise training program. Right ventricle dysfunction was evaluated by echocardiography at admission using tricuspid annular plane systolic excursion (TAPSE). Exercise tolerance was evaluated at admission and discharge using the 6-minute walk test (6MWT). Change in distance walked (Δ6MWT) was defined as the difference between 6MWT distance at discharge minus distance at admission. Patients were divided into 2 groups according to the presence of right ventricle dysfunction (TAPSE ≤16 mm). ■ RESULTS: Median age and left ventricular ejection fraction was 70.2 ± 5.2 years and 54.4 ± 9.1%, respectively. Of the 44 patients, 14 (31.8%) had TAPSE ≤16 mm. Baseline 6MWT distance was less in the group with TAPSE ≤16 mm compared with TAPSE >16 mm (110.2 ± 34 vs 185.7 ± 41, respectively; P = .02). After the training program, 6MWT distance increased in both groups, but there was less increase in the group with TAPSE ≤16 mm compared with TAPSE >16 mm (+24.3% vs +32.8%, respectively; P < .001). Tricuspid annular plane systolic excursion was significantly correlated to distance walked at the baseline 6MWT (r = 0.44; P = .002) and to Δ6MWT (r = .36; P = .006). ■ CONCLUSIONS: Tricuspid annular plane systolic excursion ≤16 mm was an indicator of decreased 6MWT distance at baseline and 6MWT distance change in COPD patients undergoing pulmonary rehabilitation. This relationship seems to be independent of pulmonary function.
70 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:70-74
K E Y
W O R D S
chronic obstructive pulmonary disease exercise tolerance right ventricular function
Author Affiliation: Department of Medical Sciences, Cardiovascular Research Unit, San Raffaele IRCCS, Rome, Italy (Dr Caminiti); Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy (Dr Cardaci, Dr Conti, Dr Battaglia, Mr D’Antoni, and Dr Volterrani); and Dipartimento di Medicina Fisica e Riabilitazione, Università Tor Vergata, Rome, Italy (Mr Murugesan). The authors declare no conflicts of interest. Correspondence: Giuseppe Caminiti, MD, Department of Medical Sciences, Cardiovascular Research Unit, IRCCS San Raffaele – Roma, via della Pisana 235, 00163 Rome, Italy (giuseppe.caminiti@ sanraffaele.it). DOI: 10.1097/HCR.0000000000000086
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 70
08/12/14 1:54 PM
Exercise intolerance causes disability and profoundly affects quality of life and survival of patients with chronic obstructive pulmonary disease (COPD).1 Several factors including pulmonary dysfunction, skeletal muscle fatigue, and pulmonary hypertension significantly contribute to the onset of exercise intolerance in these patients.2,3 Right ventricular dysfunction (RVD) is often observed in COPD patients, sometimes before the onset of pulmonary hypertension,3,4 and it seems to be related to poor physical status and survival.5 Recently, a growing number of echocardiographic markers of RVD have been evaluated as possible predictors of poor exercise tolerance in COPD. However, there is no general agreement on which are the most useful in clinical practice.5,6 The evaluation of tricuspid annular plane systolic excursion (TAPSE) by echocardiography provides a simple, rapid, quantitative tool for noninvasively assessing right ventricular systolic function.7 Given its proprieties, TAPSE assessment seems to be particularly useful in clinical practice, especially in the setting of pulmonary rehabilitation, where a combination of factors affecting exercise tolerance is important. To our knowledge, the possibility that TAPSE is related to exercise tolerance and to the response to exercise training (ET) has not been previously explored. In this study, we hypothesized that TAPSE would be correlated with exercise tolerance as evaluated by 6-minute walk test (6MWT) distance and the change in 6MWT distance following an ET program in patients with COPD.
METHODS Subjects were recruited from the pulmonary rehabilitation department at San Raffaele IRCCS, Rome, Italy. Forty-four patients (median age: 70.2 ± 5.2 years; male/female: 29/15) with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease classes 2-4) were enrolled. All subjects had a previous diagnosis of symptomatic COPD, no history of left ventricular disease, and preserved left ventricle ejection fraction (LVEF) of 54.4 ± 9.1%. Before starting the ET program, each patient underwent echocardiography evaluation and 6MWT. The rehabilitation program consisted of 2 sessions each day for 6 days per week for a total of 4 weeks. Each session lasted 30 minutes and included symptoms-limited ET (walking or cycling). Change in 6MWT (Δ6MWT) distance was defined as the difference between the distance walked at the end of ET program minus 6MWT distance performed at baseline. According to the American Society of Echocardiography guidelines,8 a www.jcrpjournal.com
TAPSE cutoff of ≤16 mm was chosen to identify RVD. Patients were divided into the following 2 groups on the basis of their right ventricular systolic function: reduced (TAPSE ≤16 mm) or normal (TAPSE >16 mm). Results were expressed as median ± standard deviation (SD) or percentages where appropriate. Withingroup changes in the reported variables were evaluated by a paired t test or the Wilcoxon signed rank test for nonnormally distributed variables. Betweengroups comparisons were performed using the unpaired t test and the Mann-Whitney rank sum test. Relationship between variables was assessed by the Pearson correlation or the Spearman rank test for nonnormally distributed data.
RESULTS Forty-four patients (median age: 70.2 ± 5.2 years; male/female: 29/15) with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease classes 2-4) were enrolled. All subjects had a diagnosis of symptomatic COPD, no history of left ventricular disease, and a preserved LVEF of 54.4 ± 9.1%. Fourteen patients (31.8%) had TAPSE ≤16 mm. At baseline patients with TAPSE ≤16 mm had similar LVEF compared with patients with TAPSE >16 mm (54.6 ± 4.9% vs 54.0 ± 7.1, respectively) and forced expiratory volume in 1 second (FEV1) percentage of predicted (48.7 ± 5.8 vs 49.3 ± 4.2, respectively) (Table 1). Baseline 6MWT distance was significantly less in the TAPSE ≤16 mm group compared with the TAPSE >16 mm group (110.2 ± 34 vs 185.7 ± 41; P = .02). After the ET program, 6MWT distance increased in both groups but there was less of an increase in the group with TAPSE ≤16 mm compared with TAPSE >16 mm (+24.3% vs +32.8%, respectively; P = .001). Tricuspid annular plane systolic excursion was directly related to distance walked at baseline 6MWT (r = 0.44; P = .002) (Figure 1) and to Δ6MWT (r = 0.36; P = .006) (Figure 2). Forced expiratory volume in 1 second and LVEF were poorly related to the performance of the 6MWT.
DISCUSSION This study found that TAPSE was strongly related to baseline 6MWT distance in COPD patients with moderate to severe disease and participating in an ET program. Our data are in agreement with those reported by Tanaka et al,5 who demonstrated that right ventricular function, evaluated through total ejection isovolume index, was strongly correlated with scores Right Ventricular Dysfunction in COPD / 71
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 71
08/12/14 1:54 PM
T a b l e 1 • Baseline Characteristics in Subjects With (TAPSE ≤16 mm) or Without (TAPSE >16 mm) Right Ventricular Dysfunctiona All Patients (n = 44)
TAPSE ≤16 mm (n = 14)
TAPSE >16 mm (n = 30)
70.2 ± 5.2
71.2 ± 8.4
69.5 ± 11.0
29:15
9:5
20:10
Body mass index, kg/m
27.7 ± 6.3
27.4 ± 8.5
28.1 ± 11.6
GOLD classes 2/3/4, n
25/14/5
9/4/1
16/10/4
LVEF, %
54.4 ± 9.1
54.6 ± 4.9
54.0 ± 7.1
LVDD, mm
47.5 ± 9.2
47.6 ± 7.5
47.1 ± 8.3
LVSD, mm
23.1 ± 7.1
23.4 ± 6.3
22.9 ± 8.1
E, cm/s
79.5 ± 11.3
78.9 ± 8.0
79.8 ± 14.8
A, cm/s
88.7 ± 13.5
89.1 ± 10.1
88.4 ± 9.0
E/A ratio
0.89 ± 0.4
0.88 ± 0.5
0.90 ± 0.2
RVDD, mm
33 ± 11.4
35 ± 7.1
32 ± 8.4
E, cm/s
52.6 ± 9.0
53.3 ± 11.4
52.1 ± 7.7
A, cm/s
47.5 ± 13.4
47.3 ± 13.0
47.8 ± 13.2
E/A ratio
1.11 ± 0.3
1.12 ± 0.2
1.08 ± 0.3
FEV1, % predicted
49.1 ± 7.3
48.7 ± 5.8
49.3 ± 4.2
FVC, % predicted
68.2 ± 11.0
67.6 ± 13.1
68.8 ± 9.2
IC, % predicted
54.5 ± 8.0
54.7 ± 6.5
54.3 ± 8.5
RV, % predicted
180 ± 32.7
178.4 ± 36.1
180.9 ± 29.3
TLC, % predicted
115 ± 28.4
117.1 ± 21.8
116.6 ± 29.0
Age, y Sex (male:female), n 2
Echocardiography data Left ventricle
Right ventricle
Spirometry data
Abbreviations: A, late ventricular filling velocity; E, early ventricular filling velocity; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease; IC, inspiratory capacity; LVDD, left ventricular diastolic diameter; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic diameter; RV, residual volume; RVDD, right ventricle diastolic diameter; TLC, total lung capacity. a Continuous data expressed as median ± SD.
reflecting daily living activity. Interestingly in our sample, we found similar values for FEV1 and other functional lung parameters in subjects with or without RVD. This result suggests that the relation between RVD and poor exercise tolerance is independent from the degree of pulmonary dysfunction. Similarly, Cuttica et al6 found that RVD, assessed with echocardiography, was related to exercise capacity but independently from the results of lung function tests. We also observed that TAPSE was significantly related to the improvement of 6MWT distance after ET. A similar finding has been recently described by our group in patients with heart failure.9 This is a new finding in COPD patients, and, in our opinion, it underscores the importance of assessing TAPSE before
starting an ET program. The assessment of TAPSE in this context could help physicians have a more complete understanding of the parameters affecting exercise tolerance in COPD and to realistically anticipate the individual response to ET in these patients.
CONCLUSIONS Our results confirm the association between RVD and poor exercise tolerance in COPD, regardless of functional lung parameters. They also demonstrate the utility of TAPSE for evaluating this relationship in the context of pulmonary rehabilitation programs. The assessment TAPSE is a simple and effective tool that can
72 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:70-74
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 72
08/12/14 1:54 PM
Figure 1. Scatterplot showing the relation between TAPSE and baseline 6MWT distance. Abbreviations: 6MWT, 6-minute walk test; TAPSE, tricuspid annular plane systolic excursion.
Figure 2. Scatterplot showing the relation between TAPSE and delta in 6MWT distance. Abbreviations: 6MWT, 6-minute walk test; TAPSE, tricuspid annular plane systolic excursion. www.jcrpjournal.com
Right Ventricular Dysfunction in COPD / 73
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 73
08/12/14 1:54 PM
be adopted in the routine clinical assessment of patients with COPD to explore the relationship between right ventricular function and exercise tolerance. This could give physicians, in the setting of pulmonary rehabilitation, the opportunity to better understand which patients will have a lower 6MWT performance upon admission to pulmonary rehabilitation and how 6MWT distance will change after an ET program.
References 1. Calverley PM, Walker P. Chronic obstructive pulmonary disease. Lancet. 2003;362:1053-1061. 2. Saey D, Debigare R, LeBlanc P, et al. Contractile leg fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2003;168:425-430. 3. Sims MW, Margolis DJ, Localio AR, Panettieri RA, Kawut SM, Christie JD. Impact of pulmonary artery pressure on exercise function in severe COPD. Chest. 2009;136:412-419.
4. Hilde JM, Skjorten I, Grotta J, et al. Right ventricle dysfunction and remodeling in chronic obstructive pulmonary disease without hypertension. J Am Coll Cardiol. 2013;62:1103-1111. 5. Tanaka Y, Hino M, Mizuno K, Gemma A. Evaluation of right ventricular function in patients with COPD. Respir Care. 2013; 58:816-823. 6. Cuttica MJ, Shah SJ, Rosenberg SR, et al. Right heart structural changes are independently associated with exercise capacity in non-severe COPD. PLoS ONE. 2011;6:e29069. 7. Meluzin J, Spinarova L, Bakala J, et al. Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion. A new, rapid, and non-invasive method of evaluating right ventricular systolic function. Eur Heart J. 2001;22:340-348. 8. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713. 9. Caminiti G, Volterrani M, Murugesan J, et al. Tricuspid annular plane systolic excursion is related to performance at six minute walking test in patients with heart failure undergoing exercise training. Int J Cardiol. 2013;169:91-92.
74 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:70-74
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00021.indd 74
08/12/14 1:54 PM
