Striking similarities in systemic factors contributing to decreased exercise capacity in patients with severe chronic heart failure or COPD

Striking similarities in systemic factors contributing to decreased exercise capacity in patients with severe chronic heart failure or COPD. Gosker HR, Lencer NH, Franssen FM, van der Vusse GJ, Wouters EF, Schols AM. Department of Pulmonology, University of Maastricht, the Netherlands. [email protected] AIMS: Chronic heart failure (CHF) and COPD are both characterized by muscular impairment. To assess whether the severity and functional consequences of muscular impairment are disease specific, we compared skeletal muscle function, body composition, and daily activity level relative to exercise capacity between these two disorders. METHODS: Twenty-five patients with CHF and 25 patients with COPD, and 36 healthy gender- and age-matched control subjects underwent measurement of fat-free mass (FFM) [by bioelectrical impedance analysis] as an index of muscle mass. Quadriceps and biceps functions were tested by isokinetic methods, and daily activity level was assessed by the Physical Activity Scale for Elderly (PASE) questionnaire. Peak oxygen consumption (O(2)peak) was measured by incremental cycle ergometry. RESULTS: PASE results were similar in patients with CHF and in patients with COPD, each group scoring lower than control subjects. FFM was also lower in patients than control subjects and correlated closely with quadriceps and biceps strength in all three subgroups, R values ranging from 0.63 to 0.78, with identical slopes. FFM also correlated significantly with O(2)peak (p < 0.05), but slopes were less steep in patients than in control subjects. The type and severity of muscle dysfunction were similar in each group of patients. There were no significant correlations between indexes of cardiopulmonary function and muscle function or exercise performance in patients with CHF or in patients with COPD. In both control subjects and patients, FFM was the most significant determinant of O(2)peak. CONCLUSION: Muscle dysfunction is not limited to the lower limbs, but generalized and comparable between patients with CHF and patients with COPD with similar exercise capacity. FFM is a strong predictor of peripheral muscle strength, to a lesser extent of O(2)peak, and not at all of peripheral muscle enduranc

Symptoms, Comorbidities, and Health Care in Advanced Chronic Obstructive Pulmonary Disease or Chronic Heart Failure

Abstract Background: Patients with advanced chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF) may experience significant symptom distress. For development of palliative care programs that adequately address symptoms of patients with COPD or CHF, it is necessary to know severity of symptom distress and to gain insight in comorbidities and current provision of health care. Objective of the present cross-sectional observational study was to assess severity of symptoms, presence of comorbidities, and current provision of health care in outpatients with advanced COPD or CHF. Methods: A total of 105 outpatients with clinically stable but advanced COPD (Global initiative for chronic Obstructive Lung Disease [GOLD] stage III or IV) and 80 patients with advanced CHF (New York Heart Association [NYHA] class III or IV) were assessed for demographics, clinical characteristics, self-reported comorbidities, and severity of symptoms using visual analogue scales. In addition, current health care and symptom-related interventions have been assessed. Results: Comorbidities were reported by 96.3% of the CHF patients and 61.9% of the COPD patients. Patients suffered from multiple symptoms, like dyspnea, fatigue, muscle weakness, coughing, low mood, sleeplessness, and frequent micturition. For most symptoms, only the minority of patients had received symptom-related treatment. Involvement of allied health care professionals was low. The majority of COPD and CHF patients had received home adaptation and medical aids. Conclusions: Patients with advanced COPD or CHF experience comorbidities and suffer from multiple symptoms, which are often under treated. Further development and implementation of palliative care programs, consisting of regular assessment of the patients' comorbidities and symptoms as well as the provision of patient-tailored interventions is needed

Frequency and relevance of ischemic electrocardiographic findings in patients with chronic obstructive pulmonary disease

Cardiovascular disease is common in patients with chronic obstructive pulmonary disease (COPD) but often remains unrecognized. Ischemic electrocardiographic (ECG) changes are associated with a higher risk of dying from coronary heart disease but have never been systematically evaluated in COPD. Also, their relation to clinical outcome has not been studied. We aimed to determine the frequency of ischemic ECG changes and its relevance in relation to clinical outcome and predictors of impaired survival in patients with COPD. Clinical characteristics, pulmonary function, and co-morbidities were assessed in 536 patients with COPD during baseline assessment of a comprehensive pulmonary rehabilitation program. Moreover, electrocardiograms at rest were obtained in all patients. All electrocardiograms were scored independently by 2 cardiologists using the Minnesota scoring system. Major or minor Q or QS pattern, ST junction and segment depression, T-wave items, or left bundle branch block were considered ischemic ECG changes. One hundred thirteen patients (21%) had ischemic ECG changes. Moreover, 42 of 293 patients (14%) without self-reported cardiovascular co-morbidities had ischemic ECG changes. In addition, patients with ischemic ECG changes had higher dyspnea grades (Modified Medical Research Council (mMRC) 2.9 +/- 1.1 vs 2.6 +/- 1.1, p = 0.032), worse exercise performance (6-minute walking distance 387 +/- 126 vs 425 +/- 126 m, p = 0.004), more systemic inflammation (high-sensitivity C-reactive protein 11.2 +/- 16.2 vs 7.9 +/- 10.7 mmol/l, p = 0.01), higher scores on the Charlson Co-morbidity Index (1.8 +/- 0.9 vs 1.5 +/- 0.8 points), and higher scores BODE (5.3 +/- 3.7 vs 4.5 +/- 3.4 points, p = 0.033) and on ADO indexes (5.2 +/- 1.7 vs 4.8 +/- 1.7 points, p = 0.029) compared to patients without ischemic ECG changes, whereas forced expiratory volume in the first second was similar (40.8 +/- 15.2% vs 42.6% +/- 15.9%, p = 0.30). In conclusion, ischemic ECG changes are common in patients with COPD and associated with poor clinical outcome irrespective of forced expiratory volume in the first second. These results suggest an important role for cardiovascular disease in impaired survival in these patients

Heterogeneity in clinical characteristics and co-morbidities in dyspneic individuals with COPD GOLD D: Findings of the DICES trial

SummaryIntroductionChronic obstructive pulmonary disease (COPD) is a complex and heterogeneous respiratory disease with important extra-pulmonary features and comorbidities. The aim of this study was to assess clinical heterogeneity in a well-defined subgroup of individuals with COPD GOLD D, including possible gender differences.MethodsPulmonary function, arterial blood gases, exercise performance, quadriceps muscle function, problematic activities of daily life, dyspnea, health status and comorbidities have been assessed in 117 individuals with a MRC dyspnea grade 4/5 and COPD GOLD D entering pulmonary rehabilitation.ResultsA broad range of values were found for diffusion capacity, exercise capacity, quadriceps muscle function and health status. Indeed, the high coefficients of variation were found for these outcomes. Problematic activities of daily life as well as objectified comorbidities also varied to a great extent. Moreover, significant gender differences were found for exercise performance, lower-limb muscle function and various comorbidities.ConclusionThe current findings emphasize that COPD is a heterogeneous disease whose clinical presentation varies significantly, even in individuals with very severe COPD with the same degree of dyspnea and all classified as GOLD D.Trial registration: NTR2322

Prospective study on clinical effects of renal replacement therapy in treatment-resistant congestive heart failure.

Background/aims. Clinical outcome in cardiorenal syndrome (CRS) Type 2 and treatment with dialysis.METHODS: Prospective observational non-randomized study.RESULTS: Twenty-three patients were included, mean age 66 +/- 21 years. Twelve (52%) patients were treated with peritoneal dialysis (PD) and 11 (48%) with intermittent haemodialysis (IHD). Median survival time after start of dialysis was 16 months. Hospitalizations for cardiovascular causes were reduced (1.4 +/- 0.6 pre-dialysis versus 0.4 +/- 0.6 days/patient/month post-dialysis, P = 0.000), without significant changes in hospitalization for all causes (1.8 +/- 1.6 versus 2.1 +/- 2.9 days/patient/month). New York Heart Association (NYHA) class (3.8 +/- 0.4 at start versus 2.4 +/- 0.7 after 4 months, P = 0.000, versus 2.7 +/- 0.9 after 8 months, P = 0.001) and quality of life tended to improve (63 +/- 21 at start, versus 41 +/- 20 after 4 months, versus 51 +/- 25 after 8 months; P = 0.056). Left ventricular ejection fraction did not change. The number of technical complications associated with dialysis therapy was relatively high in this population.CONCLUSIONS: After starting dialysis for CRS, hospitalizations for cardiovascular causes were reduced, but not hospitalizations for all causes. Functional NYHA class improved and quality of life tended to improve, without evidence for a change in cardiac function. In this small study, no differences between IHD and PD were observed

Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with chronic heart failure or COPD: a systematic review of the English-language literature.

Despite optimal drug treatment, many patients with CHF or COPD still suffer from disabling dyspnea, fatigue and exercise intolerance. They also exhibit significant changes in body composition. Attempts to rehabilitate these patients are often futile because conventional exercise training modalities are limited by the severity of exertional dyspnea. Therefore, there is substantial interest in new training modalities that do not evoke dyspnea, such as transcutaneous neuromuscular electrical stimulation (NMES). Herein, we systematically review the literature that addresses the effects of NMES applied to the muscles of ambulation. We focused on the effects of NMES on strength, exercise capacity, and disease-specific health status in patients with CHF or COPD. We also address the methodological quality of the reported studies as well as the safety of NMES. Manuscripts published prior to December 2007 were identified by searching the Medline /PubMed, Embase, Cochrane Controlled Trials Register, CINAHL and The Physical Therapy Evidence Database (PEDro) databases. Fourteen trials were identified: nine trials that examined NMES in CHF and five in COPD. PEDro scores for methodological quality of the trials were generally moderate tot good. Many of the studies reported significant improvements in muscle strength, exercise capacity and/or health status. Nonetheless the limited number of studies, the disparity in patient populations and variability in NMES methodology prohibit the use of meta-analysis. Yet, from the viewpoint of a systematic review NMES looks promising as a means of rehabilitating patients with COPD and CHF. At least, there is sufficient evidence to warrant more large prospective RCTs

Task-related oxygen uptake during domestic activities of daily life in patients with COPD and healthy elderly subjects

ABSTRACTBackground Patients with COPD generally have a poor peak aerobic capacity and may therefore experience more inconvenience during domestic activities of daily life (ADLs). Yet, task-related oxygen uptake and symptom perception during ADLs have been studied rarely in COPD. It therefore remains unknown whether and to what extent differences may exist in task-related oxygen uptake and symptom perception during ADLs in COPD patients after stratification for gender, GOLD stage, MRC dyspnea grade or score on BODE index. Methods Ninety-seven COPD patients and 20 healthy subjects performed 5 self-paced domestic ADLs with 4-min rest intervals: putting on socks, shoes and vest; folding 8 towels; putting away groceries; washing up 4 dishes, cups and saucers; and sweeping the floor for 4 min. Task-related oxygen uptake was assessed using a mobile oxycon, while Borg scores were used to assess task-related dyspnea and fatigue. Results COPD patients used a significantly higher proportion of their peak aerobic capacity and ventilation to perform ADLs compared to healthy elderly subjects, accompanied by higher task-related Borg dyspnea scores. Patients with GOLD stage IV, MRC dyspnea grade 5 or BODE score of &gt;/=6 points had the highest task-related oxygen uptake and dyspnea perception during the performance of domestic ADLs. Results showed no gender-related differences. Conclusion COPD patients experience a relatively high metabolic load and symptom perception during the performance of ADLs that is not the same as seen in their healthy peers, particularly in patients with GOLD stage IV, MRC dyspnea grade 5 or BODE score of &gt;/=6 points