Hemodynamic responses during leg press exercise in patients with chronic congestive heart failure.

To increase muscle mass and strength in patients with chronic congestive heart failure (CHF), there is a need for implementing resistance exercises in exercise training programs. This study sought to assess the safety of rhythmic strength exercise with respect to left ventricular function in 9 patients with stable CHF, compared with 6 stable coronary patients with mild left ventricular dysfunction (control group). With use of right-sided catheterization, changes in left ventricular function were assessed during double leg press exercise at loads of 60% and 80% of maximum voluntary contraction. The exercise sessions lasted 14 minutes each, divided into work and recovery phases of 60/120 seconds. In CHF, during exercise at a 60% load, there was a significant increase in heart rate (mean +/- SEM 90 +/- 4 beats/min; p <0.05), mean arterial blood pressure (95 +/- 3 mm Hg; p <0.01), diastolic pulmonary artery pressure (20.2 +/- 2.7 mm Hg; p <0.01), and cardiac index (3 +/- 0.3 L/m2/min; p <0.05). Additionally, during leg press exercise at an 80% load, there was a significant decrease in systemic vascular resistance (1,086 +/- 80 dynes x s x cm(-5); p <0.001), an increased cardiac index (3.4 +/- 0.1; p <0.001), and left ventricular stroke work index (75 +/- 5 g x m/m2; p <0.01), suggesting enhanced left ventricular function. Compared with controls, in CHF the magnitude of changes in hemodynamic parameters during exercise, demonstrated at a 60% load, was significantly smaller (systemic vascular resistance: [mean] 1,613 --> 1000 vs 1472 --> 1,247 dynes x s x cm(-5); cardiac index: 2.4 --> 3 vs 2.8 --> 4.4 L/m2/min, and stroke work index: 60 --> 69 vs 114 --> 155 g x m/m2; p <0.05 each). Nevertheless, changes indicated an enhanced contractile function of the left ventricle in CHF. This study demonstrates stability of left ventricular function during resistance exercise in well-compensated CHF patients with optimal drug therapy, as well as the appropriateness of the chosen mode and intensity applied as these factors relate to cardiovascular stress. This conclusion cannot be extrapolated to patients with less well-compensated heart failure, or to more protracted resistance training.

Predictors of response to exercise training in severe chronic congestive heart failure.

We prospectively assessed whether baseline central hemodynamics and exercise capacity can predict improvement of VO2 at ventilatory threshold (VT) after exercise training in patients with severe chronic congestive heart failure. Eighteen patients (mean +/- SEM; age 52 +/- 2 years), half of them listed for transplant, underwent 3 weeks of exercise training (interval cycle and treadmill walking; 5 x/week) and 3 weeks of activity restriction in a random-order crossover trial. Baseline data were not significantly different for groups with exercise training first and activity restriction first: cardiac index at rest (2.1 +/- 0.1 L/m2/min), maximum cardiac index (3.1 +/- 0.2 L/m2/min) (Fick), and echocardiographic ejection fraction (21 +/- 1%). The same was true for cardiopulmonary exercise data (cycle ergometry; up 12.5 W/min): VO2 at VT (9.3 +/- 0.4 ml/kg/min), maximum VO2 (12.2 +/- 0.7 ml/kg/min), VT in percentage of predicted maximum VO2 (31 +/- 2%), heart rate at VT (95 +/- 4 beats/min), and decrease of dead space-to-tidal volume ratio from rest to VT (33 +/- 1 --> 29 +/- 1). Improvement of VO2 at VT after training (2.2 +/- 0.4 ml/kg/min; p <0.001) was not related to baseline central hemodynamics (r = <0.10 for each), but was greater in patients with a lower baseline VO2 at VT (r = -0.65; p <0.01), peak VO2 (r = -0.66; p <0.01), VT in percentage of predicted maximum VO2 (r = -0.74; p <0.001), heart rate at VT (r = -0.63; p <0.01), and smaller decrease of dead space-to-tidal volume ratio from rest to VT (r = 0.65; p <0.01). Ejection fraction after exercise training (24 +/- 2%) and activity restriction (23 +/- 2%) did not differ significantly compared with baseline, and patient status (heart failure and cardiac rhythm) remained stable. Three parameters accounted for 84% of the variance of improvement in VO2 at VT: VO2 at VT in percent predicted maximum VO2, decrease of dead space-to-tidal volume ratio, and heart rate at VT. The findings suggest that there was a greater increase in VO2 at VT after exercise training in patients with greater peripheral deconditioning at baseline. The improvement was unrelated to central hemodynamics. Clinically stable patients with severe chronic congestive heart failure, potential heart transplant candidates, and those awaiting transplantation may benefit from involvement in a short-term exercise training program.

Relationship between exercise tolerance, hemodynamics at rest and during exercise and ejection fraction, and their prognostic relevance in asymptomatic postinfarction patients.

In 309 postmyocardial infarction patients (age 40 +/- 7.7 years) without persistent ischemia there is only a weak correlation between ejection fraction (EF) and exercise tolerance (r = 0.45, p < 0.01), and between EF and maximum cardiac output (CO; r = 0.41, p < 0.01) and maximum pulmonary capillary wedge pressure (PCWP; r = -0.32, p < 0.001). The same was true for exercise tolerance and maximum PCWP (r = -0.53, p < 0.001). A big scattering of individual values could be observed. Although we found a high positive correlation between maximum CO and exercise tolerance (r = 0.80, p < 0.001), in individual cases a low CO could be related to high exercise tolerance and vice versa. In the multivariate analysis, only the heart volume/kg body weight and maximum PCWP could be shown to be of independent prognostic importance for survival and/or mortality in the following years (chi 2 = 5.9, p < 0.015 and chi 2 = 7.2, p < 0.007, respectively).

Comparison of the effects of two different galenical preparations of glyceryl trinitrate on pulmonary artery pressure and on the finger pulse curve.

The time course and the magnitude of the effect of glyceryl trinitrate (GTN) on central venous (pulmonary artery diastolic pressure-PAPd) and peripheral arterial (a/b-ratio of the finger pulse wave) haemodynamics were compared in a randomized double-blind cross-over study in 12 patients suffering from congestive heart failure (NYHA II-III) with elevated PAPd at rest (> or = 15 mmHg). The data were obtained in a bioavailability study of two sprays of glyceryl trinitrate, which differed in their galenical characteristics and in the dose of GTN (0.4 mg vs. 0.8 mg). Following sublingual administration of each spray, PAPd, a/b-ratio and the plasma concentrations of GTN and its metabolites were measured up to 30 min. The relative bioavailability of GTN of the test preparation was estimated to be 157%, 161% and 147%, when calculated from the plasma concentration-time data or the integrated effect of GTN on a/b-ratio or PAPd, respectively. The mean time courses of the decrease in PAPd and the increase in the a/b-ratio of the finger pulse curve were mirror images. Thus, there was a strong correlation between the mean values of PAPd and a/b-ratio following the administration of glyceryl trinitrate. Since the slope of the relationship differed considerably between the patients, the magnitude of effect of GTN on PAPd in the individual patient could not be predicted from the changes in a/b-ratio.

Hemodynamics and exercise tolerance after bisoprolol, nifedipine, and their combination in patients with angina pectoris.

The different mechanisms of action of beta-blockers and calcium antagonists could result in an additive therapeutic effect in patients with angina pectoris. Twenty-one male patients aged between 41 and 68 years and suffering from chronic stable angina pectoris and coronary artery disease confirmed by angiography took part in a randomized, double-blind study to examine the acute effect of 10 mg of bisoprolol, 20 mg of nifedipine, and a combination of the two drugs on hemodynamics at rest and during exercise [heart rate (HR), systolic blood pressure (SBP), rate-pressure product (RPP), cardiac index (CI), total peripheral resistance (TPR), and pulmonary capillary wedge pressure (PCP)], the behavior of the ST segment (ST), and exercise tolerance until occurrence of an ST-segment depression of 0.1 mV (W-ST01) and until onset of anginal pain (W-AP1). Following a baseline exercise test, 11 patients were given 10 mg of bisoprolol orally, whereas 10 patients received placebo. Two hours later, a second exercise test was carried out. All patients in both groups then received 20 mg of N orally. A third exercise test was performed 2 h later. On exercise, bisoprolol resulted in significant changes in HR (-16%), RPP (-22%), and CI (-16%), as well as in TPR (+ 13%); PCP was not significantly affected. Nifedipine led to significant changes in CI (+9%) and PCP (-34%). The effects of bisoprolol on HR and RPP and of nifedipine on PCP were retained in the combination. Competition was detectable as regards the opposing effects on CI and TPR. Measured by W-ST01 and ST, bisoprolol had a marked anti-ischemic effect, whereas that of nifedipine was distinctly less. There was an increase in effect after combination of the drugs (not significant). In patients with chronic angina pectoris due to coronary artery disease, bisoprolol and nifedipine had different hemodynamic profiles after acute administration; when the two drugs were combined, these effects were partly intensified and partly canceled out. There was a tendency for the effect of bisoprolol to be intensified by nifedipine in the combination. The combination of bisoprolol and nifedipine was well tolerated in the doses selected.

[Effect of intravenous diltiazem on stress-induced myocardial ischemia (study of hemodynamics and reproducibility of repeated studies]. / Wirkung von Diltiazem i.v. auf die belastungsinduzierte Myokardischämie (Untersuchung zur Hämodynamik und Reproduzierbarkeit von Wiederholungsuntersuchungen).

UNLABELLED: To obtain data about (a) the reproducibility of repeated standardized exercise tests, under blank and placebo conditions and (b) the improvement of ischaemic symptoms and of haemodynamics after intravenous application of diltiazem (0.3 mg/kg body weight), 20 patients with angina pectoris and angiographically proven coronary heart disease were analysed in a randomized double-blind study. RESULTS: a) A control exercise test 1 h after the first blank test showed no significant changes of the following parameters neither at rest nor during exercise: heart rate, systolic and diastolic blood pressure, double product, pulmonary capillary wedge pressure, cardiac output, peripheral vascular resistance, stroke volume, ST-segment depression, symptoms of angina pectoris, and maximal work tolerance (steady state, supine position). b) After intravenous application of diltiazem, at rest, both systolic blood pressure (-13 mm Hg, p less than 0.03); diastolic blood pressure (-10 mm Hg, p less than 0.01) and peripheral vascular resistance (-189 dyn x s x cm-5, p less than 0.02) decreased. During exercise testing, diastolic blood pressure (-9 mm Hg, p less than 0.02), pulmonary capillary wedge pressure (-13 mm Hg, p less than 0.01) and peripheral vascular resistance (-152 dyn x s x cm-5, p less than 0.02) were reduced, and angina pectoris was less severe (p less than 0.01): in comparison to placebo the onset of anginal symptoms occurred later (24 vs 49 W, p less than 0.01). Maximal exercise tolerance and maximal cardiac output were improved, and ST-segment depression was less pronounced. The study shows that haemodynamic data and ischaemic parameters are well reproducible in repeated exercise tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bisoprolol on exercise tolerance in patients with coronary heart disease: placebo-controlled double-blind crossover study.

Twelve patients with stable angina pectoris due to coronary heart disease received single oral doses of 5, 10, and 20 mg bisoprolol in a placebo-controlled double-blind crossover study. A significant, dose-related increase in exercise tolerance in symptom-limited bicycle exercise tests performed 2.5 h after administration (p less than 0.05) was demonstrated. The dose-effect relationship was especially marked in reduction of heart rate, rate-pressure product, and ischemic ST-segment depression at the highest comparable workload (p less than 0.01). Compared with placebo, mean improvements in work performance (determined by the maximal workload attained, i.e., W X minutes) increased to 105% with 5 mg, to 122% with 10 mg, and to 131% with 20 mg bisoprolol. The lower incidence rate of exercise-induced symptoms of angina pectoris at an identical workload was marked at the 10- and 20-mg dose.

[Condition following myocardial infarct: which studies at what time and with what patients?]. / Zustand nach Herzinfarkt: welche Untersuchungen zu welchem Zeitpunkt und bei welchen Patienten?

This review discusses the stepwise approach to postinfarction patients. For some patients only a few basic steps are needed, for others the whole diagnostic spectrum becomes necessary. The baseline diagnostic workup at the time of discharge from the hospital includes: history, clinical examination and risk factor analysis, ECG at rest; x-ray examination of the heart; Holter-ECG recording and exercise testing. The results of this routine diagnostic program determine whether additional and invasive methods are necessary, e.g. echocardiography, myocardial perfusion scintigraphy, radionuclide angiography and coronary angiography. The indication for coronary angiography should be adjusted to the indications for aortocoronary bypass surgery and aneurysmectomy. In young postinfarction patients and those in specific jobs, coronary angiography is also indicated to improve the evaluation of prognosis.

Does exercise testing with invasive measurements of cardiac output and pressure really contribute?

Quantification of heart failure is possible with hemodynamic parameters such as cardiac output and filling pressure at rest and during exercise. These parameters can easily but invasively be achieved by floating catheter measurements. In our experience, the risk of this method is low but existent. In greater than 20 000 patients with chronic diseases no death occurred in connection with the procedure; 26 patients developed ventricular fibrillation or ventricular tachycardias which made defibrillation necessary in 10 of these patients. In three patients asystolia demanded resuscitation. Hemoptysis did not occur. In the acute stage of a disease, e.g. in the acute myocardial infarction, the risk may be higher, especially if the catheter remains in the circulation for longer periods. The possibilities and limitations of the method will be discussed for the following patient groups: (1) Patients with acute myocardial infarction, (2) Postinfarction patients, (3) Patients with cardiomyopathies, (4) Patients with valvular heart disease.

Partial atrial standstill in sick sinus syndrome; intraatrial and AV nodal block with short PR interval.

Standstill and inexcitability (quiescence) of the high right atrium could be demonstrated in a patient with sinus node dysfunction and bradycardia--tachycardia syndrome. The onset of P wave in surface electrocardiogram did not represent the beginning of atrial excitation but followed 130 msec the high right atrial and 50 msec the low right atrial deflection, leading thereby to a short PR interval which gave misinformation on the atrioventricular conduction. A pacemaker implant with right ventricular stimulation freed the patient of his previous complaints. 4 wk after the implantation the demand unit was inhibited for 5 h by external stimulation. Continuous ECG monitoring, esophageal ECG recording and fluoroscopic study could not reveal any atrial activity. The conditions for atrial pacemaker implantation are discussed.

[Can predictability of coronary angiographic findings be improved by additional measurement of pulmonary wedge pressure during exercise? (author's transl)]. / Verbessert die zusätzliche Messung des Pulmonalkapillardruckes während körperlicher Belastung die Voraussage des koronarangiographischen Betundes bei Patienten ohne transmuralen Herzinfarkt?

The correlation between the three ischemia indicators angina pectoris (AP), ST-segment depression (ST) and excessive pulmonary wedge pressure rise (PCP) during exercise, and the coronary angiographic findings, were analysed in 293 patients without previous transmural myocardial infarction. This patient material consisted of 253 men and 40 women between the age of 20 and 65 years, the mean age being 48. The exercise tests were performed on a bicycle ergometer in supine position and in relatively steady state conditions. Pulmonary wedge pressure was measured by means of a Swan-Ganz floating catheter. The essential findings were: 1. If all three ischemia indicators were positive, the incidence of a positive angiographic finding i.e. a greater than or equal to 50% stenoses in at least one main coronary artery was 96.3%. 2. If only the two classic ischemia indicators were evaluated and positive, the incidence of a positive angiographic finding was only 86.1% (24). This difference is mainly due to false positive results of AP and ST in women. 3. If all three ischemia indicators were negative, the incidence of a negative angiographic finding was 89.2%. 4. If only the two classic ischemia indicators were evaluated and negative the incidence of a negative angiographic finding was as high (87,6% [24]). This lack of difference is due to the fact that patients with a previous intramural infarcion can be free not only of AP and ST but also of PCP during exercise. 5. The combination of AP and PCP, or ST and PCP, is equally reliable in predicting coronary morphology as the classic combination of AP and ST. It follows that PCP measurement is recommended, if one of the classic ischemia indicators cannot be properly evaluated.