Functional capacity before and after cardioversion of atrial fibrillation: a controlled study.

Gosselink, A. T. M.; Crijns, H. J. G. M.; Berg, Maarten P. van den; Broek, Stan A.J. van den; Hillege, Hans; Landsman, Mlj; Lie, Kong I.

doi:10.1136/hrt.72.2.161

Cited by 109 publications

(32 citation statements)

References 28 publications

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“…Each of these mechanisms is of particular importance at peak exercise when maximal contractile reserve is used. As such, AF has been associated with exercise intolerance in patients with lone AF and more notably in those with associated heart disease 9, 23, 24, 25. Some studies have shown that peak VO 2 , a surrogate of maximal aerobic capacity,12 is 10% to 20% lower in patients with HFrEF with AF 6, 8, 9, 25.…”

Section: Discussionmentioning

confidence: 99%

Impact of Atrial Fibrillation on Exercise Capacity and Mortality in Heart Failure With Preserved Ejection Fraction: Insights From Cardiopulmonary Stress Testing

El‐Shazly

Senn²,

et al. 2017

JAHA

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BackgroundAtrial fibrillation (AF) has been objectively associated with exercise intolerance in patients with heart failure with reduced ejection fraction; however, its impact in patients with heart failure with preserved ejection fraction has not been fully scrutinized.Methods and ResultsWe identified 1744 patients with heart failure and ejection fraction ≥50% referred for cardiopulmonary stress testing at the Cleveland Clinic (Cleveland, OH), 239 of whom had AF. We used inverse probability of treatment weighting to balance clinical characteristics between patients with and without AF. A weighted linear regression model, adjusted for unbalanced variables (age, sex, diagnosis, hypertension, and β‐blocker use), was used to compare metabolic stress parameters and 8‐year total mortality (social security index) between both groups. Weighted mean ejection fraction was 58±5.9% in the entire population. After adjusting for unbalanced weighted variables, patients with AF versus those without AF had lower mean peak oxygen consumption (18.5±6.2 versus 20.3±7.1 mL/kg per minute), oxygen pulse (12.4±4.3 versus 12.9±4.7 mL/beat), and circulatory power (2877±1402 versus 3351±1788 mm Hg·mL/kg per minute) (P<0.001 for all comparisons) but similar submaximal exercise capacity (oxygen consumption at anaerobic threshold, 12.0±5.1 versus 12.4±6.0mL/kg per minute; P =0.3). Both groups had similar peak heart rate, whereas mean peak systolic blood pressure was lower in the AF group (150±35 versus 160±51 mm Hg; P<0.001). Moreover, AF was associated with higher total mortality.ConclusionsIn the largest study of its kind, we demonstrate that AF is associated with peak exercise intolerance, impaired contractile reserve, and increased mortality in patients with heart failure with preserved ejection fraction. Whether AF is the primary offender in these patients or merely a bystander to worse diastolic function requires further investigation.

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Section: Discussionmentioning

confidence: 99%

Impact of Atrial Fibrillation on Exercise Capacity and Mortality in Heart Failure With Preserved Ejection Fraction: Insights From Cardiopulmonary Stress Testing

El‐Shazly

Senn²,

et al. 2017

JAHA

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“…AF interferes with endothelial function (10,27) and exercise capacity (9,18,19,24), and a pathophysiological link seems to exist between the two variables (10). Our results have provided evidence that sinus rhythm conversion restores endothelial function in patients with lone AF and is partially effective (hypertension) or ineffective (diabetes) in those with comorbidities that cause endothelial dysfunction.…”

Section: Discussionmentioning

confidence: 99%

Endothelial dysfunction and exercise performance in lone atrial fibrillation or associated with hypertension or diabetes: different results with cardioversion

Guazzi¹,

Belletti²,

Bianco³

et al. 2006

American Journal of Physiology-Heart and Circulatory Physiology

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Endothelial dysfunction and underperfusion of exercising muscle contribute to exercise intolerance, hyperventilation, and breathlessness in atrial fibrillation (AF). Cardioversion (CV) improves endothelial function and exercise performance. We examined whether CV is equally beneficial in diabetes and hypertension, diseases that cause endothelial dysfunction and are often associated with AF. Cardiopulmonary exercise and pulmonary and endothelial (brachial artery flow-mediated dilation) function were tested before and after CV in patients with AF alone (n ϭ 18, group 1) or AF with hypertension (n ϭ 19, group 2) or diabetes (n ϭ 19, group 3). Compared with group 1, peak exercise workload, O2 consumption (V O2), O2 pulse, aerobic efficiency (⌬V O2/⌬WR), and ratio of brachial diameter changes to flow changes (⌬D/⌬F) were reduced in group 2 and, to a greater extent, in group 3; exercise ventilation efficiency (V E/V CO2 slope) and dead space-to-tidal volume ratio (VD/VT) were similar among groups. CV had less effect on peak workload (ϩ7% vs. ϩ18%), peak V O2 (ϩ12% vs. ϩ17%), O2 pulse (ϩ33% vs. ϩ50%), ⌬V O2/⌬WR (ϩ7% vs. ϩ12%), V E/V CO2 slope (Ϫ6% vs. Ϫ12%), ⌬D/⌬F (ϩ7% vs. ϩ10%), and breathlessness (Borg scale) in group 2 than in group 1 and was ineffective in group 3. The antioxidant vitamin C, tested in eight additional patients in each cohort, improved flow-mediated dilation in groups 1 and 2 before, but not after, CV and was ineffective in group 3, suggesting that the oxidative injury is least in lone AF, greater in hypertension with AF, and greater still in diabetes with AF. Comorbidities that impair endothelial activity worsen endothelial dysfunction and exercise intolerance in AF. The advantages of CV appear to be inversely related to the extent of the underlying oxidative injury.arrhythmias; endothelium; exercise ATRIAL FIBRILLATION (AF) impairs endothelial function and downregulates nitric oxide (NO) production (3, 10, 27). Exercise correlates of these dysfunctions are underperfusion of working muscle, hyperventilation, and breathlessness (10). These findings are consistent with the concept that, during exercise, an endothelium-mediated vasodilation modulates neurogenic vasoconstriction, increases arterial conductance, and upregulates muscle perfusion (6,12,16). Conversion to sinus rhythm [i.e., cardioversion (CV)] is beneficial in this respect (10). Irregular pulsatile blood flow in AF may impair the endothelial responsiveness to vascular shear stress, and loss of the cyclic stretch of atrial endocardial cells may decrease expression of NO synthase (3). Restoration of a regular flow regimen and atrial contactile activity with CV normalizes the endothelial physiology.Hypertension and diabetes cause endothelial dysfunction (13,20,23,26). Because AF is not uncommonly associated with high blood pressure and diabetes, we considered the pathophysiological and clinical significance of this association to investigate whether the improvement of endothelial function with CV, its exercise pathophysiological correlates, ...

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“…How and whether atrial fibrillation and an irregular ventricular contraction may affect exercise physiology has been matter of investigation since several years (2,8,10,12,21,23,36). Physiology-based studies have, however, primarily focused on the hemodynamic bases for exercise intolerance.…”

Section: Vascular Studiesmentioning

confidence: 99%

Exercise hyperventilation, dyspnea sensation, and ergoreflex activation in lone atrial fibrillation

Guazzi¹,

Belletti²,

Tumminello³

et al. 2004

American Journal of Physiology-Heart and Circulatory Physiology

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Lone atrial fibrillation may be associated with daily life disability and exercise limitation. The extracardiac pathophysiology of these effects is poorly explored. In 35 subjects with lone atrial fibrillation (mean age 67 Ϯ 7 yr), we investigated pulmonary function, symptom-limited cardiopulmonary exercise performance, muscle ergoreflex (handgrip exercise) contribution to ventilation, and brachial artery flow-mediated dilation (as a measure of endothelial function) before and after (average interval 20 Ϯ 5 days) restoring sinus rhythm with external cardioversion. Respiratory volumes and lung diffusing capacity at rest were within normal limits during both atrial fibrillation and after restoring sinus rhythm. Cardioversion was associated with the following changes: a decrease of the slope of exercise ventilation vs. CO2 production (from 35 Ϯ 5 to 29 Ϯ 3; P Ͻ 0.01) and of dyspnea sensation (Borg score from 4 to 2) and an increase of peak oxygen uptake (V O2; from 16 Ϯ 4 to 20 Ϯ 5 ml⅐ min Ϫ1 ⅐ kg Ϫ1 ; P Ͻ 0.01), V O2 at anaerobic threshold (from 11 Ϯ 2 to 13 Ϯ 2 ml⅐ min Ϫ1 ⅐ kg Ϫ1 ; P Ͻ 0.05), and O2 pulse (from 8 Ϯ 3 to 11 Ϯ 3 ml/beat; P Ͻ 0.01). After cardioversion, the observed improvement in ventilatory efficiency was accompanied by a significant peak end-tidal CO2 increase (from 33 Ϯ 2 to 37 Ϯ 2 mmHg; P Ͻ 0.01) and no changes in dead space-to-tidal volume ratio (from 0.23 Ϯ 0.03 to 0.23 Ϯ 0.02; P ϭ not significant). In addition, the ergoreflex contribution to ventilation was remarkably attenuated, and the brachial artery flow-mediated dilatation was significantly augmented (from 0.32 Ϯ 0.07 to 0.42 Ϯ 0.08 mm; P Ͻ 0.01). Ten patients had atrial fibrillation relapse and, compared with values after restoration of regular sinus rhythm, invariably showed worsening of endothelial function, exercise ventilatory efficiency, and muscle ergoreflex contribution to ventilation. In subjects with lone atrial fibrillation, an impairment in ventilatory efficiency appears to be involved in the pathophysiology of exercise limitation, and to be primarily related with a demodulated peripheral control of ventilation. lone atrial fibrillation; exercise; ventilation; dyspnea LONE ATRIAL FIBRILLATION is the most common sustained arrhythmia encountered in clinical practice (11,39). A reduced maximal exercise oxygen uptake (V O 2 ; see Refs. 12, 21, and 23) is a frequent finding, and exercise intolerance is not an uncommon daily life disability factor (19,22). As to the pathophysiological bases of physical limitation, previous studies have extensively investigated the putative role of hemodynamic abnormalities associated with atrial fibrillation (3,8,10,36). Exercise performance, however, not only depends on the cardiovascular system function but on any organ system involved in O 2 transport, including the respiratory system, skeletal muscles, hormonal and neural feedback control system for breathing, cardiac output, blood pressure, and blood volume. A contribution of peripheral changes resulting from this arrhythmia to the pathogenes...

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Functional capacity before and after cardioversion of atrial fibrillation: a controlled study.

Cited by 109 publications

References 28 publications

Impact of Atrial Fibrillation on Exercise Capacity and Mortality in Heart Failure With Preserved Ejection Fraction: Insights From Cardiopulmonary Stress Testing

Impact of Atrial Fibrillation on Exercise Capacity and Mortality in Heart Failure With Preserved Ejection Fraction: Insights From Cardiopulmonary Stress Testing

Endothelial dysfunction and exercise performance in lone atrial fibrillation or associated with hypertension or diabetes: different results with cardioversion

Exercise hyperventilation, dyspnea sensation, and ergoreflex activation in lone atrial fibrillation

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