Hemodynamic determinants of exercise capacity in chronic atrial fibrillation

Ueshima, Kenji; Myers, Jonathan; Ribisl, Paul M.; Atwood, J. Edwin; Morris, Charles K.; Kawaguchi, Takeo; Liu, James H.; Froelicher, Victor F.

doi:10.1016/0002-8703(93)90998-o

Cited by 44 publications

(24 citation statements)

References 17 publications

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“…During the past few decades, several invasive and noninvasive hemodynamic studies have shed light on the role played by atrial systole and normal sinus rhythm in maintaining adequate cardiac output, particularly during exercise and in patients with heart failure 5, 8, 17, 20, 21, 22, 23. Inadequate cardiac output during AF has been attributed to several mechanisms, including loss of atrial systole, irregular ventricular rhythm with beat‐to‐beat variability, and impaired ventricular filling time 9, 17, 21, 22.…”

Section: Discussionmentioning

confidence: 99%

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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%

“…Inadequate cardiac output during AF has been attributed to several mechanisms, including loss of atrial systole, irregular ventricular rhythm with beat‐to‐beat variability, and impaired ventricular filling time 9, 17, 21, 22. Each of these mechanisms is of particular importance at peak exercise when maximal contractile reserve is used.…”

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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“…However, exercise intolerance in patients with AF is related more to the underlying heart disease than to AF itself. 1) Previous studies have demonstrated that left ventricular (LV) systolic function does not predict exercise capacity. 2,3) In contrast, recent reports showed that LV diastolic dysfunction was intimately related to functional status.…”

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confidence: 99%

<b>Value of Left Atrial Function in Predicting Exercise Capacity in Heart Failure With Moderate to Severe Left Ventricular Systolic Dysfunction</b>

et al. 2005

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SUMMARYLeft atrial (LA) function is associated with left ventricular (LV) diastolic filling and cardiac output response to exercise. But the relation between LA function and exercise performance has not been adequately evaluated.The aim of this study was to investigate the relation between LA function and exercise capacity in dilated cardiomyopathy (DCM) with cardiopulmonary exercise testing.Forty-four patients with a left ventricular end-diastolic dimension (LVDd) ≥ 60 mm and an ejection fraction (EF) ≤ 40%, and in normal sinus rhythm were included in this study. Patients were divided into group 1 and group 2 according to their exercise peak oxygen uptake (VO 2 ) (group 1: peak VO 2 >14 mL/kg/min, group 2: peak VO 2 ≤ 14 mL/ kg/min). LA function indices were defined as follows: LA end-systolic diameter (LASd), end-diastolic diameter (LADd), LA systolic volume (LASV), LA diastolic volume (LADV), LA ejection volume (LAEV), and LA ejection fraction (LAEF).LASd, LADd, LASV, and LADV were significantly increased in group 2 (P < 0.001, P < 0.001, P < 0.05, P < 0.005). Group 1 had significantly higher LAEF (P < 0.001 ) and LVEF (P < 0.05). Group 2 had significantly shorter exercise duration, and decreased anaerobic threshold levels and minute ventilation volumes (P < 0.001, P < 0.001, P < 0.005 ). There was a positive correlation between peak VO 2 and LVEF (r = 0.46, P = 0.002), and LAEF (r = 0.61, P < 0.001), peak A wave velocity (r = 0.39, P = 0.009), E wave deceleration time (r = 0.56, P < 0.001), and isovolumic relaxation time (IVRT) (r = 0.35, P = 0.04). There was a negative correlation between peak VO 2 and LASd (r = -0.53, P < 0.001) LADd (r = -0.59, P < 0.001), LASVI (r = -0.34, P = 0.027), LADVI (r = -0.37, P = 0.001), and the E/A ratio (r = -0.41, P = 0.006), Decreased LAEF and increased LA sizes were associated with decreased peak VO 2 . The results clearly demonstrate that LA functions at rest are related to exercise performance in patients with heart failure. (Int Heart J 2005; 46: 123-131)

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“…[3][4][5] At submaximal exercise levels, HR in patients with AF increases more than in those with sinus rhythm. 6,7) Exercise tests in AF patients are performed mostly in order to ascertain if the ventricular rate is under control by pharmacological treatment, to determine functional capacity, and to plan rehabilitation programs. [6][7][8] Isotonic (dynamic) exercise tests, such as treadmill and bicycle ergometer tests, are usually performed with patients and healthy people to investigate the cardiovascular response to exercise.…”

Section: Discussionmentioning

confidence: 99%

“…6,7) Exercise tests in AF patients are performed mostly in order to ascertain if the ventricular rate is under control by pharmacological treatment, to determine functional capacity, and to plan rehabilitation programs. [6][7][8] Isotonic (dynamic) exercise tests, such as treadmill and bicycle ergometer tests, are usually performed with patients and healthy people to investigate the cardiovascular response to exercise. However, frequent usage of static exercises during daily activities and different cardiovascular responses compared to those in dynamic exercise has necessitated the use of static exercise tests.…”

Section: Discussionmentioning

confidence: 99%

<b>Comparison of Cardiovascular Responses to Isometric (Static) and Isotonic (Dynamic) Exercise Tests in Chronic Atrial Fibrillation</b>

et al. 2002

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SUMMARYThe aim of the present study was to evaluate the tolerance to various exercises by determining the cardiovascular response to static and dynamic exercises in patients with nonvalvular atrial fibrillation.Fifty patients (mean age: 63.6±10.3 years; male: 25, female: 25) with chronic (more than one year) nonvalvular atrial fibrillation were included in the study. All patients underwent exercise tests, adjusted appropriately according to their symptoms, as dynamic exercise on a Marquette Case 15 device according to a modified Bruce protocol. Heart rate, and systolic and diastolic arterial pressures were measured at rest and at all stages of the exercise; and the heart rate-pressure products were evaluated. A handgrip test was also conducted as static exercise. The measurements were made before, at the 1 st , 2 nd and 3 rd minutes, and in the recovery periods of the exercise.The percent values of the changes of the 1 st , 2 nd and 3 rd minute measurements in relation to the initial values for both exercises were compared. In addition, the maximal responses to the exercise tests and the post exercise values were also compared. For statistical evaluations, the paired Student-t test was used.Heart rate and pressure-heart rate product values obtained at 1, 2, and 3 minutes during the treadmill exercise test were significantly high compared to the handgrip values (P<0.0001). The arterial systolic and diastolic pressure values in the 1 st minute were also significantly higher during the handgrip test (P=0.0100 and P=0.0320, respectively). The values of diastolic arterial pressure at the 2 nd minute during the handgrip test, and systolic arterial pressure at the 3 rd minute during the treadmill test were found to be statistically significant (P=0.0240, P=0.0340, respectively). The mean exercise time and MET value during the treadmill exercise test were 7.18±2.65 minutes and 5.32±1.38 mL.kg -1 .dk -1 , respectively.During the recovery period, the 5 th minute, heart rate and pressure-heart rate product values were significantly high after the treadmill test (P<0.0001).In this study, we revealed that the heart rate response to static exercise was lower and the patients tolerated the static exercise better. Therefore, we decided that the short dura-

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Hemodynamic determinants of exercise capacity in chronic atrial fibrillation

Cited by 44 publications

References 17 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

<b>Value of Left Atrial Function in Predicting Exercise Capacity in Heart Failure With Moderate to Severe Left Ventricular Systolic Dysfunction</b>

<b>Comparison of Cardiovascular Responses to Isometric (Static) and Isotonic (Dynamic) Exercise Tests in Chronic Atrial Fibrillation</b>

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