Influence of Upright Versus Supine Position on Resting and Exercise Hemodynamics in Patients Assessed for Pulmonary Hypertension

Berlier, Charlotte; Lichtblau, Mona; Schneider, Simon; Schwarz, Esther I.; Furian, Michael; Bloch, Konrad E.; Carta, Arcangelo F.; Ulrich, Silvia

doi:10.1161/jaha.121.023839

Cited by 19 publications

(17 citation statements)

References 28 publications

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“…This is likely explained by prolonged recumbent state during infusion. Higher venous return in supine position may increase pulmonary arterial pressure 13 . Similarly, TAPSE decreased in the placebo group, possibly explained by recumbent haemodynamics and lower demands at rest.…”

Section: Discussionmentioning

confidence: 93%

Acyl ghrelin increases cardiac output while preserving right ventricular‐pulmonary arterial coupling in heart failure

Erhardsson,

Faxén,

Venkateshvaran

et al. 2023

ESC Heart Failure

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AimAcyl ghrelin increases cardiac output (CO) in heart failure with reduced ejection fraction (HFrEF). This could impair the right ventricular‐pulmonary arterial coupling (RVPAC), both through an increased venous return and right ventricular afterload. We aim to investigate if acyl ghrelin increases CO with or without worsening the right‐sided haemodynamics in HFrEF assessed by RVPAC.Methods and resultsThe Karolinska Acyl ghrelin Trial was a randomized double‐blind placebo‐controlled trial of acyl ghrelin versus placebo (120‐min intravenous infusion) in HFrEF. RVPAC was assessed echocardiographically at baseline and 120 min. ANOVA was used for difference in change between acyl ghrelin versus placebo, adjusted for baseline values. Of the 30 randomized patients, 22 had available RVPAC (acyl ghrelin n = 12, placebo n = 10). Despite a 15% increase in CO in the acyl ghrelin group (from 4.0 (3.5–4.6) to 4.6 (3.9–6.1) L/min, P = 0.003), RVPAC remained unchanged; 5.9 (5.3–7.6) to 6.3 (4.8–7.5) mm·(m/s)−1, P = 0.372, while RVPAC was reduced in the placebo group, 5.2 (4.3–6.4) to 4.8 (4.2–5.8) mm·(m/s)−1, P = 0.035. Comparing change between groups, CO increased in the acyl ghrelin group versus placebo (P = 0.036) while RVPAC and the right ventricular pressure gradient remained unchanged.ConclusionTreatment with acyl ghrelin increases CO while preserving or even improving RVPAC in HFrEF, possibly due to increased contractility, reduced PVR and/or reduced left sided filling pressures. These potential effects strengthen the role of acyl ghrelin therapy in HFrEF with right ventricular failure.

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Section: Discussionmentioning

confidence: 93%

Acyl ghrelin increases cardiac output while preserving right ventricular‐pulmonary arterial coupling in heart failure

Erhardsson,

Faxén,

Venkateshvaran

et al. 2023

ESC Heart Failure

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“…[16][17][18] When the decrease in SV is not compensated by a proportional increase in heart rate, the CO (CO = SV × HR) is therefore reduced, which also lessens the pulmonary pressures. 15,19 Conversely, the supine position enhances venous return by mobilization of blood from the lower extremities to the core circulation, which increases the ventricular preload, resulting in a higher CO. 8,9 A systematic review of healthy subjects reported that the mPAP (14.8 ± 2.9 mmHg vs. 13.8 ± 3.6 mmHg) and CO (6.6 ± 1.7 vs. 5.5 ± 1.1 L/min) at rest, as well as the mPAP (24.9 ± 7.1 mmHg vs. 22.1 ± 5.0 mmHg) and CO (15.8 ± 3.2 vs. 14.7 ± 2.9 L/min) during submaximal exercise were slightly lower in the upright than supine position. 15 The reduction in mPAP in the sitting position was more pronounced than expected as we included patients with preload insufficiency and postcapillary PH.…”

Section: Discussionmentioning

confidence: 99%

“…However, exercise above 60 W in either position did not change hemodynamic classifications in the majority of cases, and previously published studies on the same topic, the average workload achieved was even lower. 8 Lastly, there is no established definition of preload insufficiency, particularly in the absence of complimentary iCPET that could have provided oxygen consumption at different stages (to calculate Fick CO and peak CO percentage of predicted). 3,6 Body position significantly influences hemodynamics at rest and with exercise; however, the mPAP/CO and PAWP/CO were not positionally affected.…”

Section: Discussionmentioning

confidence: 99%

Impact of body position on hemodynamic measurements during exercise: A tale of two bikes

Kirupaharan,

Lane,

Melillo

et al. 2024

Pulm. circ.

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The addition of exercise testing during right heart catheterization (RHC) is often required to accurately diagnose causes of exercise intolerance like early pulmonary vascular disease, occult left heart disease, and preload insufficiency. We tested the influence of body position (supine vs. seated) on hemodynamic classification both at rest and during exercise. We enrolled patients with exercise intolerance due to dyspnea who were referred for exercise RHC at the Cleveland Clinic. Patients were randomized (1:1) to exercise in seated or supine position to a goal of 60 W followed by maximal exercise in the alternate position. We analyzed 17 patients aged 60.3 ± 10.9 years, including 13 females. At rest in the sitting position, patients had significantly lower right atrial pressure (RAP), mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP) and cardiac index (CI). In every stage of exercise (20, 40, and 60 W), the RAP, mPAP, and PAWP were lower in the sitting position. Exercise in the sitting position allowed the identification of preload insufficiency in nine patients. Exercise in either position increased the identification of postcapillary pulmonary hypertension (PH). Body position significantly influences hemodynamics at rest and with exercise; however, mPAP/CO and PAWP/CO were not positionally affected. Hemodynamic measurements in the seated position allowed the detection of preload insufficiency, a condition that was predominantly identified as no PH during supine exercise.

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“…Pulmonary haemodynamics are highly influenced by body position. Resting mPAP, PAWP and CO are lower, while heart rate, TPR and PVR are increased in the upright position, as compared to the supine position [ 17 , 23 ]. In the supine position, TPR and PVR decrease moderately during exercise, while this is more prominent in the upright position [ 5 ].…”

Section: Methodological Details For the Correct Interpretation Of Exe...mentioning

confidence: 99%

Updated definition of exercise pulmonary hypertension

Zeder

Olschewski

Kovàcs

2022

Breathe

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In the recently published European Society of Cardiology/European Respiratory Society guidelines on the diagnosis and treatment of pulmonary hypertension (PH) the haemodynamic definitions of PH were updated and a new definition for exercise PH was introduced. Accordingly, exercise PH is characterised by a mean pulmonary arterial pressure/cardiac output (CO) slope >3 Wood units (WU) from rest to exercise. This threshold is supported by several studies demonstrating prognostic and diagnostic relevance of exercise haemodynamics in various patient cohorts. From a differential diagnostic point of view, an elevated pulmonary arterial wedge pressure/CO slope >2 WU may be suitable to identify post-capillary causes of exercise PH. Right heart catheterisation remains the gold standard to assess pulmonary haemodynamics both at rest and exercise. In this review, we discuss the evidence that led to the reintroduction of exercise PH in the PH definitions.

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Influence of Upright Versus Supine Position on Resting and Exercise Hemodynamics in Patients Assessed for Pulmonary Hypertension

Cited by 19 publications

References 28 publications

Acyl ghrelin increases cardiac output while preserving right ventricular‐pulmonary arterial coupling in heart failure

Acyl ghrelin increases cardiac output while preserving right ventricular‐pulmonary arterial coupling in heart failure

Impact of body position on hemodynamic measurements during exercise: A tale of two bikes

Updated definition of exercise pulmonary hypertension

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