Authorship and contributorship
Exercise during cardiac catheterization distinguishes between pulmonary and left ventricular causes of dyspnea in systemic sclerosis patients
Article first published online: 10 AUG 2012
© 2012 John Wiley & Sons Ltd
The Clinical Respiratory Journal
Volume 7, Issue 3, pages 227–236, July 2013
How to Cite
Hager, W. D., Collins, I., Tate, J. P., Azrin, M., Foley, R., Lakshminarayanan, S. and Rothfield, N. F. (2013), Exercise during cardiac catheterization distinguishes between pulmonary and left ventricular causes of dyspnea in systemic sclerosis patients. The Clinical Respiratory Journal, 7: 227–236. doi: 10.1111/j.1752-699X.2012.00310.x
WDH: designed the study, collected and analyzed data, wrote the paper. IC: collected and analyzed data. JPT: statistical analysis, wrote paper. MA: collected and analyzed data. RF: designed the study, collected and analyze data, wrote the paper. SL: collected data. NFR: designed the study, collected and analyzed data, wrote the paper.
The study was approved by the University of Connecticut Institutional Review Board. The data analyzed are from clinical studies performed previously. Data do not identify subjects.
Conflict of interest
Dr Foley has research funding from Actelion Pharmaceuticals and Gilead Sciences.
Dr Rothfield has research funding from Actelion Pharmaceuticals, Medimmune, United Therapeutics, UCB, Pfizer, Bristol-Myers Squibb and Mediquest Therapeutics.
The authors have stated explicitly that there are no conflicts of interest in connection with this article.
- Issue published online: 8 JUL 2013
- Article first published online: 10 AUG 2012
- Accepted manuscript online: 12 JUL 2012 08:12AM EST
- Manuscript Accepted: 28 JUN 2012
- Manuscript Revised: 11 JUN 2012
- Manuscript Received: 1 JAN 2012
- diastolic dysfunction ;
- exercise-induced pulmonary arterial hypertension ;
- pulmonary hypertension ;
- scleroderma ;
- systemic sclerosis
The cause for shortness of breath among systemic sclerosis (SSc) patients is often lacking. We sought to characterize the hemodynamics of these patients by using simple isotonic arm exercise during cardiac catheterization.
Catheterization was performed in 173 SSc patients when resting echocardiographic pulmonary systolic pressures were <40 but >40 mmHg post stress. Patients with resting mean pulmonary arterial pressures (mPAP) ≤ 25 and pulmonary arterial wedge pressures (PAWP) ≤ 15 mmHg exercised with 1-pound hand weights. Normal exercise was defined as a change in mPAP divided by the change in cardiac output (CO) (ΔmPAP/ΔCO) ratio ≤ 2 for patients <50 years (≤3 for >50). An abnormal ΔmPAP/ΔCO ratio, an exercise transpulmonary gradient (TPG) ≥ 15, a PAWP < 20, a ΔTPG > ΔPAWP and a pulmonary vascular resistance (PVR) which increased defined exercise-induced pulmonary arterial hypertension (EIPAH). An abnormal ΔmPAP/ΔCO ratio, an exercise TPG < 15, a PAWP ≥ 20, a ΔTPG < ΔPAWP and a drop in PVR defined left ventricular diastolic dysfunction (DD). Twelve patients without SSc served as controls.
Pulmonary pressures increased with exercise in 53 patients. Six had EIPAH and 47 had DD. With exercise, mPAP and PAWP were 20 ± 4 and 13 ± 2 in controls, 36 ± 3 and 12 ± 4 in EIPAH and 34 ± 6 and 26 ± 4 in DD. Control ΔmPAP/ΔCO was 0.8 ± 0.7, 7.5 ± 3.9 in EIPAH and 9.1 ± 7.2 in DD. Rest and exercise TPG was normal for control and DD patients but increased (12 ± 4 to 23 ± 4) in EIPAH (P < 0.0001). PVR decreased in DD but increased in EIPAH with exercise.
Exercise during catheterization elucidates the pathophysiology of dyspnea and distinguishes EIPAH from the more common DD in SSc patients.