Study On Cardiopulmonary Function In Patients With Pulmonary Embolism And Pulmonary Hypertension By Cardiopulmonary Exercise Testing

Pulmonary vascular disease is a pulmonary circulatory disorder caused by abnormal pulmonary vascular structure or function.Such cardiovascular diseases that seriously endanger human health have received widespread attention.In recent years,the diagnosis and treatment of pulmonary vascular disease has undergone tremendous changes.How to conduct a scientific and objective comprehensive assessment of the cardiopulmonary function of such patients is very important.Therefore,we need to actively explore more simple and effective evaluation methods to further promote and improve the level of diagnosis and treatment of pulmonary vascular disease.The most common pulmonary vascular diseases in the clinic are pulmonary embolism(PE)and pulmonary hypertension(PH).PE is a disease caused by an embolus in the blood that blocks the pulmonary artery or its branches.Its pathophysiological characteristics usually manifest as pulmonary circulatory dysfunction or respiratory failure.After pulmonary artery blood flow is blocked to varying degrees,respiratory physiology and hemodynamic parameters will change accordingly.PH is a type of clinical syndrome that is affected by a variety of factors,which leads to the alteration of pulmonary arterioles.It is characterized by progressive elevation of pulmonary vascular resistance,resulting in right heart failure and even death.In the absence of treatment,from diagnosis to death,the average survival time of patients was only 2.8 years.At present,the main methods for assessing cardiopulmonary function in patients with PE and PH are: blood gas analysis,routine lung function,pulmonary ventilation perfusion imaging,CTPA,echocardiography,right heart catheterization.However,the patient's cardiopulmonary function has a large reserve capacity.The commonly used test method can only observe the cardiopulmonary circulation in the patient's calm state,but it can not reflect the cardiopulmonary function and cardiopulmonary reserve status under the patient's exercise state.Accurate cardiopulmonary assessment plays an important role in further predicting changes in the condition and guiding treatment.Cardiopulmonary exercise testing(CPET)is a very important method for assessing the circulation and respiratory function of the human body.It is an extremely important test method for assessing pulmonary vascular disease and heart failure.Including: the patient's exercise endurance,heart function,metabolism and lung ventilation,ventilation effectiveness.External breathing and internal breathing are coupled by gas exchange,and CPET is used to detect external respiration,thereby quantifying intracellular respiration,reflecting the time and state of intracellular respiration,and further reflecting the aerobic metabolism process of the human body.Cardiopulmonary reserve capacity,as well as overall changes in cellular respiratory function,are particularly important for the assessment of cardiopulmonary function.This topic is a clinical study.CPET is used as an entry point for the assessment of cardiopulmonary function in patients with common pulmonary vascular disease.The changes in the parameters such as exercise tolerance,oxygen uptake efficiency,and ventilation effectiveness during the exercise are measured.Through the application of CPET in the evaluation of pulmonary embolism and pulmonary hypertension,we hope to establish an accurate evaluation system of cardiopulmonary function in patients with pulmonary vascular disease,thus laying a solid theoretical foundation for subsequent clinical treatment and prognosis evaluation.Part 1 The value of cardiopulmonary exercise test in assessing cardiopulmonary function in patients with acute pulmonary embolism(APE)? Objective ? To investigate the evaluation value of cardiopulmonary exercise test on cardiopulmonary function in patients with acute pulmonary embolism after anticoagulation treatment for 4 weeks and 6 months,and to understand the recovery of cardiopulmonary function in patients with ape after anticoagulation treatment.?Methods? Thirty patients with APE(APE group)were enrolled in the initial admission,and were given anticoagulant therapy for 1 month and 6 months respectively.All patients met the following conditions: right ventricular systolic pressure(RVSP)< 45mmhg;PO2 > 80 mm Hg without oxygen inhalation;V / Q imaging,lower extremity vascular ultrasound and CTPA had no obvious abnormalities;patients had no obvious chest tightness and shortness of breath during general activities,and were evaluated as low-risk patients.PFT,ABG and CPET were performed before treatment,4 weeks and 6 months after anticoagulation treatment,and the results were compared and analyzed.At the same time,50 healthy volunteers(normal control group)matched by gender and age were selected,and the same examination was given,and the relevant results were recorded.?Results?(1)There was no significant difference in age,gender and BMI between APE group and normal control group(P>0.05).(2)For patients with APE,whether it is 1 month of treatment or 6 months of treatment,the resting ABG and PFT parameters Pa O2,FVC% pred,FEV1%pred,DLCO %pred,TLC%pred,MVV%pred The control group decreased significantly(P<0.05),while P(A-a)O2 was significantly higher than the control group(P<0.01).(3)After 6 months of treatment,the FVC% pred of APE patients was significantly higher than that of the first month of treatment(P<0.01),and the rest of resting ABG and PFT parameters Pa O2,FEV1% pred,DLCO %pred,TLC%pred,MVV There was no significant difference between %pred and 1 month of treatment(P>0.05).(4)Compared with the normal control group,AT,AT-V?O2%pred,Peak V?O2,Peak V?O2%pred,Peak workload,and Peak workload% pred were significantly lower after treatment(P<0.01).The Lowest V?E /V?CO2,Lowest V?E /V?CO2%pred,V?E /V?CO2 slope,V?E /V?CO2 slope%pred,AT-V?E /V?CO2,AT-V?E /V?CO2%pred were significantly higher than the normal control group(P<0.001).(5)Peak V?O2,Peak V?O2%pred,Peakload,and Peakload%pred were significantly higher in patients with APE after 6 months of treatment(P<0.01),and lowerest V?E /V?CO2 and lowerest V?E /V?CO2%pred were decreased(P=0.001).(6)The elevated Peak V?O2%pred in the APE group was negatively correlated with the decreased Lowest V?E /V?CO2%pred(r=-0.639,p<0.001),but not correlated with the increase in FVC%pred(r= 0.058,p=0.769).?Conclusion? CPET can be used to evaluate cardiopulmonary function in patients with APE,and is an effective means for clinical evaluation and prognosis of APE patients.Part 2 Evaluation of cardiopulmonary function and EIS in patients with IPAH and CTEPH?Objective?To explore the value of CPET in the evaluation of cardiopulmonary function in patients with p H and the difference between CTEPH and IPAH,and to further explore the value of CPET in the diagnosis and evaluation of EIS in patients with p H.?Methods? A total of 60 IPAH patients and 44 CTEPH patients in Shanghai Pulmonary Hospital from February 2010 to February 2015 were enrolled.All patients were selected according to 2009 ESC / ERS guidelines and underwent right heart catheterization to confirm the diagnosis.The routine lung function,6-minute walk test,right heart catheterization and cardiopulmonary exercise test were performed in both groups.At the same time,35 healthy controls were enrolled for routine lung function and cardiopulmonary function tests.Determination method of EIS: three researchers independently judged whether 104 p H patients had shunt,and then summarized the results of three researchers: p H patients with EIS + judged by three researchers were included in EIS positive group(EIS +),and p H patients with EIS-judged by three researchers were included in EIS negative group(EIS-).The inconsistent results of three researchers were excluded.?Result?1)The PFT results of PH patients showed that the diffuse function(DLCO)of the PH group was 78.74%,which was significantly lower than that of the normal population(P<0.0001);the FEV1/FVC value of the PH group Compared with the normal control group,there was a significant decrease(P<0.05),and there was mild obstructive ventilatory dysfunction.The airway resistance of the PH group was significantly higher than that of the control group(P<0.05).2)The results of CPET in PH patients showed that Peak V?O2,AT,Peakload,Peak oxygen pulse,Peak HR and PETCO2 of PH patients were significantly lower than normal population;Lowest V?E /V?CO2,V?E /V?CO2-slope and V?E /V?CO2_AT significantly increased,3)Further analysis of IPAH group and CTEPH group: Oxygen efficiency at anaerobic threshold of IPAH group(OUE@ AT),the oxygen uptake efficiency platform(OUEP)was significantly increased,V?E /V?CO2 slope and Lowest V?E /V?CO2 were significantly lower,and the difference was statistically significant(P value <0.05).Pearson correlation analysis showed that OUEP was positively correlated with HR_AT in patients with IPAH(r=0.376,P<0.05),but not correlated with V?E_AT(r=-0.074,P>0.05).Conversely,in CTEPH patients,the results were exactly the opposite(r=0.307,P>0.05 and r=-0.709,P<0.05).The oxygen uptake efficiency platform was significantly correlated with Peak oxygen uptake and Peak oxygen pulse(r=0.428-0.723,P<0.05).Among the two groups of patients,WHO I-II patients had significant differences in oxygen uptake efficiency and Peak oxygen uptake compared with WHO III-IV patients(P values were ?0.05).4)CPET has a good diagnostic value for EIS in patients with PAH.Comparison of EIS-and EIS+ PAH patients found that: a)CPET parameters Peak V?O2,AT,OUES,etc.were significantly lower in the EIS+ group than in the EIS-group PH patients,V?E /V?CO2 Slope and Lowest V?E /V?CO2was significantly increased in the EIS+ group,suggesting that the motor capacity/oxygen efficiency/ventilation effectiveness of the EIS+ patients decreased more significantly.b)The EIS+ group in the 6MWD was also better than the EIS-group.Group PH patients significantly reduced c)hemodynamic results: EPS+ patients with m PAP,m RAP,PVR and NT-pro BNP were significantly elevated,CO,CI significantly decreased.? Conclusion ? CPET can accurately assess the exercise capacity of PH patients,reflect the severity of the disease,and have a good diagnostic value for EIS in patients with IPAH.The ventilation effectiveness and oxygen uptake efficiency of IPAH patients were significantly higher than those of CTEPH patients.Part 3 Differences in hemodynamics between patients with IPAH and CTEPH in differentgenders by CPET? Objective ? To explore the difference in the value of CPET parameters in evaluating the hemodynamics and disease severity of patients with different genders.?Methods? A retrospective study included 56 patients with IPAH and 73 patients with CTEPH who were initially hospitalized in the pulmonary circulatory department from February 2010 to February 2016.All patients underwent right heart catheterization and cardiopulmonary exercise test.The patients with IPAH were analyzed according to whether there were clinical deterioration events.Clinical deterioration events were defined as admission to hospital for treatment with aggravation of the disease,and the deterioration of cardiopulmonary function leading to the change of dosage of targeted drug therapy or oral medication to injection medication.The predictive value of CPET parameters for hemodynamic parameters was analyzed by single factor and multivariate linear regression.The event-free survival rate was calculated using the Kaplan-Meier method.?Results?1)The CPET parameters of male patients with IPAH Peak V?O2,V?O2 at AT,Peak O2 pulse,Peak V?CO2,Peak V?E and OUES were significantly higher than females;2)In male patients with IPAH,Peak PETCO2 could be a good independent predictor of PVR and Peak V?O2 is a good independent predictor of CO.In female patients with IPAH,the independent predictors of CO and PVR are Peak O2 pulse.3)Men have higher Peak workload,V?E,O2 pulse,PETO2 at AT,and V?E /V?CO2 than female CTEPH patients;while OUEP is significantly lower than female patients.4)In patients with CTEPH,V?E /V?CO2 can independently predict an increase in male PVR,while OUEP can independently predict an increase in PVR in female CTEPH patients.? Conclusions ? Gender-specific CPET parameters can be used to predict hemodynamics in women and men with IPAH and CTEPH, respectively and to assess the severity of disease in patients with different genders of IPAH.