Decreased Exercise Tolerance Research Articles

Diagnosis of pulmonary hypertension associated with congenital heart disease. Part 1. Definition, classification and initial examination of patients

Having discussed current definitions and classification of pulmonary hypertension associated with congenital heart defects, the authors consider characteristic clinical symptoms and data of physical examination separately for every subgroup. An increase in pulmonary vascular resistance after radical correction and with small / concomitant defects leads to insufficient filling of the systemic ventricle and the progression of symptoms of low cardiac output , i.e. shortness of breath, palpitations, fatigue, weakness and decreased exercise tolerance. At late stages, due to transient systemic hypotension the patients feel dizziness, lightheadedness and fainting, as well as signs of congestive right ventricular failure – peripheral edema, liver enlargement, ascites and swelling of the cervical veins. The patients with Eisenmenger syndrome develop cyanosis and signs of systemic complications – polycythemia, deformation of the distal phalanges of the fingers like «drumsticks» and «watch glasses», posture disturbance due to osteoarthropathy and scoliosis, pulmonary and paradoxical systemic thrombosis and embolism, bleeding, symptoms of gout and cholelithiasis, impaired renal function. Even mild pulmonary hypertension after Fontaine’s surgery causes venous hypertension with congestive heart failure, hydrothorax, protein deficiency enteropathy and plastic bronchitis, as well as insufficient blood flow to the systemic ventricle with low cardiac output, shortness of breath, palpitations, fatigue, weakness and decreased exercise tolerance. All forms of pulmonary hypertension cause pain in the region of the heart, hemoptysis, pulmonary hemorrhage, arrhythmias, and developmental delay in children. The patient shall be examined «from head to toe.» The diagnostic value of auscultation depends on the complexity of the congenital malformation leading to pulmonary hypertension Pulse oximetry should be performed separately on the arms and legs at rest and exercise.

Abstract 13471: HFpEF in Spontaneously Obese Mice Due to Genomic Rearrangement in Non-Coding Region of Chromosome 1

Background: Obesity is the most common comorbidity and risk factor for heart failure (HF) in patients with preserved ejection fraction (HFpEF), a subclass containing more than 50% of HF cases. However, effective treatment of HFpEF remains scarce due to the incomplete understanding of the mechanisms. Methods: A mouse line (C57/B6J) of Floxed-stop Overexpression of IF1 (FEI) was generated and maintained for Cre-mediated conditional IF1 overexpression. We observed that severe obesity became a fixed phenotype in inbred FEI mice after inbreeding for 5-6 generations. Targeted-Locus-Amplification (TLA) analyses revealed that FEI inbreeding triggered a genomic rearrangement in a non-coding region of chromosome 1. A heterozygous line with genotype and phenotype fixation was obtained via outbreeding with wild type mice. In the present study, we focus on assessing the cardiac phenotype of FEI mice using echocardiography, histology, and exercise tolerance tests. Results: The early onset of obesity was consistent in the heterozygotes of obese FEI mice with increased peripheral fats and circulating tissue lipids, as well as reduced systemic metabolic rates. FEI mice also exhibited increased food intake, fasting blood glucose, insulin, and leptin with impaired glucose/insulin tolerance. Echocardiography revealed that the FEI mice developed concentric left ventricular hypertrophy with preserved ejection fraction. However, E/A ratio results from Doppler flow measurement at mitral valve suggest diastolic dysfunction in the FEI mice. Heart weight to tibial length ratio was significantly increased in FEI compared with WT mice. H&E and Trichrome blue staining on heart sections exhibited increased cardiomyocyte hypertrophy and cardiac fibrosis. Treadmill exercise tolerance test revealed a significantly decreased exercise tolerance in FEI mice. Conclusions: We conclude that the cardiac phenotypes in the obese FEI mice closely recapitulate obese patients who suffer from HFpEF. Thus, further studies on these mice should yield novel and translational insight into the molecular and metabolic mechanisms underlying the HFpEF development, leading to improved treatments.

Clinical, laboratory and psychological aspects of moderate COVID-19 in cardiovascular patients one month after discharge from the hospital

Aim. To study clinical, laboratory and psychological aspects of moderate coronavirus disease 2019 (COVID-19) in cardiovascular patients one month after discharge from the hospital.Material and methods. The study included 88 patients with cardiovascular diseases hospitalized for COVID-19. After 1 month, 72 respondents continued the participation in the study. Medical history collection, physical examination, and diagnostic investigations were performed. We used the Hospital Anxiety and Depression Scale (HADS) by Zigmond A. S., Snaith R. P., Beck Anxiety Inventory scale, Mini-mental State Examination (MMSE) scale for assessing mental status.Results. One month after discharge, there was a decrease in the number of patients with signs of impaired respiratory system, such as cough, shortness of breath, chest congestion, while a decrease in exercise tolerance persists was revealed in 80,5% (out of 95,5% during hospiatalization), generalized weakness and increased sweating — in 69,5%. In addition, 38,9% of patients noted a noticeable, newly reported, hair loss. Attention is drawn to the high prevalence of neurological symptoms during hospiatalization, including dizziness, severe headaches not relieved by analgesics and non-steroidal anti-inflammatory drugs, lethargy, disorientation of place and time, and in some cases even hallucinations. Some of the symptoms persist after 1 month: 55,5% note a decrease in memory, 36% — feelings of fear and anxiety, 63,9% — sleep disorders in the form of frequent nocturnal awakenings (19,4%), insomnia (16,6%), long falling asleep (11,1%). Some of the respondents revealed unfavorable events over the past month as follows: blood pressure (BP) destabilization in the form of episodes of BP increase and decrease during the day — 36,0%, hypertensive crisis — 14,0%. There was an increase in the number of patients with subclinical and clinical depression (p<0,05). There was also an increase in the number of patients with hypercholesterolemia compared with inhospital data by 15,5%.Conclusion. One month after discharge, the respiratory symptoms naturally decrease, but new symptoms appear, such as shortness of breath during exercise, fatigue, unsteady gait, hair loss, and increased sweating. There was an increase in the number of patients with subclinical and clinical depression on the HADS scale. Among laboratory parameters, an increase in the number of patients with increased level of total cholesterol and low-density lipoproteins was revealed.

Features of chronic heart failure in COVID-19 pandemic

RelevanceCurrent and past coronavirus infection can provoke and aggravate the course of previous chronic heart failure by initiating the processes of thrombus formation, inflammation and fibrinogen synthesis, affecting the pleuropericardial space, increasing the load on the right heart due to pulmonary hypertension.Purpose of the studyTo identify the features of chronic heart failure after COVID-19 infection with lung damage.MaterialAn open cohort prospective study of 50 patients was carried out. Inclusion criteria: the presence of a positive brain natriuretic peptide and echocardiographic changes corresponding to systolic or diastolic dysfunction before the onset of the pandemic, signed informed consent. The diagnosis of COVID - 19 was confirmed by a positive PCR test and the presence of M and G antibodies, lung damage - by the results of computed tomography of the lungs.MethodsStandard clinical examination, quality of life questionnaire, echocardiography with measurement of cavity volume, indicators of left ventricular systolic and diastolic function, size and function of the right ventricle. The second examination was carried out one month after hospitalization.ResultsThe features of the clinical picture were an increase in shortness of breath (38 people, 86%), a decrease in exercise tolerance (40 people, 90%), an increase in chest pain (25 people, 60%), palpitations (40 people, 90%). On echocardiography, the most frequent dynamics compared to the 2019 echocardiography indicators were an increase in pressure in the pulmonary artery (44 people, 100%), the size of the right (38 people, 86%) and left ventricles (30 people, 68%), left atrium (38 people, 86%), an increase in the severity of valvular regurgitation (44 people, 100%) and a decrease in the ejection fraction within the “gray zone” (38 people, 86%). The newly emerging decrease in EF below 45% was recorded much less frequently, in 13 people (30%). In 40 (80%) patients, certain signs of deterioration of left ventricular diastolic function were revealed: dilatation of the left atrium, decrease in the mean e, increase in E/e' according to tissue Doppler ultrasonography. The TAPSE index, which characterizes the global function of the right ventricle, practically did not decrease. Frequent findings during echocardiography one month after the disease were a small amount of fluid in the pericardial cavity (30 people, 68%) and pleuropericardial adhesions.ConclusionThe clinical condition of patients with CHF in the first month after a previous infection with COVID-19 with lung involvement corresponded to a worsening of CHF with rhythm disturbances and instability of blood pressure, which on echocardiographic examination was manifested by dilatation of the heart cavities, valvular regurgitation, diastolic dysfunction of the left ventricle and increased pressure in the arteries.Funding AcknowledgementType of funding sources: None. Dynamics of echocardiography in patients

PH-ILD: Identification, Evaluation, and Monitoring: A Diagnostic View From Both Sides

PH-ILD: Identification, Evaluation, and Monitoring: A Diagnostic View From Both Sides

IDIOPATHIC INTERSTITIAL PNEUMONITIS: A MANIFESTATION OF SYSTEMIC SCLEROSIS SINE SCLERODERMA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Fellow Case Reports INTRODUCTION: Systemic Sclerosis (SSc) is a multisystem disease characterized by vascular dysfunction and progressive fibrosis. Systemic sclerosis sine scleroderma (ssSSc) is a rare subtype of SSc which lacks the hallmark feature of the disease i.e., scleroderma. We present a case of systemic sclerosis sine scleroderma manifesting as interstitial pneumonitis. CASE PRESENTATION: A 76-year-old Caucasian female presented to the clinic for evaluation of dyspnea and decreased exercise tolerance since recent TAVR performed 1 month ago. She had a history of Raynaud phenomenon, renal artery stenosis, CKD 4, and HTN. She was hypoxic at rest with SpO2 87% on room air, the rest of the vitals were normal. Chest x-ray showed coarse reticular opacities. Pulmonary function tests (PFTs) showed mild restriction (FEV1/FVC 85%, TLC 74% of predicted) and severely decreased diffusing capacity for carbon monoxide (DLCO) 31% of predicted (N: 80-120%). High-resolution CT chest demonstrated bilateral middle and lower lung zone reticular opacities, and traction bronchiectasis. Pre TAVR right heart catheterization was consistent with pulmonary arterial hypertension (PAH). Her PAH was not considered as the cause of all her symptoms.Further workup showed positive serum ANA 1:1280 (N: <1:80), and weakly positive RNA polymerase III antibody at 30.2U (N: < 20U). Anti CCP, anti- dsDNA, anticentromere antibodies, rheumatoid factor, serum aldolase, CRP, complement levels, ESR, and ANCA panel were normal. Although she did not have any skin findings suggestive of scleroderma, based on serological and imaging abnormalities she was diagnosed with ssSSc presenting as interstitial pneumonitis. She was treated initially with prednisone followed by mycophenolate for 5 months. Despite stabilization of PFTs, her respiratory status continues to decline from worsening PAH. She remains on supplemental oxygen, sildenafil, and treprostinil. DISCUSSION: ssSSc is a subset of SSc affecting 5-10% of patients, with clinical and laboratory features resembling limited SSc (lcSSc) subset. Lungs are the second most common organ involved. ILD followed by PH are the most common presentations. Patients with ssSSc are reported to have a greater degree of dyspnea, and reduced DLCO (<70% of predicted normal). Other predominant features include a positive ANA, restrictive lung disease, and Raynaud's phenomenon, which were present in our patient. CONCLUSIONS: Systemic sclerosis should be considered in patients with idiopathic ILD even in the absence of skin involvement. REFERENCE #1: Poormoghim H, Lucas M, Fertig N, Medsger TA Jr. Systemic sclerosis sine scleroderma: demographic, clinical, and serologic features, and survival in forty-eight patients. Arthritis Rheum. 2000 Feb;43(2):444-51. doi: 10.1002/1529-0131(200002)43:2<444: AID-ANR27>3.0.CO;2-G. PMID: 10693887. REFERENCE #2: Diab S, Dostrovsky N, Hudson M, Tatibouet S, Fritzler MJ, Baron M, Khalidi N; Canadian Scleroderma Research Group. Systemic sclerosis sine scleroderma: a multicenter study of 1417 subjects. J Rheumatol. 2014 Nov;41(11):2179-85. doi: 10.3899/jrheum.140236. Epub 2014 Oct 1. PMID: 25274885. REFERENCE #3: Kucharz EJ, Kopeć-Mędrek M. Systemic sclerosis sine scleroderma. Adv Clin Exp Med. 2017 Aug;26(5):875-880. doi: 10.17219/acem/64334. PMID: 29068586. DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by Shujaa Faryad, source=Web Response No relevant relationships by Hasan Shoaib, source=Web Response

Persistent endotheliopathy in the pathogenesis of long COVID syndrome

BackgroundPersistent symptoms including breathlessness, fatigue, and decreased exercise tolerance have been reported in patients after acute SARS‐CoV‐2 infection. The biological mechanisms underlying this “long COVID” syndrome remain unknown. However, autopsy studies have highlighted the key roles played by pulmonary endotheliopathy and microvascular immunothrombosis in acute COVID‐19. ObjectivesTo assess whether endothelial cell activation may be sustained in convalescent COVID‐19 patients and contribute to long COVID pathogenesis. Patients and MethodsFifty patients were reviewed at a median of 68 days following SARS‐CoV‐2 infection. In addition to clinical workup, acute phase markers, endothelial cell (EC) activation and NETosis parameters and thrombin generation were assessed. ResultsThrombin generation assays revealed significantly shorter lag times (p < .0001, 95% CI −2.57 to −1.02 min), increased endogenous thrombin potential (p = .04, 95% CI 15–416 nM/min), and peak thrombin (p < .0001, 95% CI 39–93 nM) in convalescent COVID‐19 patients. These prothrombotic changes were independent of ongoing acute phase response or active NETosis. Importantly, EC biomarkers including von Willebrand factor antigen (VWF:Ag), VWF propeptide (VWFpp), and factor VIII were significantly elevated in convalescent COVID‐19 compared with controls (p = .004, 95% CI 0.09–0.57 IU/ml; p = .009, 95% CI 0.06–0.5 IU/ml; p = .04, 95% CI 0.03–0.44 IU/ml, respectively). In addition, plasma soluble thrombomodulin levels were significantly elevated in convalescent COVID‐19 (p = .02, 95% CI 0.01–2.7 ng/ml). Sustained endotheliopathy was more frequent in older, comorbid patients, and those requiring hospitalization. Finally, both plasma VWF:Ag and VWFpp levels correlated inversely with 6‐min walk tests. ConclusionsCollectively, our findings demonstrate that sustained endotheliopathy is common in convalescent COVID‐19 and raise the intriguing possibility that this may contribute to long COVID pathogenesis.

OLEOTHORAX: PULMONARY PLOMBAGE

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plombage (extra-pleural pneumonolysis) is a surgical treatment method used to treat cavitary lesions of the lung in patients with pulmonary tuberculosis (TB) during 1930–50s before the introduction of anti-TB chemotherapy by creating a cavity surgically under the ribs in the chest wall and filling the space with inert material [1]. The materials used in this procedure are acrylic balls, fat, wax, rubber, and mineral oil (Oleothorax). Rarely, Plombage is used to seal a large bronchopleural fistula that causes refractory pneumothorax, with only one reported case in the literature [2]. We present another case of Pulmonary Plombage (Oleothorax) used in successfully treating refractory pneumothorax. CASE PRESENTATION: A 62-year-old man with a history of hypertension and symptomatic bradycardia requiring a permanent pacemaker came in with worsening shortness of breath associated with decreased exercise tolerance and orthopnea. The examination was remarkable for pan systolic murmur at the apex, jugular venous distention, and decreased breath sounds in the right lung base. Chest radiograph (Image 1) revealed cardiomegaly and a pleural-based rounded mass in the right pleural space inferiorly. Computed tomography (Image 2) showed a loculated cystic mass (label A) (13x9x10 cm) measuring slightly above water density and apical bullae. An echocardiogram revealed severe left atrial and left ventricular dilation with an ejection fraction of 55% and prolapse of the anterior leaflet of the mitral valve (MV) with severe mitral regurgitation (MR). Pulmonary service was consulted for loculated cystic mass in the lung, upon further questioning, the patient mentioned he had lung surgery in 1993 due to recurrent pneumothorax, which was found to be Pulmonary Plombage. He was started on intravenous loop diuretics for congestive heart failure secondary to MR with improvement in symptoms. DISCUSSION: We presented the modern imaging description of a Plombage thoracoplasty performed to treat refractory pneumothorax with an uncomplicated outcome 28 years after surgery. A new method to treat pneumothorax due to a large cavity with a bronchopleural fistula. The utility of Pulmonary Plombage to seal a large bronchopleural fistula causing refractory pneumothorax has not been studied, with only one case report [2] in the literature where they used pericardial fat pad as Plombage to successfully treat refractory pneumothorax without complications after 48 years. This technique involves complications like hemorrhage, infection, fistulization to the skin. Radiographic characters depend on the material used in the Plombage treatment. The cystic mass measuring slightly above water density seen in our patient was filled with mineral oil (Oleothorax). CONCLUSIONS: Pulmonary Plombage, a historical treatment used to treat cavitary lesions in tuberculosis patients, can be used effectively in treating refractory pneumothorax. REFERENCE #1: Namana V, Gupta SS, Sarasam R, Mathur P: Historical TB treatment—Plombage. QJM An Int J Med. 2017, 110:191. 10.1093/qjmed/hcw213 REFERENCE #2: Nakano T, Tsubochi H, Minegishi K, Endo S: Pericardial fat pad plombage for pulmonary cavity causing massive air leakage. Surg Case Reports. 2020, 6:156. 10.1186/s40792-020-00917-7 DISCLOSURES: No relevant relationships by Akshay Avula, source=Web Response No relevant relationships by Elias Chuki, source=Web Response No relevant relationships by Raja Jadav, source=Web Response No relevant relationships by Harry Sequeira gross, source=Web Response

PULMONARY HYPERTENSION AS AN INITIAL PRESENTATION OF UNCORRECTED TETRALOGY OF FALLOT IN A 27-YEAR-OLD

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease (CHD) affecting children. It is characterized by ventricular septal defect (VSD), an overriding aorta, pulmonary stenosis or atresia, and right ventricular hypertrophy. Historically, severity of RV outflow obstruction determined the need for surgical intervention and only 3% of patients with unrepaired TOF reached the age of 40. With advances in early surgical repair and excellent surgical outcomes, survival 25 years after TOF repair has reached more than 94% in the United States and TOF is rarely left unrepaired, however, pulmonary arterial hypertension (PAH) continues to be a major complication in both repaired and unrepaired cases. CASE PRESENTATION: Case: A 27-year-old Vietnamese immigrant presented with complaints of hemoptysis, dyspnea, orthopnea, decreased exercise tolerance, and congestion. In the emergency department he was febrile, normotensive, non-tachycardic, cyanotic and hypoxic with an oxygen saturation of 79%. Investigations were significant for abnormal chest X-rays, leukocytosis to 19 and polycythemia to 20. He was treated for community-acquired pneumonia. Computed tomography angiogram of the chest showed the features of TOF with direct arterial communications to both lungs associated with the descending aorta. Echocardiogram showed an ejection fraction of 55%, an overriding aorta, a dilated aortic root (5cm), severely elevated pulmonary artery systolic pressure, VSD with right to left shunt, and tricuspid regurgitation velocity of 4.3m/s suggesting a Right Ventricle systolic pressure of 85 mmHg. He was diagnosed with unrepaired TOF with pulmonary valve atresia and major aortopulmonary collateral arteries (MAPCAs). Right and left heart catheterization showed a mean pulmonary artery pressure of 68 mmHg and pulmonary artery wedge pressure 14. He was diagnosed with PAH and was started on Bosentan therapy. His symptoms and exercise tolerance significantly improved. His follow-up visit saturation was 84%. DISCUSSION: Patients with TOF usually have systemic-pulmonary shunting. This increased flow leads to increased pressure and progressive endothelial dysfunction which results in arterial remodeling/PAH. Early surgical repair in CHD limits the amount of vascular remodeling and development of PAH. However, up to 15% of patients develop PAH even after surgical repair. There is a high mortality if untreated. CONCLUSIONS: In this case of TOF with MAPCAS and Eisenmenger syndrome, the endothelin receptor antagonist Bosentan was used with success. PAH can be the initial presentation of adult TOF. REFERENCE #1: John Willis Hurst, et al. Hurst's the Heart. 14th ed., vol. 2, New York, McGraw-Hill Medical, 2011, pp. 1380–1381. REFERENCE #2: https://onlinelibrary.wiley.com/doi/pdf/10.1002/clc.4960070807 REFERENCE #3: https://jamanetwork.com/journals/jamacardiology/fullarticle/2718499#:~:text=Tetralogy%20of%20Fallot%20%28TOF%29%20is%20the%20most%20common, or%20variation%20in%20population%20or%20health%20care%20systems. DISCLOSURES: No relevant relationships by Moises Cossio, source=Web Response No relevant relationships by Fernando Fuentes, source=Web Response No relevant relationships by Mohammad Nimer, source=Web Response

Home Management of the Device Detected Atrial Fibrillation during COVID-19 Pandemic: A Case Report

BACKGROUND: Patients with heart failure (HF) and implanted heart devices constitute a vulnerable category during the coronavirus disease –2019 (COVID-19) pandemic. The remote monitoring function allows the physician to detect atrial fibrillation (AF) in these patients and to prevent thromboembolic complications by prescribing anticoagulants. Under quarantine conditions, such patients can receive fully remote consultation and treatment, which will protect them from the risk of infection, and also reduce the burden on medical institutions. CASE REPORT: A 56-year-old man presented to the clinic with shortness of breath when climbing the second floor, moderate non-specific fatigue, general weakness, and a decrease in exercise tolerance. The patient received standard treatment for HF for at least 3 months (ACEI, beta blockers, MR antagonists, and loop diuretics) in individually selected adequate doses. ECG on admission showed a QRS of 150 ms, left bundle branch block (LBBB). Echo showed dilatation of all heart chambers, diffuse hypokinesis of the walls with akinesis of the apical, middle anterior LV segments, as well as hypokinesis of the basal, middle apical, and anterior septal segment of the LV. The ejection fraction was reduced to 35%. RV function is reduced. After a detailed discussion with the team, it was decided to do implantation of a cardioverter-defibrillator with resynchronization function, equipped with remote monitoring (Biotronik, and Home monitoring). Date of implantation is June 19, 2014. Due to the fact that the patient was connected to the remote monitoring system, May 5, 2020, he was diagnosed with asymptomatic AF. The episode lasted 1 min 22 s. On the following days of monitoring, episodes of AF were also recorded. The duration of the episodes ranged from a few seconds to 12 h/day. The patient received a doctor’s consultation through phone call, his risk of stroke was four when assessed using the CHA2DS2VASc scale. In treatment, it was recommended to add antiarrhythmic drugs (amiodarone 600 mg a day) and oral anticoagulants (rivaroxaban 20 mg × 1 time/day). Later, periodic IEGM showed absence of AF. CONCLUSION: In the context of the COVID-19 pandemic, health-care providers should rethink their approach to managing patients with implanted heart devices. Modern cardiovascular implantable electronic devices allow the physician to monitor the status of patients and immediately respond to situations requiring a change in treatment. Consultations can be carried out completely online.

Cardiac remodeling after anthracycline and radiotherapy exposure in adult survivors of childhood cancer: A report from the St Jude Lifetime Cohort Study.

Limited data exist regarding left ventricular remodeling patterns observed in adult survivors of childhood cancer after therapy. Among 1190 adult survivors diagnosed with childhood cancer (median age at diagnosis, 9 years [interquartile range (IQR), 3.8-14.4 years]; age at evaluation, 35.6 years [IQR, 29.5-42.8 years]), treatment exposures included anthracyclines (n = 346), chest radiotherapy (n = 174), both (n = 245), or neither (n = 425). Prospective echocardiographic assessment compared survivors with 449 noncancer controls classified according to left ventricle geometric patterns. Associations between left ventricle geometric patterns and decreased exercise tolerance were assessed. Overall, 28.2% of survivors (95% confidence interval [CI], 25.6%-30.8%) exhibited concentric remodeling, 2.4% (95% CI, 1.6%-3.5%) exhibited eccentric hypertrophy, and 1.1% (95% CI, 0.6%-1.9%) exhibited concentric hypertrophy. A greater proportion of survivors who received only chest radiotherapy (41%) had concentric remodeling compared with those who received only anthracyclines (24%), both (27%), or neither (27%; all P < .001), and all were greater than the proportions in noncancer controls (18%; all P < .05). Concentric remodeling was associated with radiation exposure, but not with anthracycline exposure, in multivariable models. Survivors who had concentric remodeling were more likely to have a maximal oxygen uptake peak <85% compared with those who had normal geometry (81.0% vs 66.3%; odds ratio, 1.75; 95% CI, 1.15-2.68). Chest radiation therapy, but not anthracycline therapy, increased the risk for concentric remodeling in survivors of childhood cancer. The presence of concentric remodeling was associated with increased exercise intolerance.

Skeletal muscle is associated with exercise tolerance evaluated by cardiopulmonary exercise testing in Japanese patients with chronic obstructive pulmonary disease

Decreasing exercise tolerance is one of the key features related to a poor prognosis in patients with chronic obstructive pulmonary disease (COPD). Cardiopulmonary exercise testing (CPET) is useful for evaluating exercise tolerance. The present study was performed to clarify the correlation between exercise tolerance and clinical parameters, focusing especially on the cross-sectional area (CSA) of skeletal muscle. The present study investigated 69 patients with COPD who underwent CPET. The correlations between oxygen uptake ({{dot{text{V}} text{O}}}_{2}) at peak exercise and clinical parameters of COPD, including skeletal muscle area measured using single-section axial computed tomography (CT), were evaluated. The COPD assessment test score (ρ = − 0.35, p = 0.02) was weakly correlated with {{dot{text{V}} text{O}}}_{2} at peak exercise. In addition, forced expiratory volume in one second (FEV1) (ρ = 0.39, p = 0.0009), FEV1/forced vital capacity (ρ = 0.33, p = 0.006), and the CSA of the pectoralis muscles (PMs) (ρ = 0.36, p = 0.007) and erector spinae muscles (ECMs) (ρ = 0.39, p = 0.003) were correlated with {{dot{text{V}} text{O}}}_{2} at peak exercise. Multivariate analysis adjusted by age and FEV1 indicated that PMCSA was weakly correlated after adjustment (β value [95% confidence interval] 0.175 [0.03–0.319], p = 0.02). In addition, ECMCSA tended to be correlated, but not significantly after adjustment (0.192 [− 0.001–0.385] p = 0.052). The COPD assessment test, FEV1, FEV1/FVC, PMCSA, and ECMCSA were significantly correlated with {{dot{text{V}} text{O}}}_{2} at peak exercise.

Pulmonary veno-occlusive disease in childhood-a rare disease not to be missed.

Pulmonary veno-occlusive disease (PVOD) is a rare disease leading to pulmonary hypertension and potentially death related to right heart failure and/or respiratory insufficiency. Clinical symptoms are heterogenous and nonspecific: fatigue, decreased exercise tolerance, shortness of breath on exertion, cough, dizziness, chest pain with exercise, palpitations, syncope, as well as nonspecific symptoms such as headache, poor appetite, pallor or perioral cyanosis. Mutations in the EIF2AK4 (eukaryotic translation initiation factor 2-alpha kinase 4) have been recently described, other risk factors include exposure to organic solvent and trichloroethylene, tobacco exposure and chemotherapy. Echocardiography helps to estimate right ventricular systemic pressure, but further diagnostic workup includes cardiac catheterization to confirm pulmonary hypertension and increased pulmonary vascular resistance. High-resolution computed tomography reveals typical findings: centrilobular ground-glass nodules or opacities, septal lines, thickened interlobular septa, mosaic perfusion, and lymphadenopathy. Histology remains the gold standard, but carries risks for the patient. Proper workup is essential in order to avoid incorrect diagnosis. Pulmonary hypertension targeted treatment has been used in patients with PVOD, however, experience is limited, vasodilatory effects on pulmonary vasculature may lead to deterioration of the patients and should be used with great caution. Lung transplantation is currently the only valid treatment option for patients with PVOD. With prolonged waiting time and progression of the disease mechanical support could be considered.

Follow-up on the therapeutic effects of a budesonide, azithromycin, montelukast, and acetylcysteine (BAMA) regimen in children with post-infectious bronchiolitis obliterans.

BackgroundPost-infectious bronchiolitis obliterans (PIBO) is a rare, severe chronic lung disease without optimal treatment. Currently, treatment in children mainly relies on systemic corticosteroids, but long-term use of these drugs may lead to adverse reactions. This study aimed to evaluate the short-term efficacy of the budesonide, azithromycin, montelukast, and acetylcysteine (BAMA) regimen in paediatric PIBO patients and whether it can reduce systemic corticosteroid use.MethodsThis was a prospective study. From June 2017 to July 2020, patients diagnosed with PIBO at Yuying Children’s Hospital of Wenzhou Medical University were treated with the BAMA regimen for 3 months. Methylprednisolone was added only when the clinical manifestations did not improve or deteriorated. All patients were followed up every 2 to 4 weeks, and changes in clinical symptoms were recorded. Pulmonary function tests and high-resolution computed tomography (HRCT) were performed, and systemic corticosteroid use was recorded after the 3-month follow-up.ResultsA total of 75 patients with PIBO were included; overall, 54 patients completed the course of treatment. After treatment, the respiratory manifestations were improved in 37 patients (68.5%), but 4 patients (7.4%) showed decreased exercise tolerance, and 2 patients (3.7%) were readmitted to the hospital. Additionally, 17 (56.7%) of the 30 patients whose pulmonary function was re-examined showed improvement, and 28 (77.8%) of the 36 patients who underwent HRCT showed marked improvement. Importantly, 20 patients (54.1%) received systemic corticosteroids for 2 weeks or less, while 31.5% of patients used no corticosteroids.ConclusionsThe BAMA regimen effectively relieved clinical symptoms and signs of PIBO in children, improved pulmonary function and HRCT manifestations, and reduced the use of systemic corticosteroids.

Exercise tolerance in school-age children with hypertension based on body weight

Hypertension and obesity are important problems among adolescents. In clinical practice, these diseases are often combined and worsen the quality of life, so the study on indicators of tolerance to exercise is of great scientific and practical importance. The aim. To determine the state of tolerance to physical activity among school-age children with stable hypertension depending on body weight. Materials and methods. The study involved 95 children aged from 9 to 18 years who were divided into four groups: the first – 18 patients with normal blood pressure and body weight; the second – 39 with stable hypertension and normal body weight; the third – 20 with normal blood pressure and obesity; the fourth – 18 children with stable hypertension and obesity. Exercise tolerance was examined during cycling ergometry according to the PWC 170 protocol; the maximum myocardial oxygen uptake index – VO2peak (the “gold standard” for determining tolerance) was evaluated. Results. According to the study results, among children with a combination of primary hypertension and obesity, the clinical picture of the condition is characterized by significantly more frequent complaints of dizziness, heart pain, headache and loss of consciousness. The total score of complaints was 5.8 ± 1.9 points in the combined pathology of primary hypertension and obesity group, which is significantly higher (P &lt; 0.01) than that among children with primary hypertension or obesity. In primary hypertension and obesity, there is a decrease in VO2peak, which is most pronounced in the combination of these conditions (up to 26.4 ± 6.7 ml/min/kg among boys and up to 22.7 ± 3.6 ml/min/kg among girls) indicating a significant decrease in exercise tolerance. Conclusions. It has been proven that the combined pathology of primary arterial hypertension and obesity among adolescents greatly worsens the clinical condition of children and significantly reduces exercise tolerance more pronounced than in primary arterial hypertension or obesity.

Anxiety among Egyptian patients with stable chronic obstructive pulmonary disease and its effect on their functional assessment

Context Anxiety disorders are underestimated comorbid conditions in patients with chronic obstructive pulmonary disease (COPD). The Global Initiative for Chronic Obstructive Lung Disease (GOLD; updated 2019) has given wide importance on assessment of underdiagnosed comorbid conditions to evaluate patients with stable COPD. Aims To investigate the occurrence of anxiety as a hidden comorbid disease among patients with stable COPD and their effect on 6-min walk distance (6MWD) and COPD assessment test (CAT) score. Settings and design This is a descriptive cross-sectional study. Patients and methods Patients with COPD who were attending the outpatient chest clinic for follow-up at Ain Shams University Hospitals were included in the study during the period between January 2019 and July 2019. Patients were classified according to GOLD criteria 2019. The validated questionnaire for anxiety (State Trait Anxiety Inventory) was fulfilled. The patients were functionally assessed by 6MWD and CAT score. Statistical analysis Statistical Package for Social Sciences program software, version 18.0, was used for statistical analysis. Results Anxiety among Patients with COPD was 54.5%. The lower the forced expiratory volume in the first second % predicted, the greater the anxiety (P=0.027). A positive significant correlation was found between anxiety state and GOLD staging (P=0.042). 6MWD showed a statistically significant negative correlation with the degree of anxiety (P=0.018). CAT scoring had an apparent positive correlation with the anxiety state but unfortunately did not reach the statistically significant difference (P=0.081). Conclusion The underestimated comorbid anxiety disorders are found to be common in patients with COPD. It adds to patients’ dyspnea, especially with high CAT scores and decreased exercise tolerance.

Physical Training effectiveness and Tolerance in Patients after Myocardial Infraction, Depending on the Initial Physical activity Tolerance

Aim. To investigate exercise tolerance in patients undergoing acute coronary syndrome with outcome in myocardial infarction, dependingon physical activity tolerance. Material and methods. We studied 80 patients aged from 40 to 75 years old who were admitted from primary vascular centers for athree-week rehabilitation course to the department of medical rehabilitation for patients with somatic diseases of the clinic of the IvanovoState Medical University of the Ministry of Health of Russia, of which 61 were men (76,3%) and 19 women (23,7%). In accordancewith the aim of the study, a 6-minute walk test was performed in all patients before and after the completion of the rehabilitationcourse. Based on the test results, physical exercise tolerance was assessed and the functional class (FC) of coronary heart disease (CHD) was determined. The patients with I class coronary heart disease (CHD) in the number of 20 patients (25%) made up the 1st group, 21patients (26,3%) with II class – the 2nd group, 21 patients (26,3%) with III class – the 3rd group, and 18 patients (22,5%) with IV class– the 4th group. Results. Every third patient who was admitted to a 3-week cardiac rehabilitation course had short-term adverse reactionson loading during physical training on simulators. Most cases of inadequate reactions were noted in patients with III and IV IHDclass III (according to the 6-minute walk test) having, according to the International Classification of Functioning, Disability and Health(ICF), moderate and pronounced reduction of exercise tolerance function. Patients often had tachycardic and hypertensive reactionsin the porcess of prysical training on stimulators and some patients (more often those with the pronounced decrease in exercise tolerancefunction) had hypotensive reaction which is the most unfavorable type of response to the load. In the vast majority of patientswith I and II CHF with no impairment or mild decrease in exercise tolerance according to ICF, an adequate response of hemodynamicparameters to exercise was determined. Adverse reactions were observed only in every fifth-seventh patient and were manifested onlyin the form of tachycardic and hypertensive reactions to exercise. The study analyzed the effectiveness of rehabilitation measures inthe groups of patients with different levels of tolerance to physical activity. It was found out that all the patients with myocardial infarction,regardless of the initial level, had increased exercise tolerance after cardiac rehabilitation. Conclusion. The 6-minute walk test is insufficiently informative for patients with markedly reduced tolerance to physical activity. The«gold standard» of qualitative and quantitative assessment of reactions and interaction between cardiovascular and respiratory systems,as well as metabolic response of the body during physical activity for these patients is the spiroergometric study.

Підходи до фізичної терапії пацієнтів із COVID -19 у гострій і післягострій фазах хвороби

Coronavirus disease 2019 (COVID-19) has created global problems around the world, and because of the great international health threat, the World Health Organization has recognized its spread as a pandemic. The severity of the disease may be mild, moderate, severe and critical. There are such peculiarities of COVID-19 as changes in the lungs with a tendency to develop rapidly progressive atypical pneumonia, the course of which is often complicated by acute respiratory failure and acute respiratory distress syndrome, and in the future, there is a risk of pulmonary fibrosis and, consequently, chronic respiratory failure. Quite common cases of long COVID, which includes ongoing symptomatic COVID-19 and post-COVID-19 syndrome, are characterized by persistent pulmonary dysfunction, muscle weakness, pain, fatigue, depression, anxiety, decreased exercise tolerance, occupational problems, and poor quality of life. Appropriate protocols have been developed for the treatment of patients with COVID-19, which are constantly updated and supplemented. Concerning methods of physical therapy and pulmonary rehabilitation in the management of patients with COVID-19, they are elaborated insufficiently, especially for patients in acute and post-acute phases of the disease. Rational use of means and methods of physical therapy in combination with pharmacological treatment and psychotherapy will allow mobilizing, as much as possible, restorative and compensatory resources of patients with COVID-19 in overcoming disease at all phases, irrespective of a place of treatment and rehabilitation. Therefore, standards of care for patients with COVID-19 should include an optimal set of methods of physical therapy and pulmonary rehabilitation, taking into account the period and severity of the disease, including critical disease in patients undergoing mechanical ventilation. The education of a patient and people from his immediate surroundings with the aim of their active participation in the process of treatment and rehabilitation is very important. In the implementation of pulmonary rehabilitation programs, methods of distant communication with patients should be used as much as possible, and if they are unable, live courses with strict adherence to anti-epidemic measures should be provided. Taking into account all aspects of treatment and rehabilitation will help patients recover as quickly as possible and return to active life, as well as prevent the development of complications of the disease and the spread of infection

MO617EFFECTS OF 12 WEEK PHYSICAL EXERCISES ON ECHO-GEOMETRIC PARAMETERS IN PATIENTS WITH CKD

Abstract Background and Aims Structural and functional changes in the cardiovascular system in patients with chronic kidney disease (CKD) will lead to decreased exercise tolerance, decreased quality of life, and, ultimately, premature death. The aim of this study was to study morphometric changes in the left ventricle of the heart depending on the direction of therapeutic physical training. Method The study involved 60 patients with CKD stage C3. The average age of the patients was 54.2 ± 3.40 years. The average level of GFR for the sample as a whole was 79.1 ± 9.4 ml / min / 1.73 m2. The control group (CG) consisted of 20 people (10 men and 10 women) comparable to the main group in terms of gender and age. The examination of patients included a general examination, assessment of complaints, collection of anamnestic data, anthropometry with calculation of BMI cardiopulmonary stress test, echocardiography. According to the data of the cardiopulmonary stress test, 3 groups were formed on the basis of the predominant manifestation of any physical quality in the course of therapeutic training: group 1 (n = 20) - with a respiratory orientation of the training process; 2nd group (n = 20) - with a focus on cardio loads; 3rd group (n = 20) - development of predominantly endurance. Results Of all groups of patients with CKD, the LVMM indicator reached the highest values in men in group 2 (with a cardio-load orientation of the treatment-training process), as well as in women in group 3 (predominantly endurance development). It is this orientation of the training process that has the greatest effect on the increase in the mass of the left ventricular myocardium in patients with CKD. The 2nd group of patients with CKD stage CKD had the highest values of LVTD in diastole both among men and women. In addition, men in this group had the highest RTI per systole. In patients of the 2nd group, undergoing mainly cardio load, the change concerned a slightly more pronounced increase in the wall thickness of the left ventricle. In the 3rd group of patients with CKD stages C3, both men and women had the maximum values of TMV in diastole, as well as LVTD in systole. Types of physiotherapy exercises with a predominance of endurance in physical exertion are distinguished by the most pronounced signs of left ventricular myocardial hypertrophy. Conclusion The present study has shown that patients with pre-dialysis CKD have decreased maximal and submaximal exercise tolerance. Analysis of the data obtained made it possible to reveal the peculiarities of adaptation of the cardiovascular system of patients with CKD stages CKD to a specific type of therapeutic training and to determine the quantitative values of echocardiographic parameters in patients with CKD.

MO613EFFECT OF 12 WEEK TRAINIG ON PHYSICAL ACTIVITY ON PATIENT ON A LOW PROTEIN DIET

Abstract Background and Aims Symptoms such as fatigue, muscle weakness and impaired nutritional status are common in CKD and lead to decreased exercise tolerance. The aim of the study was to study the effect of 12-week training on physical activity in patients with pre-dialysis stages of CKD on a low-protein diet. Method The study included 119 patients with CKD C3 and C4 stages. Clinical data included anthropometric data: body mass index (BMI), mid-thigh circumference and mid-shoulder circumference, laboratory data: urea, creatinine, electrolytes, albumin, total protein, hemoglobin. All patients underwent instrumental research methods: ECG, EchoCG, cardiopulmonary stress test. The patients included in the study were offered three dietary options - with a low protein content (0.6 g / kg / day;) and a limited protein content (0.6-0.8 g / kg / day;), and low protein diet with keto analogs (1 tab / 5 kg body weight / day). The physical exercise program was designed for independent home use and included cardiovascular exercises (primarily walking, morning exercises) and strength training exercises with dumbbells 1 and 3 kg. The training frequency was at least 3 times a week and had a duration of at least 20–30 minutes. The patients kept exercise diaries, which were reviewed by the doctor at each subsequent visit. The training exercise was adjusted depending on the self-perception of the patients; if necessary, the training time was increased to 60 minutes. Results The 1 group 24% of patients received a diet with a low protein content, the second group consisted of 40% of patients, the third group consisted of 37% of patients receiving a diet with a limited protein content. The male to female ratio, mean glomerular filtration rate, daily proteinuria and BMI did not differ significantly between groups. In the dynamics of 12 weeks of training, an increase in the mid-thigh and upper arm circumference was recorded. The study of physical activity of patients with different types of diet showed that in patients of the 1st group, even with a low nutritional status in the dynamics of 12 weeks of training, there was an improvement in such physical indicators as the circumference of the mid-thigh and upper arm, and also a slight improvement in the BMD. When comparing the groups of patients who received and did not receive ketoanologs (groups 2 and 3, respectively), physical training for 12 weeks instilled a significant improvement in indicators such as mid-arm circumference and maximum oxygen consumption(peak VO2). However, in the group receiving keto analogs, there was a significantly greater improvement in maximum oxygen consumption (peak VO2). Conclusion Regular dosed exercise has a positive effect on physical fitness in CKD patients on a low-protein diet. Correction of nutrition with keto analogs improves the cardiorespiratory status of patients.