Cardiopulmonary exercise testing utility in assessing chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

CHEN Shubing , ZHONG Liping , YU Xinxin , PENG Yongyi , ZHENG Jinping ,  GAO Yi

National Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510120, P. R. China;

Corresponding?author：

GAO Yi, Email: misstall2@163.com

Keywords：

Chronic thromboembolic disease; chronic thromboembolic pulmonary hypertension; cardiopulmonary exercise testing

DOI：

10.7507/1671-6205.202206053

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Objective To determine the ability of cardiopulmonary exercise testing (CPET) to distinguish chronic thromboembolic pulmonary hypertension (CTEPH) from chronic thromboembolic disease (CTED). Methods Fifty patients diagnosed with CTED and fifty-eight patients with CTEPH in the the First Affiliated Hospital of Guangzhou Medical University from April 2019 to February 2022 were retrospectively included. The basic characteristics including age, gender, body mass index, symptom duration, and N-terminal prohormone of brain natriuretic peptide (NTpro-BNP), parameters of arterial blood gas analysis, right heart catheterization, echocardiography, pulmonary function, and CPET were all compared between patients with CTED and those with CTEPH. Results Patients with CTEPH displayed longer symptom duration, increased NTpro-BNP, decreased arterial partial pressure of oxygen, larger right atrial and ventricular diameters, and impaired worse resting pulmonary diffusing function compared with those with CTED (P<0.05). However, there was no statistically significant difference in the resting pulmonary ventilation function between the two groups (P>0.05). Among the CPET parameters of the CTEPH group, peak exercise oxygen uptake per kilogram, oxygen uptake at anaerobic threshold, oxygen pulse, oxygen uptake efficiency slope and oxygen saturation were all decreased, while the minute ventilation-carbon dioxide production at anaerobic threshold (VE/VCO₂@AT) and VE/VCO₂ slope were increased (P<0.05). However, there was no statistically significant difference in heart rate reserve and breathing reserve (P>0.05). Furthermore, VE/VCO₂@AT showed high accuracy for distinguishing CTEPH from CTED (sensitivity, 0.825; specificity, 0.860; and the area under the receiver operating characteristic curve 0.897). Conclusions Patients with CTEPH showed more significant decreased exercise endurance, diffusion dysfunction, and hypoxemia during exercise and insufficient increase in cardiac output compared with CTED patients. Therefore, it is feasible to apply CPET as a new objective examination to distinguish CTED from CTEPH.

Citation： CHEN Shubing, ZHONG Liping, YU Xinxin, PENG Yongyi, ZHENG Jinping, GAO Yi. Cardiopulmonary exercise testing utility in assessing chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension. Chinese Journal of Respiratory and Critical Care Medicine, 2023, 22(2): 77-82. doi: 10.7507/1671-6205.202206053 Copy

1.	McCabe C, Dimopoulos K, Pitcher A, et al. Chronic thromboembolic disease following pulmonary embolism: time for a fresh look at old clot. Eur Respir J, 2020, 55(4): 1901934.
2.	謝萬木. 慢性肺血栓栓塞癥與慢性血栓栓塞性肺動脈高壓. 中國實用內科雜志, 2021, 41(6): 508-511.
3.	Lewczuk J, Piszko P, Jagas J, et al. Prognostic factors in medically treated patients with chronic pulmonary embolism. Chest, 2001, 119(3): 818-823.
4.	Maron BA, Hess E, Maddox TM, et al. Association of borderline pulmonary hypertension with mortality and hospitalization in a large patient cohort: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circulation, 2016, 133(13): 1240-1248.
5.	Fabyan KD, Holley AB. Postpulmonary embolism syndrome. Curr Opin Pulm Med, 2021, 27(5): 335-341.
6.	孫興國. 整體整合生理學醫學新理論體系: 人體功能一體化自主調控. 中國循環雜志, 2013, 28(2): 88-92.
7.	陳奕霖, 張婷婷, 陳豫欽, 等. 慢性血栓栓塞性肺動脈高壓發病機制研究進展. 中華結核和呼吸雜志, 2022, 45(3): 304-308.
8.	Held M, Hesse A, G?tt F, et al. A symptom-related monitoring program following pulmonary embolism for the early detection of CTEPH: a prospective observational registry study. BMC Pulm Med, 2014, 14: 141.
9.	Wiedenroth CB, Olsson KM, Guth S, et al. Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic disease. Pulm Circ, 2018, 8(1): 2045893217753122.
10.	Kim NH, Delcroix M, Jais X, et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J, 2019, 53(1): 1801915.
11.	Lang IM, Campean IA, Sadushi-Kolici R, et al. Chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension. Clin Chest Med, 2021, 42(1): 81-90.
12.	Papamatheakis DG, Poch DS, Fernandes TM, et al. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol, 2020, 76(18): 2155-2169.
13.	劉格婧, 李愛莉, 翟亞楠, 等. 慢性血栓栓塞性肺動脈高壓患者左心室功能改變及肺動脈內膜剝脫術后恢復情況. 中華超聲影像學雜志, 2022, 31(3): 245-251.
14.	Held M, Kolb P, Grün M, et al. Functional characterization of patients with chronic thromboembolic disease. Respiration, 2016, 91(6): 503-509.
15.	C Robertson L, E Oates K, J Fletcher A, et al. The association of six-minute walk work and other clinical measures to cardiopulmonary exercise test parameters in pulmonary vascular disease. Pulm Circ, 2021, 11(4): 1-12.
16.	孫興國, 王桂芝, 呂婧, 等. 攝氧和二氧化碳排出通氣效率是反映循環功能的指標. 中華心血管病雜志, 2014, 42(12): 1022-1028.
17.	Claeys M, Claessen G, La Gerche A, et al. Impaired cardiac reserve and abnormal vascular load limit exercise capacity in chronic thromboembolic disease. JACC Cardiovasc Imaging, 2019, 12(8 Pt 1): 1444-1456.
18.	Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J, 2009, 30(20): 2493-2537.
19.	Held M, Grün M, Holl R, et al. Cardiopulmonary exercise testing to detect chronic thromboembolic pulmonary hypertension in patients with normal echocardiography. Respiration, 2014, 87(5): 379-387.
20.	唐毅, 羅勤, 柳志紅, 等. 攝氧效率斜率預測特發性肺動脈高壓預后. 中國循環雜志, 2017, 32(4): 367-371.
21.	王林宣, 郭健, 楊文蘭, 等. 不同類型肺動脈高壓患者運動耐量的研究. 國際呼吸雜志, 2015, 35(24): 1878-1882.

1. McCabe C, Dimopoulos K, Pitcher A, et al. Chronic thromboembolic disease following pulmonary embolism: time for a fresh look at old clot. Eur Respir J, 2020, 55(4): 1901934.
2. 謝萬木. 慢性肺血栓栓塞癥與慢性血栓栓塞性肺動脈高壓. 中國實用內科雜志, 2021, 41(6): 508-511.
3. Lewczuk J, Piszko P, Jagas J, et al. Prognostic factors in medically treated patients with chronic pulmonary embolism. Chest, 2001, 119(3): 818-823.
4. Maron BA, Hess E, Maddox TM, et al. Association of borderline pulmonary hypertension with mortality and hospitalization in a large patient cohort: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circulation, 2016, 133(13): 1240-1248.
5. Fabyan KD, Holley AB. Postpulmonary embolism syndrome. Curr Opin Pulm Med, 2021, 27(5): 335-341.
6. 孫興國. 整體整合生理學醫學新理論體系: 人體功能一體化自主調控. 中國循環雜志, 2013, 28(2): 88-92.
7. 陳奕霖, 張婷婷, 陳豫欽, 等. 慢性血栓栓塞性肺動脈高壓發病機制研究進展. 中華結核和呼吸雜志, 2022, 45(3): 304-308.
8. Held M, Hesse A, G?tt F, et al. A symptom-related monitoring program following pulmonary embolism for the early detection of CTEPH: a prospective observational registry study. BMC Pulm Med, 2014, 14: 141.
9. Wiedenroth CB, Olsson KM, Guth S, et al. Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic disease. Pulm Circ, 2018, 8(1): 2045893217753122.
10. Kim NH, Delcroix M, Jais X, et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J, 2019, 53(1): 1801915.
11. Lang IM, Campean IA, Sadushi-Kolici R, et al. Chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension. Clin Chest Med, 2021, 42(1): 81-90.
12. Papamatheakis DG, Poch DS, Fernandes TM, et al. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol, 2020, 76(18): 2155-2169.
13. 劉格婧, 李愛莉, 翟亞楠, 等. 慢性血栓栓塞性肺動脈高壓患者左心室功能改變及肺動脈內膜剝脫術后恢復情況. 中華超聲影像學雜志, 2022, 31(3): 245-251.
14. Held M, Kolb P, Grün M, et al. Functional characterization of patients with chronic thromboembolic disease. Respiration, 2016, 91(6): 503-509.
15. C Robertson L, E Oates K, J Fletcher A, et al. The association of six-minute walk work and other clinical measures to cardiopulmonary exercise test parameters in pulmonary vascular disease. Pulm Circ, 2021, 11(4): 1-12.
16. 孫興國, 王桂芝, 呂婧, 等. 攝氧和二氧化碳排出通氣效率是反映循環功能的指標. 中華心血管病雜志, 2014, 42(12): 1022-1028.
17. Claeys M, Claessen G, La Gerche A, et al. Impaired cardiac reserve and abnormal vascular load limit exercise capacity in chronic thromboembolic disease. JACC Cardiovasc Imaging, 2019, 12(8 Pt 1): 1444-1456.
18. Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J, 2009, 30(20): 2493-2537.
19. Held M, Grün M, Holl R, et al. Cardiopulmonary exercise testing to detect chronic thromboembolic pulmonary hypertension in patients with normal echocardiography. Respiration, 2014, 87(5): 379-387.
20. 唐毅, 羅勤, 柳志紅, 等. 攝氧效率斜率預測特發性肺動脈高壓預后. 中國循環雜志, 2017, 32(4): 367-371.
21. 王林宣, 郭健, 楊文蘭, 等. 不同類型肺動脈高壓患者運動耐量的研究. 國際呼吸雜志, 2015, 35(24): 1878-1882.

Chinese Journal of Respiratory and Critical Care Medicine

Cardiopulmonary exercise testing utility in assessing chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension

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