先天性心脏病成人患者心肺运动试验与B型利钠肽对运动能力的评估

Evaluation of exercise capacity with cardiopulmonary exercise test and B-type natriuretic peptide in adults with congenital heart disease.

作者信息

Trojnarska Olga, Gwizdała Adrian, Katarzyński Sławomir, Katarzyńska Agnieszka, Szyszka Andrzej, Lanocha Magdalena, Grajek Stefan, Kramer Lucyna

机构信息

Department of Cardiology, Poznań University of Medical Science, 61-848 Poznań, Poland.

出版信息

Cardiol J. 2009;16(2):133-41.

DOI:

PMID:19387960

Abstract

BACKGROUND

Adult patients with congenital heart disease (CHD) usually find their exercise capacity satisfactory. However, objective evaluation is important for diagnostic and prognostic purposes. The aim of this study was to evaluate exercise capacity using cardiopulmonary exercise tests and measurement of serum B-type natriuretic peptide (BNP) levels in adult patients with CHDs, both in the entire study cohort and in subjects with individual types of cardiac lesions, as well as to verify the relation between BNP level and cardiac performance.

METHODS

The study group included 265 patients (136 males; mean age 34.4 +/- 11.6 years) 173 of whom were operated on at the mean age of 9.2 +/- 7.3 years. They represented the following types of CHD: 72 patients--surgically corrected coarctation of the aorta, 62--surgically corrected tetralogy of Fallot, 28--Ebstein anomaly, 26--patent atrial septal defect, 24--Eisenmenger syndrome, 20--uncorrected or palliated complex cyanotic lesions, 11--corrected transposition of the great arteries (TGA), 14--TGA after Senning operation, and 8--common ventricle after Fontana operation. The control group consisted of 39 healthy individuals (17 males) with a mean age of 35.8 +/- 9.3 years.

RESULTS

According to NYHA classification, 207 patients were recognized as representing class I symptoms, 47 subjects class II, and 11 class III. Cardiopulmonary exercise revealed significantly reduced exercise capacity in adults with CHD in general, compared to control subjects: maximal oxygen uptake (VO2max) was 23.3 +/- 6.9 vs. 33.6 +/- 7.2 mL/kg/min, respectively (p = 0.00001); maximum heart rate at peak exercise (HRmax) -161.1 +/- 33.2 vs. 179.6 +/- 12.3 bpm (p = 0.00001); respiratory workload (VE/VCO2slope) - 35.7 +/- 9.7 vs. 26.3 +/- 3.1 (p = 0.00001); and forced vital capacity (FVC) - 3.8 +/- 1.1 vs. 4.6 +/- 0.7 L (p = 0.00003). Various degrees of peak VO2max reduction were observed across the spectrum of CHD. Patients after repair of aortic coarctation demonstrated the highest VO2max (26.8 +/- 6.6 mL/kg/min), and the lowest was demonstrated by patients with Eisenmenger syndrome (12.8 +/- 4.8; ANOVA p = 0.00001). Serum BNP levels in the study group were higher than in the controls: 55.4 +/- 67.5 vs. 13.9 +/- 13.7 pg/mL, respectively (p = 0.00001). Various degrees of BNP level increase were found across the spectrum of CHD. Patients after repair of aortic coarctation demonstrated the lowest BNP level (24.8 pg/mL), and the highest level was found in patients with cyanotic defects (120.7 pg/mL; ANOVA p = 0.00001). BNP levels across the NYHA classes were as follows: I--35.7 pg/mL, II--94.1 pg/mL, and III--225.6 pg/mL. BNP levels showed negative correlation with VO2max (r = -0.525, p = 0.0001), FVC (r = -0.349, p = 0.00001), FEV1 (r = -0.335, p = 0.00001), and positive correlation with VE/VCO2slope (r = 0.447, p = 0.00001).

CONCLUSIONS

The exercise capacity of patients with CHD is, in general, compromised, most strikingly in patients suffering from pulmonary hypertension and cyanosis. Serum BNP levels in these subjects are increased and correlate well with exercise capacity. BNP level is higher in patients with cyanotic CHDs.

摘要

背景

成年先天性心脏病（CHD）患者通常认为其运动能力令人满意。然而，客观评估对于诊断和预后目的很重要。本研究的目的是使用心肺运动试验和测量血清B型利钠肽（BNP）水平来评估成年CHD患者的运动能力，包括整个研究队列以及患有个别类型心脏病变的受试者，并验证BNP水平与心脏功能之间的关系。

方法

研究组包括265例患者（136例男性；平均年龄34.4±11.6岁），其中173例在平均年龄9.2±7.3岁时接受手术。他们代表以下类型的CHD：72例——手术矫正的主动脉缩窄，62例——手术矫正的法洛四联症，28例——埃布斯坦畸形，26例——房间隔缺损，24例——艾森曼格综合征，20例——未矫正或姑息性复杂青紫型病变，11例——矫正型大动脉转位（TGA），14例——森宁手术后的TGA，以及8例——Fontana手术后的共同心室。对照组由39名健康个体（17名男性）组成，平均年龄35.8±9.3岁。

结果

根据纽约心脏协会（NYHA）分类，207例患者被认定为I级症状，47例为II级，11例为III级。心肺运动显示，与对照组相比，成年CHD患者的运动能力总体上显著降低：最大摄氧量（VO2max）分别为23.3±6.9与33.6±7.2 mL/kg/min（p = 0.00001）；运动峰值时的最大心率（HRmax）——161.1±33.2与179.6±12.3次/分钟（p = 0.00001）；呼吸负荷（VE/VCO2斜率）——35.7±9.7与26.3±3.1（p = 0.00001）；以及用力肺活量（FVC）——3.8±1.1与4.6±0.7 L（p = 0.00003）。在整个CHD范围内观察到不同程度的VO2max峰值降低。主动脉缩窄修复术后的患者VO2max最高（26.8±6.6 mL/kg/min），而艾森曼格综合征患者最低（12.8±4.8；方差分析p = 0.00001）。研究组的血清BNP水平高于对照组：分别为55.4±67.5与13.9±13.7 pg/mL（p = 0.00001）。在整个CHD范围内发现BNP水平有不同程度的升高。主动脉缩窄修复术后的患者BNP水平最低（24.8 pg/mL），青紫型缺损患者的水平最高（120.7 pg/mL；方差分析p = 0.00001）。NYHA分级各等级的BNP水平如下：I级——35.7 pg/mL，II级——94.1 pg/mL，III级——225.6 pg/mL。BNP水平与VO2max呈负相关（r = -0.525，p = 0.0001），与FVC呈负相关（r = -0.349，p = 0.00001），与FEV1呈负相关（r = -0.335，p = 0.00001），与VE/VCO2斜率呈正相关（r = 0.447，p = 0.00001）。