Malfatto Gabriella, Cuoccio Paola, Bizzi Caterina, Branzi Giovanna, Villani Alessandra, Della Rosa Francesco, Parati Gianfranco, Facchini Mario
Divisione di Cardiologia, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milano, Italy.
Monaldi Arch Chest Dis. 2009 Jun;72(2):84-90. doi: 10.4081/monaldi.2009.333.
Color-Doppler ecocardiography and cardiopulmonary stress test are pivotal in the evaluation of patients with heart failure. Besides determining systolic function through left ventricular ejection fraction (EF), color-Doppler ecocardiography evaluates the presence and degree of functional mitral regurgitation and the severity of diastolic dysfunction. Moreover, in addition to the aerobic capacity indicated by peak O2 consumption, other parameters of cardiopulmonary stress have proven useful for diagnostic purposes, such as the peak VE/VCO2 ratio or ventilatory efficiency. Since in elderly patients with heart failure the functional impairment often is a combination of the effects of aging with those of disease, the relationship between symptoms, i.e. the NYHA class, ventricular pump function and aerobic performance is sometimes difficult to estabilish.
In 60 elderly with systolic heart failure (75 +/- 3 years, EF 30 +/- 6%), we correlated symptoms (i.e. NYHA class) with [1] degree of functional mitral regurgitation (FMR) determined by color-Doppler echocardiography; [2] degree of left ventricular diastolic dysfunction, measured by Doppler analysis of transmitralic and pulmonary veins flow; [3] VO2 and VE/VCO2 at peak exercise at cardiopulmonary test.
In all patients, NYHA class was only weakly related with EF and peak VO2, with wide overlap of individual values among patients with different NYHA class. Instead, we observed a tight relationship between NYHA class, FMR degree, and severity of diastolic dysfunction and VE/VCO2 ratio at peak exercise (p<0.001), with a more evident partition among patients in different NYHA classes.
In elderly heart failure patients, the reduced effort tolerance expressed by the NYHA classification is only weakly associated with reduced aerobic capacity and pump function, but rather is related with the presence of mitral regurgitation, left ventricular diastolic dysfunction, and a poor ventilatory efficiency during exercise.
彩色多普勒超声心动图和心肺应激试验在心力衰竭患者评估中至关重要。彩色多普勒超声心动图除了通过左心室射血分数（EF）确定收缩功能外，还可评估功能性二尖瓣反流的存在及程度以及舒张功能障碍的严重程度。此外，除了通过峰值耗氧量表示的有氧运动能力外，心肺应激的其他参数已被证明对诊断有用，如峰值VE/VCO2比值或通气效率。由于老年心力衰竭患者的功能损害往往是衰老效应与疾病效应的综合结果，症状（即纽约心脏协会分级）、心室泵功能和有氧运动能力之间的关系有时难以确定。
在60例老年收缩性心力衰竭患者（75±3岁，EF 30±6%）中，我们将症状（即纽约心脏协会分级）与以下因素进行关联：[1]通过彩色多普勒超声心动图确定的功能性二尖瓣反流（FMR）程度；[2]通过二尖瓣和肺静脉血流的多普勒分析测量的左心室舒张功能障碍程度；[3]心肺试验中运动峰值时的VO2和VE/VCO2。
在所有患者中，纽约心脏协会分级仅与EF和峰值VO2弱相关，不同纽约心脏协会分级患者的个体值有广泛重叠。相反，我们观察到纽约心脏协会分级、FMR程度、舒张功能障碍严重程度与运动峰值时的VE/VCO2比值之间存在紧密关系（p<0.001），不同纽约心脏协会分级患者之间的区分更为明显。
在老年心力衰竭患者中，纽约心脏协会分级所表示的运动耐力降低仅与有氧运动能力和泵功能降低弱相关，而与二尖瓣反流、左心室舒张功能障碍的存在以及运动期间通气效率差有关。
