心肺运动试验和血流动力学评估特发性肺动脉高压患者预后的作用

Cardiopulmonary exercise testing combined with haemodynamics for the prediction of outcome in idiopathic pulmonary arterial hypertension

目的 通过研究患者的心肺运动试验和血流动力学特点,探索其预测特发性肺动脉高压（IPAH）临床预后方面的意义.方法 收集2012年3月至2014年3月入住上海市肺科医院并明确诊断的IPAH患者.经筛选一共纳入64例患者,所有患者均进行6分钟步行距离、肺功能、心肺运动功能、血流动力学等相关检查,并进行随访.对研究人群的基线水平进行分析.结果 平均随访时间（29.1±15.4）个月,其中20例患者发生了临床恶化事件.与未发生临床事件（non-CW）人群相比,发生恶化事件组（CW）的无氧阈时摄氧量（VO2 at AT）、峰值摄氧量（Peak VO2）、峰值氧脉搏（Peak O2pulse）显著降低,无氧阈时二氧化碳当量（VE/VCO2 at AT）明显升高.CW组的平均肺动脉压（mPAP）、肺血管阻力（PVR）明显高于non-CW组（P〈0.01）,心输出量（CO）、心指数（CI）明显低于non-CW组（均P〈0.01）.在心肺运动试验参数中,Peak VO2（HR 0.702,95%CI 0.598～0.823,P〈0.000 1）和无氧阈时的VE/VCO2at AT（HR 1.040,95%CI 1.017～1.064,P〈0.001）是预测发生临床恶化事件的显著相关因素.在血流动力学中,mPAP（HR 1.046,95%CI 1.017～1.077;P=0.002）,CO（HR 0.401,95%CI 0.227～0.701;P=0.002）和CI （HR 0.231,95%CI 0.099～0.541;P〈0.001）均是临床恶化事件发生的影响因素.多因素回归模型中显示Peak VO2、VE/VCO2at AT、CI是研究人群发生临床恶化事件的独立预测因素.结论 Peak VO2、VE/VCO2at AT、静息CI对预测IPAH患者的临床预后具有重要意义.

Objective To explore the value of cardiopulmonary exercise testing and haemodynamics on long-term prognosis in patients of idiopathic pulmonary arterial hypertension（IPAH）.Methods Sixty-four IPAH patients hospitalized at Shanghai Pulmonary Hospital from March 2012 to March 2014 were enrolled in this study.6-minute walk distance tests,cardiopulmonary exercise testing and right heart catheterization were performed in these pantients at baseline.Subjects were followed for at least 2 years.Results Subjects were followed for 29.1±15.4 months.There were 20 events.Compared with non-clinical worsening,patients with clinical worsening had lower VO2at AT,Peak VO2,Peak O2pulse,cardiac output,cardiac index and higher VE/VCO2 at anaerobic threshold,mean pulmonary arterial pressure,pulmonary vascular resistance.Cox proportional hazards analyses were performed to determine association with the composite endpoint.Among CPET variables,peak oxygen uptake （Peak VO2：hazard ratio [HR] 0.702,95% confidence interval [CI]0.598-0.823,P〈0.000 1） and the minute ventilation （VE）/carbon dioxide production （VCO2） at anaerobic threshold （HR 1.040,95%CI 1.017-1.064,P〈0.001） were significant predictors of risk for adverse events.Among hemodynamic variables,mean pulmonary arterial pressure （HR 1.046,95%CI 1.017-1.077;P=0.002）,cardiac output （HR 0.401,95%CI 0.227-0.701;P=0.002） and cardiac index （HR 0.231,95%CI 0.099-0.541;P〈0.001） were significant predictors of risk.In a multivariate cox proportional hazards analyze,this study shows that Peak VO2,VE/VCO2 at anaerobic threshold and cardiac index contribute significantly and independently to predicting risk.Conclusions These findings suggest that cardiopulmonary exercise testing combined with haemodynamics provides relevant information of quantifying risk in idiopathic pulmonary arterial hypertension patients.