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. 2020 Apr;157(4):936-944.
doi: 10.1016/j.chest.2019.10.047. Epub 2019 Nov 22.

Dyspnea Postpulmonary Embolism From Physiological Dead Space Proportion and Stroke Volume Defects During Exercise

Timothy M Fernandes  1 , Mona Alotaibi  1 , Danielle M Strozza  1 , William W Stringer  2 , Janos Porszasz  2 , Garner G Faulkner  1 , Cara F Castro  1 , Don A Tran  1 , Timothy A Morris  3
Affiliations

Dyspnea Postpulmonary Embolism From Physiological Dead Space Proportion and Stroke Volume Defects During Exercise

Timothy M Fernandes et al. Chest. 2020 Apr.

Abstract

Background: Many patients with pulmonary embolism (PE) report dyspnea on exertion following long-term treatment. Increased physiological dead space proportion (VD/VT) and decreased cardiac stroke volume reserve may distinguish persistent effects of PE itself from symptoms reflecting comorbid conditions or deconditioning.

Methods: This retrospective study analyzed a consecutive series of incremental symptom-limited cardiopulmonary exercise tests that had been ordered to evaluate persistent dyspnea on exertion following long-term treatment for acute PE. Physiological VD/VT was determined at anaerobic threshold from exhaled CO2 and transcutaneous Pco2 (validated against Paco2 measurements). Cardiac stroke volume reserve was estimated at rest and at anaerobic threshold by using oxygen consumption/pulse and previously validated estimates of the arteriovenous oxygen content difference.

Results: Cardiopulmonary exercise tests were performed on 40 patients with post-PE dyspnea. In 65.0% (95% CI, 50.2-79.8), VD/VT at anaerobic threshold was abnormally elevated, stroke volume reserve was decreased, or both defects occurred. VD/VT at anaerobic threshold was abnormally elevated (≥ 0.27) in 35.0% (95% CI, 20.2-49.8). VD/VT at anaerobic threshold significantly correlated with the extent of unmatched perfusion defects on subsequent ventilation-perfusion scans (P = .0085). In 55.0% (95% CI, 39.6-70.4), stroke volume reserve at anaerobic threshold was abnormally decreased (≤ 128% of the resting value). Both defects were present in 25.0% (95% CI, 11.6-38.4).

Conclusions: Increased VD/VT at anaerobic threshold and decreased stroke volume reserve during exercise are common among patients with dyspnea on exertion after long-term treatment of PE. The defects can be disclosed noninvasively by using cardiopulmonary exercise testing.

Keywords: cardiopulmonary exercise testing; chronic thromboembolic disease; pulmonary embolism; residual pulmonary vascular obstruction; thromboembolic disease.

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Comment in

  • Dyspnea Postpulmonary Embolism: The Relevance of Ve/VCO2 Slope.
    Caviedes I, Soto R. Caviedes I, et al. Chest. 2020 Oct;158(4):1780-1781. doi: 10.1016/j.chest.2020.05.624. Chest. 2020. PMID: 33036091 No abstract available.
  • Response.
    Morris TA, Porszasz J, Stringer WW. Morris TA, et al. Chest. 2020 Oct;158(4):1781-1782. doi: 10.1016/j.chest.2020.07.037. Chest. 2020. PMID: 33036092 No abstract available.