Exercise capacity in COPD patients with exercise-induced pulmonary hypertension

Ingunn Skjørten,^1,2 Janne Mykland Hilde,³ Morten Nissen Melsom,¹ Jonny Hisdal,⁴ Viggo Hansteen,⁵ Kjetil Steine,^2,3 Sjur Humerfelt⁶

¹Department of Pulmonary Medicine, LHL Hospital Gardermoen, Jessheim, ²Faculty of Medicine, University of Oslo, Oslo, ³Department of Cardiology, Akershus University Hospital, Lørenskog, ⁴Section of Vascular Investigations, Oslo University Hospital-Aker, ⁵Department of Cardiology, Oslo University Hospital-Aker, ⁶Clinic of Allergology and Respiratory Medicine, Oslo, Norway

Background: Pulmonary hypertension (PH) in patients with COPD is associated with reduced exercise capacity. A subgroup of COPD patients has normal mean pulmonary artery pressure (mPAP) at rest, but develops high mPAP relative to cardiac output (CO) during exercise, a condition we refer to as exercise-induced pulmonary hypertension (EIPH). We hypothesized that COPD patients with EIPH could be identified by cardiopulmonary exercise test (CPET) and that these patients have lower exercise capacity and more abnormal CPET parameters compared to COPD patients with normal hemodynamic exercise response.
Methods: Ninety-three stable outpatients with COPD underwent right heart catheterization with the measurement of mPAP, CO, and capillary wedge pressure at rest and during supine exercise. Resting mPAP <25 mmHg with ΔmPAP/ΔCO slope above or below 3 mmHg/L/min were defined as COPD-EIPH and COPD-normal, respectively. Pulmonary function tests and CPET with arterial blood gases were performed. Linear mixed models were fitted to estimate differences between the groups with adjustment for gender, age, and airflow obstruction.
Results: EIPH was observed in 45% of the study population. Maximal workload was lower in COPD-EIPH compared to COPD-normal, whereas other CPET measurements at peak exercise in % predicted values were similar between the two groups. After adjustment for gender, age, and airflow obstruction, patients with COPD-EIPH showed significantly greater increase in oxygen uptake, ventilation, respiratory frequency, heart rate, and lactate with increasing work load, as well as more reduction in pH compared to those with normal hemodynamic responses.
Conclusion: COPD-EIPH could not be discriminated from COPD-normal by CPET. However, COPD-EIPH experienced a higher cost of exercise in terms of higher oxygen uptake, ventilation, respiratory frequency, heart rate, and lactate for a given increase in workload compared to COPD-normal.

Keywords: COPD, pulmonary hypertension, right heart catheterization, cardiopulmonary exercise test

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