fit pour voyager? · • moderate–severe pulmonic valve regurgitation • sinus of valsalva...
TRANSCRIPT
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Michel White MD, FRCPC(C), FACC, FESC
Fit pour Voyager?
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Plan de la Presentation
• Physiologie et exigences de l’altitude • Les challenges physiologiques chez le patient a haut
risque: Hypertension, arythmies, cardiopathies et MCAS • Comment stratifier, quoi recommander? • Quoi faire avec la medication CV?
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Physiologie et exigences de l’altitude
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Question 1
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Hemodynamic adaptations to high altitude
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MW 2008-01 7
La réponse cardiovasculaire en reponse a une exposition aigüe à la haute altitude
• ↑ FC ~16 bpm à 4000 mètres • Élévation du débit cardiaque • ↓ légère des volumes cardiaques • ↑ FEVG (activation sympathique et ↓ de l’activité
vagale) • La réponse semble indépendante de l’âge et du
sexe.
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Altitude-induced autonomic and CV adjustments
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Time course of CV and autonomic changes in high
altitude
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Exercise increases O2 desaturation at high altitude
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Beneficial/detrimental effects of high altitude adjustments with health and
disease state
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MAM leger = 1-3; modere = 4-6 ; severe > 6 points
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MW 2008-01 15
MAM – Facteurs favorisants et predisposants
• Vitesse de montee: max 500 metres/ 24 heures > 3000 m 1 semaine pour atteindre 3000- 5000 metres
• Femme = homme mais oedeme facial plus frequent • Plus elevee <18 ans et > 50 ans • Favorisee par exercise intense • Sujets obeses et migraineux plus a risque de MAM • Non reliee = capacitee aerobique, entrainement
physique et tabac
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Reponse 1
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Les challenges physiologiques chez le patient a haut risque: Hypertension, arythmies, cardiopathies
et MCAS
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Question 2
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20
IVUS data – Proximal LAD
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Lund LH and DM Mancini. Int J Cardiol 2008;125:166-171
Decline in peak VO2 with age in men and women
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Main pathophysiologic changes and their interactions with CV
conditions
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Prevalence of self-reported CVD among high-altitude mountaineers
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Chronic conditions affected by altitude exposure
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MW 2008-01 25
Hypertension artérielle et la haute altitude
• Traitement pharmacologique ? Trop ou trop peu • ↑ de la T.A surtout systolique
─ ↑ Arythmie ─ Hypertension artérielle nocturne
• Grande susceptibilité individuelle – Le patient hypertendu est-il à risque d’évènement cardiaque à haute altitude ?
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MW 2008-01 26
Les adaptations de la circulation coronarienne
• Régulation du flot coronarien = fréquence cardiaque, contractilité et tension murale
• Changement aigü: ─ La réserve de flot coronarien (5 à 6 fois) est
suffisante pour repondre aux demandes physiques élevées en haute altitude
• Chroniquement: ─ ↓ du flot coronarien comparé au niveau de la mer
(~ 30% altitude des Andes) ─ ↓ de la fréquence cardiaque, polyglobulie, ↑ de la
différence artério-veineuse = identique au changement de la circulation périphérique.
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27 MW 03-2006
Impact of hypoxemia and high altitude (5245m) on hemodynamics and gas exchange parameters in healthy climbers
Ghofrani HA, et al. Ann Int Med 2004; 141: 169-177
Systolic blood pressure (mmHg)
Heat rate (bpm)
Saturation (%)
Systolic pulmonary artery pressure (mmHg)
Cardiac output (L/min)
Maximum level of exercise (W)
148.0
76.0
99.0
17.5
6.0
--
Rest Normoxic
232.0
171.0
98.0
25.1
14.4
262.5
Stress
142.5
84.8
72.0
30.5
5.1
--
Rest Hypoxic
209.5
157.3
60.8
42.9
11.1
130.6
Stress
120.0
84.0
83.0
22.0
5.6
--
Rest Sidenafil
185.0
148.5
71.0
27.5
15.1
189.5
Stress
Low altitude High altitude
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Categories of Disease Complexity in Congenital Heart Disease
Simple congenital heart disease • Isolated congenital aortic or mitral valve disease • Isolated patent foramen ovale or small atrial septal
defect • Isolated small ventricular septal defect without
associated lesions • Mild pulmonic stenosis • Previously ligated or occluded patent ductus arteriosus • Repaired secundum or sinus venosus atrial septal defect
without residua • Repaired ventricular septal defect without residua
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Categories of Disease Complexity in Congenital Heart Disease
Moderate severity congenital heart disease • Aorto-left ventricular fistulae • Total or partial anomalous pulmonary venous return • Partial or complete atrioventricular canal defects • Coarctation of the aorta • Ebstein’s anomaly • Infundibular right ventricular outflow obstruction of significance • Ostium primum or sinus venosus atrial septal defect • Patent ductus arteriosus (not closed) • Moderate–severe pulmonic valve regurgitation • Sinus of Valsalva fistula/aneurysm • Subvalvular or supravalvular aortic stenosis (except HOCM) • Tetralogy of Fallot • Ventricular septal defect with absent valve(s), aortic regurgitation,
coarctation, mitral disease, right ventricular outflow obstruction, straddling tricuspid/mitral valve, or subaortic stenosis
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Categories of Disease Complexity in Congenital Heart Disease
Congenital heart disease of great complexity • Conduits (valved or nonvalved) • Cyanotic congenital heart disease (all forms) • Double-outlet ventricle • Eisenmenger syndrome • Fontan procedure • Mitral or tricuspid atresia • Single ventricle • Pulmonary atresia (all forms) • Pulmonary vascular obstructive diseases • Transposition of the great arteries • Truncus arteriosus/hemitruncus • Other abnormalities of atrioventricular or ventriculoarterial connection
(crisscross heart, isomerism, heterotaxy syndromes ventricular inversion)
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Reponse 2
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Comment stratifier, quoi recommander?
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Question 3
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Prerequisites, general recommendations, and contraindications to high altitude
exposure
General prerequisites at low altitude • Stable clinical condition • Asymptomatic at rest • Functional class < II NYHA
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Prerequisites, general recommendations, and contraindications to high altitude
exposure General recommendations at high altitude • Ascent at a slow rate > 2000 m (increasing
sleeping altitude by < 300 m/d) • Avoid overexertion • Avoid direct transportation to an altitude >
3000 m
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Prerequisites, general recommendations, and contraindications to high altitude
exposure Absolute contraindications to high altitude exposure • Unstable clinical condition, ie,
- unstable angina - symptoms or signs of ischemia during exercise testing at low to
• moderate workload (<80 W or <5 metabolic equivalents) - decompensated heart failure - uncontrolled atrial or ventricular arrhythmia
• Myocardial infarction and/or coronary revascularization in the past 3-6 mo
• Decompensated heart failure during the past 3 mo • Poorly controlled arterial hypertension (blood pressure ≥ 160/100
mm Hg at rest, > 220 mm Hg systolic blood pressure during exercise)
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Prerequisites, general recommendations, and contraindications to high altitude
exposure Absolute contraindications to high altitude exposure (suite) • Marked pulmonary hypertension (mean pulmonary artery pressure >
30 mm Hg, RV-RA gradient > 40 mm Hg) and/or any pulmonary hypertension associated with functional class ≥ II and/or presence of markers of poor prognosis37
• Severe valvular heart disease, even if asymptomatic • Thromboembolic event during the past 3 mo • Cyanotic or severe acyanotic congenital heart disease • ICD implantation or ICD intervention for ventricular arrhythmias in
the past 3-6 mo • Stroke, transient ischemic attack, or cerebral hemorrhage during the
past 3-6 mo
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
Arterial hypertension If not well controlled → ambulatory blood pressure recording Instructions for self-monitoring of blood pressure and treatment adjustments if uncontrolled hypertension or hypotension develops
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MW 2008-01 39
Maladie coronarienne et la haute altitude
• ↓ du risque MCAS et IM chez les résidents haute altitude
• Vasoconstriction coronarienne possible en présence de dysfonction endothéliale et MCAS
• Hypoxémie = moins stressant pour le cœur que l’exercice
• Le rôle de l’hypoxémie souvent combinée avec l’exercice intense, le froid et le stress émotionnel
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
CAD Asymptomatic revascularization < 6 mo
Asymptomatic revascularization > 6 mo
Asymptomatic reduced LVEF
Consider exercise testing according to coronary status Exercise testing If not conclusive → exercise testing with imaging modality Exercise testing If not conclusive → exercise testing with imaging modality Transthoracic echocardiography at rest
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MW 2008-01 41
Évaluation du patient à risque CV
• Épreuve d’effort (capacité maximale, récupération FC 1 et 2 min)
• Épreuve d’effort avec analyses des gaz expiratoires • Épreuve d’effort avec MIBI ou échocardiographie • CCTA (Angio IRM) • Angiographie coronarienne • Holter ou cardiomémo ?
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MW 2008-01 43
L’altitude contribue-t-elle à la décompensation du patient insuffisant cardiaque ?
• L’ascension est sécuritaire jusqu’à 2,500 mètres chez le patient bien compensé
• Il y aurait rétention hydrosodée associé à l’AMS rendant le patient défaillant plus à risque
• La majoration des diurétiques, le diamox, sildenafil sont à considérer
• Ajustement de la médication concomitante ?
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
Reduced LVEF Any cause
Exercise testing Transthoracic echocardiography at rest Instructions for treatment adjustments if heart failure develops
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
Pulmonary hypertension Exposure contraindicated if marked pulmonary hypertension or if functional class > I (see Table 2) Echocardiographic assessment of RV function and of pulmonary artery pressure under simulated high altitude (FIO2: 12%; if RV-RA gradient > 40 mm Hg patients should be strongly discouraged)
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
Valvular heart disease Symptomatic and/or severe Mild aortic or mitral regurgitation
Exposure contraindicated Exercise testing, transthoracic echocardiography at rest Instructions for self-monitoring of blood pressure and treatment adjustments if uncontrolled hypertension or hypotension develops Instructions for self-monitoring of international normalized ratio and dosis adaptation
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
Congenital heart disease Acyanotic or cyanotic Exposure contraindicated if functional
class > I Exercise testing and echocardiographic assessment of left and RV function and pulmonary pressure under simulated high altitude (FIO2, 12%; if RV-RA gradient > 40 mm Hg patients should be strongly discouraged)
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MW 2008-01 48
La haute altitude provoque-t-elle des arythmies cardiaques ?
• ESV ↑ de 63% en réponse à l’ascension rapide. Ceci est couplé d’une ↑ de norepinéphrine de 67%.
• Impact de l’altitude sur les arythmies supra ventriculaires indépendamment de l’effort et de la température froide demeure inconnu
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Recommendations and preexposure assessment according to CV disease
Clinical Condition Proposed Preexposure Assessment and Recommendations for patients
Arrhythmia Associated with CAD/CHF Pacemaker
Supraventricular tachycardia/atrial flutter
Paroxysmal or persistent atrial fibrillation
Exercise testing Testing only if VVIR, DDDR, or AAIR mode to adapt PM rates Consider catheter ablation before high-altitude exposure Exercise testing and Holter-ECG Instruction for heart rate self-monitoring and therapy adjustments in case of insufficient rate control (>90 beats per min at rest)
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Clinical Condition Proposed Preexposure Assessment and
Recommendations for patients Cerebrovascular disease All conditions Ischemic stroke or TIA b 90 d ago
Ischemic stroke or TIA N 90 d ago, thorough workup of the stroke has been performed and risk factors are treated adequately
Stenosis or occlusion of a major extra- or intracranial cerebral artery
Hypertensive hemorrhage
Hemorrhage as a result of amyloid angiopathy Known cerebral aneuryms, arteriovenous malformation, or cerebral cavernoma
Avoid trekking or climbing alone Avoid traveling to higher altitudes (>2000-2500 m) Avoid air travel Avoid extreme altitude > 4500 m
Avoid traveling to altitude > 2000-2500 m
Travel to high altitude only if blood pressure is controlled and not before 90 d after the event Avoid high altitude Check blood pressure. Avoid extreme altitude > 4500 m
Recommendations and preexposure assessment according
to CV disease
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51
Facing our limits 6120m
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MW 03-2007
Capacite physique requise pour la haute montagne
• Endurance musculaire et cardiovasculaire • Capacitee de travailler sans oxygene – amelioration du
seuil ventilatoire • Force exceptionelle au niveau des cuisses, dos et epaules • Stabilisation au niveau du “core” • Bonne flexibilitee • Capacitee de relaxation
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“There are three kinds of lies: lies, damned lies, and statistics”
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MW 2002-03
Links between physiologic systems and the sources
of perceived sensation limiting exercise in humans Motor command
Excitation - contraction (Na+ - K+)
Cross-bridge formation (Ca2+)
Glycogen + ADP → ATP + Lactate + H+
Glycogen + ADP + O2 → ATP + CO2
FFA + ADP + O2 → ATP + CO2
Process
Brain
System
Effort
Sensation
Power output (ATP → ADP)
Nerve Weakness
Muscle Tension
Metabolism Fatigue
Blood flow
Ventilation O2 CO2
Circulation
Lungs Epstein FH, NEJM 2000; 31: 632-641
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Relationship between mitochondrial volume and number of capillaries in humans
Esposito F, at al. J Am Coll Cardiol 2010;55:1945-54
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MW 2003
Exercise conditioning training improves submaximal exercise capacity in older CAD patients
Ades PA et al. Circulation 1993; 88: 572-577
Rest HR Systolic BB
Low submaximal exercise Intensity (% VO2 max) HR Serum lactate Perceived exertion
High submaximal exercise Intensity (% VO2 max) HR Serum lactate Perceived exertion
Submaximal exercise duration Mean exercise time (min) Complete 45-min protocol
70 ± 16 135 ± 25
58 ± 17% 94 ± 16
1.85 ± 0.96 9.9 ± 2.6
79 ± 14% 108 ± 16
2.30 ± 1.08 14.0 ± 2.2
30 ± 10 10/45 (22%)
Baseline (n = 45)
68 ± 14 134 ± 21
50 ± 8* 84 ± 12
1.44 ± 0.46* 8.7 ± 2.2*
67 ± 10%* 97 ± 16*
1.60 ± 0.43* 11.7 ± 2.2*
41 ± 10* 33/43 (77%)*
3 months conditioning
(n = 43)
68 ± 1* 122 ± 20*†
46 ± 7* 84 ± 10*
1.39 ± 0.26* 7.9 ± 1.2*
55 ± 12%*† 97 ± 10*
1.60 ± 0.41* 11.5 ± 2.5*
43 ± 7* 10/11 (91%)*
12 months conditioning
(n = 11)
* p < 0.05 vs baseline † p < 0.05 vs 3 months’ conditioning
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Reponse 3
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MW 2008-01 58
Le patient à bas risque
• Hypertension artérielle traitée • Patients diabétiques • Sujets «jeunes» ou «âgés» • Maladies coronariennes athérosclérotiques minimes • Statut post-dilatation coronarienne ou pontages
aorto-coronariens • Statut post infarctus du myocarde sans dysfonction
ventriculaire gauche résiduelle
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MW 2008-01 59
Le patient à risque modéré
• Angine d’effort stable avec seuil ischémique élevé • Maladie coronarienne athérosclérotique documentée
(uni ou bi tronculaire) • Dysfonction ventriculaire gauche asymptomatique
(FEVG ≥40%) • Hypertension artérielle labile • Arythmie supra-ventriculaire ou ventriculaire traitées
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MW 2008-01 60
Le patient à risque élevé
• Ces patients devraient vraisemblablement s’abstenir d’une exposition et une altitude modérée (1000- 2500 m) ─ Patients porteurs de cardiopathie cyanogène ─ Toute forme d’hypertension artérielle pulmonaire ─ Dysfonction ventriculaire gauche avec F.E. à 40% ─ Hypertension artérielle mal contrôlée ─ Maladie coronarienne athérosclérotique de plusieurs
troncs vasculaires avec seuil ischémique bas ─ Arythmie cardiaque mal controlée
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Quoi faire avec la RX cardiovasculaire?
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Question 4
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Medication for the prevention and treatment of AMS
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PDE5Is for HAPE and HAPH
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BP reduction with PDE5Is
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Reponse 4