Unexplained exertional intolerance associated with impaired systemic oxygen extraction

Purpose The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE). Method...

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Published in:European journal of applied physiology 2019-10, Vol.119 (10), p.2375-2389
Main Authors: Melamed, Kathryn H., Santos, Mário, Oliveira, Rudolf K. F., Urbina, Mariana Faria, Felsenstein, Donna, Opotowsky, Alexander R., Waxman, Aaron B., Systrom, David M.
Format: Article
Language:English
Subjects:
Adult
Aged
Anaerobic Threshold
Biomedical and Life Sciences
Biomedicine
Carbon dioxide
Cardiorespiratory Fitness
Exercise - physiology
Exercise Tolerance
Female
Heart
Heart Rate
Human Physiology
Humans
Hyperventilation
Intolerance
Male
Middle Aged
Occupational Medicine/Industrial Medicine
Original Article
Oxygen
Pulmonary Gas Exchange
Pulmonary Ventilation
Skeletal muscle
Sports Medicine
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container_issue 10
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container_title European journal of applied physiology
container_volume 119
creator Melamed, Kathryn H.
Santos, Mário
Oliveira, Rudolf K. F.
Urbina, Mariana Faria
Felsenstein, Donna
Opotowsky, Alexander R.
Waxman, Aaron B.
Systrom, David M.
description Purpose The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE). Methods We reviewed invasive cardiopulmonary exercise test (iCPET) results of 313 consecutive patients presenting with unexplained exertional intolerance. An exercise limit due to poor SOE was defined as peak exercise (Ca-vO 2 )/[Hb] ≤ 0.8 and V O 2max   0.8, V O 2max  ≥ 80%, and no cardiac or pulmonary limit were considered otherwise normal. The otherwise normal group was divided into hyperventilators (HV) and normals (NL). Hyperventilation was defined as peak PaCO 2  
doi_str_mv 10.1007/s00421-019-04222-6
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F. ; Urbina, Mariana Faria ; Felsenstein, Donna ; Opotowsky, Alexander R. ; Waxman, Aaron B. ; Systrom, David M.</creator><creatorcontrib>Melamed, Kathryn H. ; Santos, Mário ; Oliveira, Rudolf K. F. ; Urbina, Mariana Faria ; Felsenstein, Donna ; Opotowsky, Alexander R. ; Waxman, Aaron B. ; Systrom, David M.</creatorcontrib><description>Purpose The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE). Methods We reviewed invasive cardiopulmonary exercise test (iCPET) results of 313 consecutive patients presenting with unexplained exertional intolerance. An exercise limit due to poor SOE was defined as peak exercise (Ca-vO 2 )/[Hb] ≤ 0.8 and V O 2max  &lt; 80% predicted in the absence of a cardiac or pulmonary mechanical limit. Those with peak (Ca-vO 2 )/[Hb] &gt; 0.8, V O 2max  ≥ 80%, and no cardiac or pulmonary limit were considered otherwise normal. The otherwise normal group was divided into hyperventilators (HV) and normals (NL). Hyperventilation was defined as peak PaCO 2  &lt; [1.5 × HCO 3  + 6]. Results Prevalence of impaired SOE as the sole cause of exertional intolerance was 12.5% (32/257). At peak exercise, poor SOE and HV had less acidemic arterial blood compared to NL (pHa = 7.39 ± 0.05 vs. 7.38 ± 0.05 vs. 7.32 ± 0.02, p  &lt; 0.001), which was explained by relative hypocapnia (PaCO 2  = 29.9 ± 5.4 mmHg vs. 31.6 ± 5.4 vs. 37.5 ± 3.4, p  &lt; 0.001). For a subset of poor SOE, this relative alkalemia, also seen in mixed venous blood, was associated with a normal PvO 2 nadir (28 ± 2 mmHg vs. 26 ± 4, p  = 0.627) but increased SvO 2 at peak exercise (44.1 ± 5.2% vs. 31.4 ± 7.0, p  &lt; 0.001). Conclusions We identified a cohort of patients whose exercise limitation is due only to systemic oxygen extraction, due to either an intrinsic abnormality of skeletal muscle mitochondrion, limb muscle microcirculatory dysregulation, or hyperventilation and left shift the oxyhemoglobin dissociation curve.</description><identifier>ISSN: 1439-6319</identifier><identifier>EISSN: 1439-6327</identifier><identifier>DOI: 10.1007/s00421-019-04222-6</identifier><identifier>PMID: 31493035</identifier><language>eng</language><publisher>Berlin/Heidelberg: Springer Berlin Heidelberg</publisher><subject>Adult ; Aged ; Anaerobic Threshold ; Biomedical and Life Sciences ; Biomedicine ; Carbon dioxide ; Cardiorespiratory Fitness ; Exercise - physiology ; Exercise Tolerance ; Female ; Heart ; Heart Rate ; Human Physiology ; Humans ; Hyperventilation ; Intolerance ; Male ; Middle Aged ; Occupational Medicine/Industrial Medicine ; Original Article ; Oxygen ; Pulmonary Gas Exchange ; Pulmonary Ventilation ; Skeletal muscle ; Sports Medicine</subject><ispartof>European journal of applied physiology, 2019-10, Vol.119 (10), p.2375-2389</ispartof><rights>Springer-Verlag GmbH Germany, part of Springer Nature 2019</rights><rights>European Journal of Applied Physiology is a copyright of Springer, (2019). All Rights Reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c418t-f46b87b513ebf556766958b2f7c8b3da6d74782418588d3697c1df711c9fa1063</citedby><cites>FETCH-LOGICAL-c418t-f46b87b513ebf556766958b2f7c8b3da6d74782418588d3697c1df711c9fa1063</cites><orcidid>0000-0003-0837-3488</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,27924,27925</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31493035$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Melamed, Kathryn H.</creatorcontrib><creatorcontrib>Santos, Mário</creatorcontrib><creatorcontrib>Oliveira, Rudolf K. F.</creatorcontrib><creatorcontrib>Urbina, Mariana Faria</creatorcontrib><creatorcontrib>Felsenstein, Donna</creatorcontrib><creatorcontrib>Opotowsky, Alexander R.</creatorcontrib><creatorcontrib>Waxman, Aaron B.</creatorcontrib><creatorcontrib>Systrom, David M.</creatorcontrib><title>Unexplained exertional intolerance associated with impaired systemic oxygen extraction</title><title>European journal of applied physiology</title><addtitle>Eur J Appl Physiol</addtitle><addtitle>Eur J Appl Physiol</addtitle><description>Purpose The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE). Methods We reviewed invasive cardiopulmonary exercise test (iCPET) results of 313 consecutive patients presenting with unexplained exertional intolerance. An exercise limit due to poor SOE was defined as peak exercise (Ca-vO 2 )/[Hb] ≤ 0.8 and V O 2max  &lt; 80% predicted in the absence of a cardiac or pulmonary mechanical limit. Those with peak (Ca-vO 2 )/[Hb] &gt; 0.8, V O 2max  ≥ 80%, and no cardiac or pulmonary limit were considered otherwise normal. The otherwise normal group was divided into hyperventilators (HV) and normals (NL). Hyperventilation was defined as peak PaCO 2  &lt; [1.5 × HCO 3  + 6]. Results Prevalence of impaired SOE as the sole cause of exertional intolerance was 12.5% (32/257). At peak exercise, poor SOE and HV had less acidemic arterial blood compared to NL (pHa = 7.39 ± 0.05 vs. 7.38 ± 0.05 vs. 7.32 ± 0.02, p  &lt; 0.001), which was explained by relative hypocapnia (PaCO 2  = 29.9 ± 5.4 mmHg vs. 31.6 ± 5.4 vs. 37.5 ± 3.4, p  &lt; 0.001). For a subset of poor SOE, this relative alkalemia, also seen in mixed venous blood, was associated with a normal PvO 2 nadir (28 ± 2 mmHg vs. 26 ± 4, p  = 0.627) but increased SvO 2 at peak exercise (44.1 ± 5.2% vs. 31.4 ± 7.0, p  &lt; 0.001). 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F.</au><au>Urbina, Mariana Faria</au><au>Felsenstein, Donna</au><au>Opotowsky, Alexander R.</au><au>Waxman, Aaron B.</au><au>Systrom, David M.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Unexplained exertional intolerance associated with impaired systemic oxygen extraction</atitle><jtitle>European journal of applied physiology</jtitle><stitle>Eur J Appl Physiol</stitle><addtitle>Eur J Appl Physiol</addtitle><date>2019-10-01</date><risdate>2019</risdate><volume>119</volume><issue>10</issue><spage>2375</spage><epage>2389</epage><pages>2375-2389</pages><issn>1439-6319</issn><eissn>1439-6327</eissn><abstract>Purpose The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE). Methods We reviewed invasive cardiopulmonary exercise test (iCPET) results of 313 consecutive patients presenting with unexplained exertional intolerance. An exercise limit due to poor SOE was defined as peak exercise (Ca-vO 2 )/[Hb] ≤ 0.8 and V O 2max  &lt; 80% predicted in the absence of a cardiac or pulmonary mechanical limit. Those with peak (Ca-vO 2 )/[Hb] &gt; 0.8, V O 2max  ≥ 80%, and no cardiac or pulmonary limit were considered otherwise normal. The otherwise normal group was divided into hyperventilators (HV) and normals (NL). Hyperventilation was defined as peak PaCO 2  &lt; [1.5 × HCO 3  + 6]. Results Prevalence of impaired SOE as the sole cause of exertional intolerance was 12.5% (32/257). At peak exercise, poor SOE and HV had less acidemic arterial blood compared to NL (pHa = 7.39 ± 0.05 vs. 7.38 ± 0.05 vs. 7.32 ± 0.02, p  &lt; 0.001), which was explained by relative hypocapnia (PaCO 2  = 29.9 ± 5.4 mmHg vs. 31.6 ± 5.4 vs. 37.5 ± 3.4, p  &lt; 0.001). For a subset of poor SOE, this relative alkalemia, also seen in mixed venous blood, was associated with a normal PvO 2 nadir (28 ± 2 mmHg vs. 26 ± 4, p  = 0.627) but increased SvO 2 at peak exercise (44.1 ± 5.2% vs. 31.4 ± 7.0, p  &lt; 0.001). Conclusions We identified a cohort of patients whose exercise limitation is due only to systemic oxygen extraction, due to either an intrinsic abnormality of skeletal muscle mitochondrion, limb muscle microcirculatory dysregulation, or hyperventilation and left shift the oxyhemoglobin dissociation curve.</abstract><cop>Berlin/Heidelberg</cop><pub>Springer Berlin Heidelberg</pub><pmid>31493035</pmid><doi>10.1007/s00421-019-04222-6</doi><tpages>15</tpages><orcidid>https://orcid.org/0000-0003-0837-3488</orcidid></addata></record>
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1439-6327
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subjects Adult
Aged
Anaerobic Threshold
Biomedical and Life Sciences
Biomedicine
Carbon dioxide
Cardiorespiratory Fitness
Exercise - physiology
Exercise Tolerance
Female
Heart
Heart Rate
Human Physiology
Humans
Hyperventilation
Intolerance
Male
Middle Aged
Occupational Medicine/Industrial Medicine
Original Article
Oxygen
Pulmonary Gas Exchange
Pulmonary Ventilation
Skeletal muscle
Sports Medicine
title Unexplained exertional intolerance associated with impaired systemic oxygen extraction
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