Murat YALÇIN, Ejder KARDEŞOĞLU, Zafer IŞILAK

Yüksek irtifa ve kalp

Günümüzde havacılık ve dağcılık gibi yüksek irtifa ile ilişkili durumlar insanların gittikçe daha da artan düzeyde ilgisini çekmektedir. Yükseklere çıkılırken gaz basıncı azalmakta ve hipoksi ile karşılaşılmaktadır. İnsan vücudunun farklı yüksekliklere vereceği fizyolojik ve patolojik cevaplar farklıdır. Bu nedenle yükseklikle beraber oluşabilecek fizyolojik ve patolojik değişikliklerin ve klinik sonuçlarının bilinmesi önemlidir. Yüksek irtifa ile oluşan akut dağ hastalığı ve yüksek irtifa beyin ödemi, uygun önlemler ile engellenebilir hastalıklardır. Yükseklikle beraber azalan atmosferik oksijen, birçok adaptasyon mekanizmasını başlatmaktadır. Bu adaptasyon mekanizmaları ve aklimatizasyon; çevresel etmenler, egzersiz soğuk gibi nedenlerden dolayı kişiler arasında büyük farklılıklar gösterir. Yüksek irtifa kardiyovasküler sistemde birçok mekanizma ile farklı değişikliklere neden olur. Normal bireyler bu değişikliklere kolay uyum sağlayabilse de kalp hastalığı olan kişilerde bu durum istenmeyen sonuçlara neden olabilmektedir. Bu nedenle bilinen kalp hastalığı olan kişiler yükseğe seyahatleri öncesi etkin bir şekilde değerlendirilmeleri ve yükseklik ile oluşan değişikliklere bağlı gelişebilecek komplikasyonlar ve bu hastalara yapılabilecek öneriler bilinmelidir.

High altitude and heart

Nowadays, situations associated with high altitude such as mountaineering, aviation increasingly draw the attention of people. Gas pressure decreases and hypoxia is encountered when climbing higher. Physiological and pathological responses of human body to different heights are different. Therefore, physiological and pathological changes that may occur together with height and to know the clinical outcomes of these are important . Acute mountain sickness caused by high altitude and high altitude cerebral edema are preventable diseases with appropriate precautions. Atmospheric oxygen decreasing with height, initiates many adaptive mechanisms. These adaptation mechanisms and acclimatization vary widely among individuals because of reasons such as environmental factors, exercise and cold. High altitude causes different changes in the cardiovascular system with various mechanisms. Although normal individuals easily adapt to these changes, this situation can lead to undesirable results in people with heart disease. For this reason, it should be known the effective evaluation of the people with known heart disease before traveling to high altitude and the complications due to the changes with height and the recommendations can be made to these patients.

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1 Rimoldia SF, Sartorib C, Seilera C, et al. High-Altitude Exposure in Patients with Cardiovascular Disease: Risk Assessment and Practical Recommendations. Progress in Cardiovascular Diseases. 2010; 52: 512–524.
2 Noyan B. Yüksek irtifa, havacılık ve uzay fizyolojisi. http://tip.uludag.edu.tr/fizyoloji/ders-notlari.php
3 Hackett PH, Roach RC: High altitude medicine. Eds.: Auerbach PS. Wilderness Medicine: Management of Wilderness and Environmental Emergencies. 3rd ed. St. Louis. Mosby, 1995. p. 1-37.
4 Hackett PH, Roach RC: High altitude cerebral edema. High Alt Med Biol. 2004; 5: 136-146.
5 Whymper E, Shipton E: Travels amongst the great andes of the equator. London, England. Charles Knight, 1972.
6 Ravenhill TH: Some experiences of mountain sickness in the Andes. J Trop Med Hygiene. 1913; 1620: 313-320.
7 Silber E, Sonnenberg P, Collier DJ, Pollard AJ, Murdoch DR, Goadsby PJ. Clinical features of headache at altitude: a prospective study. Neurology. 2003; 60: 1167-1171.
8 Serrano-Duenas M. High altitude headache. A prospective study of it’s clinical characteristics. Cephalalgia. 2005; 25: 1110-1116.
9 Hackett PH, Rennie D: The incidence, importance, and prophylaxis of acute mountain sickness. Lancet. 1976; 2: 1149-1155.
10 Roach RC, Bärtsch P, Oelz O. The Lake Louise acute mountain sickness scoring system. Eds.: Sutton JR, Houston CS, Coates G. Hypoxia and molecular medicine. Burlington. VT: Queen City Pres, 1993. p. 272-274.
11 Sampson JB, Cymerman A, Burse RL, Maher JT, Rock PB. Procedures for the measurement of acute mountain sickness. Aviat Space Environ Med. 1983; 54: 1063-1073.
12 Webb JD, Coleman ML, Pugh CW: Hypoxia, hypoxia-inducible factors (HIF), HIF hydroxylases and oxygen sensing. Cell Mol Life Sci. 2009; 66(22): 3539-3354.
13 Schneider M, Bernasch D, Weymann J, Holle R, Bartsch P. Acute mountain sickness: influence of susceptibility, preexposure, and ascent rate. Med Sci Sports Exerc. 2002; 34: 1886-1891.
14 Honigman B, Theis MK, Koziol-McLain J, et al. Acute mountain sickness in a general tourist population at moderate altitudes. Ann Intern Med. 1993; 118: 587-592.
15 Schneider M, Bernasch D, Weymann J, Holle R, Bartsch P. Susceptibility, rate of ascent and pre-acclimatization are major determinants for prevalence of acute mountain sickness (AMS). High Altitude Med Biol. 2001; 2: 1.
16 Hackett P, Roach RC: High-altitude illness. N Engl J Med. 2001; 345: 107-114.
17 Roach RC, Houston CS, Honigman B, et al: How well do older persons tolerate moderate altitude? West J Med. 1995; 162: 32-36.
18 Pollard AJ: Altitude induced illness. BMJ. 1992; 304: 1324-1325.
19 Wright AD, Winterborn MH, Forster PJ. Carbonic anhydrase inhibition in the immediate therapy of acute mountain sickness. J Wilderness Med. 1994; 5: 49-55.
20 Hackett PH, Roach RC, Wood RA, et al. Dexamethasone for prevention and treatment of acute mountain sickness. Aviat Space Environ Med. 1988; 59: 950-954.
21 Johnson TS, Rock PB, Fulco CS, Trad LA, Spark RF, Maher JT. Prevention of acute mountain sickness by dexamethasone. N Engl J Med. 1984; 310: 683-686.
22 Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989; 321: 1707-1713.
23 Chan CW, Hoar H, Pattinson K, Bradwell AR, Wright AD, Imray CH. Effect of sildenafil and acclimatization on cerebral oxygenation at altitude. Clin Sci (Lond). 2005; 109: 319-324.
24 Fischer R, Lang SM, Steiner U, et al. Theophylline improves acute mountain sickness. Eur Respir J. 2000; 15: 123-127.
25 Bailey DM, Davies B. Acute mountain sickness; prophylactic benefits of antioxidant vitamin supplementation at high altitude. High Alt Med Biol. 2001; 2: 21-29.
26 Chen CH, Chen AC, Liu HJ. Involvement of nitric oxide and Nmethyl- D-aspartate in acute hypoxic altitude convulsion in mice. Aviat Space Environ Med. 1997; 68: 296-299.
27 Singh I, Khanna PK, Srivastava MC, Lal M, Roy SB, Subramanyam CS. Acute mountain sickness. N Engl J Med. 1969; 280: 175-184.
28 Beaumont M, Goldenberg F, Lejeune D, Marotte H, Harf A, Lofaso F. Effect of zolpidem on sleep and ventilatory patterns at simulated altitude of 4,000 meters. Am J Respir Crit Care Med. 1996; 153: 1864-1869.
29 Tune JD: Control of coronary blood flow during hypoxemia. Adv Exp Med Biol. 2007; 618: 25-39.
30 Robert Naeije. Physiological Adaptation of the Cardiovascular System to High Altitude. Progress in Cardiovascular Diseases. 2010; 52: 456-466.
31 Naeije R, Mélot C, Mols P, Hallemans R. Effects of vasodilators on hypoxic pulmonary vasoconstriction in normal man. Chest. 1982; 82: 404-410.
32 Klausen K. Cardiac output in man at rest and work during and after acclimatization to 3,800 m. J Appl Physiol. 1966; 21: 609-616.
33 Vogel JA, Harris CW: Cardiopulmonary responses of resting man during early exposure to high altitude. J Appl Physiol. 1967; 22: 1124-1128.
34 Hartley LH, Alexander JK, Modelski M, Grover RF. Subnormal cardiacoutput at rest and during exercise in residents at 3100 m altitude. J Appl Physiol. 1967; 23: 839-848.
35 Banchero N, Sime F, Penaloza D. Pulmonary pressure, cardiac output, and arterial oxygen saturation during exercise at high altitude and at sea level. Circulation. 1968; 33: 249-262.
36 Vogel JA, Hartley H, Cruz JC: Cardiac output during exercise in altitude natives at sea level and high altitude. J Appl Physiol. 1974; 36: 173-176.
37 Rahn H, Otis AB: Man's respiratory response during and after acclimatization to high altitude. Am J Physiol. 1949; 157: 445-462.
38 Milnor WR, Bergel DH, Bargainer JD: Hydraulic power associated with pulmonary flow and its relation to heart rate. Circ Res. 1966; 19: 467-480.
39 Cerritelli P. Gas exchange at high altitude. Eds.: West JB. Pulmonary gas Exchange. vol II. New York. Academic Pres, 1980. p. 97-147.
40 Alexander JK, Hartley LH, Modelski M, Grover RF. Reduction of stroke volume during exercise in man following ascent to 3100 m altitude. J Appl Physiol. 1967; 23: 849-858.
41 Cunningham WL, Becker EJ, Kreuzer F: Catecholamines in plasma and urine at high altitude. J Appl Physiol. 1965; 20: 607-610.
42 Bogaard HJ, Hopkins SR, Yamaya Y, Niizeki K, Ziegler MG, Wagner PD. Role of autonomic nervous system in the reduced maximal cardiac output at altitude. J Appl Physiol. 2002; 93: 271-279.
43 Noakes TD. Physiological models to understand exercise fatigue and the adaptations that predict or enhance athletic performance. Scand J Med Sci Sports. 2000; 10: 119-123.
44 Tucker CE, James WE, Berry MA, Johnstone CJ, Grover RF. Depressed myocardial function in the goat at high altitude. J Appl Physiol. 1976; 41: 356-361.
45 Silverman HS, Wei S, Haigney MC, Ocampo CJ, Stern MD. Myocyte adaptation to chronic hypoxia and development of tolerance to subsequent acute severe hypoxia. Circ Res. 1997; 80: 699-707.
46 Moso A. La stanchezza del cuore. Fisiologia dell'uomo sulle Alpi. Molano: Fraztelli Treves, Editori; 1897.
47 Grover RF, Reeves JT, Maher JT, et al. Maintained stroke volume but impaired arterial oxygenation in man at high altitude with supplemental CO2. Circ Res. 1978; 38: 391-396.
48 Pugh LGCE: Blood volume and hemoglobin concentration at altitudes above 18,000 ft (5,500 m). J Physiol. 1964; 170: 344-354.
49 Grover RF, Selland MA, McCullough RG, et al. Beta-adrenergic blockade does not prevent polycythemia or decrease plasma volume in men at 4300 m altitude. Eur J Appl Physiol. 1998; 77: 264-270.
50 Robach P, Déchaux M, Jarrot S, et al: Operation Everest III: role of plasma volume expansion on VO2max during prolonged altitude exposure. J Appl Physiol. 2000; 89: 29-37.
51 Pugh IGCE: Cardiac output in muscular exercise at 5800m(19,000 ft). J Appl Physiol. 1964; 19: 441-447.
52 Reeves JT, Groves BM, Sutton JR, et al. Operation Everest II: preservation of cardiac function at high altitude. J Appl Physiol. 1987; 63: 531-539.
53 Sarnquist F, Scoene R, Hackett P, Townes BD. Hemodilution of polycythemic mountaineers; effects of relative polycythemia. Aviat Space Environm Med. 1986; 57: 313-317.
54 Richardson TQ, Guyton AC. Effects of polycythemia andanemia on cardiac output and other circulatory factors. Am J Physiol. 1959; 197: 1667-1670.
55 Penaloza D, Arias-Stella J. The heart and pulmonary circulation at high altitudes. Healthy highlanders and chronic mountain sickness. Circulation. 2007; 115: 1132-1146.
56 Ghofrani HA, Reichenberger F, Kohstall MG, et al. Sildenafil increased exercise capacity during hypoxia at low altitudes and at mount Everest base camp: a randomized, double-blind, placebocontrolled crossover trial. Ann Intern Med. 2004; 141: 169-177.
57 Wagner PD: Gas exchange and peripheral diffusion limitation. Med Sci Sports Exerc. 1992; 24: 54-58.
58 Suarez J, Alexander JK, Houston CS: Enhanced left ventricular systolic performance at high altitude during Operation Everest II. Am J Cardiol. 1987; 60: 137-142.
59 Allemann Y, Rotter M, Hutter D, et al: Impact of acute hypoxic pulmonary hypertension on LV diastolic function in healthy mountaineers at high altitude. Am J Physiol Heart Circ Physiol. 2004; 286: H856-862.
60 Hilton R, Eichholtz F. The influence of some chemical factors on the coronary circulation. J Physiol. 1925; 9: 413-425.
61 Wyss CA, Koepfli P, Fretz G, Seebauer M, Schirlo C, Kaufmann PA. Influence of altitude exposure on coronary flow reserve. Circulation. 2003; 108: 1202-1207.
62 Grover RF, Lufschanowski R, Alexander JK. Alterations in the coronary circulation of man following ascent to 3100 m altitude. J Appl Physiol. 1976; 41: 832-838.
63 Moret PR. Coronary blood flow and myocardial metabolism in man at high altitude. High altitude physiology: cardiac and respiratory aspects. Ciba. 1971. p. 131.
64 Wolfel E, Selland M, Mazzeo R, Reeves JT. Sympathetic hypertension at 4300 m is related to sympathoadrenal activity. J Appl Physiol. 1994; 76: 1643-1650.
65 Hultgren HN. Effect of high altitude on cardiovascular diseases. J Wilderness Med. 1992; 3: 301-308.
66 Ruiz L, Penaloza D. Altitude and hypertension. Mayo Clin Proc. 1977; 52: 442-445.
67 Westendorp RG, Blauw GJ, Frolich M, Simons R. Hypoxic syncope. Aviat Space Environ Med. 1997; 68: 410-414.
68 Karliner JS, Sarnquist FF, Graber DJ, Peters RMJ, West JB. The electrocardiogram at extreme altitude: experience on Mt Everest. Am Heart J. 1985; 109: 505-513.
69 Bärtsch P, Gibbs S. Effect of altitude on the heart and the lungs. Circulation. 2007; 116: 2191-2202.
70 Gordon JB, Ganz P, Nabel EG, et al. Atherosclerosis influences the vasomotor response of epicardial coronary arteries to exercise. J Clin Invest. 1989; 83: 1946-1952.
71 Yasue H, Nagao M, Omote S, Nagao M. Coronary arterial spasm and Prinzmetal's variant form of angina induced by hyperventilation and Tris-buffer infusion. Circulation. 1978; 58: 56-62.
72 Seiler C: The collateral circulation of the heart. London. Springer. 2009.
73 Grover RF, Tucker CE, McGroarty SR, Travis RR. The coronary stres of skiing at high altitude. Arch Intern Med. 1990; 150: 1205-1208.
74 Levine BD, Zuckerman JH, deFilippi CR. Effect of high-altitude exposure in the elderly: the Tenth Mountain Division study. Circulation. 1997; 96: 1224-1232.
75 Morgan BJ, Alexander JK, Nicoli SA. The patient with coronary heart disease at altitude: observations during acute exposure to 3100 meters. J Wilderness Med. 1990; 1: 147-153.
76 Okin JT. Response of patients with coronary heart disease to exercise at varying altitudes. Adv Cardiol. 1970; 5: 92-96.
77 Schmid JP, Noveanu M, Gaillet R, Hellige G, Wahl A, Saner H. Safety and exercise tolerance of acute high altitude exposure (3454 m) among patients with coronary artery disease. Heart. 2006; 92: 921-925.
78 Erdmann J, Sun KT, Masar P, Niederhauser H. Effects of exposure to altitude on men with coronary artery disease and impaired left ventricular function. Am J Cardiol. 1998; 81: 266-270.
79 Faeh D, Gutzwiller F, Bopp M. Lower mortality from coronary heart disease and stroke at higher altitudes in Switzerland. Circulation. 2009; 120: 495-501.
80 Agostoni P, Cattadori G, Guazzi M, et al: Effects of simulated altitude-induced hypoxia on exercise capacity in patients with chronic heart failure. Am J Med. 2000; 109: 450-455.
81 Mahmud E, Raisinghani A, Hassankhani A, et al. Correlation of left ventricular diastolic filling characteristics with right ventricular overload and pulmonary artery pressure in chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol. 2002; 40: 318-324.
82 Palatini P, Businaro R, Berton G, et al: Effects of low altitude exposure on 24-hour blood pressure and adrenergic activity. Am J Cardiol. 1989; 64: 1379-1382.
83 Nault P, Halman S, Paradis J. Ankle-brachial index onKilimanjaro: lessons from high altitude. Wilderness Environ Med. 2009; 20: 72-76.
84 Ponchia A, Noventa D, Bertaglia M, et al: Cardiovascular neural regulation during and after prolonged high altitude exposure. Eur Heart J. 1994; 15: 1463-1469.
85 Burtscher M. Risk of cardiovascular events during mountain activities. Adv Exp Med Biol. 2007; 618: 1-11.
86 Wu TY, Ding SQ, Liu JL, et al. Who should not go high: chronic disease and work at altitude during construction of the Qinghai-Tibet railroad. High Alt Med Biol. 2007; 8: 88-107.
87 Mancia G, De Backer G, Dominiczak A, et al: Guidelines for the Management of Arterial Hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007; 25: 1105-1187.
88 Agostoni P, Contini M, Magini A, et al: Carvedilol reduces exerciseinduced hyperventilation: A benefit in normoxia and a problem with hypoxia. Eur J Heart Fail. 2006; 8: 729-735.
89 Pratt MC, Lewis-Barned NJ, Walker RJ, Bailey RR, Shand BI, Livesey J. Effect of angiotensin converting enzyme inhibitors on erythropoietin concentrations in healthy volunteers. Br J Clin Pharmacol. 1992; 34: 363-365.
90 Swenson ER. Renal function and fluid homeostasis. In: Hornbein TF, Schoene RB, editors. High altitude: an exploration of human adaptation. New York. Marcel Dekker, 2001. p. 525-568.
91 Reinhart WH, Kayser B, Singh A, Waber U, Oelz O, Bärtsch P. Blood rheology in acute mountain sickness and high-altitude pulmonary edema. J Appl Physiol. 1991; 71: 934-938.
92 Pichler Hefti J, Risch L, Hefti U, et al: Changes of coagulation parameters during high altitude expedition. Swiss Med Wkly. 2010; 140: 111-117.
93 Groves BM, Reeves JT, Sutton JR, et al: Operation Everest II: elevated high-altitude pulmonary resistance unresponsive to oxygen. J Appl Physiol. 1987; 63: 521-530.
94 Galie N, Hoeper MM, Humbert M, et al: Guidelines for the diagnosis and treatment of pulmonary hypertension: The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009; 30: 2493-2537.
95 Sartori C, Allemann Y, Scherrer U. Pathogenesis of pulmonary edema: learning from high-altitude pulmonary edema. Respir Physiol Neurobiol. 2007; 159: 338-349.
96 Hackett PH, Creagh CE, Grover RF, et al: High-altitude pulmonary edema in persons without the right pulmonary artery. N Engl J Med. 1980; 302: 1070-1073.
97 Naeije R, De Backer D, Vachiery JL, De Vuyst P. High-altitude pulmonary edema with primary pulmonary hypertension. Chest. 1996; 110: 286-289.
98 Allemann Y, Hutter D, Lipp E, et al: Patent foramen ovale and highaltitude pulmonary edema. JAMA. 2006; 296: 2954-2958.
99 Das BB, Wolfe RR, Chan KC, Larsen GL, Reeves JT, Ivy D. High-altitude pulmonary edema in children with underlying cardiopulmonary disorders and pulmonary hypertension living at altitude. Arch Pediatr Adolesc Med. 2004; 158: 1170-1176.
100 Harinck E, Hutter PA, Hoorntje TM, et al. Air travel and adults with cyanotic congenital heart disease. Circulation. 1996; 93: 272-276.
101 Burtscher M, Mittleman MA. Time-dependent SCD risk during mountain sports changes with age. Circulation. 1995; 92: 3151-3152.
102 Burtscher M, PhiladelphyM, Nachbauer W, Likar R. The risk of death to trekkers and hikers in the mountains. JAMA. 1995; 273: 460.
103 Burtscher M, Pachinger O, Mittleman MA. Prior myocardial infarction is the major risk factor associated with sudden cardiac death during downhill skiing. Int J Sports Med. 2000; 21: 613-615.
104 Gibelli G, Fantoni C, Anza C, et al: Arrhythmic risk evaluation during exercise at high altitude in healthy subjects: role of microvolt T-wave alternans. Pacing Clin Electrophysiol. 2008; 31: 1277-1283.
105 Kujanik S, Snincak M, Vokal J, Podracký J, Koval J. Periodicity of arrhythmias in healthy elderly men at the moderate altitude. Physiol Res. 2000; 49: 285-287.
106 Weilenmann D, Duru F, Schonbeck M, et al. Influence of acute exposure to high altitude and hypoxemia on ventricular stimulation thresholds in pacemaker patients. Pacing Clin Electrophysiol. 2000; 23: 512-515.