Cardiopulmonary Exercise Test Responses Research Articles

Clusters of multidimensional exercise response patterns and estimated heart failure risk in the Framingham Heart Study.

New tools are needed to identify heart failure (HF) risk earlier in its course. We evaluated the association of multidimensional cardiopulmonary exercise testing (CPET) phenotypes with subclinical risk markers and predicted long-term HF risk in a large community-based cohort. We studied 2532 Framingham Heart Study participants [age 53±9years, 52% women, body mass index (BMI) 28.0±5.3kg/m2, peak oxygen uptake (VO2) 21.1±5.9kg/m2 in women, 26.4±6.7kg/m2 in men] who underwent maximum effort CPET and were not taking atrioventricular nodal blocking agents. Higher peak VO2 was associated with a lower estimated HF risk score (Spearman correlation r: -0.60 in men and -0.55 in women, P<0.0001), with an observed overlap of estimated risk across peak VO2 categories. Hierarchical clustering of 26 separate CPET phenotypes (values residualized on age, sex, and BMI to provide uniformity across these variables) identified three clusters with distinct exercise physiologies: Cluster 1-impaired oxygen kinetics; Cluster 2-impaired vascular; and Cluster 3-favourable exercise response. These clusters were similar in age, sex distribution, and BMI but displayed distinct associations with relevant subclinical phenotypes [Cluster 1-higher subcutaneous and visceral fat and lower pulmonary function; Cluster 2-higher carotid-femoral pulse wave velocity (CFPWV); and Cluster 3-lower CFPWV, C-reactive protein, fat volumes, and higher lung function; all false discovery rate<5%]. Cluster membership provided incremental variance explained (adjusted R2 increment of 0.10 in women and men, P<0.0001 for both) when compared with peak VO2 alone in association with predicted HF risk. Integrated CPET response patterns identify physiologically relevant profiles with distinct associations to subclinical phenotypes that are largely independent of standard risk factor-based assessment, which may suggest alternate pathways for prevention.

Differences In Cardiopulmonary Exercise Testing Responses Between Patients With Sarcoidosis And Age-and Sex-matched Healthy Controls

Differences In Cardiopulmonary Exercise Testing Responses Between Patients With Sarcoidosis And Age-and Sex-matched Healthy Controls

Determinants of cardiopulmonary exercise test responses in hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Exercise capacity and ventilatory efficiency are often altered in hypertrophic cardiomyopathy (HCM) and several factors have been advocated as possible causes. Aim This study investigates the determinants of cardiopulmonary exercise test (CPET) prognostic markers for HCM (VO2Peak, VE/VCO2 Slope and PETCO2 apex), by considering echocardiographic and cardiac magnetic resonance (CMR) parameters. Secondly, it scopes if myocardial fibrosis at CMR leads to clinical and functional differences. Methods 64 patients with HCM underwent a clinical assessment, including maximal CPET, echocardiography, and CMR. Exclusion criteria were the corrective surgery for cardiac hypertrophy and heart failure stage. Results The study included 66% males, age 40±17 years, NYHA class I or II 91%. Mean left ventricle (LV) ejection fraction was 63,8±7,7%, with a mean LV maximal wall thickness (MVT) of 20,2±5,6 mm; LVOT gradient was &amp;gt;30mmHg in 14% of patients. Late gadolinium enhancement (LGE) was described in 70,3% of cases with a mean LGE extension on bullseye plot of 11%. 39% of patients had a VO2 peak &amp;lt;80% of predicted, 35% a reduced PETCO2 apex and 26% an increased VE/VCO2 Slope. At the stepwise multivariate analysis, age (β=-0,33; p=0,00), BMI (β=-0,80; p=0,002), systolic blood pressure increase (β=0,22; p=0,02), left atrial volume (β=-0,15; p=0,02) and BB therapy (β=-0,45; p=0,00) were independently associated with VO2 peak (R2-adjusted index 0,95). Concerning ventilatory efficiency, sex (β=-0,41; p=0,03), left atrial volume (β=0,46; p=0,01) and LGE extension (β=0,33; p=0,01) were independently associated with VE/VCO2 Slope (R2-adjusted index 0,46). Similar data, with reversed correlations, emerged for PETCO2 apex. Patients with LGE had a LV mass index (mean 104,6 vs 82,7 g/m2, p=0,04), MWT (mean 21,8 vs 16,2 mm, p=0,00) and diastolic function (mean E/e’ 13,4 vs 10,0, p=0,01) worse that the counterpart. No differences were found in sex, age, therapy, CPET parameters and arrhythmic burden. BB+ patients were older, had more LV hypertrophy, worse diastolic parameters, and functional capacity while ventilatory efficiency was similar. Conclusions This study supports previous data about VO2 peak determinants. The correlation between the extension of the LGE and ventilatory efficiency in patients with HCM is an original finding. It confirms the pathophysiological explanation of a lung ventilation/perfusion mismatch due to the increased left atrium pressure that is secondary to a more severe LV diastolic disfunction in patients with LGE. The reduced VO2 in BB+ compared to BB- patients is not inferable given the different age and severity of disease. Moreover, the negative chronotropic effect of BB during exercise prolongs the diastolic filling time, thus, improving stroke volume and alleviating the LV filling pressures, thus normalising, in the less advanced stages of pathology, the ventilatory efficiency in HCM patients.

P295 EXERCISE OXYGEN KINETIC IN HYPERTROPHIC CARDIOMYOPATHY: RESULTS FROM A MULTICENTER CARDIOPULMONARY EXERCISE TESTING STUDY

Abstract Aims Reduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). We evaluated the cardiopulmonary exercise testing (CPET) response in HCM focusing on parameters strongly associated with stroke volume (SV) and cardiac output (CO), such as oxygen uptake (VO2) and O2–pulse, considering both their absolute values and temporal behavior during physical exercise. Methods and Results We enrolled 312 non–end stage HCM patients, divided according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva maneuver (72% with LVOTO&amp;lt;30; 10% between 30 and 49 and 18% ≥ 50mmHg). Peak VO2 (percent of predicted), O2–pulse and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety–six (31%) HCM patients presented an abnormal O2–pulse temporal behavior, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106±45 vs. 130±49W), VO2 (74±17 vs. 80±20%) and O2–pulse (12 [9–14] vs. 14 [11–17]ml/beat), with higher VE/VCO2 slope (28 [25–31] vs. 27 [24–31]) (p &amp;lt; 0.005 for all). Only 2 patients had an abnormal VO2/work slope. Conclusion None of CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal O2–pulse exercise behavior, which is strongly related to inadequate SV during exercise, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, helping identifying more advanced disease irrespectively of LVOTO. Adding O2–pulse kinetics evaluation to standard CPET could lead to a potential incremental benefit in terms of HCM prognostic stratification and, then, therapeutic management.

Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy

ObjectivesReduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). Absolute value and temporal behaviour of O2-pulse (oxygen uptake/heart rate (VO2/HR)), and the VO2/work relationship...

53 Exercise oxygen kinetic in hypertrophic cardiomyopathy: results from a multicentre cardiopulmonary exercise testing study

Abstract Aims Reduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). We evaluated the cardiopulmonary exercise testing (CPET) response in HCM focusing on parameters strongly associated with stroke volume (SV) and cardiac output (CO), such as oxygen uptake (VO2) and O2-pulse, considering both their absolute values and temporal behaviour during physical exercise. Methods and results We enrolled 312 non-end stage HCM patients, divided according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuver (72% with LVOTO &amp;lt; 30; 10% between 30 and 49; and 18% ≥50 mmHg). Peak VO2 (percent of predicted), O2-pulse, and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety-six (31%) HCM patients presented an abnormal O2-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106 ± 45 vs. 130 ± 49 W), VO2 (74 ± 17% vs. 80 ± 20%) and O2-pulse (12 [9–14] vs. 14 [11–17]ml/beat), with higher VE/VCO2 slope (28 [25–31] vs. 27 [24–31]) (P &amp;lt; 0.005 for all). Only two patients had an abnormal VO2/work slope. Conclusions None of CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal O2-pulse exercise behaviour, which is strongly related to inadequate SV during exercise, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, helping identifying more advanced disease irrespectively of LVOTO. Adding O2-pulse kinetics evaluation to standard CPET could lead to a potential incremental benefit in terms of HCM prognostic stratification and, then, therapeutic management.

347 From arterial hypertension to left ventricular hypertrophy and heart failure: role of cardiopulmonary exercise testing in heart failure with preserved ejection fraction

Abstract Aims Arterial hypertension (AHT) represents the leading cause of heart failure (HF). A complex cardiovascular (CV) continuum of events leads to the progression from AHT to left ventricular hypertrophy (LVH), the hallmark of hypertensive heart (HH), towards heart failure with preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF). Cardiopulmonary exercise testing (CPET) represents an important tool to evaluate HF patients (both with HFpEF and HFrEF) allowing quantification of functional capacity and mechanisms of dyspnoea as well as providing prognostic markers. To investigate CPET responses in AHT patients at various stages of disease progression from AHT to LVH and HF with preserved and reduced ejection fraction. Methods and results From a CPET registry of 1.397 consecutive subjects, 92 patients were selected (matched according to age, gender, BMI, CV risk factors, beta-blockers) and divided into four groups: 23 AHT patients without LVH, 23 HH patients, 23 HFpEF patients and 23 HFrEF. HFrEF were defined according to LV-EF values while HFpEF were defined according to the presence of NYHA Class ≥2 and HFA-PEFF Score. Mean age was 65 ± 10 years, mean BMI was 28.5 ± 5, male gender was prevalent 83% and 33% had diabetes. Both HFpEF and HFrEF showed lower cardiorespiratory fitness (peak VO2; P &amp;lt; 0.001), cardiovascular efficiency (VO2/Watt slope: P &amp;lt; 0.001), oxygen pulse (VO2/HR: P &amp;lt; 0.001), cardiac output (P &amp;lt; 0.001) and stroke volume (P &amp;lt; 0.001) at peak as well as lower chronotropic response (P &amp;lt; 0.001), ventilatory efficiency (VE/VCO2 slope: P &amp;lt; 0.001), and heart rate recovery (HRR: P = 0.004) compared with both AHT and HH groups. Interestingly, no differences between HFpEF and HFrEF have been found in all CPET data except for chronotropic response (using Tanaka equation), lower in HFpEF (37.5 ± 16.5 vs. 53.5 ± 20.5; P &amp;lt; 0.001) and ventilatory efficiency, lower in HFrEF (VE/VCO2 slope: 32 ± 5 vs. 37 ± 10; P &amp;lt; 0.001). Finally, adding functional capacity (peak VO2) data to ESC Criteria an improvement in HFpEF diagnosis accuracy was found, with 82% sensitivity and 90% specificity (AUC: 859—95% CI: 754–963; P &amp;lt; 0.0001). Conclusions Despite the intrinsic differences in ejection fraction, both HFpEF and HFrEF shares similar cardiopulmonary mechanisms and cardiovascular responses to exercise. CPET may represent a useful tool in order to identify and stratify hypertensive heart patients with HFpEF with high diagnostic accuracy.

Cardiopulmonary Exercise Test Responses Are Related To Aortic Stiffness

Cardiopulmonary Exercise Test Responses Are Related To Aortic Stiffness

Cardiopulmonary assessment of patients diagnosed with Gaucher's disease type I.

BackgroundUnderstanding the basis of the phenotypic variation in Gaucher's disease (GD) has proven to be challenging for efficient treatment. The current study examined cardiopulmonary characteristics of patients with GD type 1.MethodsTwenty Caucasian subjects (8/20 female) with diagnosed GD type I (GD‐S) and 20 age‐ and sex‐matched healthy controls (C), were assessed (mean age GD‐S: 32.6 ± 13.1 vs. C: 36.2 ± 10.6, p > .05) before the initiation of treatment. Standard echocardiography at rest was used to assess left ventricular ejection fraction (LVEF) and pulmonary artery systolic pressure (PASP). Cardiopulmonary exercise testing (CPET) was performed on a recumbent ergometer using a ramp protocol.ResultsLVEF was similar in both groups (GD‐S: 65.1 ± 5.2% vs. C: 65.2 ± 5.2%, p > .05), as well as PAPS (24.1 ± 4.2 mmHg vs. C: 25.5 ± 1.3 mmHg, p > .05). GD‐S had lower weight (p < .05) and worse CPET responses compared to C, including peak values of heart rate, oxygen consumption, carbondioxide production (VCO2), end‐tidal pressure of CO2, and O2 pulse, as well as HR reserve after 3 min of recovery and the minute ventilation/VCO2 slope.ConclusionsPatients with GD type I have an abnormal CPET response compared to healthy controls likely due to the complex pathophysiologic process in GD that impacts multiple systems integral to the physiologic response to exercise.

Deconditioning does not explain orthostatic intolerance in ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome)

BackgroundOrthostatic intolerance (OI) is a frequent finding in individuals with myalgic encephalomyelitis /chronic fatigue syndrome (ME/CFS). Published studies have proposed that deconditioning is an important pathophysiological mechanism in various forms of OI, including postural orthostatic tachycardia syndrome (POTS), however conflicting opinions exist. Deconditioning can be classified objectively using the predicted peak oxygen consumption (VO2) values from cardiopulmonary exercise testing (CPET). Therefore, if deconditioning is an important contributor to OI symptomatology, one would expect a relation between the degree of reduction in peak VO2during CPET and the degree of reduction in CBF during head-up tilt testing (HUT).Methods and resultsIn 22 healthy controls and 199 ME/CFS patients were included. Deconditioning was classified by the CPET response as follows: %peak VO2 ≥ 85% = no deconditioning, %peak VO2 65–85% = mild deconditioning, and %peak VO2 < 65% = severe deconditioning. HC had higher oxygen consumption at the ventilatory threshold and at peak exercise as compared to ME/CFS patients (p ranging between 0.001 and < 0.0001). Although ME/CFS patients had significantly greater CBF reduction than HC (p < 0.0001), there were no differences in CBF reduction among ME/CFS patients with no, mild, or severe deconditioning. We classified the hemodynamic response to HUT into three categories: those with a normal heart rate and blood pressure response, postural orthostatic tachycardia syndrome, or orthostatic hypotension. No difference in the degree of CBF reduction was shown in those three groups.ConclusionThis study shows that in ME/CFS patients orthostatic intolerance is not caused by deconditioning as defined on cardiopulmonary exercise testing. An abnormal high decline in cerebral blood flow during orthostatic stress was present in all ME/CFS patients regardless of their %peak VO2 results on cardiopulmonary exercise testing.

L-Arginine Improves Endurance to High-Intensity Interval Exercises in Overweight Men.

The effects of acute consumption of L-Arginine (L-Arg) in healthy young individuals are not clearly defined, and no studies on the effects of L-Arg in individuals with abnormal body mass index undertaking strenuous exercise exist. Thus, we examined whether supplementation with L-Arg diminishes cardiopulmonary exercise testing responses, such as ventilation (VE), VE/VCO2, oxygen uptake (VO2), and heart rate, in response to an acute session of high-intensity interval exercise (HIIE) in overweight men. A double-blind, randomized crossover design was used to study 30 overweight men (age, 26.5 ± 2.2years; body weight, 88.2 ± 5.3kilogram; body mass index, 28.0 ± 1.4kg/m2). Participants first completed a ramped-treadmill exercise protocol to determine VO2max velocity (vVO2max), after which they participated in two sessions of HIIE. Participants were randomly assigned to receive either 6g of L-Arg or placebo supplements. The HIIE treadmill running protocol consisted of 12 trials, including exercise at 100% of vVO2max for 1min interspersed with recovery intervals of 40% of vVO2max for 2min. Measurements of VO2 (ml·kg-1·min-1), VE (L/min), heart rate (beat per min), and VE/VCO2 were obtained. Supplementation with L-Arg significantly decreased all cardiorespiratory responses during HIIE (placebo+HIIE vs. L-Arg+HIIE for each measurement: VE [80.9 ± 4.3L/min vs. 74.6 ± 3.5L/min, p < .05, ES = 1.61], VE/VCO2 [26.4 ± 1.3 vs. 24.4 ± 1.0, p < .05, ES = 1.8], VO2 [26.4 ± 0.8ml·kg-1·min-1 vs. 24.4 ± 0.9ml·kg-1·min-1, p < .05, ES = 2.2], and heart rate [159.7 ± 6.3beats/min vs. 155.0 ± 3.7beats/min, p < .05, d = 0.89]). The authors conclude consuming L-Arg before HIIE can alleviate the excessive physiological strain resulting from HIIE and help to increase exercise tolerance in participants with a higher body mass index who may need to exercise on a regular basis for extended periods to improve their health.

Normative Cardiopulmonary Exercise Test Responses at the Ventilatory Threshold in Canadian Adults 40 to 80 Years of Age

Physiologic and symptom responses at the ventilatory threshold (Tvent) during incremental cardiopulmonary exercise testing (CPET) can provide important prognostic information. This study aimed to develop an updated normative reference set for physiologic and symptom responses at Tvent during cycle CPET (primary aim) and to evaluate previously recommended reference equations from a 1985 study for predicting Tvent responses (secondary aim). Participants were adults 40 to 80 years of age who were free of clinically relevant disease from the Canadian Cohort Obstructive Lung Disease. Rate of oxygen consumption (V˙O2) at Tvent was identified by two independent raters; physiologic and symptom responses corresponding to V˙O2 at Tvent were identified by linear interpolation. Reference ranges (5th-95th percentiles) for responses at Tvent were calculated according to participant sex and age for 29 and eight variables, respectively. Prediction models were developed for nine variables (oxygen pulse, V˙O2, rate of CO2 production, minute ventilation, tidal volume, inspiratory capacity, end-inspiratory lung volume [in liters and as percentage of total lung capacity], and end-expiratory lung volume) using quantile regression, estimating the 5th (lower limit of normal), 50th (normal), and 95th (upper limit of normal) percentiles based on readily available participant characteristics. The two one-sided test of equivalence for paired samples evaluated the measured and 1985-predicted V˙O2 at Tvent for equivalence. Reference ranges and equations were developed based on 96 participants (49%men) with a mean ± SD age of 63 ± 9 years. Mean V˙O2 at Tvent was 50%of measured V˙O2 peak; the normal range was 33%to 66%. The 1985 reference equations overpredicted V˙O2 at Tvent: mean difference in men, -0.17 L/min (95%CI, -0.25 to -0.09 L/min); mean difference in women, -0.19 L/min (95%CI, -0.27 to -0.12 L/min). A contemporary reference set of CPET responses at Tvent from Canadian adults 40 to 80 years of age is presented that differs from the previously recommended and often used reference set from1985. ClinicalTrials.gov; No.: NCT00920348; URL: www.clinicaltrials.gov.

Identification of Subclinical Lung Involvement in ACPA-Positive Subjects through Functional Assessment and Serum Biomarkers.

Lung involvement is related to the natural history of anti-citrullinated proteins antibodies (ACPA)-positive rheumatoid arthritis (RA), both during the pathogenesis of the disease and as a site of disease-related injury. Increasing evidence suggests that there is a subclinical, early lung involvement during the course of the disease, even before the onset of articular manifestations, which can potentially progress to a symptomatic interstitial lung disease. To date, reliable, non-invasive markers of subclinical lung involvement are still lacking in clinical practice. The aim of this study is to evaluate the diagnostic potential of functional assessment and serum biomarkers in the identification of subclinical lung involvement in ACPA-positive subjects. Fifty ACPA-positive subjects with or without confirmed diagnosis of RA (2010 ARC-EULAR criteria) were consecutively enrolled. Each subject underwent clinical evaluation, pulmonary function testing (PFT) with assessment of diffusion lung capacity for carbon monoxide (DLCO), cardiopulmonary exercise testing (CPET), surfactant protein D (SPD) serum levels dosage and high-resolution computed tomography (HRCT) of the chest. The cohort was composed of 21 ACPA-positive subjects without arthritis (ND), 10 early (disease duration < 6 months, treatment-naïve) RA (ERA) and 17 long-standing (disease duration < 36 months, on treatment) RA (LSRA). LSRA patients had a significantly higher frequency of overall HRCT abnormalities compared to the other groups (p = 0.001). SPD serum levels were significantly higher in ACPA-positive subjects compared with healthy controls (158.5 ± 132.3 ng/mL vs 61.27 ± 34.11 ng/mL; p < 0.0001) and showed an increasing trend from ND subjects to LSRD patients (p = 0.004). Patients with HRCT abnormalities showed significantly lower values of DLCO (74.19 ± 13.2% pred. vs 131.7 ± 93% pred.; p = 0.009), evidence of ventilatory inefficiency at CPET and significantly higher SPD serum levels compared with subjects with no HRCT abnormalities (213.5 ± 157.2 ng/mL vs 117.7 ± 157.3 ng/mL; p = 0.018). Abnormal CPET responses and higher SPD levels were also associated with specific radiological findings. Impaired DLCO and increased SPD serum levels were independently associated with the presence of HRCT abnormalities. Subclinical lung abnormalities occur early in RA-associated autoimmunity. The presence of subclinical HRCT abnormalities is associated with several functional abnormalities and increased SPD serum levels of SPD. Functional evaluation through PFT and CPET, together with SPD assessment, may have a diagnostic potential in ACPA-positive subjects, contributing to the identification of those patients to be referred to HRCT scan.

Normative Peak Cardiopulmonary Exercise Test Responses in Canadian Adults Aged ≥40 Years

Up-to-date normative reference sets for cardiopulmonary exercise testing (CPET) are important to aid in the accurate interpretation of CPET in clinical or research settings. This study aimed to (1) develop and externally validate a contemporary reference set for peak CPET responses in Canadian adults identified with population-based sampling; and (2) evaluate previously recommended reference equations for predicting peak CPET responses. Participants were healthy adults who were≥40 years old from the Canadian Cohort Obstructive Lung Disease who completed an incremental cycle CPET. Prediction models for peak CPET responses were estimated from readily available participant characteristics (age, sex, height, body mass) with the use of quantile regression. External validation was performed with a second convenience sample of healthy adults. Peak CPET parameters that were measured and predicted in the validation cohort were assessed for equivalence (two one-sided tests of equivalence for paired-samples and level of agreement (Bland-Altman analyses). Two one-sided tests of equivalence for paired samples assessed differences between responses in the derivation cohort using previously recommended reference equations. Normative reference ranges (5th-95th percentiles) for 28 peak CPET parameters and prediction models for 8 peak CPET parameters were based on 173 participants (47%male) who were 64 ± 10 years old. In the validation cohort (n= 84), peak CPET responses that were predicted with the newly generated models were equivalent to the measured values. Peak cardiac parameters predicted by the previously recommended reference equations by Jones and colleagues and Hansen and colleagues were significantly higher. This study provides reference ranges and prediction models for peak cardiac, ventilatory, operating lung volume, gas exchange, and symptom responses to incremental CPET and presents the most comprehensive reference set to date in Canadian adults who were≥40 years old to be identified with population-based sampling.

Study protocol of a single-arm pre-post study to assess the preliminary effectiveness and feasibility of a home-based bimodal prehabilitation program on preoperative aerobic fitness in high-risk patients scheduled for liver or pancreatic resection

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Controversial evidence currently exists regarding the feasibility and effectiveness to improve preoperative aerobic fitness during home-based prehabilitation in patients scheduled for liver or pancreatic resection, whereas morbidity rates are high following these resections. The primary aim of this study is to evaluate the preoperative oxygen uptake (VO&lt;sub&gt;2&lt;/sub&gt;) at the ventilatory anaerobic threshold before and after a four-week home-based preoperative training program with nutritional supplementation in high-risk patients scheduled for elective liver or pancreatic resection. Secondary aims are to evaluate program feasibility, immune system function, cardiopulmonary exercise test responses, individual progression profiles on training responses, quality of life, and postoperative course.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this multicenter study with a pretest-posttest design, patients with a liver or pancreatic tumor scheduled for elective resection will be recruited. To select the high-risk fraction of this surgical population, their VO&lt;sub&gt;2&lt;/sub&gt; at the ventilatory anaerobic threshold should be &amp;lt;11 ml/kg/min for final inclusion. A planned total of 24 high-risk patients will participate in a four-week (three sessions per week) home-based bimodal prehabilitation program. The partly supervised home-based preoperative training program consists of individualized goal setting followed by titration of interval and endurance training on an advanced cycle ergometer, combined with functional task exercises. Additionally, patients will be given protein and vitamin/mineral supplementation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Discussion: &lt;/strong&gt;Effects of a partly supervised home-based bimodal prehabilitation regimen are unknown in high-risk patients opting for liver or pancreatic resection. Improved preoperative aerobic fitness might translate into improved postoperative outcomes and a reduced demand on care resources.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Trial Registration:&lt;/strong&gt; The study is registered in the Netherlands Trial Registry (NL6151) and was approved by the Institutional Ethics Committee, Twente, Enschede, the Netherlands (P17-08).&lt;/p&gt;

The Value of Cardiopulmonary Exercise Testing in Determining Severity in Patients with both Systolic Heart Failure and COPD

Our aim was to identify optimal cardiopulmonary exercise testing (CPET) threshold values that distinguish disease severity progression in patients with co-existing systolic heart failure (HF) and chronic obstructive pulmonary disease (COPD), and to evaluate the impact of the cut-off determined on the prognosis of hospitalizations. We evaluated 40 patients (30 men and 10 woman) with HF and COPD through pulmonary function testing, doppler echocardiography and maximal incremental CPET on a cycle ergometer. Several significant CPET threshold values were identified in detecting a forced expiratory volume in 1 second (FEV1) < 1.6 L: 1) oxygen uptake efficiency slope (OUES) < 1.3; and 2) circulatory power (CP) < 2383 mmHg.mlO2.kg−1. CPET significant threshold values in identifying a left ventricular ejection fraction (LVEF) < 39% were: 1) OUES: < 1.3; 2) CP < 2116 mmHg.mlO2.kg−1.min−1 and minute ventilation/carbon dioxide production (V̇E/V̇CO2) slope>38. The 15 (38%) patients hospitalized during follow-up (8 ± 2 months). In the hospitalizations analysis, LVEF < 39% and FEV1 < 1.6, OUES < 1.3, CP < 2116 mmHg.mlO2.kg−1.min−1 and V̇E/V̇CO2 > 38 were a strong risk predictor for hospitalization (P ≤ 0.050). The CPET response effectively identified worsening disease severity in patients with a HF-COPD phenotype. LVEF, FEV1, CP, OUES, and the V̇E/V̇CO2 slope may be particularly useful in the clinical assessment and strong risk predictor for hospitalization.

Cardiopulmonary Exercise Testing, Impedance Cardiography, and Reclassification of Risk in Patients Referred for Heart Failure Evaluation

An impaired cardiac output response to exercise is a hallmark of chronic heart failure (HF). We determined the extent to which impedance cardiography (ICG) during exercise in combination with cardiopulmonary exercise test (CPX) responses reclassified risk for adverse events in patients with HF. CPX and ICG were performed in 1236 consecutive patients (48±15 years) evaluated for HF. Clinical, ICG and CPX variables were acquired at baseline and subjects were followed for the composite outcome of cardiac-related death, hospitalization for worsening HF, cardiac transplantation, and left ventricular assist device implantation. Cox proportional hazards analyses including clinical, noninvasive hemodynamic, and CPX variables were performed to determine their association with the composite endpoint. Net reclassification improvement (NRI) was calculated to quantify the impact of adding hemodynamic responses to a model including established CPX risk markers on reclassifying risk. There were 422 events. Among CPX variables, peak VO2 and indices of ventilatory inefficiency (VE/VCO2 slope, oxygen uptake efficiency slope) were significant predictors of risk for adverse events. Among hemodynamic variables, change in cardiac index, peak cardiac time interval, and peak left cardiac work index were the strongest predictors of risk. Having 5 impaired CPX and ICG responses to exercise yielded a sevenfold higher risk for adverse events compared with having no abnormal responses. Combining ICG responses to CPX resulted in NRIs ranging between 0.34 and 0.89, attributable to better reclassification of events. Cardiac hemodynamics determined by ICG complement established CPX measures in reclassifying risk among patients with HF.

Quantification of coronary artery disease using different modalities of cardiopulmonary exercise testing

BackgroundThis study examined the accuracy of cardiopulmonary exercise testing (CPET) on a treadmill (TM) and recumbent ergometry (RE) in the predicting coronary artery disease (CAD) severity and prognosis. MethodsForty Caucasian subjects, mean age 63.5 ± 7.6, with significant coronary artery lesions (≥50%) were included. Within two months of coronary angiography, TM and RE CPET were performed on two visits 2–4 days apart and subsequently followed up to 32 ± 10 months. ResultsMean left ventricular ejection fraction was 56.7 ± 9.6%. TM CPET exhibited a higher occurrence of ST segment depression ≥ 1 mm (71.05% vs 28.95%, p = 0.04). Subjects with 1–2 stenotic coronary arteries (SCA) demonstrated a better CPET response compared to those with 3-SCA. ROC analysis revealed a high predictive value for the ventilation/carbon dioxide production (VE/VCO2) slope obtained on TM (area 0.84, p = 0.003, Sn 88.9%, Sp 72%) in distinguishing between 1 and 2-SCA and 3-SCA. Among all CPET parameters, work efficiency (∆VO2/∆WR) during RE predicted cumulative cardiac events (p < 0.01). ConclusionsCPET parameters hold predictive value for CAD severity and prognosis. CPET on a TM appears to be more reliable in the quantification of CAD compared to RE.

Peak Blood Pressure Responses During Maximum Cardiopulmonary Exercise Testing

The objective of this study is to expand on previous efforts in establishing normative standards of exercising blood pressure (BP) at maximal physical exertion derived from treadmill cardiopulmonary exercise testing in the United States. Four experienced laboratories in the United States with established quality control procedures contributed data from September 1, 1986, to February 1, 2015. A total of 2917 maximal (peak respiratory exchange ratio ≥1.00) treadmill cardiopulmonary exercise testing responses from apparently healthy men and women (aged 20–79 years) without cardiovascular disease were submitted to FRIEND (Fitness Registry and the Importance of Exercise: A National Database). Percentiles of maximal systolic and diastolic BP were determined for each decade. Our results show a continued increase in peak systolic BP with age in both men and women to the sixth decade, followed by a plateau between the sixth and seventh decades. However, the trajectory of peak diastolic BP with age is different between men and women. Men showed an increase in peak systolic BP until the fifth decade, which plateaued by the seventh decade. In contrast, women showed a continued increase in peak diastolic BP across each decade. Existing reference data for exercising BP have not been updated for &gt;20 years. Normative peak exercising BP values from FRIEND can be used to provide a more current representation of maximal BP during exercise testing in the US population.

Association of Oscillatory Ventilation during Cardiopulmonary Test to Clinical and Functional Variables of Chronic Heart Failure Patients.

ObjectiveThe aim of this study is to characterize the presence of exercise oscillatory ventilation (EOV) and to relate it with other cardiopulmonary exercise test (CET) responses and clinical variables.MethodsForty-six male patients (age: 53.1±13.6 years old; left ventricular ejection fraction [LVEF]: 30±8%) with heart failure were recruited to perform a maximal CET and to correlate the CET responses with clinical variables. The EOV was obtained according to Leite et al. criteria and VE/VCO2 > 34 and peak VO2 < 14 ml/kg/min were used to assess patients' severity.ResultsThe EOV was observed in 16 of 24 patients who performed the CET, as well as VE/VCO2 > 34 and peak VO2 < 14 ml/kg/min in 14 and 10 patients, respectively. There was no difference in clinical and CET variables of the patients who presented EOV in CET when compared to non-EOV patients. Also, there was no difference in CET and clinical variables when comparing patients who presented EOV and had a VE/VCO2 slope > 34 to patients who just had one of these responses either.ConclusionThe present study showed that there was an incidence of patients with EOV and lower peak VO2 and higher VE/VCO2 slope values, but they showed no difference on other prognostic variables. As well, there was no influence of the presence of EOV on other parameters of CET in this population, suggesting that this variable may be an independent marker of worst prognosis in HF patients.