Cardiopulmonary Exercise Testing In Patients Research Articles

Diastolic Dysfunction Is Associated with Impaired Cardiopulmonary Exercise Performance in Sickle Cell Disease

▪Background:Left ventricular diastolic dysfunction is associated with increased mortality in sickle cell disease (SCD). Diffuse myocardial fibrosis is common in patients with SCD and is associated with diastolic dysfunction. Measurement of functional capacity by cardiopulmonary exercise test (CPET) has prognostic value in several cardiac diseases. Exercise impairment is common in SCD, but the causes and correlates are not well understood. Diastolic dysfunction is associated with a shorter 6-minute walk distance in SCD, but the effect of diastolic dysfunction and myocardial fibrosis on CPET has not been studied before.Methods:As part of a prospective study to characterize the cardiomyopathy of SCD (NCT02410811), children and adults with SCD underwent cardiac MRI (CMR), echocardiography and cycle ergometer CPET. Diffuse myocardial fibrosis was assessed by CMR-based measurement of extracellular volume fraction (ECV) from pre- and post-gadolinium T1 maps. Cardiac chamber sizes and cardiac performance were evaluated using CMR, and diastolic parameters were measured by echocardiography. Patients were classified to have diastolic dysfunction if they had left atrial enlargement and abnormalities in two diastolic parameters (E/e' ratio and e'). The following measures were recorded during CPET: percent predicted VO2 at maximum exercise (VO2 max) and ventilation efficiency (VE/VCO2 slope at maximum exercise (VE/VCO2 max). Reduced exercise capacity was defined by VO2 max <80% and classified as mild (VO2max 60-80%) or moderate to severe (VO2 max <60%).Results:Fifteen patients with SCD have completed the study (age range 8-38 years). No adverse events were reported within one month of CPET. Only one patient did not reach maximum exercise due to muscular fatigue. Fourteen patients (93%) had reduced exercise capacity; four of them (28%) had mild impairment and 10 (71%) had moderate to severe impairment. Four patients had diastolic dysfunction and none had systolic dysfunction. Patients with diastolic dysfunction had lower exercise capacity compared to patients with normal diastolic function as measured by lower VO2 max (46.6 ± 5.9% vs 59.2 ± 11.5%; p=0.02). The z-score of the left ventricular lateral E/e' ratio, a diastolic measure that reflects left ventricular filling pressure, negatively correlated with the maximal exercise capacity VO2 max (r=-0.57, p=0.02) and positively with worse ventilation efficiency measured by VE/VCO2 max (r=0.61, p=0.01), indicating an association between diastolic dysfunction and worse exercise performance. We did not find an association between ECV and exercise capacity. Hemoglobin concentration was moderately associated with VO2 max (r=0.37) but this association was not statistically significance (p=0.09).Conclusion:Diastolic dysfunction is associated with poor exercise capacity assessed by CPET in patients with SCD. Myocardial diastolic dysfunction may be one of the causes of impaired exercise capacity in SCD. Strategies to prevent or delay the acquisition of diastolic dysfunction to improve exercise capacity and long-term outcomes in SCD should be explored. DisclosuresQuinn:Global Blood Therapeutics: Research Funding.

ASO Author Reflections: The Importance of the Preoperative Cardiopulmonary Exercise Test in Patients Undergoing Cancer Surgery.

ASO Author Reflections: The Importance of the Preoperative Cardiopulmonary Exercise Test in Patients Undergoing Cancer Surgery.

Cardiopulmonary Exercise Test in Patients with Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis

Background: Patients with chronic diseases frequently adapt their lifestyles to their functional limitations. Functional capacity in Hypertrophic Cardiomyopathy (HCM) can be assessed by stress testing. We aim to review and analyze the available data from the literature on the value of Cardiopulmonary Exercise Test (CPET) in HCM. Objective measurements from CPET are used for evaluation of patient response to traditional and new developing therapeutic measurements. Methods: A systematic review of the literature was conducted in PubMed, Web of Science and Cochrane in Mar-20. The original search yielded 2628 results. One hundred and two full texts were read after the first screening, of which, 69 were included for qualitative synthesis. Relevant variables to be included in the review were set and 17 were selected, including comorbidities, body mass index (BMI), cardiac-related symptoms, echocardiographic variables, medications and outcomes. Results: Study sample consisted of 69 research articles, including 11,672 patients (48 ± 14 years old, 65.9%/34.1% men/women). Treadmill was the most common instrument employed (n = 37 studies), followed by upright cycle-ergometer (n = 16 studies). Mean maximal oxygen consumption (VO2max) was 22.3 ± 3.8 mL·kg−1·min−1. The highest average values were observed in supine and upright cycle-ergometer (25.3 ± 6.5 and 24.8 ± 9.1 mL·kg−1·min−1; respectively). Oxygen consumption in the anaerobic threshold (ATVO2) was reported in 18 publications. Left ventricular outflow tract gradient (LVOT) > 30 mmHg was present at baseline in 31.4% of cases. It increased to 49% during exercise. Proportion of abnormal blood pressure response (ABPRE) was higher in severe (>20 mm) vs. mild hypertrophy groups (17.9% vs. 13.6%, p < 0.001). Mean VO2max was not significantly different between severe vs. milder hypertrophy, or for obstructive vs. non-obstructive groups. Occurrence of arrhythmias during functional assessment was higher among younger adults (5.42% vs. 1.69% in older adults, p < 0.001). Twenty-three publications (9145 patients) evaluated the prognostic value of exercise capacity. There were 8.5% total deaths, 6.7% cardiovascular deaths, 3.0% sudden cardiac deaths (SCD), 1.2% heart failure death, 0.6% resuscitated cardiac arrests, 1.1% transplants, 2.6% implantable cardioverter defibrillator (ICD) therapies and 1.2 strokes (mean follow-up: 3.81 ± 2.77 years). VO2max, ATVO2, METs, % of age-gender predicted VO2max, % of age-gender predicted METs, ABPRE and ventricular arrhythmias were significantly associated with major outcomes individually. Mean VO2max was reduced in patients who reached the combined cardiovascular death outcome compared to those who survived (−6.20 mL·kg−1·min−1; CI 95%: −7.95, −4.46; p < 0.01). Conclusions: CPET is a valuable tool and can safely perform for assessment of physical functional capacity in patients with HCM. VO2max is the most common performance measurement evaluated in functional studies, showing higher values in those based on cycle-ergometer compared to treadmill. Subgroup analysis shows that exercise intolerance seems to be more related to age, medication and comorbidities than HCM phenotype itself. Lower VO2max is consistently seen in HCM patients at major cardiovascular risk.

Assessment for cardiovascular fitness in patients with stroke: which cardiopulmonary exercise testing method is better?

ABSTRACT Background: Assessment for cardiovascular disease (CVD) is important in stroke patients, both being one of the main factors limiting success in stroke rehabilitation and its increased risk in stroke patients. Reduced exercise capacity after stroke decreases patients’ functionality and further increases the risk of CVD. Carefully selected cardiopulmonary exercise testing (CPET) can be safely used to determine the risk of CVD and to prescribe exercise program in stroke rehabilitation. Objectives: The primary purpose of this study is to determine the most appropriate CPET in patients with stroke. The secondary aim is to determine the relationship between cardiorespiratory fitness and functional status of the patients. Methods: Two CPETs using treadmill and bicycle ergometer protocols determined with a preliminary study were performed on participants. The main outcome measure was VO2peak. Patients were also evaluated according to Brunnstrom motor staging, Modified Ashworth Scale, Berg Balance Scale, and Functional Independence Measure. Results: In total, 38 patients reached higher VO2peak values at treadmill test compared to bicycle test (p < 0.001). The mean VO2peak reached at treadmill CPET was 62% of the control group where mean VO2peak reached at bicycle was 76% of the control group. No significant correlation was found between Brunnstrom staging, spasticity, Berg Balance Scale, and VO2peak . Discussion: The results of this study indicate that CPET can be performed safely in stroke patients when appropriate protocol was selected and that treadmill was more appropriate to determine cardiorespiratory fitness in this study population.

Cardiopulmonary exercise testing in patients with Cardiac Amyloidosis

BackgroundCardiac involvement and dysfunction are common in patients presenting with AL and ATTR Amyloidosis. Cardiopulmonary exercise testing (CPET) performance is the gold standard to quantify functional capacity. Patients and MethodsIn this study, we evaluated CPET measurements in 41 patients with cardiac Amyloidosis and their correlation with current amyloid specific staging criteria. ResultsIn both AL and ATTR cardiac Amyloidosis, percent predicted peak VO2 is significantly reduced and correlates with biomarker abnormalities. The association of cardiac biomarkers with peak VO2 is stronger for AL Amyloidosis (NT-proBNP (r = −0.57, P=0.006), Troponin (r = −0.70, p < 0.001) than ATTR (NT-proBNP (r = −0.4, P = 0.04) and Troponin (r = −0.57, P = 0.002) despite lower left ventricular mass in the former, suggesting that this may be further evidence for light chain toxicity in AL amyloidosis. ConclusionOur findings suggest further evidence for AL toxicity.

Effects of resistance training on metabolic and cardiovascular responses to a maximal cardiopulmonary exercise test in Parkinson`s disease.

ABSTRACT:Objective:To evaluate the effects of resistance training on metabolic and cardiovascular responses during maximal cardiopulmonary exercise testing in patients with Parkinson’s disease.Methods:Twenty-four patients with Parkinson’s disease (modified Hoehn and Yahr stages 2 to 3) were randomly assigned to one of two groups: Control or Resistance Training. Patients in the Resistance Training Group completed an exercise program consisting of five resistance exercises (two to four sets of six to 12 repetitions maximum per set) twice a week. Patients in the Control Group maintained their usual lifestyle. Oxygen uptake, systolic blood pressure and heart rate were assessed at rest and during cycle ergometer-based maximal cardiopulmonary exercise testing at baseline and at 12 weeks. Assessments during exercise were conducted at absolute submaximal intensity (slope of the linear regression line between physiological variables and absolute workloads), at relative submaximal intensity (anaerobic threshold and respiratory compensation point) and at maximal intensity (maximal exercise). Muscle strength was also evaluated.Results:Both groups had similar increase in peak oxygen uptake after 12 weeks of training. Heart rate and systolic blood pressure measured at absolute and relative submaximal intensities and at maximal exercise intensity did not change in any of the groups. Muscle strength increased in the Resistance Training but not in the Control Group after 12 weeks.Conclusion:Resistance training increases muscle strength but does not change metabolic and cardiovascular responses during maximal cardiopulmonary exercise testing in patients with Parkinson’s disease without cardiovascular comorbidities.

Cardiopulmonary exercise testing in patients with end-stage kidney disease: principles, methodology and clinical applications of the optimal tool for exercise tolerance evaluation.

Chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), is associated with an increased risk for cardiovascular events and all-cause mortality. Exercise intolerance as well as reduced cardiovascular reserve is extremely common in patients with CKD. Cardiopulmonary exercise testing (CPET) is a non-invasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, neuropsychological and metabolic function during maximal or submaximal exercise, allowing the evaluation of functional reserves of these systems. This assessment is based on the principle that system failure typically occurs when the system is under stress and thus CPET is currently considered to be the gold standard for identifying exercise limitation and differentiating its causes. It has been widely used in several medical fields for risk stratification, clinical evaluation and other applications, but its use in everyday practice for CKD patients is scarce. This article describes the basic principles and methodology of CPET and provides an overview of important studies that utilized CPET in patients with ESKD, in an effort to increase awareness of CPET capabilities among practicing nephrologists.

A clinical research report on the pathophysiological characteristics of exercise in patients with mitral regurgitation

Objective: Cardiopulmonary exercise testing (CPET) was used to investigate the exercise pathophysiology of mitral regurgitation. Methods: 26 patients with moderate and severe mitral regurgitation who completed standardized extreme exercise CPET under strict quality control after signing informed consent since 2016, and 11 normal subjects in the same period as the control group. The core indexes of CPET were analyzed and calculated according to the standard method and compared with normal subjects for intergroup statistical independent sample t-test. At the same time, the patients with heart failure and exercise oscillation breathing (OB) were divided into two subgroups: 11 cases without heart failure, 15 cases with heart failure, 8 cases with non-OB and 18 cases with OB, and their similarities and differences were compared between each subgroup. Results: The core indexes of CPET, such as peak oxygen uptake (85.60 ±9.06)%pred and anaerobic threshold (AT, (87.59 ±15.38)%pred) were normal. The peak oxygen uptake of CPET in patients with mitral regurgitation was (48.15 ±12.11)%pred, peak oxygen pulse was (66.57 ±12.20)%pred, AT was (56.75 ±11.50)%pred, oxygen uptake efficiency plateau was (88.24 ±16.42)%pred , lowest value of carbon dioxide ventilatory efficiency was (125.89 ±27.05)%pred and slope of carbon dioxide ventilatory efficiency was (128.31 ±31.68)%pred. Among them, only oxygen uptake efficiency plateau (OUEP) was normal and low, and the other indexes were significantly abnormal. There were significant differences between the patients and the control group (P<0.01). There was no significant difference between the non-OB group and the OB group, but there was significant difference between the non-OB group and the control group (P<0.05). There was no significant difference between the non-heart failure group and the heart failure group, but there was significant difference between the non-heart failure group and the control group. Conclusion: All the core indexes of cardiopulmonary exercise are significantly abnormal in patients with mitral regurgitation who are significantly lower than those in normal subjects except for the low effectiveness of oxygen ventilation. And with or without heart failure and OB did not affect the cardiopulmonary function.

February 2021 at a glance: focus on amyloidosis, myocarditis and cardiomyopathy

Cardiac amyloidosis (CA) is emerging as a major cause of heart failure (HF).1-3 Castiglione et al.4 reviewed the role of circulating biomarkers as tools to guide diagnosis, prognostic stratification, and therapy in CA. The independent prognostic role of cardiopulmonary exercise testing in patients with light chain or transthyretin CA (TTR-CA) was shown by Nicol et al.5 in a multicentre study. Both peak oxygen consumption (VO2) ≤13 mL/kg/min and N-terminal pro B-type natriuretic peptide (NT-proBNP) ≥1800 ng/L had independent prognostic value with a hazard ratio (HR) of 2.7 [95% confidence interval (CI) 1.6–4.8] and 2.2 (95% CI 1.1–4.3), respectively. No events occurred in patients with peak VO2 >13 mL/kg/min and NT-proBNP <1800 ng/L during a median follow-up of 20 months, despite overall 25% mortality and 29% hospitalization rates. Amyloidosis may be present in patients with severe aortic stenosis.2, 6 TTR-CA was detected in 13% of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. It had no impact on mortality but was associated with a higher HF hospitalization rate during a 3-year follow-up.3 Tafamidis has emerged as an effective treatment option to improve prognosis in patients with TTR-CA.7, 8 A single-centre study in 648 real-world patients with TTR-CA matching the inclusion criteria of the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) showed a significant benefit of tafamidis on major cardiovascular outcomes (HR after propensity score matching 0.546, P = 0.0132).9 In an analysis of the long-term extension of ATTR-ACT, both tafamidis 80 mg and 20 mg reduced all-cause mortality and cardiovascular hospitalizations at 30 months compared with placebo, with the higher dose associated with better outcomes without safety issues in the long-term extension.10 Sinagra et al.11 reviewed data about the role of viral detection for immunomodulation in acute lymphocytic myocarditis, highlighting current limitations of this approach and providing a framework for future dedicated studies. The Authors pointed out that the value of viral presence to guide immunosuppressive treatment in lymphocytic myocarditis requires more evidence and remains a subject of debate. As a further support, intravenous immunoglobulin did not improve cardiac systolic function or functional status in patients with chronic inflammatory cardiomyopathy, namely idiopathic dilated cardiomyopathy with parvovirus B19 persistence, in a randomized controlled trial.12 Over the last years, improvement in survival was observed in patients with dilated cardiomyopathy, with many patients with new-onset cardiomyopathy who may show reverse remodelling.13, 14 In TRED-HF, withdrawal of pharmacological treatment for HF in patients with recovered dilated cardiomyopathy was associated with relapses in 44% of patients.15 In a further analysis by cardiac magnetic resonance, treatment withdrawal resulted in early ventricular remodelling with an increase in myocardial mass and a reduction in global longitudinal strain. Interestingly, these changes may also occur in patients who do not show clinical deterioration.16 Shorter left ventricular systolic ejection time has been identified as a marker of worse prognosis among patients with HF with reduced ejection fraction (HFrEF).17 Alhakak et al.18 confirmed the prognostic impact of left ventricular systolic ejection time on mortality in a large HFrEF population (per 10 ms decrease: adjusted HR 1.06, 95% CI 1.01–1.11, P = 0.030), hence supporting its use to stratify patients' risk and to guide therapeutic response. Heightened chemosensitivity has a major role in the excessive ventilatory response to exercise and sleep breathing abnormalities in patients with HF. Buspirone, a 5HT1A receptor agonist that inhibits serotonergic chemoreceptor neuron firing, reduced carbon dioxide chemosensitivity and improved central apnoeas in patients with HF.19 A relatively large number of patients with advanced HF may benefit from long-term mechanical circulatory support.20 This indication might be further expanded if this device therapy may cause regression of myocardial fibrosis. Unfortunately, such hypothesis was not proven in a recent study in 125 patients.21

Diagnostic Application of Invasive Cardiopulmonary Exercise Test in Patients with Unexplained Dyspnea

To explore the clinical diagnostic application of invasive cardiopulmonary exercise test (iCPET) in patients with unexplained dyspnea. A retrospective analysis was conducted, covering patients with a chief complaint of exertional dyspnea between May 5, 2017 and October 1, 2020. Right cardiac catheterization examination was performed on patients whose cause had not been identified through routine examination, and further iCPET was performed on patients if no clear etiology was identified through right cardiac catheterization. According to the results and the diagnostic criteria of iCPET, patients showing no obvious abnormalities in the right cardiac catheterization examination were divided into four subgroups: exercise-induced pulmonary arterial hypertension (eiPAH), exercise-induced heart failure with preserved ejection fraction (eiHFpEF), preload failure, and oxidative myopathy. By comparing the lab test, echocardiography, right heart catheter and iCPET peak exercise data of the subgroups, the disease distribution and exercise hemodynamic characteristics of patients with unexplained dyspnea examined by iCPET were described. Of the 1 046 patients with exertional dyspnea, 771 were diagnosed with routine examination, while among the remaining 275 patients, 131 (47.6%) were diagnosed with right cardiac catheterization and 144 (52.4%) showed no clear etiology after routine examination and right cardiac catheterization. Of these 144 patients, 49 (34.0%) received iCPET with a median exercise time of 375 s. A total of 47 patients completed the examination, with a male-to-female ratio of 0.27∶1 and an average age of (47.9±14.4) years old. Among the 47 patients, 76.6% (36/47) aged between 20 and 59 and 78.7% (36/47) lived in urban areas. The preload failure group ( n=27) showed low right atrium pressure at peak exercise intensity. The eiHFpEF group ( n=9) showed high wedge pressure of pulmonary capillaries at peak of exercise intensity. The eiPAH group ( n=8) showed high average pulmonary artery pressure at peak exercise intensity. The oxidative myopathy group ( n=3) was characterized by impairment of tissue uptake and/or utilization of oxygen during exercise. According to the comparison among the three subgroups of the preload failure, eiHFpEF and eiPAH, the eiPAH group had the highest blood K + level in routine examination, while the preload failure group had the lowest blood K + level ( P=0.014). The iCPET of the three subgroups showed statistically significant ( P=0.001) difference in right atrial pressure increase during exercise. Among the three, the eiHFpEF group had the highest increase and the preload failure group had the lowest increase. Conclusion In unexplained dyspnea patients showing no abnormal results in right cardiac catheterization examination, the main cause was preload failure, which manifested as low right atrial pressure at peak exercise intensity. The study showed that iCPET was of important value for dyspnea cases when the cause of the condition was not revealed with right cardiac catheterization.

Риски периоперационных осложнений у пациентов старших возрастных групп: причины, механизмы, возможности прогнозирования

Age-related changes in the body and concomitant somatic pathology can have a significant impact on the body adaptation processes to operational stress, which is associated with the development of adverse events in the intraoperative period, postoperative complications and long-term prognosis. Both the initial state of the body and the severity of changes in metabolism in response to operational stress, as well as the involvement degree of the body functional reserves, are important. Traditionally used methods for risk stratification, based on a patient’s survey or assessment of his daily activity, do not always provide a comprehensive, objective assessment of the body functional capabilities, especially in patients of older age groups. The prognostic value of cardiopulmonary exercise testing for determining the indications and the risk of complications in various types of surgical interventions has been proved. Based on the results of preoperative cardiopulmonary exercise testing, it is possible to make a more complete, comprehensive assessment of the patient’s body functional status, which is especially important for polymorbid patients. However, at present, there are no clearly defined normative limits for the indicators of cardiopulmonary exercise testing for patients of older age groups, which determines the future prospects for studying the use of this method for patients over 60 years of age with various pathological conditions. KEYWORDS: aging, operational stress, adaptation, functional reserve, prognosis, age-related features, cardiopulmonary exercise testing. FOR CITATION: Trotsyuk D.V., Medvedev D.S., Zaripova Z.A., Chikov A.E. Risks of perioperative complications in patients of older age groups: causes, mechanisms and prognostic possibilities. Russian Medical Inquiry. 2021;5(3):150–155. DOI: 10.32364/2587-6821-2021-5-3-150-155.

The characteristics of core parameters during cardiopulmonary exercise testing in patients with hypertrophy cardiomyopathy

Objective: The patients with Hypertrophic CardioMyopathy (HCM), characterized by hypertrophy of the myocardium with a high risk of sudden death, was less clear for the exercise pathophysiology. Under the guidance of holistic integrative physiology and medicine (HIPM), the ramp protocol symptom-limited CardioPulmonary Exercise Testing (CPET) is the only method to evaluate the overall functional status of human body. We investigated the CPET pathophysiology in patients with HCM. Methods: From April 2017 to January 2020, 244 subjects were enrolled after signed the informed consent form and completing CPET in Fuwai Hospital. They 219 HCM patients and 25 healthy normal subjects as control (NS). The changes of CPET core parameters between two them were calculated, compared and did Individual analysis. Results: ①The gender of HCM was 163 maleand 56 female. The gender of NS was 11 male and 14 female. The age of HCM was (46.7±12.8, 16.0~71.0) year; NS was (43.7±10.4, 26.0~61.0) year.②The core CPET parameters of HCM: peak oxygen uptake (Peak VO2) was (65.2±13.8, 22.8~103.4) %pred; anaerobic threshold (AT) was (66.4±13.0, 33.7~103.5) %pred; Peak O2 pulse was (84.3±19.0, 90.9~126.0)%pred; oxygen uptake efficiency platform (OUEP) was (99.2±13.4, 69.1~155.5) %pred; Lowest VE/VCO2 was (108.0±13.2, 70.4~154.0)%pred; VE/VCO2 Slope was (108.5±17.9, 66.9~164.9)%pred. Compared with NS, the Peak VO2, AT, Peak O2 pulse, and OUEP were significantly decreased (P<0.01 or P<0.05), but the Lowest VE/VCO2 and VE/VCO2 Slope were significantly increased (P<0.05). For Individual analysis of the overall functional status of CPET, some were very sever but some HCM were still within the normal range.③ The Peak VO2 was positively correlated with AT, OUEP, Peak O2 pulse, and peak systolic blood pressure, but was negative correlated with Lowest VE/VCO2 and VE/VCO2 Slope. Conclusion: CPET is safe and specific characteristics for patients with HCM, which deserve further research and clinical application. Under HIPM guidance, CPET can not only be used for overall functional evaluation, disease diagnosis and differential diagnosis, risk stratification, curative effect evaluation and accurate prognostic prediction, but also be utilized in formulating the individualized training prescription and management of chronic diseases.

Blood Glucose Responses during Cardiopulmonary Incremental Exercise Testing in Type 1 Diabetes: A Pooled Analysis.

This study aimed to determine the glycemic responses to cardiopulmonary exercise testing (CPET) in individuals with type 1 diabetes (T1D) and to explore the influence of starting blood glucose (BG) concentrations on subsequent CPET outcomes. This study was a retrospective, secondary analysis of pooled data from three randomized crossover trials using identical CPET protocols. During cycling, cardiopulmonary variables were measured continuously, with BG and lactate values obtained minutely via capillary earlobe sampling. Anaerobic threshold was determined using ventilatory parameters. Participants were split into (i) euglycemic ([Eu] >3.9 to ≤10.0 mmol·L-1, n = 26) and (ii) hyperglycemic ([Hyper] >10.0 mmol·L-1, n = 10) groups based on preexercise BG concentrations. Data were assessed via general linear modeling techniques and regression analyses. P values of ≤0.05 were accepted as significant. Data from 36 individuals with T1D (HbA1c, 7.3% ± 1.1% [56.0 ± 11.5 mmol·mol-1]) were included. BG remained equivalent to preexercise concentrations throughout CPET, with an overall change in BG of -0.32 ± 1.43 mmol·L-1. Hyper had higher HR at peak (+10 ± 2 bpm, P = 0.04) and during recovery (+9 ± 2 bpm, P = 0.038) as well as lower O2 pulse during the cool down period (-1.6 ± 0.04 mL per beat, P = 0.021). BG responses were comparable between glycemic groups. Higher preexercise BG led to greater lactate formation during exercise. HbA1c was inversely related to time to exhaustion (r = -0.388, P = 0.04) as well as peak power output (r = -0.355, P = 0.006) and O2 pulse (r = -0.308, P = 0.015). This study demonstrated 1) stable BG responses to CPET in patients with T1D; 2) although preexercise hyperglycemia did not influence subsequent glycemic dynamics, it did potentiate alterations in various cardiac and metabolic responses to CPET; and 3) HbA1c was a significant factor in the determination of peak performance outcomes during CPET.

Effect of anxiety and depression on cardiopulmonary exercise test in patients with coronary artery disease.

To compare the core indexes of cardiopulmonary exercise test (CPET) in the patients with coronary artery disease and combining anxiety and/or depression, and to explore the effect of the emotional disorder with "anxiety and/or depression" on cardiopulmonary function and exercise tolerance in patients with coronary artery disease. A total of 255 patients with stable coronary artery disease and 302 patients without coronary artery disease were selected as subjects. According to the results of anxiety and depression scale, they were divided into a control group (n=96), an anxiety group (n=35), a depression group (n=36), an anxiety and depression group (n=135), a coronary artery disease group (n=91), a coronary artery disease combined with anxiety group (n=35), a coronary artery disease combined with depression group (n=34) and a coronary artery disease combined with anxiety and depression group (n=95). The differences in the core indexes of CPET among the different groups were compared. Peak oxygen uptake, anaerobic domain, peak metabolic equivalent, and peak heart rate in all coronary artery disease groups were significantly lower than those in the control group, while peak systolic pressure and heart rate reserve were significantly increased (all P<0.05); among them, there were significantly difference in the above indexes between the coronary artery disease combined with anxiety and depression group and the coronary artery disease group (all P<0.05); there was no significant difference among the anxiety group, the depression group, and the anxiety and depression group and the control group (all P>0.05). The cardiopulmonary function and exercise tolerance is significantly decreased in the coronary artery disease combined with anxiety and depression patients; there is a declining trend in the cardiopulmonary function and exercise tolerance in the simple anxiety or simple depression patients. Simple anxiety, simple depression and simple anxiety combined with depression don't cause a negative impact on cardiopulmonary function and exercise tolerance in non-coronary artery disease control population.

Abstract 16004: Clinical and Hemodynamic Correlates of Exaggerated Metabolic Cost of Exercise Initiation

Introduction: Exercise intolerance is common in cardiovascular disease and is a cardinal manifestation of heart failure with preserved ejection fraction (HFpEF). Decreased exercise capacity is often attributed to cardiac limitations, though HFpEF is increasingly recognized to be both a metabolic and a cardiovascular disorder. Hypothesis: Patients with HFpEF will have exaggerated metabolic cost of exercise initiation with associated high expenditure of hemodynamic reserve capacity. Methods: We quantified the workload-equivalent cost of initiating exercise using cardiopulmonary exercise testing in patients with HFpEF (N=184, age 62±13, 47% women, peak VO2 13.8±3.3 ml/kg/min). Individualized VO2-work rate relationships during loaded exercise were used to derive the work-equivalents required to move extremities with zero external resistance (0 watts)—termed “internal work” (IW). Standard linear regression techniques were used for comparisons. Results: In individuals with HFpEF, the internal work (42±28 W) was often a large portion of the total workload achieved. BMI accounted for the greatest variance in IW (23%), suggesting a metabolic basis for IW. Resting measures of myocardial function and biventricular filling pressures did not measurably contribute to explanatory variance in IW, suggesting a non-cardiac origin. Individuals with HFpEF in the fourth quartile of IW (76±28W) had a dramatic hemodynamic response to exercise in pulmonary capillary wedge and mean pulmonary arterial pressures. Changes in hemodynamic measurements were more modest between quartiles of IW in the submaximal ramp period following unloaded exercise. Conclusions: Internal work is a new measure that captures the metabolic cost of initiating movement. Internal work is associated with limitations in achievable external workload as well as steep early increases in cardiac filling pressures in HFpEF. Further investigation into the pathophysiology of elevated IW is needed.

Abstract 16032: Determinants of Exercise Capacity Assessed Using Combined Stress Echocardiography and Cardiopulmonary Exercise Testing in Patients Treated for Acute Myocardial Infarction

Introduction: Exercise capacity (EC) after acute myocardial infarction (AMI) influences prognosis, but the causes of its reduction are complex and not sufficiently studied. Methods: We prospectively enrolled consecutive patients who underwent percutaneous coronary intervention for their first AMI without residual coronary stenosis and with left ventricular ejection fraction (LVEF) &gt; 40% more than 4 weeks after the AMI. We performed combined stress echocardiography and cardiopulmonary exercise testing (CPET-SE) using a semi-supine cycle ergometer to determine predictors of EC (peak oxygen uptake [VO 2 ]). Results: Among 81 patients (70% male, mean age 58 ± 11 years), 40% suffered AMI with ST-segment elevation (STEMI), and 60% non-STEMI, LVEF was 57 ± 7%; wall motion score index, 1.18 (IQR 1.06 - 1.31); peak VO 2 , 19.5 ± 5.4 mL/kg/min. Multivariate analysis ( Table ) revealed that parameters at peak exercise: heart rate (β = 0.17, p &lt; 0.001), stroke volume (β = 0.09, p &lt; 0.001), and arteriovenous oxygen difference (β = 93.51, p &lt; 0.001) were independently positively correlated with peak VO 2 , with arteriovenous oxygen difference being its strongest contributor. At rest, left ventricular systolic and diastolic function parameters and the extent of myocardial scarring (wall motion score index) did not predict EC (p &gt; 0.05). Conclusions: In patients treated for AMI with normal/mildly reduced LVEF, EC is associated with peak peripheral oxygen extraction as well as peak heart rate and peak stroke volume. CPET-SE is a useful tool to evaluate decreased fitness in this group.

GNRI correlates with ventilatory efficacy parameters during cardiopulmonary exercise testing in patients with heart disease

Rationale: Minimum VE/VCO2 and VE vs VCO2 slope are ventilatory efficacy parameters (VEPs) during cardiopulmonary exercise test (CPET). VEPs reveal Ventilation/Perfusion (V/Q) mismatch during exercise. These VEPs and nutrition parameters are predictor of mortality in patients with heart disease. However, there is no report correlation between the nutrition parameters and VEPs. The present study aimed to investigate correlation between the nutrition parameters and VEPs during CPET in patients with heart disease.

Severity of depression and its relationship with the parameters obtained in the cardiopulmonary exercise test in patients of a cardiac rehabilitation program

Abstract Background Cardiovascular diseases are the leading cause of global morbidity and mortality. Depression causes specific disorders such as autonomic nervous system dysfunction, neurohormonal axis imbalance, proinflammatory and prothrombotic states. The alteration profiles in the parameters measured in the cardiopulmonary exercise testing (CPET) associated with the different severities of depression have not yet been characterized. Purpose To determine the association of the degree of depression and the parameters obtained in the CPET in patients undergoing a cardiac rehabilitation program. Methods Observational, comparative, cross-sectional, retrospective study of adult patients examined in the period from January 1, 2010 to December 31, 2017. Independent variables were degrees of depression according to Beck depression inventory, dependent variables were parameters reported in the CPET. Categorical variables were reported in frequency and continuous variables as averages. The comparison between groups was made with x2, T test, ANOVA according to type and number of variables and their distribution. Pearson's correlation to determine association. Results From a total of 594 patients: 490 were men (82.4%), age 57.34±11.3. Maximum METs 7.49±2.42, heart rate (HR) response (percentage of theoretical maximum heart rate achieved) 82.79±12.69 and systolic blood pressure response (SBP) (ratio of peak SBP to resting SBP) 1.29±0.18. Bivariate analysis found significant differences between Beck's depression scale and study variables: Male (p&amp;lt;0.0001), married (p=0.022), diabetes (p=0.012), surgical revascularization (p=0.05), use of angiotensin II receptor antagonists (p=0.027). Conclusions The present study found association of depressive symptoms with male gender, married marital status, diabetes, surgical myocardial revascularization and treatment with angiotensin II receptor antagonists. In the CPET, significant differences were found in exercise tolerance measured by METs, HR response and SBP response between subjects without depression and those with mild and moderate depression. Depression and Exercise Tolerance Funding Acknowledgement Type of funding source: None

Mismatch between self-estimated and objectively assessed exercise capacity in patients with congenital heart disease varies in regard to complexity of cardiac defects.

Regular evaluation of physical capacity takes a crucial part in long-term follow-up in patients with congenital heart disease (CHD). This study aims to examine the accuracy of self-estimated exercise capacity compared to objective assessments by cardiopulmonary exercise testing in patients with CHD of various complexity. We conducted a single centre, cross-sectional study with retrospective analysis on 382 patients aged 8-68 years with various CHD who completed cardiopulmonary exercise tests. Peak oxygen uptake was measured. Additionally, questionnaires covering self-estimation of exercise capacity were completed. Peak oxygen uptake was compared to patient's self-estimated exercise capacity with focus on differences between complex and non-complex defects. Peak oxygen uptake was 25.5 ± 7.9 ml/minute/kg, corresponding to 75.1 ± 18.8% of age- and sex-specific reference values. Higher values of peak oxygen uptake were seen in patients with higher subjective rating of exercise capacity. However, oxygen uptake in patients rating their exercise capacity as good (mean oxygen uptake 78.5 ± 1.6%) or very good (mean oxygen uptake 84.8 ± 4.8%) was on average still reduced compared to normal. In patients with non-complex cardiac defects, we saw a significant correlation between peak oxygen uptake and self-estimated exercise capacity (spearman-rho -0.30, p < 0.001), whereas in patients with complex cardiac defects, no correlation was found (spearman-rho -0.11, p < 0.255). The mismatch between self-estimated and objectively assessed exercise capacity is most prominent in patients with complex CHD.Registration number at Charité Universitätsmedizin Berlin Ethics Committee: EA2/106/14.

Cardiopulmonary exercise testing in patients with non-small cell lung cancer: trust the V˙ O2peak?

BackgroundMaximal oxygen consumption (V˙ O2max) is the most frequently used variable to determine postoperative risk in patients with non-small cell lung cancer (NSCLC), however patients frequently cannot provide the necessary maximum effort to ensure the validity of the V˙ O2 measurements. The aim of this observational study was to assess exercise-limiting factors and the rate of achievement of the currently recommended maximality criteria in patients with NSCLC who had been routinely referred for cardiopulmonary exercise testing (CPET) to assess their postoperative risk.MethodsPatient data, including peak exercise variables and markers used to designate the exercise test as maximal, were retrospectively analysed from 203 preoperative CPET assessments that were performed at Rouen University Hospital from January 2014 until July 2019.ResultsVentilatory limitation was the most common physiological cause of exercise cessation. A total of 62 patients (or 30.5%) achieved either one, or no, markers of maximality. The mean duration of the incremental phase (after the 3-minute warm-up) was 5.1±2 minutes.ConclusionsAbout 30% of the patients in this study did not generate maximum effort during CPET. As a result, it is likely that their V˙ O2peak was underestimated and that their post-operative risk was overestimated. It is therefore important to incorporate strategies to verify V˙ O2peak results for patients with values close to the risk threshold.