Cardiopulmonary Stress Testing Research Articles

Comparison of Incremental Shuttle Walking Test, 6-Minute Walking Test, and Cardiopulmonary Exercise Stress Test in Patients with Myocardial Infarction.

BACKGROUND This study aimed to analyze the correlations among peak oxygen uptake (VO2) in cardiopulmonary exercise test (CPX), incremental shuttle walking test (ISWT), and 6-minute walking test (6MWT) distances in patients with myocardial infarction (MI). Additionally, we aimed to determine the relationship between the maximum heart rate (HRmax) and the rate of perceived exertion (RPE) among the tests and compare the changes in heart rate to verify the clinical benefit of the submaximal stress test. MATERIAL AND METHODS We analyzed the correlation by using the ISWT and 6MWT at 30-min intervals after 24 h of CPX in patients with MI. The differences in HRmax and RPE between the tests were also compared. Additionally, changes in heart rate were analyzed using descriptive statistics. RESULTS The ISWT distance was more strongly correlated with peak VO₂ (r=.823: 95% CI, 0.681-0.910) than was 6MWT (r=0.776: 95% CI, 0.683-0.870). HRmax in the CPX demonstrated a significant correlation with that in the ISWT and 6MWT (P<0.05), with the ISWT (r=0.815: 95% CI, 0.451-0.996) having a stronger correlation than the 6MWT (r=0.664: 95% CI, 0.146-0.911). The value of RPE was significantly different (P<0.05); however, there was no significant correlation. Changes in heart rate in the 6MWT plateaued after the initial increase, while the heart rate in the ISWT and CPX increased gradually. CONCLUSIONS We recommend the ISWT as a submaximal exercise test to evaluate exercise capacity in patients with MI.

Role of cardiopulmonary stress testing in patients with severe aortic stenosis

Role of cardiopulmonary stress testing in patients with severe aortic stenosis

THE INFLUENCE OF SUDDEN VIGOROUS PHYSICAL EXERTION ON CARDIAC DEMAND UNDER AMBULATORY CONDITIONS AMONG FIREFIGHTERS

Firefighters have a high prevalence of cardiovascular disease and its risk factors compared to the general population. The poor heart health of firefighters is implicated in their increased risk of sudden cardiac death (SCD) accounting for nearly 50% of all on-duty fatalities. Exercise may confer protective benefits against SCD in part due to the immediate blood pressure (BP) reductions of 5-8 mmHg following exercise, termed postexercise hypotension (PEH). PURPOSE: To examine the time course of PEH under ambulatory conditions after a maximal cardiopulmonary graded exercise stress test (GEST) among career firefighters. METHODS: Firefighters (n = 19) completed a maximal GEST and a non-exercise control (CONTROL) in random order on separate nonwork days and left the laboratory attached to an ambulatory BP (ABP) monitor for 19 hr. Ambulatory systolic BP (ASBP), diastolic BP (ADBP), and heart rate (AHR) were recorded at hourly intervals over 19 hr. The ambulatory rate pressure product (ARPP), an indicator of cardiac demand, was calculated as ASBPxAHRx10-3 at each hourly interval over 19 hr. Repeated measures ANCOVA tested if the ABP, AHR, and ARPP responses differed after GEST vs CONTROL over 19 hr. RESULTS: Firefighters were middle-aged (39.5 ± 8.9 yr), overweight (29.2 ± 4.0 kg/m2) men with elevated resting BP (123.1 ± 9.6/79.8 ± 10.4 mmHg), while resting HR (67.7 ± 11.3 bpm) and RPP (8.4 ± 1.7 mmHg*bpm*10-3) were in normal ranges. ASBP (16.6 ± 5.7 mmHg) and ADBP (3.1 ± 4.6 mmHg) increased after the GEST vs CONTROL over 19 hr (ps < 0.01), as did AHR (9.4 ± 7.9 bpm, p = 0.02) and ARPP (2.5 ± 1.1 mmHg*bpm*10-3, p < 0.01). CONCLUSION: Unexpectedly, the firefighters exhibited postexercise hypertension rather than PEH. The increases in ABP and AHR we observed resulted in a sustained increase in cardiac demand. Further investigation is needed to confirm our findings and determine whether the adverse hemodynamic responses we observed contribute to the high prevalence of SCD that firefighters experience on the job.

Hypotension on cardiopulmonary stress test predicts 90day mortality after LVAD implantation in INTERMACS 3-6 patients.

Cardiopulmonary stress test (CPX) is routinely performed when evaluating patient candidacy for left ventricular assist device (LVAD) implantation. The predictive value of hypotensive systolic blood pressure (SBP) response during CPX on clinical outcomes is unknown. This study aims to determine the effect of hypotensive SBP response during to clinical outcomes among patients who underwent LVAD implantation. This was a retrospective single center study enrolling consecutive patients implanted with a continuous flow LVAD between 2011 and 2022. Hypotensive SBP response was defined as peak exercise SBP below the resting value. Multivariable Cox-regression analysis was performed to evaluate the relationship between hypotensive SBP response and all-cause mortality within 30 and 90days of LVAD implantation. A subgroup analysis was performed for patients implanted with a HeartMate III (HM III) device. Four hundred thirty-two patients underwent LVAD implantation during the pre-defined period and 156 with INTERMACS profiles 3-6 met our inclusion criteria. The median age was 63years (IQR 54-69), and 52% had ischaemic cardiomyopathy. Hypotensive SBP response was present in 35% of patients and was associated with increased 90day all-cause mortality (unadjusted HR 9.16, 95% CI 1.98-42; P=0.0046). Hazard ratio remained significant after adjusting for age, INTERMACS profile, serum creatinine, and total bilirubin. Findings were similar in the HM III subgroup. Hypotensive SBP response on pre-LVAD CPX is associated with increased perioperative and 90day mortality after LVAD implantation. Additional studies are needed to determine the mechanism of increased mortality observed.

P408 CERTIFICATION FOR COMPETITIVE SPORTS ACTIVITY IN A TEENAGER WITH WPW BY VIA INTRAHYSSIAN ACCESSORY PATHWAY

Abstract The case of a 12–year–old male, height 160 cm, weight 46 kg, who practices water polo at a competitive level is reported. Negative family history of cardiovascular pathologies, general and cardiovascular physical examination within the limits of normality. On the electrocardiographic trace (ECG) presence of delta wave from ventricular pre–excitation from intrahyssian accessory pathway (Fig. 1). Echocardiography + color Doppler was normal. The subject underwent a cardiopulmonary stress test with an incremental ramp protocol and steps of 20 watts / min. Shutdown at 190 watts for muscle exhaustion with peak oxygen consumption (VO2) = 43.9 mL / Kg / min, Heart rate = 197 beats / minute, BP = 210/70 mmHg, VE / VCO2 slope = 27.6. Normal course of the cronotropic and pressure curve. The ventricular pre–excitation delta wave persisted for the entire duration of the test and in recovery (Fig. 2, Fig. 3). Secondary disturbances of ventricular repolarization characterized by ST segment sub–leveling and negative T wave appeared at high load and persisted in the first minutes of recovery, delta VO2 / delta WR = 12. Given the non–disappearance of the delta wave from ventricular pre–excitation during the maximal stress test, the subject was sent to an electrophysiological study and subsequent ablation of the accessory pathway. The electrophysiological study was negative for inducibility of atrial fibrillation (AF) and ventricular arrhythmias. Safe ablation was impossible given the intrahyssian position of the accessory pathway. Considering the negativity of the electrophysiological study due to non inducibility of supraventricular and ventricular arrhythmias, eligibility for competitive sports was granted.

Centres of sports cardiology in Czechia - first experiences

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Sports cardiology is a subspeciality of cardiology. It differs from general cardiology practice; the presence of an athlete’s heart can be challenging to differentiate from incipient cardiac pathologies, and athletes often present with atypical symptoms and expectations. In Czechia, three Centres of Sports Cardiology (CSC) for athletes older than 15 years and one for children were founded 2020 and endorsed by the Czech Society of Cardiology and the Czech Society of Sports medicine. Purpose The present study aims to share our experience from the first two years of functioning two tertiary sport cardiology centres (Centre 1 and Centre 2) Methods Only athletes registered for the examination from 1st January 2020 till 7th November 2021 were included. Results We included 149 athletes (79 from Centre 1 and 71 from Centre 2). The mean age was 29 ± 13 years. The majority of sports were mixed (n= 83) than endurance (n=58) and very few power (n=3) and skill sports (n=1). The main reason for examination was abnormal preparticipation screening results (n=46), symptoms (n=45) and abnormal findings on complementary examination (n=31). Only two athletes were indicated from cascade screening and one athlete after sudden cardiac arrest. In CSC we performed electrocardiograms (n=101), echocardiography (n=77), HolterECG (n=39), 24-hour ambulatory blood pressure monitoring (n=3), cardiac magnetic resonance (n=13) one CT-coronary angiography, cardiopulmonary exercise stress test (n=41), invasive coronary angiography (n=3), other examination (n=15). We were able to ascertain a diagnosis in 113 athletes; a suspected diagnosis was in 14 athletes, and in 20, we were unable to set any diagnosis. The main conclusions were that 79 (53%) of athletes were eligible to sport participation, in 34 (23%) of athletes, the eligibility had a condition, and only 10 (6.7 %) athletes were ineligible to sport participation. (However, the main conclusions were that 79 (53%) of athletes were eligible to sport participation, in 34 (23%) of athletes, the eligibility had a condition, and only 10 (6.7 %) athletes were ineligible to sport participation. ) The ineligibility was due to cardiomyopathy (n=5), long QT syndrome (n=2), valvular heart disease (n=1), Marfan syndrome (n=1), preexcitation syndrome (n=1). Only six athletes were lost to follow-up, and in 13 (8.7 %), the examination process was not yet closed. Conclusion(s) The establishment of sports cardiology centres in Czechia respects the global trend in cardiovascular care for athletes. The first 22 months of their work confirm the importance of their existence with the centralization of subspecialty cardiology care. Confirmation of the trend is the establishment of full eligibility in 76% of examined athletes. Similarly, the non-recommendation of further sports activity in less than 7% of examined athletes again confirms the correctness of the existence of sports cardiology centres.

Cardiopulmonary Exercise Performance in the Pediatric and Young Adult Population Before and During the COVID-19 Pandemic.

Physical activity (PA) decreased and sedentary behavior (SB) increased in the pediatric population during the Coronavirus Disease 2019 (COVID-19) pandemic. We examined the effects of PA and SB on cardiopulmonary exercise performance in children, adolescents and young adults both with and without underling cardiac disease, and hypothesized that there will be a change in aerobic and physical working capacity during the pandemic. This was a single-center retrospective longitudinal cohort study in patients age 6–22 years who underwent serial maximal cardiopulmonary exercise stress testing before and during the COVID-19 pandemic. Metabolic variables were obtained; PA and SB data were extracted from clinic notes. A total of 122 patients (60% male) underwent serial exercise testing with a median age of 14 years at the first CPET. Predicted peak aerobic capacity significantly decreased among both females and males during the pandemic, even after adjusting for changes in somatic growth. There was no significant change in physical working capacity during the pandemic. Patients who were more aerobically fit experienced a greater decrease in aerobic capacity during the pandemic compared to those less fit. In conclusion, cardiopulmonary exercise performance, notably aerobic activity, decreased during the COVID-19 pandemic in children, adolescents and young adults compared to pre-pandemic values. This decline was most notable in those with the highest pre-pandemic aerobic capacity values and was independent of somatic growth or changes in BMI. This study has public health implications and demonstrates the importance of PA on overall cardiovascular health.

Cardiopulmonary exercise testing for treatment effect assessment in chronic thromboembolic pulmonary hypertension patients.

Aim To determine possibilities of the cardiopulmonary stress test (CPST) as an unbiassed, noninvasive method for evaluation of the effect of managing patients with chronic thromboembolic pulmonary hypertension (CTEPH).Material and methods This study included 37 patients with CTEPH, 24 men (mean age, 53±15 years) and 13 women (mean age, 58±8.5 years). The diagnosis was verified and theCoperability was assessed according to 2015 European Society of Cardiology Clinical Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension (PH). The surgical treatment was used in 65 % (n=24) of CTEPH patients: the group with pulmonary thromboendarterectomy constituted 35 % (n=13); the group with balloon pulmonary angioplasty 30% (n=11); and the conservative tactics was used in 27 % (n=10) of patients.Results Baseline CPST parameters significantly correlated with parameters of right heart catheterization (RHC): mixed venous oxygen saturation (SvO2) significantly positively correlated with V´O2peak (r=0.640, p&lt;0.05), V´O2 / heart rate (HR) (r=0.557; p&lt;0.001), PETCO2 peak (r=0.598, p&lt;0.05), and V´E / V´CO2 (r=0.587; p&lt;0.001); cardiac output (CO) correlated with V´O2 / HR (r=0.555, p&lt;0.001), PETCO2peak (r= -0.476; p&lt;0.05 and r=0.555, p&lt;0.001 for ´E / V´CO2). In repeated testing, the physical working capacity (V´O2peak) increased only in patients after the surgical treatment of CTEPH. Importantly in this process, significant correlations remained between a number of CPST and RHC parameters: SvO2 correlated with V´O2peak (r=0.743; p&lt;0.05), V´O2 /HR (r=0.627; p&lt;0.001), PETCO2peak (r=0.538; p&lt;0.05), and V´E / V´CO2 (r=0.597; p&lt;0.001); V´O2 / HR, PETCO2peak, and V´E / V´CO2 significantly correlated with CO (r=0.645, p&lt;0.001; r= -0.516, p&lt;0.001, and r=0.555, p&lt;0.001, respectively.Conclusion CPST can be used as a noninvasive instrument for evaluation of the effect of CTEPH treatment, particularly in the absence of echocardiographic data for residual PH.

Red cell distribution width as a predictor of impaired exercise capacity in patients with heart failure

Aim To test a hypothesis that increased values of red cell distribution width (RDW) in patients with chronic heart failure (CHF) can be related with low exercise tolerance.Material and methods 102 patients were evaluated who had CHF with mid-range and reduced left ventricular ejection fraction (LV EF) without anemia (72% men, mean age 66±10.2 years). Cardiopulmonary stress test (CPST), echocardiography, 6‑min walk test (6MWT), blood count, and measurements of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and serum iron were performed.Results The average LV EF was 39±8.7 %; the peak oxygen consumption (VO2peak) was 13.7±4.8 ml /kg /min; and the median NT-pro-BNP was 595.3 pg /ml (Q1-3 1443-2401). RDW variables, including the RDW coefficient of variation (RDW-CV) and RDW standard deviation (RDW-SD), were not significantly related with serum iron or hemoglobin concentrations. A one-factor linear regression analysis showed a significant correlation of VO2peak with RDW-SD (р=0.039). A multivariate linear regression analysis with adjustments for LV EF, hemoglobin concentration, and age did not reveal any significant correlation of VO2peak with RDW variables. The distance covered in the 6MWT was significantly associated with RDW-CV both in the one-factor analysis and with adjustments for LV EF, hemoglobin and serum iron concentrations, and age.Conclusion This study showed that high RDW values in CHF patients without anemia predicted low exercise tolerance regardless of the age, LV systolic function, and hemoglobin and serum iron concentrations. A 16% increase in RDW-CV significantly decreased the likelihood of covering a distance longer than 360 m during 6 min.

Impact of SGLT2i Use on Functional Capacity in Heart Failure

<h3>Purpose</h3> Recently published trials have shown benefit for patients with heart failure with reduced or preserved ejection fraction with the addition of sodium glucose co-transporter 2 inhibitors (SGLT2i) to optimal medical therapy (OMT). Outcomes are limited to readmission and mortality but fail to elucidate a benefit in functional capacity. Data regarding the impact of SGLT2i on hemodynamic optimization has not demonstrated benefit in heart failure patients. The impact of SGLT2i on peak oxygen consumption measured by cardiopulmonary stress testing (CPET) has only been evaluated in animal models. Our aim was to evaluate the physiological impact of SGLT2i in the advanced heart failure population. <h3>Methods</h3> We performed a retrospective study between August 1, 2020 and August 15, 2021 to evaluate all patients with heart failure (preserved or reduced ejection fraction) undergoing CPET. Pre and post CPET were required after initiation of SGLT2i or after OMT. The SGLT2i group was compared to matched controls on OMT. <h3>Results</h3> A total of 13,213 patients were on SGLT2i during our study period. Of those, 2,063 (16%) had a diagnosis of heart failure with a total of 96 patients with CPET. 46 of these (48%) patients were in the SGLT2i group and 50 (52%) were matched controls on OMT. Median LVEF was 33% (IQR 25-40) in the SGLT2i group and 38% (IQR 25 -50) in the OMT group, p=0.10. Median duration between baseline and follow-up CPET in SGLT2i group was 352 days and 437 days in the OMT group, p=0.06. Pre and post comparison between OMT and SGLT2i was not different for exercise time (p=0.09), VE/VCO2 (p=0.11), RER (p=0.45), METS (p=0.25) or NYHA class (p=0.28). Less ARNI use (29 vs. 39, p=0.05), higher A1C (6.5 vs 5.7, p=0.01), similar GFR (65 vs 63, p=0.25) and less hypotensive blood pressure response at peak exercise (p<0.01) was noted in the SGLT2i group. Estimated GFR was not impacted by SGLT2i use (p=0.21) There was no significant difference in VO2 max at baseline (p=0.18) or follow-up (p=0.19) between the two groups. Change in VO2 max after SGLT2i was not significant (p=0.31). <h3>Conclusion</h3> The pluripotent mechanism of SGLT2i effect in heart failure is not clearly understood. Current outcomes have limited focus on readmission and mortality. Our data suggest that SGLT2i use does not improve functional capacity in heart failure. Optimization with SGLT2i is potentially due to a predominant effect on neurohormonal modulation and diuretic effect in addition to OMT.

Hemodynamic Gain Index Is An Independent Predictor Of Adverse Clinical Outcomes In Patients With Heart Failure With Reduced Ejection Fraction Undergoing Cardiopulmonary Exercise Stress Test

<h3>Introduction</h3> Recently, the hemodynamic gain index (HGI), a simple parameter calculated from resting and peak systolic blood pressure (SBP) and heart rate (HR) during exercise stress testing without a metabolic cart, was shown to be an independent predictor of mortality. However, the prognostic implications of the HGI in patients with heart failure with reduced ejection fraction (HFrEF) have not been well studied. <h3>Hypothesis</h3> We hypothesized that lower HGI is independently associated with adverse outcomes in the entire cohort and in subgroups of patients with HFrEF and comparable to peak VO2 in risk stratification. <h3>Method</h3> Electronic medical records of 954 HFrEF patients (LVEF ≤40%) undergoing cardiopulmonary exercise stress test from December 2012 to September 2020 were reviewed. HGI was calculated using the formula, [(SBP_peak x HR_peak)-(SBP_rest x HR_rest)]/(SBP_rest x HR_rest). We excluded patients who had a negative HGI, hypotensive, or bradycardic response. The primary outcome was the composite of all-cause mortality, LVAD implantation, or heart transplantation. Multivariable Cox proportional hazard models and the log rank test were used for statistical comparisons. Subgroups of HFrEF were stratified by respiratory exchange ratio (RER) of 1.05, median age, sex, body mass index (BMI) of 35 kg/m², and beta-blocker use. <h3>Results</h3> In our study cohort (mean age 56.3±12.0 years, 72% men, 86% with beta-blockers, mean LVEF 24.6 ±7.9%, 17% with BMI ≥35 kg/m², 73% with RER >1.05), there were 331 (34.7%) patients who met the primary outcome during a median follow up time of 946 days. After adjustment for age, sex, comorbidities, and LVEF, lower HGI was independently associated with greater risk of the primary outcome(quartile 1 vs 4, HR 2.89, 95% CI 2.00-4.20, <i>p</i><0.001, <b>Figure 1A</b>). There is no difference in the association between HGI and risk by subgroup (<b>Figure 1B</b>). The HGI was also comparable to peak VO₂ in terms of primary outcome prediction (AUC 0.69 [95%CI 0.65-0.72] vs 0.70 [95%CI 0.66-0.73], <i>p</i>=0.777). <h3>Conclusion</h3> In this well-characterized, contemporary cohort of patients with HFrEF undergoing CPET evaluation, lower HGI is independently associated with a greater risk of death, LVAD implantation and heart transplantation. The prognostic value of HGI was comparable to that of peak VO2, suggesting it may have a potential clinical utility in risk stratification when considering advanced heart failure therapies.

Granulomatous Myocarditis After Cardiac Transplantation for Giant Cell Myocarditis

<h3>Introduction</h3> Cardiac sarcoidosis and idiopathic giant cell myocarditis are uncommon but serious inflammatory cardiomyopathies which share some clinical and histopathologic features. We present the case of a patient who developed end-stage heart failure due to giant cell myocarditis requiring heart transplant, and years after transplantation, developed cardiac sarcoidosis <h3>Case Report</h3> A 45-year-old man with no significant medical history was preparing for a triathlon but began to experience subacute heart failure symptoms culminating in a sudden cardiac arrest shortly after endomyocardial biopsy (EMBx) revealing giant cell myocarditis. He required ECMO cannulation as a bridge to biventricular HeartWare HVADs and was treated with cyclosporin. After 10 months of biventricular support, he underwent heart transplant. Post-operative course was uneventful and was maintained on standard immunosuppression with tacrolimus, mycophenolate, and prednisone. At three-years post-transplant, he was transitioned to sirolimus and remained stable. During his sixth annual visit, he noted exertional intolerance. His echocardiogram revealed a drop in his left ventricular ejection fraction from 58% to 47%, an increase LVIDd from 41 mm to 51 mm, and an increase in LV mass index from 70 to 80 g/m2. He also had a cardiopulmonary exercise stress test and his peak VO2 went from 36 ml/(min/kg) to 32.9 (ml/min/kg). Event monitor showed PVC's and non-sustained VT. Coronary angiogram showed mild non obstructive cardiac allograft vasculopathy. Endomyocardial biopsy revealed an active granulomatous myocarditis which had the appearance of sarcoidosis. His steroid regimen was augmented to prednisone 30 mg daily, then tapered. Three months after immunosuppression changes, cardiac PET scan revealed findings compatible with an inflammatory cardiomyopathy process associated with edema, fibrosis and scar. Tacrolimus was added to his regimen, mycophenolate dose was increased and received 3 days of pulse dose steroids <h3>Summary</h3> While previous descriptions of recurrent sarcoidosis in cardiac allografts have been described, the unique features of GCM on native heart explantation and clear features of sarcoidosis in the allograft despite adequate immunosuppression highlight not only the challenges with regard to management of active myocarditis after transplant but also the overlap of the two disease entities

Sarcoidosis: Hiding in Plain Sight

<h3>Introduction</h3> Sarcoidosis is a systemic disease that can masquerade as many conditions. Due to its often patchy distribution, myocardial biopsy is only ∼30% sensitive. Herein we present a case of sarcoidosis diagnosed from an extra-cardiac biopsy years after the onset of cardiomyopathy. <h3>Case Report</h3> A 54 year old man initially presented with dyspnea and fatigue due to new onset HFrEF of 20%. He had a significant family history of SCD. His workup revealed non-obstructive CAD, a myxomatous mitral valve with bileaflet prolapse and moderate regurgitation, and a cystic structure attached to the tricuspid valve. Given his frequent ventricular ectopy, he was discharged on guideline therapy for HFrEF and a wearable cardioverter defibrillator. Genetic testing for dilated cardiomyopathies revealed EYA4 and TTN variants of unknown significance. A cardiac MRI a few months later demonstrated no abnormal late gadolinium enhancement and persistent systolic dysfunction, so he underwent AICD implant. His course was further complicated by recurrent admissions for supraventricular and ventricular tachyarrhythmias. A cardiopulmonary exercise stress test demonstrated low-risk results. Further evaluation noted prolonged AV conduction. A RHC revealed mild post-capillary pulmonary hypertension and a mildly decreased cardiac index at 2.01 L/min/m². Months later, he underwent CRT-D upgrade. He started improving functionally until he developed left eyelid swelling, initially thought to be lymphoma. An orbital biopsy revealed non-caseating granulomas. A PET/CT demonstrated FDG uptake within subcarinal lymph nodes but no cardiac uptake. Initially he declined immunomodulatory therapy, but as his symptoms worsened, he started corticosteroids and transitioned to mycophenolate mofetil due to intolerance of methotrexate. Due to disease progression on repeat FDG-PET, he was switched to infliximab. <h3>Summary</h3> The diagnosis of sarcoidosis can be difficult due to its variable presentation, including heart block, heart failure, ventricular arrhythmias and sudden cardiac death. Cardiac involvement occurs in 25% of cases. Our case was complicated by a cMRI that was negative for cardiac involvement, which emphasizes the importance of complimentary inflammatory imaging with FDG-PET. A multidisciplinary approach is needed that engages sarcoid specialists for earlier diagnosis to ensure rapid initiation of therapy to reduce end-organ dysfunction.

Subjective and Objective Impact of Angiotensin Receptor–Neprilysin Inhibitors on Systemic Right Ventricle Patients

Patients with adult congenital heart disease (ACHD) who have an anatomic right ventricle supporting the systemic circulation have increased mortality and morbidity from heart failure (HF). Angiotensin receptor-neprilysin inhibitors (ARNI) have emerged as a standard of therapy for adults with HF. However, the effects of this therapy have not been extensively studied in ACHD patients, especially those with systemic right ventricle (SRV). ARNIs are associated with subjective and objective improvement in SRV patients. Eighteen (18) SRV patients were prescribed ARNI at our institution in the last 5 years. Data before and during treatment, including demographics, medical history, New York Heart Association functional class (NYHA FC), labs, cardiac computed tomography (CT) or magnetic resonance imaging (MRI), echocardiographic measurements, cardiopulmonary stress test (CPET), and hospitalisation for HF were obtained by review of the electronic medical record. Statistical analysis was performed using paired t and Wilcoxon rank sum tests. Eighteen (18) SRV patients (mean age 40 yrs, 72% male) were treated with ARNI (median duration 13 mo) in addition to other HF medications. All patients tolerated ARNI without symptomatic or asymptomatic hypotension or worsening kidney function. High ARNI dose (97/103 mg) was achieved in three (17%) patients, and moderate (49/51 mg) in three (17%). At baseline, nine patients were NYHA FC 2, seven FC 3, and two FC 4. Mean baseline cardiopulmonary exercise testing (CPET) and echocardiographic data were: oxygen uptake (VO2) 18 mL/kg/min, minute ventilation/carbon dioxide (VE/VCO2) 38, right ventricular ejection fraction (RVEF) 32%, fractional area change (FAC) 21%. Significant tricuspid regurgitation was present in 33% (28% moderate, and 5% severe) and mean tricuspid annular plane systolic excursion (TAPSE) was 9.4 mm. With treatment, there was no statistically significant difference in blood pressure, labs, testing, or imaging. There was a statistically significant improvement in median NYHA FC (2 vs 2.5, p=0.005). When compared to an equal pre-ARNI median timeframe, there was a noted decrease in cardiac hospitalisation (4 vs 9) that did not reach statistical significance (p=0.313). In adult patients with failing systemic right ventricle, ARNI is safe and well tolerated. Their use is associated with improvement in functional status. Prospective studies on a larger group of patients are warranted to better understand the causes of this improvement.

Abstract EP18: Cardiopulmonary Testing In Long Covid Versus Non-CovidPatients With Undifferentiated Dyspnea On Exertion

Background: COVID-19 reveals new manifestations not only in the acute phase but also in the long term. The latter is what has been termed as ‘post acute sequelae of SARS-CoV-2 infection’ (PASC) — or “long COVID”— with dyspnea as one of its hallmarks. Cardiopulmonary stress testing (CPET) is increasingly being used to better evaluate such patients. Objective: To compare CPET findings of long COVID patients versus non-COVID patients with undifferentiated dyspnea on exertion seen at Mayo Clinic. Methods: A cohort study was carried out using Mayo Clinic’s exercise testing database. The study group included 77 PASC patients confirmed by a positive antigen or PCR test with no prior history of heart or lung disease. PASC patients were compared to 766 non-COVID patients with unspecified dyspnea without known diagnosis of cardiac or pulmonary disease. ANOVA according to the general linear model and Pearson’s Chi square were used for the bivariate analysis of the quantitative and categorical variables, respectively. Analyses were controlled for age, sex, and beta blocker use as appropriate. Both HR and SBP at rest and peak exercise were significantly different between groups, although the absolute differences were small. Results: Compared with the control group, the post-COVID patients were younger (mean age 47 SD ±14.9 years versus 50.5 SD ±10.1 years) and more likely to be female (70.1% (54 of 77) vs 57.6% (441 of 766)). Although there were many significant differences in the CPET results, the most outstanding were a lower FAC (73 SD ±19.4% vs 85.2 SD ±20.8%) and peak VO2 (22 SD ±6.4 ml/kg/min vs 25.8 SD ±7.37 ml/kg/min) in the study group (p&lt;.0001). Also, CNS changes during CPET were reported at higher rates (19.5% (15 of 77) vs 11.4% (87 of 766)) while dyspnea at lower rates (55.8% (43 of 77) vs 65.7% (503 of 766)) in post-COVID patients (p=0.02). When adjusting for age and sex, weight was significantly higher in the study group (p=0.03) although the absolute difference was modest and BMI remained not significant. PFTs did not suggest any pulmonary abnormalities. Conclusions: We identified a high rate of severe exercise limitation among long COVID patients. Young women may be at higher risk for these complications. Pre-exercise PFTs and absence of objective respiratory limitation during CPET argue against a primary pulmonary cause of the observed limitations, though evaluation of cardiac, autonomic, and muscular impairment is pending. Further studies are warranted to untangle the physiologic abnormalities responsible for these observations.

Effectiveness of Video Games as Physical Treatment in Patients with Cystic Fibrosis: Systematic Review.

Physical training at home by making individuals play active video games is a new therapeutic strategy to improve the condition of patients with cystic fibrosis (CF). We reviewed studies on the use of video games and their benefits in the treatment of CF. We conducted a systematic review with data from six databases (PubMed, Medline, Scopus, Web of Science, PEDro, and Cochrane library plus) since 2010, according to PRISMA standards. The descriptors were: “Cystic Fibrosis”, “Video Game”, “Gaming Console”, “Pulmonary Rehabilitation”, “Physiotherapy”, and “Physical Therapy”. Nine articles with 320 participants met the inclusion criteria and the study objective. Patients who played active video games showed a high intensity of exercise and higher ventilatory and aerobic capacity compared to the values of these parameters in tests such as the cardiopulmonary stress test or the six-minute walk test. Adequate values of metabolic demand in these patients were recorded after playing certain video games. A high level of treatment adherence and satisfaction was observed in both children and adults. Although the quality of the included studies was moderate, the evidence to confirm these results was insufficient. More robust studies are needed, including those on evaluation and health economics, to determine the effectiveness of the treatment.

Arterial Hypertension and Cardiopulmonary Function: The Value of a Combined Cardiopulmonary and Echocardiography Stress Test.

Arterial hypertension (AH) is a global burden and the leading risk factor for mortality worldwide. Haemodynamic abnormalities, longstanding neurohormonal and inflammatory activation, which are commonly observed in patients with AH, promote cardiac structural remodeling ultimately leading to heart failure (HF) if blood pressure values remain uncontrolled. While several epidemiological studies have confirmed the strong link between AH and HF, the pathophysiological processes underlying this transition remain largely unclear. The combined cardiopulmonary-echocardiography stress test (CPET-ESE) represents a precious non-invasive aid to detect alterations in patients at the earliest stages of HF. The opportunity to study the response of the cardiovascular system to exercise, and to differentiate central from peripheral cardiovascular maladaptations, makes the CPET-ESE an ideal technique to gain insights into the mechanisms involved in the transition from AH to HF, by recognizing alterations that might be silent at rest but influence the response to exercise. Identifications of these subclinical alterations might allow for a better risk stratification in hypertensive patients, facilitating the recognition of those at higher risk of evolution towards established HF. This may also lead to the development of novel preventive strategies and help tailor medical treatment. The purpose of this review is to summarise the potential advantages of using CPET-ESE in the characterisation of hypertensive patients in the cardiovascular continuum.

The Effects of an Oral Nutritional Supplement with Whey Peptides and Branched-Chain Amino Acids for Cardiac Rehabilitation of Patients with Chronic Heart Failure.

The aim of the present study was to determine whether the addition of an oral nutritional supplement with whey peptides and branched-chain amino acids for cardiac rehabilitation improves cardiopulmonary function, skeletal muscle function, and metabolism in CHF patients.In this randomized, parallel-group comparative pilot study, 20 CHF patients were randomly assigned to the nutrition group (n = 10) or the control group (n = 10). At baseline and 12 weeks, we performed physical examinations, motor function evaluation, clinical laboratory tests, nutritional status assessment, and echocardiography. The primary outcome was exercise tolerance, as determined by the cardiopulmonary stress test (CPX), 6-minute walking test (6MWT), and brain natriuretic peptide (BNP) levels.During follow-up, body weight, body mass index, total muscle mass, and total lean mass did not change significantly in either group. The total fat mass significantly increased in the nutrition group (14.3 ± 5.4 kg versus 16.1 ± 5.5 kg, P < 0.001) but did not change in the control group, and the difference in the changes in total fat mass between groups was significant (-0.26 ± 0.96 kg versus 1.49 ± 0.63 kg, P < 0.001). The peakVO2 and 6-minute walk test (6 MWT) significantly increased in the nutrition group (14.6 ± 3.4 mL/minute/kg versus 15.8 ± 3.8 mL/minute/kg, P = 0.029; 346.9 ± 103.1 m versus 382.7 ± 102.1 m, P = 0.048; respectively) but did not change in the control group. The changes in peakVO2 and 6MWT did not significantly differ between the groups.The oral nutritional supplement for the treatment of CHF was effective for cardiac rehabilitation in terms of fat mass and exercise capacity.The present study demonstrated that oral nutritional supplements with whey peptides and branched-chain amino acid (BCAA) for cardiac rehabilitation in patients with chronic heart failure (CHF) increased fat mass and exercise capacity. We conclude that whey peptides and BCAA supplementation may be a useful treatment for CHF patients.

Use of Cardiopulmonary Stress Testing for Patients With Unexplained Dyspnea Post–Coronavirus Disease

ObjectivesThe authors used cardiopulmonary exercise testing (CPET) to define unexplained dyspnea in patients with post-acute sequelae of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection (PASC). We assessed participants for criteria to diagnose myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). BackgroundApproximately 20% of patients who recover from coronavirus disease (COVID) remain symptomatic. This syndrome is named PASC. Its etiology is unclear. Dyspnea is a frequent symptom. MethodsThe authors performed CPET and symptom assessment for ME/CFS in 41 patients with PASC 8.9 ± 3.3 months after COVID. All patients had normal pulmonary function tests, chest X-ray, and chest computed tomography scans. Peak oxygen consumption (peak VO2), slope of minute ventilation to CO2 production (VE/VCO2 slope), and end tidal pressure of CO2 (PetCO2) were measured. Ventilatory patterns were reviewed with dysfunctional breathing defined as rapid erratic breathing. ResultsEighteen men and 23 women (average age: 45 ± 13 years) were studied. Left ventricular ejection fraction was 59% ± 9%. Peak VO2 averaged 20.3 ± 7 mL/kg/min (77% ± 21% predicted VO2). VE/VCO2 slope was 30 ± 7. PetCO2 at rest was 33.5 ± 4.5 mm Hg. Twenty-four patients (58.5%) had a peak VO2 <80% predicted. All patients with peak VO2 <80% had a circulatory limitation to exercise. Fifteen of 17 patients with normal peak VO2 had ventilatory abnormalities including peak respiratory rate >55 (n = 3) or dysfunctional breathing (n = 12). For the whole cohort, 88% of patients (n = 36) had ventilatory abnormalities with dysfunctional breathing (n = 26), increased VE/VCO2 (n = 17), and/or hypocapnia PetCO2 <35 (n = 25). Nineteen patients (46%) met criteria for ME/CFS. ConclusionsCirculatory impairment, abnormal ventilatory pattern, and ME/CFS are common in patients with PASC. The dysfunctional breathing, resting hypocapnia, and ME/CFS may contribute to symptoms. CPET is a valuable tool to assess these patients.

Impact of diabetes on cardiopulmonary function: the added value of a combined cardiopulmonary and echocardiography stress test.

Type 2 diabetes mellitus (T2DM) represents a major health issue worldwide, as patients with T2DM show an excess risk of death for cardiovascular causes, twice as high as the general population. Among the many complications of T2DM, heart failure (HF) deserves special consideration as one of the leading causes of morbidity and reduced life expectancy. T2DM has been associated with different phenotypes of HF, including HF with reduced and preserved ejection fraction. Cardiopulmonary exercise testing (CPET) can evaluate the metabolic and ventilatory alterations related to myocardial dysfunction and/or peripheral impairment, representing a unique tool for the clinician to study the whole HF spectrum. While CPET allows for a thorough evaluation of functional capacity, it cannot directly differentiate central and peripheral determinants of effort intolerance. Combining CPET with imaging techniques could provide even higher accuracy and further insights into the progression of the disease since signs of left ventricular systolic and diastolic dysfunction can be detected during exercise, even in asymptomatic diabetic individuals. This review aims to dissect the alterations in cardiopulmonary function characterising patients with T2DM and HF to improve patient risk stratification.