Noninvasive Exercise Testing Research Articles

Use of exercise tests in screening for pulmonary arterial hypertension in systemic sclerosis: A systematic literature review

Background and objective: Patients with systemic sclerosis (SSc) and pulmonary arterial hypertension (PAH) have a poor prognosis, accounting for 30% of all SSc-related deaths. Guidelines recommend annual screening for PAH regardless of symptoms, as early treatment improves outcomes. Current protocols include combinations of clinical features, biomarkers, pulmonary function tests, and echocardiography. None include exercise testing, although early-stage PAH may only be evident during exercise. This systematic review assessed the performance of exercise tests in predicting the presence of PAH in patients with SSc, where PAH was confirmed through right heart catheterisation (RHC). Methods: Comprehensive literature searches were performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trails, CINAHL, Scopus and Web of Science from inception to May 2023. Articles were screened for eligibility by two independent reviewers. Eligibility criteria included the use of a non-invasive exercise test to screen adult patients to detect PAH in a population without a previous diagnosis of PAH, with diagnosis confirmed by RHC. Results: Eight studies met the inclusion criteria, describing at least one of three different non-invasive exercise tests: cardiopulmonary exercise test, six-minute walk test and stress Doppler echocardiography. All studies found that exercise tests had some ability to predict the presence of PAH, with sensitivity between 50% and 100% and specificity from 73% to 91%. Conclusion: Exercise tests are infrequently used for screening for PAH in SSc but can predict the presence of PAH. More data are required to establish which tests are most effective.

Clinical Exercise Physiologists in Cardiac Rehabilitation and Clinical Exercise Testing

ABSTRACT Background The unique training of clinical exercise physiologists (CEPs) positions them to be an integral part of multidisciplinary teams in phase 2 cardiac rehabilitation (CR). However, the roles and responsibilities of CEPs vary widely between institutions. In addition, job tasks of CEPs at some institutions might not fully leverage their knowledge and skills. The purpose of this study was to describe the roles and responsibilities of CEPs working in CR and noninvasive clinical exercise testing at select institutions in the United States. Methods This was a descriptive study of the job tasks performed by CEPs in CR and noninvasive clinical exercise testing at select institutions. Job tasks that are common to CR and noninvasive clinical exercise testing were identified by a working group of the Clinical Exercise Physiology Association. Results The 6 CR programs in this report are predominately staffed by CEPs with no other health care professional present during exercise classes. In 5 of these programs CEPs perform all tasks required of phase 2 CR, from patient screening to program discharge. At 3 of the 4 programs that also performed noninvasive exercise testing, CEPs performed all the necessary tasks with no other health care professional present in the room during testing. Conclusion CEPs play an integral role in the conduct of phase 2 CR and noninvasive cardiology exercise testing. Granting privileges to CEPs that allow them to work at the top of their knowledge and skills will allow other health care professionals to better use their skills in other high demand areas.

Invasive Cardiopulmonary Exercise Testing: A Review

Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.

Assessing and Managing Asymptomatic Ventricular Preexcitation in the Young Athlete

Assessing and Managing Asymptomatic Ventricular Preexcitation in the Young Athlete

Exercise Intolerance in Patients with Chronic Iliocaval Venous Occlusion: Initial Experience with Noninvasive Exercise Testing before and after Intervention

Patients with chronic iliocaval occlusions after thrombosis often present with exercise intolerance, which improves after venous reconstruction. Three male patients with chronic iliocaval occlusions underwent a cardiorespiratory fitness test before and 2.5–11 months after venous reconstruction using stents. After the intervention, average absolute oxygen consumption increased by 29.5%, maximal oxygen consumption relative to body weight increased by 38.7%, total work at maximum exercise increased by 74.4%, and exercise time increased by 18.7%. The cardiorespiratory fitness test may be a useful noninvasive tool to objectively evaluate exercise intolerance due to chronic venous occlusions and response to therapy.

Effect of Body Weight Loss on Cardiopulmonary Function Assessed by 6‐Minute Walk Test and Arterial Blood Gas Analysis in Obese Dogs

BackgroundFew studies show the detrimental effect of canine obesity on cardiopulmonary function (CPF). The 6‐Minute Walk Test (6MWT) is a noninvasive exercise test easy to perform in clinical settings.ObjectiveThe aim of this study was to investigate the effect of obesity and body weight loss (BWL) on CPF assessed by the 6MWT and arterial blood gas analysis.AnimalsSix experimental Beagles and 9 privately owned obese dogs were enrolled in a diet‐induced BWL program.MethodsArterial blood gas analysis and 6MWT were repeated in obese subjects (BCS 8‐9/9), in the middle of BWL (overweight, BCS 6‐7/9), and in lean dogs (BCS 5/9). Heart rate (HRp) and oxygen saturation (SpO2) were measured by pulse oximetry before the 6MWT, at midtest, and during a 5‐minute recovery period.ResultsTwelve dogs completed the BWL program (initial BW, 27.3 ± 2.9 kg; final BW, 20.85 ± 2.9, lsmeans ± SE, P ≤ .001). BWL caused a significant increase in 6MWT walked distance (WD; obese: 509 ± 35 m; overweight: 575 ± 36 m; lean: 589 ± 36 m; P ≤ .05). Resting arterial blood gas results were not influenced by BWL. Including all time points, obese dogs showed higher HRp and lower SpO2 compared to overweight and lean dogs. SpO2 at the end of the walk was significantly lower in obese dogs.Conclusion and Clinical ImportanceObesity negatively affects 6MWT performances in dogs. The 6MWT may be used to demonstrate the efficacy of BWL to improve CPF and quality of life in obese dogs. Although BWL induced significant improvement of cardiopulmonary parameters before ideal BW, WD improved until the end of the BWL program.

Coronary anomalies: Cardiac CT evaluation of the symptomatic adult athlete

Cardiac CT has become widely available as a diagnostic test. It is noninvasive, low risk (for contrast allergies), quick, and highly sensitive for identifying the coronary origins and course. Two coronary anomalies, the left main artery from the right sinus of Valsalva, and the right coronary artery originating from the left sinus, have been associated both with myocardial ischemia and sudden cardiac death when they course between the aorta and pulmonary arteries. These anomalies can go undetected into adulthood. The yield of noninvasive exercise testing is low. In the past, the ability to demonstrate these anomalies depended on a high index of suspicion and an aggressive invasive work-up with cardiac catheterization. Now cardiac CT can demonstrate these anomalies with ease and facilitate appropriate treatment.

Successful percutaneous treatment of gluteal claudication secondary to isolated bilateral hypogastric stenoses

We report an unusual case of bilateral buttock claudication at ambulation of less than two blocks in a 57-year-old man with normal lower-extremity segmental pressure on noninvasive exercise testing. He was found to have bilateral high-grade internal iliac artery stenoses on arteriography. Both sides were successfully treated in a staged fashion via a contralateral approach with percutaneous transluminal angioplasty and a balloon-expandable stent, with complete symptom resolution. A clinical vascular examination with normal findings of the common iliac, external iliac, and common and superficial femoral arteries eliminates significant vascular obstruction as a cause of claudication. However, internal iliac occlusive disease may be suspected when symptoms are limited to the gluteal musculature and other causes are eliminated. Percutaneous interventions can be of diagnostic and therapeutic value.

THE PHYSIOLOGIC EVALUATION OF THE LUNG RESECTION CANDIDATE

The evaluation of patients with lung cancer should include an assessment of physiologic risk. This assessment begins with simple pulmonary function studies such as spirometry and diffusing capacity. Abnormalities of these test results should stimulate further assessment with quantitative lung scanning and noninvasive exercise testing. Resection should not be recommended in patients with extremely high risk; however, because of the poor prognosis, patients must be integrally involved in the decision to not resect the lung cancer.

Single Versus Double Chamber Rate Responsive Cardiac Pacing: Comparison by Cardiopulmonary Noninvasive Exercise Testing

A new double chamber rate responsive cardiac pacemaker (DDDMR) has been implanted in seven patients (four males and three females) with a mean age of 62 years. Indication for pacemaker treatment was complete AV block in two patients, complete AV block associated to sinus node disease in three patients and sinus node disease alone in two patients. Six patients underwent two maximal stress tests on a cycloergometer performed twice randomly starting with VVIMR or DDDMR. Basic work load of 50 watts was increased by steps of 25 watts every 2 minutes. Heart rate, respiratory frequency, blood pressure, exercise duration, maximal charge developed, oxygen consumption, rate pressure product, efficiency and Borg scale were compared. Our results show a general trend but no significant differences between all the measured parameters except for efficiency which was significantly higher with DDDMR. These results prove a slight improvement of cardiopulmonary performance in DDDMR pacing compared to VVIMR and also confirm the importance of atrial contribution to cardiac output on exercise.

Cardiorespiratory response to exercise after the Fontan procedure for tricuspid atresia.

Noninvasive exercise testing was used to assess gas exchange in 13 patients age 6-25 yr who had undergone Fontan procedures for tricuspid atresia, five of whom had preexisting Glenn shunts. The results were compared to 28 age- and sex-matched controls. Oxygen saturation was measured by ear oximetry at rest and after exercise. Ventilation, oxygen consumption (VO2), carbon dioxide production (VCO2), and heart rate were measured during progressive exercise. The ventilatory equivalents for oxygen (VE/VO2) and carbon dioxide (VE/VCO2), mixed expired pCO2 (PECO2) end-tidal pCO2 (PETCO2), and dead space to tidal volume ratio (VD/VT) were determined during steady state exercise on a cycle ergometer. Heart rate was higher for VO2 by 15% (p less than 0.02) and ventilation was higher for both VO2 (by 37%, p less than 0.001) and VCO2 (by 27%, p less than 0.002) in the patients than the controls. Mean VE/VO2 was 35.4 +/- 7.8 (SD) compared to 25.8 +/- 3.1 (p less than 0.001) and mean VE/VCO2 was 41.7 +/- 9.0 compared to 31.6 +/- 4.3 (p less than 0.001). Mean PECO2 was 21.4 +/- 4.4 torr with controls at 27.9 +/- 3.8 (p less than 0.001) and mean PETCO2 was 33.0 +/- 5.3 torr compared to 40.0 +/- 3.3 (p less than 0.001). The patients had a mean oxygen saturation of 92 +/- 5% at rest and abnormal saturation after exercise (87 +/- 9, p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

104 RESPONSE TO EXERCISE AFTER FONTAN PROCEDURE

Previous studies demonstrating maldistribution of pulmonary blood flow in patients who had undergone Fontan procedures (FP) predict high physiologic dead space during exercise. We used non-invasive exercise testing to assess gas exchange in 5 patients age 10-19, compared to 11 age and sex matched controls. Oxygen saturation was measured by ear oximetry at rest and after exercise. The ventilatory equivalents for oxygen (Ve/VO2) and carbon dioxide (Ve/VCO2) were measured during progressive exercise and mixed expired pCO2 (PeCO2) and end-tidal pCO2 (PetCO2) were measured during steady state exercise on a cycle ergometer. We obtained the following results: In addition, the patients had a mean oxygen saturation of 89±6% at rest and desaturated further during exercise (81±11, p<0.05). These data show high ventilation for O2 consumption and CO2 production, low expired CO2 concentrations and oxygen desaturation during exercise. The results strongly indicate elevated physiologic dead space and ventilation perfusion mismatch consistent with maldistribution of pulmonary blood flow.

Changes in echocardiographic left ventricular minor axis dimensions during exercise in patients with aortic stenosis.

Twelve patients with aortic stenosis (gradient 62 (25) mm Hg), and six normal subjects were examined using M mode echocardiography before and during submaximal bicycle exercise. Normal subjects showed a progressive fall in the end systolic minor axis dimension of the left ventricle and a rise in end diastolic dimension, giving an increase in stroke dimension and shortening fraction of 45% and 37% respectively at peak exercise. Patients with aortic stenosis showed no consistent alteration in either end systolic or end diastolic dimension, and consequently stroke dimension was unchanged during exercise. None of the patients with an abnormal exercise response had evidence of left ventricular failure at rest, and all but one completed the exercise protocol without undue dyspnoea. Non-invasive exercise testing in patients with aortic stenosis may detect abnormalities of left heart function which are not apparent at rest. These abnormalities may provide early evidence either of severe aortic stenosis or of incipient left ventricular failure.

Bayesian comparison of cost-effectiveness of different clinical approaches to diagnose coronary artery disease

The objective of this study was to compare the cost-effectiveness of four clinical policies (policies I to IV) in the diagnosis of the presence or absence of coronary artery disease. A model based on Bayes' theorem and published clinical data was constructed to make these comparisons. Effectiveness was defined as either the number of patients with coronary disease diagnosed or as the number of quality-adjusted life years extended by therapy after the diagnosis of coronary disease. The following conclusions arise strictly from analysis of the model and may not necessarily be applicable to all situations. As prevalence of coronary disease in the population increased, it caused a linear increase in cost per patient tested, but a hyperbolic decrease in cost per effect, that is, increased cost-effectiveness. Thus, cost-effectiveness of all policies (I to IV) was poor in populations with a prevalence of disease below 10%, for example, asymptomatic people with no risk factors. Analysis of the model also indicates that at prevalences less than 80%, exercise thallium scintigraphy alone as a first test (policy II) is a more cost-effective initial test than is exercise electrocardiography alone as a first test (policy I) or exercise electrocardiography first combined with thallium imaging as a second test (policy IV). Exercise electrocardiography before thallium imaging (policy IV) is more cost-effective than exercise electrocardiography alone (policy I) at prevalences less than 80%. 4) Noninvasive exercise testing before angiography (policies I, II and IV) is more cost-effective than using coronary angiography as the first and only test (policy III) at prevalences less than 80%. 5) Above a threshold value of prevalence of 80% (for example patients with typical angina), proceeding to angiography as the first test (policy III) was more cost-effective than initial noninvasive exercise tests (policies I, II and IV). One advantage of this quantitative model is that it estimates a threshold value of prevalence (80%) at which the rank order of policies changes. The model also allows substitution of different values for any variable as a way of accounting for the uncertainty inherent in the data. In conclusion, it is essential to consider the prevalence of disease when selecting the most cost-effective clinical approach to making a diagnosis.

Non-invasive non-nuclear exercise testing.

Non-invasive non-nuclear exercise testing.

Can noninvasive exercise test criteria identify patients with left main or 3-vessel coronary disease after a first myocardial infarction?

This study attempts to determine whether exercise treadmill testing with clinical, electrocardiographic, and thallium-201 myocardial perfusion imaging data can identify which patients have left main or 3-vessel (anatomically high-risk) coronary artery disease (CAD) after their first transmural myocardial infarct (MI). Twelve exercise test criteria for high-risk disease were compared in 40 patients referred for cardiac catheterization; 34 had a history of chest pain and 17 had angiographically defined high-risk CAD. A thallium image defect outside the vascular distribution of the MI was the most reliable criterion to distinguish patients with high-risk CAD (p = 0.00052 for Fisher's exact test of discrimination). Thallium imaging was somewhat more sensitive (92 versus 65%, p = 0.108) when patients with negative thallium imaging criteria who failed to achieve 85% of the age-predicted maximal heart rate were excluded. Failure to achieve 85% of predicted heart rate was by itself a useful criterion for detecting high-risk CAD (p = 0.017), especially in patients not taking propranolol (p = 0.004). Development of positive S-T segment depression at less than 70% predicted heart rate also discriminated left main or 3-vessel disease from less extensive CAD (p = 0.016). Other criteria failed to discriminate significantly between high-risk and less extensive CAD in patients after their first MI (p greater than 0.05). S-T segment depression (p = 0.199) or chest pain (p = 0.577) during exercise testing were particularly unreliable. Further, none of the criteria for high-risk CAD were influenced by irreversible left ventricular dysfunction. It is concluded that patients with thallium imaging defects outside the region of the infarct, decreasing blood pressure during exercise, failure to achieve 85% of predicted heart rate, or S-T depression at less than 70% of predicted heart rate have a high probability of having left main or 3-vessel disease. Patients without these criteria have a very low probability of having high-risk CAD and probably do not need coronary angiography for the purpose of excluding these high-risk coronary lesions after a first MI.

Detection of severity of coronary artery disease by the ST segment/heart rate relationship in patients on beta-blocker therapy.

Many patients presenting with anginal pain are on beta-blocker therapy and it has been suggested that noninvasive exercise tests for coronary artery disease are adversely affected by such therapy. Recently a new exercise test has been introduced claiming the ability accurately to detect the presence and severity of coronary heart disease in patients with anginal pain; the claim was based on results obtained in patients not undergoing beta-blocker therapy. Therefore using this test, the maximal rate of progression of ST segment depression relative to increases in heart rate during exercise (maximal ST/HR slope) as an index of the severity of myocardial ischaemia, 60 patients on beta-blocker therapy were studied and the results compared with results of coronary arteriography independently obtained. There was a complete agreement, without false results, between the maximal ST/HR slope and the number of significantly diseased coronary arteries. In 21 of these 60 patients the maximal ST/HR slopes obtained before and after beta-blockade were compared; the maximal ST/HR slopes after beta-blockade were not different from those before. It is concluded, that the maximal SR/HR slope can be used reliably to detect the pressure and the severity of coronary heart disease in patients with angina pectoris who are already on beta-blocker therapy.

Popliteal artery entrapment syndrome: Clinical, noninvasive and angiographic diagnosis

The popliteal artery entrapment syndrome is increasingly recognized as a cause of arterial insufficiency in the leg. Diagnosis is based on a clinical history of claudication, which may be atypical, physical examination, noninvasive exercise testing and angiography. Patients with normal ankle pulses and resting ankle/brachial pressure indexes may require extensive exercise testing to document arterial insufficiency. Angiographic demonstration of medial deviation of the popliteal artery is diagnostic of the popliteal artery entrapment syndrome. Arteries that appear normal on routine angiography require biplane angiography with various provocative maneuvers to demonstrate induced arterial stenosis. Using this approach, three additional cases of popliteal artery entrapment syndrome were diagnosed preoperatively and successfully treated with surgery.

Assessment of left heart function by noninvasive exercise test in normal subjects.

ArticleAssessment of left heart function by noninvasive exercise test in normal subjects.B Ayotte, H Bogren, E Carlsson, and M McIlroyB Ayotte, H Bogren, E Carlsson, and M McIlroyPublished Online:01 May 1973https://doi.org/10.1152/jappl.1973.34.5.644MoreSectionsPDF (1 MB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInWeChat Previous Back to Top Next Download PDF FiguresReferencesRelatedInformationCited BySpezielle Untersuchungsmethoden: nichtinvasivNoninvasive Measurement of Cardiac Function during Exercise, Using Resaturation CurvesChest, Vol. 70, No. 6 More from this issue > Volume 34Issue 5May 1973Pages 644-9 https://doi.org/10.1152/jappl.1973.34.5.644PubMed4574186History Published online 1 May 1973 Published in print 1 May 1973 Metrics