Role Of Cardiopulmonary Exercise Testing Research Articles

The role of cardiopulmonary exercise testing in decision-making in adults with congenital heart disease

The role of cardiopulmonary exercise testing in decision-making in adults with congenital heart disease

Corrigendum to 'Role of cardiopulmonary exercise testing in clinical stratification in heart failure. A position paper from the Committee on Exercise Physiology and Training of the Heart Failure Association of the European Society of Cardiology' [Eur J Heart Fail 2018;20:3-15

The surname of an author of this HFA Position Paper was corrected from “Veli-Pekka Hairola” to “Veli-Pekka Harjola”. The original online version has also been corrected.

The role of cardiopulmonary exercise testing in the initial evaluation of patients wearing intracardiac devices submitted to cardiac rehabilitation

The role of cardiopulmonary exercise testing in the initial evaluation of patients wearing intracardiac devices submitted to cardiac rehabilitation

Letter by Tzanis et al Regarding Article, “Stress Testing in Asymptomatic Aortic Stenosis”

HomeCirculationVol. 136, No. 19Letter by Tzanis et al Regarding Article, “Stress Testing in Asymptomatic Aortic Stenosis” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Tzanis et al Regarding Article, “Stress Testing in Asymptomatic Aortic Stenosis” Georgios Tzanis, MD, PhD, Christos Charitos, MD and Serafim Nanas, MD, PhD Georgios TzanisGeorgios Tzanis From Cardiopulmonary Exercise Testing and Rehabilitation Laboratory (G.T., S.N.), Department of Cardiac Surgery (C.C.), Evaggelismos Hospital, Athens, Greece. Search for more papers by this author , Christos CharitosChristos Charitos From Cardiopulmonary Exercise Testing and Rehabilitation Laboratory (G.T., S.N.), Department of Cardiac Surgery (C.C.), Evaggelismos Hospital, Athens, Greece. Search for more papers by this author and Serafim NanasSerafim Nanas From Cardiopulmonary Exercise Testing and Rehabilitation Laboratory (G.T., S.N.), Department of Cardiac Surgery (C.C.), Evaggelismos Hospital, Athens, Greece. Search for more papers by this author Originally published7 Nov 2017https://doi.org/10.1161/CIRCULATIONAHA.117.029575Circulation. 2017;136:1866–1867To the Editor:We read with great interest the state-of-the-art review by Redfors et al1 regarding the emerging role of stress testing in the field of asymptomatic aortic stenosis (AS) management. With this letter, we would like to highlight the role of cardiopulmonary exercise test (CPET) in the evaluation of symptoms and disease prognosis of asymptomatic AS. Insights from cardiopulmonary exercise tests could possibly answer how symptomatic asymptomatic AS could be.Five decades ago, Ross and Braunwald2 described the importance of symptom estimation in AS, stating, “Once symptoms develop, the average course is short.” Since then, little has changed in the management of severe AS. We know we have to intervene when symptoms develop, but little is known about how to evaluate the symptoms and the (a)symptomatic patient.CPET is the gold standard for estimating symptoms, objective assessing functional capacity, evaluating the origin of the symptoms (cardiac/pulmonary), and obtaining prognostic information for a series of diseases, especially heart failure where CPET indices are closely associated with morbidity and survival.Related to this concept, a recent study by Domanski et al3 showed that a significant proportion of patients with asymptomatic AS have really low peak oxygen consumption due to cardiac limitation, as assessed by CPET, possibly indicating high incidence of false “asymptomatic”. CPET, unlike the AS severity criteria derived from rest and supine exercise echocardiography, predicted a poor event free survival. Levy et al4 also suggested that CPET could accurately detect false asymptomatic patients with AS and patients likely to develop symptoms. CPET parameters (peak oxygen consumption and ventilation-carbon dioxide production slope) that provide prognostic information and are strongly linked with survival in heart failure were both predictors of an abnormal exercise test and the development of cardiac symptoms related to AS (dyspnea, syncope, or angina), both representing triggers for surgery with current practice.Another important study by Dhole et al5 evaluated the prognostic role of CPET in AS. Authors found that exercise capacity was significantly reduced in patients with moderate/severe AS, and that peak oxygen consumption was independently associated with survival in these groups of patients, whereas the self-estimation of equivocal symptoms was not associated with increased mortality or aortic valve replacement compared with the patients who were asymptomatic.Severe AS is not a black-and-white scenario but a continuum. AS is a chronic, slow-developing disease where patients sometimes adapt by decreasing their level of activity or even underestimate their condition (false asymptomatic), while symptoms and reduced exercise capacity may be of noncardiac origin (false symptomatic). With the progression of the disease, symptoms can be debilitating for activities of daily living, and usually only then are patients sent for surgery. The whole concept could be not just categorizing patients as asymptomatic/symptomatic but objectively assessing the functional capacity and subjective nature of symptoms by CPET. It is important to note that CPET might also be used to obtain information for the prognosis, as in other disease states such as heart failure.Further studies implementing CPET should estimate the optimal prognostic parameters that would consequently elucidate the optimal timing for intervention in AS.Georgios Tzanis, MD, PhDChristos Charitos, MDSerafim Nanas, MD, PhDDisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.

Role of cardiopulmonary exercise testing in clinical stratification in heart failure. A position paper from the Committee on Exercise Physiology and Training of the Heart Failure Association of the European Society of Cardiology.

Traditionally, the main indication for cardiopulmonary exercise testing (CPET) in heart failure (HF) was for the selection of candidates to heart transplantation: CPET was mainly performed in middle-aged male patients with HF and reduced left ventricular ejection fraction. Today, CPET is used in broader patients' populations, including women, elderly, patients with co-morbidities, those with preserved ejection fraction, or left ventricular assistance device recipients, i.e. individuals with different responses to incremental exercise and markedly different prognosis. Moreover, the diagnostic and prognostic utility of symptom-limited CPET parameters derived from submaximal tests is more and more considered, since many patients are unable to achieve maximal aerobic power. Repeated tests are also being used for risk stratification and evaluation of intervention, so that these data are now available. Finally, patients, physicians and healthcare decision makers are increasingly considering how treatments might impact morbidity and quality of life rather than focusing more exclusively on hard endpoints (such as mortality) as was often the case in the past. Innovative prognostic flowcharts, with CPET at their core, that help optimize risk stratification and the selection of management options in HF patients, have been developed.

Prognostic Role of Cardiopulmonary Exercise Testing in Clinical Practice.

Risk stratification is a mainstay in the care of cardiac and pulmonary disorders, as the identification of adverse outcomes helps provide measures to improve survival and quality of life. The cardiopulmonary exercise test is a useful prognostic tool in the clinical evaluation of several pathological conditions, such as heart diseases, respiratory disorders, and pulmonary hypertension. If not contraindicated, a cardiopulmonary exercise test should always be performed and integrated with clinical, laboratory, and hemodynamic parameters to better stratify patient risk. In heart failure, the cardiopulmonary exercise test is important in all the stages of patient management, from diagnosis to risk assessment. Different exercise variables have been advocated as prognostic indicators in this condition, including peak oxygen uptake, ventilatory efficiency, respiratory patterns, and identification of the anaerobic threshold. The prognostic role of the cardiopulmonary exercise test in heart failure is amplified when included in multiparametric risk stratification methodology, currently considered the best method to assess patient outcome. In respiratory disorders and in pulmonary hypertension, cardiopulmonary exercise test parameters, focusing on ventilatory performance during exercise, may help evaluate the risk of adverse events. Finally, the cardiopulmonary exercise test may help define the presence of coexisting cardiac and respiratory disorders, a combination that leads to increased rates of disability and mortality.

Cardiopulmonary Exercise Testing in Patients with Heart Failure with Specific Comorbidities.

Exercise capacity is one of the most powerful predicting factors of life expectancy, both in patients with and those without cardiac disease. Cardiopulmonary exercise testing provides a global assessment of the integrative exercise responses involving the pulmonary, cardiovascular, hematopoietic, neuropsychological, and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. This relatively noninvasive, dynamic, physiologic overview allows the evaluation of both submaximal and peak exercise responses, providing the physician with relevant information for clinical decision-making. Chronic heart failure is a significant cause of worldwide mortality and morbidity, whose clinical picture is characterized by exercise intolerance and impaired quality of life. The purpose of this review is to provide an update of the role of cardiopulmonary exercise testing in patients with heart failure with specific comorbidities. Patients with heart failure frequently present concomitant clinical conditions, such as obesity, anemia, lung or kidney disease, diabetes mellitus, cancer, depression, and psychogenic disorders, which could affect length and quality of life, including everyday activities and exercise performance. Poor effort and malingering may be suspected when early discontinuation of the exercise test with irregular breathing occurs.

The Role of Cardiopulmonary Exercise Testing for Decision Making in Patients with Repaired Tetralogy of Fallot.

Tetralogy of Fallot is the most common form of cyanotic congenital heart disease. As a result of the surgical strategies employed at the time of initial repair, chronic pulmonary regurgitation (PR) is prevalent in this population. Despite sustained research efforts, patient selection and timing of pulmonary valve replacement (PVR) to address PR in young asymptomatic patients with repaired tetralogy of Fallot (rToF) remain a fundamental but as yet unanswered question in the field of congenital heart disease. The ability of the heart to compensate for the chronic volume overload imposed by PR is critical in the evaluation of the risks and benefits of PVR. The difficulty in clarifying the functional impact of PR on the cardiovascular capacity may be in part responsible for the uncertainty surrounding the timing of PVR. Cardiopulmonary exercise testing (CPET) may be used to assess abnormal cardiovascular response to increased physiologic demands. However, its use as a tool for risk stratification in asymptomatic adolescents and young adults with rToF is still ill-defined. In this paper, we review the role of CPET as a potentially valuable adjunct to current risk stratification strategies with a focus on asymptomatic rToF adolescents and young adults being considered for PVR. The role of maximal and submaximal exercise measurements to identify young patients with a decreased or borderline low peak VO2 resulting from impaired ventricular function is explored. Current knowledge gaps and research perspectives are highlighted.

The role of cardiopulmonary exercise testing in major head and neck surgery

The role of cardiopulmonary exercise testing in major head and neck surgery

Cardiopulmonary exercise test in adults with prior Fontan operation: The prognostic value of serial testing

BackgroundThe purpose of the study was to determine the role of cardiopulmonary exercise test (CPET) indices in predicting cardiovascular adverse events (CAEs) in patients with Fontan palliation. CAE was defined as death or cardiac surgery. MethodsRetrospective review of adult Fontan patients who had treadmill CPET at Mayo Clinic, 1994–2013. Patients with loss of follow-up defined as ≥2years without clinical follow-up were excluded. The results of serial CPETs were reviewed, and patients with CPETs meeting the following criteria were selected for analysis: maximum effort on serial CPETs, minimum of 3-year interval between CPETs, and absence of CAE between CPETs. ResultsA total of 145 patients met inclusion criteria for the study; age at baseline CPET was 24±3years; age at Fontan operation was 11±5years; and 91 (63%) were males. Baseline peak oxygen consumption (VO2) was 22.7±5.4ml/kg/min (63±11% predicted), peak heart rate was 135±31beats per minute, and oxygen saturation at peak exercise was 86±7%. Serial CPETs were performed in 71/145 patients (49%); mean duration between CPETs was 3.8±0.3years. The % predicted peak VO2 decreased by 1.7±0.9 percentage points/year.CAE (deaths n=22; cardiac surgery n=45) occurred in 54/145 patients (37%) within 8±3years. Decline in % predicted peak VO2≥3 percentage points/year was the only predictor of 5-year risk of CAE (HR 1.86, 95% CI 1.11–3.48, P=0.02). ConclusionsSerial CPET is prognostic of CAE in the adult Fontan population, and can be used to risk stratify these patients.

Exertional dyspnoea in COPD: the clinical utility of cardiopulmonary exercise testing.

Activity-related dyspnoea is often the most distressing symptom experienced by patients with chronic obstructive pulmonary disease (COPD) and can persist despite comprehensive medical management. It is now clear that dyspnoea during physical activity occurs across the spectrum of disease severity, even in those with mild airway obstruction. Our understanding of the nature and source of dyspnoea is incomplete, but current aetiological concepts emphasise the importance of increased central neural drive to breathe in the setting of a reduced ability of the respiratory system to appropriately respond. Since dyspnoea is provoked or aggravated by physical activity, its concurrent measurement during standardised laboratory exercise testing is clearly important. Combining measurement of perceptual and physiological responses during exercise can provide valuable insights into symptom severity and its pathophysiological underpinnings. This review summarises the abnormal physiological responses to exercise in COPD, as these form the basis for modern constructs of the neurobiology of exertional dyspnoea. The main objectives are: 1) to examine the role of cardiopulmonary exercise testing (CPET) in uncovering the physiological mechanisms of exertional dyspnoea in patients with mild-to-moderate COPD; 2) to examine the escalating negative sensory consequences of progressive respiratory impairment with disease advancement; and 3) to build a physiological rationale for individualised treatment optimisation based on CPET.

When is the right time for Fontan conversion? The role of cardiopulmonary exercise test

BackgroundTo determine if Fontan conversion (FC) resulted in improvement in exercise capacity (EC), and to determine the role of cardiopulmonary exercise test (CPET) in risk stratification of patients undergoing FC. MethodsA retrospective review of patients who underwent CPET prior to FC at Mayo Clinic from 1994 to 2014. The patients who also underwent post-operative CPET were selected for the analysis of improvement in EC defined as 10% increase in baseline peak oxygen consumption (VO2). Results75 patients CPET prior to FC; mean age 24±6years; 44 males (59%); and 51 (68%) were in NYHA III/IV prior to FC. Pre-operative peak VO2 was 15.5±3.4ml/kg/min. A comparison of pre- and post-FC CPET data was performed using 42 patients (56%) that underwent CPET after FC. Improvement in EC occurred in 18 of 42 patients (43%). Baseline peak VO2 >14ml/kg/min was associated with improved EC (hazard ratio [HR] 1.85; P=.02). Improvement in New York Heart Association (NYHA) class occurred in 12 (67%) patients with improved EC vs 2 (8%) without improved EC. Improvement in NYHA class was more likely to occur in patients with improved EC compared to those without improvement EC (odds ratio 4.11, P=.01). There were 10 (13%) perioperative deaths, and baseline peak VO2 ≤14ml/kg/min was predictive of perioperative mortality (HR 3.74; P<.001). ConclusionsBaseline peak VO2 was predictive of perioperative survival, and improvement in EC. Performance on CPET in failing Fontan patients might be a useful clinical parameter in determining appropriate timing of FC.

Role of Cardiopulmonary Exercise Testing for Preoperative Evaluation

Role of Cardiopulmonary Exercise Testing for Preoperative Evaluation

Role of Cardiopulmonary Exercise Testing for Preoperative Evaluation

Role of Cardiopulmonary Exercise Testing for Preoperative Evaluation

Influence of percutaneous pulmonary valve implantation on exercise capacity: Which group of patients benefits most from the intervention?

The aim of the study was to evaluate the role of cardiopulmonary exercise testing (CPET) parameters in assessing exercise capacity improvement after percutaneous pulmonary valve implantation (PPVI). Additionally, it aimed to determine if there are any baseline characteristics influencing that change. The study comprised 32 patients (mean age 26 ± 9); 53% males; diagnosis: tetralogy of Fallot (n = 18), pulmonary atresia (n = 6), Ross procedure (n = 4), other (transposition of great arteries, pulmonary stenosis, double outlet right ventricle, common arterial trunk type II--n = 4) who underwent successful PPVI due to right ventricular out-flow tract dysfunction (predominant pulmonary regurgitation--n = 17, predominant pulmonary stenosis--n = 15). Treadmill CPET was performed before and a year after PPVI along with clinical evaluation, cardiac magnetic resonance and transthoracic echocardiography. Twelve months post successful PPVI (pulmonary valve competence restoration and pulmonary gradient reduction from 58.8 ± 47.1 to 26.6 ± 10.8 mm Hg) there was a significant decrease in the ventilatory equivalent for CO2 at peak exercise (EQCO₂) (25.3 ± 3.3 to 24.3 ± 3.0, p = 0.04) and oxygen consumption at peak exercise (pVO2) (20.4 ± 5.0 to 22.6 ± 5.3 mL/kg/min, p = 0.04). Improved EQCO2 correlated with an increase in right and left ventricular ejection fraction (respectively R = -0.57, p = 0.002; R = -0.56, p = 0.002). In this study, no baseline factors that might affect improvement in exercise function were found. Successful PPVI leads to an improvement in exercise capacity and hemodynamic response to exercise. The correlation between the improvement in EQCO2 or peak VO2 and baseline characteristics was too weak to reliably identify the group of patients that will benefit from the procedure.

G377 The role of cardiopulmonary exercise testing in children with cystic fibrosis

Introduction Cardiopulmonary exercise testing (CPET) is the gold standard test of aerobic fitness in Cystic Fibrosis (CF). CPET is measured by peak oxygen uptake (VO2 peak) during maximal exercise. It can be used to identify the cause of exercise intolerance, prescribe exercise programmes, evaluate therapeutic interventions1 and predict prognosis.2 The American Thoracic Society defines a normal VO2 peak as >84% predicted.3 In our centre, CPET was included in the CF annual reviews from 2013. Currently no guidelines exist as to the frequency of CPET in CF patients. Aims To determine whether CPET was a useful and feasible routine test in children with CF and to assess whether VO2 peak correlated with Forced Expiratory Volume in 1 s (FEV1), disease severity, gender, genotype or previous intravenous antibiotics. Method A pilot observational study was performed. Body mass index (BMI) was used as a marker of disease severity. Genotype was divided into 3 groups; DF508 homozygous, heterozygous and all other genotypes. Data was retrieved from case notes and our CF database. Results 38 patients (17 male, 21 female) underwent CPET. Age range 7–14 (mean 9.8) years. 36/38 had technically satisfactory CPET. Mean VO2 peak was 107% predicted, standard deviation 18%. Only 8% had an abnormal VO2 peak. Mean FEV1 was 91% predicted, standard deviation 15%. There was no relationship between VO2 peak and FEV1 [p = 0.297] or BMI [p = 0.382] (Pearson correlation). Additionally, no correlation was demonstrated between VO2 peak and genotype [p = 0.236] (one-way ANOVA), gender [p = 0.902] or patients who had received at least one course of intravenous antibiotics in the past year [p = 0.253] (two-sample T test). Conclusions CPET is a feasible test with 95% of our patients achieving technically satisfactory assessments and reassuringly, VO2 peak was largely normal. We could not demonstrate a relationship with FEV1 or disease severity although our study is limited by the small sample size. It is recognised that the CF annual review is already a long day for patients and we plan to reserve CPET for those showing exercise intolerance rather than performing it annually. References Rogers D, Prasad SA, Doull I. Exercise testing in children with cystic fibrosis. J Royal Society Med 2003;96:23–29 Nixon PA, Orenstein DM, Kelsey SF, et al. The prognostic value of exercise testing in patients with cystic fibrosis. N Engl J Med 1992;327:1785–88 American Thoracic Society/American College of Chest Physicians. ATS/ACCP statement on cardiopulmonauy exercise testing. Am J Respir Crit Care Med 2003;167:211–77

Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS).

PurposeThis review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs.Principal findingsThere is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain.ConclusionsPerioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.

Cardiopulmonary exercise testing (CPET) as preoperative test before lung resection

Lung resection is still the only potentially curative therapy for patients with localized non-small lung cancer (NSCLC). However, the presence of cardiovascular comorbidities and underlying lung disease increases the risk of postoperative complications. Various studies have evaluated the use of different preoperative tests in order to identify patients with an increased risk for postoperative complications, associated with prolonged hospital stay and increased morbidity and mortality. In this topic review, we discuss the role of cardiopulmonary exercise testing (CPET) as one of the preoperative tests suggested for lung cancer patients scheduled for lung resection. We describe different types of exercise testing techniques and present algorithms of preoperative evaluation in lung cancer patients. Overall, patients with maximal oxygen consumption (VO2max) <10 mL/kg/min or those with VO2max <15 mL/kg/min and both postoperative FEV1 and DLCO<40% predicted, are at high risk for perioperative death and postoperative cardiopulmonary complications, and thus should be offered an alternative medical treatment option.

The role of cardiopulmonary exercise testing in cardiac rehabilitation

The role of cardiopulmonary exercise testing in cardiac rehabilitation

Putting lung function and physiology into perspective: cystic fibrosis in adults.

Adult cystic fibrosis (CF) is notable for the wide heterogeneity in severity of disease expression, both between patients and within the lungs of individuals. Although CF airways disease appears to start in the small airways, in adults there is typically widespread bronchiectasis, increased airway secretions, and extensive obstruction and inflammation of the small airways. The complexity and heterogeneity of airways disease in CF means that although there are many different methods of assessing and describing lung 'function', none of these single-dimensional tests is able to provide a comprehensive assessment of lung physiology across the spectrum seen in adult CF. The most widely described measure, the forced expiratory volume in 1 s, remains a useful and simple clinical tool, but is insensitive to early changes and may be dissociated from other more detailed assessments of disease severity such as computed tomography. In this review, we also discuss the use of more sensitive novel assessments such as multiple breath washout tests and impulse oscillometry, as well as the role of cardiopulmonary exercise testing. In the future, hyperpolarized gas magnetic resonance imaging techniques that combine regional structural and functional information may help us to better understand these measures, their applications and limitations.