Use Of Cardiopulmonary Exercise Testing Research Articles

Ventilatory efficiency in long-term dyspnoeic patients following COVID-19 pneumonia

BackgroundLong COVID is defined as persistency of symptoms, such as exertional dyspnea, twelve weeks after recovery from SARS-CoV-2 infection. ObjectivesTo investigate ventilatory efficiency by the use of cardiopulmonary exercise testing (CPET) in patients with exertional dyspnea despite normal basal spirometry after 18 (T18) and 36 months (T36) from COVID-19 pneumonia. MethodsOne hundred patients with moderate-critical COVID-19 were prospectively enrolled in our Long COVID program. Medical history, physical examination and lung high-resolution computed tomography (HRCT) were obtained at hospitalization (T0), 3 (T3) and 15 months (T15). All HRCTs were revised using a semi-quantitative CT severity score (CSS). Pulmonary function tests were obtained at T3 and T15. CPET was performed in a subset of patients with residual dyspnea (mMRC ≥ 1), at T18 and at T36. ResultsRemarkably, at CPET, ventilatory efficiency was reduced both at T18 (V’E/V’CO2 slope = 31.4±3.9 SD) and T36 (V’E/V’CO2 slope = 31.28±3.70 SD). Furthermore, we identified positive correlations between V’E/V’CO2 slope at T18 and T36 and both percentage of involvement and CSS at HRCT at T0, T3 and T15. Also, negative linear correlations were found between V’E/V’CO2 slope at T18 and T36 and DLCO at T3 and T15. ConclusionsAt eighteen months from COVID-19 pneumonia, 20 % of subjects still complains of exertional dyspnea. At CPET this may be explained by persistently reduced ventilatory efficiency, possibly related to the degree of lung parenchymal involvement in the acute phase of infection, likely reflecting a damage in the pulmonary circulation.

Practical Aspects of Cardiopulmonary Exercise Testing in Children.

The use of cardiopulmonary exercise testing (CPET) in pediatrics provides critical insights into potential physiological causes of unexplained exercise-related complaints or symptoms, as well as specific pathophysiological patterns based on physiological responses or abnormalities. Furthermore, CPET helps evaluate exercise performance in children with chronic (lung/heart) diseases. For instance, it can ascertain any adverse reaction to exercise and estimate the effects of specific treatment measures. It affords a global assessment of the pathophysiological patterns, responses and abnormalities to exercise that is inadequately reflected by resting lung function and/or cardiac function assessment. Clinical interpretation of the results of a CPET in pediatrics requires specific knowledge regarding pathophysiological responses and interpretative strategies that can be adapted to address concerns specific to the child's medical condition or disability.

The use of cardiopulmonary exercise testing (CPET) for assessment and guiding interventions in adolescents with obesity

The use of cardiopulmonary exercise testing (CPET) for assessment and guiding interventions in adolescents with obesity

Cardiopulmonary exercise testing augments watchful waiting in asymptomatic severe primary mitral regurgitation.

Our aim is to describe the use of cardiopulmonary exercise testing in watchful waiting for asymptomatic severe primary mitral regurgitation. Between October 2016 and October 2017, ten patients with asymptomatic severe primary mitral regurgitation underwent watchful waiting in a single centre. Baseline assessment included history, physical examination, transthoracic echocardiogram and cardiopulmonary exercise testing. Patients were re-evaluated every 6months with history, physical examination and transthoracic echocardiogram; and at 12months with cardiopulmonary exercise testing. At 1year follow up, five patients remained asymptomatic with no significant change in left ventricular ejection fraction (p = 0.18). This was associated with no significant change in cardiopulmonary exercise testing parameters. However, five patients developed early new symptoms or changes in echocardiographic parameters with a significant fall in left ventricular ejection fraction (p < 0.01). This was associated with a significant fall in anaerobic threshold (p = 0.04) and four of the five patients having an abnormal percentage predicted peak VO2 at 1year follow up. Changes in symptomatic status or echocardiographic parameters during a watchful waiting approach for asymptomatic severe primary mitral regurgitation is associated with a significant reduction in cardiopulmonary exercise testing parameters.

The relevance of the use of cardiopulmonary exercise testing (CPET) in elderly and senile patients

Cardiopulmonary exercise testing is a study that provides both prognostic and diagnostic information about the state of the cardiovascular, respiratory systems and metabolic processes allowing us to determine how these systems contribute to a decrease in exercise tolerance. A large number of clinical studies using this method have shown its safety and diagnostic value. However, due to insufficient education among doctors and little experience, CPNT is currently not widely used in diagnostics, especially in the geriatrics. This review of available literature over the last 10 years is devoted to the relevance of the use of cardiopulmonary exercise testing in older and oldest older patients, the essence and methodology of the study, possible changes in indicators in patients with frailty, chronic heart failure, and diseases of the bronchopulmonary system.

Responses to exercise in systemicsclerosis-associated interstitial lung disease.

Pulmonary complications in systemic sclerosis (SSc) significantly increase morbidity and mortality. Our aim was to determine the factors limiting exercise capacity in SSc patients with and without interstitial lung disease (ILD), and to identify and quantify abnormalities during exercise that might assist in clinical assessment of this complication. Fifteen patients with SSc and ILD(SSc-ILD) were compared with 10 patients with SSc without ILD and 9age- and sex-matched normal volunteers. Subjects performed symptom-limited incremental treadmill exercise with online measurement of respiratory gas exchange, arterial blood gas sampling and measurement of neurohormones in venous blood. Patients with SSc-ILD had lower exercise capacity than SSc patients without ILD or normal subjects (peak oxygen consumption (PV̇O2 ) (17.1 [4.2] vs. 22.0 [4.7] and 23.0 [5.4] ml kg-1 min-1 , respectively, mean [SD], p < 0.01 ANOVA), but PV̇O2 did not correlate with static pulmonary function measurements. Ventilatory equivalent for CO2 (V̇E/V̇CO2 ; nadir) was higher in SSc-ILD patients than the other two groups (36.6 [8.0] vs. 29.9 [4.4] and 30.0 [2.5], p < 0.005) as were peak exercise dead-space tidal volume ratio (0.44 [0.06] vs. 0.26 [0.09] and 0.26 [0.05], p < 0.001) and peak exercise alveolar-arterial difference (28.9 [16.9] vs. 18.8 [14.0] and 11.5 [6.9] mmHg, p < 0.05). Atrial natriuretic peptide was elevated in both SSc patient groups. SSc-ILD results in lower exercise capacity than SSc without ILD, and abnormalities of gas exchange are seen. The possible use of cardiopulmonary exercise testing to identify disease and quantify impairment in SSc-ILD merits further study.

Use of Cardiopulmonary Exercise Testing to Evaluate Long COVID-19 Symptoms in Adults

Reduced exercise capacity is commonly reported among individuals with COVID-19 symptoms more than 3 months after SARS-CoV-2 infection (long COVID-19 [LC]). Cardiopulmonary exercise testing (CPET) is the criterion standard to measure exercise capacity and identify patterns of exertional intolerance. To estimate the difference in exercise capacity among individuals with and without LC symptoms and characterize physiological patterns of limitations to elucidate possible mechanisms of LC. A search of PubMed, EMBASE, Web of Science, preprint servers, conference abstracts, and cited references was performed on December 20, 2021, and again on May 24, 2022. A preprint search of medrxiv.org, biorxiv.org, and researchsquare.com was performed on June 9, 2022. Studies of adults with SARS-CoV-2 infection more than 3 months earlier that included CPET-measured peak oxygen consumption (V̇o2) were screened independently by 2 blinded reviewers; 72 (2%) were selected for full-text review, and 35 (1%) met the inclusion criteria. An additional 3 studies were identified from preprint servers. Data extraction was performed by 2 independent reviewers according to the PRISMA reporting guideline. Data were pooled using random-effects models. Difference in peak V̇o2 (in mL/kg/min) among individuals with and without persistent COVID-19 symptoms more than 3 months after SARS-CoV-2 infection. A total of 38 studies were identified that performed CPET on 2160 individuals 3 to 18 months after SARS-CoV-2 infection, including 1228 with symptoms consistent with LC. Most studies were case series of individuals with LC or cross-sectional assessments within posthospitalization cohorts. Based on a meta-analysis of 9 studies including 464 individuals with LC symptoms and 359 without symptoms, the mean peak V̇o2 was -4.9 (95% CI, -6.4 to -3.4) mL/kg/min among those with symptoms with a low degree of certainty. Deconditioning and peripheral limitations (abnormal oxygen extraction) were common, but dysfunctional breathing and chronotropic incompetence were also described. The existing literature was limited by small sample sizes, selection bias, confounding, and varying symptom definitions and CPET interpretations, resulting in high risk of bias and heterogeneity. The findings of this systematic review and meta-analysis study suggest that exercise capacity was reduced more than 3 months after SARS-CoV-2 infection among individuals with symptoms consistent with LC compared with individuals without LC symptoms, with low confidence. Potential mechanisms for exertional intolerance other than deconditioning include altered autonomic function (eg, chronotropic incompetence, dysfunctional breathing), endothelial dysfunction, and muscular or mitochondrial pathology.

Physicians' Self-reported Exercise Testing and Physical Activity Recommendations in Kawasaki Patients.

Recommendations for management of patients with Kawasaki disease (KD) and coronary artery aneurysms (CAA) include physical activity (PA) promotion. This study aimed to characterize self-reported practices of KD providers to evaluate practice variation in use of cardiopulmonary exercise testing (CPET) and PA recommendations. We developed a REDCap survey with different clinical scenarios of KD patients. It was completed by members of the International Kawasaki Disease Registry (IKDR) and community pediatric cardiologists. Twenty-eight physicians responded; 63% practiced in the US, 63% practiced in an academic setting, 48% were general pediatric cardiologists, and 55% were IKDR members. Most respondents (69%) followed < 50 KD patients. The great majority (93%) agreed that patients with no CAA do not require CPET and could be cleared for all PA. For patients with small CAA, 43% of respondents recommended CPET and 75% cleared for all PA if CAAs regressed completely, but only 32% cleared if CAA persisted. For patients with medium CAA, 66% respondents cleared for PA if CAA regressed, and only 7% if CAA persisted; with 66% and 75% recommending CPET, respectively. For patients with large/giant CAA, 81% of respondents recommended CPET. No respondents felt comfortable clearing their patients with persistent large/giant CAA for PA and 19% would restrict from the entire physical education program. There is practice variation in use of CPET in KD patients with CAAs. Providers are hesitant to promote PA in KD patients with CAA despite known benefits and current guidelines.

Evaluation of the relationship between cardiopulmonary exercise test findings and clinical status in children and adolescents with congenital heart disease

The cardiopulmonary exercise test is accepted as a helpful diagnostic tool in risk stratification, evaluation of prognosis, and guiding treatment modality in adults with congenital heart disease. In this study, we present our experience with the use of cardiopulmonary exercise test in children with congenital heart disease in different physiological and anatomical classifications. In this retrospective study, 25 children and adolescents who applied to the pediatric cardiology outpatient clinic between 2017 and 2020 with the diagnosis of different types of congenital heart disease were included. Demographic characteristics, electrocardiogram, echocardiogram, cardiopulmonary exercise test, spirometry, pro-BNP values, and in selected 20 patients; cardiac MRI data were examined. The modified Ross classification was used for heart failure grading. The mean age of the patients was 14.8 ±2.39 years. Fifteen (60%) of the patients were male and 10 (40%) were female. In the modified Ross classification, patients in group I-II had significantly higher maximum exercise time, heart rate reserve %, peak VO2, and VO2/kg values compared to those in group III (p=0.026, p=0.007, p=0.043, p= 0.018, respectively). Cardiopulmonary exercise test and spirometry values obtained from the patients were evaluated in the light of clinical and other laboratory findings, and surgical/interventional treatment was decided for 4 patients with the use of these test results. Cardiopulmonary exercise test is a useful noninvasive diagnostic tool in guiding the treatment decision and predicting the prognosis of pediatric patients with congenital heart disease, who have borderline symptoms.

Cardiopulmonary exercise testing: an essential tool for a tailored exercise prescription in patients with cardiac disease

Cardiovascular diseases are the leading cause of death in high-income countries. Exercise prescription is an effective tool for primary and secondary cardiovascular prevention and the cardiovascular benefits of physical activity are well established, ranging from improving the quality of life to reducing mortality. A tailored approach based on patient's personal and clinical characteristics represents a cornerstone for the benefits of exercise prescription. The use of cardiopulmonary exercise testing is well-established for a tailored exercise prescription, as ventilatory thresholds allow to define exercise intensity in a highly individualized manner.

Run for It: Use of Cardiopulmonary Exercise Testing for Hemodynamic Assessment in Advanced Heart Failure

Cardiopulmonary exercise testing (CPET) is an underutilized resource in the assessment of advanced heart failure (HF) after listing for heart transplant (HT). Currently, the ISHLT recommends repeating right heart catheterization (RHC) periodically after HT listing. The objective of this study was to assess whether CPET metrics could reliably predict hemodynamic pressures. Patients with pre-transplant RHC and CPET measured within 3 months of each other were included. Pearson correlation between CPET and hemodynamic variables were calculated. We applied a Random Forest method to develop a prediction model with demographics and CPET metrics for each hemodynamic variable. In addition, we ranked the input variables in terms of their relative importance, defined as the relative reduction in accuracy or, equivalent relative increase in RMSE. 102 patients were included. Of those, 65 had a CI ≥2 and 37 had a CI< 2 LPM. Mean peak oxygen consumption (pVO2) was 12.2±2.8 ml/kg/min, with a %predicted 45.8%±11.4%, a respiratory exchange ratio (RER) 1.12±0.11 and a VE/VCO2 slope 41.4±10.4. When comparing HF etiologies, RER was lowest in those with ischemic cardiomyopathy (ICMP 1.08±0.1, DCMP 1.1±0.11, Other 1.16±0.11, p=0.029). There were no differences in pVO2, %predicted or VE/VCO2 slope. The cross-correlation analysis stratified by CI is shown in Fig 1A. We found modest correlations in the low CI group between VE/VCO2 slope and diastolic PA pressure (r=0.44), VE/VCO2 slope and mean PA pressure (r=0.42), and pVO2 and CI (r=0.37). When combining CPET data and demographic data, we were able to rank the importance of each predictor within in each model (Fig 1B). Using CPET data as a surrogate for invasive hemodynamics in those listed for HT is feasible. The use of serial exercise testing may allow a safer means to monitor patients and determine the timing of more aggressive support prior to HT.

Utility of Stroke Volume Reserve to Evaluate Ventilatory Efficiency in Heart Failure Patients

Introduction The use of cardiopulmonary exercise testing (CPET) to evaluate cardiac limitations in heart failure with reduced ejection fraction (HFrEF) patients is well described. Ventilatory inefficiency or increased VE/VCO2 slope > 34 in HFrEF patients has been shown to correlate with poor prognosis. Ventilatory inefficiency in heart failure is often attributed to increased VD/VT during exercise, presumably due to increased filling pressures and resultant pulmonary congestion. Stroke volume reserve is a novel noninvasive parameter, calculated by response in stroke volume at anaerobic threshold (AT) compared to rest. Previous studies have shown an increase in stroke volume at AT compared to resting value to be greater than or equal to 128% in normal patients. In this study, we utilized stroke volume (SV) reserve to evaluate and better understand ventilatory efficiency in HFrEF patients. Objective The study aimed to utilize SV reserve (SV-AT/SV-rest) to evaluate ventilatory efficiency and changes in VD/VT in HFrEF patients. Based on a combinational derivation of Fick's equation [CO=VO2 / Ca - Cv] and the equation for physiological dead space proportion [VD/VT = 1 - (863xVCO2 / VExPaCO2)], we hypothesized that an inappropriate SV reserve (less than 128%) would correlate with decreased carbon dioxide production at anaerobic threshold (VCO2-AT), decreased oxygen consumption at anaerobic threshold, and an increased VE/VCO2 slope. Methods This was a retrospective, cohort analysis of 47 HFrEF patients (EF Results A significant increase in VCO2-AT (0.80 ± 0.32 vs 0.62 ± 0.18, p=0.04) and VO2-AT (11.85 ± 3.22 vs 8.82 ± 1.95, p=0.001) occurred for the appropriate SV reserve cohort compared to the inappropriate SV reserve cohort. VE/VCO2 slope was significantly higher in the inappropriate SV reserve group when compared to the appropriate SV reserve group (34.18 ± 7.86 vs 30.12 ± 4.58, p=0.03). There was an associated increase in VD/VT in the inappropriate SV reserve cohort with exercise. Conclusions In patients with inappropriate stroke volume reserve, the VE/VCO2 slope was elevated above 34 and also correlated with increased VD/VT with exercise. This study is the first to use stroke volume reserve to non-invasively demonstrate inappropriate circulatory response as a potential cause for elevation in VE/VCO2 slope with exercise.

The association between preoperative cardiopulmonary exercise–test variables and short-term morbidity after esophagectomy: A hospital-based cohort study

BackgroundPostoperative complications after esophagectomy are thought to be associated with reduced fitness. This observational study explored the associations between aerobic fitness, as determined objectively by preoperative cardiopulmonary exercise testing (CPEX), and 30-day morbidity after esophagectomy. MethodsWe retrospectively identified 254 consecutive patients who underwent esophagectomy at a single academic teaching hospital between September 2011 and March 2017. Postoperative complication data were measured using the Esophageal Complications Consensus Group definitions and graded using the Clavien-Dindo classification system of severity (blinded to cardiopulmonary exercise testing values). Associations between preoperative cardiopulmonary exercise testing variables and postoperative outcomes were estimated using logistic regression. ResultsA total of 206 patients (77% male) were included in the analyses, with a mean age of 67 years (SD 9). The mean values for the maximal oxygen consumed at the peak of exercise (VO2peak) and the anaerobic threshold were 21.1 mL/kg/min (SD 4.5) and 12.4 mL/kg/min (SD 2.8), respectively. The vast majority of patients (98.5%) had malignant disease—predominantly adenocarcinoma (84.5%), for which most received neoadjuvant chemotherapy (79%) and underwent minimally invasive Ivor Lewis esophagectomy (53%). Complications at postoperative day 30 occurred in 111 patients (54%), the majority of which were cardiopulmonary (72%). No associations were found between preoperative cardiopulmonary exercise testing variables and morbidity for either VO2peak (OR 1.00, 95% CI 0.94–1.07) or anaerobic threshold (OR 0.98, 95% CI 0.89–1.09). ConclusionPreoperative cardiopulmonary exercise testing variables were not associated with 30-day complications after esophagectomy. The findings do not support the use of cardiopulmonary exercise testing as an isolated preoperative screening tool to predict short-term morbidity after esophagectomy. This modestly sized observational work highlights the need for larger studies examining associations between preoperative cardiopulmonary exercise testing and outcomes after esophagectomy to look for consistency in our findings.

Use of Ventilatory Efficiency Slope as a Marker for Increased Mortality in Wild-Type Transthyretin Cardiac Amyloidosis

Wild-type transthyretin amyloidosis (ATTRwt) results in an infiltrative cardiomyopathy often culminating in symptomatic heart failure. The use of cardiopulmonary exercise testing (CPET) in determining outcomes in ATTRwt cardiac amyloidosis is unknown. Given the emergence of novel therapies to treat transthyretin amyloidosis, we sought to investigate the utility of CPET on outcomes in patients with ATTRwt cardiomyopathy. Fifty-six patients, with biopsy and immunohistochemically proved ATTRwt, were enrolled between 2005 and 2015, as part of an NIH ATTRwt substudy at the Boston University Amyloidosis Center. Patients were prospectively studied, which included laboratory tests, electrocardiogram, echocardiography, in addition to CPET. In this cohort of ATTRwt patients who performed CPET were elderly, all were male, and predominantly white (69.9%). The overall median survival was 59.01 months (95% confidence interval [CI] 49.29 to 88.69). By multivariate analysis, C-reactive protein (CRP; hazard ratio [HR] 1.10 [1.03 to 1.18]), decreased sodium (HR 0.75 [0.58 to 0.97]), creatinine (HR 7.48 [2.44 to 22.98]) and VE/VCO2 (HR 1.10 [1.05 to 1.16]) were significant risk factors for mortality (p <0.05). Peak VO2 was insignificant by both univariate and multivariate analyses. ATTRwt patients with VE/VCO2 >40 had a worse median survival of 38.54 months (95% CI 32.63 to 51.47) versus 88.69 months (95% CI 56.26 to 89.49) than patients with VE/VCO2 slope ≤40. Receiver-operating characteristic curve showed that the combination of VE/VCO2, CRP, sodium, and creatinine (Area under the ROC Curve [AUC], 0.89) predicted 1-year mortality in ATTRwt cardiac amyloidosis. In conclusion, increased VE/VCO2, in combination with CRP, sodium, and creatinine, may identify patients at increased risk of death in ATTRwt cardiomyopathy. VE/VCO2 might have a role in objectively assessing therapeutic response in ATTRwt cardiac amyloidosis.

A Systematic Approach to Interpreting the Cardiopulmonary Exercise Test in Pediatrics

The use of cardiopulmonary exercise testing in pediatrics provides critical insights into potential physiological causes of unexplained exercise-related complaints or symptoms, as well as specific pathophysiological patterns based on physiological responses or abnormalities. Clinical interpretation of the results of a cardiopulmonary exercise test in pediatrics requires specific knowledge with regard to pathophysiological responses and interpretative strategies that can be adapted to address concerns specific to the child's medical condition or disability. In this review, the authors outline the 7-step interpretative approach that they apply in their outpatient clinic for diagnostic, prognostic, and evaluative purposes. This approach allows the pediatric clinician to interpret cardiopulmonary exercise testing results in a systematic order to support their physiological reasoning and clinical decision making.

The use of cardiopulmonary exercise testing in identifying the presence of obstructive sleep apnea syndrome in patients with compatible symptomatology

The aim of this study was to investigate the relationship between cardiopulmonary exercise testing (CPET) and the presence of obstructive sleep apnea syndrome (OSAS) in order to provide an innovative tool to identify patients with OSAS. A prospective nested case control design was adopted. A consecutive population of male volunteers referred to a Sleep Unit was subjected to nocturnal polysomnography, full lung function testing and maximal CPET. A stepwise linear discriminant function analysis (DFA) was applied to construct a model which could identify individuals with moderate-to-severe OSAS from healthy controls. The total of 30 volunteers formed the OSAS and 24 the non-OSAS groups. Demographic and somatometric parameters were similar between groups. Patients presented with lower Expiratory Reserve Volume (ERV: 106.7 ± 28.3 vs. 123.9 ± 22.1, p < 0.001), Leg FatigueBorg scale (3.9 ± 1.1 vs. 6.1 ± 1.4, p < 0.001), VO2peak(25.0 ± 5.9 vs. 32.9 ± 7.2 ml/kg−1/min−1, p < 0.001), peak breathing frequency (31.0 ± 5.8 vs. 35.5 ± 7.3 1/min−1, p < 0.001) and peak heart rate (151.1 ± 17.7 vs. 171.2 ± 12.6 beats/min−1, p < 0.001) compared to controls, but higher peak end-tidal CO2 (PETCO2peak:38.6 ± 4.2 vs. 35.0 ± 4.9 mmHg, p = 0.043) and peak systolic (SBP:188.3 ± 21.9 vs. 173.1 ± 17.9 mmHg, p = 0.009) and diastolic (DBP: 91.3 ± 8.2 vs. 85.4 ± 8.2 mmHg, p = 0.011) blood pressure. Stepwise DFA indicated that ERV% of predicted (0.372), PETCO2peak (−0.376), SpO2resting (0.0667), Leg Fatigue Borg scale (0.564), HRpeak (0.530) and DBPpeak (−0.543) could separate the two groups, with an overall predictive accuracy of 96.3%. Selected CPET parameters (ERV% of predicted, PETCO2peak, SpO2resting, HRpeak, DBPpeak and Leg FatigueBorg Scale) are independently associated with OSAS presence and could discriminate patients with and without this disorder.

A practical clinical approach to utilize cardiopulmonary exercise testing in the evaluation and management of coronary artery disease: a primer for cardiologists.

Purpose of reviewThere is growing clinical interest for the use of cardiopulmonary exercise testing (CPET) to evaluate patients with or suspected coronary artery disease (CAD). With mounting evidence, this concise review with relevant teaching cases helps to illustrate how to integrate CPET data into real world patient care.Recent findingsCPET provides a novel and purely physiological basis to identify cardiac dysfunction in symptomatic patients with both obstructive-CAD and nonobstructive-CAD (NO-CAD). In many cases, abnormal cardiac response on CPET may be the only objective evidence of potentially undertreated ischemic heart disease. When symptomatic patients have NO-CAD on coronary angiogram, they are still at increased risk for cardiovascular events. This problem appears to be more common in women than men and may warrant more aggressive risk factor modification. As the main intervention is lifestyle (diet, smoking cessation, exercise) and medical therapy (statins, angiotensin-converting enzyme inhibitors, beta-blockers), serial CPET testing enables close surveillance of cardiovascular function and is responsive to clinical status.SummaryCPET can enhance outpatient evaluation and management of CAD. Diagnostically, it can help to identify physiologically significant obstructive-CAD and NO-CAD in patients with normal routine cardiac testing. CPET may be of particular value in symptomatic women with NO-CAD. Prognostically, precise quantification of improvements in exercise capacity may help to improve long-term lifestyle and medication adherence for this chronic condition.

Clinical use of cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease undergoing a pulmonary rehabilitation programme: A retrospective cohort study

Background: Exercise training is a core component of pulmonary rehabilitation programmes (PRP). In addition to characterising patient limitations, pre-PRP cardiopulmonary exercise testing (CEPT) can be used to screen for adverse effects of exercise, such as ischaemia, arrhythmia, or hypoxaemia, and to design individual exercise training regimens that are effective and tolerable. This study aimed to investigate the impact of pre-PRP CPET on outcomes Methods: Screened patients with COPD were invited to participate in PRP at a local acute hospital in Hong Kong. Patients with contraindications to exercise were excluded. Eligible patients were arranged to undergo CPET before training. Positive outcomes were defined as improvement in St George’s Respiratory Questionnaire (SGRQ) score by four points or greater and/or improvement in 6-minute walk test (6MWT) distance by 30 m or more. Findings: 70 patients were recruited, 40 (57.1%) of whom achieved positive outcomes after training. More patients who had exercise testing (29 of 42; 69%) than those who did not have exercise testing (13 of 42; 31%) attained positive outcomes (p=0.014). All participants attained a training intensity close to the exercise testing determined target. Participants with positive outcome attained training intensity at 97.64±45.77% of their target; participants without positive outcome attained a lower training intensity at 87.10±21.90% of their target. Interpretation: This study shows that CPET was effective in helping PRP participants achieve positive outcomes. Whether the performance of patients without exercise testing had been limited by undiagnosed underlying medical condition was uncertain. Further studies exploring the impact of pre-PRP CPET in improving the safety and effectiveness of PRP are warranted. Funding: None. Contributors: CMC was responsible for data collection and analysis. Other authors were responsible for giving expert opinion. Conflicts of interest: We declare that we have no conflicts of interest.

Cardiopulmonary Exercise Testing: Basics of Methodology and Measurements.

Cardiopulmonary exercise testing adds measurement of ventilation and volume of oxygen uptake and exhaled carbon dioxide to routine physiological and performance parameters obtainable from conventional exercise testing, furnishing an all-around vision of the systems involved in both oxygen transport from air to mitochondria and its use during exercise. Peculiarities of cardiopulmonary exercise testing methodology are the use of ramp protocols and calibration procedures for flow meters and gas analyzers. Among the several parameters provided by this technique, peak oxygen uptake, first and second ventilatory thresholds, respiratory exchange ratio, oxygen pulse, slope of ventilation divided by exhaled carbon dioxide relationship, exercise oscillatory ventilation, circulatory power, and partial pressure of end-tidal carbon dioxide are among the most relevant in the clinical setting. The choice of parameters to be considered will depend on the indication to cardiopulmonary exercise testing in the individual subject or patient, namely, exercise tolerance assessment, prognostic stratification, training prescription, treatment efficacy evaluation, diagnosis of causes of unexplained exercise tolerance reduction, or exercise (patho)physiology evaluation for research purposes. Overall, cardiopulmonary exercise testing is a methodology now widely available and supported by sound scientific evidence. Despite this, its potential still remains largely underused. Strong efforts and future investigations are needed to address these issues and further promote the use of cardiopulmonary exercise testing in the clinical and research setting.

Prognostic Usefulness of Cardiopulmonary Exercise Testing for Managing Patients With Severe Aortic Stenosis

The approach to managing asymptomatic or questionably symptomatic patients for aortic stenosis is difficult. We aimed to determine whether cardiopulmonary exercise testing (CPET) is prognostically useful in such patients. Patients judged asymptomatic or questionably symptomatic for aortic stenosis with aortic valve area index <0.6 cm2/m2 and left ventricular ejection fraction ≥0.50 were managed conservatively provided they had either (group 1) normal peak oxygen consumption and peak oxygen pulse (>83% and >95% of the predicted values, respectively) or (group 2) subnormal peak oxygen consumption or peak oxygen pulse but with CPET data pointing to pathologies other than hemodynamic compromise from aortic stenosis. Increase in systolic blood pressure <20 mm Hg, ST depression ≥2 mm, or symptoms during the exercise test were allowed. Unexpected events included cardiac death or hospitalization with heart failure in patients who had not been recommended valve replacement. The median age of the study population (n = 101) was 75 years (interquartile range 65 to 79 years), and 67% were judged questionably symptomatic. During a follow-up at 24 ± 6 months, the rate of unexpected cardiac death and unexpected hospitalization with heart failure was 0% and 6.0%, respectively. All-cause mortality was 4.0% compared with 8.0% in the age- and gender-matched population. For group 1, 26 of 70 (37.1%) succumbed to cardiac death, or were hospitalized because of heart failure, or underwent valve replacement, and for group 2 this was 12 of 31 (38.7%). In conclusion, if CPET does not indicate a significant hemodynamic compromise because of aortic stenosis, an initially conservative strategy results in a good prognosis and an acceptable event rate.