Value Of Cardiopulmonary Exercise Testing Research Articles

The Value of Cardiopulmonary Exercise Testing in Predicting the Severity of Coronary Artery Disease.

Background: There have been a limited number of quantitative studies on the relationship between coronary artery disease (CAD) and cardiorespiratory fitness (CRF), as measured by cardiopulmonary exercise testing (CPET). Thus, we aimed to investigate the association between CRF and the severity of coronary artery disease from the most comprehensive perspective possible, and to affirm the predictive value of CPET in the severity assessment of CAD. Methods: Our study included 280 patients with coronary angiography, who had undergone CPET in Tongji Hospital. The patients’ CRF was measured through their peak oxygen uptake (VO2@peak), their oxygen uptake at the anaerobic threshold (VO2@AT) and through other parameters of CPET on a bicycle ergometer. The severity of the coronary artery disease was assessed in the following three layers: functionally significant lesions (quantitative flow ratio [QFR] ≤ 0.8), the number of stenotic coronary arteries (SCA, stenosis ≥ 50%) and the Gensini score. The correlation analyses were carried out between the CRF and the severity of the coronary artery disease. A ROC curve was plotted, and the AUC was calculated to distinguish the severe CAD and the non-severe CAD patients, as measured by the QFR, the number of SCA, and the Gensini score. Results: The VO2@AT and VO2@peak were inversely associated with the QFR. The VO2@AT, VO2@peak and VO2/kg@peak were associated with the number of SCA. Meanwhile, the VO2@AT, VO2/kg@AT, VO2@peak and VO2/kg@peak were associated with the Gensini score. An ROC analysis proved that a combination of traditional clinical risk factors and the VO2@peak/VO2prediction is valuable in predicting CAD severity. Conclusions: Our study demonstrated a strong and inverse association between CRF and the severity of CAD. A combination of traditional clinical risk factors and CRF is valuable in predicting CAD severity.

La place de l’Exploration Fonctionnelle (cardio-)respiratoire d’eXercice (EFX) dans la prise en charge de la sclérodermie systémique

Cardiopulmonary complications are the leading cause of mortality in patients with systemic sclerosis (SSc) requiring an early identification. A global and comprehensive approach is needed due to the complexity of the overlapping aetiologies of dyspnoea in SSc. Through its integrative approach of ventilatory, metabolic, cardiovascular, skeletal muscular and gas exchange findings, cardiopulmonary exercise testing (CPET) has been known to identify and sort competing mechanisms of exercise limitation in scleroderma patients presenting with dyspnoea. CPET may be used to screen for pulmonary arterial hypertension, suspect interstitial lung disease and guide therapeutic strategies including exercise rehabilitation. This review focuses on the clinical value of CPET in the decision-making processes for a more personalised diagnostic approach to SSc-related complications.

Incremental value of cardiopulmonary exercise testing in intermediate-risk pulmonary arterial hypertension.

Risk assessment in pulmonary arterial hypertension (PAH) is essential for prognostication. However, the majority of patients end-up in an intermediate risk status, offering insufficient guidance in clinical practice. The added value of cardiopulmonary exercise testing in this setting remains undefined. Two independent cohorts with idiopathic PAH at intermediate risk were used to develop (n=124) and externally validate (n=143) the prognostic model. Cross-validation on the overall population was used to strengthen the results of the analysis. Risk assessment was based on the simplified version of the ESC/ERS guidelines score. Discrimination and calibration were assessed. A risk score was constructed based on the beta-coefficient of the cross-validated model, including the stroke volume index (SVI) and the peak oxygen uptake (VO2 peak). Patients were grouped based on cutoff values of the risk score allowing the highest discrimination in the overall cohort. Group 1, score ≤2 (101 patients) with VO2 peak ≥14 ml/kg/min and SVI >30 ml/m2; Group 2, score between 2 and 5 (112 patients) with VO2 peak between 9 and 14 ml/kg/min, and SVI between 20 and 50 ml/m2; Group 3, score >5 (46 patients) with VO2 peak <10 ml/kg/min and SVI <30 ml/m2. The event-free survival rates at 1, 2 and 3 years, were 96%, 83% and 79% for Group 1, respectively; 82%, 67% and 52% for Group 2; 69%, 50% and 41% for Group 3. Combinations of VO2 peak and SVI may provide important information to further stratify intermediate-risk prevalent patients with idiopathic PAH.

Functional Capacity in Patients Who Recovered from Mild COVID-19 with Exertional Dyspnea.

Background: Post mild COVID-19 dyspnea is poorly understood. We assessed physiologic limitations in these patients. Methods: Patients with post mild COVID-19 dyspnea (group A) were compared (pulmonary function tests, 6-min walk test (6MWT), echocardiography and cardiopulmonary exercise test (CPET)) to post moderate/severe COVID-19 (group B) and to CPET and spirometry of patients with unexplained dyspnea (group C). Results: The study included 36 patients (13 in A, 9 in B and 14 in C). Diffusion capacity was lower in group B compared to group A (64 ± 8 vs. 85 ± 9% predicted, p = 0.014). 6MWT was normal and similar in both patient groups. Oxygen uptake was higher in group A compared to groups B and C (108 ± 14 vs. 92 ± 13 and 91 ± 23% predicted, p = 0.013, 0.03, respectively). O2 pulse was normal in all three groups but significantly higher in the mild group compared to the control group. Breathing reserve was low/borderline in 2/13 patients in the mild group, 2/9 in the moderate/severe group and 3/14 in the control group (NS). Conclusions: Patients with post mild COVID-19 dyspnea had normal CPET, similar to patients with unexplained dyspnea. Other mechanisms should be investigated and the added value of CPET to patients with post mild COVID-19 dyspnea is questionable.

Independent and additional value of cardiopulmonary exercise test to the new york heart association classification in heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background The Cardiopulmonary Exercise Test (CPET) is the gold standard test for functional assessment in Heart Failure (HF), but it has not been adequately evaluated on top of the New York Heart Association (NYHA) class. Purpose We aimed to assess the independent and additional value of CPET to NYHA class in patients with HF and ejection fraction (EF) &amp;lt;50%. Our secondary purpose is to assess the performance of CPET variables in patients with better (NYHA I or II) and worse (NYHA III or IV) functional class. Methods Patients with HF and reduced or mid range ejection fraction (EF) who underwent CPET were followed for the occurrence of the primary end point of death, heart transplantation and left ventricular assist device (LVAD) implant. Cox regression analysis and ROC curve analysis were used to determine independent predictors for the primary outcome and the additional CPET value, respectively. Kaplan–Meier failure curves were created to illustrate time to primary end point. A value of p &amp;lt;0.05 was considered statistically significant. Results 613 patients were followed for a mean of 30 ± 22 months. Mean age was 56 ± 12 years, 64% were male, mean EF was 30 ± 8%. NYHA as follows: NYHA I 32%, NYHA II 41%, NYHA III 24% and NYHA IV 2.8%. The rate of primary outcomes was 13%. Death occurred in 8.7%, heart transplantation in 4.4% and there were no cases of LVAD´s implantation. Independent predictors of the primary outcome were: EF (HR 0.946; 95% CI 0.918-0.976; p&amp;lt;0.001), NYHA (HR 2.1; 95% CI 1.55-2.73; p&amp;lt;0.001). When peak VO2 was added to the model, it was maintained as an independent predictor (HR 0.90; 95% CI 0.85-0.96; p 0.001), as was the percentage of predicted peak VO2 (HR 0.03; 95% CI 0.007-0.147; p&amp;lt;0.001), VE/VCO2 slope (HR 1.02; 95% CI 1.01-1.04; p 0.011) and CPET score (HR 1.16; 95% CI 1.06-1.27; p&amp;lt;0.001). ROC curve of the predictor model with only NYHA and ROC curves of the models adding the other CPET variables are shown in Figure 1. There was no significant difference between the curves of the model containing only NYHA and the models with the CPET parameters or the CPET score (Table 1). VO2 peak and VE/VCO2 slope were able to discern survival in functional classes I and II (log rank p &amp;lt; 0.001), but were not clearly in classes III and IV (log rank p = 0.113 and p = 0.124 respectively). CPET score was able to discern survival in both groups, in those with the best and worst functional class (log rank p &amp;lt; 0.05). Conclusion CPET variables were independent predictors of prognosis in HF, even when controlled by NYHA class. Although they have independent value, their additional value was modest and not statistically significant.

Prognostic Role Of Cardiopulmonary Exercise Testing In Wild Type Transthyretin Amyloid Cardiomyopathy Patients Treated With Tafamidis

<h3>Background</h3> Prognostic value of cardiopulmonary exercise test (CPET) in heart failure with reduced ejection fraction is well established, but it's utility in wild type transthyretin cardiac amyloidosis (wtATTR) patients treated with Tafamidis is unknown. <h3>Objective</h3> To determine the role of baseline CPET in Tafamidis treated wtATTR amyloid patients. <h3>Methods</h3> A retrospective study was conducted to identify wtATTR patients who were treated with Tafamidis and underwent baseline CPET at The University of Kansas Amyloid Clinic from 8/31/2018 until 3/31/2020. Univariate and multivariate logistic regression models were used to predict the occurrence of the primary outcome (composite of mortality, heart transplant, and palliative inotrope initiation). <h3>Results</h3> A total of 33 patients were included with a mean age of 81 ± 5.7 years. About 84% were Caucasians and 79% were males. Mean peak oxygen consumption (VO₂) and peak circulatory power (CP) were low at 11.88 ± 3.74 ml/kg/min and 1667.8 ± 804.2 mmHg/ml/min, respectively. Mean VE/VCO₂ (Ventilatory efficiency) was 36.65 ± 8.7. After 1 year follow-up, 11 patients had reached the primary outcome. Median exercise duration was significantly lower in patients with primary outcomes compared to those without as shown in figure 1 [4.4 (IQR 3.6-4.7) vs 6.9 (IQR 5.9-8.9), p <0.001]. Upon multivariate analysis; peak VO₂ [OR 0.25, CI(0.07-0.91), p=0.03], peak CP [OR 0.99,CI(0.98-0.99), p=0.03] and peak VO₂/HR (Oxygen pulse) [OR 0.44, CI(0.22-0.87), p=0.02] were significantly associated with the primary outcome. VE/VC0₂ (Ventilatory efficiency) was not significantly associated with the primary outcome. (Table 1) <h3>Conclusion</h3> Peak V02, peak CP, and peak VO₂/HR may have a prognostic role in selecting which wtATTR patients will benefit from Tafamidis treatment.

Value of Cardiopulmonary Exercise Testing in Prognostic Assessment of Patients with Interstitial Lung Diseases.

Background: Interstitial lung disease (ILD) is associated with high rates of comorbidities and non-infectious lung disease mortality. Against this background, we aimed to evaluate the prognostic capacity of lung function and cardiopulmonary exercise testing (CPET) in patients with ILD. Materials and Methods: A total of 183 patients with diverse ILD entities were included in this monocentric analysis. Prediction models were determined using Cox regression models with age, sex, body mass index (BMI), and all parameters from pulmonary function testing and CPET. Kaplan–Meier curves were plotted for selected variables. Results: The median follow-up period was 3.0 ± 2.5 years. Arterial hypertension (57%) and pulmonary hypertension (38%) were the leading comorbidities. The Charlson comorbidity index score was 2 ± 2 points. The 3-year and 5-year survival rates were 68% and 50%, respectively. VO2peak (mL/kg/min or %pred.) was identified as a significant prognostic parameter in patients with ILD. The cut-off value for discriminating mortality was 61%. Conclusion: The present analyses consistently revealed the high prognostic power of VO2peak %pred. and other parameters evaluating breathing efficacy (VÉ/VCO2 @AT und VÉ/VCO2 slope) in ILD patients. VO2peak %pred., in contrast to the established prognostic values FVC %pred., DLCO/KCO %pred., and GAP, showed an even higher prognostic ability in all statistical models.

Exercise Physiology Impairments of Patients With Amyotrophic Lateral Sclerosis: Cardiopulmonary Exercise Testing Findings.

Background and ObjectiveIn amyotrophic lateral sclerosis (ALS), progressive weakness significantly limits the ability to exercise. However, measurements of the impaired exercise function and their practical value to assess disease progression in ALS are scarce. Cardiopulmonary exercise testing (CPET) is a non-invasive accurate method used to comprehensively quantify exercise physiology in a variety of diseases. This study aimed to evaluate the clinical value of CPET and to explore its association with disease severity and prognosis prediction in ALS.MethodsA total of 319 participants were enrolled in this 3-year prospective study. After strict quality control, 109 patients with ALS and 150 age- and sex-matched healthy controls were included with comprehensive clinical assessment and follow-ups. The incremental ramp protocol for symptom-limited CPET was applied in both groups. The exercise physiology during peak effort exercise was systematically measured, including the overall aerobic capacity of exercise (VO2 peak) and the respective capacity of the exercise-involved organs [cardiac response (heart rate peak—HR peak), ventilatory efficiency (VE/VCO2 slope), breathing economy (VE/VO2 peak), and other relevant parameters]. Disease severity and progression were evaluated using recognized scales. Survival was monitored with regular follow-ups every 6 months.ResultsDecreased exercise capacity (VO2 peak < 16 ml/kg/min) occurred more frequently in patients with ALS than in controls (44.95% vs. 9.33%, p < 0.01). In patients with ALS, the average VO2 peak (16.16 ± 5.43 ml/kg/min) and HR peak [135 (112–153) bpm] were significantly lower (p < 0.01) than in controls [22.26 ± 7.09 ml/kg/min; 148 (135–164) bpm], but the VE/VCO2 slope was significantly higher [28.05 (25.03–32.16) vs. 26.72 (24.37–29.58); p = 0.03]. In patients with ALS, the VO2 peak and HR peak were significantly correlated with disease severity and progression scores (p < 0.05). Survival analyses revealed the VO2 peak and HR peak as protective indicators while the VE/VO2 peak as a detrimental indicator for the prognostic prediction in ALS (HR = 0.839, p = 0.001; HR = 0.967, p < 0.001; HR = 1.137, p = 0.028, respectively).ConclusionOur prospective study quantified the significantly decreased exercise capacity in ALS through non-invasive CPET. The impaired VO2 peak and HR peak closely correlated with disease severity and independently predicted a worse prognosis. Our findings identified the clinical value of CPET as an objective indicator of disease progression in ALS.

Diagnostic value of the cardiopulmonary exercise test in coronary artery disease.

BackgroundCoronary angiography (CAG) is “gold standard” for the diagnosis of coronary heart disease (CHD). This study aimed to explore the diagnostic value of cardiopulmonary exercise testing (CPET) and the oxygen uptake kinetics indexes of CPET.MethodsOne hundred thirty-one patients with chest pain who underwent coronary angiography in the Department of Cardiology of our hospital from April to September 2021 were selected. According to the results of angiography, the patients were divided into an observation group (patients with coronary heart disease, n=80) and a control group (patients without coronary heart disease, n=75). Both groups underwent CPET before angiography. The differences of peak oxygen uptake, anaerobic threshold, peak kilogram oxygen uptake, peak oxygen pulse, maximum exercise load, maximum metabolic equivalent, and exercise time between the two groups were compared. Also, the correlation between the above indexes and the degree of coronary artery stenosis was analyzed, and the clinical value of the CPET in the diagnosis of CHD was evaluated.ResultsThe peak oxygen uptake, anaerobic threshold, peak kilogram oxygen uptake, peak oxygen pulse, maximum exercise load, maximum metabolic equivalent, and exercise time in the observation group were lower than those in the control group (P<0.01), and were negatively correlated with the Gensini score (P<0.01). The area under the receiver operating characteristic (ROC) curve of the above seven indexes in the combined diagnosis of CHD was 0.974, the sensitivity was 86.40%, and the specificity was 98.50%, which was better than the clinical value of any of the above indexes alone.ConclusionsCPET is an effective non-invasive examination in the diagnosis of CHD, and has a certain clinical value in the evaluation of the severity of coronary artery stenosis.

Cardiopulmonary Exercise Testing in Repaired Tetralogy of Fallot: Multiparametric Overview and Correlation with Cardiac Magnetic Resonance and Physical Activity Level.

Patients with repaired Tetralogy of Fallot (rToF) typically report having preserved subjective exercise tolerance. Chronic pulmonary regurgitation (PR) with varying degrees of right ventricular (RV) dilation as assessed by cardiac magnetic resonance imaging (MRI) is prevalent in rToF and may contribute to clinical compromise. Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity, and the International Physical Activity Questionnaire (IPAQ) can provide additional data on physical activity (PA) achieved. Our aim was to assess the association between CPET values, IPAQ measures, and MRI parameters. All rToF patients who had both an MRI and CPET performed within one year between March 2019 and June 2021 were selected. Clinical data were extracted from electronic records (including demographic, surgical history, New York Heart Association (NYHA) functional class, QRS duration, arrhythmia, MRI parameters, and CPET data). PA level, based on the IPAQ, was assessed at the time of CPET. Eighty-four patients (22.8 ± 8.4 years) showed a reduction in exercise capacity (median peak VO2 30 mL/kg/min (range 25–33); median percent predicted peak VO2 68% (range 61–78)). Peak VO2, correlated with biventricular stroke volumes (RVSV: β = 6.11 (95%CI, 2.38 to 9.85), p = 0.002; LVSV: β = 15.69 (95% CI 10.16 to 21.21), p < 0.0001) and LVEDVi (β = 8.74 (95%CI, 0.66 to 16.83), p = 0.04) on multivariate analysis adjusted for age, gender, and PA level. Other parameters which correlated with stroke volumes included oxygen uptake efficiency slope (OUES) (RVSV: β = 6.88 (95%CI, 1.93 to 11.84), p = 0.008; LVSV: β = 17.86 (95% CI 10.31 to 25.42), p < 0.0001) and peak O2 pulse (RVSV: β = 0.03 (95%CI, 0.01 to 0.05), p = 0.007; LVSV: β = 0.08 (95% CI 0.05 to 0.11), p < 0.0001). On multivariate analysis adjusted for age and gender, PA level correlated significantly with peak VO2/kg (β = 0.02, 95% CI 0.003 to 0.04; p = 0.019). We observed a reduction in objective exercise tolerance in rToF patients. Biventricular stroke volumes and LVEDVi were associated with peak VO2 irrespective of RV size. OUES and peak O2 pulse were also associated with biventricular stroke volumes. While PA level was associated with peak VO2, the incremental value of this parameter should be the focus of future studies.

150 Incremental value of cardiopulmonary exercise testing in intermediate-risk pulmonary arterial hypertension

Abstract Aims Risk assessment in pulmonary arterial hypertension (PAH) is essential for prognostication. However, the majority of patients end-up in an intermediate risk status despite targeted-therapy, offering insufficient guidance in clinical practice. The added value of cardiopulmonary exercise testing (CPET) in this setting remains undefined. Methods and results Two independent cohorts with idiopathic PAH at intermediate risk were used to develop (n = 124) and externally validate (n = 143) the prognostic model. Risk assessment was based on the simplified version of the ESC/ERS guidelines score. The same definition of clinical worsening (CW) was used for both cohorts. Discrimination and calibration were assessed. Seventy-four derivation cohort patients experienced CW (51.2%) during a median of 34 months. Stroke volume index (SVI) and 6-min walk-distance (6MWD) were independent predictors of CW. With addition of CPET variables, SVI and VO2 peak independently improved the power of the prognostic model, determined by the integrated discrimination integral (IDI) index. ROC-derived cut-off values for SVI and VO2 peak were 34 and 14 ml/kg/min, respectively. Forty-eight validation cohort patients experienced CW (33.5%) during a median of 27 months follow-up. Different combinations of cut-off values of SVI and VO2 peak defined three meaningful groups showing good discrimination and calibration. The event-free survival rates at 1, 2, and 3 years were, respectively, 96%, 89%, and 89% for high SVI/high VO2 peak combination; 85%, 73%, and 61% for high SVI/low VO2 peak; and 80%, 70%, and 56% for low SVI/low VO2 peak. Conclusions Combinations of VO2 peak and SVI during follow-up is important in the prognostication of intermediate-risk prevalent patients with idiopathic PAH.

Value of Cardiopulmonary Exercise Testing in the Prognosis Assessment of Chronic Obstructive Pulmonary Disease Patients: A Retrospective, Multicentre Cohort Study

Introduction: Chronic obstructive pulmonary disease (COPD) is one of the most common chronic diseases associated with high mortality. Previous studies suggested a prognostic role for peak oxygen uptake (VO₂peak) assessed during cardiopulmonary exercise testing (CPET) in patients with COPD. However, most of these studies had small sample sizes or short follow-up periods, and despite their relevance, CPET parameters are not included in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) tool for assessment of severity. Objectives: We therefore aimed to assess the prognostic value of CPET parameters in a large cohort of outpatients with COPD. Methods: In this retrospective, multicentre cohort study, medical records of patients with COPD who underwent CPET during 2004–2017 were reviewed and demographics, smoking habits, GOLD grade and category, exacerbation frequency, dyspnoea score, lung function measurements, and CPET parameters were documented. Relationships with survival were evaluated using Kaplan-Meier analysis, Cox regression, and receiver operating characteristic (ROC) curves. Results: Of a total of 347 patients, 312 patients were included. Five-year and 10-year survival probability was 75% and 57%, respectively. VO₂peak significantly predicted survival (hazard ratio: 0.886 [95% confidence interval: 0.830; 0.946]). The optimal VO₂peak threshold for discrimination of 5-year survival was 14.6 mL/kg/min (area under ROC curve: 0.713). Five-year survival in patients with VO₂peak <14.6 mL/kg/min versus ≥ 14.6 mL/kg/min was 60% versus 86% in GOLD categories A/B and 64% versus 90% in GOLD categories C/D. Conclusions: We confirm that VO₂peak is a highly significant predictor of survival in COPD patients and recommend the incorporation of VO₂peak into the assessment of COPD severity.

Cardiopulmonary Exercise Test Parameters in Athletic Population: A Review.

Although still underutilized, cardiopulmonary exercise testing (CPET) allows the most accurate and reproducible measurement of cardiorespiratory fitness and performance in athletes. It provides functional physiologic indices which are key variables in the assessment of athletes in different disciplines. CPET is valuable in clinical and physiological investigation of individuals with loss of performance or minor symptoms that might indicate subclinical cardiovascular, pulmonary or musculoskeletal disorders. Highly trained athletes have improved CPET values, so having just normal values may hide a medical disorder. In the present review, applications of CPET in athletes with special attention on physiological parameters such as VO2max, ventilatory thresholds, oxygen pulse, and ventilatory equivalent for oxygen and exercise economy in the assessment of athletic performance are discussed. The role of CPET in the evaluation of possible latent diseases and overtraining syndrome, as well as CPET-based exercise prescription, are outlined.

Prognostic value of cardiopulmonary exercise testing in valvular heart disease

Abstract Introduction Cardiopulmonary exercise testing (CEPT) is not routinely used for the assessment of valvular heart disease (VHD) patients. The cutoff values of percentage of predicted peak VO2 and ventilatory efficiency parameters that carry out a bad prognosis have been predominantly validated in heart failure. The aim of this study was to analyze the prognostic value of CPET parameters in a broad population of VHD patients. Methods 163 patients (51% female) with moderate or severe VHD who underwent a CEPT (n=197) at their physician's discretion from 2017 until 2019 were included. We calculated the net reclassification index of CPET, compared to the classical clinical or echocardiographic parameters, regarding the need for surgical indication. Also, the predictive value of CPET for death and symptom development during follow-up was estimated using regression analysis. Results At inclusion, all patients were asymptomatic or with minimal equivocal symptoms. Aortic valvular lesions were the most common (47%), followed by mitral valvular disease (44%). There was a predominance of severe valvular heart disease (71%) and most of the CEPTs were performed on a treadmill (74%). The percentage of predicted peak VO2 was 76±18% and at anaerobic threshold was 61±18%. The mean follow-up time was 15±10 months. There were 5 deaths (3%) and 24 patients became symptomatic. The net reclassification index of CPET over either clinical or echocardiographic parameters was 46%. The CEPT parameters that predicted increased risk of death were VE/VCO2 slope (p=0.009), % of predicted peak VO2 (p=0.049) and Eq CO2 at anaerobic threshold (p=0.047). None of the CEPT parameters was predictive of symptom development during follow-up, however, in the subgroup of patients who became clearly symptomatic, the ventilatory efficiency parameters were similar to the cut off values that confer bad prognosis (see Table in Figure). Conclusion In our series, CPET added prognostic mortality value to patients with VHD. The cut off values used for patients with HF can also be applied in a VHD population. In addition, CEPT clearly improved the clinical decision for surgical referral. Nevertheless, these results need to be validated in a broader population. Funding Acknowledgement Type of funding sources: None.

Risk stratification and survival in patients with HFmrEF: the role of cardiopulmonary exercise testing

Abstract Background The prognostic value of cardiopulmonary exercise testing (CPET) is established for risk stratification in patients with heart failure (HF) and reduced ejection fraction (HFrEF). Since the introduction of HF with mid-range ejection fraction (HFmrEF) as an additional category in 2016, optimal management strategy and risk stratification for these patients is a field of ongoing research. Purpose Left ventricular ejection fraction (LVEF) is only one part of the picture when planning treatment and estimating long time risk for patients with HF. We planned to investigate the predictive long-term value of exercise intolerance as measured by CPET in patients with HFmrEF in comparison to HFrEF. Methods We performed a single-center retrospective cohort study of ambulatory consecutive patients that showed signs of heart failure (NYHA functional class II or III) and had a LVEF of 49% or below as measured by echocardiography at the time of CPET. All patients underwent CPET evaluation with an upright bicycle between 2015–2017. The primary endpoint of all-cause mortality as well as the secondary composite endpoint of all-cause mortality or heart transplant/ventricular assist device implantation (transplant/VAD free survival) were assessed. Results For the primary analysis, 253 patients (mean age 61.2±13.0 years, 82.6% male) were included. 68 patients showed an LVEF between 40 and 49% (HFmrEF) whereas 185 patients had an LVEF of below 40% (HFrEF). HF etiology was in 31.3% ischemic. Mean BNP values were 788±1061 pg/ml while HFmrEF patients had on average lower values than HFrEF (322±676 vs. 945±1121, p&amp;lt;0.001). Patients were followed up for a median of 4.2 years (IQR: 3.5–5.0 years). Over this period, the primary and secondary end-point occurred in 22.5%/30.8% of patients. Patients in the HFmrEF group showed a higher mean peak oxygen uptake compared to HFrEF (pVO2; 17.3±4.6 vs 14.2±3.7 ml/min/kg, p&amp;lt;0.001), peak exercise power (Pmax; 111±49 vs 91±38 Watt, p=0.02) and peak oxygen pulse (pO2/HR; 12.6±4.2 vs 10.4±4.1 ml/min/kg, p&amp;lt;0.001). The Kaplan-Meier-Estimate showed a significant difference in survival for both HFmrEF and HFrEF who had pVO2 below 14 ml/min/kg (Log Rank: Chi2: 4.45, p=0.035 and Chi2: 10.05, p=0.02). In univariate Cox regression, pVO2 was predictive of the primary endpoint (HR per +1 mL/kg/min: 0.81; CI: 0.71–0.93; p=0.002 and HR per +1 mL/kg/min: 0.84; CI: 0.77–0.92; p&amp;lt;0.001) in both groups as was Pmax and pO2/HR (p&amp;lt;0.05 for both variables in both groups). Conclusion As in HFrEF, CPET is a useful tool to stratify risk in HFmrEF as well. Our findings support the prognostic role of pVO2 as well as pO2/HR and Pmax in HF with mid-range LVEF. Using a cut off of pVO2 14 ml/min/kg selected patients at risk with similar long-term prognosis as in the HFrEF cohort. Further research to identify subgroups at risk within the heterogeneous group of HFmrEF is warranted for optimal risk stratification. Funding Acknowledgement Type of funding sources: None.

Prognostic Role of Cardiopulmonary Exercise Testing in Wild-Type Transthyretin Amyloid Cardiomyopathy Patients Treated With Tafamidis

BackgroundThe prognostic value of cardiopulmonary exercise testing (CPET) in patients with wild-type transthyretin cardiac amyloidosis treated with tafamidis is unknown. Methods and ResultsThis retrospective study included patients with wtATTR who underwent baseline cardiopulmonary exercise testing and were treated with tafamidis from August 31, 2018, until March 31, 2020. Univariate logistic and multivariate cox-regression models were used to predict the occurrence of the primary outcome (composite of mortality, heart transplant, and palliative inotrope initiation). A total of 33 patients were included (median age 82 years, interquartile range [IQR] 79–84 years), 84% were Caucasians and 79% were males). Majority of patients had New York Heart Association functional class III disease at baseline (67%). The baseline median peak oxygen consumption (VO2) and peak circulatory power (CP) were 11.35 mL/kg/min (IQR 8.5–14.2 mL/kg/min) and 1485.8 mm Hg/mL/min (IQR 988–2184 mm Hg/mL/min), respectively, the median ventilatory efficiency was 35.7 (IQR 31–41.2). After 1 year of follow-up, 11 patients experienced a primary end point. Upon multivariate analysis, the low peak VO2 (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.23–0.79, P = .007], peak CP (HR 0.98, 95% CI 0.98–0.99, P = .02), peak oxygen pulse (HR 0.62, 95% CI 0.39–0.97, P = .03), and exercise duration of less than 5.5 minutes (HR 5.82, 95% CI 1.29–26.2, P = .02) were significantly associated with the primary outcome. ConclusionsTafamidis-treated patients with wtATTR who had baseline low peak VO2, peak CP, peak O2 pulse, and exercise duration of less than 5.5 minutes had worse outcomes.

Cardiopulmonary exercise testing and prognosis in patients with systemic sclerosis without baseline pulmonary hypertension: a prospective cohort study.

Cardiopulmonary Exercise Testing (CPET) is a standardized, non-invasive procedure assessing pulmonary, cardiovascular, hematopoietic, and skeletal muscle functions during a symptom-limited test. Few studies have examined whether CPET is of prognostic value in Systemic Sclerosis (SSc), a disease characterized by highly increased cardiorespiratory morbidity and mortality. To examine the prognostic value of CPET in SSc patients without baseline pulmonary hypertension (PH). Sixty-two consecutive SSc patients underwent CPET, Pulmonary Function Tests (PFTs) and echocardiography at baseline. Four patients with Right Ventricular Systolic Pressure ≥ 40mmHg, were excluded. Participants repeated PFTs approximately every 3years. At the end of the follow-up period [median (IQR): 9.79 (2.78) years] patient vital status was recorded. Cox Regression analysis was used to identify predictors of deterioration of PFTs and 10-year survival. Median (IQR) age of 58 patients (90% women) at baseline was 54.0 (15.0) years, whereas 10-year survival was 88%. Baseline respiratory Oxygen uptake (VO2max) predicted PFT deterioration, defined either as a decline in FVC ≥ 10% or a combined decline in FVC 5%-9% plus DLCO ≥ 15%, during follow-up, after correction for age, gender and smoking status (HR: 0.874, 95%CI: 0.779-0.979, p = 0.021). In addition, lower baseline VO2max (HR = 0.861, 95%CI:0.739-1.003, p = 0.054) and DLCO (HR = 0.957, 95%CI: 0.910-1.006 p = 0.088), as well as male gender (HR = 5.68, 95%CI: 1.090-29.610 p = 0.039) and older age (HR = 1.069, 95%CI: 0.990-1.154, p = 0.086) were associated, after adjustment, with an increased risk for death. In the absence of baseline PH, CPET indices may predict pulmonary function deterioration and death in SSc patients during a nearly 10-year follow-up period.

Prognostic value of cardiopulmonary exercise test after heart transplantation.

The clinical utility of cardiopulmonary exercise testing (CPET) has not been extensively studied yet in heart transplantation (HTX) patients. To analyze the predictive value of the CPET on hospitalizations and mortality in HTX recipients. A retrospective cohort was performed from a secondary database. Patients>18years with HTX who underwent a CPET between 3 and 12months after transplantation were included. Time to the first primary endpoint (HTX-related hospitalization) was analyzed and adjusted using Cox proportional hazards regression model. A total of 122 patients (mean age 50.1years, 77.0% men) were included. Fifty-seven patients (46.7%) had the primary endpoint. Peak VO2 (HR .95; CI 95% .90-.99, P=.03), oxygen pulse (HR .57; CI 95% .34-.96, P=.03) and predicted VO2 (HR .97; CI 95% .96-.99, P=.002) were associated with the endpoint. We did not find a significant association between the other variables and the outcome. In HTX recipients, peak VO2 , oxygen pulse, and predicted VO2 were independently associated with hospitalizations at follow up.

The impact of universal cardiopulmonary exercise testing on perioperative pathways and short-term patient outcomes following elective pancreatic surgery: A retrospective cohort study.

The utility of Cardiopulmonary Exercise Testing (CPET) to identify higher risk surgical patients remains controversial. There is limited research investigating the value of preoperative CPET to plan perioperative pathways for patients undergoing major pancreatic surgery. Retrospective cohort study, comprising two groups before and after a change in referral policy for High Risk preoperative anaesthetic clinic with CPET. Period 1 discretionary referral and Period 2: universal referral. The primary aim was to investigate the impact of this policy change on critical care use (planned vs unplanned) on the day of surgery and on delayed critical care admission. Secondary end points included a comparison of the total number of critical care bed days, days in hospital, complication rates and mortality data between the two cohorts. 177 patients were included; 114 in Period 1 and 63 in Period 2. There was a reduction in unplanned day of surgery postoperative admissions to critical care (28.1% vs. 11.1%, p = 0.008). Seven (6.1%) of patients in Period 1 and 1 (1.6%) patient in Period 2 had delayed admission, though no p value was calculated due to the small numbers involved. Complication rates were similar in each group. The median critical care bed days was 1 (range 0-21) days in Period 1 and 1 (0-13) days in Period 2. A universal referral policy for preoperative CPET demonstrated a decrease in unplanned day of surgery critical care admissions and a trend towards reducing delayed (>24 h postop) critical care admission which could be investigated in a larger study. No measurable impact was seen on clinical outcomes.

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

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