Author Archives: Paul Older

Does a 20-week aerobic exercise training programme increase our capabilities to buffer real-life stressors? A randomized, controlled trial using ambulatory assessment

Haaren, Birte; Ottenbacher, Joerg;
Muenz, Julia; Neumann, Rainer; Boes, Klaus; Ebner-Priemer, Ulrich.

European Journal of Applied Physiology, February 2016, Vol. 116 Issue:
Number 2 p383-394, 12p;

Abstract: The cross-stressor adaptation
hypothesis suggests that regular exercise leads to adaptations in the
stress response systems that induce decreased physiological responses
to psychological stressors. Even though an exercise intervention to
buffer the detrimental effects of psychological stressors on health
might be of utmost importance, empirical evidence is mixed. This may be
explained by the use of cross-sectional designs and non-personally
relevant stressors. Using a randomized controlled trial, we
hypothesized that a 20-week aerobic exercise training does reduce
physiological stress responses to psychological real-life stressors in
sedentary students.   Sixty-one students were  randomized to either a
control group or an exercise training group. The
academic examination period (end of the semester) served as a real-life
stressor. We used ambulatory assessment methods to assess physiological
stress reactivity of the autonomic nervous system (heart rate
variability: LF/HF, RMSSD), physical activity and perceived stress
during 2 days of everyday life and multilevel models for data analyses.
Aerobic capacity (VO2max) was assessed pre- and post-intervention via
cardiopulmonary exercise testing to analyze the effectiveness of the
intervention.   During real-life stressors, the exercise training group
showed significantly reduced LF/HF (β= −0.15,
t= −2.59, p= .01) and increased RMSSD (β= 0.15, t= 2.34, p= .02)
compared to the control group.
Using a randomized
controlled trial and a real-life stressor, we could show that exercise
appears to be a useful preventive strategy to buffer the effects of
stress on the autonomic nervous system, which might result into
detrimental health outcomes.

Impact of training methods and patient characteristics on exercise capacity in patients in cardiovascular rehabilitation

Reibis, Rona;
Salzwedel, Annett; Buhlert, Hermann; Wegscheider, Karl; Eichler, Sarah;
Völler, Heinz.

European Journal of Preventive Cardiology, March 2016,
Vol. 23 Issue: Number 5 p452-459, 8p;

Abstract: Aim  We aimed to
identify patient characteristics and comorbidities that correlate with
the initial exercise capacity of cardiac rehabilitation (CR) patients
and to study the significance of patient characteristics, comorbidities
and training methods for training achievements and final fitness of CR
patients.Methods  We studied 557 consecutive patients (51.7 ± 6.9
years; 87.9% men) admitted to a three-week in-patient CR.
Cardiopulmonary exercise testing (CPX) was performed at discharge.
Exercise capacity (watts) at entry, gain in training volume and final
physical fitness (assessed by peak O2utilization (VO2peak) were
analysed using analysis of covariance (ANCOVA) models.Results  Mean
training intensity was 90.7 ± 9.7% of maximum heart rate (81%
continuous/19% interval training, 64% additional strength training). A
total of 12.2 ± 2.6 bicycle exercise training sessions were performed.
Increase of training volume by an average of more than 100% was
achieved (difference end/beginning of CR: 784 ± 623 watts × min). In
the multivariate model the gain in training volume was significantly
associated with smoking, age and exercise capacity at entry of CR. The
physical fitness level achieved at discharge from CR as assessed by
VO2peakwas mainly dependent on age, but also on various factors related
to training, namely exercise capacity at entry, increase of training
volume and training method.

Conclusion  CR patients were trained in line
with current guidelines with moderate-to-high intensity and reached a
considerable increase of their training volume. The physical fitness
level achieved at discharge from CR depended on various factors
associated with training, which supports the recommendation that CR
should be offered to all cardiac patients.

Relationship between non‐invasive haemodynamic responses and cardiopulmonary exercise testing in patients with coronary artery disease

Sperling, Milena Pelosi Rizk; Caruso, Flávia Cristina Rossi;
Mendes, Renata Gonçalves; Dutra, Daniela Bassi; Arakelian, Vivian
Maria; Bonjorno, José Carlos; Catai, Aparecida Maria; Arena, Ross;
Borghi‐Silva, Audrey.

Clinical Physiology and Functional Imaging, March
2016, Vol. 36 Issue: Number 2 p92-98, 7p;

Abstract: Non‐invasive
assessment of haemodynamic function by impedance cardiography (IC)
constitutes an interesting approach to monitor cardiac function in
patients with coronary artery disease (CAD). However, such measurements
are most often performed at rest, whereas symptoms are also possible
during exertion, particularly at higher intensities. In addition, the
association between IC during exertion and cardiopulmonary exercise
testing (CPX) is not well understood in these patients, which was the
aim of this study. Nineteen men (age = 62 ± 6 years) with CAD [left
ventricular ejection fraction (LVEF) = 61 ± 10%] underwent a CPX using
an incremental protocol on a cycle ergometer, with simultaneous
measurement of IC. Cardiac output (CO), stroke volume (SV), cardiac
index (CI), peak oxygen consumption (VO2), the oxygen uptake efficiency
slope (OUES), circulatory power and ventilatory power were determined.
Pearson product‐moment correlation analysis revealed peak VO2 (r= 0·46)
was significantly related to CO. Peak oxygen pulse (0·52) was
associated with SV. OUES was associated with resting SV(0·47) and with
peak SV(r= 0·52). These findings suggest that ICindices are associated
with certain, but not all, established CPX measures in patients with
stable CAD.

Role of cardiopulmonary exercise testing as a risk-assessment method in patients undergoing intra-abdominal surgery: a systematic review

Moran, J.; Wilson, F.; Guinan, E.; McCormick, P.; Hussey, J.; Moriarty,

British Journal of Anaesthesia, February 2016, Vol. 116 Issue:
Number 2 p177-177, 1p;

Background. Cardiopulmonary exercise
testing (CPET) is used as a preoperative risk-stratification tool for
patients undergoing non-cardiopulmonary intra-abdominal surgery.
Previous studies indicate that CPET may be beneficial, but research is
needed to quantify CPET values protective against poor postoperative
outcome [mortality, morbidity, and length of stay (LOS)]. Methods. This
systematic review aimed to assess the ability of CPET to predict
postoperative outcome. The following databases were searched: PubMed,
EMBASE, PEDro, The Cochrane Library, Cinahl, and AMED. Thirty-seven
full-text articles were included. Data extraction included the
following: author, patient characteristics, setting, surgery type,
postoperative outcome measure, and CPET outcomes. Results. Surgeries
reviewed were hepatic transplant and resection (n</it>=7), abdominal
aortic aneurysm (AAA) repair (n</it>=5), colorectal (n</it>=6),
pancreatic (n</it>=4), renal transplant (n</it>=2), upper
gastrointestinal (n</it>=4), bariatric (n</it>=2), and general
intra-abdominal surgery (n</it>=12). Cardiopulmonary exercise
testing-derived cut-points, peak oxygen consumption (VO2pk), and
anaerobic threshold (AT) predicted the following postoperative
outcomes: 90 day–3 yr survival (AT 9–11 ml kg−1 min−1) and intensive
care unit admission (AT <9.9–11 ml kg−1 min−1) after hepatic transplant
and resection, 90 day survival after AAA repair
VO2pk 15 ml kg−1 min−1), LOS and morbidity after pancreatic surgery (AT <10–10.1 ml kg−1
min−1), and mortality and morbidity after intra-abdominal surgery (AT
10.9 and <10.1 ml kg−1 min−1, respectively).
Cardiopulmonary exercise testing is a useful preoperative
risk-stratification tool that can predict postoperative outcome.
Further research is needed to justify the ability of CPET to predict
postoperative outcome in renal transplant, colorectal, upper
gastrointestinal, and bariatric surgery.

Cardiopulmonary exercise test and sudden cardiac death risk in hypertrophic cardiomyopathy

Heart doi:10.1136/heartjnl-2015-308453




Background In hypertrophic cardiomyopathy (HCM), most of the factors associated with the risk of sudden cardiac death (SCD) are also involved in the pathophysiology of exercise limitation. The present multicentre study investigated possible ability of cardiopulmonary exercise test in improving contemporary strategies for SCD risk stratification.

Methods A total of 623 consecutive outpatients with HCM, from five tertiary Italian HCM centres, were recruited and prospectively followed, between September 2007 and April 2015. The study composite end point was SCD, aborted SCD and appropriate implantable cardioverter defibrillator (ICD) interventions.

Results During a median follow-up of 3.7 years (25th–75th centile: 2.2–5.1 years), 25 patients reached the end point at 5 years (3 SCD, 4 aborted SCD, 18 appropriate ICD interventions). At multivariate analysis, ventilation versus carbon dioxide relation during exercise (VE/VCO2 slope) remains independently associated to the study end point either when challenged with the 2011 American College of Cardiology Foundation/American Heart Association guidelines-derived score (C index 0.748) or with the 2014 European Society of Cardiology guidelines-derived score (C index 0.750). A VE/VCO2 slope cut-off value of 31 showed the best accuracy in predicting the SCD end point within the entire HCM study cohort (sensitivity 64%, specificity 72%, area under the curve 0.72).

Conclusions Our data suggest that the VE/VCO2 slope might improve SCD risk stratification, particularly in those HCM categories classified at low-intermediate SCD risk according to contemporary guidelines. There is a need for further larger studies, possibly on independent cohorts, to confirm our preliminary findings.

Prognostic value of cardiopulmonary exercise testing in heart failure with preserved ejection fraction

The Henry Ford HospITal
CardioPulmonary EXercise Testing (FIT-CPX) project by Shafiq, Ali;
Brawner, Clinton A.; Aldred, Heather A.; Lewis, Barry; Williams,
Celeste T.; Tita, Christina; Schairer, John R.; Ehrman, Jonathan K.;
Velez, Mauricio; Selektor, Yelena; Lanfear, David E.; Keteyian, Steven

American Heart Journal, 20160101, Issue: Number Preprints;

Abstract: Although cardiopulmonary exercise (CPX) testing in patients
with heart failure and reduced ejection fraction is well established,
there are limited data on the value of CPX variables in patients with
HF and preserved ejection fraction (HFpEF). We sought to determine the
prognostic value of select CPX measures in patients with HFpEF.

Case report: Subjective loss of performance after pulmonary embolism in an athlete– beyond normal values

Dumitrescu, Daniel; Gerhardt,
Felix; Viethen, Thomas; Schmidt, Matthias; Mayer, Eckhard; Rosenkranz,
Stephan. BMC

Pulmonary Medicine, December 2016, Vol. 16 Issue: Number 1
p1-4, 4p;

Abstract: Chronic thromboembolic pulmonary hypertension
(CTEPH) is a progressive disease. For patients with operable CTEPH,
there is a clear recommendation for surgical removal of persistent
thrombi by pulmonary endarterectomy (PEA). However, without the
presence of PH, therapeutic management of chronic thromboembolic
disease (CTED) is challenging – especially in highly trained subjects
exceeding predicted values of maximal exercise capacity.
A 43-year-old male athlete reported with progressive exercise
limitation since 8 months. Six months earlier, pulmonary embolism had
occurred, and was treated since with oral anticoagulation. A pulmonary
ventilation/perfusion scan showed severe ventilation/perfusion
mismatch: chest CT and pulmonary angiography revealed bilateral
wall-adherent thrombotic material, but pulmonary hemodynamics were
completely normal. His peak oxygen uptake exceeded predicted values,
however exercise ventilatory efficiency was abnormal, compared to a
matching athlete. After thoroughly discussing therapeutic options with
the patient, he successfully underwent pulmonary endarterectomy at an
expert center. Five and twelve months after surgery, his maximal
exercise capacity and ventilatory efficiency profoundly improved beyond
preoperative values, and his subjective exercise tolerance had returned
to normal.                   Significant CTED may be present without
relevant pathologic changes in pulmonary hemodynamics at rest. Reaching
normal values of maximal exercise capacity does not exclude pulmonary
vascular disease in highly trained subjects. More data are needed to
evaluate the risk-/benefit ratio of PEA in patients with CTED and
normal pulmonary hemodynamics. A thorough discussion with the patient
as well as shared decision making regarding therapy are mandatory.
Cardiopulmonary exercise testing may add important clinical information
in the non-invasive diagnostic evaluation at baseline and during

Measured by the oxygen uptake in the field, the work of refuse collectors is particularly hard work: Are the limit values for physical endurance workload too low?

Preisser, Alexandra; Zhou, Linfei; Garrido, Marcial; Harth, Volker.

International Archives of Occupational  and Environmental Health, February 2016, Vol. 89 Issue: Number 2
p211-220, 10p;

Abstract: Collecting waste is regarded as a benchmark
for “particularly heavy” work. This study aims to determine and compare
the workload of refuse workers in the field. We examined heart rate
(HR) and oxygen uptake as parameters of workload during their daily
work.   Sixty-five refuse collectors from three  task-specific groups
(residual and organic waste collection, and street
sweeping) of the municipal sanitation department in Hamburg, Germany,
were included. Performance was determined by cardiopulmonary exercise
testing (CPX) under laboratory conditions. Additionally, the oxygen
uptake (VO2) and HR under field conditions (1-h morning shift) were
recorded with a portable spiroergometry system and a pulse belt.
There was a substantial correlation of both absolute HR and
VO2during CPX [HR/VO2 R 0.89 (SD 0.07)] as well as during field
measurement [R0.78 (0.19)]. Compared to reference limits for heavy
work, 44 % of the total sample had shift values above 30 % heart rate
reserve (HRR); 34 % of the individuals had mean HR during work (HRsh)
values that were above the HR corresponding to 30 % of individual
maximum oxygen uptake (VO2,max). All individuals had a mean oxygen
uptake (VO2,1h) above 30 % of VO2,max.
HR as well as the measurement of VO2can be valuable tools for investigating
physiological workload, not only under laboratory conditions but also
under normal working conditions in the field. Both in terms of absolute
and relative HR and oxygen consumption, employment as a refuse
collector should be classified in the upper range of defined heavy
work. The limit of heavy work at about 33 % of the individual maximum
load at continuous work should be reviewed.

Biological quality control for cardiopulmonary exercise testing in multicenter clinical trials

Porszasz, Janos; Blonshine, Susan; Cao,  Robert; Paden, Heather; Casaburi, Richard; Rossiter, Harry. BMC

Pulmonary Medicine, December 2016, Vol. 16 Issue: Number 1 p1-10, 10p;

Abstract: Precision and accuracy assurance in cardiopulmonary exercise
testing (CPET) facilitates multicenter clinical trials by maximizing
statistical power and minimizing participant risk. Current guidelines
recommend quality control that is largely based on precision at
individual testing centers (minimizing test–retest variability). The
aim of this study was to establish a multicenter biological quality
control (BioQC) method that considers both precision and accuracy in
CPET.   BioQC testing was 6-min treadmill walking at 20 W and 70 W
(below the lactate threshold) with healthy non-smoking
laboratory staff (15 centers; ~16 months). Measurements were made twice
within the initial 4 weeks and quarterly thereafter. Quality control
was based on: 1) within-center precision (coefficient of variation [CV]
for oxygen uptake [V̇O2], carbon dioxide output [V̇CO2], and minute
ventilation [V̇E] within ±10 %); and 2) a criterion that V̇O2at 20 W
and 70 W, and ∆V̇O2/∆WR were each within ±10 % predicted. “Failed”
BioQC tests (i.e., those outside the predetermined criterion) prompted
troubleshooting and repeated measurements. An additional retrospective
analysis, using a composite z-score combining both BioQC precision and
accuracy of V̇O2at 70 W and ∆V̇O2/∆WR, was compared with the other
Of 129 tests (5 to 8 per center), 98 (76 %)
were accepted by within-center precision alone. Within-center CV was
<9 %, but between-center CV remained high (9.6 to 12.5 %). Only 43
(33 %) tests had all V̇O2measurements within the ±10 % predicted
criterion. However, a composite z-score of 0.67 identified 67 (52 %)
non-normal outlying tests, exclusion of which coincided with the
minimum CV for CPET variables.
Study-wide BioQC using
a composite z-score can increase study-wide precision and accuracy, and
optimize the design and conduct of multicenter clinical trials
involving CPET.

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial)

Study  protocol for a randomised controlled trial

Loughney, Lisa; West, Malcolm; Kemp, Graham; Rossiter, Harry; Burke, Shaunna; Cox, Trevor;
Barben, Christopher; Mythen, Michael; Calverley, Peter; Palmer, Daniel;
Grocott, Michael; Jack, Sandy.

Trials, December 2016, Vol. 17 Issue: Number 1 p1-13, 13p;

Abstract: The standard treatment pathway for
locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT)
followed by surgery. Neoadjuvant CRT has been shown to decrease
physical fitness, and this decrease is associated with increased
post-operative morbidity. Exercise training can stimulate skeletal
muscle adaptations such as increased mitochondrial content and improved
oxygen uptake capacity, both of which are contributors to physical
fitness. The aims of the EMPOWER trial are to assess the effects of
neoadjuvant CRT and an in-hospital exercise training programme on
physical fitness, health-related quality of life (HRQoL), and physical
activity levels, as well as post-operative morbidity and cancer
staging. The EMPOWER Trial is a randomised controlled
trial with a planned recruitment of 46 patients with locally advanced
rectal cancer and who are undergoing neoadjuvant CRT and surgery.
Following completion of the neoadjuvant CRT (week 0) prior to surgery,
patients are randomised to an in-hospital exercise training programme
(aerobic interval training for 6 to 9 weeks) or a usual care control
group (usual care and no formal exercise training). The primary
endpoint is oxygen uptake at lactate threshold (VO2 at AT)
measured using cardiopulmonary exercise testing assessed over several time points throughout the
study. Secondary endpoints include HRQoL, assessed using
semi-structured interviews and questionnaires, and physical activity
levels assessed using activity monitors. Exploratory endpoints include
post-operative morbidity, assessed using the Post-Operative Morbidity
Survey (POMS), and cancer staging, assessed by using magnetic resonance
tumour regression grading.   The EMPOWER trial is the
first randomised controlled trial comparing an in-hospital exercise
training group with a usual care control group in patients with locally
advanced rectal cancer. This trial will allow us to determine whether
exercise training following neoadjuvant CRT can improve physical
fitness and activity levels, as well as other important clinical
outcome measures such as HRQoL and post-operative morbidity. These
results will aid the design of a large, multi-centre trial to determine
whether an increase in physical fitness improves clinically relevant
post-operative outcomes.