Author Archives: Paul Older

Cardiopulmonary Exercise Testing in Heart Failure

Myers, Jonathan;
Arena, Ross; Cahalin, Lawarence P.; Labate, Valentina; Guazzi, Marco.
Current Problems in Cardiology, 20150101,
Abstract: A growing body of literature has underscored the value of
ventilatory gas exchange techniques during exercise testing (commonly
termed cardiopulmonary exercise testing, or CPX) and their applications
in the management of patients with heart failure (HF). The added
precision provided by this technology is useful in terms of
understanding the physiology and mechanisms underlying exercise
intolerance in HF, quantifying the response to therapy, evaluating
disability, making activity recommendations, and quantifying the
response to exercise training. Importantly, a wealth of data has been
published in recent years on the prognostic utility of CPX in patients
with HF. These studies have highlighted the concept that indices of
ventilatory inefficiency, such as the VE/VCO2slope and oscillatory
breathing, are particularly powerful in stratifying risk in HF. This
article provides an overview of the clinical utility of CPX in patients
with HF, including the applications of ventilatory inefficiency during
exercise, the role of the pulmonary system in HF, respiratory muscle
performance (RMP), and the application of CPX as part of a
comprehensive clinical and exercise test evaluation.

Cardiopulmonary exercise testing and survival after elective abdominal aortic aneurysm repair

Grant, S. W.; Hickey, G. L.;
Wisely, N. A.; Carlson, E. D.; Hartley, R. A.; Pichel, A. C.; Atkinson,
D.; McCollum, C. N..

British Journal of Anaesthesia, March 2015,
Vol. 114 Issue: Number 3 p430-430, 1p;

Background Cardiopulmonary exercise testing (CPET) is
increasingly used in the preoperative assessment of patients undergoing
major surgery. The objective of this study was to investigate whether
CPET can identify patients at risk of reduced survival after abdominal
aortic aneurysm (AAA) repair.

Prospectively collected data from consecutive patients who underwent
CPET before elective open or endovascular AAA repair  (EVAR) at two
tertiary vascular centres between January 2007 and October 2012 were
analysed. A symptom-limited maximal CPET was performed on each patient.
Multivariable Cox proportional hazards regression modelling was used to
identify risk factors associated with reduced survival.
Results. The study included 506 patients with a mean age
of 73.4 (range 44–90). The majority (82.6%) were men and most (64.6%)
underwent EVAR. The in-hospital mortality was 2.6%. The median
follow-up was 26 months. The 3-year survival for patients with zero or
one sub-threshold CPET value   AT<10.2 ml kg−1 min−1, peak VO2<15 ml
kg−1 min−1 or Ve/VO2 at AT>42,  was 86.4% compared with 59.9% for patients with
three sub-threshold CPET values. Risk factors independently associated
with survival were female sex [hazard ratio (HR)=0.44, 95% confidence
interval (CI) 0.22–0.85, P=0.015], diabetes (HR=1.95, 95% CI
1.04–3.69, p=0.039), preoperative statins (HR=0.58, 95% CI
0.38–0.90, P=0.016), haemoglobin g dl−1 (HR=0.84, 95% CI
0.74–0.95, P=0.006), peak VO2<15 ml kg−1 min−1 (HR=1.63, 95% CI 1.01–2.63, P=0.046), and
Ve/VCO2 at AT>42.(HR=1.68, 95% CI 1.00–2.80, P=0.049).
Conclusions</st> CPET variables are independent predictors of
reduced survival after elective AAA repair and can identify a cohort of
patients with reduced survival at 3 years post-procedure. CPET is a
potentially useful adjunct for clinical decision-making in patients
with AAA.

Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery

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

Levett, Denny; Grocott, Michael.
Canadian Journal of Anesthesia, February 2015, Vol. 62 Issue: Number 2
p131-142, 12p;

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

Cardiopulmonary Exercise Testing in Cancer Patients:…………

Cardiopulmonary Exercise Testing in Cancer Patients: Should We Really
Refrain From Considering It for Preparticipation Screening?

Scharhag-Rosenberger, Friederike; Wiskemann, Joachim; Scharhag,

Oncologist, 2015, Vol. 20 Issue: Number 2 p228-228, 1p

Abstract: Cardiopulmonary exercise testing (CPET) should continue to be
taken into consideration when screening cancer patients for
participation in exercise training programs. The benefits of CPET for
cancer patients are better examined through longitudinal rather than
cross-sectional studies.



Estimating Equations for Cardiopulmonary Exercise Testing Variables in Fontan Patients:…

Estimating Equations for Cardiopulmonary Exercise Testing Variables
    in Fontan Patients: Derivation and Validation Using a Multicenter
    Cross-Sectional Database

Butts, Ryan; Spencer, Carolyn; Jackson,
Lanier; Heal, Martha; Forbus, Geoffrey; Hulsey, Thomas; Atz, Andrew

Pediatric Cardiology, February 2015, Vol. 36 Issue: Number 2 p393-401,

Abstract: Cardiopulmonary exercise testing (CPET) is a common
method of evaluating patients with a Fontan circulation. Equations to
calculate predicted CPET values are based on children with normal
circulation. This study aims to create predictive equations for CPET
variables solely based on patients with Fontan circulation. Patients
who performed CPET in the multicenter Pediatric Heart Network Fontan
Cross-Sectional Study were screened. Peak variable equations were
calculated using patients who performed a maximal test (RER > 1.1) and
anaerobic threshold (AT) variable equations on patients where AT was
adequately calculated. Eighty percent of each cohort was randomly
selected to derive the predictive equation and the remaining served as
a validation cohort. Linear regression analysis was performed for each
CPET variable within the derivation cohort. The resulting equations
were applied to calculate predicted values in the validation cohort.
Observed versus predicted variables were compared in the validation
cohort using linear regression. 411 patients underwent CPET, 166
performed maximal exercise tests and 317 had adequately calculated AT.
Predictive equations for peak CPET variables had good performance; peak
VO2, R2= 0.61; maximum work, R2= 0.61; maximum O2pulse, R2= 0.59. The
equations for CPET variables at AT explained less of the variability;
VO2at AT, R2= 0.15; work at AT, R2= 0.39; O2pulse at AT, R2= 0.34;
VE/VCO2at AT, R2= 0.18; VE/VO2at AT, R2= 0.14. Only the models for
VE/VCO2and VE/VO2at AT had significantly worse performance in
validation cohort. Of the 8 equations for commonly measured CPET
variables, six were able to be validated. The equations for peak
variables were more robust in explaining variation in values than AT

Effect of prehabilitation……….after neoadjuvant treatment in preoperative rectal cancer patients

Effect of prehabilitation on objectively measured physical fitness
after neoadjuvant treatment in preoperative rectal cancer patients: a
blinded interventional pilot study

West, M. A.; Loughney, L.;
Lythgoe, D.; Barben, C. P.; Sripadam, R.; Kemp, G. J.; Grocott, M. P.
W.; Jack, S..

BJA: British Journal of Anaesthesia, February 2015, Vol.
114 Issue: Number 2 p244-244, 1p;

Patients requiring surgery for locally advanced rectal cancer often
additionally undergo neoadjuvant chemoradiotherapy (NACRT), of which
the effects on physical fitness are unknown. The aim of this
feasibility and pilot study was to investigate the effects of NACRT and
a 6 week structured responsive exercise training programme (SRETP) on
oxygen uptake at lactate threshold in such patients.
We prospectively studied 39 consecutive
subjects (27 males) with T3–4/N+ resection margin threatened rectal
cancer who completed standardized NACRT. Subjects underwent
cardiopulmonary exercise testing at baseline (pre-NACRT), at week 0
(post-NACRT), and week 6 (post-SRETP). Twenty-two subjects undertook a
6 week SRETP on a training bike (three sessions per week) between week
0 and week 6 (exercise group). These were compared with 17
contemporaneous non-randomized subjects (control group). Changes in VO2 at theta
over time and between the groups were compared
using a compound symmetry covariance linear mixed model. Of 39 recruited subjects, 22 out of 22 (exercise)
and 13 out of 17 (control) completed the study. There were differences
between the exercise and control groups at baseline [age, ASA score
physical status, World Health Organisation performance status, and
Colorectal Physiologic and Operative Severity Score for the Enumeration
of Mortality and Morbidity (CR-POSSUM) predicted mortality]. In all
subjects,  VO2 at theta significantly reduced between
baseline and week 0 [−1.9 ml kg−1 min−1; 95% confidence interval (CI)
−1.3, −2.6; P</it><0.0001]. In the exercise group,
VO2 theta significantly improved between week 0 and week 6
(+2.1 ml kg−1 min−1; 95% CI +1.3, +2.9; P</it><0.0001), whereas the
control group values were unchanged (−0.7 ml kg−1 min−1; 95% CI −1.66,
+0.37; P</it>=0.204).

Conclusions NACRT before rectal cancer surgery reduces physical fitness. A structured exercise
intervention is feasible post-NACRT and returns fitness to baseline
levels within 6 weeks.

Cardiopulmonary exercise testing to evaluate the exercise capacity of patients with inoperable chronic thromboembolic pulmonary hypertension: An endothelin receptor antagonist improves the peak PETCO2

Hirashiki, Akihiro; Adachi, Shiro; Nakano, Yoshihisa; Kono, Yuji;
Shimazu, Shuzo; Shimizu, Shinya; Morimoto, Ryota; Okumura, Takahiro;
Takeshita, Kyosuke; Yamada, Sumio; Murohara, Toyoaki; Kondo, Takahisa.

Life Sciences, November 2014, Vol. 118 Issue: Number 2 p397-403, 7p;
Abstract: The 6-min walking distance is often used for assessing the
exercise capacity under the treatment with an endothelin receptor
antagonist (ERA) in patients with chronic thromboembolic pulmonary
hypertension (CTEPH). The cardiopulmonary exercise testing (CPX) was
reported to be more useful for the patients with pulmonary arterial
hypertension (PAH), however, few reports exist in patients with
inoperable CTEPH. The aim of this study was to investigate the effects
of an oral dual ERA, bosentan, on exercise capacity using CPX in
patients with PAH and inoperable CTEPH.;

Reference values for cardiopulmonary exercise testing in healthy adults: a systematic review

Paap, Davy; Takken, Tim.
Expert Review of Cardiovascular Therapy, December 2014, Vol. 12 Issue: Number 12 p1439-1453, 15p

Abstract: Reference values (RV) for cardiopulmonary exercise testing (CPET) provide the comparative basis for answering
important questions concerning the normality of exercise response in
patients and significantly impacts the clinical decision-making
process. The aim of this study is to systematically review the
literature on RV for CPET in healthy adults. A secondary aim is to make
appropriate recommendations for the practical use of RV for CPET.
Systematic searches of MEDLINE, EMBASE and PEDro databases up to March
2014 were performed. In the last 30 years, 35 studies with CPET RV were
published. There is no single set of ideal RV; characteristics of each
population are too diverse to pool the data in a single equation.
Therefore, each exercise laboratory must select appropriate sets of RV
that best reflect the characteristics of the population/patient tested,
and equipment and methodology utilized.

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

Horsley, Alex; Siddiqui, Salman
Respirology, January 2015, Vol. 20 Issue: Number 1 p33-45, 13p
Abstract: Adult cystic fibrosis (CF) is notable for the wide heterogeneity in severity
of disease expression, both between patients and within the lungs of
individuals. Although CFairways disease appears to start in the small
airways, in adults there is typically widespread bronchiectasis,
increased airway secretions, and extensive obstruction and inflammation
of the small airways. The complexity and heterogeneity of airways
disease in CFmeans that although there are many different methods of
assessing and describing lung ‘function’, none of these
single‐dimensional tests is able to provide a comprehensive assessment
of lung physiology across the spectrum seen in adult CF. The most
widely described measure, the forced expiratory volume in 1 s, remains
a useful and simple clinical tool, but is insensitive to early changes
and may be dissociated from other more detailed assessments of disease
severity such as computed tomography. In this review, we also discuss
the use of more sensitive novel assessments such as multiple breath
washout tests and impulse oscillometry, as well as the role of
cardiopulmonary exercise testing. In the future, hyperpolarized gas
magnetic resonance imaging techniques that combine regional structural
and functional information may help us to better understand these
measures, their applications and limitations.;