D’Ascenzi F (Chair); Sanz-de la Garza M (Co-chair); Many International Centres
Maestrini V; Cameli M; et al

European heart journal cardiovascular Imaging. 27(8):1449-1468, 2026 Jul 31.

Exercise imaging, particularly exercise stress echocardiography (ESE), has
become a pivotal non-invasive tool for evaluating cardiovascular function
in athletes and for distinguishing physiological adaptations from
pathological conditions. This Clinical Consensus Statement by the European
Association of Preventive Cardiology and the European Association of
Cardiovascular Imaging synthesizes current evidence and provides practical
guidance on indications, protocols, and interpretation of exercise imaging
modalities in both competitive and recreational athletes. The document
emphasizes the role of ESE in assessing cardiac reserve, unmasking
concealed cardiomyopathies, and stratifying risk in clinical scenarios
such as T-wave inversion, exercise-induced repolarization abnormalities,
and extreme ventricular remodelling. Special attention is given to imaging
protocols tailored to the athletic population, including dynamic
assessment of the right and left ventricles, atria, and valvular function
during various exercise modalities, highlighting the importance of the
functional evaluation in athletes and active individuals. Additionally,
the consensus explores the integration of advanced techniques such as
cardiopulmonary exercise testing and exercise cardiac magnetic resonance
imaging, highlighting their complementary roles in comprehensive
cardiovascular evaluation. The statement advocates for individualized
testing strategies that consider sport-specific demands, demographic
factors such as body size, sex, ethnicity, and the underlying pathology.
It also underscores the importance of exercise imaging in guiding sports
eligibility and in tailoring exercise prescription for competitive
athletes, as well as for patients willing to participate in recreational
sports or exercise programs. Copyright This article has been co-published
with permission in the European Journal of Preventive Cardiology and the
European Heart Journal – Cardiovascular Imaging. All rights reserved.
The European Society of Cardiology 2026. The articles are identical
except for minor stylistic and spelling differences in keeping with each
journal’s style. Either citation can be used when citing this article.

Guerrier K; Le Bonheur Children’s Hospital, Memphis, USA.
Bejnood A; Shyam S; Hyde RA; et al

Medical Sciences. 14(3), 2026 Jul 08.

BACKGROUND: Pectus excavatum (PEX) is the most common congenital chest
wall deformity and may result in cardiac compression and arrhythmias. The
relationship between structural severity and exercise-induced
electrocardiographic (ECG) abnormalities in pediatric patients remains
unclear.

METHODS: We performed a retrospective study of patients aged 10-19 years
that underwent standardized preoperative evaluation for PEX between 2015
and 2021, including ECG, transthoracic echocardiography (TTE), computed
tomography (CT), and cardiopulmonary exercise testing (CPET). PEX severity
was assessed using the Haller index (HI), while right ventricular (RV)
compression was evaluated on CT. Tricuspid valve annular size (TVAS) on
TTE was used as a surrogate marker of RV compression. Exercise-induced ECG
abnormalities, including premature ventricular complexes (PVCs), were
analyzed and correlated with HI, RV compression, and TVAS.

RESULTS: Among 124 patients (85% male; median age 15 years), 33%
exhibited exercise-induced ECG abnormalities, most commonly PVCs (24%
overall). PVC occurrence was not associated with Haller index severity (p
= 0.35) but was significantly associated with RV compression on CT (92.6%
vs. 62.1%, OR 7.64, p = 0.02). Patients with ECG abnormalities had
significantly smaller TVAS compared to those without (1.98 +/- 0.31 cm vs.
2.09 +/- 0.33 cm, p = 0.04). Although PVCs were more frequent in patients
with TVAS z-score <= -2.0, this did not reach statistical significance.

CONCLUSIONS: Exercise-induced ventricular ectopy in pediatric PEX is
associated with right ventricular compression rather than structural
severity as defined by HI. Echocardiographic measures such as TVAS may
serve as noninvasive markers of clinically significant compression. These
findings highlight the importance of cardiac-thoracic relationships in
predicting arrhythmic risk and suggest a potential for reversibility with
surgical correction.

Selvadurai Y; The Sydney Children’s Hospitals Network, Westmead, New
South Wales, Australia & Royal North Shore Hospital, St Leonards, New South
Wales, Australia.
Kennedy B; Mcbride J; Field P; et al

BMJ open respiratory research. 13(1), 2026 Jul 30.

BACKGROUND: Complicated pneumonia in children can result in an empyema.
The management options include chest drain insertion with fibrinolytic
therapy (CDF) and video-assisted thoracoscopic surgery (VATS) with
decortication. No studies have compared the long-term cardiopulmonary
impact of treatment interventions using sensitive static and dynamic
assessments of lung function.

AIM: To compare long-term cardiopulmonary function outcomes in children
with empyema treated with CDF with those who underwent VATS using highly
sensitive static and dynamic lung function measures.

METHODS: Children aged >8 years at the time of testing who were
previously hospitalised with empyema and treated with either CDF or VATS
were prospectively recruited. At one hospital, children were only treated
by VATS, whereas CDF was used exclusively at the other site. As both sites
belonged to the same network, all other aspects of treatment protocols
were identical, and clinicians worked across both sites. Healthy controls
were assessed as a comparison. Lung function testing included spirometry,
lung volumes, multiple-breath washout (lung clearance index), oscillometry
and cardiopulmonary exercise testing, all performed according to
international standards.

RESULTS: 51 children treated with CDF, 28 treated with VATS and 24
healthy controls participated in this study. Spirometry and lung clearance
index were normal across all groups. However, oscillometry revealed
significantly lower reactance in both treatment groups compared with
controls (respiratory system reactance at 5 Hz: CDF -2.54 (0.98), VATS
-4.08 (0.94), controls -0.24 (0.85)), with VATS showing greater
impairment. The ratio of minute ventilation to oxygen uptake was highest
in the VATS group compared with CDF and controls (39.7 (2.8), 36.8 (3.2)
and 32.2 (2.7), respectively).

CONCLUSION: Long-term pulmonary outcomes following both CDF and VATS were
generally reassuring. However, oscillometry and exercise testing revealed
subtle differences in ventilatory strategies, with children post-VATS
demonstrating mild residual impairment.

Siebold E; Division of Sport and Exercise Medicine, Basel, Switzerland.
Infanti L; Gruber HJ; Stehle GT;

European Journal of Applied Physiology. 126(7):4113-4126, 2026 Jul.

PURPOSE: Hematopoietic stem cell transplantation (HSCT) depends on
effective HSC mobilization with granulocyte colony-stimulating factor
(G-CSF), though some allogeneic donors experience severe side effects.
This study compares G-CSF and acute maximal exercise for HSC collection
and cellular composition in 10 healthy family donors, examining links to
donor fitness and recipient outcomes.

METHODS: Ten donors (3 females; 40.8 (18.3) years) and their recipients
(n = 8; 3 females; 47.5 (18.5) years) were enrolled. Donors completed
cardiopulmonary exercise testing with blood samples taken pre- and
post-exercise and on apheresis day for flow cytometric analysis.
Recipients were followed up on day ~ 30 post-transplant.

RESULTS: Exercise significantly increased circulating total CD34+ cells
(1.76-fold (0.51), p = 0.002) and select progenitor subsets (CD34+CD45dim,
1.74-fold (0.56), p = 0.006; and CD34+CD38+CD133+, 1.60-fold (0.46), p =
0.013), while other subsets showed no significant change (p > 0.05).
Compared with post-exercise, apheresis resulted in markedly higher
concentrations of total CD34+ cells (20.7-fold (9.7), p < 0.001) and all
measured subsets. The largest enrichments were observed in CD34+
CD38-CD133+ (52.7-fold (69.3) p = 0.005) and CD34+CD38+CD133+ (38.2-fold
(17.0), p < 0.001) populations. HSC collection at apheresis contained a
186.1-fold (72.3) elevation of immature granulocytes (p < 0.001) compared
to the acute exercise (1.5-fold (0.3)). The proportions of apoptotic CD34+
cells and their subpopulations were similar post-exercise to apheresis (p
> 0.05). Donor CD34+CD38- cell number was significantly negatively
associated with recipient engrafting CD34+CD45dimCD90+ cells/microl
(r=-0.70, p = 0.05, n = 8).

CONCLUSION: Exercise might complement pharmacological mobilization by
enhancing key HSC subgroups, improving collection quality, and supporting
transplantation success; future research should evaluate combined
approaches and the role of CRF in donor suitability and recipient
outcomes.

Siebold E; Division of Sport and Exercise Medicine, Basel, Switzerland.
Infanti L; Gruber HJ; Stehle GT; et al

European Journal of Applied Physiology. 126(7):4113-4126, 2026 Jul.

Respiratory gas exchange during cardiopulmonary exercise testing (CPET) is
commonly measured using either a mixing chamber (MC) or a breath-by-breath
(BxB) technique. MC measurements reduce the impact of erratic ventilatory
patterns, thereby improving the accuracy of oxygen uptake ([Formula: see
text]) values, but often lack adequate temporal resolution for ventilatory
thresholds (VTs) determination. Accordingly, BxB is preferred when both
[Formula: see text] and VTs determination are sought simultaneously.
Recently, an adaptive mixing chamber (aMC) with high temporal resolution
was developed. The aims of this study were to examine the concordance of
aMC- and BxB-derived gas exchange data and to determine if the aMC
provides adequate temporal resolution for the assessment of VTs. Fourteen
healthy, recreationally active individuals (7 females, 7 males; 23.6 +/-
1.4 yr; 171.8 +/- 9.0 cm; 67.9 +/- 11.1 kg) performed a maximal CPET on a
treadmill with gas exchanges being measured simultaneously using BxB and
aMC techniques. Compared with BxB measurement, [Formula: see text] values
at peak effort were 5.0 +/- 7.8% lower using the aMC (P = 0.0419). Similar
bias was observed for [Formula: see text] values obtained at submaximal
workloads. Notably, the aMC provided adequate temporal resolution to
identify VTs among all participants in whom they could be measured with
confidence using BxB (n = 13/14). The aMC provides consistently and
reproducibly lower [Formula: see text] values compared with BxB
acquisition and provides adequate temporal resolution to determine VTs
during incremental effort CPET. This newly developed technology appears to
integrate the well-established strengths of both conventional MC and BxB
gas exchange measurement techniques. NEW & NOTEWORTHY COSMED recently
developed an adaptive mixing chamber (aMC) designed to pair the accuracy
of traditional mixing chambers with improved temporal resolution. This
study establishes the agreement between the aMC and breath-by-breath (BxB)
systems and demonstrates that the aMC consistently enabled ventilatory
threshold detection whenever BxB did. These findings indicate that the aMC
retains optimal gas-exchange measurement quality while enabling reliable
ventilatory threshold identification.

Yang X; Department of Cardiology, Hebei Province, 056002, China.
Liang J; Li Y; Miao J; Xu Y; Li W

BMC Cardiovascular Disorders. 26(1), 2026 May 23.

BACKGROUND: High-intensity interval training (HIIT) is an effective
exercise modality in cardiac rehabilitation; however, participation in
conventional centre-based programs remains suboptimal due to barriers such
as limited accessibility and adherence. Mobile health (mHealth)
technologies may improve accessibility and supervision of exercise
training. While previous studies have primarily focused on training
modality, evidence comparing different delivery models of HIIT-based
cardiac rehabilitation remains limited. This study aimed to compare the
effectiveness and safety of mHealth-supported versus centre-based delivery
of a standardized HIIT cardiac rehabilitation program in patients with
stable coronary heart disease (CHD).

METHODS: Between December 2024 and April 2025, 98 adults with stable CHD
eligible for Phase II cardiac rehabilitation were enrolled and randomly
assigned to either the control group (n = 49) or the intervention group (n
= 49). Both groups performed the same standardized HIIT protocol; the
control group received supervised centre-based rehabilitation, whereas the
intervention group performed mHealth-supported home-based training with
real-time monitoring and individualized feedback via the Xin’ankang
mHealth platform. Primary outcomes included the six-minute walk distance
(6MWD), cardiopulmonary exercise testing (CPET) parameters, and SF-36
quality of life scores. Secondary outcomes included anxiety, depression,
and sleep quality.

RESULTS: Baseline characteristics were generally comparable between
groups, although minor differences were observed in certain SF-36 domains.
After adjustment for baseline values, the intervention group demonstrated
significant improvements compared to the control group in sleep quality
scores (3.17 +/- 2.09 vs. 4.83 +/- 2.09), peak METs (5.83 +/- 0.09 vs.
4.94 +/- 0.09), anaerobic threshold METs (4.29 +/- 0.07 vs. 3.53 +/-
0.07), peak VO2 (20.12 +/- 0.30 vs. 16.70 +/- 0.30 ml/kg/min), and 6MWD
(563.83 +/- 3.21 vs. 531.49 +/- 3.21 m) (all P < 0.05). Improvements in
SF-36 scores were observed in several domains, although no significant
difference was found in vitality or mental health. Subgroup analyses
revealed consistent improvements across age groups, while a sex-specific
difference was observed for changes in VO2 peak.

CONCLUSION: Compared with centre-based delivery of the same HIIT program,
mHealth-supported HIIT was associated with greater improvements in
cardiopulmonary function, exercise capacity, and quality of life in
patients with CHD. These findings suggest that delivery modality may
influence the effectiveness of HIIT-based cardiac rehabilitation.

Kutluca A; Kayseri City Training and Research Hospital, Kayseri, Turkiye.
Sutbeyaz ST; Calis HT; Demirelli S; Citil E

International Journal of Rheumatic Diseases. 29(7):e70793, 2026 Jul.

OBJECTIVE: Patients with rheumatoid arthritis (RA) have an increased risk
of cardiovascular disease, particularly when hypertension coexists.
However, evidence regarding the role of cardiac rehabilitation (CR) in
this high-risk population remains limited. In this randomized controlled
trial, the effects of a structured CR program on estimated cardiovascular
risk, ambulatory blood pressure, and cardiorespiratory fitness were
evaluated in patients with RA and hypertension.

METHODS: In this single-center randomized controlled trial, 50 patients
with RA and hypertension were randomly assigned (1:1) to a 6-week
supervised CR program or usual care. The intervention included supervised
aerobic, resistance, and flexibility training together with weekly
educational sessions. Outcomes were assessed at baseline and at 6, 12, and
24 weeks by blinded evaluators. The primary outcome was estimated 10-year
cardiovascular risk assessed using the Framingham Risk Score (FRS), with
QRISK3 analyzed as a supportive risk measure. Secondary outcomes included
24-h ambulatory systolic blood pressure measured by ambulatory blood
pressure monitoring (ABPM), cardiorespiratory fitness assessed by
treadmill cardiopulmonary exercise testing (VO2max), and rheumatoid
arthritis disease activity (DAS28-CRP). Longitudinal changes were analyzed
using linear mixed-effects models according to the intention-to-treat
principle.

RESULTS: Linear mixed-effects modeling demonstrated a significant group x
time interaction for FRS (p < 0.001). At Week 24, the between-group
difference in FRS was -5.02 points (95% CI -8.60 to -1.44; p = 0.007).
QRISK3 showed a similar directional reduction but did not reach
statistical significance at Week 24 (-5.77 points; 95% CI -12.54 to 1.01;
p = 0.094). Significant group x time interactions were also observed for
24-h ambulatory systolic blood pressure (p < 0.001) and VO2max (p <
0.001). At Week 24, the between-group difference was -9.70 mmHg for
ambulatory systolic blood pressure and + 4.90 mL.kg-1.min-1 for VO2max.
Disease activity remained within the remission range throughout follow-up.

CONCLUSION: In selected patients with clinically stable rheumatoid
arthritis and coexisting hypertension who were receiving stable
pharmacologic therapy and were able to participate in supervised exercise,
a structured cardiac rehabilitation program was associated with
improvements in estimated cardiovascular risk profiles, ambulatory
systolic blood pressure, and cardiorespiratory fitness without worsening
disease activity. These findings support further evaluation of cardiac
rehabilitation as an adjunctive strategy for cardiovascular risk
management in a selected cardiometabolically high-risk rheumatoid
arthritis population with hypertension.

Borrani F; Institute of Sport Sciences,Lausanne, Switzerland.
Conedera L; Finel L; Daucourt C; et al

Journal of Applied Physiology. 141(2):326-336, 2026 Aug 01.

Background and aims
Respiratory gas exchange during cardiopulmonary exercise testing (CPET) is
commonly measured using either a mixing chamber (MC) or a breath-by-breath
(BxB) technique. MC measurements reduce the impact of erratic ventilatory
patterns, thereby improving the accuracy of oxygen uptake ([Formula: see
text]) values, but often lack adequate temporal resolution for ventilatory
thresholds (VTs) determination. Accordingly, BxB is preferred when both
[Formula: see text] and VTs determination are sought simultaneously.
Recently, an adaptive mixing chamber (aMC) with high temporal resolution
was developed. The aims of this study were to examine the concordance of
aMC- and BxB-derived gas exchange data and to determine if the aMC
provides adequate temporal resolution for the assessment of VTs.
Methods
Fourteen healthy, recreationally active individuals (7 females, 7 males; 23.6 +/-
1.4 yr; 171.8 +/- 9.0 cm; 67.9 +/- 11.1 kg) performed a maximal CPET on a
treadmill with gas exchanges being measured simultaneously using BxB and
aMC techniques.
Results
Compared with BxB measurement, [Formula: see text] values
at peak effort were 5.0 +/- 7.8% lower using the aMC (P = 0.0419). Similar
bias was observed for [Formula: see text] values obtained at submaximal
workloads. Notably, the aMC provided adequate temporal resolution to
identify VTs among all participants in whom they could be measured with
confidence using BxB (n = 13/14). The aMC provides consistently and
reproducibly lower [Formula: see text] values compared with BxB
acquisition and provides adequate temporal resolution to determine VTs
during incremental effort CPET. This newly developed technology appears to
integrate the well-established strengths of both conventional MC and BxB
gas exchange measurement techniques.
Conclusons
NEW & NOTEWORTHY COSMED recently
developed an adaptive mixing chamber (aMC) designed to pair the accuracy
of traditional mixing chambers with improved temporal resolution. This
study establishes the agreement between the aMC and breath-by-breath (BxB)
systems and demonstrates that the aMC consistently enabled ventilatory
threshold detection whenever BxB did. These findings indicate that the aMC
retains optimal gas-exchange measurement quality while enabling reliable
ventilatory threshold identification.

Lundgaard E; Oslo Metropolitan University, Oslo, Norway;
Kraggerud H; Hamre C; Wouda M

Journal of Rehabilitation Medicine. 58:jrm44817, 2026 Jul 23.

OBJECTIVE: To investigate lung function and ventilatory response during
cardiopulmonary exercise testing in adults with cerebral palsy and assess
the relationship between perceived breathlessness and breathing reserve at
maximal exertion.

DESIGN: Prospective, cross-sectional study. Inclusion period October
2023-June 2024.

SUBJECTS: Adults with spastic cerebral palsy, Gross Motor Function
Classification Score (GMFCS) I-III (n = 100).

METHODS: Spirometry and cardiopulmonary exercise testing were conducted.
Ventilatory response during exercise was assessed via tidal volume and
respiratory rate. Perceived breathlessness was compared with breathing
reserve at maximal exertion.

RESULTS: 89 participants completed all tests (GMFCS I = 62, GMFCS II =
20, GMFCS III = 7); 90% had lung function within normal limits. Age- and
sex-adjusted maximal oxygen uptake was lowest in group III (p < 0.01). At
maximal exertion, 70% had breathing reserve < 20%, indicating ventilatory
limitation. Breathing reserve did not significantly differ between those
who did and did not report breathlessness as the limiting factor at
maximal exertion. Tidal volume and respiratory rate showed expected values
at maximal exertion.

CONCLUSION: Lung function was normal in most participants, yet
ventilatory limitations were common during maximal exercise. Perceived
breathlessness was not related to breathing reserve at maximal exertion.

Aucoin R; Dalhousie University, Halifax, Nova Scotia, Canada.
Jensen D; Stickland M; Brotto A et al

Clinical Physiology & Functional Imaging. 46(4):e70083, 2026 Jul.

BACKGROUND: Leg discomfort, assessed with the Borg category-ratio 0-10
(Borg CR10) scale, is a primary reason for exercise cessation in both
health and disease. However, interpretation during cardiopulmonary
exercise testing (CPET) is limited by the absence of normative reference
equations.

PURPOSE: Develop normative reference equations for leg discomfort during
CPET in relation to absolute and relative power output (W) and rate of
oxygen uptake (V’O2).

METHODS: This was a retrospective analysis of the Canadian Cohort
Obstructive Lung Disease (CanCOLD) study. We included healthy males and
females aged >=40 years who completed symptom limited incremental cycle
CPET. The probability of each Borg CR10 leg discomfort rating by W or V’O2
was predicted using multinomial logistic regression. Model performance was
evaluated by fit, calibration, discrimination (c-statistic), and
externally validated in an independent sample (n = 86) of healthy Canadian
adults.

RESULTS: In total, 156 participants (43% female) were included (mean age
64.8 years). The models demonstrated good discrimination in both internal
and external validation (AUC 0.85-0.90), with similar performance across
absolute and relative W and V’O2. An upper limit of normal ([ULN]; 95th
percentile) could not be defined, as leg discomfort responses were highly
clustered within the predicted normal range across exercise intensities.

CONCLUSIONS: We present normative reference equations for leg discomfort
during CPET. Although an ULN could not be established, these models enable
grading and interpretation of leg discomfort relative to the predicted
normal responses and facilitate comparisons across individuals and groups
in both clinical and research settings.