Author Archives: Paul Older

CARDIOPULMONARY EXERCISE TEST AND ECHOCARDIOGAPHIC FINDINGS IN HOSPITALISED POST SARS-COV-2 PATIENTS: THE EFFECT OF ARTERIAL HYPERTENSION.

Kariori M; Fragoulis C;Chrysochoou C;Leontsinis I;Mantzouranis E;Iliakis P;Konstantinidis D;Konstantinou K;Andrikou I;Kalos T;Grigoriou K;Tsioufis K

Journal of hypertension [J Hypertens] 2022 Jun 01; Vol. 40 (Suppl 1), pp. e176.

Objective: There is little data concerning the impact of arterial hypertension (HTN) on the cardiopulmonary status and right ventricle (RV) function of patients with SARS-Cov-2 infection. The purpose of our study was to investigate whether HTN affects the functional status of hospitalized for SARS-Cov-2 patients, using cardiopulmonary test and echocardiographic parameters, 3 months after the first day of infection.
Design and Method: Subjects who were hospitalized and survived Covid-19 infection were divided into two groups according to history of HTN. All subjects underwent cardiorespiratory exercise using Bruce or modified Bruce protocol evaluating all parameters. Echocardiographic findings including right ventricle strain were analyzed using an offline program.
Results: A total population of 52 hospitalized Sars-Cov-2 patients with a mean age of 57 ± 11.5 years were evaluated 3 months after the symptoms onset. Males amounted to 51.9 %. History of coronary artery disease was recorded in 15.4% of them. In hypertensive subjects, age (63 ± 8 vs. 52 ± 11 years, p < 0.001), BMI (29.9 ± 4.6 vs. 27.1 ± 5.8 kg/m2, p:0.03) and BSA (2.1 ± 0.25 vs. 2 ± 0.9 m2, p:0.04) were significantly higher. When analyzing cardiopulmonary test parameters, only maximum systolic blood pressure ((SBP, mmHg), 190 ± 21 vs.171 ± 26, p: 0.02) at peak and during the 1st minute of recovery (180 ± 23 vs. 157 ± 27 mmHg, p: 0.005) were higher comparing to normotensive subjects. Furthermore, diameter of left atrium ((LA, mm), 42 ± 6 vs.38 ± 6 p: 0.009), left ventricle ejection fraction ((LVEF,%), 48 ± 11 vs. 57 ± 6, p:0.004) and the absolute mean value of right ventricle strain ((RVLS, %), 9.1 ± 4 vs. 12.7 ± 5.4, p:0.04) differed significantly between two groups. Using linear regression analysis adjusted for age, gender, HTN, coronary heart disease and LVEF, HTN.
Conclusions: Our study highlighted negative impact of HTN both in right and left ventricle functionality, implying HTN as a negative independent predictive factor for right ventricle strain in patients hospitalized for SARS-Cov-2.

Effects of Exercise on Heart Failure with Preserved Ejection Fraction: An Updated Review of Literature.

Crisci G; De Luca M; D’Assante R; Ranieri B; D’Agostino A; IValente V; Giardino F;Capone V; Chianese S; Rega S; Cocchia R; Israr MZ; Debiek R; Heaney LM; Salzano A;

Journal of cardiovascular development and disease [J Cardiovasc Dev Dis] 2022 Jul 28; Vol. 9 (8).
Date of Electronic Publication: 2022 Jul 28.

Heart failure with preserved ejection fraction (HFpEF) represents the most common HF phenotype of patients aged &gt; 65 years, with an incidence and a prevalence that are constantly growing. The HFpEF cardinal symptom is exercise intolerance (EI), defined as the impaired ability to perform physical activity and to reach the predicted age-related level of exercise duration in the absence of symptoms-such as fatigue or dyspnea-and is associated with a poor quality of life, a higher number of hospitalizations, and poor outcomes. The evidence of the protective effect between exercise and adverse cardiovascular outcomes is numerous and long-established. Regular exercise is known to reduce cardiovascular events and overall mortality both in apparently healthy individuals and in patients with established cardiovascular disease, representing a cornerstone in the prevention and treatment of many cardio-metabolic conditions. Several studies have investigated the role of exercise in HFpEF patients. The present review aims to dwell upon the effects of exercise on HFpEF. For this purpose, the relevant data from a literature search (PubMed, EMBASE, and Medline) were reviewed. The analysis of these studies underlines the fact that exercise training programs improve the cardiorespiratory performance of HFpEF patients in terms of the increase in peak oxygen uptake, the 6 min walk test distance, and the ventilatory threshold; on the other hand, diastolic or systolic functions are generally unchanged or only partially modified by exercise, suggesting that multiple mechanisms contribute to the improvement of exercise tolerance in HFpEF patients. In conclusion, considering that exercise training programs are able to improve the cardiorespiratory performance of HFpEF patients, the prescription of exercise training programs should be encouraged in stable HFpEF patients, and further research is needed to better elucidate the pathophysiological mechanisms underpinning the beneficial effects described.

Muscle strength, aerobic capacity, and exercise tolerance are impaired in left ventricular assist devices recipients: A pilot study.

Gobbo S; Favro F; Bullo V; Cugusi L; Blasio AD; Bortoletto A; Bocalini DS; Gasperetti A;Ermolao A; Bergamin M;

Frontiers in physiology [Front Physiol] 2022 Aug 08; Vol. 13, pp. 967817.
Date of Electronic Publication: 2022 Aug 08 (Print Publication: 2022).

Background: Left ventricular assist devices (LVAD) are increasingly being used as a therapy for advanced heart failure, both as a bridge to heart transplant and, given the rapid advances in the LVAD’s functionality and safety, and constant lack in availability of donor organs, as long-term destination therapy. With the diffusion of such therapy, it is crucial to assess patients’ muscle strength, aerobic capacity and exercise tolerance, to improve their functional capacity.
Methods: 38 LVAD recipients (33 men and five women) were included. Exercise testing including a maximal cardiopulmonary exercise test (CPET), handgrip, isometric and isokinetic strength testing of knee and ankle flexion/extension, and Romberg balance test in three conditions (eyes open, eyes closed, double task). Given the small and heterogeneous final sample size, a mostly descriptive statistical approach was chosen.
Results: 12 participants were classified as “Obese” (BMI>29.9). The most common comorbidities were type II diabetes and chronic kidney disease. Only 12 participants were able to successfully complete all the assessments. CPET and isokinetic strength trials were the least tolerated tests, and the handgrip test the best tolerated. Mean VO 2 peak was 12.38 ± 3.43 ml/kg/min, with 15 participants below 50% of predicted VO 2 max, of which 6 below 30% VO 2 max. Mean handgrip strength was 30.05 ± 10.61 Kg; 25 participants were below the 25° percentile of their population’s normative reference values for handgrip strength, 10 of which were below the 5° percentile. Issues with the management of the external pack of the LVAD and its influence on the test limited the validity of the balance tests data, therefore, no solid conclusions could be drawn from them. VO 2 peak did not correlate with handgrip strength or with any of the lower limb strength measures.
Conclusion: LVAD recipients show greatly reduced functional capacity and tolerance to exercise and exercise testing, with low overall strength levels. As strength variables appear to be independent from VO 2 peak, different lower limbs strength tests should be explored to find a tolerable alternative in this population, which is subjected to muscle wasting due to old age, reduced tissue perfusion, side effects from the pharmacological therapies, and prolonged periods of bedrest.

Adolescents with Atopic Dermatitis Have Lower Peak Exercise Load Capacity and Exercise Volume Compared with Unaffected Peers.

Yang TH; Chen PC; Lin YC; Lee YY; Tseng YH; Chang WH;Chang LS; Lin CH; Kuo HC;

International journal of environmental research and public health [Int J Environ Res Public Health] 2022 Aug 18; Vol. 19 (16).
Date of Electronic Publication: 2022 Aug 18.

Background: Sweating and increased skin temperature caused by exercise can reduce physical activity and the willingness to exercise in adolescents with atopic dermatitis. This study was conducted to investigate the exercise load capacity of adolescents with atopic dermatitis and analyzed their exercise behavior and motivation.
Methods: Adolescents with and without atopic dermatitis were assigned to the atopic dermatitis group and control group ( n = 27 each). Both groups completed a cardiopulmonary exercise test and questionnaires to assess their exercise capacity, weekly exercise volume, exercise motivation, and self-efficacy, respectively.
Results: The ratio of measured forced vital capacity to the predicted forced vital capacity and the peak oxygen consumption of the atopic dermatitis group were significantly lower than those of the control group. The Godin Leisure-Time Exercise Questionnaire scores of the atopic dermatitis group were significantly lower than those of the control group. As for the Behavioral Regulation in Exercise Questionnaire 2, the scores for the introjected and identified regulations of the atopic dermatitis group were significantly lower than those of the control group. Regarding the Multidimensional Self-Efficacy for Exercise Scale, the scheduling efficacy and total scores of the atopic dermatitis group were significantly lower than those of the control group.
Conclusions: Adolescents with atopic dermatitis had lower peak exercise capacity and lower weekly exercise volume. Furthermore, they lacked the negative feelings toward inactivity and the self-confidence to plan regular exercise independently. The results of this study suggest that adolescents with atopic dermatitis should be encouraged to engage in regular indoor exercise.

Chronotropic index and long-term outcomes in heart failure with preserved ejection fraction.

Palau P; Domínguez E; Seller J; Sastre C; Sanchis J; Bodí V; Llàcer P; Miñana G; Espriella R; Bayés-Genís A; Núñez J;

Revista espanola de cardiologia (English ed.) [Rev Esp Cardiol (Engl Ed)] 2022 Aug 26.
Date of Electronic Publication: 2022 Aug 26.

Introduction and Objectives: Little is known about the usefulness of heart rate (HR) response to exercise for risk stratification in heart failure with preserved ejection fraction (HFpEF). Therefore, this study aimed to assess the association between HR response to exercise and the risk of total episodes of worsening heart failure (WHF) in symptomatic stable patients with HFpEF.
Methods: This single-center study included 133 patients with HFpEF (NYHA II-III) who performed maximal cardiopulmonary exercise testing. HR response to exercise was evaluated using the chronotropic index (CI x ) formula. A negative binomial regression method was used.
Results: The mean age of the sample was 73.2 ± 10.5 years; 56.4% were female, and 51.1% were in atrial fibrillation. The median for CI x was 0.4 [0.3-0.55]. At a median follow-up of 2.4 [1.6-5.3] years, a total of 146 WHF events in 58 patients and 41 (30.8%) deaths were registered. In the whole sample, CI x was not associated with adverse outcomes (death, P = .319, and WHF events, P = .573). However, we found a differential effect across electrocardiographic rhythms for WHF events (P for interaction = .002). CI x was inversely and linearly associated with the risk of WHF events in patients with sinus rhythm and was positively and linearly associated with those with atrial fibrillation.
Conclusions: In patients with HFpEF, CI x was differentially associated with the risk of total WHF events across rhythm status. Lower CI x emerged as a risk factor for predicting higher risk in patients with sinus rhythm. In contrast, higher CI x identified a higher risk in those with atrial fibrillation.

Physiologic responses to exercise in survivors of critical illness: an exploratory pilot study.

Mart MF; Ely EW; Tolle JJ; Patel MB; Brummel NE;

Intensive care medicine experimental [Intensive Care Med Exp] 2022 Aug 26; Vol. 10 (1), pp. 35.
Date of Electronic Publication: 2022 Aug 26.

Background: ICU survivors suffer from impaired physical function and reduced exercise capacity, yet the underlying mechanisms are poorly understood. The goal of this exploratory pilot study was to investigate potential mechanisms of exercise limitation using cardiopulmonary exercise testing (CPET) and 6-min walk testing (6MWT).
Methods: We enrolled adults aged 18 years or older who were treated for respiratory failure or shock in medical, surgical, or trauma ICUs at Vanderbilt University Medical Center (Nashville, TN, United States). We excluded patients with pre-existing cardiac dysfunction, a contraindication to CPET, or the need for supplemental oxygen at rest. We performed CPET and 6MWT 6 months after ICU discharge. We measured standard CPET parameters in addition to two measures of oxygen utilization during exercise (VO 2 -work rate slope and VO 2 recovery half-time).
Results: We recruited 14 participants. Low exercise capacity (i.e., VO 2Peak  < 80% predicted) was present in 11 out of 14 (79%) with a median VO 2Peak of 12.6 ml/kg/min [9.6-15.1] and 6MWT distance of 294 m [240-433]. In addition to low VO 2Peak , CPET findings in survivors included low oxygen uptake efficiency slope, low oxygen pulse, elevated chronotropic index, low VO 2 -work rate slope, and prolonged VO 2 recovery half-time, indicating impaired oxygen utilization with a hyperdynamic heart rate and ventilatory response, a pattern seen in non-critically ill patients with mitochondrial myopathies. Worse VO 2 -work rate slope and VO 2 recovery half-time were strongly correlated with worse VO 2Peak and 6MWT distance, suggesting that exercise capacity was potentially limited by impaired muscle oxygen utilization.
Conclusions: These exploratory data suggest ICU survivors may suffer from impaired muscular oxygen metabolism due to mitochondrial dysfunction that impairs exercise capacity long-term. These findings should be further characterized in future studies that include direct assessments of muscle mitochondrial function in ICU survivors.

Is exercise stress testing useful for risk stratification in anomalous aortic origin of a coronary artery?

Qasim A; Doan TT; Dan Pham T; Reaves-O’Neal D; Sachdeva S; Mery CM; Binsalamah Z; Molossi S

Seminars in thoracic and cardiovascular surgery [Semin Thorac Cardiovasc Surg] 2022 Aug 27.
Date of Electronic Publication: 2022 Aug 27.

Data on maximal exercise-stress-testing (m-EST) in anomalous-aortic-origin-of-coronary-arteries (AAOCA) is limited and correlation with stress perfusion imaging has not been demonstrated. AAOCA patients ≤20 years were prospectively enrolled from 6/2014-01/2020. A m-EST was defined as heart rate >85%ile on ECG-EST and respiratory-exchange-ratio (RER) ≥1.05 on cardiopulmonary-exercise-testing (CPET). Abnormal m-EST included significant ST-changes or high-grade arrhythmia, ໿V̇O 2max and/or O 2 pulse <85% predicted, or abnormal O 2 pulse curve. A (+) dobutamine-stress cardiac-magnetic-resonance-imaging (+DS-CMR) had findings of inducible-ischemia. Outcomes: 1) Differences in m-EST based on AAOCA-type; 2) Assuming DS-CMR as gold-standard for detection of inducible ischemia, determine agreement between m-EST and DS-CMR. A total of 155 AAOCA (right, AAORCA = 126; left, AAOLCA = 29) patients with a median (IQR) age of 13 (11 – 15) years were included; 63% were males and a m-EST was completed in 138 (89%). AAORCA and AAOLCA had similar demographic and m-EST characteristics, although AAOLCA had more frequently evidence of inducible ischemia on m-EST (p=0.006) and DS-CMR (p=0.007). Abnormal O 2 pulse was significantly associated with +DS-CMR (OR 5.3, 95% CI 1.6 -18, p=0.005). Sensitivity was increased with addition of CPET to ECG-EST (to 58% from 19%). There was no agreement between m-EST and DS-CMR for detection of inducible ischemia. A m-EST has very low sensitivity for detection of inducible ischemia in AAOCA, and sensitivity is increased with addition of CPET. Stress perfusion abnormalities on DS-CMR were not concordant with m-EST findings and adjunctive testing should be considered for clinical decision making in AAOCA.

Reference Standards for Peak Rating of Perceived Exertion During Cardiopulmonary Exercise Testing: Data from FRIEND.

Peterman JE; Arena R; Myers J;Harber MP;Squires RW; Kaminsky LA;

Medicine and science in sports and exercise [Med Sci Sports Exerc] 2022 Aug 12.
Date of Electronic Publication: 2022 Aug 12.

Introduction: Peak rating of perceived exertion (RPE) is measured during clinical cardiopulmonary exercise testing (CPX) and is commonly used as a subjective indicator of maximal effort. However, no study to date has reported reference standards or the distribution of peak RPE across a large cohort of apparently healthy individuals.
Purpose: To determine reference standards for peak RPE when using the 6 – 20 Borg scale for both treadmill and cycle tests.
Methods: The analysis included 9,551 tests (8,821 treadmill, 730 cycle ergometer) from 13 laboratories within the Fitness Registry and Importance of Exercise National Database (FRIEND). Using data from tests conducted January 1, 1980, through January 1, 2021, percentiles of peak RPE for males and females were determined for each decade from 20 through 89 years of age for treadmill and cycle exercise modes. Two-way analysis of variance was used to compare differences in peak RPE values between sexes and across age groups.
Results: There were statistically significant differences in RPE between age groups whether the test was performed on a treadmill or cycle ergometer (P < 0.05). However, the mean and median RPE for each sex, age group, and test mode was between 18 and 19. Additionally, 83% of participants met the traditional RPE criteria of ≥18 for indicating sufficient maximal effort.
Conclusions: This report provides the first normative reference standards for peak RPE in both males and females performing CPX on a treadmill or cycle ergometer. Further, these reference standards highlight the general consistency of peak RPE responses during CPX.

Oxygen uptake kinetics and chronotropic responses to exercise are impaired in survivors of severe COVID-19.

Longobardi I; Prado DMLD; Goessler KF; Meletti MM; de Oliveira Júnior GN; de Andrade DCO; Gualano B; Roschel H;

American journal of physiology. Heart and circulatory physiology [Am J Physiol Heart Circ Physiol] 2022 Aug 19. Date of Electronic Publication: 2022 Aug 19.

The post-acute phase of COVID-19 is often marked by several persistent symptoms and exertional intolerance, which compromise survivors’ exercise capacity. This was a cross-sectional study aiming to investigate the impact of COVID-19 on oxygen uptake (VO 2 ) kinetics and cardiopulmonary function in survivors of severe COVID-19 three to six months after intensive care unit (ICU) hospitalization. Thirty-five COVID-19 survivors previously admitted to ICU (5±1 months after hospital discharge) and 18 controls matched for sex, age, comorbidities, and physical activity level with no prior history of SARS-CoV-2 infection were recruited. Subjects were submitted to a maximal graded cardiopulmonary exercise test (CPX) with an initial 3-minute period of a constant, moderate-intensity walk (i.e., below ventilatory threshold, VT). VO 2 kinetics was remarkably impaired in COVID-19 survivors as evidenced at the on-transient by an 85% (P=0.008) and 28% (P=0.001) greater oxygen deficit and mean response time (MRT), respectively. Furthermore, COVID-19 survivors showed a 11% longer (P=0.046) half-time of recovery of VO 2 (T 1/2 VO 2 ) at the off-transient. CPX also revealed cardiopulmonary impairments following COVID-19. VO 2peak , percent-predicted VO 2peak and VO 2VT were reduced by 17%, 17% and 12% in COVID-19 survivors, respectively (all P<0.05). None of the ventilatory parameters differed between groups (all P>0.05). Additionally, COVID-19 survivors also presented with blunted chronotropic responses (i.e., chronotropic index, maximum heart rate, and heart rate recovery; all P<0.05). These findings suggest that COVID-19 negatively affects central (chronotropic) and peripheral (metabolic) factors that impair the rate at which VO 2 is adjusted to changes in energy demands.

Prehabilitation in high-risk patients scheduled for major abdominal cancer surgery: a feasibility study.

Waterland JL; Ismail H; Granger CL; Patrick C; Denehy L; Riedel B;

Perioperative medicine (London, England) [Perioper Med (Lond)] 2022 Aug 23; Vol. 11 (1), pp. 32.
Date of Electronic Publication: 2022 Aug 23.

Background: Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery.
Methods: Eligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications.
Results: Eighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63-77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low-with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions.
Conclusion: Our prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin the importance of implementation research and strategies for the prehabilitation programs in major surgery.