Author Archives: Paul Older

The 2016 Practicum to be held in Milan 26th to 28th October 2016

European2016 Practicum on Cardiopulmonary Exercise Testing 2016

‘Click’ on this link to see the entire programme for this important event.

Dear colleague,
the 2016 annual CPX International congress “European Practicum on Cardiopulmonary Exercise Testing” will be held in Italy after 10 years since the last Italian edition. The congress will last from 26 to 29 October 2016 and the venue will be Centro Cardiologico Monzino, in Milan.
It is a very important event for all of us who are at the forefront in this field. Wasserman himself may come to Italy, but, since he is more than 90 years old, he could renounce.
I send you attached the official brochure of the congress with the scientific program.
The course is very intensive and gives a wide view across the CPX world.
For the first time we are going to offer three prizes of $1.500 each for the best three abstracts that will be presented on Saturday morning.

Thank you for your participation and advertising that you will give to the event.
Best regards,

Prof. Piergiuseppe Agostoni
CPX International President
Chief of Heart Failure, Clinical Cardiology and Rehabilitation Unit
Centro Cardiologico Monzino
Via C. Parea 4, 20138 Milano



Piazza Wagner, 5-  20145 Milan

Tel.: + 39 02 43 31 92 23 / 02 58 00 28 76 – Fax: + 39 02 48 51 33 53

Exercise Performance in Children and Young Adults After Complete and Incomplete Repair of Congenital Heart Disease

Rosenblum, Omer; Katz,
Uriel; Reuveny, Ronen; Williams, Craig; Dubnov-Raz, Gal.

Pediatric Cardiology, December 2015, Vol. 36 Issue: Number 8 p1573-1581, 9p;

Abstract: Few previous studies have addressed exercise capacity in
patients with corrected congenital heart disease (CHD) and significant
anatomical residua. The aim of this study was to determine the aerobic
fitness and peak cardiac function of patients with corrected CHD with
complete or incomplete repairs, as determined by resting
echocardiography. Children, adolescents and young adults (<40 years)
with CHD from both sexes, who had previously undergone biventricular
corrective therapeutic interventions (n= 73), and non-CHD control
participants (n= 76) underwent cardiopulmonary exercise testing. The
CHD group was further divided according to the absence/presence of
significant anatomical residua on a resting echocardiogram
(“complete”/“incomplete” repair groups). Aerobic fitness and cardiac
function were compared between groups using linear regression and
analysis of covariance. Peak oxygen consumption, O2pulse and
ventilatory threshold were significantly lower in CHD patients compared
with controls (all p< 0.01). Compared with the complete repair group,
the incomplete repair group had a significantly lower mean peak work
rate, age-adjusted O2pulse (expressed as % predicted) and a higher
VE/VCO2ratio (all p≤ 0.05). Peak oxygen consumption was comparable
between the subgroups. Patients after corrected CHD have lower peak and
submaximal exercise parameters. Patients with incomplete repair of
their heart defect had decreased aerobic fitness, with evidence of
impaired peak cardiac function and lower pulmonary perfusion. Patients
that had undergone a complete repair had decreased aerobic fitness
attributed only to deconditioning. These newly identified differences
explain why in previous studies, the lowest fitness was seen in
patients with the most hemodynamically significant heart

A Systematic Review of Reference Values in Pediatric Cardiopulmonary Exercise Testing

Blais, Samuel; Berbari, Jade; Counil,
Francois-Pierre; Dallaire, Frederic.

Pediatric Cardiology, December
2015, Vol. 36 Issue: Number 8 p1553-1564, 12p;

Cardiopulmonary exercise testing (CPET) is used for the diagnosis and
prognosis of cardiovascular and pulmonary conditions in children and
adolescents. Several authors have published reference values for
pediatric CPET, but evaluation of their validity is lacking. The aim of
this study was to review pediatric CPET references values published
between 1980 and 2014. We specifically assessed the adequacy of the
normalization methods used to adjust for body size. Articles that
proposed references values were reviewed. We abstracted information on
exercise protocols, CPET measurements and normalization methods. We
then evaluated the studies’ methodological quality and assessed them
for potential biases. Thirty-four studies were included. We found
important heterogeneity in the choice of exercise protocols and in the
approach to adjustment for body size or other relevant confounding
factors. Adjustment for body size was principally done using linear
regression for age or weight. Assessment of potential biases (residual
association, heteroscedasticity and departure from the normal
distribution) was mentioned in only a minority of studies. Our study
shows that contemporary pediatric reference values for CPET have been
developed based on heterogeneous exercise protocols and variable
normalization strategies. Furthermore, assessment of potential bias has
been inconsistent and insufficiently described. High-quality reference
values with adequate adjustment for confounding variables are needed in
order to optimize CPET’s specificity and sensitivity to detect abnormal
cardiopulmonary response to exercise.

The summary of the Munich Practicum and the photo are now on the website ( Many of the talks are on that page in .pdf format. Just ‘click’ on the link.

‘Click’ on Practicum and then ‘Click’ on Munich to view the page.

More talks will be added later.

Dr Paul Older

The 2015 Munich Practicum (The XIX European Practicum)

The 2015 „European Practicum on Cardiopulmonary exercise testing“ was held in Munich from 4th – 7th November 2015. It was a meeting with slightly more than 100 participants, newbies and experts, from all continents except South America and Antarctica.

There was a teaching course on the first three days covering all main topics of CPET. On Wednesday we started with basic exercise physiology. Besides the presentations there was a tutorial, where 10-15 participants could ask questions to one tutor from the faculty. On Thursday there was our “how to do” day. Different protocols and a standard report were presented. In two practical sessions the sponsoring industry could present their metabolic carts during constant work and ramp tests; tutors explained the measurements and their physiological background. On Friday various clinical applications of a CPET were shown. Again in specialized tutorials on different medical fields and in another laboratory session with an exercising patient, the CPET as a diagnostic tool was demonstrated.

On Saturday there was a scientific session with abstract presentations of new studies. We heard about new CPET variables, new algorithms how CPET results can be used to guide diagnostics or therapy, and some training studies.

It was an exhausting, but very interesting week, and we are looking forward to the next practicum in Milan / Italy from 26th to 28th October 2016.

Alfred Hager
(Chair of the 2015 Practicum)

HertzzentrumMunich2015From the perspective of CPX International Inc., this Practicum in Munich was a great sucess due in no small part to the energy of Professor Doctor Hager. Everything ran very well and the venue was excellent. The weather was very cold for those of us who came from Australia but we soon adapted. There were around 100 people enrolled of whom only a small number were German. This says a lot for the sucess of the advertising from Professor Doctor Hager. We received a lot of suggestions on how things could be improved from those attending. We will certainly take note of these and will implement the ideas where possible.

I and the Faculty, really would like to thank you for attending and remind you that you are now members of CPX International Inc.; as such you will receive regular abstracts of articles from many different journals on a regular basis

For the first time we have included on this page, some of the lectures in .pdf format. These can be accessed via ‘clicking’ on the appropriate link.

Adjunct Professor Paul Older
Executive Director of CPX International Inc

CPXI2015_BloodPressure_20151101 from Professor Doctor Hager
CPXI2015_OygenTransport_20151103 from Professor Doctor Hager
Exercise physiology and sports performance_Pressler
Training according to CPET results_Pressler
Takken presentation for website CPXI
Munich2015  Dr Older
Exercise in Myopathies Munich 2015




A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery.


Meybohm P, Bein B, Brosteanu O, Cremer J, Gruenewald M, Stoppe C, et al.

N Engl J Med. 2015;373(15):1397-407.

BACKGROUND: Remote ischemic preconditioning (RIPC) is reported to reduce biomarkers of ischemic and reperfusion injury in patients undergoing cardiac surgery, but uncertainty about clinical outcomes remains. METHODS: We conducted a prospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The trial compared upper-limb RIPC with a sham intervention. The primary end point was a composite of death, myocardial infarction, stroke, or acute renal failure up to the time of hospital discharge. Secondary end points included the occurrence of any individual component of the primary end point by day 90. RESULTS: A total of 1403 patients underwent randomization. The full analysis set comprised 1385 patients (692 in the RIPC group and 693 in the sham-RIPC group). There was no significant between-group difference in the rate of the composite primary end point (99 patients [14.3%] in the RIPC group and 101 [14.6%] in the sham-RIPC group, P=0.89) or of any of the individual components: death (9 patients [1.3%] and 4 [0.6%], respectively; P=0.21), myocardial infarction (47 [6.8%] and 63 [9.1%], P=0.12), stroke (14 [2.0%] and 15 [2.2%], P=0.79), and acute renal failure (42 [6.1%] and 35 [5.1%], P=0.45). The results were similar in the per-protocol analysis. No treatment effect was found in any subgroup analysis. No significant differences between the RIPC group and the sham-RIPC group were seen in the level of troponin release, the duration of mechanical ventilation, the length of stay in the intensive care unit or the hospital, new onset of atrial fibrillation, and the incidence of postoperative delirium. No RIPC-related adverse events were observed.

CONCLUSIONS: Upper-limb RIPC performed while patients were under propofol-induced anesthesia did not show a relevant benefit among patients undergoing elective cardiac surgery.

Feasibility of cardiopulmonary exercise testing and training using a robotics-assisted tilt table in dependent-ambulatory stroke patients

Saengsuwan, Jittima; Huber, Celine; Schreiber, Jonathan; Schuster-Amft,
Corina; Nef, Tobias; Hunt, Kenneth.

Journal of NeuroEngineering and Rehabilitation, December 2015, Vol. 12 Issue: Number 1 p1-10, 10p;

Abstract: We evaluated the feasibility of an augmented
robotics-assisted tilt table (RATT) for incremental cardiopulmonary
exercise testing (CPET) and exercise training in dependent-ambulatory
stroke patients.   Stroke patients (Functional Ambulation Category ≤ 3) underwent familiarization, an incremental
exercise test (IET) and a constant load test (CLT) on separate days. A
RATT equipped with force sensors in the thigh cuffs, a work rate
estimation algorithm and real-time visual feedback to guide the
exercise work rate was used. Feasibility assessment considered
technical feasibility, patient tolerability, and cardiopulmonary
responsiveness.  Eight patients (4 female) aged
58.3 ± 9.2 years (mean ± SD) were recruited and all completed the
study. For IETs, peak oxygen uptake (V’O2peak), peak heart rate
(HRpeak) and peak work rate (WRpeak) were 11.9 ± 4.0 ml/kg/min (45 % of
predicted V’O2max), 117 ± 32 beats/min (72 % of predicted HRmax) and
22.5 ± 13.0 W, respectively. Peak ratings of perceived exertion (RPE)
were on the range “hard” to “very hard”. All 8 patients reached their
limit of functional capacity in terms of either their cardiopulmonary
or neuromuscular performance.   A ventilatory threshold
(VT) was identified in 7 patients and a respiratory compensation point
(RCP) in 6 patients: mean V’O2at VT and RCP was 8.9 and 10.7 ml/kg/min,
respectively, which represent 75 % (VT) and 85 % (RCP) of mean
V’O2peak. Incremental CPET provided sufficient information to satisfy
the responsiveness criteria and identification of key outcomes in all 8
patients.  For CLTs, mean steady-state V’O2was
6.9 ml/kg/min (49 % of V’O2reserve), mean HR was 90 beats/min (56 % of
HRmax), RPEs were > 2, and all patients maintained the active work rate
for 10 min: these values meet recommended intensity levels for bouts of
training.  The augmented RATT is deemed feasible for
incremental cardiopulmonary exercise testing and exercise training in
dependent-ambulatory stroke patients: the approach was found to be
technically implementable, acceptable to the patients, and it showed
substantial cardiopulmonary responsiveness. This work has clinical
implications for patients with severe disability who otherwise are not
able to be tested.

CPX International Inc Friday November 5th 2015. Agenda for 2014 Annual General Meeting

CPX International Inc

Agenda for 2014 Annual General Meeting Thursday November 5th

Deutsches Herzzentrum München
Technische Universität München
Lazarettstr. 36
D-80636 München, Germany

12:30 pm. Following morning session of Practicum.


  • Minutes from Zwolle Meeting.
  • Presidents report
  • Executive Directors Report
  • Treasurer’s report.
  • Future Venues for Practicum Meetings.
  • Research Arm of the Society; Extension of meeting.
  • AOB

Executive Director

Paul Older