Author Archives: Paul Older

Functional tests in patients with ischemic heart disease.

Avram RL; Nechita AC; Popescu MN; Teodorescu M; Ghilencea LN; Turcu D; Lechea E; Maher S; Bejan GC;
Berteanu M;

Journal of medicine and life [J Med Life] 2022 Jan; Vol. 15 (1), pp. 58-64.

Lately, easier and shorter tests have been used in the functional evaluation of cardiac patients. Among these, walking speed (WS) and Timed Up and Go (TUG) tests are associated with all-cause mortality, mainly cardiovascular and the rate of re-hospitalization, especially in the elderly population. We prospectively analyzed a group of 38 patients admitted to the Cardiology Clinic from Elias Hospital, Romania, with chronic coronary syndrome (CCS) (n=22) and STEMI (n=16). We assessed the patients immediately after admission and before discharge with G-WALK between the 1 st and 30 th of September 2019. Our study group had a mean age of 62.7±12.1 years. Patients with a low WS were older (69.90±12.84 vs. 59.90±10.32 years, p=0.02) and had a lower serum hemoglobin (12.38±1.20 vs. 13.72±2.07 g/dl, p=0.02). The WS significantly improved during hospitalization (p=0.03) after optimal treatment. The TUG test performed at the time of admission had a longer duration in patients with heart failure (14.05 vs. 10.80 sec, p=0.02) and was influenced by patients’ age (r=0.567, p=0.02), serum creatinine (r=0.409, p=0.03) and dilation of right heart chambers (r=0.399, p=0.03). WS and TUG tests can be used in patients with CCS and STEMI, and are mainly influenced by age, thus having a greater value among the elderly.

Classification and occurrence of an abnormal breathing pattern during cardiopulmonary exercise testing in subjects with persistent symptoms following COVID-19 disease.

von Gruenewaldt A; Nylander E; Hedman K;

Physiological reports [Physiol Rep] 2022 Feb; Vol. 10 (4), pp. e15197.

Reduced exercise capacity and several limiting symptoms during exercise have been reported following severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. From clinical observations, we hypothesized that an abnormal breathing pattern (BrP) during exercise may be common in these patients and related to reduced exercise capacity. We aimed to (a) evaluate a method to classify the BrP as normal/abnormal or borderline in terms of inter-rater agreement; (b) determine the occurrence of an abnormal BrP in patients with post-COVID; and (c) compare characteristics of post-COVID patients with normal and abnormal BrP. In a retrospective, cross-sectional study of patients referred for CPET due to post-COVID April 2020-April 2021, we selected subjects without a history of intensive care and with available medical records. Three raters independently categorized patients’ BrP as normal, abnormal, or borderline, using four traditional CPET plots (respiratory exchange ratio, tidal volume over ventilation, ventilatory equivalent for oxygen, and ventilation over time). Out of 20 patients (11 male), 10 were categorized as having a normal, 7 an abnormal, and three a borderline BrP. Inter-rater agreement was good (Fleiss’ kappa: 0.66 [0.66-0.67]). Subjects with an abnormal BrP had lower peak ventilation, lower exercise capacity, similar ventilatory efficiency and a similar level of dyspnea at peak exercise, as did subjects with a normal BrP. Patients’ BrP was possible to classify with good agreement between observers. A third of patients had an abnormal BrP, associated with lower exercise capacity, which could possibly explain exercise related symptoms in some patients with post-COVID syndrome.

Inhaled nitric oxide does not improve maximal oxygen consumption in endurance trained and untrained healthy individuals.

Brotto AR; Phillips DB; Meah VL; Ross BA; Fuhr DP; Beaudry RI; van Diepen S; Stickland MK;

European journal of applied physiology [Eur J Appl Physiol] 2022 Mar; Vol. 122 (3), pp. 703-715.
Date of Electronic Publication: 2022 Jan 22.

Purpose: Previous work suggests that endurance-trained athletes have superior pulmonary vasculature function as compared to untrained individuals, which may contribute to their greater maximal oxygen uptake ([Formula: see text]O 2max ). Inhaled nitric oxide (iNO) reduces pulmonary vascular resistance in healthy individuals, which could translate into greater cardiac output and improved [Formula: see text]O 2max , particularly in untrained individuals. The purpose of the study was to examine whether iNO improved [Formula: see text]O 2max in endurance trained and untrained individuals.
Methods: Sixteen endurance-trained and sixteen untrained individuals with normal lung function completed this randomized double-blind cross-over study over four sessions. Experimental cardiopulmonary exercise tests were completed while breathing either normoxia (placebo) or 40 ppm of iNO, on separate days (order randomized). On an additional day, echocardiography was used to determine pulmonary artery systolic pressure at rest and during sub-maximal exercise (60 Watts) while participants breathed normoxia or iNO.
Results: Right ventricular systolic pressure was significantly reduced by iNO during exercise (Placebo: 34 ± 7 vs. iNO: 32 ± 7; p = 0.04). [Formula: see text]O 2max was greater in the endurance trained group (Untrained: 3.1 ± 0.7 vs. Endurance: 4.3 ± 0.9 L min -1 ; p < 0.01), however, there was no effect of condition (p = 0.79) and no group by condition interaction (p = 0.68). Peak cardiac output was also unchanged by iNO in either group.
Conclusion: Despite a reduction in right ventricular systolic pressure, the lack of change in [Formula: see text]O 2max with iNO suggests that the pulmonary vasculature does not limit [Formula: see text]O 2max in young healthy individuals, regardless of fitness level.

Effect of self-tailored high-intensity interval training versus moderate-intensity continuous exercise on cardiorespiratory fitness after myocardial infarction: A randomised controlled trial.

Marcin T; Trachsel LD; Dysli M; Schmid JP; Eser P; Wilhelm M

Annals of Physical & Rehabilitation Medicine. 65(1):101490, 2022 Jan.
VI 1

BACKGROUND: Whether high-intensity interval training (HIIT) is more
efficient than moderate-intensity continuous exercise (MICE) to increase
cardiorespiratory fitness in patients with acute coronary syndrome at
moderate-to-high cardiovascular risk is controversial. The best approach
to guide training intensity remains to be determined.

OBJECTIVE: We aimed to assess intensities achieved with self-tailored
HIIT and MICE according to perceived exertion and to compare the effect on
cardiorespiratory fitness in patients early after ST-elevation myocardial
infarction (STEMI).

METHODS: We included 69 males starting cardiac rehabilitation within 4
weeks after STEMI. After a 3-week run-in phase with MICE, 35 patients were
randomised to 9 weeks of HIIT (2xHIIT and 1xMICE per week) and 34 patients
to MICE (3xMICE). Training workload for MICE was initially set at the
patients’ first ventilatory threshold (VT). HIIT consisted of 4×4-min
intervals with a workload above the second VT in high intervals. Training
intensity was adjusted weekly to maintain the perceived exertion (Borg
score 13-14 for MICE, >=15 for HIIT). Session duration was 38min in both
groups. Peak oxygen consumption (VO2) was measured by cardiopulmonary
exercise testing pre- and post-intervention.

RESULTS: Both groups improved peak VO2 (ml/kg/min) (HIIT +1.9, P<0.001;
MICE +3.2, P<0.001, Cohen’s d -0.4), but changes in VO2 were not
significantly different between groups (P=0.104). Exercise regimes did not
differ between groups in terms of energy expenditure or training time, but
perceived exertion was higher with HIIT.

CONCLUSIONS: Self-tailored HIIT was feasible in patients early after
STEMI. It was more strenuous but not superior nor more time-efficient than
MICE in improving peak VO2.

OSA and cardiorespiratory fitness: a review.

Powell TA; Mysliwiec V; Brock MS; Morris MJ

Journal of Clinical Sleep Medicine. 18(1):279-288, 2022 01 01.
VI 1

The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary
function remain unclear. Cardiorespiratory fitness (CRF), commonly
reflected by VO2 max measured during cardiopulmonary exercise testing, has
gained popularity in evaluating numerous cardiopulmonary conditions and
may provide a novel means of identifying OSA patients with the most
clinically significant disease. This emerging testing modality provides
simultaneous assessment of respiratory and cardiovascular function with
results helping uncover evidence of evolving pathology in either organ
system. In this review, we highlight the current state of the literature
in regard to OSA and CRF with a specific focus on changes in
cardiovascular function that have been previously noted. While OSA does
not appear to limit respiratory function during exercise, studies seem to
suggest an abnormal cardiovascular exercise response in this population
including decreased cardiac output, a blunted heart rate response (ie,
chronotropic incompetence), and exaggerated blood pressure response.
Surprisingly, despite these observed changes in the cardiovascular
response to exercise, results involving VO2 max in OSA remain
inconclusive. This is reflected by VO2 max studies involving middle-aged
OSA patients showing both normal and reduced CRF. As prior studies have
not extensively characterized oxygen desaturation burden, we propose that
reductions in VO2 max may exist in OSA patients with only the most
significant disease (as reflected by nocturnal hypoxia). Further
characterizing this relationship remains important as some research
suggests that positive airway pressure therapy or aerobic exercise may
improve CRF in patients with OSA. In conclusion, while it likely that
severe OSA, via an abnormal cardiovascular response to exercise, is
associated with decreased CRF, further study is clearly warranted to
include determining if OSA with decreased CRF is associated with increased
morbidity or mortality.

Can Non-invasive Ventilation Modulate Cerebral, Respiratory, and Peripheral Muscle Oxygenation During High-Intensity Exercise in Patients With COPD-HF?

Goulart CDL; Caruso FR; de Araújo ASG; de Moura SCG; Catai AM; Agostoni P; Mendes RG; Arena R; Borghi-Silva A

Frontiers in cardiovascular medicine [Front Cardiovasc Med] 2022 Jan 31; Vol. 8, pp. 772650.
Date of Electronic Publication: 2022 Jan 31 (Print Publication: 2021).

Aim: To evaluate the effect of non-invasive positive pressure ventilation (NIPPV) on (1) metabolic, ventilatory, and hemodynamic responses; and (2) cerebral (Cox), respiratory, and peripheral oxygenation when compared with SHAM ventilation during the high-intensity exercise in patients with coexisting chronic obstructive pulmonary disease (COPD) and heart failure (HF).
Methods and Results: On separate days, patients performed incremental cardiopulmonary exercise testing and two constant-work rate tests receiving NIPPV or controlled ventilation (SHAM) (the bilevel mode-Astral 150) in random order until the limit of tolerance (Tlim). During exercise, oxyhemoglobin (OxyHb+Mb) and deoxyhemoglobin (DeoxyHb+Mb) were assessed using near-infrared spectroscopy (Oxymon, Artinis Medical Systems, Einsteinweg, The Netherlands). NIPPV associated with high-intensity exercise caused a significant increase in exercise tolerance, peak oxygen consumption (V·O2in mlO 2 ·kg -1 ·min -1 ), minute ventilation peak (V·Ein ml/min), peak peripheral oxygen saturation (SpO 2 , %), and lactate/tlim (mmol/s) when compared with SHAM ventilation. In cerebral, respiratory, and peripheral muscles, NIPPV resulted in a lower drop in OxyHb+Mb ( p < 0.05) and an improved deoxygenation response DeoxyHb+Mb ( p < 0.05) from the half of the test (60% of Tlim) when compared with SHAM ventilation.
Conclusion: Non-invasive positive pressure ventilation during constant work-rate exercise led to providing the respiratory muscle unloading with greater oxygen supply to the peripheral muscles, reducing muscle fatigue, and sustaining longer exercise time in patients with COPD-HF.

Transferability of Cardiopulmonary Parameters between Treadmill and Cycle Ergometer Testing in Male Triathletes-Prediction Formulae.

Wiecha S; Price S; Cieśliński I; Kasiak PS; Tota Ł; Ambroży T; Śliż D;

International journal of environmental research and public health [Int J Environ Res Public Health] 2022 Feb 06; Vol. 19 (3). Date of Electronic Publication: 2022 Feb 06.

Cardiopulmonary exercise testing (CPET) on a treadmill (TE) or cycle ergometry (CE) is a common method in sports diagnostics to assess athletes’ aerobic fitness and prescribe training. In a triathlon, the gold standard is performing both CE and TE CPET. The purpose of this research was to create models using CPET results from one modality to predict results for the other modality. A total of 152 male triathletes (age = 38.20 ± 9.53 year; BMI = 23.97 ± 2.10 kg·m -2 ) underwent CPET on TE and CE, preceded by body composition (BC) analysis. Speed, power, heart rate (HR), oxygen uptake (VO 2 ), respiratory exchange ratio (RER), ventilation (VE), respiratory frequency (fR), blood lactate concentration (LA) (at the anaerobic threshold (AT)), respiratory compensation point (RCP), and maximum exertion were measured. Random forests (RF) were used to find the variables with the highest importance, which were selected for multiple linear regression (MLR) models. Based on R 2 and RF variable selection, MLR equations in full, simplified, and the most simplified forms were created for VO 2AT , HR AT , VO 2RCP , HR RCP , VO 2max , and HR max for CE (R 2 = 0.46-0.78) and TE (R 2 = 0.59-0.80). By inputting only HR and power/speed into the RF, MLR models for practical HR calculation on TE and CE (both R 2 = 0.41-0.75) were created. BC had a significant impact on the majority of CPET parameters. CPET parameters can be accurately predicted between CE and TE testing. Maximal parameters are more predictable than submaximal. Only HR and speed/power from one testing modality could be used to predict HR for another. Created equations, combined with BC analysis, could be used as a method of choice in comprehensive sports diagnostics.

Long-term evolution of N-terminal pro-brain natriuretic peptide levels and exercise capacity in 132 left ventricular assist device recipients.

Van Edom C; Jacobs S; Fresiello L; Vandersmissen K; Vandenbriele C; Droogné W; Meyns B;

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery [Eur J Cardiothorac Surg] 2022 Feb 10. Date of Electronic Publication: 2022 Feb 10.

Objectives: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a widely used biomarker in clinical practice in the context of heart failure. Little is known about the long-term evolution of NT-proBNP levels in left ventricular assist device (LVAD) recipients. Besides this, the potential correlation of NT-proBNP with exercise capacity on the long term after LVAD implantation has not been previously studied.
Methods: We retrospectively analysed 132 single-centre LVAD recipient records (HeartMate II/III; HeartWare; between March 2007 and January 2018; mean follow-up 559 days). Blood samples, 6-min walking test (6MWT) and maximal cardiopulmonary exercise test were performed in a standardized way.
Results: Pre-LVAD NT-proBNP levels were increased (9736 ± 1072 ng/l) and dropped significantly after implantation [14 days: 4360 ± 545 ng/l (P < 0.0001), 6 months: 1485 ± 139 ng/l (P < 0.0001)]. Afterwards a steady state was reached during follow-up (after 1 year: 1592 ± 214 ng/l, after 5 years: 1679 ± 311 ng/l). Submaximal exercise capacity significantly improved postoperatively [percentage of the predicted distance walked during the 6MWT 50 ± 2% (0-3 months); 61 ± 2% (3-6 months, P < 0.001)], with a steady state afterwards [66 ± 2% (6-12 months, P = 0.08); 64 ± 3%, P = 0.70 later on]. We found a gradual increment of percentage of the expected peak oxygen consumption postoperatively [44 ± 2% (0-3 months); 49 ± 2% (3-6 months); 52 ± 2% (6-12 months); 53 ± 1% (after 12 months)] with a significant improvement between 0 and 3 months versus after the first year on LVAD. Furthermore, we showed a significant moderate correlation between NT-proBNP levels and results at both the 6MWT (correlation coefficient: -0.31, P < 0.0001) and cardiopulmonary exercise testing (correlation coefficient: -0.28, P < 0.0001).
Conclusions: NT-proBNP decreased on LVAD support. We showed that submaximal (6MWT) and maximal exercise capacity (cardiopulmonary exercise testing) improve after LVAD implantation and demonstrated an inverse correlation of both tests with NT-proBNP levels.

Relationship between spleen size and exercise tolerance in advanced heart failure patients with a left ventricular assist device.

Hiraiwa H; Okumura T; Sawamura A; Araki T; Mizutani T; Kazama S; Kimura Y; Shibata N; Oishi H; Kuwayama T; Kondo T; Furusawa K; Morimoto R; Adachi T; Yamada S; Mutsuga M; Usui A; Murohara T;

BMC research notes [BMC Res Notes] 2022 Feb 10; Vol. 15 (1), pp. 40.
Date of Electronic Publication: 2022 Feb 10.

Objective: Spleen volume increases in patients with advanced heart failure (HF) after left ventricular assist device (LVAD) implantation. However, the relationship between spleen volume and exercise tolerance (peak oxygen consumption [VO 2 ]) in these patients remains unknown. In this exploratory study, we enrolled 27 patients with HF using a LVAD (median age: 46 years). Patients underwent blood testing, echocardiography, right heart catheterization, computed tomography (CT), and cardiopulmonary exercise testing. Spleen size was measured using CT volumetry, and the correlations/causal relationships of factors affecting peak VO 2 were identified using structural equation modeling.
Results: The median spleen volume was 190.0 mL, and peak VO 2 was 13.2 mL/kg/min. The factors affecting peak VO 2 were peak heart rate (HR; β = 0.402, P = .015), pulmonary capillary wedge pressure (PCWP; β =  - 0.698, P = .014), right ventricular stroke work index (β = 0.533, P = .001), blood hemoglobin concentration (β = 0.359, P = .007), and spleen volume (β = 0.215, P = .041). Spleen volume correlated with peak HR, PCWP, and hemoglobin concentration, reflecting sympathetic activity, cardiac preload, and oxygen-carrying capacity, respectively, and was thus related to peak VO 2 . These results suggest an association between spleen volume and exercise tolerance in advanced HF.

Prediction and types of dead-space fraction during exercise in male chronic obstructive pulmonary disease patients.

Chuang ML; Hsieh BY; Lin IF;

Medicine [Medicine (Baltimore)] 2022 Feb 11; Vol. 101 (6), pp. e28800.

Abstract: A high dead space (VD) to tidal volume (VT) ratio during peak exercise (VD/VTpeak) is a sensitive and consistent marker of gas exchange abnormalities; therefore, it is important in patients with chronic obstructive pulmonary disease (COPD). However, it is necessary to use invasive methods to obtain VD/VTpeak, as noninvasive methods, such as end-tidal PCO2 (PETCO2peak) and PETCO2 adjusted with Jones’ equation (PJCO2peak) at peak exercise, have been reported to be inconsistent with arterial PCO2 at peak exercise (PaCO2peak). Hence, this study aimed to generate prediction equations for VD/VTpeak using statistical techniques, and to use PETCO2peak and PJCO2peak to calculate the corresponding VD/VTpeaks (i.e., VD/VTpeakETVD/VTpeakJ).A total of 46 male subjects diagnosed with COPD who underwent incremental cardiopulmonary exercise tests with PaCO2 measured via arterial catheterization were enrolled. Demographic data, blood laboratory tests, functional daily activities, chest radiography, two-dimensional echocardiography, and lung function tests were assessed.In multivariate analysis, diffusing capacity, vital capacity, mean inspiratory tidal flow, heart rate, and oxygen pulse at peak exercise were selected with a predictive power of 0.74. There were no significant differences in the PCO2peak values and the corresponding VD/VTpeak values across the three types (both p = NS).In subjects with COPD, VD/VTpeak can be estimated using statistical methods and the PETCO2peak and PJCO2peak. These methods may have similar predictive power and thus can be used in clinical practice.