Pritchard A; Burns P; Correia J; Jamieson P; Moxon P; Purvis J; Thomas M; Tighe H;

BMJ open respiratory research [BMJ Open Respir Res] 2021 Nov; Vol. 8 (1).

Cardiopulmonary exercise testing (CPET) has become an invaluable tool in healthcare, improving the diagnosis of disease and the quality, efficacy, assessment and safety of treatment across a range of pathologies. CPET’s superior ability to measure the global exercise response of the respiratory, cardiovascular and skeletal muscle systems simultaneously in a time and cost-efficient manner has led to the application of CPET in a range of settings from diagnosis of disease to preoperative assessment.
The Association for Respiratory Technology and Physiology Statement on Cardiopulmonary Exercise Testing 2021 provides the practitioner and scientist with an outstanding resource to support and enhance practice, from equipment to testing to leadership, helping them deliver a quality assured service for the benefit of all patient groups.

Petek BJ; Churchill TW; Sawalla Guseh J; Loomer G; Gustus SK; Lewis GD; Weiner RB; Baggish AL; Wasfy MM;

Physiological reports [Physiol Rep] 2021 Nov; Vol. 9 (21), pp. e15105.

Cardiopulmonary exercise testing (CPET) guidelines recommend analysis of the oxygen (O ₂ ) pulse for a late exercise plateau in evaluation for obstructive coronary artery disease (OCAD). However, whether this O ₂ pulse trajectory is within the range of normal has been debated, and the diagnostic performance of the O ₂ pulse for OCAD in physically fit individuals, in whomV˙O2may be more likely to plateau, has not been evaluated. Using prospectively collected data from a sports cardiology program, patients were identified who were free of other cardiac disease and underwent clinically-indicated CPET within 90 days of invasive or computed tomography coronary angiography. The diagnostic performance of quantitative O ₂ pulse metrics (late exercise slope, proportional change in slope during late exercise) and qualitative assessment for O ₂ pulse plateau to predict OCAD was assessed. Among 104 patients (age:56 ± 12 years, 30% female, peakV˙O2119 ± 34% predicted), the diagnostic performance for OCAD (n = 24,23%) was poor for both quantitative and qualitative metrics reflecting an O ₂ pulse plateau (late exercise slope: AUC = 0.55, sensitivity = 68%, specificity = 41%; proportional change in slope: AUC = 0.55, sensitivity = 91%, specificity = 18%; visual plateau/decline: AUC = 0.51, sensitivity = 33%, specificity = 67%). When O ₂ pulse parameters were added to the electrocardiogram, the change in AUC was minimal (-0.01 to +0.02, p ≥ 0.05). Those patients without OCAD with a plateau or decline in O ₂ pulse were fitter than those with linear augmentation (peakV˙O2133 ± 31% vs. 114 ± 36% predicted, p < 0.05) and had a longer exercise ramp time (9.5 ± 3.2 vs. 8.0 ± 2.5 min, p < 0.05). Overall, a plateau in O ₂ pulse was not a useful predictor of OCAD in a physically fit population, indicating that the O ₂ pulse should be integrated with other CPET parameters and may reflect a physiologic limitation of stroke volume and/or O ₂ extraction during intense exercise.

Cafiero G; Passi F; Calo’ Carducci FI; Gentili F; Giordano U;  Perri C;   Hashem Said M; Turchetta A;

Italian journal of pediatrics [Ital J Pediatr] 2021 Nov 06; Vol. 47 (1), pp. 221.
Date of Electronic Publication: 2021 Nov 06.

Background: With the gradual resumption of sports activities after the lock-down period for coronavirus pandemic, a new problem is emerging: Allow all athletes to be able to return to compete after SARS-CoV-2 infection in total safety. Several protocols have been proposed for healed athletes but all of them have been formulated for the adult population. The aim of the present study is to evaluate the adequacy of Italian practical recommendations for return-to-paly, in order to exclude cardiorespiratory complications due to COVID-19 in children and adolescents.
Methods: Between April 2020 and January 2021 the Italian Sports Medical Federation formulated cardiorespiratory protocols to be applied to athletes recovered from SARS-CoV-2 infection. The protocols take into account the severity of the infection. Protocols include lung function tests, cardiopulmonary exercise test, echocardiographic evaluation, blood chemistry tests.
Results: From September 2020 to February 2021, 45 children and adolescents (aged from 9 to 18 years; male = 26) with previous SARS-CoV-2 infection were evaluated according to the protocols in force for adult. 55.5% of the subjects (N = 25) reported an asymptomatic infection; 44.5% reported a mild symptomatic infection. Results of lung function test have exceeded the limit of 80% of the theoretical value in all patients. The cardiorespiratory capacity of all patients was within normal limits (average value of maximal oxigen uptake 41 ml/kg/min). No arrhythmic events or reduction in the ejection fraction were highlighted.
Conclusion: The data obtained showed that, in the pediatric population, mild coronavirus infection does not cause cardiorespiratory complications in the short and medium term. Return to play after Coronavirus infection seems to be safe but it will be necessary to continue with the data analysis in order to modulate and optimize the protocols especially in the pediatric field.

Apostolo A; Vignati C; Della Rocca M; de Martino F; Berna G; Campodonico J; Contini M; Muratori M; Palermo P; Mapelli M; Alimento M; Pezzuto B; Agostoni P;

Journal of cardiac failure [J Card Fail] 2021 Nov 08.
Date of Electronic Publication: 2021 Nov 08.

Background: In advanced heart failure (HF), Levosimendan increases peak oxygen uptake (peakVO ₂ ). We investigated whether peakVO ₂ increase is linked to cardiovascular, respiratory or muscular performance changes.
Methods and Results: Twenty patients hospitalized for advanced HF underwent, before and shortly after Levosimendan infusion, two different cardiopulmonary exercise tests (CPET): a) a personalized ramp protocol with repeated arterial blood gas analysis and standard spirometry including alveolar-capillary gas diffusion measurements at rest and at peak exercise, and b) a step incremental workload CPET with continuous near-infrared spectroscopy analysis and cardiac output (CO) assessment by bioelectrical impedance analysis. Levosimendan significantly reduced natriuretic peptides, improved peakVO ₂ (11.3 [IQR 10.1-12.8] to 12.6 [10.2-14.4] ml/Kg/min, p<0.01) and reduced VE/VCO ₂ slope (47.7±10.7 to 43.4±8.1, p<0.01). In parallel, spirometry showed only a minor increase in forced expiratory volume, while peak exercise dead space ventilation was unchanged. However, during exercise, a smaller edema formation was observed after Levosimendan infusion, as inferable from the changes in diffusion components, i.e. membrane diffusion and capillary volume. The end-tidal pressure of CO ₂ (PetCO ₂ ) during the isocapnic buffering period increased after Levosimendan (from 28±3 mmHg to 31±2 mmHg, p<0.01). During exercise, CO increased in parallel with VO ₂ . After Levosimendan, total and oxygenated tissue hemoglobin, but not deoxygenated hemoglobin, increased in all exercise phases.
Conclusion: In advanced HF, Levosimendan increases peakVO ₂ , reduces the formation of exercise-induced lung edema, increases ventilation efficiency due to a reduction of reflex hyperventilation, and increases CO and muscular oxygen delivery and extraction.

Coisne A; Aghezzaf S; Galli E; Mouton S; Richardson M; Dubois D; Delsart P; Domanski O; Bauters C; Charton M; L’Official G; Modine T; Vincentelli A; Juthier F; Lancellotti P; Donal E; Montaigne D;

European heart journal. Cardiovascular Imaging [Eur Heart J Cardiovasc Imaging] 2021 Nov 09.
Date of Electronic Publication: 2021 Nov 09.

Aims: To compare the clinical significance of exercise echocardiography (ExE) and cardiopulmonary exercise testing (CPX) in patients with ≥moderate primary mitral regurgitation (MR) and discrepancy between symptoms and MR severity.
Methods and Results: Patients consulting for ≥moderate discordant primary MR prospectively underwent low (25 W) ExE, peak ExE, and CPX within 2 months in Lille and Rennes University Hospital. Patients with Class I recommendation for surgical MR correction were excluded. Changes in MR severity, systolic pulmonary artery pressure (SPAP), left ventricular ejection fraction (LVEF), and tricuspid annular plane systolic excursion were evaluated during ExE. Patients were followed for major events (ME): cardiovascular death, acute heart failure, or mitral valve surgery. Among 128 patients included, 22 presented mild-to-moderate, 61 moderate-to-severe, and 45 severe MR. Unlike MR variation, SPAP and LVEF were successfully assessed during ExE in most patients. Forty-one patients (32%) displayed reduced aerobic capacity (peak VO2 < 80% of predicted value) with cardiac limitation in 28 (68%) and muscular or respiratory limitation in the 13 others (32%). ME occurred in 61 patients (47.7%) during a mean follow-up of 27 ± 21 months. Twenty-five Watts SPAP [hazard ratio (HR) (95% confidence interval, CI) = 1.03 (1.01-1.06), P = 0.003] and reduced aerobic capacity [HR (95% CI) = 1.74 (1.03-2.95), P = 0.04] were independently predictive of ME, even after adjustment for MR severity. The cut-off of 55 mmHg for 25 W SPAP showed the best accuracy to predict ME (area under the curve = 0.60, P = 0.05).
Conclusion: In patients with ≥moderate primary MR and discordant symptoms, 25 W exercise pulmonary hypertension, defined as an SPAP ≥55 mmHg, and poor aerobic capacity during CPX are independently associated with adverse events.

Peterman JE; Arena R; Myers J; Marzolini S; Ades PA; Savage PD; Lavie CJ; Kaminsky LA;

Journal of the American Heart Association [J Am Heart Assoc] 2021 Nov 16; Vol. 10 (22), pp. e022336.
Date of Electronic Publication: 2021 Nov 08.

Background The importance of cardiorespiratory fitness for stratifying risk and guiding clinical decisions in patients with cardiovascular disease is well-established. To optimize the clinical value of cardiorespiratory fitness, normative reference standards are essential. The purpose of this report is to extend previous cardiorespiratory fitness normative standards by providing updated cardiorespiratory fitness reference standards according to cardiovascular disease category and testing modality.
Methods and Results The analysis included 15 045 tests (8079 treadmill, 6966 cycle) from FRIEND (Fitness Registry and the Importance of Exercise National Database). Using data from tests conducted January 1, 1974, through March 1, 2021, percentiles of directly measured peak oxygen consumption (VO _2peak ) were determined for each decade from 30 through 89 years of age for men and women with a diagnosis of coronary artery bypass surgery, myocardial infarction, percutaneous coronary intervention, or heart failure. There were significant differences between sex and age groups for VO _2peak ( P <0.001). The mean VO _2peak was 23% higher for men compared with women and VO _2peak decreased by a mean of 7% per decade for both sexes. Among each decade, the mean VO _2peak from treadmill tests was 21% higher than the VO _2peak from cycle tests. Differences in VO _2peak were observed among the age groups in both sexes according to cardiovascular disease category.
Conclusions This report provides normative reference standards by cardiovascular disease category for both men and women performing cardiopulmonary exercise testing on a treadmill or cycle ergometer. These updated and enhanced reference standards can assist with patient risk stratification and guide clinical care.

Van Aerde N, Meersseman P, Debaveye Y, Wilmer A, Casaer MP, Gunst J, Wauters J, Wouters PJ, Goetschalckx K, Gosselink R, Van den Berghe G, Hermans G.

Intensive Care Med. 2021 Nov 8:1-10. doi: 10.1007/s00134-021-06541-9. Online ahead of print.

PURPOSE: To evaluate aerobic exercise capacity in 5-year intensive care unit (ICU) survivors and to assess the association between severity of organ failure in ICU and exercise capacity up to 5-year follow-up.
METHODS: Secondary analysis of the EPaNIC follow-up cohort (NCT00512122) including 433 patients screened with cardiopulmonary exercise testing (CPET) between 1 and 5 years following ICU admission. Exercise capacity in 5-year ICU survivors (N = 361) was referenced to a historic sedentary population and further compared to demographically matched controls (N = 49). In 5-year ICU survivors performing a maximal CPET (respiratory exchange ratio > 1.05, N = 313), abnormal exercise capacity was defined as peak oxygen consumption (VO2peak) < 85% of predicted peak oxygen consumption (%predVO2peak), based on the historic sedentary population. Exercise liming factors were identified. To study the association between severity of organ failure, quantified as the maximal Sequential Organ Failure Assessment score during ICU-stay (SOFA-max), and exercise capacity as assessed with VO2peak, a linear mixed model was built, adjusting for predefined confounders and including all follow-up CPET studies. RESULTS: Exercise capacity was abnormal in 118/313 (37.7%) 5-year survivors versus 1/48 (2.1%) controls with a maximal CPET, p < 0.001. Aerobic exercise capacity was lower in 5-year survivors than in controls (VO2peak: 24.0 ± 9.7 ml/min/kg versus 31.7 ± 8.4 ml/min/kg, p < 0.001; %predVO2peak: 94% ± 31% versus 123% ± 25%, p < 0.001). Muscular limitation frequently contributed to impaired exercise capacity at 5-year [71/118 (60.2%)]. SOFA-max independently associated with VO2peak throughout follow-up.
CONCLUSIONS: Critical illness survivors often display abnormal aerobic exercise capacity, frequently involving muscular limitation. Severity of organ failure throughout the ICU stay independently associates with these impairments.

Malcolm A West FRCS, PhD, William CA Baker BMBS, Saqib Rahman MRCS, Alicia Munro BMBS, Sandy Jack PhD, Michael PW Grocott MD, FRCA, Timothy J Underwood FRCS, PhD, Denny ZH Levett FRCA, PhD, For the Fit-4-Surgery Consortium

Journal of Surgical Oncology; 31 August 2021
https://doi.org/10.1002/jso.26652

Okólska M; Łach J; Matusik PT; Pająk J;Mroczek T; Podolec P; Tomkiewicz-Pająk L;

Journal of clinical medicine [J Clin Med] 2021 Sep 29; Vol. 10 (19).
Date of Electronic Publication: 2021 Sep 29.

Reduction of heart rate variability (HRV) parameters may be a risk factor and precede the occurrence of arrhythmias or the development of heart failure and complications in people with postinfarct left ventricular dysfunction and after coronary artery bypass grafting. Data on this issue in adults after a Fontan operation (FO) are scarce. This study assessed the association between HRV, exercise capacity, and multiorgan complications in adults after FO. Data were obtained from 30 FO patients (mean age 24 ± 5.4 years) and 30 healthy controls matched for age and sex. HRV was investigated in all patients by clinical examination, laboratory tests, echocardiography, a cardiopulmonary exercise test, and 24-h electrocardiogram. The HRV parameters were reduced in the FO group. Reduced HRV parameters were associated with patients’ age at the time of FO, time since surgery, impaired exercise capacity, chronotropic incompetence parameters, and multiorgan complications. Univariate analysis showed that saturated O ₂ at rest, percentage difference between adjacent NN intervals of >50 ms duration, and peak heart rate were associated with chronotropic index. Multivariable analysis revealed that all three variables were independent predictors of the chronotropic index. The results of this study suggest novel pathophysiological mechanisms that link HRV, physical performance, and organ damage in patients after FO.

Acar RD; Sarıbaş E; Güney PA; Kafkas Ç; Aydınlı D; Taşçı E; Kırali MK;

Journal of breath research [J Breath Res] 2021 Oct 04; Vol. 15 (4).
Date of Electronic Publication: 2021 Oct 04.

This study aimed to evaluate the cardiopulmonary function and impairment of exercise endurance in patients with COVID-19 after 3 months of the second wave of the pandemic in Turkey. A total of 51 consecutive COVID-19 survivors, mostly healthcare providers, still working in the emergency room and intensive care units of the hospital after the second wave of Covid 19 pandemia were included in this study. Cardiopulmonary exercise stress test was performed. The median of the exercise time of the COVID-19 survivors, was 10 (4.5-13) minutes and the mean 6.8 ± 1.3 Mets was achieved. The VO ₂ max of the COVID-19 survivors was 24 ± 4.6 ml kg ^-1 min ^-1 which corresponds the 85 ± 10% of the predicted VO ₂ max value. The VO ₂ WRs value which was reported about 8.5-11 ml min ^-1 per watt in healthy individuals as normal was found lower in Covid 19 survivors (5.6 ± 1.4). The percentage of the maximum peak VO ₂ calculated according to the predictable peak VO ₂ of the COVID-19 survivors, was found significantly lower in male patients (92 ± 9.5% vs 80 ± 8.5%, p : 0.000). Also, there was a positive correlation between the percentage of the maximum predicted VO ₂ measurements and age ( r : 0.320, p : 0000). The peak VO ₂ values of COVID-19 survivors decreased, and simultaneously, their exercise performance decreased due to peripheral muscle involvement. We believe that COVID-19 significantly affects men and young patients.