Rossi Neto JM; Tebexreni AS; Alves ANF; Smanio PEP; de Abreu FB; Thomazi MC; Nishio PA; Cuninghant IA;

Plos One [PLoS One] 2019 Jan 09; Vol. 14 (1), pp. e0209897. Date of Electronic Publication: 20190109 (Print Publication: 2019).

Purpose: Cardiorespiratory fitness is inversely associated with a high risk of cardiovascular disease, all-cause mortality, and mortality attributable to various cancers. It is often estimated indirectly using mathematical formulas for estimating oxygen uptake. Cardiopulmonary exercise testing, especially oxygen uptake, represents the “gold standard” for assessing exercise capacity. The purpose of this report was to develop reference standards for exercise capacity by establishing cardiorespiratory fitness values derived from cardiopulmonary exercise testing in a Brazilian population. We focused on oxygen uptake standards and compared the maximal oxygen uptake [mLO2·kg-1·min-1] values with those in the existing literature.
Methods: A database was constructed using reports from cardiopulmonary exercise testing performed at Fleury laboratory. The final cohort included 18,189 individuals considered to be free of structural heart disease. Percentiles of maximal oxygen uptake for men and women were determined for six age groups between 7 and 84 years. We compared the values with existing reference data from patients from Norway and the United States.
Results: There were significant differences in maximal oxygen uptake between sexes and across the age groups. In our cohort, the 50th percentile maximal oxygen uptake values for men and women decreased from 44.7 and 36.3 mLO2·kg-1·min-1 to 28.4 and 22.3 mLO2·kg-1·min-1 for patients aged 20-29 years to patients aged 60-69 years, respectively. For each age group, both Norwegian men and women had greater cardiorespiratory fitness than cohorts in the United States and Brazil.
Conclusion: To our knowledge, our analysis represents the largest reference data for cardiorespiratory fitness based on treadmill cardiopulmonary exercise testing. Our findings provide reference values of maximal oxygen uptake measurements from treadmill tests in Brazilian populations that are more accurate than previous standard values based on workload-derived estimations. This data may also add information to the global data used for the interpretation of cardiorespiratory fitness.

Abbott TEF, Gooneratne M, McNeill J, Lee A, Levett DZH, Grocott
MPW, Swart M, MacDonald N; ARCTIC study investigators.

Br J Anaesth. 2018 Mar;120(3):475-483. doi: 10.1016/j.bja.2017.11.071. Epub 2017
Nov 29.

BACKGROUND: Despite the increasing importance of cardiopulmonary exercise testing
(CPET) for preoperative risk assessment, the reliability of CPET interpretation
is unclear. We aimed to assess inter-observer reliability of preoperative CPET.
METHODS: We conducted a prospective, multi-centre, observational study of
preoperative CPET interpretation. Participants were professionals with previous
experience or training in CPET, assessed by a standardized questionnaire. Each
participant interpreted 100 tests using standardized software. The CPET variables
of interest were oxygen consumption at the anaerobic threshold (AT) and peak
oxygen consumption (VO2 peak). Inter-observer reliability was measured using
intra-class correlation coefficient (ICC) with a random effects model. Results
are presented as ICC with 95% confidence interval, where ICC of 1 represents
perfect agreement and ICC of 0 represents no agreement.
RESULTS: Participants included 8/28 (28.6%) clinical physiologists, 10 (35.7%)
junior doctors, and 10 (35.7%) consultant doctors. The median previous experience
was 140 (inter-quartile range 55-700) CPETs. After excluding the first 10 tests
(acclimatization) for each participant and missing data, the primary analysis of
AT and VO2 peak included 2125 and 2414 tests, respectively. Inter-observer
agreement for numerical values of AT [ICC 0.83 (0.75-0.90)] and VO2 peak [ICC
0.88 (0.84-0.92)] was good. In a post hoc analysis, inter-observer agreement for
identification of the presence of a reportable AT was excellent [ICC 0.93
(0.91-0.95)] and a reportable VO2 peak was moderate [0.73 (0.64-0.80)].
CONCLUSIONS: Inter-observer reliability of interpretation of numerical values of
two commonly used CPET variables was good (>80%). However, inter-observer
agreement regarding the presence of a reportable value was less consistent.

Levett DZH, Jack S, Swart M, Carlisle J, Wilson J, Snowden C,
Riley M, Danjoux G, Ward SA, Older P, Grocott MPW; Perioperative
Exercise Testing and Training Society (POETTS).

Br J Anaesth. 2018 Mar;120(3):484-500. doi: 10.1016/j.bja.2017.10.020. Epub 2017
Nov 24.

The use of perioperative cardiopulmonary exercise testing (CPET) to evaluate the
risk of adverse perioperative events and inform the perioperative management of
patients undergoing surgery has increased over the last decade. CPET provides an
objective assessment of exercise capacity preoperatively and identifies the
causes of exercise limitation. This information may be used to assist clinicians
and patients in decisions about the most appropriate surgical and non-surgical
management during the perioperative period. Information gained from CPET can be
used to estimate the likelihood of perioperative morbidity and mortality, to
inform the processes of multidisciplinary collaborative decision making and
consent, to triage patients for perioperative care (ward vs critical care), to
direct preoperative interventions and optimization, to identify new
comorbidities, to evaluate the effects of neoadjuvant cancer therapies, to guide
prehabilitation and rehabilitation, and to guide intraoperative anaesthetic
practice. With the rapid uptake of CPET, standardization is key to ensure valid,
reproducible results that can inform clinical decision making. Recently, an
international Perioperative Exercise Testing and Training Society has been
established (POETTS www.poetts.co.uk) promoting the highest standards of care for
patients undergoing exercise testing, training, or both in the perioperative
setting. These clinical cardiopulmonary exercise testing guidelines have been
developed by consensus by the Perioperative Exercise Testing and Training Society
after systematic literature review. The guidelines have been endorsed by the
Association of Respiratory Technology and Physiology (ARTP).

Mori K; Goto T; Yamamoto J; Muto K; Kikuchi S; Wakami K; Fukuta H; Ohte N;

The Tohoku Journal Of Experimental Medicine [Tohoku J Exp Med] 2018 Dec; Vol. 246 (4), pp. 265-274.

Atrial fibrillation (AF) is an exacerbating factor for exercise tolerance due to the loss of atrial kick. However, many patients with permanent AF, which lasts for at least a year without interruption, and preserved left ventricular ejection fraction (LVEF ≥ 50%) are asymptomatic and have good exercise tolerance. In such cases, the possible mechanism that compensates for the decrease in cardiac output accompanying the loss of atrial kick is a sufficient increase in heart rate (HR) during exercise. We investigated the relationship between exercise tolerance and peak HR during exercise using cardiopulmonary exercise testing in 242 male patients with preserved LVEF, 214 with sinus rhythm (SR) and 28 with permanent AF. Peak HR was significantly higher in the AF group than the SR group (148.9 ± 41.9 vs. 132.0 ± 22.0 beats/min, p = 0.001). However, oxygen uptake at peak exercise did not differ between the AF and SR groups (19.4 ± 5.7 vs. 21.6 ± 6.0 mL/kg/min, p = 0.17). In multiple regression analysis, peak HR (β, 0.091; p < 0.001) and the interaction term constructed by peak HR and presence of permanent AF (β, 0.05; p = 0.04) were selected as determinants for peak VO2; however, presence of permanent AF was not selected (β, -0.38; p = 0.31). Therefore, the impact of peak HR on exercise tolerance differed between the AF and SR groups, suggesting that a sufficient increase in HR during exercise is an important factor to preserve exercise tolerance among patients with AF.

Franssen WMA; Beyens M; Hatawe TA; Frederix I; Verboven K; Dendale P; Eijnde BO; Massa G; Hansen D;

International Journal Of Obesity (2005) [Int J Obes (Lond)] 2018 Dec 19. Date of Electronic Publication: 2018 Dec 19.

Objective: To gain greater insights in the etiology and clinical consequences of altered cardiac function in obese adolescents. Therefore, we aimed to examine cardiac structure and function in obese adolescents, and to examine associations between altered cardiac function/structure and cardiometabolic disease risk factors or cardiopulmonary exercise capacity.
Methods: In 29 obese (BMI 31.6 ± 4.2 kg/m², age 13.4 ± 1.1 years) and 29 lean (BMI 19.5 ± 2.4 kg/m², age 14.0 ± 1.5 years) adolescents, fasted blood samples were collected to study hematology, biochemistry, liver function, glycemic control, lipid profile, and hormones, followed by a transthoracic echocardiography to assess cardiac structure/function, and a cardiopulmonary exercise test (CPET) to assess cardiopulmonary exercise parameters. Regression analyses were applied to examine relations between altered echocardiographic parameters and blood parameters or CPET parameters in the entire group.
Results: In obese adolescents, left ventricular septum thickness, left atrial diameter, mitral A-wave velocity, E/e’ ratio were significantly elevated (p < 0.05), as opposed to lean controls, while mitral e’-wave velocity was significantly lowered (p < 0.01). Elevated homeostatic model assessment of insulin resistance and blood insulin, c-reactive protein, and uric acid concentrations (all significantly elevated in obese adolescents) were independent risk factors for an altered cardiac diastolic function (p < 0.01). An altered cardiac diastolic function was not related to exercise tolerance but to a delayed heart rate recovery (HRR; p < 0.01).
Conclusions: In obese adolescents, an altered cardiac diastolic function was independently related to hyperinsulinemia and whole-body insulin resistance, and only revealed by a delayed HRR during CPET. This indicates that both hyperinsulinemia, whole-body insulin resistance, and delayed HRR could be regarded as clinically relevant outcome parameters.

Stringer W; Marciniuk D;

COPD [COPD] 2018 Dec 30, pp. 1-11. Date of Electronic Publication: 2018 Dec 30.

Chronic obstructive pulmonary disease (COPD) is a common multisystem inflammatory disease with ramifications involving essentially all organ systems. Pulmonary rehabilitation is a comprehensive program designed to prevent and mitigate these disparate systemic effects and improve patient quality of life, functional status, and social functioning. Although initial patient assessment is a prominent component of any pulmonary rehabilitation (PR) program, cardiopulmonary exercise testing (CPET) is not regularly performed as a screening physiologic test prior to PR in COPD patients. Further, CPET is not often used to assess or document the improvement in exercise capacity related to completion of PR. In this review we will describe the classic physiologic abnormalities related to COPD on CPET parameters, the role of CPET in Risk Stratification/Safety prior to PR, the physiologic changes that occur in CPET parameters with PR, and the literature regarding the use of CPET to assess PR results. Finally, we will compare CPET to 6MW in COPD PR, the common minimal clinically important difference (MCID) is associated with CPET, and the potential future roles of CPET in PR and Research.

Nemoto S; Kasahara Y; Izawa KP; Watanabe S; Yoshizawa K; Takeichi N; Kamiya K; Suzuki N; Omiya K; Matsunaga A; Akashi YJ;

Heart And Vessels [Heart Vessels] 2019 Jan 02. Date of Electronic Publication: 2019 Jan 02.

Resting heart rate (HR) plus 20 or 30 beats per minute (bpm), i.e., a simplified substitute for HR at the anaerobic threshold (AT), is used as a tool for exercise prescription without cardiopulmonary exercise testing data. While resting HR plus 20 bpm is recommended for patients undergoing beta-blocker therapy, the effects of specific beta blockers on HR response to exercise up to the AT (ΔAT HR) in patients with subacute myocardial infarction (MI) are unclear. This study examined whether carvedilol treatment affects ΔAT HR in subacute MI patients. MI patients were divided into two age- and sex-matched groups [carvedilol (+), n = 66; carvedilol (-), n = 66]. All patients underwent cardiopulmonary exercise testing at 1 month after MI onset. ΔAT HR was calculated by subtracting resting HR from HR at AT. ΔAT HR did not differ significantly between the carvedilol (+) and carvedilol (-) groups (35.64 ± 9.65 vs. 34.67 ± 11.68, P = 0.604). Multiple regression analysis revealed that old age and heart failure after MI were significant predictors of lower ΔAT HR (P = 0.039 and P = 0.013, respectively), but not carvedilol treatment. Our results indicate that carvedilol treatment does not affect ΔAT HR in subacute MI patients. Therefore, exercise prescription based on HR plus 30 bpm may be feasible in this patient population, regardless of carvedilol use, without gas-exchange analysis data.

Ackland G, Abbott TEF, Pearse RM, Karmali SN, Whittle J, Minto
G; POM-HR Study Investigators.

Br J Anaesth. 2018 Jan;120(1):94-100. doi: 10.1016/j.bja.2017.11.009. Epub 2017
Nov 21.

BACKGROUND: Systemic arterial pulse pressure (systolic minus diastolic pressure)
≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke
volume and is independently associated with accelerated morbidity and mortality.
Given that deconditioned surgical and heart failure patients share similar
cardiopulmonary physiology, we examined whether lower pulse pressure is
associated with excess morbidity after major surgery.
METHODS: This was a prospective observational cohort study of patients deemed by
their preoperative assessors to be at higher risk of postoperative morbidity.
Preoperative pulse pressure was calculated before cardiopulmonary exercise
testing. The primary outcome was any morbidity (PostOperative Morbidity Survey)
occurring within 5 days of surgery, stratified by pulse pressure threshold ≤53 mm
Hg. The relationship between pulse pressure, postoperative morbidity, and oxygen
pulse (a robust surrogate for left ventricular stroke volume) was examined using
logistic regression analysis (accounting for age, sex, BMI, cardiometabolic
co-morbidity, and operation type).
RESULTS: The primary outcome occurred in 578/660 (87.6%) patients, but
postoperative morbidity was more common in 243/ 660 patients with preoperative
pulse pressure ≤53 mm Hg{odds ratio (OR): 2.24 [95% confidence interval (CI):
1.29-3.38]; P<0.001). Pulse pressure ≤53 mm Hg [OR:1.23 (95% CI: 1.03-1.46);
P=0.02] and type of surgery were independently associated with all-cause
postoperative morbidity (multivariate analysis). Oxygen pulse <90% of
population-predicted normal values was associated with pulse pressure ≤ 53 mm Hg
[OR: 1.93 (95% CI: 1.32-2.84); P=0.007].
CONCLUSIONS: In deconditioned surgical patients, lower preoperative systemic
arterial pulse pressure is associated with excess morbidity. These data are
strikingly similar to meta-analyses identifying low pulse pressure as an
independent risk factor for adverse outcomes in cardiac failure. Low preoperative
pulse pressure is a readily available measure, indicating that detailed
physiological assessment may be warranted.

Mizumi S; Goda A; Takeuchi K; Kikuchi H; Inami T; Soejima K; Satoh T;

Physiological Reports [Physiol Rep] 2018 Dec; Vol. 6 (23), pp. e13945.

Cardiopulmonary exercise testing (CPX) with right heart catheterization (RHC) widely used for early diagnosis and evaluation of pulmonary vascular disease in patients with pulmonary arterial hypertension and early stage heart failure with preserved ejection fraction, who display normal hemodynamics at rest. The aim of this study was to investigate that whether body position affects pulmonary hemodynamics, pulmonary arterial wedge pressure (PAWP), and CPX parameters during invasive CPX. Seventeen patients (58 ± 14 years; 5/12 male/female) with chronic thromboembolic pulmonary hypertension treated with percutaneous transluminal pulmonary angioplasty and near-normal pulmonary artery pressure (PAP) underwent invasive CPX twice in supine and upright position using a cycle ergometer with 6 months interval. The mean PAP (peak: 45 ± 7 vs. 40 ± 11 mmHg, P = 0.006) and PAWP (peak: 17 ± 4 vs. 11 ± 7 mmHg, P = 0.008, supine vs. upright, respectively) throughout the test in supine position were significantly higher compared with in upright position, because of preload increase. However, transpulmonary pressure gradient, pulmonary vascular resistance, and mPA-Q slope during exercise were of no significant difference between two positions. There were no differences between the results of two positions in peak VO2 (15.9 ± 4.0 vs. 16.6 ± 3.2 mL/min per kg, P = 0.456), the VE versus VCO2 slope (37.8 ± 9.2 vs. 35.9 ± 8.0, P = 0.397), or the peak work-rate (79 ± 29 vs. 84 ± 27W, P = 0.118). Body position had a significant influence on PAP and PAWP during exercise, but no influence on the pulmonary circulation, or peak VO2 , or VE vs.VCO2 slope.

Sato Y, Yoshihisa A, Kimishima Y, Kiko T, Watanabe S, Kanno Y,
Abe S, Miyata M, Sato T, Suzuki S, Oikawa M, Kobayashi A,
Yamaki T, Kunii H, Nakazato K, Ishida T, Takeishi Y.

Can J Cardiol. 2018 Jan;34(1):80-87. doi: 10.1016/j.cjca.2017.10.021. Epub 2017
Nov 8.
Comment in:
Can J Cardiol. 2018 Jan;34(1):11-12.

BACKGROUND: It is widely recognized that overt hyper- as well as hypothyroidism
are potential causes of heart failure (HF). Additionally it has been recently
reported that subclinical hypothyroidism (sub-hypo) is associated with
atherosclerosis, development of HF, and cardiovascular death. We aimed to clarify
the effect of sub-hypo on prognosis of HF, and underlying hemodynamics and
exercise capacity.
METHODS: We measured the serum levels of thyroid stimulating hormone (TSH) and
free thyroxine (FT4) in 1100 consecutive HF patients. We divided these patients
into 5 groups on the basis of plasma levels of TSH and FT4, and focused on
euthyroidism (0.4 ≤ TSH ≤ 4 μIU/mL and 0.7 ≤ FT4 ≤ 1.9 ng/dL; n = 911; 82.8%) and
sub-hypo groups (TSH > 4 μIU/mL and 0.7 ≤ FT4 ≤ 1.9 ng/dL; n = 132; 12.0%). We
compared parameters of echocardiography, cardiopulmonary exercise testing, and
cardiac catheterization, and followed up for cardiac event rate and all-cause
mortality between the 2 groups.
RESULTS: Although left ventricular ejection fraction did not differ between the 2
groups, the sub-hypo group had lower peak breath-by-breath oxygen consumption and
higher mean pulmonary arterial pressure than the euthyroidism group (peak
breath-by-breath oxygen consumption, 14.0 vs 15.9 mL/min/kg; P = 0.012; mean
pulmonary arterial pressure, 26.8 vs 23.5 mm Hg, P = 0.020). In Kaplan-Meier
analysis (mean 1098 days), the cardiac event rate and all-cause mortality were
significantly higher in the sub-hypo group than those in the euthyroidism group
(log rank, P < 0.01, respectively). In Cox proportional hazard analysis, sub-hypo
was a predictor of cardiac event rate and all-cause mortality in HF patients (P <
0.05, respectively).
CONCLUSIONS: Sub-hypo might be associated with adverse prognosis, accompanied by
impaired exercise capacity and higher pulmonary arterial pressure, in HF
patients.