Author Archives: Paul Older

Cardiopulmonary exercise testing and survival after elective abdominal aortic aneurysm repair

Grant SW, Hickey GL, Wisely NA, Carlson ED, Hartley RA, Pichel AC, et al.

Br J Anaesth. 2015;114(3):430-6.

BACKGROUND: Cardiopulmonary exercise testing (CPET) is increasingly used in the preoperative assessment of patients undergoing major surgery. The objective of this study was to investigate whether CPET can identify patients at risk of reduced survival after abdominal aortic aneurysm (AAA) repair. METHODS: Prospectively collected data from consecutive patients who underwent CPET before elective open or endovascular AAA repair (EVAR) at two tertiary vascular centres between January 2007 and October 2012 were analysed. A symptom-limited maximal CPET was performed on each patient. Multivariable Cox proportional hazards regression modelling was used to identify risk factors associated with reduced survival. RESULTS: The study included 506 patients with a mean age of 73.4 (range 44-90). The majority (82.6%) were men and most (64.6%) underwent EVAR. The in-hospital mortality was 2.6%. The median follow-up was 26 months. The 3-year survival for patients with zero or one sub-threshold CPET value ([Formula: see text] at AT<10.2 ml kg(-1) min(-1), peak [Formula: see text]<15 ml kg(-1) min(-1) or [Formula: see text] at AT>42) was 86.4% compared with 59.9% for patients with three sub-threshold CPET values. Risk factors independently associated with survival were female sex [hazard ratio (HR)=0.44, 95% confidence interval (CI) 0.22-0.85, P=0.015], diabetes (HR=1.95, 95% CI 1.04-3.69, P=0.039), preoperative statins (HR=0.58, 95% CI 0.38-0.90, P=0.016), haemoglobin g dl(-1) (HR=0.84, 95% CI 0.74-0.95, P=0.006), peak [Formula: see text]<15 ml kg(-1) min(-1) (HR=1.63, 95% CI 1.01-2.63, P=0.046), and [Formula: see text] at AT>42 (HR=1.68, 95% CI 1.00-2.80, P=0.049). CONCLUSIONS: CPET variables are independent predictors of reduced survival after elective AAA repair and can identify a cohort of patients with reduced survival at 3 years post-procedure. CPET is a potentially useful adjunct for clinical decision-making in patients with AAA.

Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients

a blinded interventional pilot study.

West MA; Loughney L;  Lythgoe D; Barben CP; Sripadam R; Kemp GJ; Grocott MP; Jack S,

British Journal Of Anaesthesia [Br J Anaesth], ISSN: 1471-6771, 2015 Feb; Vol.
114 (2), pp. 244-51;

Publisher: Oxford University Press; PMID: 25274049;

Background: Patients requiring surgery for locally advanced
rectal cancer often additionally undergo neoadjuvant chemoradiotherapy
(NACRT), of which the effects on physical fitness are unknown. The aim
of this feasibility and pilot study was to investigate the effects of
NACRT and a 6 week structured responsive exercise training programme
(SRETP) on oxygen uptake [Formula: see text] at lactate threshold
([Formula: see text]) in such patients.Methods: We prospectively
studied 39 consecutive subjects (27 males) with T3-4/N+ resection
margin threatened rectal cancer who completed standardized NACRT.
Subjects underwent cardiopulmonary exercise testing at baseline
(pre-NACRT), at week 0 (post-NACRT), and week 6 (post-SRETP).
Twenty-two subjects undertook a 6 week SRETP on a training bike (three
sessions per week) between week 0 and week 6 (exercise group). These
were compared with 17 contemporaneous non-randomized subjects (control
group). Changes in [Formula: see text] at [Formula: see text] over time
and between the groups were compared using a compound symmetry
covariance linear mixed model.Results: Of 39 recruited subjects, 22 out
of 22 (exercise) and 13 out of 17 (control) completed the study. There
were differences between the exercise and control groups at baseline
[age, ASA score physical status, World Health Organisation performance
status, and Colorectal Physiologic and Operative Severity Score for the
Enumeration of Mortality and Morbidity (CR-POSSUM) predicted
mortality]. In all subjects, [Formula: see text] at [Formula: see text]
significantly reduced between baseline and week 0 [-1.9 ml kg(-1)
min(-1); 95% confidence interval (CI) -1.3, -2.6; P<0.0001]. In the
exercise group, [Formula: see text] at [Formula: see text]
significantly improved between week 0 and week 6 (+2.1 ml kg(-1)
min(-1); 95% CI +1.3, +2.9; P<0.0001), whereas the control group values
were unchanged (-0.7 ml kg(-1) min(-1); 95% CI -1.66, +0.37;

Conclusions: NACRT before rectal cancer surgery reduces
physical fitness. A structured exercise intervention is feasible
post-NACRT and returns fitness to baseline levels within 6
weeks.Clinical Trial Registration Nct: 01325909.

Supervised exercise training reduces oxidative stress and cardiometabolic risk in adults with type 2 diabetes

a randomized controlled trial.

Vinetti, Giovanni; Mozzini, Chiara; Desenzani,
Paolo; Boni, Enrico; Bulla, Laura; Lorenzetti, Isabella; Romano,
Claudia; Pasini, Andrea; Cominacini, Luciano; Assanelli, Deodato.

Scientific Reports, March 2015, Vol. 5 Issue: Number 1 p9238-9238, 1p;

Abstract: To evaluate the effects of supervised exercise training (SET)
on cardiometabolic risk, cardiorespiratory fitness and oxidative stress
status in 2 diabetes mellitus (T2DM), twenty male subjects with T2DM
were randomly assigned to an intervention group, which performed SET in
a hospital-based setting, and to a control group. SET consisted of a
12-month supervised aerobic, resistance and flexibility training. A
reference group of ten healthy male subjects was also recruited for
baseline evaluation only. Participants underwent medical examination,
biochemical analyses and cardiopulmonary exercise testing. Oxidative
stress markers
(1-palmitoyl-2-[5-oxovaleroyl]-sn-glycero-3-phosphorylcholine [POVPC];
1-palmitoyl-2-glutaroyl-sn-glycero-3-phosphorylcholine [PGPC]) were
measured in plasma and in peripheral blood mononuclear cells. All
investigations were carried out at baseline and after 12 months. SET
yielded a significant modification (p < 0.05) in the following
parameters: V’O2max(+14.4%), gas exchange threshold (+23.4%), waist
circumference (−1.4%), total cholesterol (−14.6%), LDL cholesterol
(−20.2%), fasting insulinemia (−48.5%), HOMA-IR (−52.5%), plasma POVPC
(−27.9%) and PGPC (−31.6%). After 12 months, the control group
presented a V’O2max and a gas exchange threshold significantly lower
than the intervention group. Plasma POVC and PGPC were significantly
different from healthy subjects before the intervention, but not after.

Conclusion, SET was effective in improving cardiorespiratory
fitness, cardiometabolic risk and oxidative stress status in T2DM.;

Exercise limitation associated with asymptomatic left ventricular impairment: analogy with stage B heart failure

Kosmala W; Jellis CL; Marwick TH,

Journal Of The American College Of Cardiology
[J Am Coll Cardiol], ISSN: 1558-3597, 2015 Jan 27; Vol. 65 (3), pp.

Stage B heart failure (SBHF) describes asymptomatic ventricular disease
that may presage the development of heart failure (HF) symptoms. This
entity has been largely defined by structural changes; the roles of
sensitive indicators of nonischemic left ventricular (LV) dysfunction,
such as LV strain, are undefined.Objectives: This study sought to
define the association of exercise capacity with left ventricular
hypertrophy (LVH) and systolic/diastolic dysfunction in asymptomatic
patients with HF risk factors.Methods: We used echocardiography to
study 510 asymptomatic patients (age 58 ± 12 years) with type 2
diabetes mellitus, hypertension, or obesity. The results of
cardiopulmonary exercise testing in patients with structural evidence
of SBHF were compared with those in patients with subclinical
dysfunction, defined by reduced LV strain (>-18%) or increased LV
filling pressure (E/e’ >13).Results: Compared with healthy subjects,
groups with LV abnormalities differed in terms of oxygen uptake (peak
VO2): 25.5 ± 8.2 versus 21.0 ± 8.2 for strain >-18% (p < 0.001); 26.4 ±
8.0 versus 19.0 ± 7.2 for E/e’ >13 (p < 0.0001); and 26.0 ± 7.7 versus
15.9 ± 6.9 ml/kg/min for LVH (p < 0.0001). SBHF, defined as ≥1 imaging
variable present, was associated with lower peak VO2 (beta = -0.20; p <
0.0001) and metabolic equivalents (beta = -0.21; p < 0.0001),
independent of higher body mass index and insulin resistance, older
age, male sex, and treatment with beta-blockers.

Conclusions: LVH,
elevated LV filling pressure, and abnormal myocardial deformation were
independently associated with impaired exercise capacity. Including
functional markers may improve identification of SBHF in nonischemic
heart disease.

Clinical Significance of a Spiral Phenomenon in the Plot of CO2Output Versus O2Uptake During Exercise in Cardiac Patients

Nagayama, Osamu;
Koike, Akira; Himi, Tomoko; Sakurada, Koji; Kato, Yuko; Suzuki, Shinya;
Sato, Akira; Yamashita, Takeshi; Wasserman, Karlman; Aonuma, Kazutaka.
The American Journal of Cardiology, March 2015, Vol. 115 Issue: Number
5 p691-696, 6p;

Abstract: A spiral phenomenon is sometimes noted in the
plots of CO2output (VCO2) against O2uptake (VO2) measured during
cardiopulmonary exercise testing (CPX) in patients with heart failure
with oscillatory breathing. However, few data are available that
elucidate the clinical significance of this phenomenon. Our group
studied the prevalence of this phenomenon and its relation to cardiac
and cardiopulmonary function. Of 2,263 cardiac patients who underwent
CPX, 126 patients with a clear pattern of oscillatory breathing were
identified. Cardiopulmonary indexes were compared between patients who
showed the spiral phenomenon (n = 49) and those who did not (n = 77).
The amplitudes of VO2and VCO2oscillations were greater and the phase
difference between VO2and VCO2oscillations was longer in the patients
with the spiral phenomenon than in those without it. Patients with the
spiral phenomenon also had a lower left ventricular ejection fraction
(43.4 ± 21.4% vs 57.1 ± 16.8%, p <0.001) and a higher level of brain
natriuretic peptide (637.2 ± 698.3 vs 228.3 ± 351.4 pg/ml, p = 0.002).
The peak VO2was lower (14.5 ± 5.6 vs 18.1 ± 6.3, p = 0.002), the slope
of the increase in ventilation versus VCO2was higher (39.8 ± 9.5 vs
33.6 ± 6.8, p <0.001), and end-tidal PCO2both at rest and at peak
exercise was lower in the patients with the spiral phenomenon than in
those without it. In conclusion, the spiral phenomenon in the
VCO2-versus-VO2plot arising from the phase difference between VCO2and
VO2oscillations reflects more advanced cardiopulmonary dysfunction in
cardiac patients with oscillatory breathing.

Relationship between chronotropic incompetence and β-blockers based on changes in chronotropic response during cardiopulmonary exercise testing

Relationship between chronotropic incompetence and β-blockers based
on changes in chronotropic response during cardiopulmonary exercise

Takano, Nami; Takano, Haruhito; Fukuda, Taira; Kikuchi,
Hironobu; Oguri, Gaku; Fukumura, Kazuya; Iwasawa, Kuniaki; Nakajima,
Toshiaki. IJC

Heart & Vasculature, March 2015, Vol. 6 Issue: Number 1
p12-18, 7p;

Abstract: Chronotropic incompetence (CI), an attenuated
heart rate (HR) response to exercise, is common in patients with
cardiovascular disease. The aim of this study was to assess changes in
the chronotropic response (CR) during cardiopulmonary exercise testing
(CPET) in patients undergoing cardiac rehabilitation and investigate
the effects of β-blockers.

Cardiopulmonary Exercise Testing in Heart Failure

Myers, Jonathan;
Arena, Ross; Cahalin, Lawarence P.; Labate, Valentina; Guazzi, Marco.
Current Problems in Cardiology, 20150101,
Abstract: A growing body of literature has underscored the value of
ventilatory gas exchange techniques during exercise testing (commonly
termed cardiopulmonary exercise testing, or CPX) and their applications
in the management of patients with heart failure (HF). The added
precision provided by this technology is useful in terms of
understanding the physiology and mechanisms underlying exercise
intolerance in HF, quantifying the response to therapy, evaluating
disability, making activity recommendations, and quantifying the
response to exercise training. Importantly, a wealth of data has been
published in recent years on the prognostic utility of CPX in patients
with HF. These studies have highlighted the concept that indices of
ventilatory inefficiency, such as the VE/VCO2slope and oscillatory
breathing, are particularly powerful in stratifying risk in HF. This
article provides an overview of the clinical utility of CPX in patients
with HF, including the applications of ventilatory inefficiency during
exercise, the role of the pulmonary system in HF, respiratory muscle
performance (RMP), and the application of CPX as part of a
comprehensive clinical and exercise test evaluation.