Category Archives: Publications

Cardiopulmonary Exercise Testing: What Is its Value?

Guazzi M; Bandera F; Ozemek C; Systrom D; Arena R

Journal Of The American College Of Cardiology [J Am Coll Cardiol], ISSN: 1558-3597, 2017 Sep 26; Vol. 70 (13), pp. 1618-1636;

Compared with traditional exercise tests, cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise integrative physiology involving the pulmonary, cardiovascular, muscular, and cellular oxidative systems. Due to the prognostic ability of key variables, CPET applications in cardiology have grown impressively to include all forms of exercise intolerance, with a predominant focus on heart failure with reduced or with preserved ejection fraction. As impaired cardiac output and peripheral oxygen diffusion are the main determinants of the abnormal functional response in cardiac patients, invasive CPET has gained new popularity, especially for diagnosing early heart failure with preserved ejection fraction and exercise-induced pulmonary hypertension. The most impactful advance has recently come from the introduction of CPET combined with echocardiography or CPET imaging, which provides basic information regarding cardiac and valve morphology and function. This review highlights modern CPET use as a single or combined test that allows the pathophysiological bases of exercise limitation to be translated, quite easily, into clinical practice.

 

The Role of Cardiopulmonary Exercise Testing for Decision Making in Patients with Repaired Tetralogy of Fallot

Dallaire F; Wald RM; Marelli A,

Pediatric Cardiology [Pediatr Cardiol], ISSN:
1432-1971, 2017 Aug; Vol. 38 (6), pp. 1097-1105;

Tetralogy of Fallot is the most common form of
cyanotic congenital heart disease. As a result of the surgical
strategies employed at the time of initial repair, chronic pulmonary
regurgitation (PR) is prevalent in this population. Despite sustained
research efforts, patient selection and timing of pulmonary valve
replacement (PVR) to address PR in young asymptomatic patients with
repaired tetralogy of Fallot (rToF) remain a fundamental but as yet
unanswered question in the field of congenital heart disease. The
ability of the heart to compensate for the chronic volume overload
imposed by PR is critical in the evaluation of the risks and benefits
of PVR. The difficulty in clarifying the functional impact of PR on the
cardiovascular capacity may be in part responsible for the uncertainty
surrounding the timing of PVR. Cardiopulmonary exercise testing (CPET)
may be used to assess abnormal cardiovascular response to increased
physiologic demands. However, its use as a tool for risk stratification
in asymptomatic adolescents and young adults with rToF is still
ill-defined. In this paper, we review the role of CPET as a potentially
valuable adjunct to current risk stratification strategies with a focus
on asymptomatic rToF adolescents and young adults being considered for
PVR. The role of maximal and submaximal exercise measurements to
identify young patients with a decreased or borderline low peak VO2
resulting from impaired ventricular function is explored. Current
knowledge gaps and research perspectives are highlighted.

Value of Strain Imaging and Maximal Oxygen Consumption in Patients With Hypertrophic Cardiomyopathy

Moneghetti KJ; Stolfo D; Christle JW; Kobayashi Y; Finocchiaro G; Sinagra G; Myers J; Ashley
EA; Haddad F; Wheeler MT,

The American Journal Of Cardiology [Am JCardiol], ISSN: 1879-1913, 2017 Oct 01; Vol. 120 (7), pp. 1203-1208;

Longitudinal strain (LS) has been shown to be predictive of outcome in hypertrophic
cardiomyopathy (HC). Percent predicted peak oxygen uptake (ppVO2),
among other cardiopulmonary exercise testing (CPX) metrics, is a strong
predictor of prognosis in HC. However, there has been limited
investigation into the combination of LS and CPX metrics. This study
sought to determine how LS and parameters of exercise performance
contribute to prognosis in HC. One hundred and thirty-one consecutive
patients with HC who underwent CPX and stress echocardiography were
included. Global, septal, and lateral LS were assessed at rest and
stress. Eighty matched individuals were used as controls. Patients were
followed for the composite end point of death and worsening heart
failure. All absolute LS components were lower in patients with HC than
in controls (global 14.3 ± 4.0% vs 18.8 ± 2.2%, p <0.001; septal
11.9 ± 4.9% vs 17.9 ± 2.7%, p <0.001; lateral 16.0 ± 4.7% vs
19.4 ± 3.1%, p = 0.001). Global strain reserve was also reduced in
patients with HC (13 ± 5% vs 19 ± 8%, p = 0.002). Over a median
follow-up of 56 months (interquartile range 14 to 69), the composite
end point occurred in 53 patients. Global LS was predictive of outcome
on univariate analysis (0.55 [0.41 to 0.74], p <0.001). When combined
with CPX metrics, lateral LS was the only strain variable predictive of
outcome along with indexed left atrial volume (LAVI) and ppVO2. The
worst outcomes were observed for patients with lateral LS <16.1%, LAVI
>52 ml/m2, and ppVO2 <80%. The combination of lateral LS, LAVI, and
ppVO2 presents a simple model for outcome prediction.

Statins are related to impaired exercise capacity in males but not females.

PLoS One. 2017 Jun 15;12(6):e0179534

Bahls M, Groß S, Ittermann T, Busch R, Gläser S, Ewert
R, Völzke H, Felix SB, Dörr M

BACKGROUND: Exercise and statins reduce cardiovascular disease (CVD). Exercise
capacity may be assessed using cardiopulmonary exercise testing (CPET). Whether
statin medication is associated with CPET parameters is unclear. We investigated
if statins are related with exercise capacity during CPET in the general
population.
METHODS: Cross-sectional data of two independent cohorts of the Study of Health
in Pomerania (SHIP) were merged (n = 3,500; 50% males). Oxygen consumption (VO2)
at peak exercise (VO2peak) and anaerobic threshold (VO2@AT) was assessed during
symptom-limited CPET. Two linear regression models related VO2peak with statin
usage were calculated. Model 1 adjusted for age, sex, previous myocardial
infarction, and physical inactivity and model 2 additionally for body mass index,
smoking, hypertension, diabetes and estimated glomerular filtration rate.
Propensity score matching was used for validation.
RESULTS: Statin usage was associated with lower VO2peak (no statin: 2336;
95%-confidence interval [CI]: 2287-2,385 vs. statin 2090; 95%-CI: 2,031-2149
ml/min; P < .0001) and VO2@AT (no statin: 1,172; 95%-CI: 1,142-1,202 vs. statin:
1,111; 95%-CI: 1,075-1,147 ml/min; P = .0061) in males but not females (VO2peak:
no statin: 1,467; 95%-CI: 1,417-1,517 vs. statin: 1,503; 95%-CI: 1,426-1,579
ml/min; P = 1.00 and VO2@AT: no statin: 854; 95%-CI: 824-885 vs. statin 864;
95%-CI: 817-911 ml/min; P = 1.00). Model 2 revealed similar results. Propensity
scores analysis confirmed the results.
CONCLUSION: In the general population present statin medication was related with
impaired exercise capacity in males but not females. Sex specific effects of
statins on cardiopulmonary exercise capacity deserve further research

The Role of Cardiopulmonary Exercise Testing for Decision Making in Patients with Repaired Tetralogy of Fallot.

Pediatr Cardiol. 2017 Aug;38(6):1097-1105. doi: 10.1007/s00246-017-1656-z. Epub
2017 Jun 16.

Dallaire F, Wald RM, Marelli A.

Tetralogy of Fallot is the most common form of cyanotic congenital heart disease.
As a result of the surgical strategies employed at the time of initial repair,
chronic pulmonary regurgitation (PR) is prevalent in this population. Despite
sustained research efforts, patient selection and timing of pulmonary valve
replacement (PVR) to address PR in young asymptomatic patients with repaired
tetralogy of Fallot (rToF) remain a fundamental but as yet unanswered question in
the field of congenital heart disease. The ability of the heart to compensate for
the chronic volume overload imposed by PR is critical in the evaluation of the
risks and benefits of PVR. The difficulty in clarifying the functional impact of
PR on the cardiovascular capacity may be in part responsible for the uncertainty
surrounding the timing of PVR. Cardiopulmonary exercise testing (CPET) may be
used to assess abnormal cardiovascular response to increased physiologic demands.
However, its use as a tool for risk stratification in asymptomatic adolescents
and young adults with rToF is still ill-defined. In this paper, we review the
role of CPET as a potentially valuable adjunct to current risk stratification
strategies with a focus on asymptomatic rToF adolescents and young adults being
considered for PVR. The role of maximal and submaximal exercise measurements to
identify young patients with a decreased or borderline low peak VO2 resulting
from impaired ventricular function is explored. Current knowledge gaps and
research perspectives are highlighted.

Quality of life measures predict cardiovascular health and physical performance in chronic renal failure patients.

PLoS One. 2017 Sep 14;12(9):e0183926

Rogan A, McCarthy K, McGregor G, Hamborg T, Evans G, Hewins
S, Aldridge N, Fletcher S, Krishnan N, Higgins R, Zehnder D,
Ting SM

BACKGROUND: Patients with advanced chronic kidney disease (CKD) experience
complex functional and structural changes of the cardiopulmonary and
musculoskeletal system. This results in reduced exercise tolerance, quality of
life and ultimately premature death. We investigated the relationship between
subjective measures of health related quality of life and objective, standardised
functional measures for cardiovascular and pulmonary health.
METHODS: Between April 2010 and January 2013, 143 CKD stage-5 or CKD5d patients
(age 46.0±1.1y, 62.2% male), were recruited prospectively. A control group of 83
healthy individuals treated for essential hypertension (HTN; age 53.2±0.9y,
48.22% male) were recruited at random. All patients completed the SF-36 health
survey questionnaire, echocardiography, vascular tonometry and cardiopulmonary
exercise testing.
RESULTS: Patients with CKD had significantly lower SF-36 scores than the HTN
group; for physical component score (PCS; 45.0 vs 53.9, p<0.001) and mental
component score (MCS; 46.9 vs. 54.9, p<0.001). CKD subjects had significantly
poorer exercise tolerance and cardiorespiratory performance compared with HTN
(maximal oxygen uptake; VO2peak 19.9 vs 25.0ml/kg/min, p<0.001). VO2peak was a
significant independent predictor of PCS in both groups (CKD: b = 0.35, p = 0.02
vs HTN: b = 0.27, p = 0.001). No associations were noted between PCS scores and
echocardiographic characteristics, vascular elasticity and cardiac biomarkers in
either group. No associations were noted between MCS and any variable. The
interaction effect of study group with VO2peak on PCS was not significant (ΔB =
0.08; 95%CI -0.28-0.45, p = 0.7). However, overall for a given VO2peak, the
measured PCS was much lower for patients with CKD than for HTN cohort, a likely
consequence of systemic uremia effects.
CONCLUSION: In CKD and HTN, objective physical performance has a significant
effect on quality of life; particularly self-reported physical health and
functioning. Therefore, these quality of life measures are indeed a good
reflection of physical health correlating highly with objective physical
performance measures.

Effects of a Physical Activity Program on Cardiorespiratory Fitness and Pulmonary Function in Obese Women after Bariatric Surgery: a Pilot Study.

Onofre T; Carlos R; Oliver N; Felismino A; Fialho D; Corte R; da Silva EP; Godoy E; Bruno S,

Obesity Surgery [Obes Surg], ISSN: 1708-0428, 2017 Aug; Vol. 27 (8), pp. 2026-2033; Publisher:
Springer Science + Business Media; PMID: 28386756;

Background:
In severely obese individuals, reducing body weight induced by bariatric
surgery is able to promote a reduction in comorbidities and improve
respiratory symptoms. However, cardiorespiratory fitness (CRF)
reflected by peak oxygen uptake (VO2peak) may not improve in
individuals who remain sedentary post-surgery. The objective of this
study was to evaluate the effects of a physical training program on CRF
and pulmonary function in obese women after bariatric surgery, and to
compare them to a control group.
Methods: Twelve obese female candidates for bariatric surgery were evaluated in the preoperative, 3 months
postoperative (3MPO), and 6 months postoperative (6MPO) periods through
anthropometry, spirometry, and cardiopulmonary exercise testing (CPX).
In the 3MPO period, patients were divided into control group (CG,
n = 6) and intervention group (IG, n = 6). CG received only general
guidelines while IG underwent a structured and supervised physical
training program involving aerobic and resistance exercises, lasting
12 weeks.
Results: All patients had a significant reduction in
anthropometric measurements and an increase in lung function after
surgery, with no difference between groups. However, only IG presented
a significant increase (p < 0.05) in VO2peak and total CPX duration of
5.9 mL/kg/min (23.8%) and 4.9 min (42.9%), respectively.Conclusions:
Applying a physical training program to a group of obese women after
3 months of bariatric surgery could promote a significant increase in
CRF only in the trained group, yet also showing that bariatric surgery
alone caused an improvement in the lung function of both groups.

Quality of Life, Dyspnea, and Functional Exercise Capacity Following a First Episode of Pulmonary Embolism: Results of the ELOPE Cohort Study.

Kahn SR; Akaberi A; Granton JT; Anderson DR; Wells PS; Rodger MA; Solymoss S; Kovacs MJ; Rudski L; Shimony A; Dennie C; Rush C; Hernandez P; Aaron SD; Hirsch AM,

The American Journal Of Medicine [Am J Med], ISSN: 1555-7162, 2017 Aug; Vol. 130 (8), pp.
990.e9-990.e21; Publisher: Excerpta Medica; PMID: 28400247;

Background:
We aimed to evaluate health-related quality of life (QOL), dyspnea, and
functional exercise capacity during the year following the diagnosis of
a first episode of pulmonary embolism.
Methods: This was a prospective
multicenter cohort study of 100 patients with acute pulmonary embolism
recruited at 5 Canadian hospitals from 2010-2013. We measured the
outcomes QOL (by Short-Form Health Survey-36 [SF-36] and Pulmonary
Embolism Quality of Life [PEmb-QoL] measures), dyspnea (by the
University of California San Diego Shortness of Breath Questionnaire
[SOBQ]) and 6-minute walk distance at baseline and 1, 3, 6, and 12
months after acute pulmonary embolism. Computed tomography pulmonary
angiography was performed at baseline, echocardiogram was performed
within 10 days, and cardiopulmonary exercise testing was performed at 1
and 12 months. Predictors of change in QOL, dyspnea, and 6-minute walk
distance were assessed by repeated-measures mixed-effects models
analysis.Results: Mean age was 50.0 years; 57% were male and 80% were
treated as outpatients. Mean scores for all outcomes improved during
1-year follow-up: from baseline to 12 months, mean SF-36 physical
component score improved by 8.8 points, SF-36 mental component score by
5.3 points, PEmb-QoL by -32.1 points, and SOBQ by -16.3 points, and
6-minute walk distance improved by 40 m. Independent predictors of
reduced improvement over time were female sex, higher body mass index,
and percent-predicted VO2 peak <80% on 1 month cardiopulmonary exercise
test for all outcomes; prior lung disease and higher pulmonary artery
systolic pressure on 10-day echocardiogram for the outcomes SF-36
physical component score and dyspnea score; and higher main pulmonary
artery diameter on baseline computed tomography pulmonary angiography
for the outcome PEmb-QoL score.Conclusions: On average, QOL, dyspnea,
and walking distance improve during the year after pulmonary embolism.
However, a number of clinical and physiological predictors of reduced
improvement over time were identified, most notably female sex, higher
body mass index, and exercise limitation on 1-month cardiopulmonary
exercise test. Our results provide new information on patient-relevant
prognosis after pulmonary embolism.

Prognostic Usefulness of Cardiopulmonary Exercise Testing for Managing Patients With Severe Aortic Stenosis.

Le VD; Jensen GV; Kjøller-Hansen L,

The American Journal Of Cardiology [Am J Cardiol], ISSN: 1879-1913, 2017 Sep 01; Vol. 120 (5), pp. 844-849;
Publisher: Excerpta Medica; PMID: 28705379;

The approach to managing
asymptomatic or questionably symptomatic patients for aortic stenosis
is difficult. We aimed to determine whether cardiopulmonary exercise
testing (CPET) is prognostically useful in such patients. Patients
judged asymptomatic or questionably symptomatic for aortic stenosis
with aortic valve area index <0.6 cm2/m2 and left ventricular ejection
fraction ≥0.50 were managed conservatively provided they had either
(group 1) normal peak oxygen consumption and peak oxygen pulse (>83%
and >95% of the predicted values, respectively) or (group 2) subnormal
peak oxygen consumption or peak oxygen pulse but with CPET data
pointing to pathologies other than hemodynamic compromise from aortic
stenosis. Increase in systolic blood pressure <20 mm Hg, ST
depression ≥2 mm, or symptoms during the exercise test were allowed.
Unexpected events included cardiac death or hospitalization with heart
failure in patients who had not been recommended valve replacement. The
median age of the study population (n = 101) was 75 years
(interquartile range 65 to 79 years), and 67% were judged questionably
symptomatic. During a follow-up at 24 ± 6 months, the rate of
unexpected cardiac death and unexpected hospitalization with heart
failure was 0% and 6.0%, respectively. All-cause mortality was 4.0%
compared with 8.0% in the age- and gender-matched population. For group
1, 26 of 70 (37.1%) succumbed to cardiac death, or were hospitalized
because of heart failure, or underwent valve replacement, and for group
2 this was 12 of 31 (38.7%). In conclusion, if CPET does not indicate a
significant hemodynamic compromise because of aortic stenosis, an
initially conservative strategy results in a good prognosis and an
acceptable event rate.

Impaired myocardial relaxation with exercise determines peak aerobic exercise capacity in heart failure with preserved ejection fraction

Trankle, C., Canada, J. M., Buckley, L., Carbone, S., Dixon, D., Arena, R., Van Tassell, B., Abbate, A.

ESC Heart Fail. 2017;4(3):351-355.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by impaired exercise capacity due to shortness of breath and/or fatigue. Assessment of diastolic dysfunction at rest and with exercise may provide insight into the pathophysiology of exercise intolerance in HFpEF.
AIMS: To measure echocardio-Doppler-derived parameters of diastolic function as they relate to various indices of aerobic exercise capacity in HFpEF.
METHODS: We selected 16 subjects with clinically stable HFpEF, no evidence of volume overload, but impaired functional capacity by cardiopulmonary exercise testing [peak oxygen consumption (VO2 )]. We measured the transmitral E and A flow velocities, E/A ratio, and E deceleration time (DT) and tissue Doppler E’ velocity. We also indexed the E’ to the DT, as additional measure of impaired relaxation (E’DT ), and calculated the diastolic functional reserve index (DFRI), as the product of E’ at rest and change in E’ with exercise.
RESULTS: E’ velocity, at rest and peak exercise, as well as the DFRI positively correlated with peak VO2 , whereas DT, E’DT , and E/E’ with exercise inversely correlated with peak VO2 . Of note, the E’DT at rest also significantly predicted E’ velocity at peak exercise (R = +0.81, P < 0.001). Exercise E’ was the only independent predictor of peak VO2 at multivariable analysis (R = +0.67, P = 0.005).
CONCLUSIONS: The E’ velocity at peak exercise is a strong and independent predictor of aerobic exercise capacity as measured by peak VO2 in patients with HFpEF, providing the link between abnormal myocardial relaxation with exercise and impaired aerobic exercise capacity in HFpEF.