Category Archives: Publications

2016 Focused Update: Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations.

Circulation.133(24).,e694/711, 2016

Abstract: In the past several decades, cardiopulmonary exercise testing (CPX) has seen an exponential increase in its evidence base. The growing volume of evidence in support of CPX has precipitated the release of numerous scientific statements by societies and associations. In 2012, the European Association for Cardiovascular Prevention & Rehabilitation and the American Heart Association developed a joint document with the primary intent of redefining CPX analysis and reporting in a way that would streamline test interpretation and increase clinical application. Specifically, the 2012 joint scientific statement on CPX conceptualized an easy-to-use, clinically meaningful analysis based on evidence-vetted variables in color-coded algorithms; single-page algorithms were successfully developed for each proposed test indication. Because of an abundance of new CPX research in recent years and a reassessment of the current algorithms in light of the body of evidence, a focused update to the 2012 scientific statement is now warranted. The purposes of this update are to confirm algorithms included in the initial scientific statement not requiring revision, to propose revisions to algorithms included in the initial scientific statement, to propose new algorithms based on emerging scientific evidence, to further clarify the application of oxygen consumption at ventilatory threshold, to describe CPX variables with an emerging scientific evidence base, to describe the synergistic value of combining CPX with other assessments, to discuss personnel considerations for CPX laboratories, and to provide recommendations for future CPX research.

Right Ventricular Functional Reserve in Pulmonary Arterial Hypertension

Circulation.  133(24):2413-22, 2016 Jun 14.

Tedford,Ryan J. From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B.,
P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D.,
T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.),
Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD;
and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical
Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD.

BACKGROUND: Right ventricular (RV) functional reserve affects functional
capacity and prognosis in patients with pulmonary arterial hypertension
(PAH). PAH associated with systemic sclerosis (SSc-PAH) has a
substantially worse prognosis than idiopathic PAH (IPAH), even though many
measures of resting RV function and pulmonary vascular load are similar.
We therefore tested the hypothesis that RV functional reserve is depressed
in SSc-PAH patients.

CONCLUSIONS: RV contractile reserve is depressed in SSc-PAH versus IPAH
subjects, associated with reduced calcium recycling. During exercise, this
results in ventricular-pulmonary vascular uncoupling and acute RV
dilation. RV dilation during exercise can predict adverse
ventricular-vascular coupling in PAH patient

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign

A Scientific Statement From the American Heart Association

Robert Ross, PhD, FAHA,
Steven N. Blair, PED, FAHA,
Ross Arena, PhD, PT, FAHA   et al.

Mounting evidence has firmly established that low levels
of cardiorespiratory fitness (CRF) are associated with a high risk of
cardiovascular disease, all-cause mortality, and mortality rates attributable
to various cancers. A growing body of epidemiological and clinical evidence
demonstrates not only that CRF is a potentially stronger predictor of
mortality than established risk factors such as smoking, hypertension,
high cholesterol, and type 2 diabetes mellitus, but that the addition of
CRF to traditional risk factors significantly improves the reclassification
of risk for adverse outcomes. The purpose of this statement is to review
current knowledge related to the association between CRF and health
outcomes, increase awareness of the added value of CRF to improve
risk prediction, and suggest future directions in research. Although the
statement is not intended to be a comprehensive review, critical references
that address important advances in the field are highlighted. The underlying
premise of this statement is that the addition of CRF for risk classification
presents health professionals with unique opportunities to improve patient
management and to encourage lifestyle-based strategies designed to
reduce cardiovascular risk. These opportunities must be realized to
optimize the prevention and treatment of cardiovascular disease and hence
meet the American Heart Association’s 2020 goals.

Abnormal heart-rate response during cardiopulmonary exercise testing identifies cardiac dysfunction in symptomatic patients with non-obstructive coronary artery disease

Sundeep Chaudhry , Naresh Kumar, Hushyar Behbahani , Akshay Bagai , Binoy K. Singh , NickMenasco , Gregory D. Lewis , Laurence Sperling , Jonathan Myers

International Journal of Cardiology 228 (2017) 114–121

Background: Symptomatic non-obstructive coronary artery disease is a growing clinical dilemma for whic hcontemporary testing is proving to be of limited clinical utility. New methods are needed to identify cardiac dysfunction.
Methods and results: This is a prospective observational cohort study conducted from December 2013 to August 2015 in two outpatient cardiology clinics (symptomatic cohort) and 24 outpatient practices throughout the US (healthy cohort) with centralized methodology and monitoring to compare heart-rate responses during cardiopulmonary exercise testing (CPET). Participants were 208 consecutive patients (median age, 61; range, 32–86 years) with exercise intolerance and without prior heart or lung disease in whom coronary anatomy was defined and 116 healthy subjects (median age, 45; range, 26–66 years). Compared to stress ECG, the novel change in heartrate as a function of work-rate parameter (ΔHR-WR Slope) demonstrated significantly higher sensitivity to detect under-treated atherosclerosis with similar specificity. In men, area under the ROC curve increased from 60% to 94% for non-obstructive CAD and from 64% to 80% for obstructive CAD. In women,  AUC increased from 64% to 85% for non-obstructive CAD and from 66% to 90% for obstructive CAD. ΔHR-WR Slope correctly reclassified abnormal studies in the non-obstructive CADgroup from 22% to 81%; in the obstructive CAD group from18% to 84% and in the revascularization group from 35% to 78%.
Conclusion: Abnormal heart-rate response during CPET is more effective than stress ECG for identifying undertreated atherosclerosis and may be of utility to identify cardiac dysfunction in symptomatic patients with normal routine cardiac testing.

Primary graft dysfunction: Long-term physical function outcomes among lung transplant recipients

Armstrong, Hilary F.; Lederer, David J.;
Bacchetta, Matthew; Bartels, Matthew N..

Heart & Lung: the Journal of Acute and Critical Care, November-December 2016, Vol. 45 Issue: Number 6 p544-549, 6p;

Abstract: Adults with primary graft dysfunction (PGD)
after lung transplantation are at increased risk for pulmonary and
functional impairment. No prior studies have described the long-term
(within 1.5 years of transplant) cardiopulmonary exercise testing
(CPET) results in adults with grade 3 PGD. The objective of this study
was to compare the functional outcomes of lung transplant patients with
and without grade 3 PGD via CPET and six-minute talk tests (6MWD).;

Acute effects of exercise on the inflammatory state in patients with idiopathic pulmonary arterial hypertension

Harbaum, Lars; Renk,
Emilia; Yousef, Sara; Glatzel, Antonia; Lüneburg, Nicole; Hennigs, Jan;
Oqueka, Tim; Baumann, Hans; Atanackovic, Djordje; Grünig, Ekkehard;
Böger, Rainer; Bokemeyer, Carsten; Klose, Hans.

BMC Pulmonary Medicine, December 2016, Vol. 16 Issue: Number 1 p1-11, 11p;

Abstract: Exercise training positively influences exercise tolerance and functional
capacity of patients with idiopathic pulmonary arterial hypertension
(IPAH). However, the underlying mechanisms are unclear. We hypothesized
that exercise modulates the activated inflammatory state found in IPAH
patients.                   Single cardiopulmonary exercise testing was
performed in 16 IPAH patients and 10 healthy subjects. Phenotypic
characterization of peripheral blood mononuclear cells and circulating
cytokines were assessed before, directly after and 1 h after exercise.
Before exercise testing, IPAH patients showed elevated
Th2 lymphocytes, regulatory T lymphocytes, IL-6, and TNF-alpha, whilst
Th1/Th17 lymphocytes and IL-4 were reduced. In IPAH patients but not in
healthy subject, exercise caused an immediate relative decrease of Th17
lymphocytes and a sustained reduction of IL-1-beta and IL-6. The higher
the decrease of IL-6 the higher was the peak oxygen consumption of IPAH
patients.                   Exercise seems to be safe from an immune
and inflammatory point of view in IPAH patients. Our results
demonstrate that exercise does not aggravate the inflammatory state and
seems to elicit an immune-modulating effect in IPAH patients.