Gentili F; Calcagni G; Cantarutti N; Manno EC; Cafiero G; Tranchita E; Salvati A; Palma P; Giordano U; Drago F; Turchetta A;

Journal of clinical medicine [J Clin Med] 2023 Mar 19; Vol. 12 (6).
Date of Electronic Publication: 2023 Mar 19.

Multisystem inflammatory syndrome in children (MIS-C) is a serious health condition that imposes a long-term follow-up. The purpose of our pilot study is to evaluate the usefulness of the cardiopulmonary stress test (CPET) in the follow-up after MIS-C. All patients admitted for MIS-C in our hospital in the 12 months preceding the date of observation were considered for inclusion in the study. Pre-existing cardio-respiratory diseases and/or the lack of collaboration were the exclusion criteria. At enrolment, each subject passed a cardiological examination, rest ECG, echocardiogram, 24 h Holter-ECG, blood tests, and a CPET complete of spirometry. A total of 20 patients met the inclusion criteria (11.76 ± 3.29 years, 13 male). In contrast to the normality of all second-level investigations, CPET showed lower-than-expected peakVO ₂ and peak-oxygen-pulse values (50% of cases) and higher-than-expected VE/VCO _2- slope values (95% of cases). A statistically significant inverse correlation was observed between P-reactive-protein values at admission and peakVO ₂ /kg values ( p = 0.034), uric acid values at admission, and peakVO ₂ ( p = 0.011) or peak-oxygen-pulse expressed as a percentage of predicted ( p = 0.021), NT-proBNP values at admission and peakVO ₂ expressed as a percentage of predicted ( p = 0.046). After MIS-C (4-12 months) relevant anomalies can be observed at CPET, which can be a valuable tool in the follow-up after this condition.

Farmakis IT; Valerio L; Barco S; Alsheimer E; Ewert R; Hobohm L; Keller K; Germany.; Mavromanoli AC;
Rosenkranz S; Morris TA; Held M; Dumitrescu D;

The European respiratory journal [Eur Respir J] 2023 Mar 23.
Date of Electronic Publication: 2023 Mar 23.

Background: Cardiopulmonary exercise testing (CPET) may provide prognostically valuable information during follow-up after pulmonary embolism (PE).
Objective: To investigate the association of patterns and degree of exercise limitation, as assessed by CPET, with clinical, echocardiographic, laboratory abnormalities and quality of life (QoL) after PE.
Methods: In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3-month and 12-month follow-up, including CPET. We defined cardiopulmonary limitation as ventilatory inefficiency or insufficient cardiocirculatory reserve. Deconditioning was defined as peak VO ₂ <80% with no other abnormality.
Results: Overall, 396 patients were included. At 3 months, prevalence of cardiopulmonary limitation and deconditioning was 50.1% (34.7% mild/moderate; 15.4% severe) and 12.1%, respectively; at 12 months, it was 44.8% (29.1% mild/moderate 15.7% severe) and 14.9%. Cardiopulmonary limitation and its severity were associated with age (OR per decade 2.05; 95% CI 1.65-2.55), history of chronic lung disease (OR 2.72; 95% CI 1.06-6.97), smoking (OR 5.87; 2.44-14.15), and intermediate- or high-risk acute PE (OR 4.36; 95% CI 1.92-9.94). Severe cardiopulmonary limitation at 3 months was associated with the prospectively defined, combined clinical-haemodynamic endpoint of “post-PE impairment” (OR 6.40, 95% CI 2.35-18.45) and with poor disease-specific and generic health-related QoL.
Conclusion: Abnormal exercise capacity of cardiopulmonary origin is frequent after PE, being associated with clinical and hemodynamic impairment as well as long-term QoL reduction. CPET can be considered for selected patients with persisting symptoms after acute PE to identify candidates for closer follow-up and possible therapeutic interventions.

Kominami K; Noda K; Minagawa N; Yonezawa K; Akino M;

Medicine [Medicine (Baltimore)] 2023 Mar 24; Vol. 102 (12), pp. e33356.

Dynamic lung hyperinflation (DLH) caused by air trapping, which increases residual air volume, is a common cause of shortness of breath on exertion in chronic obstructive pulmonary disease (COPD). DLH is commonly evaluated by measuring the decrease in maximal inspiratory volume during exercise, or using the hyperventilation method. However, only few facilities perform these methods, and testing opportunities are limited. Therefore, we investigated the possibility of visually and qualitatively detecting DLH using data from a cardiopulmonary exercise test (CPET). Four men who underwent symptom-limiting CPET were included in this study, including a male patient in his 60s with confirmed COPD, a 50s male long-term smoker, and 2 healthy men in their 20s and 70s, respectively. We calculated the difference between the inspiratory tidal volume (TV I) and expiratory tidal volume (TV E) per breath (TV E-I) from the breath-by-breath data of each CPET and plotted it against the time axis. No decrease in TV E-I was observed in either of the healthy men. However, in the patient with COPD and long-term smoker, TV E-I began to decrease immediately after the initiation of exercise. These results indicate that DLH can be visually detected using CPET data. However, this study was a validation of a limited number of cases, and a comparison with existing evaluation methods and verification of disease specificity are required.

Hortegal RA; Hossri C; Giolo L;   R; Gun C; Assef J; Moriya HT; Franchini KG; Feres F; Meneghelo R;

The international journal of cardiovascular imaging [Int J Cardiovasc Imaging] 2023 Mar 31.
Date of Electronic Publication: 2023 Mar 31.

Background: Heart Failure with Preserved Ejection Fraction (HFpEF) is a syndrome characterized by different degrees of exercise intolerance, which leads to poor quality of life and prognosis. Recently, the European score (HFA-PEFF) was proposed to standardize the diagnosis of HFpEF. Even though Global Longitudinal Strain (GLS) is a component of HFA-PEFF, the role of other strain parameters, such as Mechanical Dispersion (MD), has yet to be studied. In this study, we aimed to compare MD and other features from the HFA-PEFF according to their association with exercise capacity in an outpatient population of subjects at risk or suspected HFpEF.
Methods: This is a single-center cross-sectional study performed in an outpatient population of 144 subjects with a median age of 57 years, 58% females, referred to the Echocardiography and Cardiopulmonary Exercise Test to investigate HFpEF.
Results: MD had a higher correlation to Peak VO2 (r=-0.43) when compared to GLS (r=-0.26), MD presented a significant correlation to Ventilatory Anaerobic Threshold (VAT) (r=-0.20; p = 0.04), while GLS showed no correlation (r=-0.14; p = 0.15). Neither MD nor GLS showed a correlation with the time to recover VO2 after exercise (T1/2). In Receiver Operator Characteristic (ROC) analysis, MD presented superior performance to GLS to predict Peak VO2 (AUC: 0.77 vs. 0.62), VAT (AUC: 0.61 vs. 0.57), and T1/2 (AUC: 0.64 vs. 0.57). Adding MD to HFA-PEFF improved the model performance (AUC from 0.77 to 0.81).
Conclusion: MD presented a higher association with Peak VO2 when compared to GLS and most features from the HFA-PEFF. Adding MD to the HFA-PEFF improved the model performance.

Verwerft J; Soens L; Wynants J; Meysman M; Jogani S; Plein D; Stroobants S; Herbots L; Verbrugge FH;

European heart journal [Eur Heart J] 2023 Mar 16.
Date of Electronic Publication: 2023 Mar 16.

Background and Aims: Heart failure with preserved ejection fraction (HFpEF) is a syndrome with a heterogeneous presentation. This study provides an in-depth description of haemodynamic and metabolic alterations revealed by systematic assessment through cardiopulmonary exercise testing combined with exercise echocardiography (CPETecho) within a dedicated dyspnoea clinic.
Methods and Results: Consecutive patients (n = 297), referred to a dedicated dyspnoea clinic using a standardized workup including CPETecho, with HFpEF diagnosed through a H2FPEF score ≥6 or HFA-PEFF score ≥5, were evaluated. A median of four haemodynamic/metabolic alterations was uncovered per patient: impaired stroke volume reserve (73%), impaired chronotropic reserve (72%), exercise pulmonary hypertension (65%), and impaired diastolic reserve (64%) were the most frequent cardiac alterations. Impaired peripheral oxygen extraction and a ventilatory limitation were present in 40% and 39%, respectively. In 267 patients (90%), 575 further diagnostic examinations were recommended (median of two tests per patient). Cardiac magnetic resonance imaging, coronary or amyloidosis workup, ventilation-perfusion scanning, and pulmonology referral were each recommended in approximately one out of three patients. In 293 patients (99%), 929 cardiovascular drug optimizations were performed (median of 3 modifications per patient). In 110 patients (37%), 132 cardiovascular interventions were performed, with ablation as the most frequent procedure.
Conclusion: Holistic workup of HFpEF patients within a multidisciplinary, dedicated dyspnoea clinic, including systematic implementation of CPETecho reveals various haemodynamic/metabolic alterations, leading to further diagnostic testing and potential treatment changes in the majority of cases.

Caru M; Heitzenrater J; Schmitz KH;

Pediatric research [Pediatr Res] 2023 Mar 18.
Date of Electronic Publication: 2023 Mar 18.

A letter. No abstract

Franceschi E; Drick N; Fuge J; Santus P; Fischer B; Kayser M; Welte T; Suhling H;

ERJ open research [ERJ Open Res] 2023 Mar 20; Vol. 9 (2).
Date of Electronic Publication: 2023 Mar 20 (Print Publication: 2023).

Introduction: Exercise limitation is frequently described among asthmatic patients and could be related to different mechanisms of the pulmonary, cardiovascular and muscular systems. Despite this, cardiopulmonary exercise testing (CPET) does not have an established role in the management of severe asthma. The aim of our study was to investigate the role of CPET and inspiratory pressure measurement in exercise capacity and muscle strength in severe asthmatic patients treated with anti-IL-5 therapy.
Methods: A monocentric observational study was conducted at Hanover Medical School, Germany, from April 2018 to June 2019. Patients affected by severe asthma treated with either mepolizumab or benralizumab were included. All patients underwent CPET before the initiation of antibody therapy and after 3 months, and follow-up visits were scheduled at 3, 6 and 12 months with plethysmography, inspiratory pressure measurement and blood gas analysis.
Results: 14 patients were enrolled: 10 (71.4%) females, median age 52 years (IQR 47-61). Seven patients were treated with benralizumab, seven with mepolizumab. Oxygen uptake ( V ‘ _{O 2} peak) did not change significantly after 3 months of antibody treatment, while the mean value of the breathing reserve exhaustion reduced significantly from 78% to 60% (p=0.004). Whereas at baseline seven patients depleted the breathing reserve and two of them experienced oxygen desaturation during exercise, at 3 months no one presented any desaturation or breathing reserve exhaustion. The inspiratory pressure remained unchanged before and after the antibody therapy.
Conclusion: CPET could show hints of alveolar recruitment and ventilatory efficiency in severe asthma patients treated with antibody therapy.

Mizoguchi T; Sugiura T; Kawada Y; Yamamoto J; Yokoi M; Nakasuka K; DMori K; Kikuchi S; Ito T;Kitada S; Goto T; Seo Y

Circulation journal : official journal of the Japanese Circulation Society [Circ J] 2023 Mar 21.
Date of Electronic Publication: 2023 Mar 21.

Background: The number of patients with heart failure (HF) has increased, and it is crucial to prevent the development of HF in patients at risk of HF. The present study aimed to risk stratify patients in Stage A and B HF based on associations between exercise-induced changes in aortic stiffness and exercise tolerance.Methods and Results: Patients in Stage A and B HF who performed a cardiopulmonary exercise test were enrolled in the study (n=106; median age 65.0 years [interquartile range 52.8-73.0 years]). Exercise tolerance was examined by the percentage of predicted peak oxygen consumption (%V̇O ₂ peak). The ascending aortic pressure waveform was estimated non-invasively. Aortic stiffness was assessed using the augmentation index (AIx) and reflection magnitude (RM). Multivariable regression analysis showed that AIx measured both before and after exercise was significantly associated with %V̇O ₂ peak (β=-0.221 [P=0.049] and β=-0.342 [P=0.003], respectively). When participants were divided into %V̇O ₂ peak subgroups using a cut-off value of 60%, RM decreased immediately after exercise and remained lower 5 min after exercise in the group with preserved exercise tolerance, but recovered to baseline levels 5 min after exercise in the group with reduced exercise tolerance.
Conclusions: Exercise-induced increases in aortic stiffness were associated with exercise tolerance in patients at risk of HF, suggesting that exercise-induced changes in aortic stiffness may be useful to stratify high-risk patients.

Segreti A; Picarelli F; DI Gioia G; Coletti F; Crispino SP; Fanale V; Fossati C; Antonelli Incalzi R; Pigozzi F; Grigioni F

The Journal of sports medicine and physical fitness [J Sports Med Phys Fitness] 2023 Mar 23.
Date of Electronic Publication: 2023 Mar 23.

Routine or vigorous training, particularly in competitive and elite athletes practicing dynamic sports, leads to a constellation of structural and functional cardiovascular adaptations, facilitating an increased capacity to deliver oxygen to the working muscles during sustained physical exertion. Cardiopulmonary exercise testing is the most accurate and objective method to assess performance in athletes. Although still underutilized, it provides a window into the unique cardiovascular response to exercise in athletes, integrating parameters obtained by the traditional exercise test with breath-by-breath analysis of oxygen consumption, carbon dioxide production, ventilation, and other derived parameters. This review aimed to describe the several applications of cardiopulmonary exercise testing in athletes with a principal focus on the ability to identify cardiovascular adaptations and differentiate an athlete’s heart from early cardiomyopathy. In this context, cardiopulmonary exercise testing provides many applications involving exercise physiology in athletes, allowing a precise evaluation of cardiovascular efficiency, the entity of the adaptations, the response to a training program, and identifying early modifications that could reveal early cardiomyopathy. Therefore, thanks to its several applications, this pivotal test allows us to obtain essential information about the athlete’s physiology and differentiate between the expected response of a trained athlete from early cardiomyopathy.

Seiler T; Nakas CT; Brill AK; Hefti U; Hilty MP; DPerret-Hoigné E; Sailer J; Kabitz HJ; Merz TM; Pichler Hefti J;

British journal of sports medicine [Br J Sports Med] 2023 Mar 10.
Date of Electronic Publication: 2023 Mar 10.

Objective: During a high-altitude expedition, the association of cardiopulmonary exercise testing (CPET) parameters with the risk of developing acute mountain sickness (AMS) and the chance of reaching the summit were investigated.
Methods: Thirty-nine subjects underwent maximal CPET at lowlands and during ascent to Mount Himlung Himal (7126 m) at 4844 m, before and after 12 days of acclimatisation, and at 6022 m. Daily records of Lake-Louise-Score (LLS) determined AMS. Participants were categorised as AMS+ if moderate to severe AMS occurred.
Results: Maximal oxygen uptake (V̇O _2max ) decreased by 40.5%±13.7% at 6022 m and improved after acclimatisation (all p<0.001). Ventilation at maximal exercise (VE _max ) was reduced at 6022 m, but higher VE _max was related to summit success (p=0.031). In the 23 AMS+ subjects (mean LLS 7.4±2.4), a pronounced exercise-induced oxygen desaturation (ΔSpO _2exercise ) was found after arrival at 4844 m (p=0.005). ΔSpO _2exercise >-14.0% identified 74% of participants correctly with a sensitivity of 70% and specificity of 81% for predicting moderate to severe AMS. All 15 summiteers showed higher V̇O _2max (p<0.001), and a higher risk of AMS in non-summiteers was suggested but did not reach statistical significance (OR: 3.64 (95% CI: 0.78 to 17.58), p=0.057). V̇O _2max ≥49.0 mL/min/kg at lowlands and ≥35.0 mL/min/kg at 4844 m predicted summit success with a sensitivity of 46.7% and 53.3%, and specificity of 83.3% and 91.3%, respectively.
Conclusion: Summiteers were able to sustain higher VE _max throughout the expedition. Baseline V̇O _2max below 49.0 mL/min/kg was associated with a high chance of 83.3% for summit failure, when climbing without supplemental oxygen. A pronounced drop of SpO _2exercise at 4844 m may identify climbers at higher risk of AMS.