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.
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
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.
Generati, Greta; Bandera, Francesco;
Pellegrino, Marta; Labate, Valentina; Donghi, Valeria; Alfonzetti,
Eleonora; Guazzi, Marco.
Journal of the American College of Cardiology,
March 2015, Vol. 65 Issue: Number 10, Number 10 Supplement 1
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,
Heart & Vasculature, March 2015, Vol. 6 Issue: Number 1
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.
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.
Grant, S. W.; Hickey, G. L.;
Wisely, N. A.; Carlson, E. D.; Hartley, R. A.; Pichel, A. C.; Atkinson,
D.; McCollum, C. N..
British Journal of Anaesthesia, March 2015,
Vol. 114 Issue: Number 3 p430-430, 1p;
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.
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 AT<10.2 ml kg−1 min−1, peak VO2<15 ml
kg−1 min−1 or Ve/VO2 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 VO2<15 ml kg−1 min−1 (HR=1.63, 95% CI 1.01–2.63, P=0.046), and
Ve/VCO2 at AT>42.(HR=1.68, 95% CI 1.00–2.80, P=0.049).
Conclusions</st> 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
Snowden CP, Minto G. Exercise: the new premed. Br J Anaesth. 2015;114(2):186-9.
No abstract available
Cardiopulmonary exercise testing, prehabilitation, and Enhanced
Recovery After Surgery (ERAS)
Levett, Denny; Grocott, Michael.
Canadian Journal of Anesthesia, February 2015, Vol. 62 Issue: Number 2
Abstract: This review evaluates the current and future
role of cardiopulmonary exercise testing (CPET) in the context of
Enhanced Recovery After Surgery (ERAS) programs.
There is substantial literature confirming the relationship between
physical fitness and perioperative outcome in general. The few small
studies in patients undergoing surgery within an ERAS program describe
less fit individuals having a greater incidence of morbidity and
mortality. There is evidence of increasing adoption of perioperative
CPET, particularly in the UK. Although CPET-derived variables have been
used to guide clinical decisions about choice of surgical procedure and
level of perioperative care as well as to screen for uncommon
comorbidities, the ability of CPET-derived variables to guide therapy
and thereby improve outcome remains uncertain. Recent studies have
reported a reduction in CPET-defined physical fitness following
neoadjuvant therapies (chemo- and radio-therapy) prior to surgery.
Preliminary data suggest that this effect may be associated with an
adverse effect on clinical outcomes in less fit patients. Early reports
suggest that CPET-derived variables can be used to guide the
prescription of exercise training interventions and thereby improve
physical fitness in patients prior to surgery (i.e., prehabilitation).
The impact of such interventions on clinical outcomes remains
uncertain. Perioperative CPET is finding an
increasing spectrum of roles, including risk evaluation, collaborative
decision-making, personalized care, monitoring interventions, and
guiding prescription of prehabilitation. These indications are
potentially of importance to patients having surgery within an ERAS
program, but there are currently few publications specific to CPET in
the context of ERAS programs.
Cardiopulmonary Exercise Testing in Cancer Patients: Should We Really
Refrain From Considering It for Preparticipation Screening?
Scharhag-Rosenberger, Friederike; Wiskemann, Joachim; Scharhag,
Oncologist, 2015, Vol. 20 Issue: Number 2 p228-228, 1p
Abstract: Cardiopulmonary exercise testing (CPET) should continue to be
taken into consideration when screening cancer patients for
participation in exercise training programs. The benefits of CPET for
cancer patients are better examined through longitudinal rather than
Estimating Equations for Cardiopulmonary Exercise Testing Variables
in Fontan Patients: Derivation and Validation Using a Multicenter
Butts, Ryan; Spencer, Carolyn; Jackson,
Lanier; Heal, Martha; Forbus, Geoffrey; Hulsey, Thomas; Atz, Andrew
Pediatric Cardiology, February 2015, Vol. 36 Issue: Number 2 p393-401,
Abstract: Cardiopulmonary exercise testing (CPET) is a common
method of evaluating patients with a Fontan circulation. Equations to
calculate predicted CPET values are based on children with normal
circulation. This study aims to create predictive equations for CPET
variables solely based on patients with Fontan circulation. Patients
who performed CPET in the multicenter Pediatric Heart Network Fontan
Cross-Sectional Study were screened. Peak variable equations were
calculated using patients who performed a maximal test (RER > 1.1) and
anaerobic threshold (AT) variable equations on patients where AT was
adequately calculated. Eighty percent of each cohort was randomly
selected to derive the predictive equation and the remaining served as
a validation cohort. Linear regression analysis was performed for each
CPET variable within the derivation cohort. The resulting equations
were applied to calculate predicted values in the validation cohort.
Observed versus predicted variables were compared in the validation
cohort using linear regression. 411 patients underwent CPET, 166
performed maximal exercise tests and 317 had adequately calculated AT.
Predictive equations for peak CPET variables had good performance; peak
VO2, R2= 0.61; maximum work, R2= 0.61; maximum O2pulse, R2= 0.59. The
equations for CPET variables at AT explained less of the variability;
VO2at AT, R2= 0.15; work at AT, R2= 0.39; O2pulse at AT, R2= 0.34;
VE/VCO2at AT, R2= 0.18; VE/VO2at AT, R2= 0.14. Only the models for
VE/VCO2and VE/VO2at AT had significantly worse performance in
validation cohort. Of the 8 equations for commonly measured CPET
variables, six were able to be validated. The equations for peak
variables were more robust in explaining variation in values than AT