Arroyo E;Umukoro PE; Burney HN; Li Y; Li X; Lane KA; Sher SJ; Lu TS; Moe SM; Moorthi R; Coggan AR; McGregor G; Hiemstra TF; Lim K;

Journal of the American Heart Association [J Am Heart Assoc] 2022 Jul 19; Vol. 11 (14), pp. e025656.
Date of Electronic Publication: 2022 Jul 05.

Background The transition to dialysis period carries a substantial increased cardiovascular risk in patients with chronic kidney disease. Despite this, alterations in cardiovascular functional capacity during this transition are largely unknown. The present study therefore sought to assess ventilatory exercise response measures in patients within 1 year of initiating dialysis.
Methods and Results We conducted a cross-sectional study of 241 patients with chronic kidney disease stage 5 from the CAPER (Cardiopulmonary Exercise Testing in Renal Failure) study and from the intradialytic low-frequency electrical muscle stimulation pilot randomized controlled trial cohorts. Patients underwent cardiopulmonary exercise testing and echocardiography. Of the 241 patients (age, 48.9 [15.0] years; 154 [63.9%] men), 42 were predialytic (mean estimated glomerular filtration rate, 14 mL·min ^-1 ·1.73 m ^-2 ), 54 had a dialysis vintage ≤12 months, and 145 had a dialysis vintage >12 months. Dialysis vintage ≤12 months exhibited a significantly impaired cardiovascular functional capacity, as assessed by oxygen uptake at peak exercise (18.7 [5.8] mL·min ^-1 ·kg ^-1 ) compared with predialysis (22.7 [5.2] mL·min ^-1 ·kg ^-1 ; P <0.001). Dialysis vintage ≤12 months also exhibited reduced peak workload, impaired peak heart rate, reduced circulatory power, and increased left ventricular mass index ( P <0.05 for all) compared with predialysis. After excluding those with prior kidney transplant, dialysis vintage >12 months exhibited a lower oxygen uptake at peak exercise (17.0 [4.9] mL·min ^-1 ·kg ^-1 ) compared with dialysis vintage ≤12 months (18.9 [5.9] mL·min ^-1 ·kg ^-1 ; P =0.033).
Conclusions Initiating dialysis is associated with a significant impairment in oxygen uptake at peak exercise and overall decrements in ventilatory and hemodynamic exercise responses that predispose patients to functional dependence. The magnitude of these changes is comparable to the differences between low-risk New York Heart Association class I and higher-risk New York Heart Association class II to IV heart failure.

Gadioli LP; Costa-Pereira K; Dias JBE; Moraes DA; Crescêncio JC; Schwartzmann PV; Gallo-Júnior L;
Schmidt A;Oliveira MC;

Rheumatology (Oxford, England) [Rheumatology (Oxford)] 2022 Jul 21.
Date of Electronic Publication: 2022 Jul 21.

Objectives: Autologous hematopoietic stem cell transplantation (AHSCT) is a disease-modifying treatment for patients with severe systemic sclerosis (SSc). Here, we aimed at assessing cardiopulmonary function outcomes of SSc patients after AHSCT.
Patients and Methods: Twenty-seven SSc adult patients treated with AHSCT were included in this retrospective study. Most had the diffuse cutaneous subset (93%) and pulmonary involvement (85%). Before and 12 months after AHSCT, patients underwent cardiopulmonary exercise testing (CPET), transthoracic echocardiography, pulmonary function test with diffusing capacity for carbon monoxide (DLCO), six-minute walk test (6MWT), and quality of life evaluations.
Results: After AHSCT, the peak VO2 increased from 954 to 1029 ml/min (p = 0.02), the percentage of predicted peak VO2 increased from 48.9 to 53.5 meters (p = 0.01), and the distance measured by the 6MWT increased from 445 to 502 meters (p = 0.01), respectively, compared to baseline. Improvements in peak VO2 correlated positively with improvements in 6MWT distance, and negatively with a decrease in resting heart rate. At baseline, patients with DLCO >70% had higher peak VO2 values than those with DLCO <70% (p = 0.04), but after AHSCT all patients improved VO2 values, regardless of baseline DLCO levels. Increases in VO2 levels after AHSCT positively correlated with increases in the physical component scores of the Short Form (SF)-36 quality of life questionnaire (r = 0.70; p = 0.0003).
Conclusion: AHSCT improves the aerobic capacity of SSc patients probably reflecting combined increments in lungs, skeletal muscle and cardiac function.

Cui H; Schaff HV; Olson TP; Geske JB; Dearani JA; Nishimura RA; Sun D; Ommen SR;

The Journal of thoracic and cardiovascular surgery [J Thorac Cardiovasc Surg] 2022 May 28.
Date of Electronic Publication: 2022 May 28.

Objective: The study objective was to analyze performance on cardiopulmonary exercise testing and its prognostic value in patients with obstructive hypertrophic cardiomyopathy undergoing septal myectomy.
Methods: We reviewed patients with obstructive hypertrophic cardiomyopathy who had cardiopulmonary exercise testing before septal myectomy from 2005 to 2016. Causes of functional impairment and their impact on survival were analyzed.
Results: A total of 752 patients had cardiopulmonary exercise testing at a median of 16 days (interquartile range, 2-56) before myectomy. The median exercise time was 6.6 (5.3-8.0) minutes. Functional aerobic capacity was 64% (53%-75%) of predicted, and metabolic equivalent of task was 5.2 (4.1-6.4). The peak oxygen consumption was 18.0 (14.2-21.9) mL/kg/min, which was 60% (49%-72%) of the predicted value. The primary causes for low peak oxygen consumption were impaired cardiac output (73.7%), limited heart rate reserve (52.0%), and obesity (48.2%). Resting outflow tract gradient correlated poorly to peak oxygen consumption, but the use of beta-blockers was associated with reduced peak oxygen consumption. During a median (interquartile range) of 9.0 (6.8-11.7) years of follow-up, the estimated 5- and 10-year survivals were 97% and 91%, respectively. Greater adjusted peak oxygen consumption (hazard ratio, 0.98; P = .011) and abnormal pulse oxygen increase (hazard ratio, 0.44; P = .003) were independently associated with better long-term survival after myectomy.
Conclusions: Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, functional capacity is severely impaired despite receiving optimal medical treatment. We identified risk factors of reduced long-term survival from preoperative cardiopulmonary exercise testing that may aid risk stratification in patients undergoing septal myectomy.

Kunutsor SK; Jae SY; Kauhanen J; Laukkanen JA;

The American journal of medicine [Am J Med] 2022 Jul 09.
Date of Electronic Publication: 2022 Jul 09

Background: Socioeconomic status (SES) and cardiorespiratory fitness (CRF) are each independently associated with chronic kidney disease. The interplay between SES, CRF, and chronic kidney disease is not well understood. We aimed to evaluate the separate and joint associations of SES and CRF with chronic kidney disease risk in a cohort of Caucasian men.
Methods: In 2,099 men aged 42-61 years with normal kidney function at baseline, SES was self-reported and CRF was directly measured using a respiratory gas exchange analyzer during cardiopulmonary exercise testing. Hazard ratios (HRs) (95% CIs) were estimated for chronic kidney disease.
Results: A total of 197 chronic kidney disease events occurred during a median follow-up of 25.8 years. Comparing low vs high SES, the multivariable-adjusted HR (95% CI) for chronic kidney disease was 1.55 (1.06-2.25), which remained consistent on further adjustment for CRF 1.53 (1.06-2.22). Comparing high vs low CRF, the multivariable-adjusted HR for chronic kidney disease was 0.66 (0.45-0.96), which persisted on further adjustment for SES 0.67 (0.46-0.97). Compared with high SES-high CRF, low SES-low CRF was associated with an increased risk of chronic kidney disease 1.88 (1.23-2.87), with no evidence of an association for low SES-high CRF and chronic kidney disease risk 1.32 (0.85-2.05). Positive additive (RERI=0.31) and multiplicative (ratio of HRs=1.14) interactions were found between SES and CRF in relation to chronic kidney disease risk.
Conclusions: In middle-aged and older males, SES and CRF are each independently associated with risk of incident chronic kidney disease. There exists an interplay between SES, CRF and chronic kidney disease risk, with high CRF levels appearing to offset the increased chronic kidney disease risk related to low SES..

Oyanagi H; Usui N; Tsubaki A; Ando S; Saithoh M; Kojima S; Inatsu A; Hisadome H; Ota S; Uehata A;

European journal of applied physiology [Eur J Appl Physiol] 2022 Jul 13.
Date of Electronic Publication: 2022 Jul 13.

Purpose: Exercise prescription based on a population-specific physiological response can help ensure safe and effective physical interventions. However, as a facile approach for exercise prescription in hemodialysis population that is based on their exercise capacity has not yet been established, the aim of our study was to develop a unique prediction formula for peak heart rate (HR) that can be used in this population.
Methods: This cross-sectional study measured physical function and HR at peak exercise and anaerobic threshold (AT) during cardiopulmonary exercise tests in 126 individuals. Participants were randomly assigned to the development group (n = 78), whose data were used to calculate the prediction equation, or the validation group (n = 48).
Results: The HR reserve in this population was significantly lower (0.44 ± 0.20%) and there was a large discrepancy between conventional age-predicted maximal HR and measured peak-HR values (R = 0.36). The average of the ratio between HR at AT point and peak HR was 85% (95% CI, 83.5%-86.4%). The peak-HR prediction equation was based on resting HR, presence of diabetes, physical dysfunction (gait speed < 1.0 m/s), and hypoalbuminemia (< 3.5 g/dL). It showed high prediction accuracy (R ² [95%CI] = 0.71 [0.70-0.71]) with similar correlation coefficients between the development and validation groups (R = 0.82).
Conclusion: Aerobic exercise based on estimated peak HR < 85% obtained from the equation in this study may enable safe and effective physical intervention in this population.

Sibilitz KL; Tang LH; Berg SK; Thygesen LC; Risom SS; Rasmussen TB; Schmid JP; Borregaard B; Hassager C;
Køber L; Taylor RS; Zwisler AD;

Scandinavian cardiovascular journal : SCJ [Scand Cardiovasc J] 2022 Dec; Vol. 56 (1), pp. 247-255.

Aims . The CopenHeart _VR trial found positive effects of cardiac rehabilitation (CR) on physical capacity at 4 months. The long-term effects of CR following valve surgery remains unclear, especially regarding readmission and mortality. Using data from he CopenHeart _VR Trial we investigated long-term effects on physical capacity, mental and physical health and effect on mortality and readmission rates as prespecified in the original protocol.
Methods . A total of 147 participants were included after heart valve surgery and randomly allocated 1:1 to 12-weeks exercise-based CR including a psycho-educational programme (intervention group) or control. Physical capacity was assessed as peak oxygen uptake (VO ₂ peak) measured by cardiopulmonary exercise testing, mental and physical health by Short Form-36 questionnaire, Hospital Anxiety and Depression Scale, and HeartQol. Mortality and readmission were obtained from hospital records and registers. Groups were compared using mixed regression model analysis and log rank test.
Results . No differences in VO ₂ peak at 12 months or in self-assessed mental and physical health at 24 months (68% vs 75%, p  = .120) was found. However, our data demonstrated reduction in readmissions in the intervention group at intermediate time points; after 3, 6 (43% vs 59%, p  = .03), and 12 (53% vs 67%, p  = .04) months, respectively, but no significant effect at 24 months.
Conclusions . Exercise-based CR after heart valve surgery reduces combined readmissions and mortality up to 12 months despite lack of improvement in exercise capacity, physical and mental health long-term. Exercise-based CR can ensure short-term benefits in terms of physical capacity, and lower readmission within a year, but more research is needed to sustain these effects over a longer time period. These considerations should be included in the management of patients after heart valve surgery.

Bailey DM; Halligan CL; Davies RG; Funnell A; Appadurai IR; Rose GA;
Rimmer L; Jubouri M; Coselli JS; Williams IM; Bashir M

Journal of Cardiac Surgery. 37(8):2258-2265, 2022 Aug.

Abstract
BACKGROUND: Initial clinical evaluation (ICE) is traditionally considered
a useful screening tool to identify frail patients during the preoperative
assessment. However, emerging evidence supports the more objective
assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise
testing (CPET) to improve surgical risk stratification. Herein, we
compared both subjective and objective assessment approaches to highlight
the interpretive idiosyncrasies.

METHODS: As part of routine preoperative patient contact, patients
scheduled for major surgery were prospectively “eyeballed” (ICE) by two
experienced clinicians before more detailed history taking that also
included the American Society of Anesthesiologists score classification.
Each patient was subjectively judged to be either “frail” or “not frail”
by ICE and “fit” or “unfit” from a thorough review of the medical notes.
Subjective data were compared against the more objective validated
assessment of postoperative outcomes using established CPET “cut-off”
metrics incorporating peak pulmonary oxygen uptake, VO2PEAK at the
anaerobic threshold (VO2 -AT), and ventilatory equivalent for carbon
dioxide that collectively informed risk stratification. These data were
retrospectively extracted from a single-center prospective National Health
Service database. Data were analyzed using the Chi-square automatic
interaction detection decision tree method.

RESULTS: A total of 127 patients were examined that comprised 58% male
and 42% female patients aged 69 +/- 10 years with a body mass index of 29
+/- 7 kg/m2 . Patients were poorly conditioned with a VO2PEAK almost 20%
lower than predicted for age, sex-matched healthy controls with 35%
exhibiting a VO2 -AT < 11 ml/kg/min. Disagreement existed between the
subjective assessments of risk with ~34% of patients classified as not
frail on ICE were considered unfit by notes review (p < .0001).
Furthermore, ~35% of patients considered not frail on ICE and ~31% of
patients considered fit by notes review exhibited a VO2 -AT < 11
ml/kg/min, and of these, ~28% and ~19% were classified as intermediate to
high risk.

CONCLUSIONS: These findings highlight the interpretive limitations
associated with the subjective assessment of patient frailty with surgical
risk classification underestimated in up to a third of patients compared
to the validated assessment of CRF. They reinforce the benefits of a more
objective and integrated approach offered by CPET that may help us to
improve perioperative risk assessment and better direct critical care
provision in patients scheduled for “high-stakes” surgery including open
thoracoabdominal aortic aneurysm repair

Lacavalerie MR; Pierre-Francois S; Agossou M; Inamo J; Cabie A; Barnay JL;
Neviere R

Future Cardiology. 18(7):577-584, 2022 Jul.

Abstract
Aim: To analyze the impact of obesity on cardiopulmonary response to
exercise in people with chronic post-COVID-19 syndrome. Patients &
methods: Consecutive subjects with chronic post-COVID syndrome 6 months
after nonsevere acute infection were included. All patients received a
complete clinical evaluation, lung function tests and cardiopulmonary
exercise testing. A total of 51 consecutive patients diagnosed with
chronic post-COVID-19 were enrolled in this study.
Results:
More than half of patients with chronic post-COVID-19 had a significant alteration in
aerobic exercise capacity (VO2peak) 6 months after hospital discharge.
Obese long-COVID-19 patients also displayed a marked reduction of oxygen
pulse (O2pulse).
Conclusion: Obese patients were more prone to have pathological pulmonary limitation
and pulmonary gas exchange impairment to
exercise compared with nonobese COVID-19 patients.
Other Abstract
plain-language-summary In this study, the cardiopulmonary response to
exercise in people with chronic post-COVID-19 syndrome was analyzed. More
than half of patients diagnosed with chronic post-COVID-19 had reduced
exercise capacity 6 months after hospital discharge. In addition, patients
with chronic post-COVID-19 syndrome who were overweight or obese displayed
exaggerated hyperventilation along with an impairment of oxygenation at
peak exercise.

Barbagelata L; Masson W; Iglesias D; Lillo E; Migone JF; Orazi ML;
Maritano Furcada J

Medicina Clinica. 159(1):6-11, 2022 Jul 08.

BACKGROUND AND AIM: Several reports have shown the persistence of long
term symptoms after the initial COVID-19 infection (post-COVID-19
syndrome). The objective of this study was to analyze the characteristics
of cardiopulmonary exercise testing (CPET) performed in patients with a
history of COVID-19, comparing subjects according to the presence of
post-COVID-19 syndrome.

METHODS: A cross-sectional study was performed. Consecutive patients >18
years with history of SARS-CoV-2 infection confirmed by polymerase chain
reaction test and a CPET performed between 45 and 120 days after the viral
episode were included. The association between variables related to CPET
and post-COVID-19 syndrome was assessed using univariate and multivariate
analysis.

RESULTS: A total of 200 patients (mean age 48.8+/-14.3 years, 51% men)
were included. Patients with post-COVID-19 syndrome showed significantly
lower main peak VO2 (25.8+/-8.1mL/min/kg vs. 28.8+/-9.6mL/min/kg, p=0.017)
as compared to asymptomatic subjects. Moreover, patients with
post-COVID-19 syndrome developed symptoms more frequently during CPET
(52.7% vs. 13.7%, p<0.001) and were less likely to reach the anaerobic
threshold (50.9% vs. 72.7%, p=0.002) when compared to asymptomatic
subjects. These findings were not modified when adjusting for confounders.

CONCLUSION: Our data suggest that post-COVID-19 syndrome was associated
with less peak VO2, a lower probability of achieving the anaerobic
threshold and a higher probability of presenting symptoms during the CPET.
Future studies are needed to determine if these abnormalities during CPET
would have prognostic value.

Banydeen R; Monfort A; Inamo J; Neviere R;

Frontiers in cardiovascular medicine [Front Cardiovasc Med] 2022 Jun 06; Vol. 9, pp. 898033.
Date of Electronic Publication: 2022 Jun 06 (Print Publication: 2022).

Cardiac amyloidosis (CA) is a myocardial disease characterized by extracellular amyloid infiltration throughout the heart, resulting in increased myocardial stiffness, and restrictive heart wall chamber behavior. Its diagnosis among patients hospitalized for cardiovascular diseases is becoming increasingly frequent, suggesting improved disease awareness, and higher diagnostic capacities. One predominant functional manifestation of patients with CA is exercise intolerance, objectified by reduced peak oxygen uptake (VO ₂ peak), and assessed by metabolic cart during cardiopulmonary exercise testing (CPET). Hemodynamic adaptation to exercise in patients with CA is characterized by low myocardial contractile reserve and impaired myocardial efficiency. Rapid shallow breathing and hyperventilation, in the absence of ventilatory limitation, are also typically observed in response to exercise. Ventilatory inefficiency is further suggested by an increased VE-VCO2 slope, which has been attributed to excessive sympathoexcitation and a high physiological dead space (VD/VT) ratio during exercise. Growing evidence now suggests that, in addition to well-established biomarker risk models, a reduced VO ₂ peak is potentially a strong and independent predictive factor of adverse patient outcomes, both for monoclonal immunoglobulin light chain (AL) or transthyretin (ATTR) CA. Besides generating prognostic information, CPET can be used for the evaluation of the impact of therapeutic interventions in patients with CA.