Delsart P; Delahaye C; Devos P; Domanski O; Azzaoui R; Sobocinski J; Juthier F; Vincentelli A; Rousse N; Mugnier A; Soquet J; Loobuyck V; Koussa M; Modine T; Jegou B; Bical A; Hysi I; Fabre O; Pontana F; Matran R; Mounier-Vehier C; Montaigne D;

Clinical Cardiology. 44(2):252-260, 2021 Feb.

BACKGROUND: Although recommendations encourage daily moderate activities
in post aortic dissection, very little data exists regarding
cardiopulmonary exercise testing (CPET) to personalize those patient’s
physical rehabilitation and assess their cardiovascular prognosis.

DESIGN: We aimed at testing the prognostic insight of CPET regarding
aortic and cardiovascular events by exploring a prospective cohort of
patients followed-up after acute aortic dissection.

METHODS: Patients referred to our department after an acute (type A or B)
aortic dissection were prospectively included in a cohort between
September 2012 and October 2017. CPET was performed once optimal blood
pressure control was obtained. Clinical follow-up was done after CPET for
new aortic event and major cardio-vascular events (MCE) not directly
related to the aorta.

RESULTS: Among the 165 patients who underwent CPET, no adverse event was
observed during exercise testing. Peak oxygen pulse was 1.46(1.22-1.84)
mlO2/beat, that is, 97 (83-113) % of its predicted value, suggesting
cardiac exercise limitation in a population under beta blockers (92% of
the population). During a follow-up of 39(20-51) months from CPET, 42
aortic event recurrences and 22 MCE not related to aorta occurred. Low
peak oxygen pulse (<85% of predicted value) was independently predictive
of aortic event recurrence, while low peak oxygen uptake (<70% of
predicted value) was an independent predictor of MCE occurrence.

CONCLUSION: CPET is safe in postaortic dissection patients should be used
to not only to personalize exercise rehabilitation, but also to identify
those patients with the highest risk for new aortic events and MCE not
directly related to aorta.

Lewthwaite H; Elsewify O; Niro F; Bourbeau J; Guenette JA; Maltais F;
Marciniuk DD; O’Donnell DE; Smith BM; Stickland MK; Tan WC; Jensen D;

Chest. 159(5):1922-1933, 2021 05.

RESEARCH QUESTION: This study aimed to develop an updated normative
reference set for physiologic and symptom responses at Tvent during cycle
CPET (primary aim) and to evaluate previously recommended reference
equations from a 1985 study for predicting Tvent responses (secondary
aim).

STUDY DESIGN AND METHODS: Participants were adults 40 to 80 years of age
who were free of clinically relevant disease from the Canadian Cohort
Obstructive Lung Disease. Rate of oxygen consumption (VO2) at Tvent was
identified by two independent raters; physiologic and symptom responses
corresponding to VO2 at Tvent were identified by linear interpolation.
Reference ranges (5th-95th percentiles) for responses at Tvent were
calculated according to participant sex and age for 29 and eight
variables, respectively. Prediction models were developed for nine
variables (oxygen pulse, VO2, rate of CO2 production, minute ventilation,
tidal volume, inspiratory capacity, end-inspiratory lung volume [in liters
and as percentage of total lung capacity], and end-expiratory lung volume)
using quantile regression, estimating the 5th (lower limit of normal),
50th (normal), and 95th (upper limit of normal) percentiles based on
readily available participant characteristics. The two one-sided test of
equivalence for paired samples evaluated the measured and 1985-predicted
VO2 at Tvent for equivalence.

RESULTS: Reference ranges and equations were developed based on 96
participants (49% men) with a mean +/- SD age of 63 +/- 9 years. Mean VO2
at Tvent was 50% of measured VO2 peak; the normal range was 33% to 66%.
The 1985 reference equations overpredicted VO2 at Tvent: mean difference
in men, -0.17 L/min (95% CI, -0.25 to -0.09 L/min); mean difference in
women, -0.19 L/min (95% CI, -0.27 to -0.12 L/min).

INTERPRETATION: A contemporary reference set of CPET responses at Tvent
from Canadian adults 40 to 80 years of age is presented that differs from
the previously recommended and often used reference set from 1985.

van den Bosch E; Bossers SSM; Kamphuis VP; Boersma E; Roos-Hesselink JW;
Breur JMPJ; Ten Harkel ADJ; Kapusta L; Bartelds B; Roest AAW; Kuipers IM;
Blom NA; Koopman LP; Helbing WA

Journal of the American Heart Association. 10(5):e015022, 2021 02.

Background Patients who have undergone the Fontan procedure are at high
risk of circulatory failure. In an exploratory analysis we aimed to
determine the prognostic value of blood biomarkers in a young cohort who
have undergone the Fontan procedure. Methods and Results In multicenter
prospective studies patients who have undergone the Fontan procedure
underwent blood sampling, cardiopulmonary exercise testing, and stress
cardiac magnetic resonance imaging. Several biomarkers including NT-proBNP
(N-terminal pro-B-type natriuretic peptide), GDF-15 (growth
differentiation factor 15), Gal-3 (galectin-3), ST2 (suppression of
tumorigenicity 2), DLK-1 (protein delta homolog 1), FABP-4 (fatty
acid-binding protein 4), IGFBP-1 (insulin-like growth factor-binding
protein 1), IGFBP-7, MMP-2 (matrix metalloproteinase 2), and vWF (von
Willebrand factor) were assessed in blood at 9.6 (7.1-12.1) years after
Fontan completion. After this baseline study measurement, follow-up
information was collected on the incidence of adverse cardiac events,
including cardiac death, out of hospital cardiac arrest, heart
transplantation (listing), cardiac reintervention (severe events),
hospitalization, and cardioversion/ablation for arrhythmias was collected
and the relation with blood biomarkers was assessed by Cox proportional
hazard analyses. The correlation between biomarkers and other clinical
parameters was evaluated. We included 133 patients who have undergone the
Fontan procedure, median age 13.2 (25th, 75th percentile 10.4-15.9) years,
median age at Fontan 3.2 (2.5-3.9) years. After a median follow-up of 6.2
(4.9-6.9) years, 36 (27.1%) patients experienced an event of whom 13
(9.8%) had a severe event. NT-proBNP was associated with (all) events
during follow-up and remained predictive after correction for age, sex,
and dominant ventricle (hazard ratio, 1.89; CI, 1.32-2.68). The severe
event-free survival was better in patients with low levels of GDF-15
(P=0.005) and vWF (P=0.008) and high levels of DLK-1 (P=0.041). There was
a positive correlation (beta=0.33, P=0.003) between DLK-1 and stress
cardiac magnetic resonance imaging functional reserve. Conclusions
NT-proBNP, GDF-15, vWF, DLK-1, ST-2 FABP-4, and IGFBP-7 levels relate to
long-term outcome in young patients who have undergone the Fontan
procedure.

van den Bosch E; Bossers SSM; Kamphuis VP; Boersma E; Roos-Hesselink JW;
Breur JMPJ; Ten Harkel ADJ; Kapusta L; Bartelds B; Roest AAW; Kuipers IM;
Blom NA; Koopman LP; Helbing WA

Journal of the American Heart Association. 10(5):e015022, 2021 02. VI 1

Patients with kidney failure often present with reduced cardiovascular
functional reserve and exercise tolerance. Previous studies on
cardiorespiratory fitness examined with cardiopulmonary exercise testing
(CPET) in kidney transplant recipients (KTR) had variable results. This is
a systematic review and meta-analysis of studies examining cardiovascular
functional reserve with CPET in KTR in comparison with patients with
kidney failure (CKD-Stage-5 before dialysis, hemodialysis or peritoneal
dialysis), as well as before and after kidney transplantation. Literature
search involved PubMed, Web-of-Science and Scopus databases, manual search
of article references and grey literature. From a total of 4,944
identified records, eight studies (with 461 participants) were included in
quantitative analysis for the primary question. Across these studies, KTR
had significantly higher oxygen consumption at peak/max exercise (VO2
peak/VO2 max) compared to patients with kidney failure (SMD = 0.70, 95% CI
[0.31, 1.10], I2 = 70%, P = 0.002). In subgroup analyses, similar
differences were evident among seven studies comparing KTR and
hemodialysis patients (SMD = 0.64, 95% CI [0.16, 1.12], I2 = 65%, P =
0.009) and two studies comparing KTR with peritoneal dialysis subjects
(SMD = 1.14, 95% CI [0.19, 2.09], I2 = 50%, P = 0.16). Across four studies
with relevant data, oxygen consumption during peak/max exercise showed
significant improvement after kidney transplantation compared to
pretransplantation values (WMD = 2.43, 95% CI [0.01, 4.85], I2 = 68%, P =
0.02). In conclusion, KTR exhibit significantly higher cardiovascular
functional reserve during CPET compared to patients with kidney failure.
Cardiovascular reserve is significantly improved after kidney
transplantation in relation to presurgery levels.

Andonian BJ; Hardy N; Bendelac A; Polys N; Kraus WE

Current Sports Medicine Reports. 20(10):545-552, 2021 Oct 01.
VI 1

ABSTRACT: Cardiopulmonary exercise testing (CPET) is a dynamic clinical
tool for determining the cause for a person’s exercise limitation. CPET
provides clinicians with fundamental knowledge of the coupling of external
to internal respiration (oxygen and carbon dioxide) during exercise.
Subtle perturbations in CPET parameters can differentiate exercise
responses among individual patients and disease states. However, perhaps
because of the challenges in interpretation given the amount and
complexity of data obtained, CPET is underused. In this article, we review
fundamental concepts in CPET data interpretation and visualization. We
also discuss future directions for how to best use CPET results to guide
clinical care. Finally, we share a novel three-dimensional graphical
platform for CPET data that simplifies conceptualization of organ
system-specific (cardiac, pulmonary, and skeletal muscle) exercise
limitations. Our goal is to make CPET testing more accessible to the
general medical provider and make the test of greater use in the medical
toolbox.

Nayor M; Shah RV; Tanguay M; Blodgett JB; Chernofsky A; Miller PE; Xanthakis V; Malhotra R; Houstis NE;
Velagaleti RS; Larson MG; Vasan RS; Lewis GD

American Journal of Cardiology. 157:56-63, 2021 10 15.
VI 1

Cardiorespiratory fitness (CRF) is intricately related to health status.
The optimal approach for CRF quantification is through assessment of peak
oxygen uptake (VO2), but such measurements have been largely confined to
small referral populations. Here we describe protocols and methodological
considerations for peak VO2 assessment and determination of volitional
effort in a large community-based sample. Maximum incremental ramp cycle
ergometry cardiopulmonary exercise testing (CPET) was performed by
Framingham Heart Study participants at a routine study visit (2016 to
2019). Of 3,486 individuals presenting for a multicomponent study visit,
3,116 (89%) completed CPET. The sample was middle-aged (54 +/- 9 years),
with 53% women, body mass index 28.3 +/- 5.6 kg/m2, 48% with hypertension,
6% smokers, and 8% with diabetes. Exercise duration was 12.0 +/- 2.1
minutes (limits 3.7to20.5). No major cardiovascular events occurred. A
total of 98%, 96%, 90%, 76%, and 57% of the sample reached peak
respiratory exchange ratio (RER) values of >=1.0, >=1.05, >=1.10, >=1.15,
and >=1.20, respectively (mean peak RER = 1.21 +/- 0.10). With rising peak
RER values up to =1.10, steep changes were observed for percent predicted
peak VO2, VO2 at the ventilatory threshold/peak VO2, heart rate response,
and Borg (subjective dyspnea) scores. More shallow changes for effort
dependent CPET variables were observed with higher achieved RER values. In
conclusion, measurement of peak VO2 is feasible and safe in a large sample
of middle-aged, community-dwelling individuals with heterogeneous
cardiovascular risk profiles. Peak RER >=1.10 was achievable by the
majority of middle-aged adults and RER values beyond this threshold did
not necessarily correspond to higher peak VO2 values.

Philips DB; Neder JA; Elbehairy AF; Milne KM; James MD; Vincent SG ;Day AG; de-Torres JP; Webb KA; O’Donnell DE;

Medicine and science in sports and exercise [Med Sci Sports Exerc] 2021 Jul 07.
Date of Electronic Publication: 2021 Jul 07.

Introduction: Evaluation of the intensity and quality of activity-related dyspnea is potentially useful in people with chronic obstructive pulmonary disease (COPD). The present study sought to examine associations between qualitative dyspnea descriptors, dyspnea intensity ratings, dynamic respiratory mechanics, and exercise capacity during cardiopulmonary exercise testing (CPET) in COPD and healthy controls.
Methods: In this cross-sectional study, 261 patients with mild-to-very severe COPD (forced expiratory volume in 1 second [FEV1] 62 ± 25 %pred) and 94 age-matched controls (FEV1 114 ± 14 %pred) completed an incremental cycle CPET to determine peak oxygen uptake (V[Combining Dot Above]O2peak). Throughout exercise, expired gases, operating lung volumes and dyspnea intensity were assessed. At peak exercise, dyspnea quality was assessed using a modified 15-item questionnaire.
Results: Logistic regression analysis revealed that amongst 15 dyspnea descriptors, only those alluding to the cluster “unsatisfied inspiration” were consistently associated with an increased likelihood for both critical inspiratory mechanical constraint (end-inspiratory lung volume/total lung capacity ratio ≥ 0.9) during exercise and reduced exercise capacity (V[Combining Dot Above]O2peak < lower limit of normal) in COPD (odds ratio [95% confidence interval] =3.26 [1.40-7.60] and 3.04 [1.24-7.45], respectively, both p < 0.05). Thus, patients reporting “unsatisfied inspiration” (n = 177 (68%)) had an increased relative frequency of critical inspiratory mechanical constraint and low exercise capacity, compared with those who did not select this descriptor, regardless of COPD severity or peak dyspnea intensity scores.
Conclusion: In patients with COPD, regardless of disease severity, reporting descriptors in the unsatisfied inspiration cluster complemented traditional assessments of dyspnea during CPET and helped identify patients with critical mechanical abnormalities germane to exercise intolerance.

Contini M; Angelucci A; Aliverti A; Gugliandolo P; Pezzuto B; Berna G; Romani S; Tedesco CC; Agostoni P;

Sensors (Basel, Switzerland) [Sensors (Basel)] 2021 Oct 07; Vol. 21 (19).
Date of Electronic Publication: 2021 Oct 07.

Evaluation of arterial carbon dioxide pressure (PaCO ₂ ) and dead space to tidal volume ratio (V _D /V _T ) during exercise is important for the identification of exercise limitation causes in heart failure (HF). However, repeated sampling of arterial or arterialized ear lobe capillary blood may be clumsy. The aim of our study was to estimate PaCO ₂ by means of a non-invasive technique, transcutaneous PCO ₂ (PtCO ₂ ), and to verify the correlation between PtCO ₂ and PaCO ₂ and between their derived parameters, such as V _D /V _T , during exercise in HF patients. 29 cardiopulmonary exercise tests (CPET) performed on a bike with a ramp protocol aimed at achieving maximal effort in ≈10 min were analyzed. PaCO ₂ and PtCO ₂ values were collected at rest and every 2 min during active pedaling. The uncertainty of PCO ₂ and V _D /V _T measurements were determined by analyzing the error between the two methods. The accuracy of PtCO ₂ measurements vs. PaCO ₂ decreases towards the end of exercise. Therefore, a correction to PtCO ₂ that keeps into account the time of the measurement was implemented with a multiple regression model. PtCO ₂ and V _D /V _T changes at 6, 8 and 10 min vs. 2 min data were evaluated before and after PtCO ₂ correction. PtCO ₂ overestimates PaCO ₂ for high timestamps (median error 2.45, IQR -0.635-5.405, at 10 min vs. 2 min, p -value = 0.011), while the error is negligible after correction (median error 0.50, IQR = -2.21-3.19, p -value > 0.05). The correction allows removing differences also in PCO ₂ and V _D /V _T changes. In HF patients PtCO ₂ is a reliable PaCO ₂ estimation at rest and at low exercise intensity. At high exercise intensity the overall response appears delayed but reproducible and the error can be overcome by mathematical modeling allowing an accurate estimation by PtCO ₂ of PaCO ₂ and V _D /V _T .

Triantafyllidi H; Birmpa D; Benas D; Trivilou P; Fambri; AIliodromitis EK

Cardiology [Cardiology] 2021 Oct 14. Date of Electronic Publication: 2021 Oct 14.

No abstract available

Alfred Hager

European Journal of Preventive Cardiology, Volume 28, Issue 12, November 2021, Page e19,