Category Archives: Publications

Characterising recovery following abdominal aortic aneurysm repair using cardiopulmonary exercise testing and patient reported outcome measures.

Dodds N; Angell J; Lewis SL; Pyke M; White P; Darweish-Medniuk A; Mitchell DC; Tolchard S;

Disability and rehabilitation [Disabil Rehabil] 2022 Mar 29, pp. 1-7.
Date of Electronic Publication: 2022 Mar 29.

Purpose: Surgery is associated with a post-operative stress response, changes in cardiopulmonary reserve, and metabolic demand. Here recovery after abdominal aortic aneurysm repair is investigated using cardiopulmonary exercise testing and patient-reported questionnaires.
Materials and Methods: Patients undergoing open ( n  = 21) or endovascular ( n  = 21) repair undertook cardiopulmonary exercise tests, activity, and health score questionnaires pre-operatively and, 8 and 16 weeks, post-operatively. Oxygen uptake and ventilatory parameters were measured, and routine blood tests were undertaken.
Results: Recovery was characterised by falls in anaerobic threshold, peak oxygen uptake, and oxygen pulse at 8 weeks which appeared to be associated with operative severity; the fall in peak oxygen uptake was greater following open vs. endovascular repair (3.5 vs. 1.6 ml . kg -1. min -1 ) and anaerobic threshold showed a similar tendency (3.1 vs. 1.7 ml . kg -1. min -1 ). In the smaller number of patients re-tested these changes resolved by 16 weeks. Reported health and activity did not change.
Conclusions: Aortic repair is associated with falls in the anaerobic threshold, peak oxygen uptake, and oxygen pulse of a magnitude that reflects operative severity and appears to resolve by 16 weeks. Thus, post-operatively patients may be at higher risk of further metabolic insult e.g. infection. This further characterises physiological recovery from aortic surgery and may assist in defining post-operative shielding time.IMPLICATIONS FOR REHABILITATIONAbdominal aortic aneurysm repair is a life-saving operation, the outcome from which is influenced by pre-operative cardiopulmonary reserve; individuals with poor reserve being at greater risk of peri-operative complications and death. However, for this operation, the physiological impact of surgery has not been studied.In a relatively small sample, this study suggests that AAA repair is associated with a significant decline in cardiopulmonary reserve when measured 8 weeks post-operatively and appears to recover by 16 weeks. Moreover, the impact may be greater in endovascular vs. open repair.

Validity of anaerobic threshold measured in resistance exercise.

Masuda T; Takeuchi S; Kubo Y; Nishida Y;

Journal of physical therapy science [J Phys Ther Sci] 2022 Mar; Vol. 34 (3), pp. 199-203.
Date of Electronic Publication: 2022 Mar 14.

[Purpose] Intensity for resistance exercise is estimated based on the maximum muscle strength. Exercise prescription without evaluating the biological response has a challenge. This study aimed to confirm whether anaerobic threshold measured using cardiopulmonary exercise test in resistance exercise is appropriate or not. [Participants and Methods] Resistance exercise adopted for the study was right-leg knee extension. The participants were 10 healthy young males. We investigated whether the oxygen uptake kinetics achieved a steady state within 3 min during the constant-load test with knee extension at 80% anaerobic threshold using cardiopulmonary exercise test with knee extension. If oxygen uptake kinetics achieved a steady state within 3 min, the exercise intensity measured using cardiopulmonary exercise test was considered appropriate. [Results] Anaerobic threshold was measured using the conventional approach in all participants. The steady state of oxygen uptake kinetics could be achieved within 3 min. In the constant-load test with knee extension at 80% anaerobic threshold, the oxygen uptake kinetics achieved a steady state within 3 min. [Conclusion] Based on the findings, the anaerobic threshold obtained using cardiopulmonary exercise test with resistance exercise was judged as appropriate. The results of this study contribute to the accurate setting of exercise load for resistance exercise and condition setting for the evaluation of skeletal muscle function.

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? – A systematic review of the literature and expert panel recommendations.

Crespo G; Hessheimer AJ; Armstrong MJ; Berzigotti A; Monbaliu D; Spiro M; Rapti DA; Lai JC;

Clinical transplantation [Clin Transplant] 2022 Mar 16, pp. e14644.
Date of Electronic Publication: 2022 Mar 16.

Background: To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes.
Objective: We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes.
Methods: We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS.
Results: Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications.
Conclusions: We identified 4 pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: 1) KPS (quality of evidence moderate, grade of recommendation strong), 2) LFI (quality of evidence moderate, grade of recommendation strong), 3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong), and 4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine pre-operative assessment when considering implementation of ERAS protocols for LT.

Impact of continuous vs. interval training on oxygen extraction and cardiac function during exercise in type 2 diabetes mellitus.

Van Ryckeghem L; Keytsman C; De Brandt J; Verboven K; Verbaanderd E; Marinus N; Franssen WMA;
Frederix I;Bakelants E;Petit T; Jogani S; Stroobants S; Dendale P; Verwerft J; Hansen D;

European journal of applied physiology [Eur J Appl Physiol] 2022 Apr; Vol. 122 (4), pp. 875-887.
Date of Electronic Publication: 2022 Jan 17.

Purpose: Exercise training improves exercise capacity in type 2 diabetes mellitus (T2DM). It remains to be elucidated whether such improvements result from cardiac or peripheral muscular adaptations, and whether these are intensity dependent.
Methods: 27 patients with T2DM [without known cardiovascular disease (CVD)] were randomized to high-intensity interval training (HIIT, n = 15) or moderate-intensity endurance training (MIT, n = 12) for 24 weeks (3 sessions/week). Exercise echocardiography was applied to investigate cardiac output (CO) and oxygen (O 2 ) extraction during exercise, while exercise capacity [([Formula: see text] (mL/kg/min)] was examined via cardiopulmonary exercise testing at baseline and after 12 and 24 weeks of exercise training, respectively. Changes in glycaemic control (HbA1c and glucose tolerance), lipid profile and body composition were also evaluated.
Results: 19 patients completed 24 weeks of HIIT (n = 10, 66 ± 11 years) or MIT (n = 9, 61 ± 5 years). HIIT and MIT similarly improved glucose tolerance (p Time  = 0.001, p Interaction  > 0.05), [Formula: see text] (mL/kg/min) (p Time  = 0.001, p Interaction  > 0.05), and exercise performance (W peak ) (p Time  < 0.001, p Interaction  > 0.05). O 2 extraction increased to a greater extent after 24 weeks of MIT (56.5%, p 1  = 0.009, p Time  = 0.001, p Interaction  = 0.007). CO and left ventricular longitudinal strain (LS) during exercise remained unchanged (p Time  > 0.05). A reduction in HbA1c was correlated with absolute changes in LS after 12 weeks of MIT (r = - 0.792, p = 0.019, LS at rest) or HIIT (r = - 0.782, p = 0.038, LS at peak exercise).
Conclusion: In patients with well-controlled T2DM, MIT and HIIT improved exercise capacity, mainly resulting from increments in O 2 extraction capacity, rather than changes in cardiac output. In particular, MIT seemed highly effective to generate these peripheral adaptations.

Subclinical Cardiac Dysfunction is Associated with Reduced Cardiorespiratory Fitness and Cardiometabolic Risk Factors in Firefighters

Denise L. Smith; Elliot L. Graham; Julie A. Douglas;  Kepra Jack; Michael J. Conner;
Ross Arena; Sundeep Chaudhry;

The American Journal of Medicine (2022) 000:1−9

BACKGROUND: Past studies have documented the ability of cardiopulmonary exercise testing to detect cardiac
dysfunction in symptomatic patients with coronary artery disease. Firefighters are at high risk for
work-related cardiac events. This observational study investigated the association of subclinical cardiac
dysfunction detected by cardiopulmonary exercise testing with modifiable cardiometabolic risk factors in
asymptomatic firefighters.
METHODS: As part of mandatory firefighter medical evaluations, study subjects were assessed at 2 occupational
health clinics serving 21 different fire departments. Mixed effects logistic regression analyses were
used to estimate odds ratios (ORs) and account for clustering by fire department.
RESULTS: Of the 967 male firefighters (ages 20-60 years; 84% non-Hispanic white; 14% on cardiovascular
medications), nearly two-thirds (63%) had cardiac dysfunction despite having normal predicted cardiorespiratory
fitness (median peak VO2 = 102%). In unadjusted analyses, cardiac dysfunction was significantly
associated with advanced age, obesity, diastolic hypertension, high triglycerides, low high-density lipoprotein
(HDL) cholesterol, and reduced cardiorespiratory fitness (all P values < .05). After adjusting for age
and ethnicity, the odds of having cardiac dysfunction were approximately one-third higher among firefighters
with obesity and diastolic hypertension (OR = 1.39, 95% confidence interval [CI] = 1.03-1.87 and
OR = 1.36, 95% CI = 1.03-1.80) and more than 5 times higher among firefighters with reduced cardiorespiratory
fitness (OR = 5.41, 95% CI = 3.29-8.90).
CONCLUSION: Subclinical cardiac dysfunction detected by cardiopulmonary exercise testing is a common
finding in career firefighters and is associated with substantially reduced cardiorespiratory fitness and cardiometabolic risk factors. These individuals should be targeted for aggressive risk factor modification to
increase cardiorespiratory fitness as part of an outpatient prevention strategy to improve health and safety.

Association between Right Ventricular Function and Exercise Capacity in Patients with Chronic Heart Failure.

Ohara K; Imamura T; Ihori H; Chatani K; Nonomura M; Kameyama T; Inoue H;

Journal of clinical medicine [J Clin Med] 2022 Feb 18; Vol. 11 (4).
Date of Electronic Publication: 2022 Feb 18.

Background: The association between right ventricular function and exercise capacity in patients with chronic heart failure remains uncertain. Several studies very recently mentioned the association between right ventricular reserve and exercise capacity, whereas the implication of tricuspid annular plane systolic excursion (TAPSE) remains uninvestigated. We aimed to assess the impact of TAPSE on exercise capacity in cardiac rehabilitation candidates.
Methods: Data from patients with chronic heart failure who received cardiopulmonary exercise tests and transthoracic echocardiography prior to cardiac rehabilitation were retrospectively collected, and their association was investigated.
Results: A total of 169 patients with chronic heart failure (70.3 ± 11.7 years old, 74.6% men) were included. Tertiled tricuspid annular plane systolic excursion significantly stratified anaerobic threshold (10.2 ± 2.2, 11.4 ± 2.2, and 12.2 ± 2.8 mm; p < 0.01) and peak oxygen consumption (15.9 ± 4.5, 18.3 ± 5.3, and 19.8 ± 5.6 mm; p < 0.01). In the multivariate logistic regression analyses, TAPSE was an independent factor associated with anaerobic threshold and peak oxygen consumption ( p < 0.05 for both).
Conclusions: Right ventricular impairment was associated with reduced exercise capacity in patients with chronic heart failure. Such knowledge would be useful to estimate patients’ exercise capacity and prescribe cardiac rehabilitation. Its longitudinal association and clinical implication need further studies.

Sustained Impairment in Cardiopulmonary Exercise Capacity Testing in Patients after COVID-19: A Single Center Experience.

Evers G; Schulze AB; Osiaevi I; Harmening K; Vollenberg R; Wiewrodt R; Pistulli R; Boentert M; Tepasse PR; Sindermann JR; Yilmaz A; Mohr M;

Canadian respiratory journal [Can Respir J] 2022 Mar 01; Vol. 2022, pp. 2466789.
Date of Electronic Publication: 2022 Mar 01 (Print Publication: 2022).

Background: Following COVID-19, patients often present with ongoing symptoms comparable to chronic fatigue and subjective deterioration of exercise capacity (EC), which has been recently described as postacute COVID-19 syndrome.
Objective: To objectify the reduced EC after COVID-19 and to evaluate for pathologic limitations.
Methods: Thirty patients with subjective limitation of EC performed cardiopulmonary exercise testing (CPET). If objectively limited in EC or deteriorated in oxygen pulse, we offered cardiac stress magnetic resonance imaging (MRI) and a follow-up CPET.
Results: Eighteen male and 12 female patients were included. Limited relative EC was detected in 11/30 (36.7%) patients. Limitation correlated with reduced body weight-indexed peak oxygen (O 2 ) uptake (peakV̇O 2 /kg) (mean 74.7 (±7.1) % vs. 103.6 (±14.9) %, p < 0.001). Reduced peakV̇O 2 /kg was found in 18/30 (60.0%) patients with limited EC. Patients with reduced EC widely presented an impaired maximum O 2 pulse (75.7% (±5.6) vs. 106.8% (±13.9), p < 0.001). Abnormal gas exchange was absent in all limited EC patients. Moreover, no patient showed signs of reduced pulmonary perfusion. Using cardiac MRI, diminished biventricular ejection fraction was ruled out in 16 patients as a possible cause for reduced O 2 pulse. Despite noncontrolled training exercises, follow-up CPET did not reveal any exercise improvements.
Conclusions: Deterioration of EC was not associated with ventilatory or pulmonary vascular limitation. Exercise limitation was related to both reduced O 2 pulse and peakV̇O 2 /kg, which, however, did not correlate with the initial severity of COVID-19. We hypothesize that impaired microcirculation or limited peripheral O 2 utilization might be causative for prolonged deterioration of EC following acute COVID-19 infection.

Developments in Exercise Capacity Assessment in Heart Failure Clinical Trials and the Rationale for the Design of METEORIC-HF.

Lewis GD; Docherty KF; Voors AA; Cohen-Solal A; Metra M; Whellan DJ; .Ezekowitz JA; Ponikowski P; Böhm M; Teerlink JR; Heitner SB; Kupfer S; Malik FI; Meng L; Felker GM;

Circulation. Heart failure [Circ Heart Fail] 2022 Mar 03, pp. CIRCHEARTFAILURE121008970.
Date of Electronic Publication: 2022 Mar 03.

Heart failure with reduced ejection fraction (HFrEF) is a highly morbid condition for which exercise intolerance is a major manifestation. However, methods to assess exercise capacity in HFrEF vary widely in clinical practice and in trials. We describe advances in exercise capacity assessment in HFrEF and a comparative analysis of how various therapies available for HFrEF impact exercise capacity. Current guideline-directed medical therapy has indirect effects on cardiac performance with minimal impact on measured functional capacity. Omecamtiv mecarbil is a novel selective cardiac myosin activator that directly increases cardiac contractility and in a phase 3 cardiovascular outcomes study significantly reduced the primary composite end point of time to first heart failure event or cardiovascular death in patients with HFrEF. The objective of the METEORIC-HF trial (Multicenter Exercise Tolerance Evaluation of Omecamtiv Mecarbil Related to Increased Contractility in Heart Failure) is to assess the effect of omecamtiv mecarbil versus placebo on multiple components of functional capacity in HFrEF. The primary end point is to test the effect of omecamtiv mecarbil compared with placebo on peak oxygen uptake as measured by cardiopulmonary exercise testing after 20 weeks of treatment. METEORIC-HF will provide state-of-the-art assessment of functional capacity by measuring ventilatory efficiency, circulatory power, ventilatory anaerobic threshold, oxygen uptake recovery kinetics, daily activity, and quality-of-life assessment. Thus, the METEORIC-HF trial will evaluate the potential impact of increased myocardial contractility with omecamtiv mecarbil on multiple important measures of functional capacity in ambulatory patients with symptomatic HFrEF.

Cardiopulmonary Exercise Testing: The ABC for the Clinical Cardiologist. [Review]

Triantafyllidi H; Birmpa D; Benas D; Trivilou P; Fambri A; Iliodromitis EK

Cardiology. 147(1):62-71, 2022.

BACKGROUND: Cardiopulmonary exercise testing (CPET) is the most
comprehensive technique which allows a holistic approach to
cardiopulmonary diseases.

SUMMARY: This article provides basic information addressed to the
Clinical Cardiologist regarding the utility and the indications of the
CPET technique in the everyday clinical practice. Clinical application of
CPET continues to evolve and protocols should be adapted to each specific
patient to obtain the most reliable and useful information. Key Messages:
Clinical Cardiologists with an interest over CPET may become familiar with
this exercise method and its main measured variables, refresh their
knowledge regarding the underlying pathophysiological mechanisms of oxygen
transport chain, learn how to interpret the CPET results and promote
appropriate patient referrals to experts.