Priego-Jiménez, Susana;
Priego-Jiménez, Pablo;López-González, María;Martinez-Rodrigo, Arturo;+2 more

Journal of clinical medicine,2025 Dec 25

Background/Objectives: Patient preoperative cardiorespiratory physical fitness measured by maximal oxygen consumption (VO2max) is highly relevant to postoperative outcomes, with low VO2max associated with a greater symptom burden and a greater prevalence of long-term treatment-related cardiovascular disease risk factors in patients undergoing surgery. A network meta-analysis (NMA) was conducted to determine the effects of different components of prehabilitation, including exercise, nutrition, psychological intervention, and different combinations of the aforementioned interventions, on oxygen consumption in people undergoing major abdominal or cardiothoracic surgery.
Methods: A literature search was conducted from inception to December 2025. Randomized controlled trials on the effectiveness of prehabilitation programmes on pre-surgery VO2max were included. The risk of bias was assessed via the Cochrane risk of bias (RoB 2.0) tool, and the quality of evidence was assessed via the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. Pairwise meta-analyses and NMAs were conducted for direct and indirect evidence.
Results: Fourteen studies were included in this NMA. The highest effect (ES) for VO2max scores was for the exercise group versus the control group (ES: 0.44; 95% CI: 0.11, 0.78). When exercise was categorized according to intensity, the highest effect was for high-intensity interval training (HIIT) versus the control (ES: 0.51; 95% CI: 0.04, 0.97).
Conclusions: Exercise HIIT should be considered the most effective strategy for improving exercise capacity in patients undergoing major abdominal or cardiothoracic surgery. Given the importance of VO2 as a predictor of morbidity, mortality, and the potential occurrence of adverse events after the procedure in surgical patients, it is essential to include its measurement in future studies to estimate both the risk of procedures and the effect of prehabilitation programmes.

Osailan, Ahmad M; Prince Sattam bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia.

Healthcare (Basel, Switzerland),2025 Dec 27

Background: Sleep quality is critical to health, and its disturbances may affect multiple systems, including autonomic and respiratory regulation. However, its relationship with chronotropic and ventilatory responses in healthy young men remains underexplored. Thus, the study aimed to investigate the relationship between sleep quality, as measured by the Pittsburgh Sleep Quality Index (PSQI), and chronotropic and ventilatory responses during cardiopulmonary exercise testing (CPET) in a healthy young male population and to explore group differences between good and poor sleepers.
Methods: Thirty-three healthy men completed the PSQI and a graded CPET with breath-by-breath gas analysis. Pearson correlation was used to examine relationships between the PSQI and CPET outcomes: chronotropic response (%), tidal volume (VT), minute ventilation (VE), VO ₂ , VCO ₂ , expired O ₂ /CO ₂ , VE/VO ₂ , and VE/VCO ₂ . After accounting for age, height, and weight, the correlation was reassessed. Secondary analyses using a standard cut-off point compared good (PSQI < 5) vs. poor sleepers (PSQI ≥ 5) with Welch’s t -tests. Results: Participants were predominantly poor sleepers (84.8%; PSQI 7.3 ± 3.2). A higher PSQI correlated with lower chronotropic response ( r = -0.35, p = 0.04), lower VT ( r = -0.42, p = 0.02), lower expired O ₂ ( r = -0.46, p = 0.01), and lower expired CO ₂ ( r = -0.33, p = 0.05). Associations with VE, VO ₂ , VCO ₂ , VE/VO ₂ , and VE/VCO ₂ were small and non-significant ( p > 0.05). When age, height, and weight were controlled for, the attenuated chronotropic response association with the PSQI was not significant; however, the PSQI association remained significant for expired O ₂ ( r = -0.32, p = 0.04), with a trend for VT. In group comparisons, chronotropic response was higher but not significant; good sleepers showed higher VT and greater expired O ₂ /CO ₂ ( p < 0.05).
Conclusions: Poorer sleep quality was initially associated with multiple cardiopulmonary responses at peak during CPET. However, after controlling for age and anthropometry measures, only expired O ₂ remained linked. The findings suggest that routine sleep quality screening may add interpretive value to CPET by flagging individuals with reduced ventilatory depth, warranting prospective studies to test whether improving sleep quality can enhance exercise responses.

Yanishi, Masaaki; Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
Kimura, Yutaka;Koito, Yuya;Matsushita, Jun;+4 more

Transplantation proceedings,2026 Jan 08

• Background: Sarcopenia remains a significant concern among kidney transplant recipients even after renal function improves. However, the predictors of impaired muscle recovery are not well established.
• Methods: We retrospectively analyzed 40 adults who underwent living-donor kidney transplantation at Kansai Medical University Hospital between January 2018 and December 2020. Preoperative cardiopulmonary exercise testing (CPX) was used to stratify patients into low-tolerance (anaerobic threshold VO₂ < 11 mL/kg/min and peak VO₂ < 20 mL/kg/min) and normal groups. The skeletal muscle index (SMI) was measured using dual-energy x-ray absorptiometry from baseline to 3 years post-transplantation. Multivariable linear regression and correlation analyses were performed to identify predictors of long-term SMI improvement.
• Results: Forty recipients were analyzed, including 12 (30%) in the low-tolerance group. Following transplantation, the median SMI in both groups decreased at 6 months and improved thereafter. However, from 1 year after transplantation onwards, the normal group demonstrated a significant increase in SMI compared with the low-tolerance group. Three years after transplantation, the median SMI in the normal group exceeded pretransplant levels and steadily increased, whereas in the low-tolerance group, there was little improvement and no return to baseline (P ≤ .05). Multivariable analysis identified low preoperative exercise tolerance as an independent predictor of reduced SMI recovery (P ≤ .05). Correlation analysis revealed that preoperative anaerobic threshold VO₂ and peak VO₂ were moderately and significantly associated with 3-year SMI improvement (r = 0.427 and r = 0.607, respectively).
• Conclusions: Low exercise tolerance before kidney transplantation strongly predicts impaired long-term skeletal muscle recovery. Cardiopulmonary exercise testing-based risk assessment may help identify candidates who could benefit from tailored perioperative rehabilitation strategies to enhance functional outcomes.

Utsumi, Yuya; Department of Rehabilitation, Tokushima Red Cross Hospital, Japan.
Takase, Koji;Murakami, Naoya;Nakagawa, Tokiko;+3 more

Physical therapy research,2025

• Objectives: Anaerobic threshold (AT) assessment using cardiopulmonary exercise testing (CPX) during hospitalization is considered ideal for prescribing exercise regimens in patients with acute myocardial infarction (AMI). However, practical limitations often hinder its implementation. This study evaluated strategies for prescribing exercise based on resting heart rate (RHR).
• Methods: A total of 194 consecutive male patients with AMI who underwent CPX within 13 days of hospitalization were enrolled. Bland-Altman analysis was performed to assess the agreement between the heart rate (HR) at AT (ATHR) and RHR +20, +25, and +30 beats. Multiple regression analysis was conducted to identify factors influencing ΔHR (ATHR-RHR). Decision-tree analysis was used to establish thresholds for appropriate exercise prescriptions based on RHR.
• Results: Regardless of β-blocker use, the RHR + 25 formula most closely approximated the ATHR in patients who underwent early CPX after AMI. Multivariate analysis identified RHR and hemoglobin (Hb) as significant predictors of ΔHR. Decision-tree analysis indicated that RHR + 25 was appropriate when RHR <91 bpm and Hb ≥12.0 g/dL.
• Conclusions: RHR + 25 is a practical alternative for determining the target HR in post-AMI rehabilitation among male patients, particularly in those with RHR <91 bpm and Hb ≥12.0 g/dL, when CPX is not feasible.

Bélanger, Noémie; German Center for Cardiovascular Research (DZHK), partner site Rhine-Main, Mainz, Germany.
Zeid, Silav;Velmeden, David;Schulz, Andreas;+10 more

Cardiovascular diabetology,2026 Jan 08

• Background: Cardiac autonomic dysfunction plays a pivotal role in the heart failure syndrome. Metabolic dysregulation affects both autonomic function and heart failure, but these relationships remain incompletely understood. This study aimed at investigating the role of glucose and insulin metabolism for parasympathetic reactivation.
• Methods: Data from the MyoVasc study (NCT04064450), a prospective heart failure cohort study, were analyzed. Participants underwent a highly standardized 5-hour examination, including venous blood sampling. To assess the impact of glucose and insulin metabolism (HbA _1c , HOMA-IR, and C-peptide) on parasympathetic reactivation as reflected by heart rate recovery 60 s (HRR ₆₀ ) after cardiopulmonary exercise testing, multivariable linear regression models with adjustment for sex, age, clinical profile (cardiovascular risk factors and comorbidities) and medication were calculated in cross-sectional and longitudinal settings. Additional adjustment for complementary glucose or insulin status was performed to assess the dependency of each other. Analyses were carried out in symptomatic heart failure and across the spectrum of glucose metabolism dysfunction.
• Results: The analysis sample included 1,588 individuals (median age 64.0 years [IQR 55.0;72.0]; 33% women) in a fasting state. Symptomatic heart failure was present in 43.7% of the subjects. Median HRR ₆₀ was 21.0 beats per minute (IQR 14.0;28.0). In multivariable regression analysis with adjustment for age, sex, clinical profile, and medication, both HbA _1c ([Formula: see text] _{per SD} -0.074, 95% CI [- 0.122;-0.026], P = 0.003) and HOMA-IR ([Formula: see text] _{per SD} -0.113 [- 0.165;-0.062], P < 0.0001) predicted HRR ₆₀ . Additional adjustment for both glucose and insulin status, respectively, demonstrated that HOMA-IR ([Formula: see text] _{per SD} -0.097 [- 0.155;-0.040], P < 0.0001), but not HbA _1c ([Formula: see text] _{per SD} -0.030 [- 0.084;0.025], P = 0.28), was independently related to HRR ₆₀ . This finding was confirmed in subgroups with heart failure and type 2 diabetes. In all analyses, C-peptide was related to HRR ₆₀ independently of HbA _1c with higher effect estimates than HOMA-IR ([Formula: see text] _{per SD} -0.171 [- 0.225;-0.117], P < 0.0001). Finally, higher HbA _1c ([Formula: see text] _{per SD} -0.094, [- 0.171;-0.017], P = 0.017) and C-peptide ([Formula: see text] _{per SD} -0.076, [- 0.159;0.007], P = 0.075) were more strongly associated with a lower HRR ₆₀ after two years of follow-up.
• Conclusions: This study demonstrates the relevance of insulin status for vagal activity of cardiac autonomic function, particularly in heart failure. The pathophysiological implications underlying the relationship between insulin status and parasympathetic activity merit further mechanistic exploration.

Ikegami, Shogo; Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan.
Hiraide, Takahiro;Maeda, Takashi;Momoi, Mizuki;+5 more

Journal of clinical medicine,2025 Dec 11

Background: Pulmonary arterial hypertension (PAH) leads to right ventricular failure and death. Inhaled treprostinil, a tricyclic benzindene prostacyclin analog, has become available, but evidence regarding its clinical efficacy and quality-of-life (QoL) benefits-particularly in patients already receiving optimized combination vasodilator therapy-remains limited.
Methods: Inhaled treprostinil was introduced to nine patients with PAH already receiving combination therapy with pulmonary vasodilators. Acute hemodynamic effects were assessed during initial right heart catheterization, and long-term effects were evaluated at baseline and 3 months after treatment. Exercise tolerance was assessed by the 6-minute walking distance (6MWD) test and cardiopulmonary exercise testing, while QoL was evaluated using the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12).
Results: Mean pulmonary arterial pressure significantly improved both acutely (48.9 ± 17.8 to 43.7 ± 14.5 mmHg, p = 0.036) and at 3 months (46.4 ± 16.1 to 39.8 ± 14.1 mmHg, p = 0.014). Pulmonary vascular resistance tended to decrease, while 6MWD outcomes remained unchanged. QoL improved, with KCCQ-12 overall and clinical summary scores increasing from 59.1 ± 27.4 to 67.1 ± 26.5 and 78.1 ± 26.3 to 87.5 ± 21.2, respectively.
Conclusions: Treprostinil inhalation improved hemodynamics and patient-reported outcomes despite prior combination improved hemodynamics and tended to enhance QoL in patients with PAH receiving combination vasodilator therapy.

Sakellaropoulos, Stefanos G; Department of Cardiology, University Hospital and University of Basel, Basel, Switzerland.;
Mohammed, Muhemin;Sakellaropoulos, Panagiotis;Ali, Muhammad;+6 more

Cardiology research,2025 Dec 20

Other than the traditional risk factors for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) – detected by means of anamnesis, Holter monitoring, exercise testing, echocardiography and cardiac magnetic resonance imaging – exercise oscillatory ventilation (EOV), detected by cardiopulmonary exercise testing (CPET), has recently been observed in patients with HCM. EOV is considered as one of the most important independent risk factors for morbidity, mortality and SCD in patients with reduced, as well as with preserved ejection fraction. Considering HCM as a prototype of heart failure with preserved ejection fraction, we would like to present a short, specific review concerning EOV as a potential new risk factor for SCD in HCM.

Sugita, Yousuke; Faculty of Health Sciences, Tsukuba University of Technology, Ibaraki, Japan.
Kudo, Ayano;Arakawa, Sota;Sakai, Satoshi

Heart and vessels,2025 Dec 29

Background Reduced exercise capacity is a hallmark of heart failure with preserved ejection fraction (HFpEF), and this limitation is particularly pronounced in older patients with coexisting type 2 diabetes mellitus (T2DM), a high-risk population characterized by poor prognosis. Although previous studies have demonstrated that exercise training (ET) can improve exercise capacity in patients with HFpEF, its efficacy in older patients with coexisting HFpEF and T2DM remains unclear.
Methods Therefore, we evaluated the effects of ET on peak oxygen uptake (peakVO ₂ ) and 6-min walk distance (6MWD) in older patients with HFpEF and investigated whether these effects differ based on T2DM status. A total of 99 stable outpatients with HFpEF aged 65 to 80 years were enrolled. Participants were classified into four groups based on T2DM and ET status: T2DM-ET (n = 25), non-T2DM-ET (n = 24), T2DM-usual-care (UC; n = 26), and non-T2DM-UC (n = 24). PeakVO ₂ and hemodynamic responses during exercise were assessed using cardiopulmonary exercise testing and impedance cardiography. Additionally, walking distance, cadence, step length, and metabolic cost were assessed during the 6-min walk test. The interaction between T2DM and ET on changes in these parameters was analyzed using multivariable-adjusted linear regression.
Results ET significantly improved peakVO ₂ after 5 months; however, the magnitude of improvement was attenuated in the T2DM group (0.5 mL/kg/min) compared with that in the non-T2DM group (1.9 mL/kg/min; p < 0.001). This difference was primarily attributable to a blunted increase in arteriovenous oxygen difference, which increased by only 0.2 mL/100 mL in the T2DM group vs. 0.4 mL/100 mL in the non-T2DM group (p < 0.001). In contrast, improvements in 6MWD were similar between the groups (29 vs. 31 m; p = 0.651). Step length remained unchanged, whereas cadence increased in the T2DM and non-T2DM groups (11 vs. 8 steps/min, respectively), accompanied by a reduction in metabolic cost (- 0.06 vs. – 0.04 mL/kg/m), indicating enhanced walking efficiency regardless of T2DM status. Although T2DM attenuated improvements in peakVO ₂ , the walking efficiency and functional capacity improved with ET regardless of T2DM status.
Conclusions These findings highlight the potential value of ET in older patients with HFpEF, irrespective of T2DM status.

Duregon, Federica; Sports and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy.
Quinto, Giulia;Vecchiato, Marco;Faggian, Sara;+7 more

BMC sports science, medicine & rehabilitation,2025 Dec 29

• Background: Although physical exercise is an evidence-based treatment for patients with chronic diseases, providing benefits in terms of morbidity, mortality and quality of life, its implementation in real-world healthcare systems is still limited. Even when physicians recommend physical activity, compliance and adherence to exercise programs remain very low. This study aims to implement a real-world model for tailored exercise prescription (TEP) in an outpatient clinic to evaluate feasibility, effectiveness, compliance and adherence.
• Methods: A TEP was set for each participant, based on a complete clinical and functional evaluation including cardiopulmonary exercise testing and fitness test battery. Subsequent supervised training sessions (STS) were performed for at least 6 weeks. After 6 months functional evaluations were repeated, also assessing compliance with general recommendations and adherence to the prescribed exercise program.
• Results: A total of 312 patients (44% male) with a mean age of 52.1 ± 13.6 years were enrolled. The most frequent main chronic conditions were obesity (47%), solid organ transplantation (32%), primary cardiovascular diseases (8%) and cancer (4%). The initial STS program was completed by 85.9% of patients, all without adverse events. Patient compliance, measured as attendance at the follow-up meeting, was 53.2%, while adherence to the TEP during the 6-month program was 44.9%.
• Conclusion: A real-word model for TEP followed by a period of STS is feasible in patients with chronic diseases in a real outpatient clinical setting. However, intervention strategies based on behavioral change and motivation are needed to foster greater compliance and adherence in the mid-to-long term.

Foulkes, Stephen J; Exercise and Research Trials (HEART) Lab, St Vincent’s Institute of Medical Research, Fitzroy, Australia.
Moura-Ferreira, Sara;Milani, Mauricio;Bekhuis, Youri;+13 more

Journal of cardiac failure,2025 Dec 30

• Objective: Atrial fibrillation (AF) is a common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) that contributes to increased morbidity and mortality. We sought to evaluate the impact of AF on key HFpEF features, including exercise tolerance (peak oxygen uptake, VO ₂ peak) hemodynamic responses, and peripheral oxygen extraction (a-vO ₂ diff).
• Methods: Patients referred to a multi-disciplinary unexplained dyspnea clinic and diagnosed with HFpEF following comprehensive clinical and hemodynamic evaluation were stratified on whether they were in persistent/permanent AF (AF _Persist ; n=86), paroxysmal AF (AF _Parox ; n=328) or sinus rhythm (SR; n=274). Cardiopulmonary exercise testing with simultaneous echocardiography (CPETecho) was applied to assess the VO ₂ peak, a-vO ₂ diff and exercise hemodynamics. Groups were compared using ANCOVA with adjustment for age, sex, body mass index, and the presence of hypertension and diabetes.
• Results: Compared to patients in SR or with AF _Parox , HFpEF patients with AF _Persist had a lower VO ₂ peak (1.3-2.4mL/kg/min lower, P<0.001). This coincided with lower peak exercise cardiac output (CO, 0.6-1.2L/min lower), secondary to a lesser stroke volume (14-17mL lower, P<0.001) and a smaller left-ventricular end-diastolic volume (15-18mL lower, P<0.001) that tended to decrease during exercise. In contrast, there was no impact of AF status on peak exercise a-vO ₂ diff, mean pulmonary artery pressure (mPAP) or the mPAP/CO slope.
• Conclusion: Patients with HFpEF and AF _Persist have a lower VO ₂ peak secondary to decreased CO, SV and reduced end-diastolic volume reserve. Rhythm control strategies may therefore be pivotal in optimizing exercise performance and clinical outcomes in patients with HFpEF and AF.