Abbott TEF; Pearse RM; Cuthbertson BH; Wijeysundera DN; Ackland GL;

British Journal Of Anaesthesia [Br J Anaesth] 2019 Feb; Vol. 122 (2), pp. 188-197. Date of Electronic Publication: 2018 Dec 17.

Background: The aetiology of perioperative myocardial injury is poorly understood and not clearly linked to pre-existing cardiovascular disease. We hypothesised that loss of cardioprotective vagal tone [defined by impaired heart rate recovery ≤12 beats min-1 (HRR ≤12) 1 min after cessation of preoperative cardiopulmonary exercise testing] was associated with perioperative myocardial injury.
Methods: We conducted a pre-defined, secondary analysis of a multi-centre prospective cohort study of preoperative cardiopulmonary exercise testing. Participants were aged ≥40 yr undergoing non-cardiac surgery. The exposure was impaired HRR (HRR≤12). The primary outcome was postoperative myocardial injury, defined by serum troponin concentration within 72 h after surgery. The analysis accounted for established markers of cardiac risk [Revised Cardiac Risk Index (RCRI), N-terminal pro-brain natriuretic peptide (NT pro-BNP)].
Results: A total of 1326 participants were included [mean age (standard deviation), 64 (10) yr], of whom 816 (61.5%) were male. HRR≤12 occurred in 548 patients (41.3%). Myocardial injury was more frequent amongst patients with HRR≤12 [85/548 (15.5%) vs HRR>12: 83/778 (10.7%); odds ratio (OR), 1.50 (1.08-2.08); P=0.016, adjusted for RCRI). HRR declined progressively in patients with increasing numbers of RCRI factors. Patients with ≥3 RCRI factors were more likely to have HRR≤12 [26/36 (72.2%) vs 0 factors: 167/419 (39.9%); OR, 3.92 (1.84-8.34); P<0.001]. NT pro-BNP greater than a standard prognostic threshold (>300 pg ml-1) was more frequent in patients with HRR≤12 [96/529 (18.1%) vs HRR>12 59/745 (7.9%); OR, 2.58 (1.82-3.64); P<0.001].
Conclusions: Impaired HRR is associated with an increased risk of perioperative cardiac injury. These data suggest a mechanistic role for cardiac vagal dysfunction in promoting perioperative myocardial injury.

Li MH; Bolshinsky V; Ismail H; Burbury K; Ho KM; Riedel B; Amin B; Heriot A;

Canadian Journal Of Anaesthesia = Journal Canadien D’anesthesie [Can J Anaesth] 2019 Jan 28. Date of Electronic Publication: 2019 Jan 28.

Purpose: Preoperative fitness training has been listed as a top ten research priority in anesthesia. We aimed to capture the current practice patterns and perspectives of anesthetists and colorectal surgeons in Australia and New Zealand regarding preoperative risk stratification and prehabilitation to provide a basis for implementation research.
Methods: During 2016, we separately surveyed fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) and members of the Colorectal Society of Surgeons in Australia and New Zealand (CSSANZ). Our outcome measures investigated the responders’ demographics, practice patterns, and perspectives. Practice patterns examined preoperative assessment and prehabilitation utilizing exercise, hematinic, and nutrition optimization.
Results: We received 155 responses from anesthetists and 71 responses from colorectal surgeons. We found that both specialty groups recognized that functional capacity was linked to postoperative outcome; however, fewer agreed that robust evidence exists for prehabilitation. Prehabilitation in routine practice remains low, with significant potential for expansion. The majority of anesthetists do not believe their patients are adequately risk stratified before surgery, and most of their colorectal colleagues are amenable to delaying surgery for at least an additional two weeks. Two-thirds of anesthetists did not use cardiopulmonary exercise testing as they lacked access. Hematinic and nutritional assessment and optimization is less frequently performed by anesthetists compared with their colorectal colleagues.
Conclusions: An unrecognized potential window for prehabilitation exists in the two to four weeks following cancer diagnosis. Early referral, larger multi-centre studies focusing on long-term outcomes, and further implementation research are required.

Huang W, Oliveira RKF, Lei H, Systrom DM, Waxman AB

J Card Fail. 2018 Mar;24(3):169-176. doi: 10.1016/j.cardfail.2017.11.003. Epub
2017 Nov 24.

BACKGROUND: In heart failure with preserved ejection fraction (HFpEF), the
prognostic value of pulmonary vascular dysfunction (PV-dysfunction), identified
by elevated pulmonary vascular resistance (PVR) at peak exercise, is not
completely understood. We evaluated the long-term prognostic implications of
PV-dysfunction in HFpEF during exercise in consecutive patients undergoing
invasive cardiopulmonary exercise testing for unexplained dyspnea.
METHODS: Patients with HFpEF were classified into 2 main groups: resting HFpEF
(n = 104, 62% female, age 61 years) with a pulmonary arterial wedge pressure
(PAWP) >15 mmHg at rest; and exercise HFpEF (eHFpEF; n = 81) with a PAWP <15 mmHg
at rest, but >20 mmHg during exercise. The eHFpEF group was further subdivided
into eHFpEF + PV-dysfunction (peak PVR ≥80 dynes/s/cm-5; n = 55, 60% female, age
64) group and eHFpEF – PV-dysfunction (peak PVR <80 dynes/s/cm-5; n = 26, 42%
female, age 54 years) group. Outcomes were analyzed for the first 9 years of
follow-up and included any cause mortality and heart failure (HF)-related
hospitalizations. The mean follow-up time was 6.7 ± 2.6 years (0.5-9.0).
RESULTS: Mortality rate did not differ among the groups. However, survival free
of HF-related hospitalization was lower for the eHFpEF + PV-dysfunction group
compared with eHFpEF – PV-dysfunction (P = .01). These findings were similar
between eHFpEF + PV-dysfunction and the resting HFpEF group (P = .774). By Cox
analysis, peak PVR ≥80 dynes/s/cm-5 was a predictor of HF-related hospitalization
for eHFpEF (hazard ratio 5.73, 95% confidence interval 1.05-31.22, P = .01). In
conclusion, the present study provides insight into the impact of PV-dysfunction
on outcomes of patients with exercise-induced HFpEF. An elevated peak PVR is
associated with a high risk of HF-related hospitalization.

Uithoven KE; Smith JR; Medina-Inojosa JR; Squires RW; Van Iterson EH; Olson TP;

Journal Of Clinical Medicine [J Clin Med] 2019 Jan 19; Vol. 8 (1). Date of Electronic Publication: 2019 Jan 19.

The measurement of peak oxygen uptake (VO2peak) is an important metric for evaluating cardiac transplantation (HTx) eligibility. However, it is unclear which factors (e.g., recipient demographics, clinical parameters, cardiac rehabilitation (CR) participation) influence VO2peak following HTx. Consecutive HTx patients with cardiopulmonary exercise testing (CPET) between 2007⁻2016 were included. VO2peak was measured from CPET standard protocol. Regression analyses determined predictors of the highest post-HTx VO2peak (i.e., quartile 4: VO2peak > 20.1 mL/kg/min). One hundred-forty HTx patients (women: n = 41 (29%), age: 52 ± 12 years, body mass index (BMI): 27 ± 5 kg/m²) were included. History of diabetes (Odds Ratio (OR): 0.17, 95% Confidence Interval (CI): 0.04⁻0.77, p = 0.021), history of dyslipidemia (OR: 0.42, 95% CI: 0.19⁻0.93, p = 0.032), BMI (OR: 0.90, 95% CI: 0.82⁻0.99, p = 0.022), hemoglobin (OR: 1.29, 95% CI: 1.04⁻1.61, p = 0.020), white blood cell count (OR: 0.81, 95% CI: 0.66⁻0.98, p = 0.033), CR exercise sessions (OR: 1.10, 95% CI: 1.04⁻1.15, p < 0.001), and pre-HTx VO2peak (OR: 1.17, 95% CI: 1.07⁻1.29, p = 0.001) were significant predictors. Multivariate analysis showed CR exercise sessions (OR: 1.10, 95% CI: 1.03⁻1.16, p = 0.002), and pre-HTx VO2peak (OR: 1.16, 95% CI: 1.04⁻1.30, p = 0.007) were independently predictive of higher post-HTx VO2peak. Pre-HTx VO2peak and CR exercise sessions are predictive of a greater VO2peak following HTx. These data highlight the importance of CR exercise session attendance and pre-HTx fitness in predicting VO2peak post-HTx.

Takano N; TAmiya E; Oguri G; Nakayama A; Taya M; Nakajima T; Morita H; Japan.Komuro I;

International Journal Of Cardiology. Heart & Vasculature [Int J Cardiol Heart Vasc] 2019 Jan 08; Vol. 22, pp. 84-91. Date of Electronic Publication: 20190108 (Print Publication: 2019).

To investigate the effect of atrial fibrillation (AF) on the oxygen uptake and exercise tolerance, we evaluated cardiopulmonary exercise test (CPET) data in AF patients and heart rate-matched controls with sinus rhythm (cSR) who received ambulatory cardiac rehabilitation. We compared CPET data between AF (N = 27) and cSR patients (N = 106) who had similar HRs at rest and the peak points. Oxygen uptake (VO2)/kg and relative O2 pulse (ml/bpm/kg) at rest and the anaerobic threshold (AT) level was not different between AF and cSR patients, but these parameters above the AT level were significantly lower in AF than in cSR patients. Concisely the parallel increase of relative O2 pulse during exercise was blunted above the respiratory compensation level (Rc) in the AF group. In addition, the HR change during exercise was inversely correlated with the increase of the O2 pulse above the AT level and this inverse correlation was more prominent in AF patients than in cSR patients. In conclusion, the value of VO2 was significantly lower above the AT level in AF patients. The trend of O2 pulse above the AT level was strongly associated with the detrimental response of HR increase and the response was markedly exaggerated in the AF patients.

Jiang R, Liu H, Pudasaini B, Zhang R, Xu JL, Wang L, Zhao QH, Yuan P, Guo J, He J, Gong SG, Wu C, Wu WH, Luo CJ,Qiu HL, Jing ZC, Liu JM

Clin Respir J. 2019 Jan 22. doi: 10.1111/crj.12996. [Epub ahead of print]

BACKGROUND: Pulmonary hypertension patients with mean pulmonary artery pressure
(mPAP) ≥ 25 mmHg had impaired cardiopulmonary exercise testing (CPET). Borderline
mean pulmonary pressures (boPAP; 21-24 mmHg) represents early pulmonary
vasculopathy. The CPET characteristics of boPAP is a matter of discussion. We
aimed to determine the CPET profile of such borderline hemodynamics.
METHODS: A matched case-control study was conducted on consecutive boPAP patients
at the Shanghai Pulmonary Hospital between Jan 2012 and Jan 2017. Hemodynamics,
echocardiography, the pulmonary function test (PFT) and CPET parameters were
compared between boPAP patients and normal mPAP patients which were matched 1:1
by sex and age. Conditional logistic regression analysis was performed to
determine the efficacy of CPET in detecting boPAP.
RESULTS: A total of 48 patients underwent RHC and CPET (24 Normal, 24 boPAP).
There were no differences in the demographics, echocardiography and PFT. BoPAP
patients had significantly decreased VO2 at the anaerobic threshold and peak VO2
/kg (858.4 ± 246.5 ml/min vs. 727.9 ± 228.0 ml/min, P = 0.037; 21.1 ± 6.4
mL/min/kg vs. 15.5 ± 5.6 mL/min/kg, P = 0.001, respectively). Significant
differences were not observed in ventilation efficiency. A trend of impaired
oxygen pulse and submaximal exercise tolerance were observed in boPAP patients.
Conditional logistical regression analysis revealed the risk of boPAP increased
by 2.493 (95% confident interval: 1.388 to 4.476, P = 0.002) with every 5
mL/min/kg decrease in peak VO2 /kg.
CONCLUSIONS: Patients with boPAP have a greater prevalence of exercise
intolerance, a trend of impaired oxygen pulse and submaximal exercise tolerance.

Armstrong HF; Schulze PC; Bacchetta M; Thirapatarapong W; Bartels MN.

Respirology. 19(5):675-82, 2014 Jul.
VI 1

BACKGROUND AND OBJECTIVE: Pulmonary hypertension (PH) is a known
complication in patients with interstitial lung disease (ILD).
Cardiopulmonary exercise testing (CPET) is an essential tool for the
assessment of patients with cardiac and pulmonary diseases due to its
prognostic and therapeutic implications. Few studies have evaluated the
relationship between CPET response and mean pulmonary artery pressures
(mPAP) in ILD. The purpose of the present study was to determine and
compare the potential correlations between CPET, 6-min walk test (6MWT),
pulmonary function testing (PFT) and PH in patients with ILD being
evaluated for lung transplantation.

METHODS: The present study reviewed patients with ILD who received lung
transplantations and had CPETs within 2 years before transplantation,
right heart catheterizations, PFTs and 6MWTs within 4 months of CPET.

RESULTS: A total of 72 patients with ILD were analysed; 36% had PH. There
were significant correlations between mPAP and CPET parameters in patients
with PH; but mPAP had no impact on percent of predicted diffusion capacity
of the lung for carbon monoxide or 6-min walk distance (6MWD). CPET
parameters were able to detect differences between levels of severity of
PH through the use of the ratio of minute ventilation to rate of carbon
dioxide production (VE/VCO2) and the partial pressure of end-tidal carbon
dioxide.

CONCLUSIONS: This is the first study that analyses 6MWD, PFT and CPET in
patients with ILD awaiting lung transplantation with and without PH. The
present study demonstrates the significant impact of PH on exercise
capacity and performance in patients with ILD awaiting lung
transplantation.

Biccard BM.

British Journal of Anaesthesia. 120(3):419-421, 2018 03.
VI 1

Comment in: Br J Anaesth. 2018 Aug;121(2):496-497; PMID: 30032891

Bhasipol A; Sanjaroensuttikul N; Pornsuriyasak P; Yamwong S; Tangcharoen
T.

Congenital Heart Disease. 13(6):952-958, 2018 Nov.

OBJECTIVE: We aimed to study the efficiency and safety of once-a-week
outpatient rehabilitation followed by home program with tele-monitoring in
patients with complex cyanotic congenital heart disease.

DESIGN: Prospective nonrandomized study.

METHOD: Patients who have been diagnosed either Eisenmenger’s syndrome or
inoperable complex cyanotic heart disease and able to attend 12-week
cardiac rehabilitation program were included. Training with treadmill
walking and bicycling under supervision at cardiac rehabilitation unit
once-a-week in the first 6 weeks followed by home-based exercise program
(bicycle and walking) with a target at 40%-70% of maximum heart rate
(HRmax) at pretraining peak exercise for another 6 weeks was performed in
the intervention group. Video and telephone calls were scheduled for
evaluation of compliance and complication. Data from cardiopulmonary
exercise testing (CPET) on cycle ergometry including peak oxygen
consumption (peakVO2 ), oxygen pulse (O2 pulse), ventilatory equivalent
for carbon dioxide (VE/CO2 at anaerobic threshold), constant work-rate
endurance time (CWRET) at 75% of peak VO2 , and 6-minute walk distance
(6MWD) were compared between baseline and after training by paired t test.

RESULT: Of the 400 patients in our adult congenital heart disease clinic,
60 patients met the inclusion criteria. Eleven patients who could follow
program regularly were assigned home program. There was a statistically
significant improvement of CWRET, O2 pulse, and 6MWD after finishing the
program (P = .003, .039, and .001, respectively). The mean difference of
6MWD change in the home-program group was significantly higher than in the
control group (69.3 +/- 47.9 meters vs. 4.1 +/- 43.4 meters, P = .003). No
serious adverse outcomes were reported during home training.

CONCLUSION: Once-a-week outpatient hospital-based exercise program
followed by supervised home-based exercise program showed a significant
benefit in improvement of exercise capacity in adults with complex
cyanotic congenital heart disease without serious adverse
outcomes.