Nasser R; Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium & other centres
Verelst FR; Mueller S; Winzer EB; Beckers PJ;Van De Heyning CM; Wisløff U; Pieske B; r site Berlin, Berlin, Germany.Adams V; Halle M;
Van Craenenbroeck EM; Gevaert AB;

European journal of preventive cardiology [Eur J Prev Cardiol] 2025 Sep 30.
Date of Electronic Publication: 2025 Sep 30.

Background and Aims: Chronotropic incompetence (CI) is common in heart failure with preserved ejection fraction (HFpEF) and contributes to reduced exercise tolerance. However, the effects of exercise training on CI in HFpEF remain unknown. We aimed to assess the effect of different exercise training intensities on chronotropic reserve in HFpEF.
Methods: This is a subanalysis of the OptimEx-Clin trial. Patients with HFpEF were randomized to high-intensity interval training (HIIT), moderate continuous training (MCT) or guideline control (GC). CI was assessed during cardiopulmonary exercise testing at baseline and 3 months. CI was defined as a chronotropic index ≤0.62 in patients on negative chronotropic medications and ≤0.80 in others.
Results: Among 175 patients with HFpEF (66% female, mean age 70±8 years), 144 completed follow-up. CI was present in 51% and was associated with lower peak oxygen uptake (16.5±4.2 vs. 21.1±5.2 mL/kg/min, p<.001), lower peak workload (89±28 vs. 116±39 W, p<.001), and poorer ventilatory efficiency (35.2±7.1 vs. 32.6±6.8, p=.014) at baseline. HIIT and MCT did not improve chronotropic index, %predicted peak heart rate, nor CI prevalence after 3 months (all p>.500), and adjusting for negative chronotropic drug use did not change results. Nevertheless, HIIT and MCT improved V̇O2peak and workload (p<.001) versus GC, regardless of the presence of CI.
Conclusion: In elderly patients with HFpEF, neither HIIT nor MCT during 3 months significantly improved chronotropic reserve or reduced CI prevalence, but exercise capacity was improved.

Filakovszky Á; Department of Anesthesiology and Critical Care Medicine,  Kepler University Hospital, Linz, Austria & Czech Republic
Brat K; Tschoellitsch T; Bartos S;Mazur A;Meier J; Olson L; Cundrle I;

Thorax [Thorax] 2025 Oct 02.
Date of Electronic Publication: 2025 Oct 02.

Rationale: Despite significant advances in patient care and outcomes, criteria for cardiopulmonary exercise testing (CPET) in risk stratification guidelines for lung resection have not been updated in over a decade. We hypothesised that CPET no longer holds additional predictive value for postoperative complications.
Methods: In this secondary analysis, we included lung resection candidates from two prospective, multicentre studies eligible for CPET and assessed with preoperative pulmonary function tests (PFTs) and arterial blood gas analysis. Postoperative pulmonary (PPCs) and cardiovascular complications (PCCs) were documented during hospitalisation. We trained five types of machine learning models applying nested cross-validation to predict complications and compared predictive performance based on four metrics, including area under the receiver operating characteristic curve (AUC-ROC).
Results: A total of 497 patients were included. PPCs developed in 71 (14%) patients. Adding CPET parameters to PFTs and baseline clinical data did not improve the ability of models to predict PPCs in unselected patients (AUC-ROC=0.72-0.78; p=0.47), nor in those meeting American College of Chest Physicians (ACCPs) (n=236; AUC-ROC=0.64-0.78; p=0.70) or European Respiratory Society/European Society of Thoracic Surgery (ERS/ESTS) criteria (n=168; AUC-ROC=0.59-0.76; p=0.92). PCCs developed in 90 (18%) patients. CPET parameters likewise did not improve model performance for the prediction of PCCs in unselected patients (AUC-ROC=0.65-0.73; p=0.96), nor in the ACCP (AUC-ROC=0.61-0.73; p=0.82) or ERS/ESTS subgroups (AUC-ROC=0.62-0.69; p=0.87).
Conclusions: In contemporary surgical practice, CPET did not improve the predictive performance of machine learning models for PPCs or PCCs in patients with an indication based on established guidelines or in those without. The role of CPET in preoperative risk stratification for lung resection should be re-evaluated.

Schellenberg J; Sports and Rehabilitation Medicine, University Hospital Ulm, Germany.
Matits L; Bizjak DA; Deibert P; et al;

Infection. 53(5):1685-1697, 2025 Oct. VI 1

SARS-CoV-2 infection has been predominantly reported in hospitalized
patients, but long-term cardiac sequelae in large, well-characterized
cohorts remain inconclusive. This study evaluated cardiac structure and
function in individuals with post-Coronavirus disease (COVID) syndrome
(PCS) compared to recovered controls (CON), focusing on associations with
cardiopulmonary symptoms and rapid physical exhaustion (RPE).

METHODS: This multicenter, population-based study included 1154
participants (679 PCS, 475 age- and sex matched CON; mean age 49 +/- 12
years; 760 women) 1.5 years post-infection. Transthoracic echocardiography
assessed LV global longitudinal strain (GLS), RV GLS and RV free wall
strain (FWS), and other measures. Cardiopulmonary exercise testing (CPET)
measured maximum respiratory oxygen uptake (VO2max) as a marker of
cardiopulmonary fitness.

RESULTS: PCS participants exhibited significantly lower LV GLS (-20.25%
[-21.28 – -19.22] vs. -20.73% [-21.74 – -19.72], p = 0.003), reduced
diastolic function (E/A 1.16 [1.04-1.27] vs. 1.21 [1.1-1.32], p = 0.022)
and decreased TAPSE (24.45 mm [22.14-26.77] vs. 25.05 mm [22.78-27.32], p
= 0.022) compared to CON, even after adjusting for confounders. RV strain
values were similar between groups. LV GLS correlated inversely with
VO2max (p = 0.004) and positively with RPE (p = 0.050), though no
associations were observed with other cardiopulmonary symptoms.

CONCLUSIONS: This study demonstrates subtle yet consistent reductions in
LV function, specifically LV GLS and diastolic function, and exercise
capacity in PCS compared to CON. While these changes are within reference
ranges, their potential impact on clinical outcomes warrants further
investigation. These findings highlight the need for cardiac assessments
and long-term follow-up in symptomatic PCS patients.

Bruce, Richard M; Faculty of Life Science and Medicine, King’s College London, London, UK
Rafferty, Gerrard F;Finnegan, Sarah L; et al;

The Journal of physiology,2025 Sep

In this study we have used a highly immersive virtual reality (VR) cycling environment where incongruence between virtual hill gradient (created by visual gradient and bike tilt angle) and actual workload (pedalling resistance) can experimentally manipulate perception of exercise effort. This therefore may provide a method to examine the role of effort perception in cardiorespiratory control during exercise. Twelve healthy untrained participants (7 men, age 26 ± 5 years) were studied during five visits. On visit 1 participants underwent cardiopulmonary exercise testing, and during subsequent visits (2-4) participants performed repeated hill climbs at different gradients (of 3%, 6% and 9% in counterbalanced order) with the actual workload ‘congruent’ with virtual hill gradient. On visit 5 participants completed three incongruent trials with virtual hill gradients of 3%, 6% and 9% but a fixed workload equal to that for the 6% climb (iVR3%, iVR6% and iVR9% trials). Despite no difference in power output, there was a significantly elevated rating of perceived exertion (RPE) and mean arterial blood pressure in iVR9% compared to iVR3% and iVR6%, although this effect decayed over time. There was no effect on any respiratory variable, and no significant reduction in RPE or cardiovascular responses was observed during the iVR3% trial. These data suggest that perception of effort and cardiovascular responses to exercise can be manipulated experimentally via virtual hill gradient (using visual and/or vestibular cues) in a VR environment. This work supports those previously showing the existence of a control mechanism which integrates perception of effort and the cardiovascular response to exercise in humans.
KEY POINTS: We aimed to assess whether using a highly immersive virtual reality (VR) cycling environment to create incongruence between perceived effort (virtual hill gradient) and actual effort (pedal resistance) can manipulate cardiorespiratory responses to exercise. At an equivalent power output cycling up a steeper virtual hill produced greater ratings of perceived exertion (RPEs) and blood pressure responses compared to a virtual hill congruent to power output. This work suggests the existence of a control mechanism which integrates perception of exercise effort and the cardiovascular response to exercise, which can be experimentally manipulated by VR.

Gutiérrez-Ballesteros, Guillermo; Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Córdoba, Spain.
Mazuelos-Bellido, Francisco;López-Aguilera, José;Crespín-Crespín, Manuel; et al

Frontiers in cardiovascular medicine,2025 Sep 02

• Introduction and Objectives: Left bundle branch area pacing (LBBAP) has been associated with good clinical and echocardiographic outcomes and seems to be an alternative to conventional resynchronization therapy. However, data regarding functional outcomes are scarce. Our objective was to evaluate, using cardiopulmonary exercise testing (CET), changes in the functional capacity of patients with an indication for cardiac resynchronization therapy after LBBAP.
• Methods: We conducted a prospective analysis of a cohort of patients with non-ischaemic dilated cardiomyopathy (NIDCM), left bundle branch block, QRS duration >130 ms, New York Heart Association functional class (NYHA-FC) II-IV, and left ventricular ejection fraction (LVEF) < 40% who underwent LBBAP. CET was performed before the procedure and after 6 months of follow-up. The primary endpoint was the change in peak oxygen uptake (VO ₂ ). The secondary endpoints included evaluation of clinical, echocardiographic, analytical, and other CET parameters.
• Results: A total of 50 patients were included (44% female, 64 ± 11 years, LVEF 28 ± 7%). At baseline, peak VO ₂ was 15.4 ± 4.9 ml/kg/min, and VO ₂ at the first ventilatory threshold was 10.5 ± 2.9 ml/kg/min. At follow-up, we observed an increase of 3 ml/kg/min (95% CI 1.7-4.4; p < 0.01) and 2.6 ml/kg/min (95% CI 1.6-3.5; p < 0.01), respectively. Independent predictors of peak VO ₂ at follow-up were baseline peak VO ₂ and baseline QRS duration. Improvement was observed in the remaining CET, echocardiography, and clinical parameters.
• Conclusions: In symptomatic patients with non-ischaemic dilated cardiomyopathy, LVEF < 40%, and left bundle branch block, LBBAP was associated with an improvement in peak VO ₂ . Baseline QRS duration and baseline peak VO ₂ were independent predictors of this parameter at follow-up.

Christopher Gregory;  Cardiovascular Innovation and Research Center (CIRC)  University of California, Irvine, Irvine, CA.
Raza, Farhan;Colebank, Mitchel J;Korcarz, Claudia E; et al

American journal of physiology. Heart and circulatory physiology,2025 Sep 12

Wave intensity analysis provides a novel approach to understanding the dynamic interactions between the right ventricle and pulmonary vasculature, particularly in pulmonary hypertension, a condition characterized by elevated pulmonary arterial pressures and vascular remodeling. This prospective study used wave intensity analysis to evaluate right ventricular and pulmonary vascular mechanics in 22 participants with pulmonary hypertension (including pre-capillary, isolated post-capillary, and combined pre-/post-capillary pulmonary hypertension), and 3 without pulmonary hypertension. Forward and backward compression and decompression waves were quantified at rest and during incremental exercise (25, 50, 75 watts). Relationships between metrics of wave intensity analysis, hemodynamics, right ventricular function, and oxygen consumption were analyzed using linear mixed-effects modeling. Wave intensity patterns highlighting vessel-specific pulmonary vascular and right ventricular pathobiology were observed in different phenotypes. Pre-capillary pulmonary hypertension exhibited highest forward compression waves, which correlated with right ventricular contractility (p<0.01). Backward compression waves correlated strongly with characteristic impedance (p=0.002) in combined pre-/post-capillary pulmonary hypertension and inversely with pulmonary arterial compliance (p=0.003) in pre-capillary pulmonary hypertension. The ratio of backward to forward compression (systolic) waves decreased in isolated post-capillary pulmonary hypertension during exercise (p<0.001), suggesting right ventricular reserve capacity that improves vascular-ventricular coupling. Wave intensity metrics demonstrated strong correlations with oxygen consumption in participants without pulmonary hypertension, indicating sensitivity to exercise-induced changes in cardiopulmonary status. Wave intensity analysis with exercise suggests vessel-specific pulmonary vascular and right ventricular characteristics unique to pulmonary hypertension phenotypes. These findings highlight wave intensity analysis as a promising tool for advancing understanding of cardiopulmonary pathobiology in pulmonary hypertension.

Davies, R G; Department of Anaesthesia University Hospital of Wales Cardiff UK.
Fiorini, F;Bailey, D M

Anaesthesia reports,2025 Aug 27

Heart failure is a major peri-operative risk factor associated with significant postoperative morbidity and mortality. Traditional biomarkers used in heart failure management include natriuretic peptides. Carbohydrate antigen 125 biomarker is well known to be elevated in ovarian cancer but can also be elevated in heart failure, particularly right-sided heart failure and heart failure with preserved ejection fraction. We report the management of a 71-year-old woman with a presumed diagnosis of ovarian cancer based on imaging and an elevated carbohydrate antigen 125, who underwent cardiopulmonary exercise testing as part of the pre-operative assessment. Exercise testing, despite being sub-maximal, identified significant but asymptomatic heart failure. Surgery was deferred and cardiology-led optimisation resulted in normalisation of her carbohydrate antigen biomarker, refuting her ovarian cancer diagnosis and avoidance of a major intra-abdominal surgery. This case highlights the role of biomarkers, such as carbohydrate antigen 125, in heart failure treatment and the use of exercise testing in heart failure diagnosis and management. Cardiopulmonary exercise testing facilitated the identification of hidden comorbidities leading to better pre-operative risk stratification, optimisation and collaborative decision making.

McMahon, Melissa; Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL.
Holst, Brittany;Ward, Kendra

Medicine & Science in Sports & Exercise,2025Supplement

No abstract available

Kowalski, Tomasz; Institute of Sport, National Research Institute, Warsaw 01-982, Poland.
Kasiak, Przemysław;Chomiuk, Tomasz;Mamcarz, Artur; et al

Translational sports medicine,2025 Aug 20

The present review summarizes findings from the NOODLE (“predictioN mOdels fOr enDurance athLetEs”) study. The research aimed to refine variables obtained during cardiopulmonary exercise testing (CPET) in a large cohort of highly trained endurance athletes by adjusting general reference values and predictive equations to better reflect the unique physiological profiles of this population. Ventilatory efficiency, oxygen uptake efficiency slope, oxygen uptake efficiency plateau, and peak oxygen pulse were analyzed, as they were recently applied in various models concerning risk stratification and treatment optimization. As more people engage in endurance sports, tailored CPET assessments are crucial for accurate performance evaluation and health monitoring. By characterizing differences between general formulas and those suited for endurance athletes, we offered improved tools for optimizing training and ensuring athlete safety. The findings are in line with the existing trend of precision medicine that tailors diagnostics, treatments, and interventions to individual patients’ characteristics. Moreover, we review the recent advances from widely applied CPET-obtained indices, such as maximum oxygen uptake, maximum heart rate, and breathing reserve. We also gave the recommendation for a comprehensive CPET assessment based on the relationships between all of the variables.