Juan Antonio PJ; Regenerative Medicine and Tissue Engineering Laboratory;  Centro Médico Nacional ISSSTE.
Dulce María NO; Juan Antonio SC; Jorge Antonio LV; José Rodolfo AM; Hugo Alberto RA; Eduardo Alfonso LV; Julieta Danira MP; Enrique GÁ; Brenda SJ; Paul MT;

Journal of visualized experiments : JoVE [J Vis Exp] 2023 Sep 22 (199).
Date of Electronic Publication: 2023 Sep 22.

Ischemic heart disease (IHD) represents a group of clinical syndromes characterized by myocardial ischemia, leading to an impairment in the myocardial blood supply and compromised perfusion. Several clinical variables assessed through a stress test, such as oxygen uptake (VO2) and heart rate oxygen pulse (HR/O2), have been attributed as cardiopulmonary prognostic factors in patients with IHD. However, other factors like hydration status (HS), potentially affecting the cardiopulmonary response, have been barely addressed. Unbalanced HS has a short-term effect on plasma volume and the sympathetic nervous system, which impacts blood volume, and lowers VO2 and HR/O2. Recently, bioelectrical impedance analysis (BIA), a method based on the opposition of body tissues (including fluid volume) to a low electrical current, has been widely used to assess HS by obtaining two components: resistance (R) and reactance (Xc) and using prediction formulas. However, several limitations as chronic illness or abnormal fluid status, may affect the results. In this sense, alternative BIA methods, such as bioelectrical impedance vector analysis (BIVA), have become relevant. R and Xc (adjusted by height) result in a vector plotted on the R/Xc graph, which allows interpreting the HS as normal or abnormal according to the distance of the mean vector. This study aims to describe how to determine HS by BIVA using a single-frequency device and compare the results with the cardiopulmonary response in patients with IHD.

Tanaka R; Division of Cardiovascular Rehabilitation, Okayama Heart Clinic, Okayama, Japan.
Waki I; Kamikawa S; Yamashita D; Tabita N; Nishimura S; Higashiya S; Yamaji H; Murakami T; Kusachi S;

Journal of exercise rehabilitation [J Exerc Rehabil] 2023 Oct 25; Vol. 19 (5), pp. 268-274.
Date of Electronic Publication: 2023 Oct 25 (Print Publication: 2023).

Prompt prescription and early initiation of exercise training are essential for patients undergoing elective percutaneous coronary intervention (PCI). We hypothesized that cardiopulmonary exercise testing (CPET) parameters determined the day after elective PCI during hospitalization would not differ from those obtained 1-3 weeks post-PCI in patients with stable coronary heart disease (CHD).
CPET was performed the day after and 1-3 weeks (13±4.6; 7-21 days) after PCI. CPET was performed with a bicycle ergometer up to the ventilatory aerobic threshold (VAT) on the day after PCI. Symptom-limited CPET was conducted 1-3 weeks after PCI. No complications arose from the tests. There were no significant differences in %VAT (next day: 88.6±16.7 vs. 1-3 weeks later: 91.4%±18.7%), the workload at the VAT (51.8±11.0 W vs. 52.9± 11.6 W), heart rate (HR) at the VAT (95.3±105 beats/min vs. 94.1±11.3 beats/min), or metabolic equivalent (METs) at the VAT (3.69±0.69 vs. 3.84±0.78) between the two sessions. The slope of linear regression for two repeated measurements was close to 1 (%VAT, 1.02; workload at the VAT, 0.95; METs at the VAT, 1.03), except for HR (0.70). Bland-Altman plots revealed the reproducibility of all four CPET measurements between the two sessions. In conclusion, CPET up to the VAT can be performed safely 1-day post-PCI in patients with stable CHD. CPET parameters do not significantly differ between testing performed the day after and 1-3 weeks after PCI. Next-day CPET during hospitalization after PCI may enable prompt exercise prescription without the need for another CPET 1-3 weeks later.

Leeman JE; Dana Farber Cancer Institute & Brigham and Women’s Hospital, Boston and Sloan Kettering Cancer Center, New York, NY.
Lapen K; Fuchs HE;Gonen Michalski M; Gillespie EF;Jones LW; McCormick B;

International journal of radiation oncology, biology, physics [Int J Radiat Oncol Biol Phys] 2023 Oct 30.
Date of Electronic Publication: 2023 Oct 30.

Purpose/objectives: Fatigue is among the most common but one of the most poorly understood radiotherapy-associated toxicities. This prospective study sought to investigate whether cardiorespiratory fitness, an integrative measure of whole-body cardiopulmonary function, is associated with patient-reported fatigue among women with early-stage breast cancer undergoing radiotherapy.
Materials/methods: Patients with stage Tis-T2N0M0 breast cancer and an ECOG performance status of 0-1 who were undergoing breast radiotherapy performed a symptom-limited cardiopulmonary exercise test (CPET) on a motorized treadmill to assess cardiorespiratory fitness (VO₂ peak). Fatigue was assessed by the FACIT Fatigue Scale. Both assessments were performed during or immediately after radiotherapy completion. All patients were treated with an opposed tangent technique to a dose of 4240 cGy in 16 fractions with or without a lumpectomy bed boost. Patients receiving cytotoxic chemotherapy were excluded. Pearson’s correlation coefficients and univariate linear regression were used to assess associations between VO₂ peak, fatigue, and patient characteristics.
Results: Twenty-eight patients (median age 52 years, range 31-71) completed both CPET and FACIT assessments. Median VO₂ peak was 25.1 mL O₂ ^. kg ^-1. min ^-1 (range 16.7-41.7). The majority of subjects (78.6%) displayed a VO ₂ peak less than their age-predicted VO₂ peak. Both age and BMI were significantly associated with VO₂ peak levels. Median fatigue score was 41.5 (range 10-52), with lower values indicating more fatigue. VO₂ peak was not associated with FACIT score (p=0.20).
Conclusions: Overall, VO₂ peak was not a significant predictor of radiotherapy-related fatigue. Most breast cancer patients had marked impairments in cardiorespiratory fitness as determined by VO₂ peak. Larger prospective studies are needed to further investigate this novel finding, and to evaluate the effects of interventions aimed at improving cardiorespiratory fitness and their ability to potentially prevent fatigue.

Wenzel C; TU Dortmund University, Germany; and hospitals in Cologne, Dusseldorf, Stuggart and Maastricht
Bongers BC; Schlagheck ML; Reis D; IReinhard F; Schmidt P; Bernitzki S; Oberste M; Wunram HL;
Zimmer P; Fricke O;

European journal of pediatrics [Eur J Pediatr] 2023 Oct 31.
Date of Electronic Publication: 2023 Oct 31.

Endurance training has been shown to be effective in treating adolescents with major depressive disorder (MDD). To integrate endurance training into the therapeutic setting and the adolescents’ daily lives, the current performance status of the adolescents should be accurately assessed. This study aims to examine adolescents with MDD concerning exhaustion criteria during a cardiopulmonary exercise test (CPET), as well as to compare the values obtained thereon with sex- and age-related control values. The study included a retrospective examination of exhaustion criteria ((i) oxygen consumption (V̇O ₂ ) plateau, (ii) peak respiratory exchange ratio (RER _peak ) > 1.0, (iii) peak heart rate (HR _peak ) ≥ 95% of the age-predicted maximal HR, and (iv) peak blood lactate concentration (BLC _peak ) > 8.0 mmol⋅L ^-1 ) during a graded CPET on a cycle ergometer in adolescents with MDD (n = 57). Subsequently, maximal V̇O ₂ , peak minute ventilation, V̇O ₂ at the first ventilatory threshold, and peak work rate of participants who met at least two of four criteria were compared with published control values using an independent-sample t-test. Thirty-three percent of the total population achieved a V̇O ₂ plateau and 75% a RER _peak  > 1.0. The HR and BLC criteria were met by 19% and 22%, respectively. T-test results revealed significant differences between adolescents with MDD and control values for all outcomes. Adolescents with MDD achieved between 56% and 83% of control values.   Conclusions: The study shows that compared with control values, fewer adolescents with MDD achieve the exhaustion criteria on a CPET and adolescents with MDD have significantly lower cardiorespiratory fitness.
Clinical trial registration: No. U1111-1145-1854. What is Known: • It is already known that endurance training has a positive effect on depressive symptoms. What is New: • A relevant proportion of adolescents with major depressive disorder do not achieve their V̇O2max during a graded cardiopulmonary exercise test. • Adolescents with major depressive disorder have significantly lower cardiorespiratory fitness compared to sex- and age-related control values.

Laohachai K; Sydney Medical School, Australia & and other hospitals in Australia
Cordina R; D’Udekem Y; Rice K; Weintraub R; Ayer J;

Open heart [Open Heart] 2023 Nov; Vol. 10 (2).

Background: Peak oxygen pulse (O₂ pulse=oxygen consumption/heart rate) is calculated by the product of stroke volume (SV) and oxygen extraction. It has been shown to be reduced in patients with a Fontan circulation. However, in the Fontan population, it may be a poor marker of SV. We propose that the slope of the O₂ pulse curve may be more reflective of SV during exercise.
Methods: We analysed cardiopulmonary exercise test data in 22 subjects with a Fontan circulation (cohort A) and examined the association between peak SV during exercise (aortic flow measured on exercise cardiac MRI), and O ₂ pulse parameters (absolute O ₂ pulse and O ₂ pulse slopes up to anaerobic threshold (AT) and peak exercise). In a separate Fontan cohort (cohort B, n=131), associations between clinical characteristics and O ₂ pulse kinetics were examined.
Results: In cohort A, peak aortic flow was moderately and significantly associated with O₂ pulseslope ^PEAK (r=0.47, p=0.02). However, neither absolute O₂ pulse ^AT nor O₂ pulse ^PEAK was significantly associated with peak aortic flow. In cohort B, O₂ pulseslope ^PEAK and O₂ pulseslope ^AT were not significantly associated with clinical parameters, apart from a weak association with forced vital capacity.
Conclusion: The slope of the O₂ pulse curve to peak exercise may be more reflective of peak SV in the Fontan population than a single peak O₂ pulse value.

Astley C; Children and Adolescent Institute: University of Sao Paulo, Sao Paulo, Brazil.
Prado DMLD; Sieczkowska SM; Esteves GP; Suguita P; Fink T; Lindoso L; Matsuo O; Martins F; Bain V; Badue MF; Marques HH; Malluf A; Leal G; Silva CA; Roschel H; Gualano B;

Journal of applied physiology (Bethesda, Md. : 1985) [J Appl Physiol (1985)] 2023 Nov 02.
Date of Electronic Publication: 2023 Nov 02.

Purpose: This study aimed to describe cardiopulmonary fitness and endothelial function 6 months after hospital diagnosis in a sample mainly comprising immunocompromised patients with confirmed SARS-Cov-2 infection vs. controls.
Methods: Youth (n=30; 14; 60% females) with confirmed SARS-CoV-2 seen in a tertiary hospital of Sao Paulo, Brazil, were matched by propensity score based on BMI, age, sex and pre-existing diseases with a control group who had not been tested positive for SARS-CoV-2 (n=30; age: 15; 50% females). Cardiopulmonary fitness (by means of a cardiopulmonary exercise test: CPET) and brachial flow-mediated dilation (%b-FMD) were assessed 6 months after diagnosis.
Results: Patients were similar for pre-existing diseases, sex, age and body mass index (all p>.05). Compared with controls, COVID-19 patients showed reduced VAT and peak exercise time (all p>.01), and VE/MVV (p<0.1). Brachial endothelial function variables were all adjust for body surface area (BSA). COVID-19 patients had decreased %b-FMD (3.6 vs. 5.4; p=.03) mean and positive flow (p=.02 and p=.03, respectively) vs. controls. Adjusted linear regression models exploring associations between CPET variables, %b-FMD and the potential predictors post-COVID-19 syndrome, number of symptoms, hospitalization and COVID severity did not detect significant associations, except for total shear rate in hospitalization (Coefficient: -65.07 [95%CI -119.5;-10.5], p=0.02).
Conclusion: In a sample of mainly immunocompromised youth with COVID-19, we found impaired exercise performance and endothelial function. These findings reinforce the need for preventive measures against infection in this vulnerable population and suggest that proper monitoring and treatment for these patients are warranted.

Kosmidis D; AHEPA University Hospital,  Thessaloniki, Greece.
Arvanitaki A; Farmakis IT; Liakos A; Giannopoulos A; Ziakas A; First Giannakoulas G;

Heart (British Cardiac Society) [Heart] 2023 Nov 02.
Date of Electronic Publication: 2023 Nov 02.

Objective: In Fontan circulation, pulmonary arterial hypertension (PAH)-targeted therapies could improve the patients’ exercise capacity. This study aimed to investigate the effects of PAH agents on different exercise parameters in stable Fontan patients by synthesising evidence of randomised controlled trials (RCTs).
Methods: A systematic search of PubMed, Cochrane Central Register of Controlled Trials and Web of Science databases, as well as of ClinicalTrials.gov, was performed. Primary outcomes were specific cardiopulmonary exercise test parameters: peak oxygen uptake (peak VO ₂ ), peak heart rate (peak HR), the minute ventilation/produced carbon dioxide (VE/VCO ₂ ) slope and the oxygen uptake, both measured at the anaerobic threshold (VO ₂ @AT).
Results: Five RCTs were included in the analysis including 573 Fontan patients (mean age 21.2 years, 60% male). PAH-targeted therapies did not affect peak VO ₂ (mean difference (MD) 0.72, 95% CI -0.25 to 1.70) or peak HR (MD -0.67, 95% CI -3.81 to 2.47), but resulted in a small, significant improvement in VO ₂ @AT (standardised MD 0.24, 95% CI 0.02 to 0.47). VE/VCO ₂ slope at the anaerobic threshold was also reduced (MD -1.13, 95% CI -2.25 to -0.01).
Conclusions: Although PAH-targeted therapies did not affect exercise parameters at maximal effort, they induced slight improvements in indices of submaximal effort, measured at the anaerobic threshold. Pharmacological improvement of submaximal exercise seems to be a more suitable indicator of Fontan individuals’ exercise capacity. Larger RCTs, recruiting specific subpopulations and focusing also on the anaerobic threshold, are warranted to draw more robust conclusions.

Stavrou VT;  Faculty of Medicine, University of Thessaly, 41100 Larissa, Greece.
Karetsi E; Gourgoulianis KI;

Children (Basel, Switzerland) [Children (Basel)] 2023 Sep 27; Vol. 10 (10).
Date of Electronic Publication: 2023 Sep 27.

Background: The performance of young swimmers is the result of a multifactorial process that is influenced by anthropometric characteristics and biological maturation. The purpose of our study was to investigate the effect of stages of biological maturation and body surface area on cardiopulmonary fitness indicators in preadolescent female swimmers, for whom menstruation has not started.
Methods: Thirty female preadolescent swimmers (age 13.4 ± 1.0 years) participated in this study. We recorded anthropometric and morphological characteristics, stages of biological maturation, and pulmonary function parameters, and the swimmers underwent cardiopulmonary exercise testing.
Results: The cut-off was set for body surface area (BSA) at 1.6 m ² and for biological maturation stages at score 3. The BSA results showed differences in variabilities in maximal effort oxygen pulse ( p < 0.001), oxygen uptake ( p < 0.001), ventilation ( p = 0.041), tidal volume ( p < 0.001), and oxygen breath ( p < 0.001). Tanner stage score results showed differences in variabilities in maximal effort breath frequency ( p < 0.001), tidal volume ( p = 0.013), and oxygen breath ( p = 0.045). Biological maturation stages and BSA were correlated during maximal effort with oxygen breath ( p < 0.001; p < 0.001), oxygen uptake ( p = 0.002; p < 0.001), and oxygen pulse ( p < 0.001; p < 0.001).
Conclusions: In conclusion, the findings of our study showed that the girls who had a smaller body surface area and biological maturation stage presented lower values in maximal oxygen uptake and greater respiratory work.

Honceriu C; Faculty of Physical Education and Sports, ‘Alexandru-Ioan Cuza’ University, 700115 Iasi, Romania.
Roca M;Costache AD; Abălașei B; Popescu L; Puni AR; Maștaleru A; Oancea A; Drugescu A; ‘, Adam C; Mitu O; , Costache II; Leon MM; Roca IC; ‘Mocanu V;Mitu F;

Medicina (Kaunas, Lithuania) [Medicina (Kaunas)] 2023 Sep 27; Vol. 59 (10).
Date of Electronic Publication: 2023 Sep 27.

Background and Objectives : Cortisol is a valuable marker for assessing the body’s response to any form of stress. We conducted this study in order to evaluate the variations of salivary and serum cortisol levels in professional football players in relation to cardiopulmonary exercise testing (CPET) and their significance in potentially evaluating overtraining in athletes. Also, the question of whether salivary cortisol determination could fully substitute serum sampling was addressed.
Materials and Methods : A total of 19 male professional football players were evaluated by measuring serum cortisol levels at rest (T0) and immediately after a CPET (T1) and salivary cortisol levels at rest (T0), 10 min after a CPET (T2), and 30 min after a CPET (T3).
Results : T0 serum cortisol showed a statistically significant correlation with the oxygen uptake at the anaerobic threshold divided by the body weight (VO ₂ -AT/weight), as did the T2 salivary cortisol with the maximum oxygen uptake at the anaerobic threshold (VO ₂ -AT) and VO ₂ -AT/weight. T0 salivary cortisol was significantly correlated with the subjects’ height and the predicted O ₂ pulse.
Conclusions : While some correlations were discovered, they are insufficient to recommend cortisol as a routine biomarker in athletes’ evaluation. However, significant correlations were established between salivary and serum determinations, meaning that the non-invasive procedure could substitute venous blood sampling.

Garcia Brás P; Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal.
Gonçalves AV; Reis JF; Moreira RI; Pereira-da-Silva T; Rio P; Timóteo AT; Silva S; Soares RM; Ferreira R

Life (Basel, Switzerland) [Life (Basel)] 2023 Sep 29; Vol. 13 (10).
Date of Electronic Publication: 2023 Sep 29.

Background: Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men.
Methods: Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx.
Results: A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO ₂ (pVO ₂ ), VE/VCO ₂ slope and percent of predicted pVO ₂ were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO ₂ ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO ₂ slope > 35, and percent of predicted pVO ₂ ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO ₂ , VE/VCO ₂ slope and percent of predicted pVO ₂ cut-offs in each sex group presented a higher prognostic power than the recommended thresholds.
Conclusion: Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.