Author Archives: Paul Older

Gass R; Hospital de Clínicas de Porto Alegre (HCPA), Brasil.
Plachi F; Silva FOB; Nolasco T; Tonetto MS; Goelzer LS; Muller PT; Knorst MM; Neder JA; Berton DC;

Respiratory physiology & neurobiology [Respir Physiol Neurobiol] 2024 Oct 08, pp. 104359.
Date of Electronic Publication: 2024 Oct 08.

Excess exercise ventilation (high ventilation (V̇ _E )/carbon dioxide output (V̇CO ₂ )) contributes significantly to dyspnea and exercise intolerance since the earlier stages of chronic obstructive pulmonary disease (COPD). A selective pulmonary vasodilator (inhaled nitric oxide) has shown to increase exercise tolerance secondary to lower V̇ _E /V̇CO ₂ and dyspnea in patients with early COPD. We aimed to assess whether a clinically more practical option – oral sildenafil – would be associated with similar beneficial effects. In a randomized, placebo-controlled study, twenty-four patients with mild-to-moderate COPD completed, on different days, two incremental cardiopulmonary exercise tests (CPET) one hour after sildenafil or placebo. Eleven healthy participants performed a CPET in a non-interventional visit for comparative purposes with patients when receiving placebo. Patients (FEV ₁ = 69.4 ± 13.5% predicted) showed higher ventilatory demands (V̇ _E /V̇CO ₂ ), worse pulmonary gas exchange, and higher dyspnea during exercise compared to controls (FEV ₁ = 98.3 ±11.6% predicted). Contrary to our expectations, however, sildenafil (50mg; N= 15) did not change exertional V̇ _E /V̇CO ₂ , dead space/tidal volume ratio, operating lung volumes, dyspnea, or exercise tolerance compared to placebo (P>0.05). Due to the lack of significant beneficial effects, nine additional patients were trialed with a higher dose (100mg). Similarly, active intervention was not associated with positive physiological or sensory effects. In conclusion, acute oral sildenafil (50 or 100mg) failed to improve gas exchange efficiency or excess exercise ventilation in patients with predominantly moderate COPD. The current study does not endorse a therapeutic role for sildenafil to mitigate exertional dyspnea in this specific patient subpopulation.

Exercise testing in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve intervention.

Gerçek M; Clinic for General and Interventional Cardiology/Angiology, Bad Oeynhausen, Germany.
Goncharov A; Gerçek M; Mörsdorf M; Kirchner J; Rudolph F; Rudolph TK;Rudolph V; Friedrichs KP; Dumitrescu D;

Clinical research in cardiology : official journal of the German Cardiac Society [Clin Res Cardiol] 2024 Oct 09.
Date of Electronic Publication: 2024 Oct 09.

Background: Transcatheter tricuspid valve intervention (TTVI) has shown promising results with persistent reduction of tricuspid regurgitation (TR) and improvements in functional class and quality of life (QOL).
Objectives: To analyze the impact of TTVI on maximal and submaximal exercise capacity (SEC).
Methods: Constant work-rate exercise-time (CWRET) testing reflects SEC, which is more likely to be relevant for daily life activities and provides more differentiated physiological insight into the nature of exercise intolerance. Thus, 30 patients undergoing TTVI (21 direct annuloplasty and 9 edge-to-edge repair) received cardiopulmonary exercise testing (CPET) and CWRET (at 75% of maximum work rate in the initial CPET) before and 3 months after TTVI.
Results: Patients’ age was 80.5 [74.8-82.3] years and 53.3% were female. TR reduction ≥ 2 grades was achieved in 93.3% (TR grade ≤ moderate in 83.3%). Echocardiography revealed improved right ventricular (RV) characteristics with decreased RV basal diameter (47.0 mm [43.0-54.3] vs. 41.5 mm [36.8-48.0]; p < 0.001) and decreased inferior caval vein diameter. CWRET testing showed a significantly improved SEC (246.5 s [153.8-416.8] vs. 338.5 s [238.8-611.8] p = 0.001). Maximum oxygen uptake showed a positive trend without statistically significant differences (9.9 ml/min/kg [8.6-12.4] vs. 11.7 ml/min/kg [9.7-13.3]; p = 0.31). In contrast to the six-minute-walking distance (6MWD), SEC correlated moderately with effective regurgitation orifice area reduction (r = 0.385; p = 0.036), increased cardiac output (r = 0.378; p = 0.039), and improved QOL (r = 387; p = 0.035).
Conclusion: Improvements in exercise capacity after TTVI mainly occur in the submaximal rather than in the maximal exercise range and correlate with hemodynamic effects and QOL. This may have a methodological impact on assessment of exercise capacity in these patients.

Noninvasive diagnostic modalities and prediction models for detecting pulmonary hypertension associated with interstitial lung disease: a narrative review.

Arvanitaki A; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK.;
Diller GP; Gatzoulis MA; McCabe C; Price LC

European respiratory review : an official journal of the European Respiratory Society [Eur Respir Rev] 2024 Oct 09; Vol. 33 (174).
Date of Electronic Publication: 2024 Oct 09 (Print Publication: 2024).

Pulmonary hypertension (PH) is highly prevalent in patients with interstitial lung disease (ILD) and is associated with increased morbidity and mortality. Widely available noninvasive screening tools are warranted to identify patients at risk for PH, especially severe PH, that could be managed at expert centres. This review summarises current evidence on noninvasive diagnostic modalities and prediction models for the timely detection of PH in patients with ILD. It critically evaluates these approaches and discusses future perspectives in the field. A comprehensive literature search was carried out in PubMed and Scopus, identifying 39 articles that fulfilled inclusion criteria. There is currently no single noninvasive test capable of accurately detecting and diagnosing PH in ILD patients. Estimated right ventricular pressure (RVSP) on Doppler echocardiography remains the single most predictive factor of PH, with other indirect echocardiographic markers increasing its diagnostic accuracy. However, RVSP can be difficult to estimate in patients due to suboptimal views from extensive lung disease. The majority of existing composite scores, including variables obtained from chest computed tomography, pulmonary function tests and cardiopulmonary exercise tests, were derived from retrospective studies, whilst lacking validation in external cohorts. Only two available scores, one based on a stepwise echocardiographic approach and the other on functional parameters, predicted the presence of PH with sufficient accuracy and used a validation cohort. Although several methodological limitations prohibit their generalisability, their use may help physicians to detect PH earlier. Further research on the potential of artificial intelligence may guide a more tailored approach, for timely PH diagnosis.
Competing Interests: Conflict of interest: A. Arvanitaki, M.A. Gatzoulis and C. McCabe declare no conflicts of interest relevant to this work. G.P. Diller has received honoraria and travel grants from Janssen Global. L.C. Price has received consultancy fees from Janssen and educational support and conference support from Janssen and Ferrer. S.J. Wort has received consultancy fees from Janssen, Acceleron, MSD, Ferrer and Bayer, honoraria from Janssen, Acceleron, MSD, Ferrer and Bayer, as well as travel and research grants from Janssen and Ferrer.

Cardiopulmonary exercise testing following acute pulmonary embolism: Systematic review and pooled analysis of global studies.

VanAken G; Department of Internal Medicine University of Michigan Ann Arbor Michigan USA.
Wieczorek D; Rubick D; Jabri A; Franco-Palacios D; Grafton G; Kelly B; Osinbowale O; Ahsan ST; Awdish R; Aronow HD; Shore S; Aggarwal V

Pulmonary circulation [Pulm Circ] 2024 Oct 10; Vol. 14 (4), pp. e12451.
Date of Electronic Publication: 2024 Oct 10 (Print Publication: 2024).

Recent reports have revealed a substantial morbidity burden associated with “post-PE syndrome” (PPES). Cardiopulmonary exercise testing (CPET) has shown promise in better characterizing these patients. In this systematic review and pooled analysis, we aim to use CPET data from PE survivors to understand PPES better. A literature search was conducted in PubMed, EMBASE, and Cochrane for studies reporting CPET results in post-PE patients without known pulmonary hypertension published before August 1, 2023. Studies were independently reviewed by two authors. CPET findings were subcategorized into (1) exercise capacity (percent predicted pVO ₂ and pVO ₂ ) and (2) ventilatory efficiency (VE/VCO ₂ slope and V _D /V _T ). We identified 14 studies ( n = 804), 9 prospective observational studies, 4 prospective case-control studies, and 1 randomized trial. Pooled analysis demonstrated a weighted mean percent predicted pVO ₂ of 76.09 ± 20.21% ( n = 184), with no difference between patients tested <6 months ( n = 76, 81.69±26.06%) compared to ≥6 months post-acute PE ( n = 88, 82.55 ± 21.47%; p = 0.817). No difference was seen in pVO ₂ in those tested <6 months ( n = 76, 1.67 ± 0.51 L/min) compared to ≥6 months post-acute PE occurrence ( n = 144, 1.75 ± 0.57 L/min; p = 0.306). The weighted mean VE/VCO ₂ slope was 32.72 ± 6.02 ( n = 244), with a significant difference noted between those tested <6 months ( n = 91, 36.52 ± 6.64) compared to ≥6 months post-acute PE ( n = 191, 31.99 ± 5.7; p < 0.001). In conclusion, this study, which was limited by small sample sizes and few multicenter studies, found no significant difference in exercise capacity between individuals tested <6 months versus ≥6 months after acute PE. However, ventilatory efficiency was significantly improved in patients undergoing CPET ≥ 6 months compared to those <6 months from the index PE.

Cardiopulmonary exercise testing following acute pulmonary embolism: Systematic review and pooled analysis of global studies

October 20, 2024

Gabriella VanAken University of Michigan Ann Arbor Michigan USA.
Daniel Wieczorek , Drew Rubick, Ahmad Jabri, Domingo Franco-Palacios , Gillian Grafton, Bryan Kelly, Olusegun Osinbowale , Syed T Ahsan, Rana Awdish , Herbert D Aronow Supriya Shore, Vikas Aggarwal

Pulm Circ 2024 Oct 10;14(4):

Recent reports have revealed a substantial morbidity burden associated with “post-PE syndrome” (PPES). Cardiopulmonary exercise testing (CPET) has shown promise in better characterizing these patients. In this systematic review and pooled analysis, we aim to use CPET data from PE survivors to understand PPES better. A literature search was conducted in PubMed, EMBASE, and Cochrane for studies reporting CPET results in post-PE patients without known pulmonary hypertension published before August 1, 2023. Studies were independently reviewed by two authors. CPET findings were subcategorized into (1) exercise capacity (percent predicted pVO₂ and pVO₂) and (2) ventilatory efficiency (VE/VCO₂ slope and V_D/V_T). We identified 14 studies (n = 804), 9 prospective observational studies, 4 prospective case-control studies, and 1 randomized trial. Pooled analysis demonstrated a weighted mean percent predicted pVO₂ of 76.09 ± 20.21% (n = 184), with no difference between patients tested <6 months (n = 76, 81.69±26.06%) compared to ≥6 months post-acute PE (n = 88, 82.55 ± 21.47%; p = 0.817). No difference was seen in pVO₂ in those tested <6 months (n = 76, 1.67 ± 0.51 L/min) compared to ≥6 months post-acute PE occurrence (n = 144, 1.75 ± 0.57 L/min; p = 0.306). The weighted mean VE/VCO₂ slope was 32.72 ± 6.02 (n = 244), with a significant difference noted between those tested <6 months (n = 91, 36.52 ± 6.64) compared to ≥6 months post-acute PE (n = 191, 31.99 ± 5.7; p < 0.001).
In conclusion, this study, which was limited by small sample sizes and few multicenter studies, found no significant difference in exercise capacity between individuals tested <6 months versus ≥6 months after acute PE. However, ventilatory efficiency was significantly improved in patients undergoing CPET ≥ 6 months compared to those <6 months from the index PE.

Investigation of exertional dyspnoea by cardiopulmonary exercise testing with continuous laryngoscopy

October 19, 2024

Melanie Wong, Clinical Immunology Service, Alfred Health, Australia.
Logan Gardner, Eve Denton, Brigitte M Borg, Mahesh Dharmakumara, Janine Mahoney, Janet Bondarenko, Fiona Hore-Lacy, Tiffany Lin, Asger Sverrild, Mark Hew, Joy Lee

J Sci Med Sport 2024 Sep 28

Objectives: Abnormal breathlessness at maximal exercise may be caused by a range of conditions, including exercise-induced bronchospasm, breathing pattern disorder, or exercise-induced laryngeal obstruction. These three disorders may not be detected on standard cardiopulmonary exercise testing. The aim of this study was to describe diagnostic outcomes of an expanded protocol during cardiopulmonary exercise testing.
Design: Retrospective cohort study.
Methods: Patients presenting with abnormal breathlessness on maximal exercise underwent continuous laryngoscopy with cardiopulmonary exercise testing on a stationary cycle ergometer. Breathing pattern disorder was evaluated by video and ventilatory data. Pre- and post-exercise spirometry was performed.
Results: 24 adult patients were evaluated; 10 were professional athletes. Mean age was 40 years (range 18-73). Nine of 24 (38 %) were diagnosed with exercise-induced laryngeal obstruction and referred for speech pathology. Six of these had supraglottic exercise-induced laryngeal obstruction; all were aged <30 years; 5/6 were professional athletes. One patient had breathing pattern disorder and was referred for physiotherapy; one had exercise-induced bronchospasm, requiring escalation of asthma medication; one had muscle tension dysphonia resulting in referral to an otolaryngologist who administered a laryngeal injection of botulinum toxin. A further four patients had unexplained lower maximal oxygen consumption with cardiac limitation and were referred for further cardiac investigation.
Conclusions: In patients reporting abnormal breathlessness at maximal exercise, this expanded exercise protocol provided diagnostic information in 66.7 % cases which contributed to further personalised management.

Determinants of Longitudinal Changes in Exercise Capacity in Patients with Independent Functioning on Hemodialysis

October 19, 2024

Naoto Usui ; Kisen Hospital, Tokyo, Japan.
Junichiro Nakata, Akimi Uehata, Sho Kojima, Hideki Hisadome, Akihito Inatsu, Atsuhiro Tsubaki, Masakazu Saitoh, Shuji Ando, Tatsuro Kitayama, Kenta Maikusa, Yuki Nishiyama, Yusuke Suzuki

Phys Ther 2024 Oct 18: page147

Objective: Patients with chronic kidney disease reportedly have decreased muscle oxygen utilization, which most substantially decreases exercise capacity, followed by cardiac reserve. However, determinants of longitudinal changes in exercise capacity in patients on hemodialysis and the effects of long-term exercise interventions are unknown. This study was conducted to clarify these concerns.
Methods: This was a prospective cohort study. Patients on hemodialysis that were not hospitalized were followed from baseline up to 2 years, and cardiopulmonary exercise testing results, including peak oxygen uptake, peak work rate, heart rate reserve, and ventilatory equivalent for carbon dioxide slope, as well as implementation of exercise interventions were assessed. Based on the 2-year change in peak oxygen uptake, they were divided into improvement or declined groups.
Results: Forty-five patients who were not hospitalized completed the follow-up were analyzed. In the improvement group, the variation was determined by an increase in peak work rate, which is a peripheral factor (partial regression coefficient 0.08 [95% CI = 0.01 to 0.16]), while in the decline group, the variation was determined by a decrease in the ventilatory equivalent for carbon dioxide slope, which is a cardiac factor (partial regression coefficient = -0.12; 95% CI = -0.21 to -0.03). Moreover, exercise intervention was associated with the change in peak oxygen uptake (partial regression coefficient = 3.09; 95% CI = 1.45 to 4.72).
Conclusion: Exercise intolerance even in patients on hemodialysis that were not hospitalized and stable progressed over time with deterioration of cardiac reserve, whereas exercise interventions were associated with improved exercise capacity through enhanced peripheral function.
Impact: The results support the early measurement of cardiopulmonary or skeletal muscle reserve through cardiopulmonary exercise testing and the implementation of long-term exercise interventions based on the measurement results to address the potential deterioration in exercise capacity associated with reduced cardiac reserve, even in patients on hemodialysis that are asymptomatic and stable.

Comparisons of percent-predicted peak oxygen uptake achieved on cardiopulmonary exercise testing: stratifying mortality risk by Wasserman, FRIEND, and Brazilian equations.

October 18, 2024

Braga F; Humaita, Rio de Janeiro, RJ, Brazil.
Milani M; Espinosa G; Milani JGPO; Hansen D; Junior GC; Myers J;
Mourilhe-Rocha R

European Journal of Preventive Cardiology. 31(14):1734-1737, 2024 Oct 10.

No abnstract available

Sex-specific differences of cardiopulmonary fitness and pulmonary function in exercise-based rehabilitation of patients with long-term post-COVID-19 syndrome.

October 18, 2024