Adsett JA; Bowe R; Kelly R; Louis M; Morris N; Hwang R

Journal of cardiopulmonary rehabilitation and prevention [J Cardiopulm Rehabil Prev]
2023 May 01; Vol. 43 (3), pp. 214-219.
Date of Electronic Publication: 2022 Dec 14.

Purpose: The objective of this study was to describe the psychometric properties and physiological response of the five times sit-to-stand (STST-5) and 60-sec sit-to-stand test (STST-60) in adults with heart failure (HF).
Methods: People with HF enrolled in a 12-wk exercise rehabilitation program completed two STST-5 and two STST-60 as part of their usual baseline and follow-up assessments. Test-retest reliability, validity, and responsiveness of the two STSTs were described. Results were correlated with the 6-min walk test (6MWT) and timed up and go test (TUGT), and rating of perceived exertion and physiological responses were compared between all tests. Feasibility was also reported according to the presence of adverse events and adherence to the protocol.
Results: Forty-nine adults with HF participated in this study. Intraclass correlation coefficients of the STST-5 and STST-60 were 0.91 (95% CI, 0.78-0.96) and 0.96 (95% CI, 0.93-0.98), respectively. The STST-60 was strongly associated with both the 6MWT ( r = 0.76) and the TUGT ( rs =-0.77). The STST-5 was strongly associated with the TUGT ( rs = 0.79) and moderately associated with the 6MWT ( rs =-0.70). Rating of perceived exertion and lower limb fatigue were greater in the STST-60 than in the 6MWT ( P < .001) or STST-5 ( P < .001). Adverse events occurred in five participants undertaking the STST-60 and one participant undertaking the STST-5.
Conclusions: The STST-5 and STST-60 are reliable and valid measures of functional exercise capacity in people with HF.

Driver S; Brown KD; Gilliland T; Reynolds M; Bennett M; McShan E; Kim CHJ; Freese E; Belling P; Gottlieb RL;
Jones A;

Proceedings (Baylor University. Medical Center) [Proc (Bayl Univ Med Cent)] 2023 Feb 23; Vol. 36 (3), pp. 318-324. Date of Electronic Publication: 2023 Feb 23 (Print Publication: 2023).

Wearing a cloth face mask has been shown to impair exercise performance; it is essential to understand the impact wearing a cloth face mask may have on cognitive performance. Participants completed two maximal cardiopulmonary exercise tests on a cycle ergometer (with and without a cloth face mask) with a concurrent cognitive task. Blood pressure, heart rate, oxygen saturation, perceived exertion, shortness of breath, accuracy, and reaction time were measured at rest, during each exercise stage, and following a 4-minute recovery period. The final sample included 35 adults (age = 26.1 ± 5.8 years; 12 female/23 male). Wearing a cloth face mask was associated with significant decreases in exercise duration (-2:00 ± 3:40 min, P  = 0.003), peak measures of maximal oxygen uptake (-818.9 ± 473.3 mL/min, -19.0 ± 48 mL·min ^-1 ·kg ^-1 , P  < 0.001), respiratory exchange ratio (-0.04 ± 0.08, P  = 0.005), minute ventilation (-36.9 ± 18 L/min), oxygen pulse (-3.9 ± 2.3, P  < 0.001), heart rate (-7.9 ± 12.6 bpm, P  < 0.001), oxygen saturation (-1.5 ± 2.8%, P  = 0.004), and blood lactate (-1.7 ± 2.5 mmol/L, P  < 0.001).
While wearing a cloth face mask significantly impaired exercise performance during maximal exercise testing, cognitive performance was unaffected in this selected group of young, active adults.
Competing Interests: This study was funded by the BSW Foundation.

Singh I; Leitner BP; Wang Y; Zhang H; Joseph P; Lutchmansingh DD; Gulati M; Possick JD; Damsky W; Heerdt PM;
Chun HJ;

Pulmonary circulation [Pulm Circ] 2023 Apr 01; Vol. 13 (2), pp. e12220.
Date of Electronic Publication: 2023 Apr 01 (Print Publication: 2023).

Approximately 50% of patients who recover from the acute SARS-CoV-2 experience Post Acute Sequelae of SARS-CoV-2 infection (PASC) syndrome. The pathophysiological hallmark of PASC is characterized by impaired system oxygen extraction (EO ₂ ) on invasive cardiopulmonary exercise test (iCPET). However, the mechanistic insights into impaired EO ₂ remain unclear. We studied 21 consecutive iCPET in PASC patients with unexplained exertional intolerance. PASC patients were dichotomized into mildly reduced (EO ₂ peak-mild) and severely reduced (EO ₂ peak-severe) EO ₂ groups according to the median peak EO ₂ value. Proteomic profiling was performed on mixed venous blood plasma obtained at peak exercise during iCPET. PASC patients as a group exhibited depressed peak exercise aerobic capacity (peak VO ₂ ; 85 ± 18 vs. 131 ± 45% predicted; p  = 0.0002) with normal systemic oxygen delivery, DO ₂ (37 ± 9 vs. 42 ± 15 mL/kg/min; p  = 0.43) and reduced EO ₂ (0.4 ± 0.1 vs. 0.8 ± 0.1; p  < 0.0001). PASC patients with EO ₂ peak-mild exhibited greater DO ₂ compared to those with EO ₂ peak-severe [42.9 (34.2-41.2) vs. 32.1 (26.8-38.0) mL/kg/min; p  = 0.01]. The proteins with increased expression in the EO ₂ peak-severe group were involved in inflammatory and fibrotic processes. In the EO ₂ peak-mild group, proteins associated with oxidative phosphorylation and glycogen metabolism were elevated. In PASC patients with impaired EO2, there exist a spectrum of PASC phenotype related to differential aberrant protein expression and cardio-pulmonary physiologic response. PASC patients with EO ₂ peak-severe exhibit a maladaptive physiologic and proteomic signature consistent with persistent inflammatory state and endothelial dysfunction, while in the EO ₂ peak-mild group, there is enhanced expression of proteins involved in oxidative phosphorylation-mediated ATP synthesis along with an enhanced cardiopulmonary physiological response.

Edwards T; Tas E; Leclerc K; Børsheim E;

Frontiers in pediatrics [Front Pediatr] 2023 Apr 06; Vol. 11, pp. 1103094.
Date of Electronic Publication: 2023 Apr 06 (Print Publication: 2023).

Noninvasive cardiopulmonary exercise testing (CPET) provides the valuable capacity to analyze pulmonary gas exchange and cardiovascular responses that can be used to differentiate normal cardiopulmonary responses from abnormal. This case report highlights a proposed role for CPET in identifying potential cardiac pathologies in at-risk adolescents. An abnormal CPET response in an asymptomatic adolescent revealed a family history of early-age CAD. The significance of the abnormal CPET response was further supported by the presence of an elevated concentration of circulating high sensitivity C-reactive protein (hs-CRP). These findings emphasize the importance of a thorough clinical evaluation in at-risk adolescents, as CPET can aid in the early detection and management of cardiac pathologies, especially when combined with other relevant biomarkers such as plasma hs-CRP concentration, which can further suggest underlying pathology. Management considerations using serial CPET evaluations are recommended. Thus, CPET abnormalities combined with elevated hs-CRP should be taken seriously and provide justification for further evaluation and monitoring in adolescents at risk for cardiovascular disease.

Chung JH; Tsai YJ; Lin KL; Huang MH; Chen GB; Tuan SH;

Journal of cardiovascular development and disease [J Cardiovasc Dev Dis] 2023 Apr 13; Vol. 10 (4).
Date of Electronic Publication: 2023 Apr 13.

ndividuals with mitral valve prolapse (MVP) have exercise intolerance even without mitral valve regurgitation. Mitral valve degeneration may progress with aging. We aimed to evaluate the influence of MVP on the cardiopulmonary function (CPF) of individuals with MVP through serial follow-ups from early to late adolescence. Thirty patients with MVP receiving at least two cardiopulmonary exercise tests (CPETs) using a treadmill (MVP group) were retrospectively analyzed. Age-, sex-, and body mass index-matched healthy peers, who also had serial CPETs, were recruited as the control group. The average time from the first CPET to the last CPET was 4.28 and 4.06 years in the MVP and control groups, respectively. At the first CPET, the MVP group had a significantly lower peak rate pressure product (PRPP) than the control group ( p = 0.022). At the final CEPT, the MVP group had lower peak metabolic equivalent (MET, p = 0.032) and PRPP ( p = 0.031). Moreover, the MVP group had lower peak MET and PRPP as they aged, whereas healthy peers had higher peak MET ( p = 0.034) and PRPP ( p = 0.047) as they aged. Individuals with MVP had poorer CPF than healthy individuals as they develop from early to late adolescence. It is important for individuals with MVP to receive regular CPET follow-ups.

Das BB;

Journal of cardiovascular development and disease [J Cardiovasc Dev Dis] 2023 Apr 19; Vol. 10 (4).
Date of Electronic Publication: 2023 Apr 19.

Cardiopulmonary exercise testing (CPET) is the clinical standard for children with congenital heart disease (CHD), heart failure (HF) being assessed for transplantation candidacy, and subjects with unexplained dyspnea on exertion. Heart, lung, skeletal muscle, peripheral vasculature, and cellular metabolism impairment frequently lead to circulatory, ventilatory, and gas exchange abnormalities during exercise. An integrated analysis of the multi-system response to exercise can be beneficial for differential diagnosis of exercise intolerance. The CPET combines standard graded cardiovascular stress testing with simultaneous ventilatory respired gas analysis. This review addresses the interpretation and clinical significance of CPET results with specific reference to cardiovascular diseases. The diagnostic values of commonly obtained CPET variables are discussed using an easy-to-use algorithm for physicians and trained nonphysician personnel in clinical practice.

Neder JA;

Respiratory medicine [Respir Med] 2023 Apr 24, pp. 107249.
Date of Electronic Publication: 2023 Apr 24.

Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O ₂ uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate (“anaerobic”) threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO ₂ output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea “quantity” and “quality”. Based on a conceptual framework that links exertional dyspnoea to “excessive” and/or “restrained” breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.

Pizzuto DA; Buonsenso D; Morello R; De Rose C; Valentini P; Fragano A; Baldi F; Di Giuda D;

Pediatric pulmonology [Pediatr Pulmonol] 2023 Apr 25.
Date of Electronic Publication: 2023 Apr 25.

Background: There is increasing evidence that chronic endotheliopathy can play a role in patients with Post-Covid Condition (PCC, or Long Covid) by affecting peripheral vascularization. This pilot study aimed at assessing lung perfusion in children with Long-COVID with ^99m Tc-MAA SPECT/CT.
Materials and Methods: lung ^99m Tc-MAA SPECT/CT was performed in children with Long-COVID and a pathological cardiopulmonary exercise testing (CPET). Intravenous injections were performed on patients in the supine position immediately before the planar scan according to the EANM guidelines for lung scintigraphy in children, followed by lung SPECT/CT acquisition. Reconstructed studies were visually analyzed.
Results: Clinical and biochemical data were collected during acute infection and follow-up in 14 children (6 females, mean age: 12.6 years) fulfilling Long-COVID diagnostic criteria and complaining of chronic fatigue and postexertional malaise after mild efforts, documented by CPET. Imaging results were compared with clinical scenarios during acute infection and follow-up. Six out of 14 (42.8%) children showed perfusion defects on ^99m Tc-MAA SPECT/CT scan, without morphological alterations on coregistered CT.
Conclusions: This pilot investigation confirmed previous data suggesting that a small subgroup of children can develop lung perfusion defects after severe acute respiratory syndrome coronavirus 2 infection. Larger cohort studies are needed to confirm these preliminary results, providing also a better understanding of which children may deserve this test and how to manage those with lung perfusion defects.

Hager, A; (Editorial)

 JACC; Volume 81, Issue 16, 25 April 2023, Pages 1601-1604

Infants with univentricular heart have only a single ventricle and initially a parallel circulation. The mixed blood of the single ventricle serves both the pulmonary circulation and the systemic circulation. Most patients nowadays get a palliation into a serial circulation according to the Fontan principle: the central venous blood bypasses the right ventricle into the pulmonary arteries. The staged Fontan palliation is performed, with a first stage within the first weeks of age stabilizing the parallel circulation, a second-stage in infancy with a superior cavopulmonary anastomosis and a third stage in early childhood with the completion by an inferior cavopulmonary anastomosis. Up to the third stage, there is still a substantial mortality depending on the details of the primary heart defect. At and after the third stage, there is only a minimal mortality throughout childhood, and most of these patients reach adulthood……etc.

Joseph P; Singh I; Oliveira R; Capone CA; Mullen MP; Cook DB; Stovall MC; Squires J; Madsen K; Waxman AB; Systrom DM;

Chest [Chest] 2023 Apr 11.
Date of Electronic Publication: 2023 Apr 11.

Topic Importance: Post-Acute Sequelae of SARS-CoV-2 (PASC) is a long-term consequence of acute infection from coronavirus disease 2019 (COVID-19). Clinical overlap between PASC and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) has been observed, with shared symptoms including intractable fatigue, postexertional malaise, and orthostatic intolerance. The mechanistic underpinnings of such symptoms are poorly understood.
Review Findings: Early studies suggest deconditioning as the primary explanation for exertional intolerance in PASC. Cardiopulmonary exercise testing (CPET) reveals perturbations related to systemic blood flow and ventilatory control associated with acute exercise intolerance in PASC, which are not typical of simple detraining. Hemodynamic and gas exchange derangements in PASC have substantial overlap with those observed with ME/CFS, suggestive of shared mechanisms.
Summary: This review aims to illustrate exercise pathophysiologic commonalities between PASC and ME/CFS that will help guide future diagnostics and treatment.