Kunutsor SK; Khan H; Seidu S; Laukkanen JA

Journal of cardiopulmonary rehabilitation and prevention [J Cardiopulm Rehabil Prev] 2022 Aug 04.
Date of Electronic Publication: 2022 Aug 04.

Purpose: There are inverse and independent associations between cardiorespiratory fitness (CRF) and several adverse cardiometabolic outcomes. The percentage of age-predicted CRF (%age-predicted CRF) is comparable to absolute CRF as a risk indicator for some of these outcomes, but the association between %age-predicted CRF and risk of type 2 diabetes (T2D) has not been previously investigated. We aimed to assess the association between %age-predicted CRF and T2D in a prospective cohort study.
Methods: Cardiorespiratory fitness, as measured directly by peak oxygen uptake, was assessed in 1901 men aged 42-60 yr who underwent cardiopulmonary exercise testing. The age-predicted CRF estimated from a regression equation for age was converted to %age-predicted CRF using (achieved CRF/age-predicted CRF) × 100. Hazard ratios (95% CI) were estimated for T2D.
Results: During a median follow-up of 26.8 yr, 227 T2D cases were recorded. The risk of T2D decreased continuously with increasing %age-predicted CRF (P value for nonlinearity = .30). A 1-SD increase in %age-predicted CRF was associated with a decreased risk of T2D in analysis adjusted for established risk factors (HR = 0.68: 95% CI, 0.59-0.79). The corresponding adjusted risk was (HR = 0.51: 95% CI, 0.35-0.75) comparing extreme tertiles of %age-predicted CRF. The respective estimates for the association between absolute CRF and T2D were-HR (95% CI)-0.71 (0.60-0.83) and 0.64 (0.44-0.95).
Conclusions: Percentage of age-predicted CRF is linearly, inversely, and independently associated with the risk of incident T2D and may be a stronger risk indicator for T2D compared to absolute CRF in a general population of middle-aged and older men.

de Almeida VR; di Paschoale Ostolin TLV; de Barros Gonze B; de Almeida FR; Romiti M; Arantes RL; Dourado VZ;

International journal of cardiology [Int J Cardiol] 2022 Aug 06.
Date of Electronic Publication: 2022 Aug 06.

Background: Individuals with cardiovascular exercise limitations present oxygen pulse morphology with early flattening (plateau) during the cardiopulmonary exercise test (CPET). Although this oxygen pulse response is well known in cardiac patients, these changes’ prevalence and clinical relevance in asymptomatic individuals are not known. We aimed to quantify the proportion of asymptomatic adults with an early flattening of the oxygen pulse and investigate its association with classical cardiovascular risk factors.
Methods: We carried out a cross-sectional study with a sample of 824 adults aged between 18 and 80 years. We assessed anthropometry, body composition, and cardiovascular risk. In addition, we obtained cardiorespiratory and metabolic responses during a ramp protocol treadmill CPET.
Results: The prevalence of early flattening of the oxygen pulse was 36.8%. These participants were predominantly females, older, less educated, with a higher body mass and percentage of fat and a lower percentage of lean body mass. After a multinominal multiple logistic regression analysis, we identified female sex (odds ratio, 5.46: 95% confidence interval, 3.73-7.99), low education (2.24: 1.47-3.42), dyslipidemia (1.67: 1.14-2.45), smoking (1.64: 1.00-2.69), and physical inactivity (1.39: 1.02-1.96) as the leading independent predictors of the early flattening of oxygen pulse.
Conclusion: The early flattening of oxygen pulse is common in asymptomatic adults and is highly determined by modifiable cardiovascular risk factors. These results suggest that identifying the early flattening of oxygen pulse may be helpful in the prevention of cardiovascular diseases.

Carlen A; Eklund G; Andersson A; Carlhall C: Ekstrom M; Hedman K

Journal of Cardiovascular Development and Disease: Volume 9. Issue 7. 2022

Work rate has a direct impact on the systolic blood pressure (SBP) during aerobic exercise, which may be challenging in the evaluation of the SBP response in athletes reaching high work rates. We aimed to investigate the exercise SBP response in endurance athletes in relation to oxygen uptake (VO₂), work rate and to recent reference equations for exercise SBP in the general population. Endurance athletes with a left-ventricular end-diastolic diameter above the reference one performed a maximal bicycle cardiopulmonary exercise test. The increase in SBP during exercise was divided by the increase in VO₂ (SBP/VO₂ slope) and in Watts, respectively (SBP/W slope). The maximum SBP (SBP_max) and the SBP/W slope were compared to the predicted values. In total, 27 athletes (59% men) were included; mean age, 40 ± 10 years; mean VO_2max, 50 ± 5 mL/kg/min. The mean SBP/VO₂ slope was 29.8 ± 10.2 mm Hg/L/min, and the mean SBP/W slope was 0.27 ± 0.08 mm Hg/W. Compared to the predicted normative values, athletes had, on average, a 12.2 ± 17.6 mm Hg higher SBP_max and a 0.12 ± 0.08 mm Hg/W less steep SBP/W slope (p < 0.01 and p < 0.001, respectively). In conclusion, the higher SBP_max values and the less steep SBP/W slope highlight the importance of considering work rate when interpreting the SBP response in endurance athletes and suggest a need for specific normative values in athletes to help clinicians distinguish physiologically high maximal blood pressure from a pathological blood pressure response.

Hedman K; Hylander J; Mikios B; Fyrenius A

Journal of Thoracic & Cardiovascular Surgery: July 1 2022

Objective
We aimed to evaluate whether or not using the slope of the increase in minute ventilation in relation to carbon dioxide (VE/VCo2-slope), with a cutoff value of 35, could improve risk stratification for major pulmonary complications or death following lobectomy in lung cancer patients at moderate risk (Vo2peak = 10-20 mL/kg/min).
Methods
Single center, retrospective analysis of 146 patients with lung cancer who underwent lobectomy and preoperative cardiopulmonary exercise testing in 2008-2020. The main outcome was any major pulmonary complication or death within 30 days of surgery. Patients were categorized based on their preoperative cardiopulmonary exercise testing as: low-risk group, peak oxygen uptake >20 mL/kg/min; low-moderate risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope <35; and moderate-high risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope ≥35. The frequency of complications between groups was compared using χ2 test. Logistic regression was used to calculate the odds ratio with 95% CI for the main outcome based on the cardiopulmonary exercise testing group.
Results
Overall, 25 patients (17%) experienced a major pulmonary complication or died (2 deaths). The frequency of complications differed between the cardiopulmonary exercise testing groups: 29%, 13%, and 8% in the moderate-high, low-moderate, and low-risk group, respectively (P = .023). Using the low-risk group as reference, the adjusted odds ratio for the low-moderate risk group was 3.44 (95% CI, 0.66-17.90), whereas the odds ratio for the moderate-high risk group was 8.87 (95% CI, 1.86-42.39).
Conclusions
Using the VE/VCo2-slope with a cutoff value of 35 improved risk stratification for major pulmonary complications following lobectomy in lung cancer patients with moderate risk based on a peak oxygen uptake of 10 to 20 mL/kg/min. This suggests that the VE/VCo2-slope can be used for preoperative risk evaluation in lung cancer lobectomy.

• Silvapulle E; Darvall J;

R. F. W. Franssen; A. J. J. Eversdijk; M. Kuikhoven; J. M. Klaase; F. J. Vogelaar; M. L. G. Janssen-Heijnen;

BMC Anesthesiol 2022 Vol. 22 Issue 1 Pages 131

BACKGROUND: Accurate determination of cardiopulmonary exercise test (CPET) derived parameters is essential to allow for uniform preoperative risk assessment. The objective of this prospective observational study was to evaluate the inter-observer agreement of preoperative CPET-derived variables by comparing a self-preferred approach with a systematic guideline-based approach.
METHODS: Twenty-six professionals from multiple centers across the Netherlands interpreted 12 preoperative CPETs of patients scheduled for hepatopancreatobiliary surgery. Outcome parameters of interest were oxygen uptake at the ventilatory anaerobic threshold (VO2VAT) and at peak exercise (VO2peak), the slope of the relationship between the minute ventilation and carbon dioxide production (VE/VCO2-slope), and the oxygen uptake efficiency slope (OUES). Inter-observer agreement of the self-preferred approach and the guideline-based approach was quantified by means of the intra-class correlation coefficient.
RESULTS: Across the complete cohort, inter-observer agreement intraclass correlation coefficient (ICC) was 0.76 (95% confidence interval (CI) 0.57-0.93) for VO2VAT, 0.98 (95% CI 0.95-0.99) for VO2peak, and 0.86 (95% CI 0.75-0.95) for the VE/VCO2-slope when using the self-preferred approach. By using a systematic guideline-based approach, ICCs were 0.88 (95% CI 0.74-0.97) for VO2VAT, 0.99 (95% CI 0.99-1.00) for VO2peak, 0.97 (95% CI 0.94-0.99) for the VE/VCO2-slope, and 0.98 (95% CI 0.96-0.99) for the OUES.
CONCLUSIONS: Inter-observer agreement of numerical values of CPET-derived parameters can be improved by using a systematic guideline-based approach. Effort-independent variables such as the VE/VCO2-slope and the OUES might be useful to further improve uniformity in preoperative risk assessment in addition to, or in case VO2VAT and VO2peak are not determinable.

Chao WH; Tuan SH; Tang EK; Tsai YJ; Chung JH; Chen GB; Lin KL;

Frontiers in medicine [Front Med (Lausanne)] 2022 Jun 15; Vol. 9, pp. 900165.
Date of Electronic Publication: 2022 Jun 15 (Print Publication: 2022).

Objectives: Patients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO ₂ ), VO ₂ at the ventilatory threshold (VO ₂ at VT), and slope of minute ventilation to carbon dioxide production (V _E /V _CO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.
Methods: This was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.
Results: Three intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes ( p = 0.061-0.910).
Conclusion: Patients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.

Eser P; Trachsel LD; Marcin T; Herzig D; Freiburghaus I; De Marchi S; Zimmermann AJ; Schmid JP; Wilhelm M;

Frontiers in cardiovascular medicine [Front Cardiovasc Med] 2022 Jun 17; Vol. 9, pp. 869501.
Date of Electronic Publication: 2022 Jun 17 (Print Publication: 2022).

Aim: Due to insufficient evidence on the safety and effectiveness of high-intensity interval training (HIIT) in patients early after ST-segment elevation myocardial infarction (STEMI), we aimed to compare short- and long-term effects of randomized HIIT or moderate-intensity continuous training (MICT) on markers of left ventricular (LV) remodeling in STEMI patients receiving optimal guideline-directed medical therapy (GDMT).
Materials and Methods: Patients after STEMI (<4 weeks) enrolled in a 12-week cardiac rehabilitation (CR) program were recruited for this randomized controlled trial (NCT02627586). During a 3-week run-in period with three weekly MICT sessions, GDMT was up-titrated. Then, the patients were randomized to HIIT or isocaloric MICT for 9 weeks. Echocardiography and cardiopulmonary exercise tests were performed after run-in (3 weeks), end of CR (12 weeks), and at 1-year follow-up. The primary outcome was LV end-diastolic volume index (LVEDVi) at the end of CR. Secondary outcomes were LV global longitudinal strain (GLS) and cardiopulmonary fitness.
Results: Seventy-three male patients were included, with the time between STEMI and start of CR and randomization being 12.5 ± 6.3 and 45.8 ± 10.8 days, respectively. Mixed models revealed no significant group × time interaction for LVEDVi at the end of CR ( p = 0.557). However, there was a significantly smaller improvement in GLS at 1-year follow-up in the HIIT compared to the MICT group ( p = 0.031 for group × time interaction). Cardiorespiratory fitness improved significantly from a median value of 26.5 (1st quartile 24.4; 3rd quartile 1.1) ml/kg/min at randomization in the HIIT and 27.7 (23.9; 31.6) ml/kg/min in the MICT group to 29.6 (25.3; 32.2) and 29.9 (26.1; 34.9) ml/kg/min at the end of CR and to 29.0 (26.6; 33.3) and 30.6 (26.0; 33.8) ml/kg/min at 1 year follow-up in HIIT and MICT patients, respectively, with no significant group × time interactions ( p = 0.138 and 0.317).
Conclusion: In optimally treated patients early after STEMI, HIIT was not different from isocaloric MICT with regard to short-term effects on LVEDVi and cardiorespiratory fitness. The worsening in GLS at 1 year in the HIIT group deserves further investigation, as early HIIT may offset the beneficial effects of GDMT on LV remodeling in the long term.

Dennis M; Howpage S; McGill M; Dutta S; Koay Y; Nguyen-Lal L; Lal S; Wu T; Ugander M;Wang A; Munoz PA; Wong J; Constantino MI; O’Sullivan JF; Twigg SM; Puranik R;

International journal of cardiology [Int J Cardiol] 2022 Sep 15; Vol. 363, pp. 179-184.
Date of Electronic Publication: 2022 Jun 18.

Aims: To identify biomarkers of cardiomyopathy in patients with type 2 diabetes mellitus (T2DM) using cardiovascular magnetic resonance (CMR) and to identify associations between functional status, metabolomic profile and myocardial fibrosis.
Methods: In this prospective case control study, patients (n = 49) with T2DM without significant coronary artery disease, and matched controls (n = 18) underwent CMR, cardiopulmonary exercise testing, and plasma metabolomic analyses.
Results: Patients with T2DM (n = 49, median [interquartile range] age 61 [56-63] years, 61% male, diabetes duration 11 [7-20] years), historical HbA1c 7.6% (60 mmol/mol) (6.9-8.6) and matched controls (n = 18) were examined. Study patients had increased myocardial extracellular volume (ECV) (26.9 [23.8-30.0] vs 23.4 [22.4-25.5) %, p < 0.001). Increased ECV was associated with male sex (p = 0.04), time with T2DM (p = 0.02), reduced peak VO ₂ (R2 = 0.48, p = 0.01), increased circulating choline (p = 0.002) and cysteamine (p = 0.002) both of which were also associated with reduced peak VO ₂ (p < 0.025 and 0.014 respectively).
Conclusions: Patients with well-controlled T2DM without significant coronary disease exhibit focal and diffuse myocardial fibrosis and diffuse myocardial fibrosis is associated with reduced exercise tolerance and metabolites. Plasma metabolites may provide mechanistic insights into diffuse myocardial fibrosis, and cardiopulmonary fitness.

Ren C; Zhu J; Shen T; Song Y; Tao L; Xu S; Zhao W; Gao W;

Frontiers in cardiovascular medicine [Front Cardiovasc Med] 2022 Jun 20; Vol. 9, pp. 864637.
Date of Electronic Publication: 2022 Jun 20 (Print Publication: 2022).

Background: Cardiopulmonary exercise testing (CPET) is used widely in the diagnosis, exercise therapy, and prognosis evaluation of patients with coronary heart disease (CHD). The current guideline for CPET does not provide any specific recommendations for cardiovascular (CV) safety on exercise stimulation mode, including bicycle ergometer, treadmill, and total body workout equipment.
Objective: The aim of this study was to explore the effects of different exercise stimulation modes on the occurrence of safety events during CPET in patients with CHD.
Methods: A total of 10,538 CPETs, including 5,674 performed using treadmill exercise and 4,864 performed using bicycle ergometer exercise at Peking University Third Hospital, were analyzed retrospectively. The incidences of CV events and serious adverse events during CPET were compared between the two exercise groups.
Results: Cardiovascular events in enrolled patients occurred during 355 CPETs (3.4%), including 2 cases of adverse events (0.019%), both in the treadmill group. The incidences of overall events [235 (4.1%) vs. 120 (2.5%), P < 0.001], premature ventricular contractions (PVCs) [121 (2.1%) vs. 63 (1.3%), P = 0.001], angina pectoris [45 (0.8%) vs. 5 (0.1%), P < 0.001], and ventricular tachycardia (VT) [32 (0.6%) vs. 14 (0.3%), P = 0.032] were significantly higher in the treadmill group compared with the bicycle ergometer group. No significant difference was observed in the incidence of bradyarrhythmia and atrial arrhythmia between the two groups. Logistic regression analysis showed that the occurrence of overall CV events ( P < 0.001), PVCs ( P = 0.007), angina pectoris ( P < 0.001), and VT ( P = 0.008) was independently associated with the stimulation method of treadmill exercise. In male subjects, the occurrence of overall CV events, PVCs, angina pectoris, and VT were independently associated with treadmill exercise, while only the overall CV events and angina pectoris were independently associated with treadmill exercise in female subjects.
Conclusion: In comparison with treadmill exercise, bicycle ergometer exercise appears to be a safer exercise stimulation mode for CPET in patients with CHD.