Peiffer C; Pautrat J; Benzouid C; Fuchs-Climent D; Buridans-Travier N; Houdouin V; AP-HP, Bokov P;
NeuroDiderot, Delclaux C;

Pediatric pulmonology [Pediatr Pulmonol] 2022 Jun 30.
Date of Electronic Publication: 2022 Jun 30.

Background: Inappropriate hyperventilation during exercise may be a specific subtype of dysfunctional breathing (DB).
Objective: To assess whether Nijmegen questionnaire and hyperventilation provocation test (HVPT) are able to differentiate inappropriate hyperventilation from other DB subtypes in children with unexplained exertional dyspnea, and normal spirometry and echocardiography.
Methods: The results were compared between a subgroup of 25 children with inappropriate hyperventilation (increased V’E/V’CO ₂ slope during a cardiopulmonary exercise test (CPET)) and an age and sex matched subgroup of 25 children with DB without hyperventilation (median age, 13.5 years; 36 girls). Anxiety was evaluated using State-Trait Anxiety Inventory for Children questionnaire.
Results: All children were normocapnic (at rest and peak exercise) and the children with hyperventilation had lower tidal volume/vital capacity on peak exercise (shallow breathing). The Nijmegen score correlated positively with dyspnea during the CPET and the HVPT (p = 0.001 and 0.010, respectively) and with anxiety score (p = 0.022). The proportion of children with a positive Nijmegen score (≥19) did not differ between hyperventilation (13/25) and no hyperventilation (14/25) groups (p = 0.777). Fractional end-tidal CO ₂ (FETCO ₂ ) at 5-min recovery of the HVPT was < 90% baseline in all children (25/25) of both subgroups. Likewise, there was no significant difference between the two subgroups for other indices of HVPT (FETCO ₂ at 3-min recovery and symptoms during the test).
Conclusion: The validity of the Nijmegen questionnaire and the HVPT to discriminate specific subtypes of dysfunctional breathing, as well as the relevance of the inappropriate hyperventilation subtype itself may both be questioned.

Kurpaska M; Krzesiński P; Gielerak G; Gołębiewska K; Piotrowicz K;

BMC sports science, medicine & rehabilitation [BMC Sports Sci Med Rehabil] 2022 Jul 17; Vol. 14 (1), pp. 134.
Date of Electronic Publication: 2022 Jul 17.

Background: Patients with coronary artery disease (CAD) are characterized by different levels of physical capacity, which depends not only on the anatomical advancement of atherosclerosis, but also on the individual cardiovascular hemodynamic response to exercise. The aim of this study was evaluating the relationship between parameters of exercise capacity assessed via cardiopulmonary exercise testing (CPET) and impedance cardiography (ICG) hemodynamics in patients with CAD.
Methods: Exercise capacity was assessed in 54 patients with CAD (41 men, aged 59.5 ± 8.6 years) within 6 weeks after revascularization by means of oxygen uptake (VO ₂ ), assessed via CPET, and hemodynamic parameters [heart rate (HR), stroke volume, cardiac output (CO), left cardiac work index (LCWi)], measured by ICG. Correlations between these parameters at anaerobic threshold (AT) and at the peak of exercise as well as their changes (Δpeak-rest, Δpeak-AT) were evaluated.
Results: A large proportion of patients exhibited reduced exercise capacity, with 63% not reaching 80% of predicted peak VO ₂ . Clinically relevant correlations were noted between the absolute peak values of VO ₂ versus HR, VO ₂ versus CO, and VO ₂ versus LCWi (R = 0.45, p = 0.0005; R = 0.33, p = 0.015; and R = 0.40, p = 0.003, respectively). There was no correlation between AT VO ₂ and hemodynamic parameters at the AT time point. Furthermore ΔVO ₂ (peak-AT) correlated with ΔHR (peak-AT), ΔCO (peak-AT) and ΔLCWi (peak-AT) (R = 0.52, p < 0.0001, R = 0.49, p = 0.0001; and R = 0.49, p = 0.0001, respectively). ΔVO ₂ (peak-rest) correlated with ΔHR (peak-rest), ΔCO (peak-rest), and ΔLCWi (peak-rest) (R = 0.47, p < 0.0001; R = 0.41, p = 0.002; and R = 0.43, p = 0.001, respectively).
Conclusion: ICG is a reliable method of assessing the cardiovascular response to exercise in patients with CAD. Some ICG parameters show definite correlations with parameters of cardiovascular capacity of proven clinical utility, such as peak VO ₂ .

Reis JF; Gonçalves AV; Brás PG; Moreira RI; Rio P; Timóteo AT; Soares RM; Ferreira RC;

Arquivos brasileiros de cardiologia [Arq Bras Cardiol] 2022 Jul 18.
Date of Electronic Publication: 2022 Jul 18.

Background: There is evidence suggesting that a peak oxygen uptake (pVO2) cut-off of 10ml/kg/min provides a more precise risk stratification in cardiac resynchronization therapy (CRT) patients.
Objective: To compare the prognostic power of several cardiopulmonary exercise testing (CPET) parameters in this population and assess the discriminative ability of the guideline-recommended pVO2cut-off values.
Methods: Prospective evaluation of consecutive heart failure (HF) patients with left ventricular ejection fraction ≤40%. The primary endpoint was a composite of cardiac death and urgent heart transplantation (HT) in the first 24 follow-up months, and was analysed by several CPET parameters for the highest area under the curve (AUC) in the CRT group. A survival analysis was performed to evaluate the risk stratification provided by several different cut-offs. p values <0.05 were considered significant.
Results: A total of 450 HF patients, of which 114 had a CRT device. These patients had a higher baseline risk profile, but there was no difference regarding the primary outcome (13.2% vs 11.6%, p =0.660). End-tidal carbon dioxide pressure at anaerobic threshold (PETCO2AT)had the highest AUC value, which was significantly higher than that of pVO2in the CRT group (0.951 vs 0.778, p =0.046). The currently recommended pVO2cut-off provided accurate risk stratification in this setting (p <0.001), and the suggested cut-off value of 10 ml/min/kg did not improve risk discrimination in device patients (p =0.772).
Conclusion: PETCO2ATmay outperform pVO2’s prognostic power for adverse events in CRT patients. The current guideline-recommended pVO2 cut-off can precisely risk-stratify this population.

Arroyo E;Umukoro PE; Burney HN; Li Y; Li X; Lane KA; Sher SJ; Lu TS; Moe SM; Moorthi R; Coggan AR; McGregor G; Hiemstra TF; Lim K;

Journal of the American Heart Association [J Am Heart Assoc] 2022 Jul 19; Vol. 11 (14), pp. e025656.
Date of Electronic Publication: 2022 Jul 05.

Background The transition to dialysis period carries a substantial increased cardiovascular risk in patients with chronic kidney disease. Despite this, alterations in cardiovascular functional capacity during this transition are largely unknown. The present study therefore sought to assess ventilatory exercise response measures in patients within 1 year of initiating dialysis.
Methods and Results We conducted a cross-sectional study of 241 patients with chronic kidney disease stage 5 from the CAPER (Cardiopulmonary Exercise Testing in Renal Failure) study and from the intradialytic low-frequency electrical muscle stimulation pilot randomized controlled trial cohorts. Patients underwent cardiopulmonary exercise testing and echocardiography. Of the 241 patients (age, 48.9 [15.0] years; 154 [63.9%] men), 42 were predialytic (mean estimated glomerular filtration rate, 14 mL·min ^-1 ·1.73 m ^-2 ), 54 had a dialysis vintage ≤12 months, and 145 had a dialysis vintage >12 months. Dialysis vintage ≤12 months exhibited a significantly impaired cardiovascular functional capacity, as assessed by oxygen uptake at peak exercise (18.7 [5.8] mL·min ^-1 ·kg ^-1 ) compared with predialysis (22.7 [5.2] mL·min ^-1 ·kg ^-1 ; P <0.001). Dialysis vintage ≤12 months also exhibited reduced peak workload, impaired peak heart rate, reduced circulatory power, and increased left ventricular mass index ( P <0.05 for all) compared with predialysis. After excluding those with prior kidney transplant, dialysis vintage >12 months exhibited a lower oxygen uptake at peak exercise (17.0 [4.9] mL·min ^-1 ·kg ^-1 ) compared with dialysis vintage ≤12 months (18.9 [5.9] mL·min ^-1 ·kg ^-1 ; P =0.033).
Conclusions Initiating dialysis is associated with a significant impairment in oxygen uptake at peak exercise and overall decrements in ventilatory and hemodynamic exercise responses that predispose patients to functional dependence. The magnitude of these changes is comparable to the differences between low-risk New York Heart Association class I and higher-risk New York Heart Association class II to IV heart failure.

Gadioli LP; Costa-Pereira K; Dias JBE; Moraes DA; Crescêncio JC; Schwartzmann PV; Gallo-Júnior L;
Schmidt A;Oliveira MC;

Rheumatology (Oxford, England) [Rheumatology (Oxford)] 2022 Jul 21.
Date of Electronic Publication: 2022 Jul 21.

Objectives: Autologous hematopoietic stem cell transplantation (AHSCT) is a disease-modifying treatment for patients with severe systemic sclerosis (SSc). Here, we aimed at assessing cardiopulmonary function outcomes of SSc patients after AHSCT.
Patients and Methods: Twenty-seven SSc adult patients treated with AHSCT were included in this retrospective study. Most had the diffuse cutaneous subset (93%) and pulmonary involvement (85%). Before and 12 months after AHSCT, patients underwent cardiopulmonary exercise testing (CPET), transthoracic echocardiography, pulmonary function test with diffusing capacity for carbon monoxide (DLCO), six-minute walk test (6MWT), and quality of life evaluations.
Results: After AHSCT, the peak VO2 increased from 954 to 1029 ml/min (p = 0.02), the percentage of predicted peak VO2 increased from 48.9 to 53.5 meters (p = 0.01), and the distance measured by the 6MWT increased from 445 to 502 meters (p = 0.01), respectively, compared to baseline. Improvements in peak VO2 correlated positively with improvements in 6MWT distance, and negatively with a decrease in resting heart rate. At baseline, patients with DLCO >70% had higher peak VO2 values than those with DLCO <70% (p = 0.04), but after AHSCT all patients improved VO2 values, regardless of baseline DLCO levels. Increases in VO2 levels after AHSCT positively correlated with increases in the physical component scores of the Short Form (SF)-36 quality of life questionnaire (r = 0.70; p = 0.0003).
Conclusion: AHSCT improves the aerobic capacity of SSc patients probably reflecting combined increments in lungs, skeletal muscle and cardiac function.

Cui H; Schaff HV; Olson TP; Geske JB; Dearani JA; Nishimura RA; Sun D; Ommen SR;

The Journal of thoracic and cardiovascular surgery [J Thorac Cardiovasc Surg] 2022 May 28.
Date of Electronic Publication: 2022 May 28.

Objective: The study objective was to analyze performance on cardiopulmonary exercise testing and its prognostic value in patients with obstructive hypertrophic cardiomyopathy undergoing septal myectomy.
Methods: We reviewed patients with obstructive hypertrophic cardiomyopathy who had cardiopulmonary exercise testing before septal myectomy from 2005 to 2016. Causes of functional impairment and their impact on survival were analyzed.
Results: A total of 752 patients had cardiopulmonary exercise testing at a median of 16 days (interquartile range, 2-56) before myectomy. The median exercise time was 6.6 (5.3-8.0) minutes. Functional aerobic capacity was 64% (53%-75%) of predicted, and metabolic equivalent of task was 5.2 (4.1-6.4). The peak oxygen consumption was 18.0 (14.2-21.9) mL/kg/min, which was 60% (49%-72%) of the predicted value. The primary causes for low peak oxygen consumption were impaired cardiac output (73.7%), limited heart rate reserve (52.0%), and obesity (48.2%). Resting outflow tract gradient correlated poorly to peak oxygen consumption, but the use of beta-blockers was associated with reduced peak oxygen consumption. During a median (interquartile range) of 9.0 (6.8-11.7) years of follow-up, the estimated 5- and 10-year survivals were 97% and 91%, respectively. Greater adjusted peak oxygen consumption (hazard ratio, 0.98; P = .011) and abnormal pulse oxygen increase (hazard ratio, 0.44; P = .003) were independently associated with better long-term survival after myectomy.
Conclusions: Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, functional capacity is severely impaired despite receiving optimal medical treatment. We identified risk factors of reduced long-term survival from preoperative cardiopulmonary exercise testing that may aid risk stratification in patients undergoing septal myectomy.

Kunutsor SK; Jae SY; Kauhanen J; Laukkanen JA;

The American journal of medicine [Am J Med] 2022 Jul 09.
Date of Electronic Publication: 2022 Jul 09

Background: Socioeconomic status (SES) and cardiorespiratory fitness (CRF) are each independently associated with chronic kidney disease. The interplay between SES, CRF, and chronic kidney disease is not well understood. We aimed to evaluate the separate and joint associations of SES and CRF with chronic kidney disease risk in a cohort of Caucasian men.
Methods: In 2,099 men aged 42-61 years with normal kidney function at baseline, SES was self-reported and CRF was directly measured using a respiratory gas exchange analyzer during cardiopulmonary exercise testing. Hazard ratios (HRs) (95% CIs) were estimated for chronic kidney disease.
Results: A total of 197 chronic kidney disease events occurred during a median follow-up of 25.8 years. Comparing low vs high SES, the multivariable-adjusted HR (95% CI) for chronic kidney disease was 1.55 (1.06-2.25), which remained consistent on further adjustment for CRF 1.53 (1.06-2.22). Comparing high vs low CRF, the multivariable-adjusted HR for chronic kidney disease was 0.66 (0.45-0.96), which persisted on further adjustment for SES 0.67 (0.46-0.97). Compared with high SES-high CRF, low SES-low CRF was associated with an increased risk of chronic kidney disease 1.88 (1.23-2.87), with no evidence of an association for low SES-high CRF and chronic kidney disease risk 1.32 (0.85-2.05). Positive additive (RERI=0.31) and multiplicative (ratio of HRs=1.14) interactions were found between SES and CRF in relation to chronic kidney disease risk.
Conclusions: In middle-aged and older males, SES and CRF are each independently associated with risk of incident chronic kidney disease. There exists an interplay between SES, CRF and chronic kidney disease risk, with high CRF levels appearing to offset the increased chronic kidney disease risk related to low SES..

Oyanagi H; Usui N; Tsubaki A; Ando S; Saithoh M; Kojima S; Inatsu A; Hisadome H; Ota S; Uehata A;

European journal of applied physiology [Eur J Appl Physiol] 2022 Jul 13.
Date of Electronic Publication: 2022 Jul 13.

Purpose: Exercise prescription based on a population-specific physiological response can help ensure safe and effective physical interventions. However, as a facile approach for exercise prescription in hemodialysis population that is based on their exercise capacity has not yet been established, the aim of our study was to develop a unique prediction formula for peak heart rate (HR) that can be used in this population.
Methods: This cross-sectional study measured physical function and HR at peak exercise and anaerobic threshold (AT) during cardiopulmonary exercise tests in 126 individuals. Participants were randomly assigned to the development group (n = 78), whose data were used to calculate the prediction equation, or the validation group (n = 48).
Results: The HR reserve in this population was significantly lower (0.44 ± 0.20%) and there was a large discrepancy between conventional age-predicted maximal HR and measured peak-HR values (R = 0.36). The average of the ratio between HR at AT point and peak HR was 85% (95% CI, 83.5%-86.4%). The peak-HR prediction equation was based on resting HR, presence of diabetes, physical dysfunction (gait speed < 1.0 m/s), and hypoalbuminemia (< 3.5 g/dL). It showed high prediction accuracy (R ² [95%CI] = 0.71 [0.70-0.71]) with similar correlation coefficients between the development and validation groups (R = 0.82).
Conclusion: Aerobic exercise based on estimated peak HR < 85% obtained from the equation in this study may enable safe and effective physical intervention in this population.

Sibilitz KL; Tang LH; Berg SK; Thygesen LC; Risom SS; Rasmussen TB; Schmid JP; Borregaard B; Hassager C;
Køber L; Taylor RS; Zwisler AD;

Scandinavian cardiovascular journal : SCJ [Scand Cardiovasc J] 2022 Dec; Vol. 56 (1), pp. 247-255.

Aims . The CopenHeart _VR trial found positive effects of cardiac rehabilitation (CR) on physical capacity at 4 months. The long-term effects of CR following valve surgery remains unclear, especially regarding readmission and mortality. Using data from he CopenHeart _VR Trial we investigated long-term effects on physical capacity, mental and physical health and effect on mortality and readmission rates as prespecified in the original protocol.
Methods . A total of 147 participants were included after heart valve surgery and randomly allocated 1:1 to 12-weeks exercise-based CR including a psycho-educational programme (intervention group) or control. Physical capacity was assessed as peak oxygen uptake (VO ₂ peak) measured by cardiopulmonary exercise testing, mental and physical health by Short Form-36 questionnaire, Hospital Anxiety and Depression Scale, and HeartQol. Mortality and readmission were obtained from hospital records and registers. Groups were compared using mixed regression model analysis and log rank test.
Results . No differences in VO ₂ peak at 12 months or in self-assessed mental and physical health at 24 months (68% vs 75%, p  = .120) was found. However, our data demonstrated reduction in readmissions in the intervention group at intermediate time points; after 3, 6 (43% vs 59%, p  = .03), and 12 (53% vs 67%, p  = .04) months, respectively, but no significant effect at 24 months.
Conclusions . Exercise-based CR after heart valve surgery reduces combined readmissions and mortality up to 12 months despite lack of improvement in exercise capacity, physical and mental health long-term. Exercise-based CR can ensure short-term benefits in terms of physical capacity, and lower readmission within a year, but more research is needed to sustain these effects over a longer time period. These considerations should be included in the management of patients after heart valve surgery.

Bailey DM; Halligan CL; Davies RG; Funnell A; Appadurai IR; Rose GA;
Rimmer L; Jubouri M; Coselli JS; Williams IM; Bashir M

Journal of Cardiac Surgery. 37(8):2258-2265, 2022 Aug.

Abstract
BACKGROUND: Initial clinical evaluation (ICE) is traditionally considered
a useful screening tool to identify frail patients during the preoperative
assessment. However, emerging evidence supports the more objective
assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise
testing (CPET) to improve surgical risk stratification. Herein, we
compared both subjective and objective assessment approaches to highlight
the interpretive idiosyncrasies.

METHODS: As part of routine preoperative patient contact, patients
scheduled for major surgery were prospectively “eyeballed” (ICE) by two
experienced clinicians before more detailed history taking that also
included the American Society of Anesthesiologists score classification.
Each patient was subjectively judged to be either “frail” or “not frail”
by ICE and “fit” or “unfit” from a thorough review of the medical notes.
Subjective data were compared against the more objective validated
assessment of postoperative outcomes using established CPET “cut-off”
metrics incorporating peak pulmonary oxygen uptake, VO2PEAK at the
anaerobic threshold (VO2 -AT), and ventilatory equivalent for carbon
dioxide that collectively informed risk stratification. These data were
retrospectively extracted from a single-center prospective National Health
Service database. Data were analyzed using the Chi-square automatic
interaction detection decision tree method.

RESULTS: A total of 127 patients were examined that comprised 58% male
and 42% female patients aged 69 +/- 10 years with a body mass index of 29
+/- 7 kg/m2 . Patients were poorly conditioned with a VO2PEAK almost 20%
lower than predicted for age, sex-matched healthy controls with 35%
exhibiting a VO2 -AT < 11 ml/kg/min. Disagreement existed between the
subjective assessments of risk with ~34% of patients classified as not
frail on ICE were considered unfit by notes review (p < .0001).
Furthermore, ~35% of patients considered not frail on ICE and ~31% of
patients considered fit by notes review exhibited a VO2 -AT < 11
ml/kg/min, and of these, ~28% and ~19% were classified as intermediate to
high risk.

CONCLUSIONS: These findings highlight the interpretive limitations
associated with the subjective assessment of patient frailty with surgical
risk classification underestimated in up to a third of patients compared
to the validated assessment of CRF. They reinforce the benefits of a more
objective and integrated approach offered by CPET that may help us to
improve perioperative risk assessment and better direct critical care
provision in patients scheduled for “high-stakes” surgery including open
thoracoabdominal aortic aneurysm repair