Steffens D; Ismail H; Denehy L; Beckenkamp PR; Solomon M; Koh C; Bartyn J;

Annals of surgical oncology [Ann Surg Oncol] 2021 Jun 08. Date of Electronic Publication: 2021 Jun 08.

Backgrounds: There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery.
Methods: A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO ₂ ), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (V _E /V _CO2 ), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible.
Results: Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO ₂ was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and V _E /V _CO2 also demonstrated some positive trends. None of the included studies reported a negative trend.
Conclusions: This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO ₂ , and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.

Martens P; Herbots L; Verbrugge FH; Dendale P; Borlaug BA; Verwerft J;

Journal of cardiovascular translational research [J Cardiovasc Transl Res] 2021 Jun 10. Date of Electronic Publication: 2021 Jun 10.

Little data is available about the pathophysiological mechanisms of unexplained dyspnea and their clinical meaning. Consecutive patients with unexplained dyspnea underwent prospective standardized cardiopulmonary exercise testing with echocardiography (CPETecho). Patients were grouped as having normal exercise capacity (peak VO ₂ > 80% with respiratory exchange [RER] > 1.05), reduced exercise capacity (peak VO ₂ ≤ 80% with RER > 1.05), or a submaximal exercise test (RER ≤ 1.05). From 307 patients, 144 (47%) had normal and 116 (38%) reduced exercise capacity, and 47 (15%) had a submaximal exercise test. Patients with reduced versus normal exercise capacity had significantly more mechanisms for unexplained dyspnea (2.3±1.0 vs 1.5±1.0, respectively; p<0.001). Exercise PH (42%), low heart rate reserve (51%), low stroke volume reserve (38%), low diastolic reserve (18%), and peripheral muscle limitation (17%) were most common. Patients with more mechanisms for dyspnea displayed poorer peak VO ₂ and had an increased risk for cardiovascular hospitalization (p=0.002). Patients with unexplained dyspnea display multiple coexisting mechanisms for exercise intolerance, which relate to the severity of exercise limitation and risk of subsequent cardiovascular hospitalizations.

de Souza E Silva CG; Nishijuka FA; de Castro CLB; Franca JF; Myers J; Laukkanen JA; de Araújo CGS

Journal of cardiopulmonary rehabilitation and prevention [J Cardiopulm Rehabil Prev] 2021 Jun 10. Date of Electronic Publication: 2021 Jun 10.

Purpose: Medically supervised exercise programs (MSEPs) are equally recommended for men and women with cardiovascular disease (CVD). Aware of the lower CVD mortality in women, we hypothesized that among patients attending a MSEP, women would also have better survival.
Methods: Data from men and women, who were enrolled in a MSEP between 1994 and 2018, were retrospectively analyzed. Sessions included aerobic, resistance, flexibility and balance exercises, and cardiopulmonary exercise test was performed. Date and underlying cause of death were obtained. Kaplan-Meier methods and Cox proportional hazards regression were used for survival analysis.
Results: A total of 2236 participants (66% men, age range 33-85 yr) attended a median of 52 (18, 172) exercise sessions, and 23% died during 11 (6, 16) yr of follow-up. In both sexes, CVD was the leading cause of death (39%). Overall, women had a more favorable clinical profile and a longer survival compared to men (HR = 0.71: 95% CI, 0.58-0.85; P < .01). When considering those with coronary artery disease and similar clinical profile, although women had a lower percentage of sex- and age-predicted maximal oxygen uptake at baseline than men (58 vs 78%; P < .01), after adjusting for age, women still had a better long-term survival (HR = 0.68: 95% CI, 0.49-0.93; P = .02).
Conclusion: Survival after attendance to a long-term MSEP was better among women, despite lower baseline cardiorespiratory fitness. Future studies should address whether men and women would similarly benefit when participating in an MSEP.

Rieth AJ; Richter MJ; Tello K; Gall H; Ghofrani HA; Guth S; Wiedenroth CB; Seeger W; Kriechbaum SD; Mitrovic V; Schulze PC; Hamm CW;

Clinical research in cardiology : official journal of the German Cardiac Society [Clin Res Cardiol] 2021 Jun 10. Date of Electronic Publication: 2021 Jun 10.

Objective: We sought to explore whether classification of patients with heart failure and mid-range (HFmrEF) or preserved ejection fraction (HFpEF) according to their left ventricular ejection fraction (LVEF) identifies differences in their exercise hemodynamic profile, and whether classification according to an index of right ventricular (RV) function improves differentiation.
Background: Patients with HFmrEF and HFpEF have hemodynamic compromise on exertion. The classification according to LVEF implies a key role of the left ventricle. However, RV involvement in exercise limitation is increasingly recognized. The tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/PASP) ratio is an index of RV and pulmonary vascular function. Whether exercise hemodynamics differ more between HFmrEF and HFpEF than between TAPSE/PASP tertiles is unknown.
Methods: We analyzed 166 patients with HFpEF (LVEF ≥ 50%) or HFmrEF (LVEF 40-49%) who underwent basic diagnostics (laboratory testing, echocardiography at rest, and cardiopulmonary exercise testing [CPET]) and exercise with right heart catheterization. Hemodynamics were compared according to echocardiographic left ventricular or RV function.
Results: Exercise hemodynamics (e.g. pulmonary arterial wedge pressure/cardiac output [CO] slope, CO increase during exercise, and maximum total pulmonary resistance) showed no difference between HFpEF and HFmrEF, but significantly differed across TAPSE/PASP tertiles and were associated with CPET results. N-terminal pro-brain natriuretic peptide concentration also differed significantly across TAPSE/PASP tertiles but not between HFpEF and HFmrEF.
Conclusion: In patients with HFpEF or HFmrEF, TAPSE/PASP emerged as a more appropriate stratification parameter than LVEF to predict clinically relevant impairment of exercise hemodynamics. Stratification of exercise hemodynamics in patients with HFpEF or HFmrEF according to LVEF or TAPSE/PASP, showing significant distinctions only with the RV-based strategy. All data are shown as median [upper limit of interquartile range] and were calculated using the independent-samples Mann-Whitney U test or Kruskal-Wallis test. PVR pulmonary vascular resistance; max maximum level during exercise.

Clowes GH; Del Guercio LR;

Circulatory response to trauma of surgical operations. Metabolism. 1960;9:67-81. (NOTE THE DATE)

To determine the nature of the normal cardiovascular response of man to surgi­cal operations, thirteen patients making uncomplicated recoveries after thoraco­tomy for pulmonary surgery were studied by measuring cardiac output and arterial and venous pressure before, during and for one week after surgery. Arterial pH, blood gas and electrolytes were analyzed simultaneously. Through­ out the observations, arterial blood pres­sure was more or less constantly main­tained; but during the operation cardiac output fell an average of  33  per  cent with a decrease of  stroke  volume,  and the calculated peripheral arterial resist­ance rose. Venous pressure was elevated in all patients during the  induction of anesthesia and remained so to the end of the operation. Upon awakening and during extubation, the situation was promptly reversed.  Cardiac output rose to 130 per cent of the resting value; peripheral resistance fell below normal; and venous pressure returned to levels below 10 cm. of H₂0 . These changes persisted to the end of the first post­ operative week. Three patients, who recovered satisfactorily after cardiac operations,  followed a similar  pattern of circulatory response. Arterial pH and pCO₂ were main­tained within normal limits in all pa­tients who recovered; however, all showed some degree of arterial oxygen desaturation postoperatively. Metabolic acidosis,  as  indicated   by  an  elevation of lactic acid, took  place  during  and after the operation but returned to pre­-operative values within three days. Sodium fell, on the average, to 129 mEq./L. on the second postoperative day.  Ionized calcium fell to 4.1 mg. per cent on the first day. Potassium remained unchanged. Three patients who recovered from open heart operations responded in the same fashion with a postoperative in­ crease in cardiac output.
Two patients died postoperatively. Both failed to show the normal post­ operative elevation of cardiac output; metabolic acidosis increased until re­spiratory compensation failed, and ar­terial pH fell below 7.3.

Giovanna A; Christian P; Danielle M; Christoph K; Christian M for the BASEL-PMI Investigators

BJA Vol 126 Number 1 Jan 2021 Pg 102-110

Mustafa E; Aytür YK;

Topics in stroke rehabilitation [Top Stroke Rehabil] 2021 May 22, pp. 1-9. Date of Electronic Publication:
2021 May 22.

Background : Assessment for cardiovascular disease (CVD) is important in stroke patients, both being one of the main factors limiting success in stroke rehabilitation and its increased risk in stroke patients. Reduced exercise capacity after stroke decreases patients’ functionality and further increases the risk of CVD. Carefully selected cardiopulmonary exercise testing (CPET) can be safely used to determine the risk of CVD and to prescribe exercise program in stroke rehabilitation.
Objectives : The primary purpose of this study is to determine the most appropriate CPET in patients with stroke. The secondary aim is to determine the relationship between cardiorespiratory fitness and functional status of the patients.
Methods : Two CPETs using treadmill and bicycle ergometer protocols determined with a preliminary study were performed on participants. The main outcome measure was VO _2peak . Patients were also evaluated according to Brunnstrom motor staging, Modified Ashworth Scale, Berg Balance Scale, and Functional Independence Measure. Results : In total, 38 patients reached higher VO _2peak values at treadmill test compared to bicycle test ( p < 0.001). The mean VO ₂ peak reached at treadmill CPET was 62% of the control group where mean VO _2peak reached at bicycle was 76% of the control group. No significant correlation was found between Brunnstrom staging, spasticity, Berg Balance Scale, and VO _2peak .
Discussion : The results of this study indicate that CPET can be performed safely in stroke patients when appropriate protocol was selected and that treadmill was more appropriate to determine cardiorespiratory fitness in this study population.

Douglas N; Melbourne, Australia.Altamimi H; Wang A; Basto J; Smith R; Taylor HE;

Internal medicine journal [Intern Med J] 2021 May 24. Date of Electronic Publication: 2021 May 24.

Background: One metabolic equivalent (MET) is equal to resting oxygen consumption. The average value for one MET in humans is widely quoted as 3.5ml/kg/min. However this value was derived from a single male participant at the end of the nineteenth century and has become canonical. Several small studies have identified varied estimates of one MET from widely varying populations. The ability of a patient to complete 4 METS (or 14mls/kg/min) is considered an indicator of their fitness to proceed to surgery.
Aims: The study aimed to define a typical value of one MET from a real-world patient population, as well as determine factors that influenced the value.
Methods: A database of cardiopulmonary exercise tests (CPET) tests was interrogated to find total of 1847 adult patients who had undergone CPET testing in the previous 10 years. From this database, estimates of oxygen consumption (VO ₂ ) at rest and at the anaerobic threshold and a number of other variables were obtained. The influence of age, body mass index (BMI), sex and the use of beta blockers was tested.
Results: The median resting VO ₂ at rest was 3.6ml/kg/min (IQR 3.0-4.2). Neither sex nor age greater than 65 years nor the use of beta blockers produced a significant difference in resting VO ₂ , while those with a BMI greater than 25 had a significantly lower VO ₂ at rest (3.4ml/kg/min vs 4.0ml/kg/min, p <0.001).
Conclusions: The estimate of 3.6ml/kg/min for resting VO ₂ presented here is consistent with the previous literature, despite this being the first large study of its kind. This estimate can be safely used for pre-operative risk stratification.

Chmelo J, Khaw RA, Sinclair RCF, Navidi M, Phillips AW.

Ann Surg Oncol. 2021 May 26. doi: 10.1245/s10434-021-10136-5. Online ahead of print.

BACKGROUND: Esophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes of major surgery. Variables derived from cardiopulmonary exercise testing (CPET) have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing esophagectomy is associated with long-term survival. This study aimed to evaluate whether any of the CPET variables routinely derived from patients with esophageal cancer may aid in predicting long-term survival after esophagectomy.
METHODS: Patients undergoing CPET followed by trans-thoracic esophagectomy for esophageal cancer with curative intent between January 2013 and January 2017 from single high-volume center were retrospectively analyzed. The relationship between predictive co-variables, including CPET variables and survival, was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was performed to find cutoff values for CPET variables predictive of 3-year survival.
RESULTS: The study analyzed 313 patients. The ventilatory equivalent for carbon dioxide (VE/VCO2) at the anerobic threshold was the only CPET variable independently predictive of long-term survival in the multivariable analysis (hazard ratio [HR], 1.049; 95% confidence interval [CI], 1.011-1.088; p = 0.011). Pathologic stages 3 and 4 disease was the other co-variable found to be independently predictive of survival. An ROC analysis of the VE/VCO2 failed to demonstrate a predictive cutoff value of 3-year survival (area under the curve, 0.564; 95% CI, 0.499-0.629; p = 0.056).
CONCLUSIONS: A high VE/VCO2 before esophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for clinicians to consider when counseling patients.

Brito LC; Peçanha T; Fecchio RY; Pio-Abreu A; Silva G; Mion-Junior D; Halliwill JR; Forjaz CLM

Blood pressure monitoring [Blood Press Monit] 2021 May 07. Date of Electronic Publication: 2021 May 07.

Heart rate recovery (HRR) is a marker of cardiac autonomic regulation and an independent predictor of mortality. Aerobic-exercise training conducted in the evening (evening training) produces greater improvement in resting cardiac autonomic control in hypertensives than morning training, suggesting it may also result in a faster autonomic restoration postexercise. This study compared the effects of morning training and evening training on HRR in treated hypertensive men. Forty-nine treated hypertensive men were randomly allocated into three groups: morning training, evening training and control. Training was conducted three times/week for 10 weeks. Training groups cycled (45 min, moderate intensity) while control group stretched (30 min). In the initial and final assessments of the study, HRR60s and HRR300s were evaluated during the active recovery (30 W) from cardiopulmonary exercise tests (CPET) conducted in the morning and evening. Between-within ANOVAs were applied (P ≤ 0.05). Only evening training increased HRR60s and HRR300 differently from control after morning CPET (+4 ± 5 and +7 ± 8 bpm, respectively, P < 0.05) and only evening training increased HRR300s differently from morning training and control after evening CPET (+8 ± 6 bpm, P < 0.05). Evening training improves HRR in treated hypertensive men, suggesting that this time of day is better for eliciting cardiac autonomic improvements via aerobic training in hypertensives.