Crispino SP; Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Campus Bio-Medico di Roma, 00128 Rome, Italy.
Segreti A; Ciancio M; Polito D; Guerra E; Di Gioia G; Ussia GP; Grigioni F;

Journal of cardiovascular development and disease [J Cardiovasc Dev Dis] 2024 Nov 05; Vol. 11 (11).
Date of Electronic Publication: 2024 Nov 05.

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, accounting for over 9 million deaths annually. The prevalence of CAD continues to rise, driven by ageing and the increasing prevalence of risk factors such as hypertension, diabetes, and obesity. Current clinical guidelines emphasize the importance of functional tests in the diagnostic pathway, particularly for assessing the presence and severity of ischemia. While recommended tests are valuable, they may not fully capture the complex physiological responses to exercise or provide the necessary detail to tailor personalized treatment plans. Cardiopulmonary exercise testing (CPET) offers a comprehensive assessment of the cardiovascular, pulmonary, and muscular systems under stress, potentially addressing these gaps and providing a more precise understanding of CAD, particularly in settings where traditional diagnostics may be insufficient. By enabling more personalized and precise treatment strategies, CPET could play a central role in the future of CAD management. This narrative review examines the current evidence supporting the use of CPET in CAD diagnosis and management and explores the potential for integrating CPET into existing clinical guidelines, considering its diagnostic and prognostic capabilities, cost-effectiveness, and the challenges associated with its adoption.

Dixit S; King Khalid University, Abha, , Saudi Arabia. & Federal University of Maranhao, São Luís 65080-805, MA, Brazil.
Bassi-Dibai D; Dibai-Filho AV; l.Mendes RG; Alqahtani AS; Alshehri MM; DAldhahi MI; Alkhamis BA; Reddy RS; Tedla JS; Borghi-Silva A;

Medicina (Kaunas, Lithuania) [Medicina (Kaunas)] 2024 Nov 06; Vol. 60 (11).
Date of Electronic Publication: 2024 Nov 06.

Background and Objective: The aim of this study was to evaluate cardiorespiratory fitness (CRF) measures, maximal oxygen consumption (VO ₂ max), and minute ventilation/carbon dioxide production (V _E /VCO ₂ slope and others) among the T2DM population based on glycated haemoglobin (HBA1c). Material and Methods: The present study comprised a cross-sectional design, with two groups, based on HbA1c values (≤7 and ≥7.1). Laboratory samples were taken to evaluate glycated haemoglobin and fasting blood glucose (FBS). Cardiopulmonary exercise testing was performed to calculate various fitness-related parameters. Data analysis: An independent t -test was used to analyse the outcomes in the two groups. p < 0.05 was considered significant. Linear regression was used to examine the influence of predictor variables on dependent variables.
Results: A total of 70 patients agreed to participate in the study, with 19 females and 51 males. The mean (standard deviation) BMI (body mass index) of all participants was 29.7(5.2), the mean (SD) weight was 84.4 (18.9) kg, and the mean height was 167.4 (23) cm. The average age of the individuals was 52 ± 8 years. The independent t -test revealed a significant difference between the two groups in terms of CRF measures.
Conclusions: The current research identified the presence of poor glycaemic control and cardiorespiratory fitness measures among the Brazilian population with T2DM. HBA1c, duration of diabetes, age, and BMI can be employed to predict the ventilatory threshold (VT) and VO ₂ max.

Edwards T; Arkansas Children’s Nutrition Center, Little Rock, AR.;  Little Rock, AR.
Børsheim E; Tomlinson AR;

Mayo Clinic proceedings. Innovations, quality & outcomes [Mayo Clin Proc Innov Qual Outcomes] 2024 Nov 13; Vol. 8 (6), pp. 530-535.
Date of Electronic Publication: 2024 Nov 13 (Print Publication: 2024).

A 20-year-old male underwent diagnostic testing due to unexplained shortness of breath and chest discomfort. He had no previous medical problems and was not taking any medications. Initial evaluations included cardiopulmonary exercise testing (CPET), which yielded results that were reported as normal. However, over the following 2 months, his symptoms worsened considerably, including dyspnea with climbing stairs and then hemoptysis. Seeking urgent medical care, he presented to the emergency department, where he underwent further testing and was admitted to the hospital. Computed tomography angiogram reported bilateral pulmonary emboli. His parents requested a second opinion regarding the analysis of the CPET data, which revealed previously overlooked abnormalities. This overlooked data delayed pulmonary embolism diagnosis, and the patient ultimately required bilateral pulmonary thromboendarterectomy. In this case, we describe the hallmark signs of pulmonary vascular disease seen during CPET and offer clinical pearls to aid in timely detection.

Marzolini S; KITE Research Institute; Rehabilitation Sciences Institute, University of Toronto.
Oh P; Peterman JE; Wallace P; Yadollahi A;Rivera F; Carvalho C; Kaminsky LA

The Canadian journal of cardiology [Can J Cardiol] 2024 Nov 25.
Date of Electronic Publication: 2024 Nov 25.

Background: Despite the importance of objective measures for prescribing aerobic exercise for mitigating cardiovascular risk in people with coronary artery disease (CAD), no study has examined sex differences in the utility of the cardiopulmonary exercise test (CPET) for developing the exercise prescription.
Methods: CPET results from 1,352 females and 5,875 males with CAD were analyzed to determine if there was a sex difference in achieving maximal oxygen uptake (VO2max) or an identifiable first ventilatory threshold (VT1). Secondary outcomes were to determine correlates of not achieving VO2max or VT1 in all patients and males and females separately.
Results: A greater proportion of males than females achieved VO2max or VT1 (89.7% vs 71.3%; p<0.001), specifically achieving VO2max (40.2% vs 26.7%; p<.001) and VT1 (88.0% vs 69.2%; p<.001). The most influential correlates of not achieving VO2max or VT1 were female sex (OR=3.1:95% CI, 2.6-3.7), age >60 yrs, tested on treadmill vs cycle, depressive symptoms, and a secondary heart failure diagnosis. At entry to cardiac rehabilitation, these correlates were more prevalent in females than males. Correlates differed by sex. The threshold for when age affected achieving VO2max or VT1 on the cycle CPET was earlier for females (>50 yrs) than males (>70 yrs) with no difference on treadmill (>80 yrs, both).
Conclusions: While most patients achieved VO2max or VT1 on the CPET, females were 3 times less likely to achieve VO2max or VT1 than males. Strategies to improve utility of CPETs for females such as alternative exercise test protocols and investigation into underlying mechanisms for effects of depressive symptoms should be conducted.

Shibata A; Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
Izumiya Y; Yoshida T;Tanihata A; Kitada R;Otsuka K; Ito A; DepYamazaki T; Fukuda D;

Journal of cardiology [J Cardiol] 2024 Nov 27.
Date of Electronic Publication: 2024 Nov 27.

Background: Tafamidis is used as disease-modifying treatment for patients with wild-type transthyretin cardiac amyloidosis (ATTRwt CA). However, the effects of tafamidis on exercise tolerance are unclear.
Methods: This single-center, prospective, observational study aimed to assess the effect of tafamidis on exercise tolerance in 36 patients with ATTRwt CA. Exercise tolerance was evaluated by the peak oxygen uptake (peak VO ₂ ) measured by the cardiopulmonary exercise test (CPX).
Results: The baseline CPX showed a mean anaerobic threshold value of 11.6 ± 2.2 ml/kg/min and peak VO ₂ of 15.6 ± 4.1 ml/kg/min. Twenty-eight of the 36 patients underwent a follow-up CPX after 6 months. There was no significant change in peak VO ₂ before and 6 months after tafamidis therapy (16.0 ± 4.2 vs. 14.7 ± 4.0 ml/kg/min). The baseline CPX data showed that the mean peak VO ₂ was significantly lower in the increased peak VO ₂ group than in the non-increased peak VO ₂ group (13.7 ± 3.1 vs. 17.7 ± 4.1 ml/kg/min, p = 0.008). A multivariate logistic regression analysis showed that the baseline peak VO ₂ value was an independent predictor of improved exercise tolerance by tafamidis therapy (odds ratio: 0.646, 95 % confidence interval: 0.449-0.930, p = 0.019).
Conclusions: Tafamidis prevents deterioration of exercise tolerance in patients with ATTRwt CA. In some patients with ATTRwt CA, exercise tolerance may improve with the use of tafamidis, and those with lower exercise tolerance before tafamidis administration are likely to show improved exercise tolerance.

Dhont S; Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium.
Verwerft J; Bertrand PB;

European heart journal. Cardiovascular Imaging [Eur Heart J Cardiovasc Imaging] 2024 Nov 27; Vol. 25 (12), pp. 1614-1619.

Exercise-induced pulmonary hypertension (exPHT) is a haemodynamic condition linked to increased morbidity and mortality across various cardiopulmonary diseases. Traditional definitions of exPHT rely on absolute cut-offs, such as mean pulmonary artery pressure (mPAP) above 30 mmHg during exercise. However, recent research suggests that these cut-offs may not accurately reflect pathophysiological changes, leading to false positives and false negatives. Instead, the mPAP over cardiac output (CO) slope, which incorporates both pressure and flow measurements, has emerged as a more reliable indicator. A slope exceeding 3 mmHg/L/min is now considered diagnostic for exPHT and strongly correlates with adverse outcomes. Stress echocardiography serves as a viable alternative to invasive assessment, enabling broader implementation. This review discusses the physiological basis of pulmonary haemodynamics during exercise, the advantages of the mPAP/CO slope over absolute pressure measurements, the evidence supporting its inclusion in clinical guidelines, and provides a practical guide for non-invasive determining the mPAP/CO slope in clinical practice.

Song J;  Department of Cardiology, School of Medicine, Xiamen University, Xiamen, Fujian, China
Chen X; Wang B; Cheng Y; Wang Y;

Journal of cardiopulmonary rehabilitation and prevention [J Cardiopulm Rehabil Prev] 2024 Nov 28.
Date of Electronic Publication: 2024 Nov 28.

Purpose: The objective of this study was to assess the effect of exercise-based cardiac rehabilitation (CR) with individualized exercise prescription in patients with chronic heart failure (HF) undergoing transcatheter aortic valve replacement (TAVR) in a randomized controlled trial.
Methods: A total of 60 patients with chronic HF who received TAVR treatment were randomly divided into the control group (n = 30) and exercise training (ET) group (n = 30). The control group was treated with conventional rehabilitation, and the ET group was given personalized exercise-based CR based on a cardiopulmonary exercise test (CPX). The CPX parameters, echocardiography, 6-minute walk test distance, and quality of life were evaluated in the two groups.
Results: All patients who completed symptom-restricted CPX showed no complications. After the 12-week rehabilitation period, the levels of anaerobic threshold, peak oxygen uptake, peak oxygen pulse, peak power, left ventricular ejection fraction, and 6-minute walk test distance in the ET group were significantly higher than those in the control group (P < .05). Scores on the Minnesota Life with Heart Failure Questionnaire in the ET group were lower than those in the control group (P < .05).
Conclusion: Exercise-based CR significantly improves cardiopulmonary function, exercise tolerance, and quality of life in patients with chronic HF who undergo TAVR.

Xie Y; Department of Nephrology, Xuzhou Medical University Affiliated Hospital, Xuzhou, Jiangsu, China.
Qiu X; Zhang Y; Liu Y; DeYin Z;

British journal of hospital medicine (London, England : 2005) [Br J Hosp Med (Lond)] 2024 Nov 30; Vol. 85 (11), pp. 1-13.
Date of Electronic Publication: 2024 Nov 18.

Aims/Background Pulmonary arterial hypertension (PAH) is a significant contributor to increased overall and cardiovascular mortality in peritoneal dialysis (PD) patients. Cardiopulmonary exercise testing (CPET) is an accurate method for measuring cardiorespiratory fitness (CRF) during both submaximal and peak exercise. Previous studies have demonstrated a strong correlation among CRF and increased cardiovascular and overall mortality rates. However, no literature currently reports the predictive value of CPET parameters for PAH occurrence in PD patients. This study primarily aims to analyze the risk factors for PAH in PD patients, assess the predictive value of CPET parameters, and provide a reference for the clinical prevention and management of PAH.
Methods The clinical data of 121 PD patients who underwent CPET were retrospectively collected at Xuzhou Medical University Affiliated Hospital. Based on the event of PAH, patients were divided into two groups: a PAH group (n = 39) and a non-PAH group (n = 82). Clinical data, laboratory results, ultrasound findings, and CPET parameters were compared between the groups. Multifactorial logistic regression analysis was performed to identify the risk factors for PAH. The predictive value of CPET parameters was evaluated by calculating the area under the receiver operating characteristic (ROC) curve (AUC) using ROC curve analysis.
Results White blood cell count (WBC) was an independent risk factor for PAH in PD patients ( p < 0.05). VO ₂ peak (peak oxygen uptake), VO ₂ AT (anaerobic threshold oxygen uptake), METspeak (peak metabolic equivalents), WRpeak (peak power load) were identified as protective factors for PAH in PD patients ( p < 0.05). ROC curve analysis showed that the AUC values for predicting PAH in PD patients using VO ₂ peak, VO ₂ AT, METspeak, and WRpeak were 0.675, 0.651, 0.719, and 0.689, respectively, with METspeak demonstrating the highest AUC for prediction.
Conclusion The occurrence of PAH in PD patients is associated with WBC, VO ₂ peak, VO ₂ AT, METspeak, and WRpeak. Additionally, CPET parameters exhibit predictive value for PAH, with METspeak showing the highest AUC for prediction.

Mitchell RA; Centre for Heart and Lung Innovation, Providence Research,  St. Paul’s Hospital, Vancouver, British Columbia, Canada.;
Hind AS; Canada.; Ferguson ON; Flynn M; Canada.; Arnold J; Dhillon SS; Eves ND; Sheel AW; Guenette JA;

Journal of applied physiology (Bethesda, Md. : 1985) [J Appl Physiol (1985)] 2024 Dec 03.
Date of Electronic Publication: 2024 Dec 03.

Historically, it was thought that healthy humans predominantly described their breathing as a sense of increased work or effort (W/E) during maximal exercise. However, emerging data shows that many healthy adults select unpleasant dyspnea descriptors such as “unsatisfied inspiration” (UI), with relatively more females selecting UI than males. We hypothesized that males and females who select UI would report higher dyspnea intensity ratings during exercise; select more distressing dyspnea qualities post-exercise; and have greater inspiratory constraints than those who do not. Sixty-four healthy, non-smokers (32M:32F; 23±5yr) completed questionnaires, pulmonary function tests, and maximal incremental cycling with detailed dyspnea evaluation. Males in UI and Non-UI subgroups reported similar Borg 0-10 dyspnea intensity ratings of W/E, UI, and unsatisfied expiration (UE) (all P >0.05). Females in the UI subgroup reported significantly higher UI and UE ratings than females in the Non-UI subgroup (both P <0.01). Both UI subgroups reported greater air hunger, chest tightness, and mental breathing effort than Non-UI participants (all P <0.05). In males only, masculine gender was negatively correlated (r=-0.402, P =0.02) and anxiety positively correlated (r=0.363, P =0.04) with submaximal UI ratings. Females with UI had smaller peak tidal volume (V _T ) (1.74 (0.32) vs 2.06 (0.33) L, P =0.03) than Non-UI females; and V _T was negatively correlated with submaximal (r=-0.496, P =0.004) and peak (r=-0.495, P =0.004) UI ratings in all females. There were no differences in V _T or correlations between V _T and dyspnea in male subgroups. Absolute lung volumes and psychosocial factors appear important in understanding sex differences in the perception of UI during exercise.

Ladefoged BT; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
Pedersen ALD;Dybro AM; Clemmensen TS; DGillmore J; Poulsen SH

ESC heart failure [ESC Heart Fail] 2024 Dec 03.
Date of Electronic Publication: 2024 Dec 03.

Aims: Wild-type transthyretin cardiac amyloidosis (ATTRwt) is a cardiomyopathy causing myocardial hypoperfusion and impaired cardiac mitochondrial function. Trimetazidine is an antianginal agent used in patients with stable angina pectoris, which improves cardiac contractility and mitochondrial function. The aim of the study was to investigate the effect of trimetazidine on invasive haemodynamics and cardiac mitochondrial function in ATTRwt.
Methods: In a randomized, double-blind, placebo-controlled, crossover trial, 22 patients with ATTRwt received 4 weeks of trimetazidine and placebo in randomized order. After each treatment period followed examinations with endomyocardial biopsies taken for high-resolution respirometry and right heart catheterization at rest and during a cardiopulmonary exercise test. The primary endpoint was mean pulmonary artery wedge pressure (mPAWP) during peak exercise. The secondary endpoint was cardiac mitochondrial oxidative phosphorylation capacity. Exploratory endpoints were echocardiographic parameters, cardiac biomarker levels and quality of life.
Results: Trimetazidine did not significantly reduce mPAWP during peak exercise (31 ± 12 vs. 31 ± 13 mmHg, P = 0.61) or improve the cardiac mitochondrial oxidative phosphorylation capacity (73.4 ± 7.7 vs. 75.3 ± 7.7 pmol O ₂ /(mg*s), P = 0.81) compared with placebo, nor did treatment with trimetazidine improve ejection fraction (P = 0.93), global longitudinal strain (P = 0.23), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels (P = 0.92) or the patients’ quality of life (P = 0.98).
Conclusions: In ATTRwt, treatment with trimetazidine did not improve mPAWP or cardiac mitochondrial oxidative phosphorylation capacity compared with placebo.