Ludwig V; Technical University of Munich, Munich, Germany
Freiberger A; Muller J; Hock J; Ewert P; Hager A

Journal of Cardiopulmonary Rehabilitation & Prevention. 46(1):16-27, 2026

PURPOSE: Expiratory flow limitation (EFL) and dynamic hyperinflation (DH)
may significantly impact exercise capacity in patients with heart disease.
Although commonly linked to lung diseases, recent evidence highlights
their role in cardiovascular disease (CVD), contributing to exercise
intolerance. This systematic review examines studies from the past decade
on pulmonary function during exercise, measured using inspiratory capacity
(IC) maneuvers, in patients with CVD, emphasizing prevalence and clinical
significance.

REVIEW METHODS: A systematic literature search in PubMed, Scopus, and
Cochrane (January 2014-February 2024) explored pulmonary function during
exercise in patients with CVD. Two independent reviewers assessed studies
using established Quality Assessment Tools.

SUMMARY: Seven studies including 231 patients with CVD (mean age 31-66
yr, predominantly male) used cardiopulmonary exercise testing to evaluate
exercise-induced DH or EFL with varying definitions. Study quality was
mixed. Patients with myocardial infarction showed EFL at moderate
exercise, while patients with stable coronary artery disease exhibited EFL
only at high intensities. Up to 50% of patients with pulmonary arterial
hypertension have DH during peak exercise (P < .05). In patients with
heart failure, 25% experienced DH, while others maintained stable
breathing. Patients who are post-Fontan displayed pulmonary inefficiencies
without DH. Methodological variability precludes definitive conclusions on
DH prevalence in patients with CVD. However, reduced IC during exercise,
DH, and EFL occur in a substantial proportion of patients, indicating a
lower EFL threshold and earlier ventilatory constraints. Further research
into heart-lung integration during exercise is crucial for developing
personalized treatments and improving clinical management in those
patients.

Milani M; Hasselt University, REVAL/BIOMED, Hasselt, Belgium (
Milani JGPO; Machado FVC; Cipriano GFB;et al

Journal of Cardiopulmonary Rehabilitation & Prevention. 46(1):35-43, 2026

PURPOSE: A low breathing reserve (peak ventilation [Epeak]/estimated
maximum ventilation [Emax] <= 15%) is recommended as the decision node to
indicate abnormal ventilatory limitation during incremental cycle
ergometry. Given higher Epeak during weight-bearing exercise, we aim to
establish which coefficients should multiply the forced expiratory volume
in 1 second (FEV1) to reduce the prevalence of a low breathing reserve in
healthy subjects undergoing treadmill exercise.

METHODS: We determined the coefficients for FEV1 multiplication
associated with <5% prevalence of a low breathing reserve in 3544 healthy
individuals aged 20 to 80 years. We then contrasted their performance in
differentiating healthy subjects (N = 148) from patients with chronic
obstructive pulmonary disease (COPD) (N = 133) in an external validation
sample.

RESULTS: A low breathing reserve was found in 22% and 6% of women versus
48% and 17% of men when FEV1 was multiplied by 35 and 40, respectively.
Sex-adjusted coefficients required to decrease the prevalence of a low
breathing reserve ranged from 33 and 48 in women versus 36.5 and 50 in men
in those showing peak oxygen uptake <80% and >120% predicted,
respectively. Breathing reserve using the new sex- and fitness-adjusted
coefficients were superior to previous values in differentiating health
from disease, regardless of COPD severity.

CONCLUSION: Higher coefficients for FEV1 multiplication are required to
estimate Emax at peak treadmill exercise in men than in women, increasing
as a function of cardiorespiratory fitness in both sexes. These data are
poised to improve the yield of cardiopulmonary exercise tests in
accurately indicating pathological ventilatory limitation in patients with
respiratory diseases.

Tseng WH; Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
Chiu CH; Chang SY; Yang LY; Huang SC

Annals of Surgical Oncology. 33(2):889-904, 2026 Feb.

BACKGROUND: Cardiopulmonary exercise testing (CPET) parameters, such as
ventilatory equivalent for carbon dioxide (VE/VCO2), peak oxygen
consumption (VO2peak), and anaerobic threshold (AT), have been proposed as
potential predictors of postoperative complications. Yet, few systematic
analyses have examined the association between CPET variables and major
complications after esophagectomy, as defined by the Clavien-Dindo
classification. Associations with cardiopulmonary complications and
mortality also require updating on the basis of trial sequential analysis
(TSA).

MATERIALS AND METHODS: Systematic searches were conducted to identify
relevant studies reporting preoperative CPET values and major
complications, cardiopulmonary complications, and 1-year mortality.
Standardized mean differences (SMD, random-effects model) were calculated
and TSA was conducted to evaluate the robustness of evidence in the
previous and current meta-analyses.

RESULTS: A total of 12 studies met inclusion criteria. VO2peak was
correlated with major complications (SMD = – 0.42; 95% CI – 0.70 to –
0.14, p = 0.0032) and cardiopulmonary complications (SMD = – 0.39; 95% CI
– 0.65 to – 0.13, p = 0.0032). AT showed similar but weaker associations
with both outcomes (SMD = – 0.33 and – 0.22; 95% CI – 0.63 to – 0.03 and
CI – 0.40 to – 0.04, p = 0.033 and 0.018, respectively). VE/VCO2
demonstrated no meaningful relationship with major complications. In
addition, the present study found neither VO2peak nor AT was associated
with 1-year mortality after esophagectomy.

CONCLUSIONS: VO2peak and AT were inversely associated with morbidity
after esophagectomy, while VE/VCO2 offered limited prognostic value and
none predict 1-year survival. VO2peak is a key predictor of major and
cardiopulmonary complications after esophagectomy and warrants further
investigation, either alone or as part of a composite model.

Blumer V; Baim Institute for Clinical Research, Boston, Massachusetts, USA.
Januzzi JL Jr; Liu Y; Butler J; Ezekowitz JA; et al

JACC Heart Failure. 14(1):102433, 2026 Jan.

OBJECTIVES: This analysis focuses on sex differences in baseline
characteristics of study participants with DbCM at high risk for
progression to overt HF and sex-based treatment responses to high-dose
AT-001, a novel aldose reductase inhibitor.

METHODS: The ARISE-HF trial was a Phase 3, randomized, international,
placebo-controlled study designed to evaluate the efficacy and safety of
AT-001 in study participants with DbCM.

RESULTS: Of 691 participants, 348 (50.4%) were women. At baseline, women
had higher N-terminal pro-B-type natriuretic peptide concentrations (92 vs
60 ng/L; P < 0.001), lower peak oxygen uptake (13.87 vs 17.59 mL/kg/min; P
< 0.001), shorter cardiopulmonary exercise testing durations (8.47 vs
11.05 minutes; P < 0.001), and worse quality of life and health status
(Kansas City Cardiomyopathy Questionnaire overall summary score 87.79 vs
92.55; P < 0.001; Physical Activity Scale for the Elderly score 137.87 vs
171.09; P < 0.001) compared with men. Despite these differences, there
were no significant sex differences in the efficacy or tolerability of
high-dose AT-001 compared with placebo. The placebo-corrected oxygen
uptake change was 0.26 for women and 0.27 for men (P = 0.58), and changes
from baseline to month 15 in Kansas City Cardiomyopathy Questionnaire and
Physical Activity Scale for the Elderly scores showed no significant sex
differences (all P > 0.05).

CONCLUSIONS: Despite baseline differences between women and men with
DbCM, the efficacy and safety of high-dose AT-001 are comparable across
sexes. These findings highlight the presence of sex-specific
characteristics in DbCM and underscore the importance of further research
to understand potential sex-specific mechanisms. (Aldose Reductase
Inhibition for Stabilization of Exercise Capacity in Heart Failure Trial
[ARISE-HF]; NCT04083339).

Priego-Jiménez, Susana;
Priego-Jiménez, Pablo;López-González, María;Martinez-Rodrigo, Arturo;+2 more

Journal of clinical medicine,2025 Dec 25

Background/Objectives: Patient preoperative cardiorespiratory physical fitness measured by maximal oxygen consumption (VO2max) is highly relevant to postoperative outcomes, with low VO2max associated with a greater symptom burden and a greater prevalence of long-term treatment-related cardiovascular disease risk factors in patients undergoing surgery. A network meta-analysis (NMA) was conducted to determine the effects of different components of prehabilitation, including exercise, nutrition, psychological intervention, and different combinations of the aforementioned interventions, on oxygen consumption in people undergoing major abdominal or cardiothoracic surgery.
Methods: A literature search was conducted from inception to December 2025. Randomized controlled trials on the effectiveness of prehabilitation programmes on pre-surgery VO2max were included. The risk of bias was assessed via the Cochrane risk of bias (RoB 2.0) tool, and the quality of evidence was assessed via the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. Pairwise meta-analyses and NMAs were conducted for direct and indirect evidence.
Results: Fourteen studies were included in this NMA. The highest effect (ES) for VO2max scores was for the exercise group versus the control group (ES: 0.44; 95% CI: 0.11, 0.78). When exercise was categorized according to intensity, the highest effect was for high-intensity interval training (HIIT) versus the control (ES: 0.51; 95% CI: 0.04, 0.97).
Conclusions: Exercise HIIT should be considered the most effective strategy for improving exercise capacity in patients undergoing major abdominal or cardiothoracic surgery. Given the importance of VO2 as a predictor of morbidity, mortality, and the potential occurrence of adverse events after the procedure in surgical patients, it is essential to include its measurement in future studies to estimate both the risk of procedures and the effect of prehabilitation programmes.

Osailan, Ahmad M; Prince Sattam bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia.

Healthcare (Basel, Switzerland),2025 Dec 27

Background: Sleep quality is critical to health, and its disturbances may affect multiple systems, including autonomic and respiratory regulation. However, its relationship with chronotropic and ventilatory responses in healthy young men remains underexplored. Thus, the study aimed to investigate the relationship between sleep quality, as measured by the Pittsburgh Sleep Quality Index (PSQI), and chronotropic and ventilatory responses during cardiopulmonary exercise testing (CPET) in a healthy young male population and to explore group differences between good and poor sleepers.
Methods: Thirty-three healthy men completed the PSQI and a graded CPET with breath-by-breath gas analysis. Pearson correlation was used to examine relationships between the PSQI and CPET outcomes: chronotropic response (%), tidal volume (VT), minute ventilation (VE), VO ₂ , VCO ₂ , expired O ₂ /CO ₂ , VE/VO ₂ , and VE/VCO ₂ . After accounting for age, height, and weight, the correlation was reassessed. Secondary analyses using a standard cut-off point compared good (PSQI < 5) vs. poor sleepers (PSQI ≥ 5) with Welch’s t -tests. Results: Participants were predominantly poor sleepers (84.8%; PSQI 7.3 ± 3.2). A higher PSQI correlated with lower chronotropic response ( r = -0.35, p = 0.04), lower VT ( r = -0.42, p = 0.02), lower expired O ₂ ( r = -0.46, p = 0.01), and lower expired CO ₂ ( r = -0.33, p = 0.05). Associations with VE, VO ₂ , VCO ₂ , VE/VO ₂ , and VE/VCO ₂ were small and non-significant ( p > 0.05). When age, height, and weight were controlled for, the attenuated chronotropic response association with the PSQI was not significant; however, the PSQI association remained significant for expired O ₂ ( r = -0.32, p = 0.04), with a trend for VT. In group comparisons, chronotropic response was higher but not significant; good sleepers showed higher VT and greater expired O ₂ /CO ₂ ( p < 0.05).
Conclusions: Poorer sleep quality was initially associated with multiple cardiopulmonary responses at peak during CPET. However, after controlling for age and anthropometry measures, only expired O ₂ remained linked. The findings suggest that routine sleep quality screening may add interpretive value to CPET by flagging individuals with reduced ventilatory depth, warranting prospective studies to test whether improving sleep quality can enhance exercise responses.

Yanishi, Masaaki; Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
Kimura, Yutaka;Koito, Yuya;Matsushita, Jun;+4 more

Transplantation proceedings,2026 Jan 08

• Background: Sarcopenia remains a significant concern among kidney transplant recipients even after renal function improves. However, the predictors of impaired muscle recovery are not well established.
• Methods: We retrospectively analyzed 40 adults who underwent living-donor kidney transplantation at Kansai Medical University Hospital between January 2018 and December 2020. Preoperative cardiopulmonary exercise testing (CPX) was used to stratify patients into low-tolerance (anaerobic threshold VO₂ < 11 mL/kg/min and peak VO₂ < 20 mL/kg/min) and normal groups. The skeletal muscle index (SMI) was measured using dual-energy x-ray absorptiometry from baseline to 3 years post-transplantation. Multivariable linear regression and correlation analyses were performed to identify predictors of long-term SMI improvement.
• Results: Forty recipients were analyzed, including 12 (30%) in the low-tolerance group. Following transplantation, the median SMI in both groups decreased at 6 months and improved thereafter. However, from 1 year after transplantation onwards, the normal group demonstrated a significant increase in SMI compared with the low-tolerance group. Three years after transplantation, the median SMI in the normal group exceeded pretransplant levels and steadily increased, whereas in the low-tolerance group, there was little improvement and no return to baseline (P ≤ .05). Multivariable analysis identified low preoperative exercise tolerance as an independent predictor of reduced SMI recovery (P ≤ .05). Correlation analysis revealed that preoperative anaerobic threshold VO₂ and peak VO₂ were moderately and significantly associated with 3-year SMI improvement (r = 0.427 and r = 0.607, respectively).
• Conclusions: Low exercise tolerance before kidney transplantation strongly predicts impaired long-term skeletal muscle recovery. Cardiopulmonary exercise testing-based risk assessment may help identify candidates who could benefit from tailored perioperative rehabilitation strategies to enhance functional outcomes.

Utsumi, Yuya; Department of Rehabilitation, Tokushima Red Cross Hospital, Japan.
Takase, Koji;Murakami, Naoya;Nakagawa, Tokiko;+3 more

Physical therapy research,2025

• Objectives: Anaerobic threshold (AT) assessment using cardiopulmonary exercise testing (CPX) during hospitalization is considered ideal for prescribing exercise regimens in patients with acute myocardial infarction (AMI). However, practical limitations often hinder its implementation. This study evaluated strategies for prescribing exercise based on resting heart rate (RHR).
• Methods: A total of 194 consecutive male patients with AMI who underwent CPX within 13 days of hospitalization were enrolled. Bland-Altman analysis was performed to assess the agreement between the heart rate (HR) at AT (ATHR) and RHR +20, +25, and +30 beats. Multiple regression analysis was conducted to identify factors influencing ΔHR (ATHR-RHR). Decision-tree analysis was used to establish thresholds for appropriate exercise prescriptions based on RHR.
• Results: Regardless of β-blocker use, the RHR + 25 formula most closely approximated the ATHR in patients who underwent early CPX after AMI. Multivariate analysis identified RHR and hemoglobin (Hb) as significant predictors of ΔHR. Decision-tree analysis indicated that RHR + 25 was appropriate when RHR <91 bpm and Hb ≥12.0 g/dL.
• Conclusions: RHR + 25 is a practical alternative for determining the target HR in post-AMI rehabilitation among male patients, particularly in those with RHR <91 bpm and Hb ≥12.0 g/dL, when CPX is not feasible.

Bélanger, Noémie; German Center for Cardiovascular Research (DZHK), partner site Rhine-Main, Mainz, Germany.
Zeid, Silav;Velmeden, David;Schulz, Andreas;+10 more

Cardiovascular diabetology,2026 Jan 08

• Background: Cardiac autonomic dysfunction plays a pivotal role in the heart failure syndrome. Metabolic dysregulation affects both autonomic function and heart failure, but these relationships remain incompletely understood. This study aimed at investigating the role of glucose and insulin metabolism for parasympathetic reactivation.
• Methods: Data from the MyoVasc study (NCT04064450), a prospective heart failure cohort study, were analyzed. Participants underwent a highly standardized 5-hour examination, including venous blood sampling. To assess the impact of glucose and insulin metabolism (HbA _1c , HOMA-IR, and C-peptide) on parasympathetic reactivation as reflected by heart rate recovery 60 s (HRR ₆₀ ) after cardiopulmonary exercise testing, multivariable linear regression models with adjustment for sex, age, clinical profile (cardiovascular risk factors and comorbidities) and medication were calculated in cross-sectional and longitudinal settings. Additional adjustment for complementary glucose or insulin status was performed to assess the dependency of each other. Analyses were carried out in symptomatic heart failure and across the spectrum of glucose metabolism dysfunction.
• Results: The analysis sample included 1,588 individuals (median age 64.0 years [IQR 55.0;72.0]; 33% women) in a fasting state. Symptomatic heart failure was present in 43.7% of the subjects. Median HRR ₆₀ was 21.0 beats per minute (IQR 14.0;28.0). In multivariable regression analysis with adjustment for age, sex, clinical profile, and medication, both HbA _1c ([Formula: see text] _{per SD} -0.074, 95% CI [- 0.122;-0.026], P = 0.003) and HOMA-IR ([Formula: see text] _{per SD} -0.113 [- 0.165;-0.062], P < 0.0001) predicted HRR ₆₀ . Additional adjustment for both glucose and insulin status, respectively, demonstrated that HOMA-IR ([Formula: see text] _{per SD} -0.097 [- 0.155;-0.040], P < 0.0001), but not HbA _1c ([Formula: see text] _{per SD} -0.030 [- 0.084;0.025], P = 0.28), was independently related to HRR ₆₀ . This finding was confirmed in subgroups with heart failure and type 2 diabetes. In all analyses, C-peptide was related to HRR ₆₀ independently of HbA _1c with higher effect estimates than HOMA-IR ([Formula: see text] _{per SD} -0.171 [- 0.225;-0.117], P < 0.0001). Finally, higher HbA _1c ([Formula: see text] _{per SD} -0.094, [- 0.171;-0.017], P = 0.017) and C-peptide ([Formula: see text] _{per SD} -0.076, [- 0.159;0.007], P = 0.075) were more strongly associated with a lower HRR ₆₀ after two years of follow-up.
• Conclusions: This study demonstrates the relevance of insulin status for vagal activity of cardiac autonomic function, particularly in heart failure. The pathophysiological implications underlying the relationship between insulin status and parasympathetic activity merit further mechanistic exploration.

Ikegami, Shogo; Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan.
Hiraide, Takahiro;Maeda, Takashi;Momoi, Mizuki;+5 more

Journal of clinical medicine,2025 Dec 11

Background: Pulmonary arterial hypertension (PAH) leads to right ventricular failure and death. Inhaled treprostinil, a tricyclic benzindene prostacyclin analog, has become available, but evidence regarding its clinical efficacy and quality-of-life (QoL) benefits-particularly in patients already receiving optimized combination vasodilator therapy-remains limited.
Methods: Inhaled treprostinil was introduced to nine patients with PAH already receiving combination therapy with pulmonary vasodilators. Acute hemodynamic effects were assessed during initial right heart catheterization, and long-term effects were evaluated at baseline and 3 months after treatment. Exercise tolerance was assessed by the 6-minute walking distance (6MWD) test and cardiopulmonary exercise testing, while QoL was evaluated using the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12).
Results: Mean pulmonary arterial pressure significantly improved both acutely (48.9 ± 17.8 to 43.7 ± 14.5 mmHg, p = 0.036) and at 3 months (46.4 ± 16.1 to 39.8 ± 14.1 mmHg, p = 0.014). Pulmonary vascular resistance tended to decrease, while 6MWD outcomes remained unchanged. QoL improved, with KCCQ-12 overall and clinical summary scores increasing from 59.1 ± 27.4 to 67.1 ± 26.5 and 78.1 ± 26.3 to 87.5 ± 21.2, respectively.
Conclusions: Treprostinil inhalation improved hemodynamics and patient-reported outcomes despite prior combination improved hemodynamics and tended to enhance QoL in patients with PAH receiving combination vasodilator therapy.