Dourado, Victor Zuniga; Federal University of São Paulo (UNIFESP), Santos, São Paulo, Brazil
Matheus, Agatha Caveda;Barbosa, Alan Carlos Brisola;Simões, Maria do Socorro Morais Pereira; et al

Heart & lung : the journal of critical care,2025 Oct 17

• Background: Chronotropic and biomechanical limitations, and elevated O2/workload ratio during cardiopulmonary exercise testing (CPET), often constrain the ability to reach a maximal rate of gas exchange (RER) > 1.00 in obese subjects. We hypothesize that RER during CPET differs significantly by body mass index (BMI), necessitating BMI- Age- and Sex-specific values to assess maximal effort.
• Objectives: To establish RER reference values in adults undergoing treadmill CPET based on age, sex, and BMI.
• Methods: We analyzed 1612 treadmill ramp CPETs in adults (893 women) with obesity (n=772; mean age 42±13 years, weight 104±20 kg, and BMI 37±5 kg/m²) and without (n=840; mean age 39±14 years, weight 69±12 kg, and BMI 24±2 kg/m²). We excluded CPETs with operational problems and with spirometric and/or ECG abnormalities. We generated sex-, age- (<33, 34-46, >46 years), and BMI-specific (<30, ≥30 kg/m ² ) RER values. We fit a multiple regression to explore determinants of RER. We also derived an obesity-specific estimation of maximum heart rate (HRmax).
• Results: Participants were 442 normal-weight (BMI<25 kg/m ² ), 398 overweighted (BMI=25-29.99 kg/m ² ), 295 class-1 obese (BMI=30-34.99 kg/m ² ), 247 class-2 obese (BMI=35-39.99 kg/m ² ), and 230 class-3 obese (BMI≥40 kg/m ² ). We set p<0.05 as the significance threshold for all statistical tests. Age, sex, and BMI significantly determined RER (R ² = 0.195). We found sub-1.0 RER, notably in obese and older females. The HR _bpm equation was 195.2-(0.796 x age _years ).
• Conclusion: Fixed values of RER may inadequately reflect maximal effort, particularly in obese, older, and unfit individuals. These findings have direct implications for accurately assessing cardiorespiratory fitness in individuals with obesity.

Griffith, Garett J; Department of Physical Therapy and Human Movement Sciences, Chicago, IL. USA
Thomsen, Brandi;Xie, Zepei;Zhang, Aileen; et al

Medicine and science in sports and exercise,2025 Oct 22

• Background: Parkinson’s disease (PD) is a neurodegenerative nervous system condition causing motor and non-motor symptoms. Endurance training is commonly prescribed in people with PD for possible slowing of disease progression. Since people with PD exhibit lower cardiorespiratory fitness (CRF), it is important to understand peak aerobic capacity (VO2peak) in people with PD. VO2peak prediction equations may be used when cardiopulmonary exercise testing (CPET) is unavailable; however, exercise-based PD-specific prediction equations are lacking. The purpose of the study was to develop a PD-specific VO2peak prediction equation, and to compare this equation to published VO2peak prediction equations.
• Methods: N=127 never medicated individuals with PD, aged 40-80yrs, Hoehn & Yahr stages 1-2, within 5yrs of diagnosis, exercising ≤3days/week, completed a treadmill CPET. Linear regression analyses were performed to generate the VO2peak equation from a validation sub-sample, which was applied to a cross-validation sub-sample. The equation was compared to two published equations for healthy adults.
• Results: The PD-specific VO2peak equation was: VO2peak (mL/kg/min) = 12.466 + 0.149*(TM speed [m/min]) + 85.7*(TM grade [%, as a decimal]) – 2.383*(sex [0=male, 1=female]) – 0.135*(age [years]). There was no difference between estimated and measured VO2peak in the cross-validation sub-sample. Our equation successfully predicted VO2peak in early PD, whereas VO2peak was over- and underestimated in people with PD by the ACSM and Foster equations, respectively.
• Conclusions: Clinicians can estimate VO2peak in individuals with PD to identify those for whom endurance exercise training should be a major health priority, develop an exercise prescription, and assess changes in VO2peak over time.

Walters, Grace W M;  Department of Cardiovascular Sciences,  Leicester LE3 9QP, UK
Gulsin, Gaurav S;Henson, Joseph;Argyridou, Stavroula et al

Journal of functional morphology and kinesiology,2025 Sep 26

Purpose : While peak oxygen uptake (V.O _2peak ) is the gold standard method for assessing exercise tolerance, there is a tendency for underestimation. Several other cardiopulmonary exercise testing (CPET) variables may provide additive prognostic value beyond V.O _2peak alone. The aim of this study was to examine if alternative CPET indices of exercise tolerance are (a) impaired in people with T2D and (b) independently associated with measures of cardiovascular structure and function measured via echocardiography and cardiac MRI.
Methods : Participants with type 2 diabetes (T2D) and healthy controls underwent cardiac magnetic resonance imaging, transthoracic echocardiography, and a CPET. Multiple linear regression was used to determine the relationship between indices of exercise tolerance and markers of cardiovascular structure and function.
Results : A total of 84 people with T2D and 36 healthy volunteers were included in the analysis. All CPET outcomes were worse in those with T2D vs. the controls. Three CPET outcomes were associated with markers of cardiovascular structure and function: V.O ₂ recovery with mean aortic distensibility (β = 0.218, p = 0.049); heart rate recovery with early filling velocity on transmitral Doppler/early relaxation velocity (β = -0.270, p = 0.024), left ventricular mass/volume ratio (β = -0.248, p = 0.030) and mean aortic distensibility (β = 0.222, p = 0.029); and V.O ₂ at the ventilatory threshold with myocardial perfusion reserve (β = 0.273, p = 0.018).
Perspective : These lesser-used CPET indices could be used to identify which people with T2D are at elevated risk of progression to symptomatic heart failure. However, larger longitudinal studies are required to confirm these findings and their potential clinical application.

Di Gioia, Giuseppe;
Squeo, Maria Rosaria;Ferrera, Armando;Macori, Lucrezia; et al

Journal of functional morphology and kinesiology,2025 Oct 18

Background: Body surface area is a key determinant of cardiac morphology and function, but it is often underestimated in the interpretation of athlete’s cardiac phenotypes.
Aims: This study aimed to assess the role of anthropometric characteristics and whether particularly high vs. low body surface area (BSA) is associated with distinct morpho-functional and cardiometabolic features in elite athletes.
Methods: We retrospectively included 2518 Olympic athletes. All underwent a pre-participation screening, including physical examination, ECG, blood analysis, echocardiography, and cardiopulmonary exercise testing. Participants were grouped by sex-specific BSA percentiles: Group A (<5th percentile), Group B (25th-75th), and Group C (>95th percentile). Functional, echocardiographic, and cardio-metabolic parameters were compared among groups. Results: In male athletes, Group C showed higher resting systolic blood pressure (123.8 ± 10.4 mmHg) than Group B (117.4 ± 9.6, p < 0.0001) and Group A (110.4 ± 13, p < 0.0001), and a higher prevalence of dyslipidemia (31.7% vs. 11.1% in Group B and 4% in Group A, p = 0.031). Despite greater LVEDD (59 ± 3 mm in Group C vs. 55 ± 2.9 in B and 51.1 ± 3.1 in A, p < 0.0001) and LV mass ( p < 0.0001), functional performance was lower in Group C, with VO ₂ max/kg of 35.2 ± 13.2 mL/min/kg vs. 44 ± 7.1 in B, and 47.8 ± 7.3 in A ( p < 0.0001). Similar trends were observed in females for morpho-functional parameters, though lipid profiles did not significantly differ among groups ( p > 0.05).
Conclusions: Anthropometric traits significantly influence the cardiovascular and metabolic phenotype of elite athletes. Our findings support the integration of anthropometric profiling into the routine cardiovascular assessment of athletes, especially those at the extremes of body size, to better interpret physiological adaptations and risk profiles.

Afthonidis, Nektarios Lampros; School of Physical Education and Sport Science, Aristotle University, 57001 Thessaloniki, Greece.
Michou, Vasiliki;Anyfanti, Maria;Dalkiranis, Anastasios; et al

Journal of functional morphology and kinesiology,2025 Oct 09

Background: A thorough post-myocardial infarction (MI) evaluation is essential for prognosis and rehabilitation. While cardiopulmonary exercise testing (CPET) is the standard for assessing functional capacity, combining it with dynamic stress echocardiography (DSE) may offer a more comprehensive assessment.
Aim: This study examined the role of stress echocardiography (SE) in male post-MI patients by evaluating left ventricular function with conventional indices and the change in global longitudinal strain (ΔGLS) at rest and during maximal treadmill CPET. A secondary aim was to determine whether ΔGLS could provide additional value to traditional measures in post-MI care.
Methods: Eighteen men with a recent MI [15 ST-elevation MI, three non-ST-elevation MI; mean age 53.2 ± 5.9 years, mean body mass index (BMI) 27.9 ± 2.2, 44.4% with a smoking history) and 18 age-matched male controls (mean age 50.1 ± 10.8 years, mean BMI 26.5 ± 2.4, 39.0% with smoking history) were enrolled. All MI patients were under optimal medical therapy, including β-blockers, which were withheld on the test day. Most underwent percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) n = 2, or PCI for non-ST-elevation MI (NSTEMI) n = 3. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were measured at rest and at peak effort and correlated with CPET parameters.
Results: Post-MI patients had lower LVEF (50.6% vs. 60.7% at rest; 55.3% vs. 67.4% at peak, both p < 0.001), impaired GLS (-14.7% vs. -20.2% at rest, p = 0.003; -15.8% vs. -22.7% at peak, p = 0.001), and reduced VO ₂ peak (29.2 vs. 41.9 mL/kg/min, p < 0.001) compared with controls. In the MI group, ΔGLS correlated with VO ₂ peak (r = -0.645, p = 0.003) and VE/VCO ₂ (r = 0.539, p = 0.020), indicating its potential as a marker of functional reserve.
Conclusions: Combined CPET and SE offered comprehensive insights into functional and myocardial performance, identifying ΔGLS as a useful non-invasive index for risk stratification and rehabilitation after MI, with high feasibility and safety.

Ketelhut, Sascha Institute of Sport Science, University of Bern, Bremgartenstrasse 145, 3012, Bern, Switzerland
Brand, Ralf;Hug, Daniel;Mueller, Florian ‘Floyd’ et al

Sports Medicine – Open,10/15/2025

Maximal exercise testing is a fundamental component of sports medicine and clinical practice, essential for evaluating physical fitness, tailoring training programs, and diagnosing health conditions. A crucial aspect of maximal exercise testing is ensuring that participants exert maximal effort, as insufficient effort can compromise the validity of results, potentially leading to misdiagnoses, misinterpretation of outcomes, and inappropriate exercise recommendations. Various strategies, including verbal, audio, and video-based methods, have been used in research and practice to encourage maximal effort. Despite the recognized importance of these strategies, understanding of them remains limited, with recommendations being either inconsistent or entirely lacking. Notably, innovative approaches that harness the potential of digital methods are still relatively scarce. In this article, we discuss the potential of incorporating game elements as an innovative encouragement strategy during maximal exercise testing. Drawing from research on exergaming, we provide examples of impactful game features and discuss their potential integration into exercise testing. This innovative approach has the potential to improve test reliability, enhance validity, streamline workflows, and positively influence attitudes toward exercise testing. We advocate for establishing a new area of research focused on gamifying maximal exercise tests to elevate exercise diagnostics to the next level. Key Points: • Maximal exercise testing is an important tool for assessing physical fitness and diagnosing health conditions. A critical factor in ensuring the validity of these tests is confirming that participants exert maximal effort, which can be particularly challenging in certain target groups. • Currently, verbal encouragement is predominantly used in research and practice. However, this is difficult to standardize and often lacks engagement, as it heavily depends on the individual delivering it. Game design elements may offer a more effective approach by fostering a dissociative focus, enhancing motivation, and increasing effort investment. • Immersive and engaging game design elements used as encouragement strategies may improve the validity of maximal exercise tests and enhance compliance, especially in populations with lower motivation.

Walters GWM, Leicester Biomedical Research Centre, Leicester LE3 9QP, UK
Gulsin GS, Henson J, Argyridou S, Parke KS, Yates T, Davies MJ, McCann GP, Brady EM.

J Funct Morphol Kinesiol. 2025 Sep 26;10(4):371.

Purpose: While peak oxygen uptake (V.O2peak) is the gold standard method for assessing exercise tolerance, there is a tendency for underestimation. Several other cardiopulmonary exercise testing (CPET) variables may provide additive prognostic value beyond V.O2peak alone. The aim of this study was to examine if alternative CPET indices of exercise tolerance are (a) impaired in people with T2D and (b) independently associated with measures of cardiovascular structure and function measured via echocardiography and cardiac MRI.
Methods: Participants with type 2 diabetes (T2D) and healthy controls underwent cardiac magnetic resonance imaging, transthoracic echocardiography, and a CPET. Multiple linear regression was used to determine the relationship between indices of exercise tolerance and markers of cardiovascular structure and function.
Results: A total of 84 people with T2D and 36 healthy volunteers were included in the analysis. All CPET outcomes were worse in those with T2D vs. the controls. Three CPET outcomes were associated with markers of cardiovascular structure and function: V.O2 recovery with mean aortic distensibility (β = 0.218, p = 0.049); heart rate recovery with early filling velocity on transmitral Doppler/early relaxation velocity (β = -0.270, p = 0.024), left ventricular mass/volume ratio (β = -0.248, p = 0.030) and mean aortic distensibility (β = 0.222, p = 0.029); and V.O2 at the ventilatory threshold with myocardial perfusion reserve (β = 0.273, p = 0.018).
Perspective: These lesser-used CPET indices could be used to identify which people with T2D are at elevated risk of progression to symptomatic heart failure. However, larger longitudinal studies are required to confirm these findings and their potential clinical application.

Randy H; Université Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France.
Perrin TP; Ghaith A; Kohlbrenner D; Flore P; Champigneulle B; Guinot M; Doutreleau S;
Brugniaux J;Verges S;Marillier

Physiological reports [Physiol Rep] 2025 Oct; Vol. 13 (19), pp. e70432.

Vascular aging involves reduced endothelial function, a key factor in cardiovascular diseases. Intermittent hypoxia may improve endothelial function and cardiorespiratory fitness (CRF), but its effects in elderly individuals, especially in the mid-term, have not yet been studied. This randomized, single-blind controlled trial aimed to investigate whether an 8-week intermittent hypoxic conditioning (IHC) program may enhance flow-mediated dilation (FMD) and CRF in elderly individuals. Twenty-six participants (60-80 year-old) were assigned to either the IHC (n = 12) or the control group (CTL: n = 14). The IHC group underwent 24 passive intermittent hypoxia sessions (3/week). Brachial artery FMD, cardiopulmonary exercise testing (CPET), and ambulatory 24-h blood pressure were assessed at baseline (Pre), immediately post-intervention (Post 1), and 2 months later (Post 2). FMD showed a trend toward improvement in the IHC group, being significant when normalized for baseline artery diameter (p = 0.023; η _p²  = 0.150) between Pre and Post 2. Peak ventilation during CPET increased from Pre to Post 1 (p = 0.021), with no other significant CRF changes. Daytime systolic blood pressure decreased by 6 mmHg (p = 0.070, η _p²  = 0.105). No significant alterations in these outcomes were observed in the CTL group (p &gt; 0.05). Moderate IHC enhanced mid-term endothelial function, suggesting potential to mitigate age-related vascular decline.

 Magrì, Damiano; Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.
Fiori, Emiliano; Agostoni, Piergiuseppe; Correale, Michele ;et al;

Heart failure reviews [Heart Fail Rev] 2025 Oct 07.
Date of Electronic Publication: 2025 Oct 07.

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) frequently coexist and interact through complex and bidirectional hemodynamic mechanisms that amplify symptoms’ burden and complicate clinical management. The present review explores the impact of COPD across the HF spectrum, particularly in HF with preserved ejection fraction (HFpEF), where comorbidities, such as COPD, exert a dominant role in disease expression. COPD-induced hyperinflation reduces cardiac preload and increases right ventricular afterload, while HF-related congestion impairs pulmonary function and gas exchange, illustrating a tight cardiorespiratory coupling. Diagnostic challenges stem from overlapping symptoms and the limited specificity of biomarkers, such as natriuretic peptides, especially in HFpEF. Cardiopulmonary exercise testing (CPET) emerges as a valuable tool for distinguishing between cardiac and pulmonary limitations and guiding individualized treatment strategies. From a therapeutic standpoint, β1-selective blockers are not only safe in COPD patients but are pivotal in those with HF with reduced ejection fraction (HFrEF), where they have been demonstrated to improve survival and reduce both HF and COPD exacerbations. Concerns regarding bronchodilator safety in HF remain largely theoretical, with current evidence supporting their continued use when clinically indicated. Ultimately, optimal care for patients with coexisting COPD and HF requires a phenotype-specific approach, incorporating insights from pathophysiology, diagnostic innovation, and evidence-based pharmacotherapy to improve outcomes in this challenging patient population.

Hogwood, Austin C.; University of Virginia, Charlottesville, VA. USA
Golino, Michele; Canada, Justin M.; West, Joshua; et al;

Medicine & Science in Sports & Exercise; (Baltimore, Maryland) 2025Supplement; v.57, 511-512. (2p)

The article focuses on the relationship between cardiac reserve and cardiorespiratory fitness (CRF) in patients who have experienced reperfused ST-elevation myocardial infarction (STEMI). A study involving fifty-six patients assessed cardiac reserve through Doppler echocardiography and CRF via a symptom-limited cardiopulmonary exercise test conducted approximately six weeks post-STEMI. Results indicated significant correlations between cardiac reserve metrics, such as stroke volume and cardiac output, and CRF measures, including peak oxygen uptake and ventilatory efficiency. The findings suggest that enhancing cardiac reserve may also improve CRF in this patient population.