Saratzis A;Thatcher A; Bath MF; Sidloff DA; Bown MJ; Shakespeare J; Sayers RD;
Imray C,

Annals Of The Royal College Of Surgeons Of England [Ann R Coll
Surg Engl], ISSN: 1478-7083, 2017 Feb; Vol. 99 (2), pp. 161-165;

INTRODUCTION Reporting surgeons’ outcomes has recently been introduced
in the UK. This has the potential to result in surgeons becoming risk
averse. The aim of this study was to investigate whether reporting
outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the
number and risk profile (level of fitness) of patients offered elective
treatment.
METHODS Publically available National Vascular Registry data
were used to compare the number of AAAs treated in those centres across
the UK that reported outcomes for the periods 2008-2012, 2009-2013 and
2010-2014. Furthermore, the number and characteristics of patients
referred for consideration of elective AAA repair at a single tertiary
unit were analysed yearly between 2010 and 2014. Clinic, casualty and
theatre event codes were searched to obtain all AAAs treated. The
results of cardiopulmonary exercise testing (CPET) were assessed.
RESULTS For the 85 centres that reported outcomes in all three
five-year periods, the median number of AAAs treated per unit increased
between the periods 2008-2012 and 2010-2014 from 192 to 214 per year
(p=0.006). In the single centre cohort study, the proportion of
patients offered elective AAA repair increased from 74% in 2009-2010 to
81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm
size and CPET results (anaerobic threshold levels) for those eventually
offered elective treatment did not differ significantly between 2010
and 2014.
CONCLUSIONS The results do not support the assumption that
reporting individual surgeon outcomes is associated with a risk averse
strategy regarding patient selection in aneurysm surgery at present.

J Cardiol. 2017 Mar 7. pii: S0914-5087(16)30308-2. [Epub ahead of print]

Yoshida S, Adachi H, Murata M, Tomono J, Oshima S, Kurabayashi
M.

BACKGROUND: Myocardial ischemia induces cardiac dysfunction, resulting in
insufficient oxygen supply to peripheral tissues and mismatched energy production
during exercise. To relieve the insufficient oxygen supply, heart rate (HR)
response is augmented; however, beta-adrenergic receptor blockers (BB) restrict
HR response. Although BB are essential drugs for angina pectoris, the effect of
BB on exercise tolerance in patients with angina has not been studied. The aim of
this study was to clarify the importance of HR augmentation to preserve exercise
tolerance in patients with angina pectoris.
METHODS: Forty-two subjects who underwent cardiopulmonary exercise testing (CPX)
to detect myocardial ischemia were enrolled. CPX was performed until exhaustion
or onset of significant myocardial ischemia using a ramp protocol. Subjects were
assigned to three groups (Group A: with ST depression during CPX with significant
coronary stenosis and taking BB; Group B: with ST depression and not taking BB;
Group C: without ST depression and not taking BB). HR response to exercise was
evaluated during the following two periods: below and above ischemic threshold
(IT). In Group C, it was evaluated during the first 2min and the last 2min of a
ramp exercise.
RESULTS: No significant differences were observed among the three groups with
regard to patients’ basic characteristics. Below IT, there were no differences in
oxygen pulse/watt (O2 pulse increasing rate), HR/watt (ΔHR/ΔWR), and ΔV˙O2/ΔWR.
Above IT, O2 pulse increasing rate was greater in Group A than in Group B.
ΔHR/ΔWR was smaller in Group A than in Group B. ΔV˙O2/ΔWR became smaller in Group
A than in Group B. There was no difference in anaerobic threshold, and peak V˙O2
was smaller in Group A than in Group B.
CONCLUSIONS: Restriction of HR response by a BB is shown to be one of the
important factors in diminished exercise tolerance.

Rev Port Cardiol. 2017 Feb 23

Aguiar Rosa S(1), Abreu A(2), Marques Soares R(2), Rio P(2), Filipe C(3),
Rodrigues I(2), Monteiro A(2), Soares C(2), Ferreira V(2), Silva S(2), Alves
S(2), Cruz Ferreira R(2).

INTRODUCTION: Cardiac rehabilitation (CR) has been demonstrated to improve
exercise capacity in acute coronary syndrome (ACS), but not all patients derive
the same benefit. Careful patient selection is crucial to maximize resources.
OBJECTIVE: To identify in a heterogeneous ACS population which patients would
benefit the most with CR, in terms of functional capacity (FC), by using
cardiopulmonary exercise testing (CPET).
METHODS: A retrospective analysis of consecutive ACS patients who underwent CR
and CPET was undertaken. CPET was performed at baseline and after 36 sessions of
exercise. Peak oxygen uptake (pVO2), percentage of predicted pVO2, minute
ventilation/CO2 production (VE/VCO2) slope, VE/VCO2 slope/pVO2 and peak
circulatory power (PCP) (pVO2 times peak systolic blood pressure) were assessed
in two moments. The differences in pVO2 (ΔpVO2), %pVO2, PCP and exercise test
duration were calculated. Patients were classified according to baseline pVO2
(group 1, <20 ml/kg/min vs. group 2, ≥20 ml/kg/min) and left ventricular ejection
fraction (group A, <50% vs. group B, ≥50%).
RESULTS: We analyzed 129 patients, 86% male, mean age 56.3±9.8 years. Both group
1 (n=31) and group 2 (n=98) showed significant improvement in FC after CR, with a
more significant increase in pVO2, in group 1 (ΔpVO2 4.4±7.3 vs. 1.6±5.4;
p=0.018). Significant improvement was observed in CPET parameters in group A
(n=34) and group B (n=95), particularly in pVO2 and test duration.
CONCLUSION: Patients with lower baseline pVO2 (<20 ml/kg/min) presented more
significant improvement in FC after CR. CPET which is not routinely used in
assessement before CR in context of ACS, could be a valuable tool to identify
patients who will benefit the most

Clin Cardiol. 2017 Feb;40(2):95-101. doi: 10.1002/clc.22635. Epub 2016 Nov 2.

Zhao QH(1), Wang L(1), Pudasaini B(1), Jiang R(1), Yuan P(1), Gong SG(1), Guo
J(2), Xiao Q(1), Liu H(1), Wu C(3), Jing ZC(4), Liu JM(1,)(2).

(1)Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji
University, School of Medicine, Shanghai, China. (2)Department of Pulmonary
Function, Shanghai Pulmonary Hospital, Tongji University, School of Medicine,
Shanghai, China. (3)Department of Statistics, the Second Military Medical
University, Shanghai, China. (4)State Key Laboratory of Cardiovascular Disease,
Fu Wai Hospital, Peking Union Medical College and Chinese Academy of Medical
Science, Beijing, China.

BACKGROUND: Doppler echocardiography is usually the first diagnostic
investigation for patients suspected with pulmonary hypertension (PH), but it is
often inaccurate when used alone, especially in mild PH.
HYPOTHESIS: Cardiopulmonary exercise testing (CPET) may serve as a complementary
tool to improve diagnostic accuracy in echocardiography-suspected “PH possible”
patients.
METHODS: Eighty-eight consecutive patients with suspected PH (referred to as “PH
possible” hereafter) based on echocardiography were included in the study. CPET
was assessed subsequently and PH was confirmed by right-heart catheterization in
all subjects. We analyzed CPET data from patients and derived a CPET prediction
rule to hemodynamically differentiate PH.
RESULTS: Eighty-eight patients (27 patients with confirmed PH, and PH ruled out
in 61 patients) were included in the study. Compared with non-PH patients, the PH
subjects had lower peak oxygen uptake (VO2 ), aerobic capacity (AT), peak partial
pressure of end-tidal CO2 (PET CO2 ), oxygen uptake efficiency plateau (OUEP),
and oxygen uptake efficiency slope (OUES), along with higher minute ventilation
(VE)/carbon dioxide output (VCO2 ) slope and lowest VE/VCO2 (P < 0.001). VE/VCO2
slope and AT were independent predictors of PH derived from multivariate logistic
regression adjusted for age and body mass index. A score combining VE/VCO2 slope
and AT reached a high area under the curve value of 0.98. A score ≥0.5 had 95%
specificity and 92.6% sensitivity for diagnosis of PH.
CONCLUSIONS: A score combining VE/VCO2 slope and AT provides high specificity in
screening out PH from a pool of echocardiography-suspected PH patients.

J Invasive Cardiol. 2017 Mar;29(3):83-91.

Abdullah SM(1), Hastings JL, Amsavelu S, Garcia-Morales F, Hendrix F, Karatasakis
A, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Khalili H, Banerjee S, Brilakis
ES.

OBJECTIVES: Although coronary chronic total occlusions (CTOs) are treated with
percutaneous coronary intervention (PCI) to improve symptoms, studies
demonstrating symptom improvement have been mostly limited to questionnaire
responses. The current study assessed for changes in peak oxygen uptake during
cardiopulmonary exercise testing after CTO-PCI.
METHODS: Patients with heart failure or angina symptoms referred for CTO-PCI were
prospectively enrolled. The primary outcome of the study was improvement in peak
oxygen uptake during cardiopulmonary exercise (CPX) testing 5 months after
CTO-PCI. Secondary outcomes included improvement in physical capacity, angina,
and self perception of health as assessed by questionnaires, and in plasma brain
natriuretic peptide (BNP) levels.
RESULTS: CTO-PCI was attempted in 32 men (mean age, 62 ± 6 years; CTO vessel: 47%
right coronary, 44% left anterior descending). CTO-PCI was unsuccessful in 1
patient, and 3 patients had restenosis of their CTO vessel at follow-up. In the
28 patients with patent CTO vessel at follow-up, significant improvements were
noted in self-reported physical capacity, angina, and several aspects of health
perception. In the 25 patients who underwent baseline and follow-up CPX testing,
peak oxygen uptake significantly improved from 17.7 ± 4.3 mL/kg/min to 19.1 ± 4.0
mL/kg/min (P=.02). Plasma BNP levels significantly decreased from 143 ± 138 pg/mL
to 102 ± 123 pg/mL (P=.01).
CONCLUSIONS: CTO-PCI in symptomatic patients was associated with improvements in
cardiovascular exercise capacity, as assessed by peak oxygen uptake. These
results suggest that in symptomatic patients with CTOs, PCI appears clinically
beneficial.

Eur Respir Rev. 2017 Feb 21;26(143).

Bonini M, Fiorenzano G.

Interstitial lung diseases (ILDs) represent a heterogeneous group of pathologies
characterised by alveolar and interstitial damage, pulmonary inflammation
(usually associated with fibrosis), decreased lung function and impaired gas
exchange, which can be attributed to either a known or an unknown aetiology.
Dyspnoea is one of the most common and disabling symptoms in patients with ILD,
significantly impacting quality of life. The mechanisms causing dyspnoea are
complex and not yet fully understood. However, it is recognised that dyspnoea
occurs when there is an imbalance between the central respiratory efferent drive
and the response of the respiratory musculature. The respiratory derangement
observed in ILD patients at rest is even more evident during exercise.
Pathophysiological mechanisms responsible for exertional dyspnoea and reduced
exercise tolerance include altered respiratory mechanics, impaired gas exchange,
cardiovascular abnormalities and peripheral muscle dysfunction.This review
describes the respiratory physiology of ILD, both at rest and during exercise,
and aims to provide comprehensive and updated evidence on the clinical utility of
the cardiopulmonary exercise test in the assessment and management of these
pathological entities. In addition, the role of exercise training and pulmonary
rehabilitation programmes in the ILD population is addressed.

Cleve Clin J Med. 2017 Feb;84(2):161-168.

Leclerc K.

Cardiopulmonary exercise testing (CPET) helps in detecting disorders of the
cardiovascular, pulmonary, and skeletal muscle systems. It has a class I
(indicated) recommendation from the American College of Cardiology and American
Heart Association for evaluating exertional dyspnea of uncertain cause and for
evaluating cardiac patients being considered for heart transplant. Advances in
hardware and software and ease of use have brought its application into the
clinical arena to the point that providers should become familiar with it and
consider it earlier in the evaluation of their patients.

Int J Cardiol. 2017 Feb 10. pii: S0167-5273(16)32158-1.

Kunutsor SK(1), Kurl S(2), Khan H(3), Zaccardi F(4), Laukkanen JA(5).

BACKGROUND: Oxygen uptake (VO2) at ventilatory threshold (VT), is a
cardiopulmonary exercise testing parameter which may be a proxy for peak VO2. We
aimed to assess the associations of VO2 at VT with sudden cardiac death (SCD),
fatal coronary heart disease (CHD) and cardiovascular disease (CVD), and
all-cause mortality.
METHODS AND RESULTS: VO2 at VT was assessed during a submaximal exercise test
using respiratory gas analyzers in the Kuopio Ischemic Heart Disease cohort of
1639 middle-aged men. Hazard ratios (HRs) (95% CIs) were assessed. During a
median follow-up of 25.6years, 121 SCDs, 202 fatal CHDs, 312 fatal CVDs, and 703
all-cause mortality events occurred. VO2 at VT was correlated with peak VO2
(r=0.90) and linearly associated with each outcome. Comparing extreme quartiles
of VO2 at VT, the HRs (95% CIs) for SCD, fatal CHD, fatal CVD, and all-cause
mortality on adjustment for established risk factors were 0.37 (0.18-0.78), 0.32
(0.18-0.57), 0.45 (0.30-0.69), and 0.50 (0.38-0.64) respectively. The HRs were
1.02 (0.36-2.91), 1.43 (0.63-3.25), 1.46 (0.79-2.71), and 1.02 (0.69-1.51)
respectively on further adjustment for peak VO2. Addition of VO2 at VT to a CVD
mortality risk prediction model containing established risk factors significantly
improved risk discrimination and reclassification at 25years.
CONCLUSIONS: There are linear and inverse associations of VO2 at VT with fatal
cardiovascular and all-cause mortality events, which are dependent on peak VO2.
Inclusion of VO2 at VT in the standard established risk factors panel
significantly improves the prediction and classification of long-term CVD
mortality risk.