Gupta, Ruchir; Gan, Tong J..

Anesthesiology Clinics, March 2016, Vol. 34 Issue: Number 1
p143-153, 11p;

Abstract: Enhanced recovery after surgery is the natural
evolution of what were previously referred to as fast track programs
and seeks to implement a series of interventions to improve and enhance
recovery after major surgical procedures. Two important preoperative
aspects are nutrition and prehabilitation. Identifying nutritionally
deficient patients allows preoperative intervention to optimize their
nutritional status. The contribution of cardiopulmonary exercise
testing to the evaluation of perioperative risk, subsequent development
of a training program, and the use of indices to risk stratify and
measure improvement after a training program allow a personalized
preoperative program to be developed for each patient.

Salzwedel, Annett; Reibis, Rona; Wegscheider, Karl; Eichler, Sarah; Buhlert,
Hermann; Kaminski, Stefan; Völler, Heinz.

Clinical Research in Cardiology, March 2016, Vol. 105 Issue: Number 3 p257-267, 11p;

Abstract: Return to work (RTW) is  a pivotal goal of cardiac
rehabilitation (CR) in patients after acute cardiac event. We aimed to
evaluate cardiopulmonary exercise testing (CPX) parameters as
predictors for RTW at discharge after CR.                   We analyzed
data from a registry of 489 working-age patients (51.5 ± 6.9 years,
87.9 % men) who had undergone inpatient CR predominantly after
percutaneous coronary intervention (PCI 62.6 %), coronary artery bypass
graft (CABG 17.2 %), or heart valve replacement (9.0 %).
Sociodemographic and clinical parameters, noninvasive cardiac
diagnostic (2D echo, exercise ECG, 6MWT) and psychodiagnostic screening
data, as well as CPX findings, were merged with RTW data from the
German statutory pension insurance program and analyzed for prognostic
ability.                   During a mean follow-up of
26.5 ± 11.9 months, 373 (76.3 %) patients returned to work, 116
(23.7 %) did not, and 60 (12.3 %) retired. After adjustment for
covariates, elective CABG (HR 0.68, 95 % CI 0.47–0.98; p= 0.036) and
work intensity (per level HR 0.83, 95 % CI 0.73-0.93; p= 0.002) were
negatively associated with the probability of RTW. Exercise capacity in
CPX (in Watts) and the VE/VCO2-slope had independent prognostic
significance for RTW. A higher work load increased (HR 1.17, 95 % CI
1.02–1.35; p= 0.028) the probability of RTW, while a higher
VE/VCO2slope decreased (HR 0.85, 95 % CI 0.76–0.96; p= 0.009) it. CPX
also had prognostic value for retirement: the likelihood of retirement
decreased with increasing exercise capacity (HR 0.50, 95 % CI
0.30–0.82; p= 0.006).

CPX is a valid tool for
assessing patients’ ability to return to work. Therefore, it may be an
essential part of functional assessment during CR for predicting
participation in employment.

Boutou, Afroditi K.; Pitsiou,
Georgia G.; Siakka, Panagiota; Dimitroulas, Theodoros; Paspala,
Asimina; Sourla, Evdokia; Chavouzis, Nikolaos; Garyfallos, Alexandros;
Argyropoulou, Paraskevi; Stanopoulos, Ioannis.

Respiration, February  2016, Vol. 91 Issue: Number 2 p115-123, 9p;

Abstract:
AbstractBackground:Exercise impairment is a common symptom of systemic
sclerosis (SSc), a disorder which is frequently complicated by
cardiopulmonary involvement.

Objectives:This study’s aims were: (a) to
define the prevalence and the potential causes of limited exercise
capacity and (b) to study potential differences in clinical,
radiological and functional characteristics and blood serology among
SSc patients with exercise limitation of different etiology.
Methods:Prospectively collected data on SSc patients who had conducted
full lung function testing, blood serology, thorax high-resolution
computed tomography, Doppler echocardiogram and a maximal
cardiopulmonary exercise testing (CPET) were retrospectively analyzed.
Using a CPET algorithm, patients were characterized as having normal or
subnormal exercise capacity (N), respiratory limitation (RL), left
ventricular dysfunction (LVD) or pulmonary vasculopathy (PV). Group
comparisons were conducted using either one-way ANOVA or the
Kruskal-Wallis test. A p value <0.05 was considered significant.
Results:The study population consisted of 78 patients (53.7 ± 13.7
years old; 10.3 male). PV was present in 32.1, LVD in 25.6 and RL in
10.2, while 32.1 of the patients constituted the N group. The presence
of antisclero-70 antibodies, low anaerobic threshold and low peak
exercise capacity measures could discriminate LVD from the other
groups. Low end-tidal carbon dioxide pressure and its change from rest
to anaerobic threshold could discriminate between the PV, LVD and N
groups, while respiratory restriction along with ventilatory
inefficiency indices could differentiate the RL group from the rest.

Conclusions:The combined evaluation of CPET gas exchange patterns with
baseline measurements could discriminate the causes of exercise
limitation among SSc patients.

Moran J, Wilson F, Guinan E, McCormick P, Hussey J, Moriarty J.

Br J Anaesth. 2016;116(2):177-91.

BACKGROUND: Cardiopulmonary exercise testing (CPET) is used as a preoperative risk-stratification tool for patients undergoing non-cardiopulmonary intra-abdominal surgery. Previous studies indicate that CPET may be beneficial, but research is needed to quantify CPET values protective against poor postoperative outcome [mortality, morbidity, and length of stay (LOS)].

METHODS: This systematic review aimed to assess the ability of CPET to predict postoperative outcome. The following databases were searched: PubMed, EMBASE, PEDro, The Cochrane Library, Cinahl, and AMED. Thirty-seven full-text articles were included. Data extraction included the following: author, patient characteristics, setting, surgery type, postoperative outcome measure, and CPET outcomes.

RESULTS: Surgeries reviewed were hepatic transplant and resection (n=7), abdominal aortic aneurysm (AAA) repair (n=5), colorectal (n=6), pancreatic (n=4), renal transplant (n=2), upper gastrointestinal (n=4), bariatric (n=2), and general intra-abdominal surgery (n=12). Cardiopulmonary exercise testing-derived cut-points, peak oxygen consumption ([Formula: see text]), and anaerobic threshold (AT) predicted the following postoperative outcomes: 90 day-3 yr survival (AT 9-11 ml kg(-1) min(-1)) and intensive care unit admission (AT <9.9-11 ml kg(-1) min(-1)) after hepatic transplant and resection, 90 day survival after AAA repair ([Formula: see text] 15 ml kg(-1) min(-1)), LOS and morbidity after pancreatic surgery (AT <10-10.1 ml kg(-1) min(-1)), and mortality and morbidity after intra-abdominal surgery (AT 10.9 and <10.1 ml kg(-1) min(-1), respectively).

CONCLUSION: Cardiopulmonary exercise testing is a useful preoperative risk-stratification tool that can predict postoperative outcome. Further research is needed to justify the ability of CPET to predict postoperative outcome in renal transplant, colorectal, upper gastrointestinal, and bariatric surgery.

Haaren, Birte; Ottenbacher, Joerg;
Muenz, Julia; Neumann, Rainer; Boes, Klaus; Ebner-Priemer, Ulrich.

European Journal of Applied Physiology, February 2016, Vol. 116 Issue:
Number 2 p383-394, 12p;

Abstract: The cross-stressor adaptation
hypothesis suggests that regular exercise leads to adaptations in the
stress response systems that induce decreased physiological responses
to psychological stressors. Even though an exercise intervention to
buffer the detrimental effects of psychological stressors on health
might be of utmost importance, empirical evidence is mixed. This may be
explained by the use of cross-sectional designs and non-personally
relevant stressors. Using a randomized controlled trial, we
hypothesized that a 20-week aerobic exercise training does reduce
physiological stress responses to psychological real-life stressors in
sedentary students.   Sixty-one students were  randomized to either a
control group or an exercise training group. The
academic examination period (end of the semester) served as a real-life
stressor. We used ambulatory assessment methods to assess physiological
stress reactivity of the autonomic nervous system (heart rate
variability: LF/HF, RMSSD), physical activity and perceived stress
during 2 days of everyday life and multilevel models for data analyses.
Aerobic capacity (VO2max) was assessed pre- and post-intervention via
cardiopulmonary exercise testing to analyze the effectiveness of the
intervention.   During real-life stressors, the exercise training group
showed significantly reduced LF/HF (β= −0.15,
t= −2.59, p= .01) and increased RMSSD (β= 0.15, t= 2.34, p= .02)
compared to the control group.
Using a randomized
controlled trial and a real-life stressor, we could show that exercise
appears to be a useful preventive strategy to buffer the effects of
stress on the autonomic nervous system, which might result into
detrimental health outcomes.

Reibis, Rona;
Salzwedel, Annett; Buhlert, Hermann; Wegscheider, Karl; Eichler, Sarah;
Völler, Heinz.

European Journal of Preventive Cardiology, March 2016,
Vol. 23 Issue: Number 5 p452-459, 8p;

Abstract: Aim  We aimed to
identify patient characteristics and comorbidities that correlate with
the initial exercise capacity of cardiac rehabilitation (CR) patients
and to study the significance of patient characteristics, comorbidities
and training methods for training achievements and final fitness of CR
patients.Methods  We studied 557 consecutive patients (51.7 ± 6.9
years; 87.9% men) admitted to a three-week in-patient CR.
Cardiopulmonary exercise testing (CPX) was performed at discharge.
Exercise capacity (watts) at entry, gain in training volume and final
physical fitness (assessed by peak O2utilization (VO2peak) were
analysed using analysis of covariance (ANCOVA) models.Results  Mean
training intensity was 90.7 ± 9.7% of maximum heart rate (81%
continuous/19% interval training, 64% additional strength training). A
total of 12.2 ± 2.6 bicycle exercise training sessions were performed.
Increase of training volume by an average of more than 100% was
achieved (difference end/beginning of CR: 784 ± 623 watts × min). In
the multivariate model the gain in training volume was significantly
associated with smoking, age and exercise capacity at entry of CR. The
physical fitness level achieved at discharge from CR as assessed by
VO2peakwas mainly dependent on age, but also on various factors related
to training, namely exercise capacity at entry, increase of training
volume and training method.

Conclusion  CR patients were trained in line
with current guidelines with moderate-to-high intensity and reached a
considerable increase of their training volume. The physical fitness
level achieved at discharge from CR depended on various factors
associated with training, which supports the recommendation that CR
should be offered to all cardiac patients.

Sperling, Milena Pelosi Rizk; Caruso, Flávia Cristina Rossi;
Mendes, Renata Gonçalves; Dutra, Daniela Bassi; Arakelian, Vivian
Maria; Bonjorno, José Carlos; Catai, Aparecida Maria; Arena, Ross;
Borghi‐Silva, Audrey.

Clinical Physiology and Functional Imaging, March
2016, Vol. 36 Issue: Number 2 p92-98, 7p;

Abstract: Non‐invasive
assessment of haemodynamic function by impedance cardiography (IC)
constitutes an interesting approach to monitor cardiac function in
patients with coronary artery disease (CAD). However, such measurements
are most often performed at rest, whereas symptoms are also possible
during exertion, particularly at higher intensities. In addition, the
association between IC during exertion and cardiopulmonary exercise
testing (CPX) is not well understood in these patients, which was the
aim of this study. Nineteen men (age = 62 ± 6 years) with CAD [left
ventricular ejection fraction (LVEF) = 61 ± 10%] underwent a CPX using
an incremental protocol on a cycle ergometer, with simultaneous
measurement of IC. Cardiac output (CO), stroke volume (SV), cardiac
index (CI), peak oxygen consumption (VO2), the oxygen uptake efficiency
slope (OUES), circulatory power and ventilatory power were determined.
Pearson product‐moment correlation analysis revealed peak VO2 (r= 0·46)
was significantly related to CO. Peak oxygen pulse (0·52) was
associated with SV. OUES was associated with resting SV(0·47) and with
peak SV(r= 0·52). These findings suggest that ICindices are associated
with certain, but not all, established CPX measures in patients with
stable CAD.

Moran, J.; Wilson, F.; Guinan, E.; McCormick, P.; Hussey, J.; Moriarty,
J..

British Journal of Anaesthesia, February 2016, Vol. 116 Issue:
Number 2 p177-177, 1p;

Abstract:
Background. Cardiopulmonary exercise
testing (CPET) is used as a preoperative risk-stratification tool for
patients undergoing non-cardiopulmonary intra-abdominal surgery.
Previous studies indicate that CPET may be beneficial, but research is
needed to quantify CPET values protective against poor postoperative
outcome [mortality, morbidity, and length of stay (LOS)]. Methods. This
systematic review aimed to assess the ability of CPET to predict
postoperative outcome. The following databases were searched: PubMed,
EMBASE, PEDro, The Cochrane Library, Cinahl, and AMED. Thirty-seven
full-text articles were included. Data extraction included the
following: author, patient characteristics, setting, surgery type,
postoperative outcome measure, and CPET outcomes. Results. Surgeries
reviewed were hepatic transplant and resection (n</it>=7), abdominal
aortic aneurysm (AAA) repair (n</it>=5), colorectal (n</it>=6),
pancreatic (n</it>=4), renal transplant (n</it>=2), upper
gastrointestinal (n</it>=4), bariatric (n</it>=2), and general
intra-abdominal surgery (n</it>=12). Cardiopulmonary exercise
testing-derived cut-points, peak oxygen consumption (VO2pk), and
anaerobic threshold (AT) predicted the following postoperative
outcomes: 90 day–3 yr survival (AT 9–11 ml kg−1 min−1) and intensive
care unit admission (AT <9.9–11 ml kg−1 min−1) after hepatic transplant
and resection, 90 day survival after AAA repair
VO2pk 15 ml kg−1 min−1), LOS and morbidity after pancreatic surgery (AT <10–10.1 ml kg−1
min−1), and mortality and morbidity after intra-abdominal surgery (AT
10.9 and <10.1 ml kg−1 min−1, respectively).
Conclusion.
Cardiopulmonary exercise testing is a useful preoperative
risk-stratification tool that can predict postoperative outcome.
Further research is needed to justify the ability of CPET to predict
postoperative outcome in renal transplant, colorectal, upper
gastrointestinal, and bariatric surgery.

Heart doi:10.1136/heartjnl-2015-308453

• Damiano Magrì
• Giuseppe Limongelli
• Federica Re
• Piergiuseppe Agostoni
• Elisabetta Zachara
• Michele Correale
• Vittoria Mastromarino
• Caterina Santolamazza
• Matteo Casenghi
• Giuseppe Pacileo
• Fabio Valente
• Beatrice Musumeci
• Antonello Maruotti
• Massimo Volpe
• Camillo Autore

Abstract

Background In hypertrophic cardiomyopathy (HCM), most of the factors associated with the risk of sudden cardiac death (SCD) are also involved in the pathophysiology of exercise limitation. The present multicentre study investigated possible ability of cardiopulmonary exercise test in improving contemporary strategies for SCD risk stratification.

Methods A total of 623 consecutive outpatients with HCM, from five tertiary Italian HCM centres, were recruited and prospectively followed, between September 2007 and April 2015. The study composite end point was SCD, aborted SCD and appropriate implantable cardioverter defibrillator (ICD) interventions.

Results During a median follow-up of 3.7 years (25th–75th centile: 2.2–5.1 years), 25 patients reached the end point at 5 years (3 SCD, 4 aborted SCD, 18 appropriate ICD interventions). At multivariate analysis, ventilation versus carbon dioxide relation during exercise (VE/VCO₂ slope) remains independently associated to the study end point either when challenged with the 2011 American College of Cardiology Foundation/American Heart Association guidelines-derived score (C index 0.748) or with the 2014 European Society of Cardiology guidelines-derived score (C index 0.750). A VE/VCO₂ slope cut-off value of 31 showed the best accuracy in predicting the SCD end point within the entire HCM study cohort (sensitivity 64%, specificity 72%, area under the curve 0.72).

Conclusions Our data suggest that the VE/VCO₂ slope might improve SCD risk stratification, particularly in those HCM categories classified at low-intermediate SCD risk according to contemporary guidelines. There is a need for further larger studies, possibly on independent cohorts, to confirm our preliminary findings.

The Henry Ford HospITal
CardioPulmonary EXercise Testing (FIT-CPX) project by Shafiq, Ali;
Brawner, Clinton A.; Aldred, Heather A.; Lewis, Barry; Williams,
Celeste T.; Tita, Christina; Schairer, John R.; Ehrman, Jonathan K.;
Velez, Mauricio; Selektor, Yelena; Lanfear, David E.; Keteyian, Steven
J..

American Heart Journal, 20160101, Issue: Number Preprints;

Abstract: Although cardiopulmonary exercise (CPX) testing in patients
with heart failure and reduced ejection fraction is well established,
there are limited data on the value of CPX variables in patients with
HF and preserved ejection fraction (HFpEF). We sought to determine the
prognostic value of select CPX measures in patients with HFpEF.