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.

Reichenberger F; Department of Pneumology, Augustinum Hospital Munich, Munich, Germany.
Popp F; Hoffmann M;  Fischinger C; von Wulffen W; DKneidinger N; Welcker M;

BMC pulmonary medicine [BMC Pulm Med] 2024 Nov 23; Vol. 24 (1), pp. 581.
Date of Electronic Publication: 2024 Nov 23.

Background: Seropositive rheumatoid arthritis (RA) is associated with significant cardiovascular and pulmonary morbidity. However, screening for early detection of pulmonary involvement especially interstitial lung disease (ILD) is not established in RA.
Methods: We propose a non-invasive radiation-free approach to screen for interstitial lung involvement (ILI) by means of pulmonary function tests (PFT) and pleuro-pulmonary transthoracic ultrasound (LUS) with additional cardiopulmonary exercise tests (CPET) with ECG, and echocardiography. We included patients with confirmed diagnosis of seropositive RA according to ACR criteria, but without symptoms for or known cardiopulmonary disease. ILD was suspected when significant LUS abnormalities and additional PFT changes were present.
Results: We included 67 consecutive patients (78% female, mean age 61 ± 12 years, 48% active or previous smokers), who fulfilled the inclusion criteria and gave written informed consent. We found 48% of patients with suspected changes in PFT with a diffusion capacity (DLCOc-SB) ≤ 80%, among them 7% with forced vital capacity (FVC) ≤ 80%. In 40% of patients, we found noticeable changes in LUS, 24% with an ILD compatible pattern. In 16% of cases, LUS abnormalities and additional PFT changes were present, and ILI was suspected. Additional findings included obstructive lung disease (n = 11), subpleural consolidation (n = 6) including one confirmed lung cancer, minimal pleural effusion (n = 6), and ischemic cardiac disease (n = 2). None of the patients showed signs of pulmonary vascular involvement.
Conclusions: ILI was suspected in 16% of cases using a new radiation-free screening protocol in asymptomatic RA patients.

Tuan SH;  National Cheng Kung University, Tainan 701,Taiwan
Huang IC; Huang WC; Chen GB; Sun SF; Lin KL;

Life (Basel). 2024 Nov 6;14(11):1429. doi: 10.3390/life14111429.

(1) Background: Heart failure (HF) leads to functional disability and major cardiovascular events (MACEs). Cardiopulmonary exercise testing (CPET) is the gold standard for assessing aerobic capacity and prognostic stratification. This study aimed to evaluate the predischarge CPET variables in patients with acute decompensated HF and identify the submaximal CPET variables with prognostic value.
(2) Methods: A retrospective cohort study was conducted at a tertiary center in Taiwan. Patients surviving their first episode of decompensated HF and undergoing predischarge CPET (February 2017 to January 2023) were analyzed. Follow-up was conducted until a MACE or administrative censoring (up to 5 years). Cox regression identified the significant predictors of MACE.
(3) Results: The study included 553, 485, and 267 patients at the 3-month, 1-year, and 5-year follow-ups, respectively. MACE rates were 15.0%, 34.2%, and 50.9%. The VE/VCO2 slope was a significant predictor of MACE at all intervals. A VE/VCO2 slope >38.95 increased the risk of MACE by 2.49-fold at 3 months and 1.81-fold at 1 year (both p < 0.001). A slope > 37.35 increased the 5-year MACE risk by 1.75-fold (p = 0.002).
(4) Conclusions: The VE/VCO2 slope is a significant submaximal CPET predictor of MACE in patients post-acute decompensated HF for both short- and long-term outcomes.

Eysenck W; London Bridge Hospital UK
Sulke N; Patel N; Furniss S; Veasey R; Freemantle N; Bodagh N;

The British journal of cardiology [Br J Cardiol] 2024 Apr 16; Vol. 31 (2), pp. 014.
Date of Electronic Publication: 2024 Apr 16 (Print Publication: 2024).

Our objective was to compare the efficacy of atrial fibrillation (AF) ablation versus permanent pacemaker (PPM) with atrioventricular node ablation (AVNA) versus direct current cardioversion (DCCV) for persistent AF in patients ≥65 years old. Seventy-seven patients (aged 66-86, mean 75.4 years) with persistent AF were randomised (1:1:1) to AF ablation + amiodarone (± DCCV), PPM with AVNA (+DCCV) or DCCV + amiodarone. The primary end point was persistent AF recurrence, measured with an implanted cardiac monitor or PPM.
Cardiopulmonary exercise testing (CPET) was performed at baseline and six months. Symptom questionnaires were completed monthly. Follow-up was 12 months. The primary end point occurred in fewer patients following AF ablation + amiodarone than DCCV + amiodarone (seven patients, 28% vs. 15 patients, 60%; hazard ratio [HR] 0.559, 95% confidence interval [CI] 0.293 to 1.065, p=0.073) with no differences between DCCV + amiodarone and PPM with AVNA (HR 0.990, 95%CI 0.539 to 1.818, p=0.973). AF ablation + amiodarone resulted in a lower AF burden at 12 months compared with DCCV + amiodarone (17.0 ± 37.9% vs. 61.7 ± 48.6%, p<0.0001). Modified European Heart Rhythm Association (EHRA) symptom class improved in all patients (baseline 2.4 ± 0.495 vs. 12-month follow-up 1.84 ± 0.081, p=0.00001). Six-month CPET demonstrated a higher VO ₂ peak in sinus rhythm (SR) compared with baseline in AF (12.1 ± 4.2 ml/kg/min at baseline to 15.3 ± 4.2 ml/kg/min at six months, p=0.013). In conclusion, in older patients with persistent AF, ablation + amiodarone resulted in a lower AF burden at 12 months than DCCV + amiodarone. There was a non-significant trend toward reduced recurrence of device detected persistent AF episodes. All therapies improved symptoms despite DCCV restoring SR in <50% of patients at 12 months. CPET demonstrated improved VO ₂ peak with SR restoration.

Faigenbaum AD; Department of Kinesiology and Health Sciences, The College of New Jersey, Ewing, NJ, USA.
Kang J; Ingui J; Fish A; Dimatteo J;Leazier I; Bush JA; DeRatamess NA;

International journal of exercise science [Int J Exerc Sci] 2024 Nov 01; Vol. 17 (4), pp. 1530-1539.
Date of Electronic Publication: 2024 Nov 01 (Print Publication: 2024).

The aim of this study was to compare the warm-up effects of a treadmill walking warm-up (TW) with a dynamic warm-up (DW) on the responses to cardiopulmonary exercise testing (CPET) in youth. A sample of 16 active youth (age 13.6 ± 1.8 yr) were tested for peak oxygen uptake (VO ₂ peak) using the Fitkids treadmill test protocol on 2 nonconsecutive days following different 6-min warm-up procedures. The TW consisted of walking on a treadmill at 2.2 mph and 0% grade whereas the DW consisted of 12 bodyweight exercises with a 2 kg medicine ball. Maximal heart rate (HR) was significantly higher following DW vs TW (200.8 ± 6.16 vs. 197.9 ± 7.3 bpm, respectively; p < 0.05), whereas no significant differences were found between DW and TW for VO ₂ peak (50.5 ± 9.9 vs 50.6 ± 11.1 ml/kg/min), maximal minute ventilation (V _E ; 93.0 ±21.4 vs. 92.7 ±21.2 L/min), maximal respiratory exchange ratio (1.19 ± 0.08 vs 1.22 ± 0.08), and total exercise test time (668.1 ± 103.5 vs 686.3 ± 97.0 s), respectively. During the Fitkids treadmill test protocol HR and V _E were significantly higher following DW vs TW at stage 1, stage 2, stage 3 and stage 4, and oxygen uptake was significantly higher following DW vs TW during stage 1 (all p < 0.05). Findings indicate a DW elicits a higher maximal HR and higher submaximal HR, V _E , and oxygen uptake values than TW during CPET in youth, although no differences in VO ₂ peak were observed.

Hughes DL; Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL.
Lizaola-Mayo B; Wheatley-Guy CM; Vargas HE; Bloomer PM; Wolf C; Carey EJ; Forman DE; Duarte-Rojo A;

Transplantation direct [Transplant Direct] 2024 Nov 15; Vol. 10 (12), pp. e1725.
Date of Electronic Publication: 2024 Nov 15 (Print Publication: 2024).

Background: Cardiovascular disease and physical decline are prevalent and associated with morbidity/mortality in liver transplant (LT) patients. Cardiopulmonary exercise testing (CPX) provides comprehensive cardiopulmonary and exercise response assessments. We investigated cardiorespiratory fitness (CRF) and cardiac stress generated during CPX in LT candidates.
Methods: LT candidates at 2 centers underwent CPX. Standard-of-care cardiac stress testing (dobutamine stress echocardiography, DSE) results were recorded. Physical function was assessed with liver frailty index and 6-min walk test. CPX/DSE double products were calculated to quantify cardiac stress. To better study the association of CPX-derived metrics with physical function, the cohort was divided into 2 groups based on 6-min walk test median (372 m).
Results: Fifty-four participants (62 ± 8 y; 65% men, Model for End-Stage Liver Disease-Na 14 [10-18]) underwent CPX. Peak oxygen consumption was 14.1 mL/kg/min for an anerobic threshold of 10.2 mL/kg/min, with further CRF decline in the lower 6MWT cohort despite lack of liver frailty index-frailty in 90%. DSE was nondiagnostic in 18% versus 4% of CPX ( P  = 0.058). All CPX were negative for ischemia. A double product of ≥25 000 was observed in 32% of CPX and 11% of DSE ( P  = 0.020). Respiratory function testing was normal. No patient presented major cardiovascular events at 30 d post-LT.
Conclusions: CPX provided efficient and effective combined cardiopulmonary risk and frailty assessments of LT candidates in a 1-stop test. The CRF was found to be very low despite preserved physical function or lack of frailty.