Category Archives: Abstracts

The evolving role of cardiopulmonary exercise testing in ischemic heart disease – state of the art review.

Chaudhry S; Kumar N; Arena R; Verma S;

Current opinion in cardiology [Curr Opin Cardiol] 2023 Sep 08.
Date of Electronic Publication: 2023 Sep 08.

Purpose of Review: Cardiopulmonary exercise testing (CPET) is the gold standard for directly assessing cardiorespiratory fitness (CRF) and has a relatively new and evolving role in evaluating atherosclerotic heart disease, particularly in detecting cardiac dysfunction caused by ischemic heart disease. The purpose of this review is to assess the current literature on the link between cardiovascular (CV) risk factors, cardiac dysfunction and CRF assessed by CPET.
Recent Findings: We summarize the basics of exercise physiology and the key determinants of CRF. Prognostically, several studies have been published relating directly measured CRF by CPET and outcomes allowing for more precise risk assessment. Diagnostically, this review describes in detail what is considered healthy and abnormal cardiac function assessed by CPET. New studies demonstrate that cardiac dysfunction on CPET is a common finding in asymptomatic individuals and is associated with CV risk factors and lower CRF. This review covers how key CPET parameters change as individuals transition from the asymptomatic to the symptomatic stage with progressively decreasing CRF. Finally, a supplement with case studies with long-term longitudinal data demonstrating how CPET can be used in daily clinical decision making is presented.
Summary: In summary, CPET is a powerful tool to provide individualized CV risk assessment, monitor the effectiveness of therapeutic interventions, and provide meaningful feedback to help patients guide their path to improve CRF when routinely used in the outpatient setting.

Postoperative hyperlactataemia and preoperative cardiopulmonary exercise testing in an elective noncardiac surgical cohort: a retrospective observational study.

Darwen C; MBryan A; Quraishi-Akhtar T; Moore J;

BJA open [BJA Open] 2023 Feb 23; Vol. 5, pp. 100124.
Date of Electronic Publication: 2023 Feb 23 (Print Publication: 2023).

Background: Blood lactate concentration in the postoperative period is a marker of physiological stress and a predictor of complications and mortality. Cardiopulmonary exercise testing (CPET) is a common preoperative risk stratification tool. We aimed to investigate the association between preoperative CPET results and postoperative lactate concentration with postoperative mortality after major noncardiac surgery.
Methods: We analysed data from patients undergoing major noncardiac surgery in a tertiary UK centre between 2007 and 2014 who had preoperative CPET and postoperative lactate measurements. Univariate and multivariate analyses were performed to assess the association between lactate concentration, CPET results, or both and mortality.
Results: We analysed data from 1075 patients. A mean lactate concentration >2 mM in the first 12, 24, and 48 h after surgery was associated with odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality of 3.9 (2.1-7.3; P <0.005), 4.5 (2.4-8.4; P <0.005), and 6.1 (3.3-11.5; P <0.005), respectively. The dichotomous CPET variable, ventilatory equivalence for CO 2 ( E/ co2 ; cut-off 34), was associated with increased risk of 30-day mortality (OR 2.5; 95% CI: 1.3-4.8; P <0.005). In a multivariable model, hyperlactataemia and poor E/ co2 retained their significant associations with 30- and 90-day mortality when adjusted for age, BMI, and surgical risk. When looking at the combined effect of the dichotomous hyperlactataemia in the first 24 h (cut-off 2 mM) and preoperative E/ co2 , the OR for 30-day mortality was 11.53 (95% CI: 4.6-28.8; P ≤0.005).
Conclusions: Our study suggests that postoperative hyperlactataemia and preoperative poor E/ co2 are independently associated with an increased risk of mortality after major noncardiac surgery.

Prognostic value of cardiopulmonary exercise testing repetition during follow-up of clinically stable patients with severe dilated cardiomyopathy. A preliminary study.

Baracchini N; Zaffalon D; Merlo M; Baschino S; Barbati G; Pezzuto B; Capovilla TM; Rossi M; Carriere C; Agostoni P; Sinagra G;

International journal of cardiology [Int J Cardiol] 2023 Aug 08, pp. 131252.
Date of Electronic Publication: 2023 Aug 08.

Background: Cardiopulmonary exercise testing (CPET) is a recognized tool for prognostic stratification in patients with dilated cardiomyopathy (DCM). Given the lack of data currently available, the aim of this study was to test the prognostic value of repeating CPET during the follow-up of patients with DCM.
Methods: This multicenter, retrospective study, analyzed DCM patients who consecutively performed two echocardiographies and CPETs during clinical stability. The study end-point was a composite of death from all causes, heart transplantation, left ventricular assist device implantation, life-threatening ventricular arrhythmias or hospitalization for heart failure.
Results: 216 DCM patients were enrolled (52 years, 78% male, NYHA I-II 82%, LVEF 32%, 94% on ACE inhibitors/ARNI, 95% on beta-blockers). The interval between CPETs was 15 months. During a median follow-up of 38 months from the second CPET, 102 (47%) patients experienced the study end-point. Among them, there was stability of echocardiographic values but a significant worsening of functional capacity. Among the 173 patients (80%) who did not show echocardiographic left ventricular reverse remodeling (LVRR), the 1-year prevalence of the study-end point was higher in patients who worsened vs patients who maintained stable their functional capacity at CPET (38 vs. 15% respectively, p-value: 0.001). These results were consistent also when excluding life-threatening ventricular arrhythmias from the composite end-point.
Conclusion: In clinically stable DCM patients with important depression of LVEF, the repetition of combined echocardiography and CPET might be recommended. When LVRR fails, 1-year repetition of CPET could identify higher-risk patients.


Cardiorespiratory fitness in women after severe pre-eclampsia.

Gronningsaeter L; Estensen ME; Skulstad H; Langesaeter E; Edvardsen E;

Hypertension in pregnancy [Hypertens Pregnancy] 2023 Dec; Vol. 42 (1), pp. 2245054.

Aims: To objectively study cardiorespiratory fitness (CRF) and physical activity (PA) and to evaluate limiting factors of exercise intolerance associated with poor CRF after severe pre-eclampsia.
Methods: In this single-centre, cross-sectional study, CRF was measured as peak oxygen uptake (VO 2peak ) during a cardiopulmonary exercise test (CPET) on a treadmill in women 7 years after severe pre-eclampsia. Ninety-six patients and 65 controls were eligible to participate. Cardiac output (CO) was measured by impedance cardiography. PA was measured using accelerometers.
Results: In 62 patients and 35 controls (mean age 40 ± 3 years), the VO 2peak (in mL·kg-1·min-1) values were 31.4 ± 7.2 and 39.1 ± 5.4, respectively (p<0.01). In the patients, the COpeak was (9.6 L·min-1), 16% lower compared to controls (p<0.01). Twelve patients (19%) had a cardiac limitation to CPET. Twenty-three (37%) patients and one (3%) control were classed as unfit, with no cardiopulmonary limitations. The patients demonstrated 25% lower PA level (in counts per minute; p<0.01) and 14% more time being sedentary (p<0.01), compared with the controls. Twenty-one patients (34%) compared with four (17%) controls did not meet the World Health Organization’s recommendations for PA (p=0.02). Body mass index and PA level accounted for 65% of the variability in VO 2peak .
Conclusion: Significantly lower CRF and PA levels were found in patients on long-term follow-up after severe pre-eclampsia. CPET identified cardiovascular limitations in one third of patients. One third appeared unfit, with adiposity and lower PA levels. These findings highlight the need for clinical follow-up and exercise interventions after severe pre-eclampsia.

Down-staging of obesity one year after bariatric surgery: a new proposal of Edmonton obesity staging system.

Quinto G; Bettini S; Neunhaeuserer D; Battista F; SMilan G; Gasperetti A; Vecchiato M; Vettor R; Ermolao A; Busetto L;

Frontiers in endocrinology [Front Endocrinol (Lausanne)] 2023 Jul 21; Vol. 14, pp. 1147171.
Date of Electronic Publication: 2023 Jul 21 (Print Publication: 2023).

Background: Different approaches are used to classify obesity severity. The Edmonton Obesity Staging System (EOSS) considers medical, physical and psychological parameters. A new modified EOSS with a different functional evaluation method, measuring Cardiorespiratory Fitness (CRF), has been recently proposed, EOSS-CRF. Bariatric surgery (BS) is one of the most efficient treatments of obesity and all aspect of related disorders. No studies have yet applied EOSS-CRF after BS. Therefore, the aim of this study was to evaluate modifications in EOSS and EOSS-CRF before and after BS.
Methods: This observational study finally enrolled 72 patients affected by obesity. A multi-disciplinary assessment in order to evaluate eligibility to surgical treatment has been performed, including anamnesis, physical evaluation, anthropometric data measurement, biochemical blood exams and cardiopulmonary exercise testing. One year after BS the same protocol was applied. Patients have been classified according to EOSS and EOSS-CRF before and one year after BS.
Results: After BS, patients categorized in classes associated to severe obesity (EOSS ≥ 2 or EOSS-CRF ≥ 2) reduced significantly. Using EOSS, patients without functional impairment were 61% before surgery and 69% after BS (p=0.383). Using EOSS-CRF, patients considered without functional impairment were only 9.7% before BS; this percentage significantly raised to 50% after BS (p<0.001). The impact of functional domains before and after BS is different in grading patients in EOSS and EOSS-CRF, respectively.
Conclusions: Improvements obtained after BS are adequately summarized by EOSS and EOSS-CRF. The EOSS-CRF grading method for functional impairment seems to better reflect the known amelioration obtained after BS. Objective measurements of CRF may provide additional value to classify severity of obesity, also in the follow-up after BS.

Effect of tele-yoga on aerobic capacity, respiratory muscle strength, and cognitive performance in patients with obstructive sleep apnea syndrome.

Eyuboglu F; Inal-Ince D; Karamancioglu B;Vardar-Yagli N; Kaya-Utlu D; Dalkilic O; Somay G;

Heart & lung : the journal of critical care [Heart Lung] 2023 Aug 01; Vol. 62, pp. 157-167.
Date of Electronic Publication: 2023 Aug 01.

Background: Obstructive sleep apnea syndrome (OSAS) causes a decrease in aerobic capacity, respiratory muscle strength, and cognitive function, negatively affecting health-related quality of life.
Objectives: This study aimed to compare aerobic capacity, respiratory muscle strength, cognitive performance, functional capacity, sleep quality and daytime sleepiness in OSAS patients practicing and not practicing tele-yoga (TY).
Methods: 44 OSAS patients (40 M, 4F) were randomized into TY and control groups. TY group underwent live synchronous group-based TY sessions, 60 min/day, three days/week, for 12 weeks. Control group performed unsupervised thoracic expansion exercises at home 4 times daily for 12 weeks. The following were evaluated at baseline and at the end of the 6th and 12th weeks: inspiratory and expiratory respiratory muscle strength (MIP, MEP), cardiopulmonary exercise test, Corsi Block Tapping Test (CBTT) and Stroop TBAG test, six-minute walk test (6MWT), Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS).
Results: TY significantly improved MIP, and exercise test parameters (VE, HR max ,%HR, heart rate recovery in the first minute and RQ max ), CBTT (forward) and Stroop TBAG test scores (parts of 3,4,5) compared to the controls (p<0.05). There were no significant changes 6MWT in the TY group compared to the control group (p > 0.05). Sleep duration (min), sleep efficiency, sleep quality of PSQI and ESS score improved significantly in the TY group compared to the control group (p < 0.05).
Conclusion: We suggest including TY intervention as a method of exercise in addition to CPAP treatments since it improves the health-related parameters of OSAS patients.

Cognitive impairment in pulmonary arterial hypertension.

Heller S; See C; Singh I; Fredericks CA;

Annals of clinical and translational neurology [Ann Clin Transl Neurol] 2023 Aug 07.
Date of Electronic Publication: 2023 Aug 07.

Pulmonary arterial hypertension (PAH) is characterized by progressive pulmonary vascular remodeling with resultant abnormal increase in pulmonary artery pressure and right heart dysfunction. There is evidence that PAH includes cognitive impairment. However, the cognitive impairment syndrome has not been well described, and both the underlying mechanism and the relationship between cardiopulmonary and cognitive dysfunction in PAH are unknown. We performed cognitive evaluations and same day sub-maximum cardiopulmonary exercise testing on adult subjects with PAH. A frontal-subcortical syndrome suggestive of vascular cognitive impairment was found in 26% of subjects and was associated with noninvasive markers of pulmonary vascular remodeling.

Cardiorespiratory responses: Pilates compared to different walking speeds in healthy adults.

Gultekin SC; Ozcan Kahraman B; Kahraman T;

Irish journal of medical science [Ir J Med Sci] 2023 Jul 29.
Date of Electronic Publication: 2023 Jul 29.

Background: The impact of a single-session Pilates exercise on cardiorespiratory fitness and metabolic parameters is still uncertain.
Aims: The aim of this study was to examine the cardiorespiratory changes during a single-session Pilates exercise and compare cardiorespiratory fitness-related parameters with walking at different speeds on a treadmill, at low (3.2 kph) and moderate intensities (4.8 kph).
Methods: Cardiorespiratory responses were measured with a cardiopulmonary exercise test device in 31 healthy young adults at rest, during a single Pilates session, walking at 3.2 kph and walking at 4.8 kph. The study design employed a cross-over design. Participants were randomly assigned to two experimental groups: a Pilates training session following treadmill walking or treadmill walking following a Pilates training session.
Results: Mean MET, oxygen and energy consumption during Pilates were similar to walking at 3.2 kph (p > 0.05), but significantly lower than walking at 4.8 kph (p < 0.05). The mean heart rate during Pilates was higher than walking at 3.2 kph (p < 0.05), but similar to walking at 4.8 kph (p > 0.05). Significantly higher carbohydrate metabolism was used during Pilates compared to walking (p < 0.05).
Conclusion: The cardiopulmonary responses to a single Pilates session are similar to walking at a speed of 3.2 kph but lower than walking at 4.8 kph. These results indicate that while Pilates may not generate sufficient cardiopulmonary changes to enhance cardiorespiratory fitness as a moderate-intensity exercise in healthy young adults, it may still offer other benefits such as improvements in flexibility, core strength, and posture.

Functional training improves peak oxygen consumption and quality of life of individuals with heart failure: a randomized clinical trial.

do Nascimento DM; Machado KC; Bock PM; Saffi MAL; Goldraich LA; Silveira AD; Clausell N; Schaan BD;

BMC cardiovascular disorders [BMC Cardiovasc Disord] 2023 Jul 29; Vol. 23 (1), pp. 381.
Date of Electronic Publication: 2023 Jul 29.

Background: Functional training may be an effective non-pharmacological therapy for heart failure (HF). This study aimed to compare the effects of functional training with strength training on peak VO 2 and quality of life in individuals with HF.
Methods: A randomized, parallel-design and examiner-blinded controlled clinical trial with concealed allocation, intention-to-treat and per-protocol analyses. Twenty-seven participants with chronic HF were randomly allocated to functional or strength training group, to perform a 12-week physical training, three times per week, totalizing 36 sessions. Primary outcomes were the difference on peak VO 2 and quality of life assessed by cardiopulmonary exercise testing and Minnesota Living with Heart Failure Questionnaire, respectively. Secondary outcomes included functionality assessed by the Duke Activity Status Index and gait speed test, peripheral and inspiratory muscular strength, assessed by hand grip and manovacuometry testing, respectively, endothelial function by brachial artery flow-mediated dilation, and lean body mass by arm muscle circumference.
Results: Participants were aged 60 ± 7 years, with left ventricular ejection fraction 29 ± 8.5%. The functional and strength training groups showed the following results, respectively: peak VO 2 increased by 1.4 ± 3.2 (16.9 ± 2.9 to 18.6 ± 4.8 -1 .min -1 ; p time = 0.011) and 1.5 ± 2.5 -1 .min -1 (16.8 ± 4.0 to 18.6 ± 5.5 -1 .min -1 ; p time = 0.011), and quality of life score decreased by 14 ± 15 (25.8 ± 14.8 to 10.3 ± 7.8 points; p time = 0.001) and 12 ± 28 points (33.8 ± 23.8 to 19.0 ± 15.1 points; p time = 0.001), but no difference was observed between groups (peak VO 2 : p interaction = 0.921 and quality of life: p interaction = 0.921). The functional and strength training increased the activity status index by 6.5 ± 12 and 5.2 ± 13 points (p time = 0.001), respectively, and gait speed by 0.2 ± 0.3 m/s (p  time = 0.002) in both groups.
Conclusions: Functional and strength training are equally effective in improving peak VO 2 , quality of life, and functionality in individuals with HF. These findings suggest that functional training may be a promising and innovative exercise-based strategy to treat HF.

Breath analysis combined with cardiopulmonary exercise testing and echocardiography for monitoring heart failure patients: the AEOLUS protocol.

Biagini D; Pugliese NR; Vivaldi FM; Ghimenti S; Lenzi A; De Angelis F; Ripszam M; Bruderer T; Armenia S; Cappeli F; Taddei S;
Masi S; Francesco FD; Lomonaco T;

Journal of breath research [J Breath Res] 2023 Aug 09; Vol. 17 (4).
Date of Electronic Publication: 2023 Aug 09.

This paper describes the AEOLUS pilot study which combines breath analysis with cardiopulmonary exercise testing (CPET) and an echocardiographic examination for monitoring heart failure (HF) patients. Ten consecutive patients with a prior clinical diagnosis of HF with reduced left ventricular ejection fraction were prospectively enrolled together with 15 control patients with cardiovascular risk factors, including hypertension, type II diabetes or chronic ischemic heart disease. Breath samples were collected at rest and during CPET coupled with exercise stress echocardiography (CPET-ESE) protocol by means of needle trap micro-extraction and were analyzed through gas-chromatography coupled with mass spectrometry. The protocol also involved using of a selected ion flow tube mass spectrometer for a breath-by-breath isoprene and acetone analysis during exercise. At rest, HF patients showed increased breath levels of acetone and pentane, which are related to altered oxidation of fatty acids and oxidative stress, respectively. A significant positive correlation was observed between acetone and the gold standard biomarker NT-proBNP in plasma ( r = 0.646, p < 0.001), both measured at rest. During exercise, some exhaled volatiles (e.g., isoprene) mirrored ventilatory and/or hemodynamic adaptation, whereas others (e.g., sulfide compounds and 3-hydroxy-2-butanone) depended on their origin. At peak effort, acetone levels in HF patients differed significantly from those of the control group, suggesting an altered myocardial and systemic metabolic adaptation to exercise for HF patients. These preliminary data suggest that concomitant acquisition of CPET-ESE and breath analysis is feasible and might provide additional clinical information on the metabolic maladaptation of HF patients to exercise. Such information may refine the identification of patients at higher risk of disease worsening.