Category Archives: Abstracts

Use of exercise tests in screening for pulmonary arterial hypertension in systemic sclerosis: A systematic literature review.

Madigan S; School of Medicine, The University of Adelaide,  Australia.;
Proudman S; Schembri D; Davies H; Adams R;

Journal of scleroderma and related disorders [J Scleroderma Relat Disord] 2024 Feb; Vol. 9 (1), pp. 50-58.
Date of Electronic Publication: 2023 Oct 02.

Background and Objective: Patients with systemic sclerosis (SSc) and pulmonary arterial hypertension (PAH) have a poor prognosis, accounting for 30% of all SSc-related deaths. Guidelines recommend annual screening for PAH regardless of symptoms, as early treatment improves outcomes. Current protocols include combinations of clinical features, biomarkers, pulmonary function tests, and echocardiography. None include exercise testing, although early-stage PAH may only be evident during exercise. This systematic review assessed the performance of exercise tests in predicting the presence of PAH in patients with SSc, where PAH was confirmed through right heart catheterisation (RHC).
Methods: Comprehensive literature searches were performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trails, CINAHL, Scopus and Web of Science from inception to May 2023. Articles were screened for eligibility by two independent reviewers. Eligibility criteria included the use of a non-invasive exercise test to screen adult patients to detect PAH in a population without a previous diagnosis of PAH, with diagnosis confirmed by RHC.
Results: Eight studies met the inclusion criteria, describing at least one of three different non-invasive exercise tests: cardiopulmonary exercise test, six-minute walk test and stress Doppler echocardiography. All studies found that exercise tests had some ability to predict the presence of PAH, with sensitivity between 50% and 100% and specificity from 73% to 91%.
Conclusion: Exercise tests are infrequently used for screening for PAH in SSc but can predict the presence of PAH. More data are required to establish which tests are most effective.


Pre-participation screenings frequently miss occult cardiovascular conditions in apparently healthy male middle-aged first-time marathon runners.

Laily I; Wiggers TGH; van Steijn N; Bijsterveld N; Bakermans AJ; Froeling M; van den Berg-Faay S; de Haan FH; de Bruin-Bon RHACM; Boekholdt SM; Planken RN; Verhagen E;  Jorstad HT;

Cardiology [Cardiology] 2024 Feb 07.
Date of Electronic Publication: 2024 Feb 07.

Introduction: The optimal pre-participation screening strategy to identify athletes at risk for exercise-induced cardiovascular events is unknown. We therefore aimed to compare the American College of Sports Medicine (ACSM) and European Society of Cardiology (ESC) pre-participation screening strategies against extensive cardiovascular evaluations in identifying high-risk individuals among 35-50-year-old apparently healthy men.
Methods: We applied ACSM and ESC pre-participation screenings to 25 men participating in a study on first-time marathon running. We compared screening outcomes against medical history, physical examination, electrocardiography, blood tests, echocardiography, cardiopulmonary exercise testing, and magnetic resonance imaging.
Results: ACSM screening classified all participants as ‘medical clearance not necessary’. ESC screening classified two participants as ‘high-risk’. Extensive cardiovascular evaluations revealed ≥1 minor abnormality and/or cardiovascular condition in 17 participants, including three subjects with mitral regurgitation and one with a small atrial septal defect. Eleven participants had dyslipidaemia, six had hypertension, and two had premature atherosclerosis. Ultimately, three (12%) subjects had a serious cardiovascular condition warranting sports restrictions: aortic aneurysm, hypertrophic cardiomyopathy (HCM), and myocardial fibrosis post-myocarditis. Of these three participants, only one had been identified as ‘high-risk’ by the ESC screening (for dyslipidaemia, not HCM) and none by the ACSM screening.
Conclusion: Numerous occult cardiovascular conditions are missed when applying current ACSM/ESC screening strategies to apparently healthy middle-aged men engaging in their first high-intensity endurance sports event.

Taking a walk on the heart failure side: comparison of metabolic variables during walking and maximal exertion.

Mapelli M; Centro Cardiologico Monzino IRCCS, Milan, Italy.;
Salvioni E; Bonomi A; Paneroni M; Raimondo R; Gugliandolo P; Mattavelli I; Bidoglio J; Mirza KK; La Rovere MT; Gustafsson F; Agostoni P;

ESC heart failure [ESC Heart Fail] 2024 Jan 29.
Date of Electronic Publication: 2024 Jan 29.

Aims: Although cardiopulmonary exercise testing (CPET) is the gold standard to assess exercise capacity, simpler tests (i.e., 6-min walk test, 6MWT) are also commonly used. The aim of this study was to evaluate the relationship between cardiorespiratory parameters during CPET and 6MWT in a large, multicentre, heterogeneous population.
Methods: We included athletes, healthy subjects, and heart failure (HF) patients of different severity, including left ventricular assist device (LVAD) carriers, who underwent both CPET and 6MWT with oxygen consumption measurement.
Results: We enrolled 186 subjects (16 athletes, 40 healthy, 115 non-LVAD HF patients, and 15 LVAD carriers). CPET-peakV̇O 2 was 41.0 [35.0-45.8], 26.2 [23.1-31.0], 12.8 [11.1-15.3], and 15.2 [13.6-15.6] ml/Kg/min in athletes, healthy, HF patients, and LVAD carriers, respectively (P < 0.001). During 6MWT they used 63.5 [56.3-76.8], 72.0 [57.8-81.0], 95.5 [80.3-109], and 95.0 [92.0-99.0] % of their peakV̇O 2 , respectively. None of the athletes, 1 healthy (2.5%), 30 HF patients (26.1%), and 1 LVAD carrier (6.7%), reached a 6MWT-V̇O 2 higher than their CPET-peakV̇O 2 . Both 6MWT-V̇O 2 and walked distance were significantly associated with CPET-peakV̇O 2 in the whole population (R 2  = 0.637 and R 2  = 0.533, P ≤ 0.001) but not in the sub-groups. This was confirmed after adjustment for groups.
Conclusions: The 6MWT can be a maximal effort especially in most severe HF patients and suggest that, in absence of prognostic studies related to 6MWT metabolic values, CPET should remain the first method of choice in the functional assessment of patients with HF as well as in sport medicine.

Cardiopulmonary Exercise Testing Interpretation in Athletes: What the Cardiologist Should Know.

Husaini M; Department of Medicine,  Washington University School of Medicine,
Emery MS;

Cardiac electrophysiology clinics [Card Electrophysiol Clin] 2024 Mar; Vol. 16 (1), pp. 71-80.

The noninvasive assessment of oxygen consumption, carbon dioxide production, and ventilation during a cardiopulmonary exercise test (CPET) provides insight into the cardiovascular, pulmonary, and metabolic system’s ability to respond to exercise. Exercise physiology has been shown to be distinct for competitive athletes and highly active persons (CAHAPs), thus creating more nuanced interpretations of CPET parameters. CPET in CAHAP is an important test that can be used for both diagnosis (provoking symptoms during a truly maximal test) and performance.

Perioperative Exercise Testing in Pregnant and Non-Pregnant Women of Reproductive Age: A Systematic Review.

Spicer MG; Department of Obstetrics and Gynaecology,  Alice Springs, NT 0870, Australia.
Dennis AT; Department of Anaesthesia, Pain and Perioperative Medicine, Joan Kirner Women’s and Children’s Hospital,

Journal of clinical medicine [J Clin Med] 2024 Jan 11; Vol. 13 (2).
Date of Electronic Publication: 2024 Jan 11.

Background: Women have classically been excluded from the development of normal data and reference ranges, with pregnant women experiencing further neglect. The incidence of Caesarean section in pregnant women, and of general operative management in young women (both pregnant and non-pregnant), necessitates the formal development of healthy baseline data in these cohorts to optimise their perioperative management. This systematic review assesses the representation of young women in existing reference ranges for several functional exercise tests in common use to facilitate functional assessment in this cohort.
Methods: Existing reference range data for the exercise tests the Six Minute Walk Test (6MWT), the Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary Exercise Testing (CPET) in young women of reproductive age were assessed using the MEDLINE (Ovid) database, last searched December 2023. Results were comparatively tabulated but not statistically analysed given underlying variances in data.
Results: The role of exercise testing in the perioperative period as an assessment tool, as well as its safety during pregnancy, was evaluated using 65 studies which met inclusion criteria.
Conclusion: There is a significant lack of baseline data regarding these tests in this population, especially amongst the pregnant cohort, which limits the application of exercise testing clinically.

Determinants of VO2peak changes after aerobic training in coronary heart disease patients.

Guirault A; Montreal Heart Institute, Montréal, Canada: Amiens, France: Bern, Switzerland: Manchester. UK
Leprêtre PM; Trachsel LD; Besnier F; Boidin M; Lalongé J; Juneau M; Bherer L; Nigam A; Gayda M;

International journal of sports medicine [Int J Sports Med] 2024 Jan 24.
Date of Electronic Publication: 2024 Jan 24.

This study aimed to highlight the ventilatory and circulatory determinants of changes in VO2peak after exercise-based cardiac rehabilitation (ECR) in patients with coronary heart disease (CHD). Eighty-two CHD patients performed, before and after a 3-month ECR, a cardiopulmonary exercise testing (CPET) on a bike with gas exchanges measurments (VO2peak, minute ventilation; VE) and cardiac output (Qc). The arteriovenous difference in O2 (C(a-v )O2) and the alveolar capillary gradient in O2 (PAi-aO2) were calculated using Fick’s laws. Oxygen uptake efficiency slope (OUES) was calculated. A 5.0% cut off was applied for differentiating non- (NR: ∆VO2<0.0%), low (LR: 0.0≤ ∆VO2<5.0%), moderate- (MR: 5.0≤∆VO2<10.0%) and high responders (HR: ∆VO2≥10.0%) to ECR. Forty-four % of patients were HR (n=36), 20% MR (n=16), 23% LR (n=19) and 13% NR (n=11). For HR, the VO2peak increase (p<0.01) was associated to increases in VE (+12.8±13.0L/min, p<0.01), Qc (+1.0±0.9L/min, p<0.01), and C(a-v)O2 (+2.3±2.5mLO2/100mL, p<0.01). MR patients were characterized by +6.7±19.7L/min increase in VE (p=0.04) and +0.7±1.0L/min of Qc (p<0.01). ECR induced decreases in VE (p=0.04) and C(a-v )O2 (p<0.01) and Qc increase in LR and NR patients (p<0.01). Peripheral and ventilatory responses more than central adaptations could responsible of the VO2peak change with ECR in CHD patients.

Patients with CTEPH and mild hemodynamic severity of disease improve to a similar level of exercise capacity after pulmonary endarterectomy compared to patients with severe hemodynamic disease.

van Kan C; Department of Respiratory Medicine OLVG Amsterdam The Netherlands.
Tramper J; Bresser P; J Meijboom L; Symersky P; Winkelman JA; Nossent EJ; Aman J; Bogaard HJ; Vonk Noordegraaf A; van Es J;

Pulmonary circulation [Pulm Circ] 2024 Jan 24; Vol. 14 (1), pp. e12316.
Date of Electronic Publication: 2024 Jan 24 (Print Publication: 2024).

The correlation between hemodynamics and degree of pulmonary vascular obstruction (PVO) is known to be poor in chronic thromboembolic pulmonary hypertension (CTEPH), which makes the selection of patients eligible for pulmonary endarterectomy (PEA) challenging. It can be postulated that patients with similar PVO but different hemodynamic severity have different postoperative hemodynamics and exercise capacity. Therefore, we aimed to assess the effects of PEA on hemodynamics and exercise physiology in mild and severe CTEPH patients. We retrospectively studied 18 CTEPH patients with a mild hemodynamic profile (mean pulmonary arterial pressure [mPAP] between 25 and 30 mmHg at rest) and CTEPH patients with a more severe hemodynamic profile (mPAP > 30 mmHg), matched by age, gender, and PVO. Cardiopulmonary exercise testing parameters were evaluated at baseline and 18 months following PEA. At baseline, exercise capacity, defined as oxygen uptake, was less severely impaired in the mild CTEPH group compared to the severe CTEPH group. After PEA, in the mild CTEPH group, ventilatory efficiency and oxygen pulse improved significantly ( p  < 0.05), however, the change in ventilatory efficiency and oxygen pulse was smaller compared to the severe CTEPH group. Only in the severe CTEPH group exercise capacity improved significantly ( p  < 0.001). Hence, in the present study, postoperative hemodynamic outcome and the CPET-determined recovery of exercise capacity in mild CTEPH patients did not differ from a matched group of severe CTEPH patients.

Using Machine Learning-Based Algorithms to Identify and Quantify Exercise Limitations in Clinical Practice: Are We There Yet?

SCHWENDINGER, F;  Multi centre study from many European countries

Med Sci Sports Exerc 2024 Vol. 56 Issue 2 Pages 159-169

INTRODUCTION: Well-trained staff is needed to interpret cardiopulmonary exercise tests (CPET). We aimed to examine the accuracy of machine learning-based algorithms to classify exercise limitations and their severity in clinical practice compared with expert consensus using patients presenting at a pulmonary clinic.
METHODS: This study included 200 historical CPET data sets (48.5% female) of patients older than 40 yr referred for CPET because of unexplained dyspnea, preoperative examination, and evaluation of therapy progress. Data sets were independently rated by experts according to the severity of pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular limitations using a visual analog scale. Decision trees and random forests analyses were calculated.
RESULTS: Mean deviations between experts in the respective limitation categories ranged from 1.0 to 1.1 points (SD, 1.2) before consensus. Random forests identified parameters of particular importance for detecting specific constraints. Central parameters were nadir ventilatory efficiency for CO2 , ventilatory efficiency slope for CO2 (pulmonary-vascular limitations); breathing reserve, forced expiratory volume in 1 s, and forced vital capacity (mechanical-ventilatory limitations); and peak oxygen uptake, O2 uptake/work rate slope, and % change of the latter (cardiocirculatory limitations). Thresholds differentiating between different limitation severities were reported. The accuracy of the most accurate decision tree of each category was comparable to expert ratings. Finally, a combined decision tree was created quantifying combined system limitations within one patient.
CONCLUSIONS: Machine learning-based algorithms may be a viable option to facilitate the interpretation of CPET and identify exercise limitations. Our findings may further support clinical decision making and aid the development of standardized rating instruments.

Prehabilitation before general surgery: Worth the effort?

J. G. Kovoor, S. D. Nann, C. Chambers, K. Mishra, S. Goel, I. Thompson, Koh D; Litwin P; Bacchi S; Harford PJ; Stretton B; Gupta AK,

J Perioper Pract 2023 Pages 17504589231214395

Prehabilitation, or interventions before surgery aimed at improving preoperative health and postoperative outcomes, has various forms. Although it may confer benefit to patients undergoing general surgery, this is not certain. Furthermore, although it may yield a net monetary gain, it is also likely to require substantial monetary and non-monetary investment. The impact of prehabilitation is highly variable and dependent on multiple factors. Physical function and pulmonary outcomes are likely to be improved by most forms of prehabilitation involving physical and multimodal exercise programmes. However, other surgical outcomes have demonstrated mixed results from prehabilitation. Within this issue, the measures used for evaluating baseline patient biopsychosocial health are important, and collecting sufficient data to accurately inform patient-centred prehabilitation programmes is only possible through thorough clinical and laboratory investigation and synthesised metrics such as cardiopulmonary exercise testing. Although a multimodal approach to prehabilitation is the current gold standard, societal factors may affect engagement with programmes that require a significant in-person activity. However, this is weighed against the substantial financial and non-financial investment that accompanies many programmes. The overall effectiveness and optimal mode of intervention across the discipline of general surgery remains unclear, and further research is needed to prove prehabilitation’s full worth.

Reduced tidal volume-inflection point and elevated operating lung volumes during exercise in females with well-controlled asthma.

Brotto AR; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.;
Phillips DB; Rowland SD; Moore LE; Wong E;Stickland MK;

BMJ open respiratory research [BMJ Open Respir Res] 2023 Dec 22; Vol. 10 (1).
Date of Electronic Publication: 2023 Dec 22.

Introduction: Individuals with asthma breathe at higher operating lung volumes during exercise compared with healthy individuals, which contributes to increased exertional dyspnoea. In health, females are more likely to develop exertional dyspnoea than males at a given workload or ventilation, and therefore, it is possible that females with asthma may develop disproportional dyspnoea on exertion. The purpose of this study was to compare operating lung volume and dyspnoea responses during exercise in females with and without asthma.
Methods: Sixteen female controls and 16 females with asthma were recruited for the study along with 16 male controls and 16 males with asthma as a comparison group. Asthma was confirmed using American Thoracic Society criteria. Participants completed a cycle ergometry cardiopulmonary exercise test to volitional exhaustion. Inspiratory capacity manoeuvres were performed to estimate inspiratory reserve volume (IRV) and dyspnoea was evaluated using the Modified Borg Scale.
Results: Females with asthma exhibited elevated dyspnoea during submaximal exercise compared with female controls (p<0.05). Females with asthma obtained a similar IRV and dyspnoea at peak exercise compared with healthy females despite lower ventilatory demand, suggesting mechanical constraint to tidal volume (V T ) expansion. V T -inflection point was observed at significantly lower ventilation and O 2 in females with asthma compared with female controls. Forced expired volume in 1 s was significantly associated with V T -inflection point in females with asthma (R 2 =0.401; p<0.01) but not female controls (R 2 =0.002; p=0.88).
Conclusion: These results suggest that females with asthma are more prone to experience exertional dyspnoea, secondary to dynamic mechanical constraints during submaximal exercise when compared with females without asthma.