Category Archives: Publications

The effects of CPET-guided cardiac rehabilitation on the cardiopulmonary function, the exercise endurance, and the NT-proBNP and hscTnT levels in CHF patients.

Wang Y; Cao J; Kong X; Wang S; Meng L; Wang Y;

American journal of translational research [Am J Transl Res] 2021 Jun 15; Vol. 13 (6), pp. 7104-7114. Date of Electronic Publication: 2021 Jun 15 (Print Publication: 2021).

Objective: To explore the effects of cardiopulmonary exercise testing (CPET) on the cardiopulmonary function, the exercise endurance, and the NT-proBNP and hscTnT levels in chronic heart failure (CHF) patients.
Methods: Altogether 98 patients with CHF were randomly divided into a control group and a CPET group, with 49 cases in each group. The control group was administered routine treatment, and the CPET group was administered CPET cardiac rehabilitation training in addition to the routine treatment. Heart and lung function, exercise endurance, and the peripheral blood NTproBNP, hscTnT, and CRP levels were observed. The patients’ quality of life, anxiety, and depression were observed using the scale.
Results: After the treatment, the left ventricular end systolic diameters (LVESD) and the left ventricular end diastolic diameters (LVEDD) were significantly decreased, the left ventricular ejection fractions (LVEF), the stroke volumes (SV), and the CI levels were significantly increased, and there were significant differences in these indexes between the CPET group and the control group (all P<0.05). After the treatment, the carbon dioxide ventilation equivalent slope (VE/VCO 2 slop) decreased significantly, the peak oxygen consumption (peakVO 2 ) and anaerobic threshold oxygen consumption (VO 2 AT) levels increased significantly, and there were significant differences in these indicators between the CPET group and the control group (all P<0.05). Compared with the control group, the exercise endurance, the maximum oxygen uptake capacity (VO 2 max), the maximum power, the exhaustion times, and the six-minute walking test (6MWT) levels in the CPET group increased significantly (all P<0.05). After the treatment, the N-terminal precursor brain natriuretic peptide (NTproBNP), the high sensitivity cardiac troponin (hscTnT), and the C-reactive protein (CRP) levels in the two groups were decreased compared with their pre-treatment levels, and there were significant differences in these indexes between the CPET group and the control group (all P<0.05). After the treatment, the Minnesota living with heart failure questionnaire (MLHFQ), the self-rating anxiety scale (SAS), and the self-rating depression scale (SDS) scores in the two groups were significantly lower than they were before the treatment, and there were significant differences in the two scores between the CPET group and the control group (all P<0.05).
Conclusion: CPET for patients with CHF helps increase heart and lung function, improves exercise endurance, reduces the NT-proBNP and hscTnT levels, and improves patients’ quality of life.

Cardiopulmonary exercise testing in COVID-19 patients at 3 months follow-up.

Clavario P; De Marzo V; Lotti R; Barbara C; Porcile A; Russo C; Beccaria F; Bonavia M; Bottaro LC; Caltabellotta M; Chioni F; Hautala AJ; Griffo R; Parati G; Corrà U; Porto I;

International journal of cardiology [Int J Cardiol] 2021 Jul 23. Date of Electronic Publication: 2021 Jul 23.

Background: Long-term effects of Coronavirus Disease of 2019 (COVID-19) and their sustainability are of the utmost relevance. We aimed to determine: 1) functional capacity of COVID-19 survivors by cardiopulmonary exercise testing (CPET); 2) characteristics associated with cardiopulmonary exercise testing (CPET) performance; 3) safety and tolerability of CPET.
Methods: We prospectively enrolled consecutive patients with laboratory-confirmed COVID-19 discharged alive at Azienda Sanitaria Locale-3, Genoa. At 3-month from hospital discharge, complete clinical evaluation, trans-thoracic echocardiography, CPET, pulmonary function test, and dominant leg extension (DLE) maximal strength evaluation were performed.
Results: From 225 patients discharged from March to November 2020, we excluded 12 incomplete/missing cases, 13 unable to perform CPET leading to a final population of 200. Median percent-predicted peak oxygen uptake (%pVO2) was 88% (78.3-103.1). Ninety-nine(49.5%) patients had %pVO2 below, whereas 101(50.5%) above the 85% predicted value (indicating normality). Of 61/99 patients with reduced %pVO2 but normal anaerobic threshold, 9(14.8%) had respiratory, 21(34.4%) cardiac, and 31(50.8%) non-cardiopulmonary limitation of exercise. One-hundred sixty(80.0%) patients complain at least one symptom, without relationship with pVO2. Multivariate linear regression analysis showed percent-predicted forced expiratory volume in one-second(β = 5.29,p = 0.023), percent-predicted diffusing capacity of lungs for carbon monoxide(β = 6.31,p = 0.001), and DLE maximal strength(β = 14.09,p = 0.008) independently associated with pVO2. None adverse event was reported during/after CPET neither the involved health professionals developed COVID-19.
Conclusions: CPET after COVID-19 is safe and about 1/3rd of COVID-19 survivors show functional capacity limitation mainly explained by muscular impairment, calling for future research to identify patients at higher risk of long-term effects that may benefit from careful surveillance and targeted rehabilitation.

Comparing individual and population differences in minute ventilation/carbon dioxide production slopes using centile growth curves and log-linear allometry.

Nevill AM; Myers J; Kaminsky LA; Arena R; Myers TD;

ERJ open research [ERJ Open Res] 2021 Jul 26; Vol. 7 (3). Date of Electronic Publication: 2021 Jul 26
(Print Publication: 2021).

Identifying vulnerable groups and/or individuals’ cardiorespiratory fitness (CRF) is an important challenge for clinicians/researchers alike. To quantify CRF accurately, the assessment of several variables is now standard practice including maximal oxygen uptake ( VCO 2 ) and ventilatory efficiency, the latter assessed using the minute ventilation/carbon dioxide production ( VE / VCO 2 ) slope. Recently, reference values (centiles) for VE / VCO 2 slopes for males and females aged 20 to 80 have been published, using cardiopulmonary exercise testing (CPX) data (treadmill protocol) from the Fitness Registry and the Importance of Exercise National Database (FRIEND Registry). In the current observational study we provide centile curves for the FRIEND Registry VE / VCO 2 slopes, fitted using the generalised additive model for location, scale and shape (GAMLSS), to provide individuals with a more precise estimate of where their VE / VCO 2 slopes fall within the population. We also confirm that by adopting allometric models (incorporating a log transformation), the resulting ANCOVAs provided more normal and homoscedastic residuals, with superior goodness-of-fit using the Akaike information criterion (AIC)=14 671 (compared with traditional ANCOVA’s AIC=15 008) that confirms allometric models are vastly superior to traditional ANCOVA models. In conclusion, providing sex-by-age centile curves rather than referring to reference tables for ventilatory efficiency ( VE / VCO 2 slopes) will provide more accurate estimates of where an individual’s particular VE / VCO 2 slope falls within the population. Also, by adopting allometric models researchers are more likely to identify real and valid inferences when analysing population/group differences in VE / VCO 2 slopes.

Jumping into a Healthier Future: Trampolining for Increasing Physical Activity in Children.

Schöffl I; Ehrlich B; Rottermann K; Weigelt A; Dittrich S; Schöffl V;

Sports medicine – open [Sports Med Open] 2021 Jul 30; Vol. 7 (1), pp. 53. Date of Electronic Publication: 2021
Jul 30.

Objectives: Physical activity in children and adolescents has positive effects on cardiopulmonary function in this age group as well as later in life. As poor cardiopulmonary function is associated with higher mortality and morbidity, increasing physical activity especially in children needs to become a priority. Trampoline jumping is widely appreciated in children. The objective was to investigate its use as a possible training modality.
Methods: Fifteen healthy children (10 boys and 5 girls) with a mean age of 8.8 years undertook one outdoor incremental running test using a mobile cardiopulmonary exercise testing unit. After a rest period of at least 2 weeks, a trampoline test using the mobile unit was realized by all participants consisting of a 5-min interval of moderate-intensity jumping and two high-intensity intervals with vigorous jumping for 2 min, interspersed with 1-min rests.
Results: During the interval of moderate intensity, the children achieved [Formula: see text]-values slightly higher than the first ventilatory threshold (VT1) and during the high-intensity interval comparable to the second ventilatory threshold (VT2) of the outdoor incremental running test. They were able to maintain these values for the duration of the respective intervals. The maximum values recorded during the trampoline test were significantly higher than during the outdoor incremental running test.
Conclusion: Trampoline jumping is an adequate tool for implementing high-intensity interval training as well as moderate-intensity continuous training in children. As it is a readily available training device and is greatly enjoyed in this age group, it could be implemented in exercise interventions.

Cardiorespiratory fitness assessed by cardiopulmonary exercise testing between different stages of pre-dialysis chronic kidney disease: A systematic review and meta-analysis.

Alexandrou ME; P Theodorakopoulou M; Boutou A; Pella E; Boulmpou A; Papadopoulos CE; Zafeiridis A;
Papagianni A; Sarafidis P;

Nephrology (Carlton, Vic.) [Nephrology (Carlton)] 2021 Jul 20. Date of Electronic Publication: 2021 Jul 20.

Aim: The burden of several cardiovascular risk factors increases in parallel to renal function decline. Exercise intolerance is common in patients with chronic kidney disease (CKD) and has been associated with increased risk of adverse outcomes. Whether indices of cardiorespiratory capacity deteriorate with advancing CKD stages is unknown.
Methods: We conducted a systematic review and meta-analysis of studies assessing cardiorespiratory capacity in adult patients with pre-dialysis CKD using cardiopulmonary exercise testing (CPET) and reporting data for different stages. Our primary outcome was differences in peak oxygen uptake (VO 2 peak) between patients with CKD Stages 2-3a and those with Stages 3b-5(pre-dialysis). Literature search was undertaken in PubMed, Web of Science and Scopus databases, and abstract books of relevant meetings. Quality assessment was undertaken with Newcastle-Ottawa-Scale.
Results: From 4944 records initially retrieved, six studies with 512 participants fulfilling our inclusion criteria were included in the primary meta-analysis. Peak oxygen uptake (VO 2 peak) was significantly higher in patients with CKD Stages 2-3a versus those with Stages 3b-5(pre-dialysis) [weighted-mean-difference, WMD: 2.46, 95% CI (1.15, 3.78)]. Oxygen consumption at ventilatory threshold (VO 2 VT) was higher in Stages 2-3a compared with those in Stages 3b-5(pre-dialysis) [standardized-mean-difference, SMD: 0.59, 95% CI (0.06, 1.1)], while no differences were observed for maximum workload and respiratory-exchange-ratio. A secondary analysis comparing patients with CKD Stages 2-3b and Stages 4-5(pre-dialysis), yielded similar results [WMD: 1.78, 95% CI (1.34, 2.22)]. Sensitivity analysis confirmed the robustness of these findings.
Conclusion: VO 2 peak and VO 2 VT assessed with CPET are significantly lower in patients in CKD Stages 3b-5 compared with Stages 2-3a. Reduced cardiorespiratory fitness may be another factor contributing to cardiovascular risk increase with advancing CKD.

Ventilatory efficiency in pulmonary vascular diseases.

Weatherald J; Philipenko B; Montani D; Laveneziana P;

European respiratory review : an official journal of the European Respiratory Society [Eur Respir Rev] 2021 Jul 20; Vol. 30 (161). Date of Electronic Publication: 2021 Jul 20 (Print Publication: 2021).

Cardiopulmonary exercise testing (CPET) is a frequently used tool in the differential diagnosis of dyspnoea. Ventilatory inefficiency, defined as high minute ventilation ( V’ E ) relative to carbon dioxide output ( V’ CO 2 ), is a hallmark characteristic of pulmonary vascular diseases, which contributes to exercise intolerance and disability in these patients. The mechanisms of ventilatory inefficiency are multiple and include high physiologic dead space, abnormal chemosensitivity and an altered carbon dioxide (CO 2 ) set-point. A normal V’ E / V’ CO 2 makes a pulmonary vascular disease such as pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) unlikely. The finding of high V’ E /V’ CO 2 without an alternative explanation should prompt further diagnostic testing to exclude PAH or CTEPH, particularly in patients with risk factors, such as prior venous thromboembolism, systemic sclerosis or a family history of PAH. In patients with established PAH or CTEPH, the V’ E / V’ CO 2 may improve with interventions and is a prognostic marker. However, further studies are needed to clarify the added value of assessing ventilatory inefficiency in the longitudinal follow-up of patients.

Exercise tolerance and quality of life in hemodynamically partially improved patients with chronic thromboembolic pulmonary hypertension treated with balloon pulmonary angioplasty.

Miura K; Katsumata Y; Kawakami T; Ikura H; Ryuzaki T; Shiraishi Y; Fukui S; Kawakami M; Kohno T; Sato K;
Fukuda K;

PloS one [PLoS One] 2021 Jul 23; Vol. 16 (7), pp. e0255180. Date of Electronic Publication: 2021 Jul 23 (Print Publication: 2021).

The efficacy of extensive balloon pulmonary angioplasty (BPA) beyond hemodynamic improvement in chronic thromboembolic pulmonary hypertension (CTEPH) patients has been verified. However, the relationship between extensive BPA in CTEPH patients after partial hemodynamic improvement and exercise tolerance or quality of life (QOL) remains unclear. We prospectively enrolled 22 CTEPH patients (66±10 years, females: 59%) when their mean pulmonary artery pressure initially decreased to <30 mmHg during BPA sessions. Hemodynamic and echocardiographic data, cardiopulmonary exercise testing, and QOL scores using the 36-item short form questionnaire (SF-36) were evaluated at enrollment (entry), just after the final BPA session (finish), and at the 6-month follow-up (follow-up). We analyzed whether extensive BPA improves exercise capacity and QOL scores over time. Moreover, the clinical characteristics leading to improvement were elucidated. The peak oxygen uptake (VO2) showed significant improvement at entry, finish, and follow-up (17.3±5.5, 18.4±5.9, and 18.9±5.3 mL/kg/min, respectively; P<0.001). Regarding the QOL, the physical component summary (PCS) scores significantly improved (32±11, 38±13, and 43±13, respectively; P<0.001), but the mental component summary scores remained unchanged. Linear regression analysis revealed that age and a low peak VO2 at entry were predictors of improvement in peak VO2, while low PCS scores and low TAPSE at entry were predictors of improvement in PCS scores. In conclusion, extensive BPA led to improved exercise tolerance and physical QOL scores, even in CTEPH patients with partially improved hemodynamics.

How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease.

Lewthwaite H; Jensen D; Ekström M;

International journal of chronic obstructive pulmonary disease [Int J Chron Obstruct Pulmon Dis] 2021 Jun 03; Vol. 16, pp. 1581-1598. Date of Electronic Publication: 2021 Jun 03 (Print Publication: 2021).

Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg’s 0-10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.

Cardiorespiratory Fitness After Open Repair for Acute Type A Aortic Dissection – A Prospective Study.

Norton EL; Rubenfire M; Fink S; Sitzmann J; Hobbs RD; Saberi S; Willer CJ; Yang B; Hornsby WE;

Seminars in thoracic and cardiovascular surgery [Semin Thorac Cardiovasc Surg] 2021 Jun 05. Date of Electronic Publication: 2021 Jun 05.

Objective: Cardiorespiratory fitness (as measured by peak oxygen consumption [VO 2peak ]) is an independent predictor of cardiovascular disease and all-cause mortality. Limited data exist on VO 2peak following repair for an acute type A aortic dissection (ATAAD) or proximal thoracic aortic aneurysm (pTAA). This study prospectively evaluated VO 2peak , functional capacity, and health-related quality of life (HR-QOL) following open repair.
Methods: Participants with a history of an ATAAD (n=21) or pTAA (n=43) performed cardiopulmonary exercise testing (CPX), six-minute walk testing, and HR-QOL at 3 (early) and 15 (late) months following open repair.
Results:   The median age at time of surgery was 55-years-old and 60-years-old in the ATAAD and pTAA groups, respectively. Body mass index significantly increased between early and late timepoints for both ATAAD (p=0.0245, 56% obese) and pTAA groups (p=0.0045, 54% obese). VO 2peak modestly increased by 0.8 mLO2•kg-1•min-1 within the ATAAD group (P=0.2312) while VO 2peak significantly increased by 2.2 mLO2•kg-1•min-1 within the pTAA group (P=0.0003). Anxiety significantly decreased in the ATAAD group whereas functional capacity and HR-QOL metrics (social roles and activities, physical function) significantly improved in the pTAA group (p values<0.05). There were no serious adverse events during CPX.
Conclusion: Cardiorespiratory fitness among the ATAAD group remained 36% below predicted normative values >1 year after repair. CPX should be considered post-operatively to evaluate exercise tolerance and blood pressure response to determine whether mild-to-moderate aerobic exercise should be recommended to reduce future risk of morbidity and mortality.


Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses.

Steffens D; Ismail H; Denehy L; Beckenkamp PR; Solomon M; Koh C; Bartyn J;

Annals of surgical oncology [Ann Surg Oncol] 2021 Jun 08. Date of Electronic Publication: 2021 Jun 08.

Backgrounds: There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery.
Methods: A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO 2 ), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (V E /V CO2 ), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible.
Results: Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO 2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and V E /V CO2 also demonstrated some positive trends. None of the included studies reported a negative trend.
Conclusions: This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO 2 , and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.