Bailey DM; Halligan CL; Davies RG; Funnell A; Appadurai IR; Rose GA;
Rimmer L; Jubouri M; Coselli JS; Williams IM; Bashir M

Journal of Cardiac Surgery. 37(8):2258-2265, 2022 Aug.

Abstract
BACKGROUND: Initial clinical evaluation (ICE) is traditionally considered
a useful screening tool to identify frail patients during the preoperative
assessment. However, emerging evidence supports the more objective
assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise
testing (CPET) to improve surgical risk stratification. Herein, we
compared both subjective and objective assessment approaches to highlight
the interpretive idiosyncrasies.

METHODS: As part of routine preoperative patient contact, patients
scheduled for major surgery were prospectively “eyeballed” (ICE) by two
experienced clinicians before more detailed history taking that also
included the American Society of Anesthesiologists score classification.
Each patient was subjectively judged to be either “frail” or “not frail”
by ICE and “fit” or “unfit” from a thorough review of the medical notes.
Subjective data were compared against the more objective validated
assessment of postoperative outcomes using established CPET “cut-off”
metrics incorporating peak pulmonary oxygen uptake, VO2PEAK at the
anaerobic threshold (VO2 -AT), and ventilatory equivalent for carbon
dioxide that collectively informed risk stratification. These data were
retrospectively extracted from a single-center prospective National Health
Service database. Data were analyzed using the Chi-square automatic
interaction detection decision tree method.

RESULTS: A total of 127 patients were examined that comprised 58% male
and 42% female patients aged 69 +/- 10 years with a body mass index of 29
+/- 7 kg/m2 . Patients were poorly conditioned with a VO2PEAK almost 20%
lower than predicted for age, sex-matched healthy controls with 35%
exhibiting a VO2 -AT < 11 ml/kg/min. Disagreement existed between the
subjective assessments of risk with ~34% of patients classified as not
frail on ICE were considered unfit by notes review (p < .0001).
Furthermore, ~35% of patients considered not frail on ICE and ~31% of
patients considered fit by notes review exhibited a VO2 -AT < 11
ml/kg/min, and of these, ~28% and ~19% were classified as intermediate to
high risk.

CONCLUSIONS: These findings highlight the interpretive limitations
associated with the subjective assessment of patient frailty with surgical
risk classification underestimated in up to a third of patients compared
to the validated assessment of CRF. They reinforce the benefits of a more
objective and integrated approach offered by CPET that may help us to
improve perioperative risk assessment and better direct critical care
provision in patients scheduled for “high-stakes” surgery including open
thoracoabdominal aortic aneurysm repair

Lacavalerie MR; Pierre-Francois S; Agossou M; Inamo J; Cabie A; Barnay JL;
Neviere R

Future Cardiology. 18(7):577-584, 2022 Jul.

Abstract
Aim: To analyze the impact of obesity on cardiopulmonary response to
exercise in people with chronic post-COVID-19 syndrome. Patients &
methods: Consecutive subjects with chronic post-COVID syndrome 6 months
after nonsevere acute infection were included. All patients received a
complete clinical evaluation, lung function tests and cardiopulmonary
exercise testing. A total of 51 consecutive patients diagnosed with
chronic post-COVID-19 were enrolled in this study.
Results:
More than half of patients with chronic post-COVID-19 had a significant alteration in
aerobic exercise capacity (VO2peak) 6 months after hospital discharge.
Obese long-COVID-19 patients also displayed a marked reduction of oxygen
pulse (O2pulse).
Conclusion: Obese patients were more prone to have pathological pulmonary limitation
and pulmonary gas exchange impairment to
exercise compared with nonobese COVID-19 patients.
Other Abstract
plain-language-summary In this study, the cardiopulmonary response to
exercise in people with chronic post-COVID-19 syndrome was analyzed. More
than half of patients diagnosed with chronic post-COVID-19 had reduced
exercise capacity 6 months after hospital discharge. In addition, patients
with chronic post-COVID-19 syndrome who were overweight or obese displayed
exaggerated hyperventilation along with an impairment of oxygenation at
peak exercise.

Barbagelata L; Masson W; Iglesias D; Lillo E; Migone JF; Orazi ML;
Maritano Furcada J

Medicina Clinica. 159(1):6-11, 2022 Jul 08.

BACKGROUND AND AIM: Several reports have shown the persistence of long
term symptoms after the initial COVID-19 infection (post-COVID-19
syndrome). The objective of this study was to analyze the characteristics
of cardiopulmonary exercise testing (CPET) performed in patients with a
history of COVID-19, comparing subjects according to the presence of
post-COVID-19 syndrome.

METHODS: A cross-sectional study was performed. Consecutive patients >18
years with history of SARS-CoV-2 infection confirmed by polymerase chain
reaction test and a CPET performed between 45 and 120 days after the viral
episode were included. The association between variables related to CPET
and post-COVID-19 syndrome was assessed using univariate and multivariate
analysis.

RESULTS: A total of 200 patients (mean age 48.8+/-14.3 years, 51% men)
were included. Patients with post-COVID-19 syndrome showed significantly
lower main peak VO2 (25.8+/-8.1mL/min/kg vs. 28.8+/-9.6mL/min/kg, p=0.017)
as compared to asymptomatic subjects. Moreover, patients with
post-COVID-19 syndrome developed symptoms more frequently during CPET
(52.7% vs. 13.7%, p<0.001) and were less likely to reach the anaerobic
threshold (50.9% vs. 72.7%, p=0.002) when compared to asymptomatic
subjects. These findings were not modified when adjusting for confounders.

CONCLUSION: Our data suggest that post-COVID-19 syndrome was associated
with less peak VO2, a lower probability of achieving the anaerobic
threshold and a higher probability of presenting symptoms during the CPET.
Future studies are needed to determine if these abnormalities during CPET
would have prognostic value.

Banydeen R; Monfort A; Inamo J; Neviere R;

Frontiers in cardiovascular medicine [Front Cardiovasc Med] 2022 Jun 06; Vol. 9, pp. 898033.
Date of Electronic Publication: 2022 Jun 06 (Print Publication: 2022).

Cardiac amyloidosis (CA) is a myocardial disease characterized by extracellular amyloid infiltration throughout the heart, resulting in increased myocardial stiffness, and restrictive heart wall chamber behavior. Its diagnosis among patients hospitalized for cardiovascular diseases is becoming increasingly frequent, suggesting improved disease awareness, and higher diagnostic capacities. One predominant functional manifestation of patients with CA is exercise intolerance, objectified by reduced peak oxygen uptake (VO ₂ peak), and assessed by metabolic cart during cardiopulmonary exercise testing (CPET). Hemodynamic adaptation to exercise in patients with CA is characterized by low myocardial contractile reserve and impaired myocardial efficiency. Rapid shallow breathing and hyperventilation, in the absence of ventilatory limitation, are also typically observed in response to exercise. Ventilatory inefficiency is further suggested by an increased VE-VCO2 slope, which has been attributed to excessive sympathoexcitation and a high physiological dead space (VD/VT) ratio during exercise. Growing evidence now suggests that, in addition to well-established biomarker risk models, a reduced VO ₂ peak is potentially a strong and independent predictive factor of adverse patient outcomes, both for monoclonal immunoglobulin light chain (AL) or transthyretin (ATTR) CA. Besides generating prognostic information, CPET can be used for the evaluation of the impact of therapeutic interventions in patients with CA.

Durstenfeld MS; Sun K; Tahir PM; Peluso MJ; Deeks SG; Aras MA; Grandis DJ; Long CS; Beatty A; Hsue PY

MedRxiv : the preprint server for health sciences [medRxiv] 2022 Jun 16.
Date of Electronic Publication: 2022 Jun 16.

Importance: Reduced exercise capacity is commonly reported among individuals with Long COVID (LC). Cardiopulmonary exercise testing (CPET) is the gold-standard to measure exercise capacity to identify causes of exertional intolerance.
Objectives: To estimate the effect of SARS-CoV-2 infection on exercise capacity including those with and without LC symptoms and to characterize physiologic patterns of limitations to elucidate possible mechanisms of LC.
Data Sources: We searched PubMed, EMBASE, and Web of Science, preprint severs, conference abstracts, and cited references in December 2021 and again in May 2022.
Study Selection: We included studies of adults with SARS-CoV-2 infection at least three months prior that included CPET measured peak VO ₂ . 3,523 studies were screened independently by two blinded reviewers; 72 (2.2%) were selected for full-text review and 36 (1.2%) met the inclusion criteria; we identified 3 additional studies from preprint servers.
Data Extraction and Synthesis: Data extraction was done by two independent reviewers according to PRISMA guidelines. Data were pooled with random-effects models.
Main Outcomes and Measures: A priori primary outcomes were differences in peak VO ₂ (in ml/kg/min) among those with and without SARS-CoV-2 infection and LC.
Results: We identified 39 studies that performed CPET on 2,209 individuals 3-18 months after SARS-CoV-2 infection, including 944 individuals with LC symptoms and 246 SARS-CoV-2 uninfected controls. Most were case-series of individuals with LC or post-hospitalization cohorts. By meta-analysis of 9 studies including 404 infected individuals, peak VO ₂ was 7.4 ml/kg/min (95%CI 3.7 to 11.0) lower among infected versus uninfected individuals. A high degree of heterogeneity was attributable to patient and control selection, and these studies mostly included previously hospitalized, persistently symptomatic individuals. Based on meta-analysis of 9 studies with 464 individuals with LC, peak VO ₂ was 4.9 ml/kg/min (95%CI 3.4 to 6.4) lower compared to those without symptoms. Deconditioning was common, but dysfunctional breathing, chronotropic incompetence, and abnormal oxygen extraction were also described.
Conclusions and Relevance: These studies suggest that exercise capacity is reduced after SARS-CoV-2 infection especially among those hospitalized for acute COVID-19 and individuals with LC. Mechanisms for exertional intolerance besides deconditioning may be multifactorial or related to underlying autonomic dysfunction.

Van de Wiel HJ; Groen WG; Kampshoff CS; Buffart LM; van Mechelen W; van Harten WH; Aaronson PDNK;
Stuiver PDMM;

Archives of physical medicine and rehabilitation [Arch Phys Med Rehabil] 2022 Jun 19.
Date of Electronic Publication: 2022 Jun 19.

Objective: To investigate the construct validity of the Steep Ramp Test by longitudinally comparing the correlation between Maximum Short Exercise Capacity (MSEC) of the Steep Ramp Test (SRT) and direct measurements of VO ₂ peak during or shortly after treatment in patients with breast cancer and the potential impact of chemotherapy-induced symptom burden.
Design: Cross-sectional SETTING: Multicenter PARTICIPANTS: We used data from two studies that included women with breast cancer treated with chemotherapy, resulting in 274 observations. 161 patients performed the Cardiopulmonary Exercise Test (CPET) and the Steep Ramp Test in two test sessions on different time points around chemotherapy treatment.
Interventions: Not Applicable MAIN OUTCOME MEASURES: Fatigue was assessed with the Multidimensional Fatigue Inventory, and nausea and vomiting and pain by the EORTC Quality of Life Questionnaire -Core 30. The longitudinal correlation between the Maximum Short Exercise Capacity and VO ₂ peak was investigated using a linear mixed model. Interaction terms were added to the model, to investigate whether the correlation varied by symptom burden.
Results: We found a statistically significant moderate correlation between VO₂peak and Maximum Short Exercise Capacity (.61, 95% CI; .51 .70, p < .01) over time. This correlation was slightly attenuated (-.07, 95% CI; -.13 .00, p = .04) in patients’ with chemotherapy-related nausea and vomiting, indicating smaller correlations of VO ₂ peak with the Maximum Short Exercise Capacity with increasing symptom burden. Pain and fatigue did not significantly modify the correlation.
Conclusion: The Steep Ramp Test can only be used as a proxy for changes in aerobic capacity with great caution and with attention for the level of nausea and vomiting.

Salvioni E; Mapelli M; Bonomi A; Magrì D; Piepoli M; Frigerio M; Paolillo S; Corrà U; Raimondo R; Lagioia R; Badagliacca R; Filardi PP; Senni M; Correale M; Cicoira M; Perna E; Metra M; Guazzi M; Limongelli G; Sinagra G; Parati G; Cattadori G; Bandera F; Bussotti M; Vignati C; Lombardi C; Scardovi AB; Sciomer S; Passantino A; Emdin M; Passino C; Santolamazza C; Girola D; Zaffalon D; De Martino F; Agostoni P;

Chest [Chest] 2022 Jun 23.
Date of Electronic Publication: 2022 Jun 23.

Background: In clinical practice, anaerobic threshold (AT), is used to guide training and rehabilitation programs, to define risk of major thoracic or abdominal surgery, and to assess prognosis in heart failure (HF). VO ₂ AT has been reported as absolute value (VO ₂ ATabs), as percentage of predicted peak VO ₂ (VO ₂ AT%peak&#95;pred) or as percentage of observed peak VO ₂ value (VO ₂ AT%peak&#95;obs). A direct comparison of the prognostic power among these different ways to report AT is missing.
Research Question: What is the prognostic power of these different ways to report AT?
Study Design and Methods: Observational cohort study. We screened data of 7746 HF patients with history of reduced ejection fraction (<40%), recruited between 1998 and 2020 and enrolled in the MECKI register. All patients underwent a maximal cardiopulmonary exercise test (CPET), executed using a ramp protocol on an electronically braked cycle ergometer.
Results: In this study we considered 6157HF patients with identified AT. Follow up was 4.2 years (1.9-5.0). Both VO ₂ ATabs (823(305 mL/min)) and VO ₂ AT%peak&#95;pred (39.6(13.9%)) but not VO ₂ AT%peak&#95;obs (69.2(17.7%)) well stratified the population as regards prognosis (composite endpoint: cardiovascular death, urgent heart transplant or left ventricular assist device). Comparing AUC values, VO ₂ ATabs (0.680) and VO ₂ AT%peak&#95;pred (0.688) performed similarly, while VO ₂ AT%peak&#95;obs (0.538) was significantly weaker (P<0.001). Moreover, VO ₂ AT%peak&#95;pred AUC value was the only performing as well as AUC based on peakVO ₂ (0.710), with even a higher AUC (0.637 vs. 0.618 respectively) in the group with severe HF (peakVO ₂ <12mL/min/kg). Finally, the combination of VO ₂ AT%peak&#95;pred with Peak VO ₂ and VE/VCO ₂ shows the highest prognostic power.
Interpretation: In HF, VO ₂ AT%peak&#95;pred is the best way to report VO ₂ at AT in relation to prognosis, with a prognostic power comparable to that of peak VO ₂ and, remarkably, in severe HF patients.

Antoniou V; Xanthopoulos A; Giamouzis G; Davos C; Batalik L; Stavrou V; Gourgoulianis KI; Kapreli E; Skoularigis J; Pepera G;

BMJ open [BMJ Open] 2022 Jun 23; Vol. 12 (6), pp. e059945.
Date of Electronic Publication: 2022 Jun 23.

Introduction: Exercise-based cardiac rehabilitation (CR) is a beneficial tool for the secondary prevention of cardiovascular diseases with, however, low participation rates. Telerehabilitation, intergrading mobile technologies and wireless sensors may advance the cardiac patients’ adherence. This study will investigate the efficacy, efficiency, safety and cost-effectiveness of a telerehabilitation programme based on objective exercise telemonitoring and evaluation of cardiorespiratory fitness.
Methods and Analysis: A supervised, parallel-group, single-blind randomised controlled trial will be conducted. A total of 124 patients with coronary disease will be randomised in a 1:1 ratio into two groups: intervention telerehabilitation group (TELE-CR) (n=62) and control centre-based cardiac rehabilitation group (CB-CR) (n=62). Participants will receive a 12-week exercise-based rehabilitation programme, remotely monitored for the TELE-CR group and standard supervised for the CB-CR group. All participants will perform aerobic training at 70% of their maximal heart rate, as obtained from cardiopulmonary exercise testing (CPET) for 20 min plus 20 min for strengthening and balance training, three times per week. The primary outcomes will be the assessment of cardiorespiratory fitness, expressed as peak oxygen uptake assessed by the CPET test and the 6 min walk test. Secondary outcomes will be the physical activity, the safety of the exercise intervention (number of adverse events that may occur during the exercise), the quality of life, the training adherence, the anxiety and depression levels, the nicotine dependence and cost-effectiveness. Assessments will be held at baseline, end of intervention (12 weeks) and follow-up (36 weeks).
Ethics and Dissemination: The study protocol has been reviewed and approved by the Ethics Committee of the University of Thessaly (1108/1-12-2021) and by the Ethics Committee of the General University Hospital of Larissa (3780/31-01-2022). The results of this study will be disseminated through manuscript publications and conference presentations.
Trial Registration Number: NCT05019157.

de Vries JT; Wiggers TGH; Goedegebuure S; Reurink G;

Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine [Clin J Sport Med] 2022 Jul 01; Vol. 32 (4), pp. 387-395.
Date of Electronic Publication: 2022 Jan 25.

Objective: To evaluate the number of medical conditions detected by periodic health evaluations (PHEs) in elite athletes, and their consequences for management and medical clearance.
Design: Retrospective design.
Participants: Elite athletes of various sports in a high-performance program in The Netherlands, in the period between 2009 and 2020.
Interventions: The PHEs consisted of a questionnaire, general and musculoskeletal physical examination, laboratory blood test, electrocardiogram, pulmonary function testing, and (cardiopulmonary) exercise test.
Main Outcome Measures: We extracted and analyzed the medical conditions that led to advice, clinical follow-up, further diagnostic investigation or treatment, and the medical clearance status of the athlete (clearance, temporarily no clearance, or permanently no clearance).
Results: We included 721 PHEs of 451 elite athletes. We found 1389 medical conditions that led to advice (n = 923, 66%), clinical follow-up (n = 124, 9%), further diagnostic investigation (n = 190, 14%), treatment (n = 132, 10%), or sports restriction (n = 20, 1%). Only 20 cases (3%) led to temporarily no medical clearance. After further investigation or treatment, no permanent sports restriction was imposed on any of the athletes.
Conclusions: We found a high number of medical conditions detected with a PHE in elite athletes. However, the vast majority of detected conditions were mild, with consequences limited to preventive advice and follow-up. The yield of PHE to detect (potentially) severe pathological conditions seems low. Clinical relevance of PHE in elite athletes and potential future health benefits remain unclear.

Salzano A; D’Assante R; Iacoviello M; Triggiani V; Rengo G; Cacciatore F; Maiello C; Limongelli G; Masarone D; Sciacqua A; Filardi PP; Mancini A; Volterrani M; Vriz O; Castello R; Passantino A; Campo M; Modesti PA; De Giorgi A; Arcopinto M; Gargiulo P; Perticone M; Colao A; Milano S; Garavaglia A; Napoli R; Suzuki T; Bossone E; Marra AM; Cittadini A;

Cardiovascular diabetology [Cardiovasc Diabetol] 2022 Jun 16; Vol. 21 (1), pp. 108.
Date of Electronic Publication: 2022 Jun 16.

Background: Findings from the T.O.S.CA. Registry recently reported that patients with concomitant chronic heart failure (CHF) and impairment of insulin axis (either insulin resistance-IR or diabetes mellitus-T2D) display increased morbidity and mortality. However, little information is available on the relative impact of IR and T2D on cardiac structure and function, cardiopulmonary performance, and their longitudinal changes in CHF.
Methods: Patients enrolled in the T.O.S.CA. Registry performed echocardiography and cardiopulmonary exercise test at baseline and at a patient-average follow-up of 36 months. Patients were divided into three groups based on the degree of insulin impairment: euglycemic without IR (EU), euglycemic with IR (IR), and T2D.
Results: Compared with EU and IR, T2D was associated with increased filling pressures (E/e’ratio: 15.9 ± 8.9, 12.0 ± 6.5, and 14.5 ± 8.1 respectively, p < 0.01) and worse right ventricular(RV)-arterial uncoupling (RVAUC) (TAPSE/PASP ratio 0.52 ± 0.2, 0.6 ± 0.3, and 0.6 ± 0.3 in T2D, EU and IR, respectively, p < 0.05). Likewise, impairment in peak oxygen consumption (peak VO ₂ ) in TD2 vs EU and IR patients was recorded (respectively, 15.8 ± 3.8 ml/Kg/min, 18.4 ± 4.3 ml/Kg/min and 16.5 ± 4.3 ml/Kg/min, p < 0.003). Longitudinal data demonstrated higher deterioration of RVAUC, RV dimension, and peak VO ₂ in the T2D group (+ 13% increase in RV dimension, - 21% decline in TAPSE/PAPS ratio and - 20% decrease in peak VO ₂ ).
Conclusion: The higher risk of death and CV hospitalizations exhibited by HF-T2D patients in the T.O.S.CA. Registry is associated with progressive RV ventricular dysfunction and exercise impairment when compared to euglycemic CHF patients, supporting the pivotal importance of hyperglycaemia and right chambers in HF prognosis.