Category Archives: Abstracts

Identifying poor cardiorespiratory fitness in overweight and obese children and adolescents by using heart rate variability analysis under resting conditions.

Redón P; Grassi G; Redon J; Álvarez-Pitti J; Lurbe E;

Blood Pressure [Blood Press] 2019 Dec 12, pp. 1-8. Date of Electronic Publication: 2019 Dec 12.

Background: Childhood obesity, including overweight, continues increasing worldwide affecting health expectancy, quality of life and healthcare expenditure. These subjects have higher probability of suffering or developing cardio metabolic risk factors. Recent studies have revealed cardiorespiratory fitness (CRF) as a valuable clinical parameter to identify these subjects and have even suggested cut-off values. However, evaluating CRF in overweight and obese youth can be difficult to implement, unfriendly and expensive.
Objective: Develop a screening tool to identify high-risk subjects in a representative population of those attending overweight/obesity assessment programmes without prior intervention. It will be based on heart rate variability parameters, which has strong association with CRF and cardio metabolic risk factors.
Methods: Sixty-three subjects, overweight and obese, between 9 and 17 years of age, and of both sexes were enrolled. None of them had secondary obesity syndromes and/or suffered from acute or chronic disease. Anthropometric parameters, electrocardiogram signal recording under resting conditions and cardiorespiratory fitness – evaluated by oxygen consumption and time elapsed of cardiopulmonary exercise test – were measured.
Results: Significant differences in the sympathetic nervous system activity – assessed by heart rate variability analysis – are observed when grouping by overweight and obesity degree as well as by CRF (poor/normal). Body mass index, puberty and sympathetic nervous system activity are the significant variables of a logistic regression model develop to identify poor CRF individuals. Its accuracy reaches 92%.
Conclusions: A screening tool based on heart rate variability and anthropometric parameters was developed to identify subjects with higher probability of suffering or developing cardio metabolic risk factors.

The role of cardiopulmonary exercise testing and training in patients with pulmonary hypertension: making the case for this assessment and intervention to be considered a standard of care.

Sabbahi A; Severin R; Ozemek C; Phillips SA; Arena R;

Expert Review Of Respiratory Medicine [Expert Rev Respir Med] 2020 Jan 03, pp. 1-11. Date of Electronic Publication: 2020 Jan 03.

Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease.

Wouters EF; Posthuma R; Koopman M; Liu WY; Sillen MJ; Hajian B; Sastry M; Spruit M;Franssen FM;

Expert Review Of Respiratory Medicine [Expert Rev Respir Med] 2020 Jan 14, pp. 1-13. Date of Electronic Publication: 2020 Jan 14.

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.

Cardiorespiratory fitness in long-term juvenile dermatomyositis: a controlled, cross-sectional study of active/inactive disease.

Berntsen KS; Edvardsen E; Hansen BH; Flato B; Sjaastad I; Sanner H.

Rheumatology. 58(3):492-501, 2019 03 01.

OBJECTIVES: To compare cardiorespiratory fitness (CRF) expressed as
maximal oxygen uptake (VO2max) between patients with long-term JDM and
controls and between patients with active and inactive disease, as well as
to explore exercise limiting factors and associations between CRF and
disease variables.

METHODS: JDM patients (n = 45) and age- and gender-matched controls (n =
45) performed a cardiopulmonary exercise test (CPET) on a treadmill until
exhaustion. Physical activity was measured by accelerometers. Disease
activity, damage and muscle strength/function were assessed by validated
tools. Clinically inactive disease was defined according to PRINTO
criteria.

RESULTS: The mean disease duration was 20.8 (s.d. 11.9) years and 29/45
(64%) patients had inactive disease. A low VO2max was found in 27% of
patients vs 4% of controls (P = 0.006). The mean VO2max and maximal
ventilation (VEmax) were lower in patients with active and inactive
disease compared with controls. Patients with active disease also had
lower maximal voluntary ventilation (MVV) compared with controls and lower
VEmax and MVV compared with those with inactive disease. Patients with
inactive disease had lower physical activity levels compared with
controls. VO2max correlated negatively with disease damage in patients
with inactive disease and positively with muscle strength/function in
patients with active disease.

CONCLUSION: CRF was lower in JDM patients, both with active and inactive
disease, compared with controls after a mean 20 years disease duration.
Cardiopulmonary exercise test results suggested different limiting factors
contributing to the reduced CRF according to disease activity, including
deconditioning in inactive disease and reduced ventilatory capacity in
active disease. Further research is needed to verify this.

Aerobic capacity attainment and reasons for cardiopulmonary exercise test termination in people with cancer: a descriptive, retrospective analysis from a single laboratory.

Santa Mina D, Au D, Papadopoulos E, O’Neill M, Diniz C, Dolan L, Lipton J, Chang E, Jones JM.

2020 Jan 4. doi: 10.1007/s00520-019-05094-4. [Epub ahead of print]

PURPOSE:

Aerobic exercise prescriptions in clinical populations commonly involve target intensities based on cardiopulmonary exercise tests (CPET). CPETs are often discontinued prior to a patient achieving true maximum oxygen consumption (VO2 max) which can adversely affect exercise dose and efficacy monitoring; however, reasons for early discontinuation are poorly reported. Accordingly, we explored the CPET termination reasons in persons with cancer participating in exercise intervention studies.

METHODS:

This study comprised of an exploratory, descriptive analysis of retrospective CPET data (VO2 and anaerobic threshold) and termination reasons in a convenience sample of people with cancer participating in exercise intervention studies in a single laboratory. CPETs were standardized using the modified Bruce treadmill protocol with expired gas collection and analysis using a metabolic cart. VO2 max was considered “met” when participants demonstrated (a) oxygen consumption plateau or (b) two of the following criteria: rating of perceived exertion ≥ 9/10, respiratory exchange ratio ≥ 1.15, and/or heart rate of 95% of age-predicted maximum. The frequency and distribution of reasons for test termination relative to the number of CPET exposures for the participants were reported.

RESULTS:

Forty-four participants engaged in exercise studies between February 2016 and March 2018 provided data for the analysis. Participants completed up to three CPETs during this period (total of 78 CPETs in the current analysis). Eighty-six percent of all CPETs were terminated prior to achieving VO2 max verification criteria and no tests resulted in an oxygen consumption plateau. For those that did not demonstrate achievement of VO2 max verification criteria, reasons for discontinuation were distributed as follows: equipment discomfort-49%, volitional peak-36%, and physical discomfort-14.9%. For those who met VO2 max criteria, volitional peak was the most common reason for test termination (45.5%), followed by physical discomfort (36.4%), and equipment discomfort (18.2%).

CONCLUSIONS:

In our sample of cancer survivors, VO2 max criteria were infrequently met with equipment discomfort being a primary reason for participant-driven test termination. Protocol and equipment considerations are necessary for interpretation and application of CPET findings in clinical practice.

Ventilatory and sensory responses to incremental exercise in adults with a Fontan circulation.

Guenette JA; Ramsook AH; Dhillon SS; Puyat JH; Riahi M; Opotowsky AR;
Grewal J.

American Journal of Physiology – Heart & Circulatory Physiology.
316(2):H335-H344, 2019 02 01.

Many adults with single-ventricle congenital heart disease who have
undergone a Fontan procedure have abnormal pulmonary function resembling
restrictive lung disease. Whether this contributes to ventilatory
limitations and increased dyspnea has not been comprehensively studied. We
recruited 17 Fontan participants and 17 healthy age- and sex-matched
sedentary controls. All participants underwent complete pulmonary function
testing followed by a symptom-limited incremental cardiopulmonary cycle
exercise test with detailed assessments of dyspnea and operating lung
volumes. Fontan participants and controls were well matched for age, sex,
body mass index, height, and self-reported physical activity levels (all P
> 0.05), although Fontan participants had markedly reduced
cardiorespiratory fitness and peak work rates ( P < 0.001). Fontan
participants had lower values for most pulmonary function measurements
relative to controls with 65% of Fontan participants showing evidence of a
restrictive ventilatory defect. Relative to controls, Fontan participants
had significantly higher breathing frequency, end-inspiratory lung volume
(% total lung capacity), ventilatory inefficiency (high ventilatory
equivalent for CO2), and dyspnea intensity ratings at standardized
absolute submaximal work rates. There were no between-group differences in
qualitative descriptors of dyspnea. The restrictive ventilatory defect in
Fontan participants likely contributes to their increased breathing
frequency and end-inspiratory lung volume during exercise. This abnormal
ventilatory response coupled with greater ventilatory inefficiency may
explain the increased dyspnea intensity ratings in those with a Fontan
circulation. Interventions that enhance the ventilatory response to
exercise in Fontan patients may help optimize exercise rehabilitation
interventions, resulting in improved exercise tolerance and exertional
symptoms.
NEW & NOTEWORTHY This is the first study to comprehensively
characterize both ventilatory and sensory responses to exercise in adults
that have undergone the Fontan procedure. The majority of Fontan
participants had a restrictive ventilatory defect. Compared with
well-matched controls, Fontan participants had increased breathing
frequency, end-inspiratory lung volume, and ventilatory inefficiency.
These abnormal ventilatory responses likely form the mechanistic basis for
the increased dyspnea intensity ratings observed in our Fontan
participants during exercise.

The association between preoperative cardiopulmonary exercise-test variables and short-term morbidity after esophagectomy: A hospital-based cohort study.

Lam S; Alexandre L; Hardwick G; Hart AR.

Surgery. 166(1):28-33, 2019 07.

BACKGROUND: Postoperative complications after esophagectomy are thought to
be associated with reduced fitness. This observational study explored the
associations between aerobic fitness, as determined objectively by
preoperative cardiopulmonary exercise testing (CPEX), and 30-day morbidity
after esophagectomy.

METHODS: We retrospectively identified 254 consecutive patients who
underwent esophagectomy at a single academic teaching hospital between
September 2011 and March 2017. Postoperative complication data were
measured using the Esophageal Complications Consensus Group definitions
and graded using the Clavien-Dindo classification system of severity
(blinded to cardiopulmonary exercise testing values). Associations between
preoperative cardiopulmonary exercise testing variables and postoperative
outcomes were estimated using logistic regression.

RESULTS: A total of 206 patients (77% male) were included in the
analyses, with a mean age of 67 years (SD 9). The mean values for the
maximal oxygen consumed at the peak of exercise (VO2peak) and the
anaerobic threshold were 21.1 mL/kg/min (SD 4.5) and 12.4 mL/kg/min (SD
2.8), respectively. The vast majority of patients (98.5%) had malignant
disease-predominantly adenocarcinoma (84.5%), for which most received
neoadjuvant chemotherapy (79%) and underwent minimally invasive Ivor Lewis
esophagectomy (53%). Complications at postoperative day 30 occurred in 111
patients (54%), the majority of which were cardiopulmonary (72%). No
associations were found between preoperative cardiopulmonary exercise
testing variables and morbidity for either VO2peak (OR 1.00, 95% CI
0.94-1.07) or anaerobic threshold (OR 0.98, 95% CI 0.89-1.09).

CONCLUSION: Preoperative cardiopulmonary exercise testing variables were
not associated with 30-day complications after esophagectomy. The findings
do not support the use of cardiopulmonary exercise testing as an isolated
preoperative screening tool to predict short-term morbidity after
esophagectomy. This modestly sized observational work highlights the need
for larger studies examining associations between preoperative
cardiopulmonary exercise testing and outcomes after esophagectomy to look
for consistency in our findings.

Low income as a determinant of exercise capacity in COPD.

Porta AS; Lam N; Novotny P; Benzo R;

Chronic Respiratory Disease [Chron Respir Dis] 2019 Jan-Dec; Vol. 16, pp. 1479972318809491.

Exercise capacity (EC) is a critical outcome in chronic obstructive lung disease (chronic obstructive pulmonary disease (COPD)). It measures the impact of the disease and the effect of specific interventions like pulmonary rehabilitation (PR). EC determines COPD prognosis and is associated with health-care utilization and quality of life. Field walking tests and cardiopulmonary exercise test (CPET) are two ways to measure EC. The 6-minute walking test (6MWT) is the commonest and easiest field test. CPET has the advantage of assessing maximal aerobic capacity. Determinants of EC include age, gender, breathlessness, and lung function. Previous research suggests that socioeconomic status (SES), a meaningful factor in COPD, may also be associated with EC. However, those findings have not been replicated. We aimed to determine whether SES is an independent factor associated with EC in COPD. For this analysis, we used the National Emphysema Treatment Trial (NETT) database. NETT was a multicenter clinical trial where severe COPD patients were randomized to lung volume reduction surgery or medical therapy. Measures used were taken at baseline, postrehabilitation. Patients self-reported their income and were divided in two groups whether it was less or above US$30,000. Patients with a lower income had worse results in 6MWT ( p < 0.0001). We found an independent association between income and the 6MWT in patients with severe COPD after adjusting for age, gender, lung function, dyspnea, and living conditions ( p < 0.0007). One previous publication stated the relationship between income and EC. Our research confirms and extends previous publications associating EC with income by studying a large and well characterized cohort of severe COPD patients, also addressing EC by two different methods (maximal watts and 6MWT). Our results highlight the importance of addressing social determinants of health such as income when assessing COPD patients.

Prognostic value of cardiopulmonary exercise testing in cardiac patients with atrial fibrillation.

Tsuneoka H; Koike A; Nagayama O; Sakurada K; Kato J; Sato A; Yamashita T;
Aonuma K.

International Heart Journal. 53(2):102-7, 2012.

Parameters obtained from cardiopulmonary exercise testing (CPX) are
recognized for their high prognostic value in predicting future cardiac
events in cardiac patients. Our group compared the prognostic value of CPX
parameters between patients with sinus rhythm (SR) and patients with
atrial fibrillation (AF).Peak O2 uptake (VO2), the ratio of the increase
in VO2 to the increase in work rate (DELTAVO2/DELTAWR), and the slope of
the increase in ventilation to the increase in CO2 output (VE-VCO2 slope)
were obtained from CPX in 72 AF patients and 478 SR patients. The
prognostic values of these indices were compared between the two
groups.Six cardiac deaths and 25 cardiac events were observed in the AF
group and 9 cardiac deaths and 96 cardiac events were observed in the SR
group, over a prospective follow-up period of 1,192 days. The percentages
of cardiac deaths and cardiac events were higher in the AF group than in
the SR group. In a multivariate Cox proportional hazards analysis, peak
VO2 was identified as a sole significant predictor of cardiac death and
cardiac events in SR patients and VE-VCO2 slope was identified as a sole
significant predictor of cardiac death and cardiac events in AF
patients.
Our results suggest that the VE-VCO2 slope is strongly predictive
of future cardiac events in patients with AF and that peak VO2 is strongly
predictive of future cardiac events in SR patients.