May SM; Reyes A; Martir G; Reynolds J; Paredes LG; Karmali S; Stephens RCM; Brealey D; Ackland GL;

British Journal Of Anaesthesia [Br J Anaesth] 2019 Sep 03. Date of Electronic Publication: 2019 Sep 03.

Background: Myocardial injury is more frequent after noncardiac surgery in patients with preoperative cardiac vagal dysfunction, as quantified by delayed heart rate (HR) recovery after cessation of cardiopulmonary exercise testing. We hypothesised that serial and dynamic measures of cardiac vagal activity are also associated with myocardial injury after noncardiac surgery.
Methods: Serial autonomic measurements were made before and after surgery in patients undergoing elective noncardiac surgery. Cardiac vagal activity was quantified by HR variability and HR recovery after orthostatic challenge (supine to sitting). Revised cardiac risk index (RCRI) was calculated for each patient. The primary outcome was myocardial injury (high-sensitivity troponin ≥15 ng L-1) within 48 h of surgery, masked to investigators. The exposure of interest was cardiac vagal activity (high-frequency power spectral analysis [HFLn]) and HR recovery 90 s from peak HR after the orthostatic challenge.
Results: Myocardial injury occurred in 48/189 (25%) patients, in whom 41/48 (85%) RCRI was <2. In patients with myocardial injury, vagal activity (HFLn) declined from 5.15 (95% confidence interval [CI]: 4.58-5.72) before surgery to 4.33 (95% CI: 3.76-4.90; P<0.001) 24 h after surgery. In patients who remained free of myocardial injury, HFLn did not change (4.95 [95% CI: 4.64-5.26] before surgery vs 4.76 [95% CI: 4.44-5.08] after surgery). Before and after surgery, the orthostatic HR recovery was slower in patients with myocardial injury (5 beats min-1 [95% CI: 3-7]), compared with HR recovery in patients who remained free of myocardial injury (10 beats min-1 [95% CI: 7-12]; P=0.02).
Conclusions: Serial HR measures indicating loss of cardiac vagal activity are associated with perioperative myocardial injury in lower-risk patients undergoing noncardiac surgery.

Tadic M; Cuspidi C; Suzic-Lazic J; Andric A; Sala C; Santoro C; Iracek O; Celic V;

Journal Of Clinical Hypertension (Greenwich, Conn.) [J Clin Hypertens (Greenwich)] 2019 Aug 26. Date of Electronic Publication: 2019 Aug 26.

We sought to assess functional capacity in recently diagnosed untreated hypertensive patients with different 24-hour blood pressure (BP) patterns (dipping, non-dipping, extreme dipping, and reverse dipping). This cross-sectional study involved 164 untreated hypertensive patients who underwent 24-hour ambulatory BP monitoring and cardiopulmonary exercise testing. Our findings showed that 24-hour and daytime BP values did not differ between four groups. Nighttime BP significantly and gradually increased from extreme dippers to reverse dippers. There was no significant difference in BPs at baseline and at the peak of exercise among four observed groups. Peak oxygen consumption (peak VO2) was significantly lower in reverse dippers than in dippers and extreme dippers. Heart rate recovery was significantly lower among reverse dippers than in dippers and extreme dippers. Ventilation/carbon dioxide slope (VE/VCO2) was significantly higher in reverse dippers and non-dippers in comparison with dippers and extreme dippers. Non-dipping BP pattern (non-dippers and reverse dippers together) was independently and negatively associated lower heart rate recovery in the first minute and peak VO2. Reverse dipping BP pattern was independently associated not only with heart rate recovery in the first minute and peak VO2, but also with VE/VCO2. In conclusion, untreated hypertensive patients with reverse dipping BP patterns showed significantly worse functional capacity than those with dipping and extreme dipping BP patterns. Circadian BP rhythm is related with functional capacity and should be taken into account in the risk assessment of hypertensive patients.

O’Neill LM; Guinan E; Doyle SL; Bennett AE; Murphy C; Elliott JA;
O’Sullivan J; Reynolds JV; Hussey J.

Annals of Surgery. 268(5):747-755, 2018 11.

OBJECTIVE: The Rehabilitation Strategies in Esophagogastric cancer
(RESTORE) randomized controlled trial evaluated the efficacy of a 12-week
multidisciplinary program to increase the cardiorespiratory fitness and
health-related quality of life (HRQOL) of esophagogastric cancer
survivors.

BACKGROUND: Patients following treatment for esophagogastric cancer are
at risk of physical deconditioning, nutritional compromise, and
sarcopenia. Accordingly, compelling rationale exists to target these
impairments in recovery.

METHODS: Disease-free patients treated for esophagogastric cancer were
randomized to either usual care or the 12-week RESTORE program (exercise
training, dietary counseling, and multidisciplinary education). The
primary outcome was cardiopulmonary exercise testing (VO2peak). Secondary
outcomes included body composition (bioimpedance analysis), and HRQOL
(EORTC-QLQ-C30). Outcomes were assessed at baseline (T0), postintervention
(T1), and at 3-month follow-up (T2).

RESULTS: Twenty-two participants were randomized to the control group
[mean (standard deviation) age 64.14 (10.46) yr, body mass index 25.67
(4.83) kg/m, time postsurgery 33.68 (19.56) mo], and 21 to the
intervention group [age 67.19(7.49) yr, body mass index 25.69(4.02) kg/m,
time postsurgery 23.52(15.23) mo]. Mean adherence to prescribed exercise
sessions were 94(12)% (supervised) and 78(27)% (unsupervised). Correcting
for baseline VO2peak, the intervention arm had significantly higher
VO2peak at both T1, 22.20 (4.35) versus 21.41 (4.49) mL . min . kg, P <
0.001, and T2, 21.75 (4.27) versus 20.74 (4.65) mL . min . kg, P = 0.001,
compared with the control group. Correcting for baseline values, no
changes in body composition or HRQOL were observed.

CONCLUSIONS: The RESTORE program significantly improved cardiorespiratory
fitness of disease-free patients after esophagogastric cancer surgery,
without compromise to body composition. This randomized controlled trial
provides proof of principle for rehabilitation programs in esophagogastric
cancer.

Borghi-Silva A; Di Thommazo-Luporini L; Carvalho LP.

Polish Archives Of Internal Medicine. 129(4):219-221, 2019 Apr 30.
VI 1

No abstract available

Takken T; Mylius CF; Paap D; Broeders W; Hulzebos HJ; Van Brussel M;
Bongers BC.

Expert Review of Cardiovascular Therapy. 17(6):413-426, 2019 Jun.
VI 1

Introduction: Reference values for cardiopulmonary exercise testing (CPET)
parameters provide the comparative basis for answering important questions
concerning the normalcy of exercise responses in patients, and
significantly impacts the clinical decision-making process.
Areas covered:
The aim of this study was to provide an updated systematic review of the
literature on reference values for CPET parameters in healthy subjects
across the life span. A systematic search in MEDLINE, Embase, and PEDro
databases were performed for articles describing reference values for CPET
published between March 2014 and February 2019.
Expert opinion:
Compared to the review published in 2014, more data have been published in the last
five years compared to the 35 years before. However, there is still a lot
of progress to be made. Quality can be further improved by performing a
power analysis, a good quality assurance of equipment and methodologies,
and by validating the developed reference equation in an independent
(sub)sample. Methodological quality of future studies can be further
improved by measuring and reporting the level of physical activity, by
reporting values for different racial groups within a cohort as well as by
the exclusion of smokers in the sample studied. Normal reference ranges
should be well defined in consensus statements.

VAN DE Sande DAJP; Schoots T; Hoogsteen J; Doevendans PA; Kemps HMC;

Medicine And Science In Sports And Exercise [Med Sci Sports Exerc] 2019 Jan; Vol. 51 (1), pp. 12-18.

Purpose: The clinical relevance of abnormal exercise testing (ET) results (at least 0.1 mV ST segment depression measured during exercise or recovery in three consecutive beats) in athletes without obstructive coronary artery disease (CAD) is not well understood. It is unknown whether this phenomenon reflects a physiological adaptation to sport or a truly ischemic response and a concomitant attenuated stroke volume (SV) response. The aim of this study was to investigate if athletes with abnormal ET results without obstructive CAD showed signs of an attenuated SV response using cardiopulmonary ET parameters.
Methods: A total of 78 male master athletes with abnormal ET results without obstructive CAD underwent cardiopulmonary ET. ΔO2 pulse/Δwork rate (WR), ΔV˙O2/ΔWR, and Δheart rate (HR)/ΔWR were assessed and compared with data from 78 male master athletes with normal ET results, matched for age, sports characteristics, and exercise capacity.
Results: The ΔO2 pulse/ΔWR ratio beyond anaerobic threshold in athletes with abnormal ET results was lower than that in athletes with normal ET results (0.73 ± 0.41 vs 1.12 ± 0.54, respectively, P < 0.001). The ΔV˙O2/ΔWR ratio was also lower in athletes with abnormal ET results (0.9 ± 0.2 vs 1.0 ± 0.3, respectively, P = 0.041). Furthermore, these athletes showed a greater increase in HR in the last 2 min of exercise (ΔHR/ΔWR ratio: 1.19 ± 0.5 vs 0.80 ± 0.6, P < 0.001).
Conclusion: Athletes with abnormal ET results without obstructive CAD showed an attenuated O2 pulse slope, decreased ΔV˙O2/ΔWR ratio, and increased ΔHR/ΔWR ratio beyond anaerobic threshold when compared with athletes with a normal ET result. These results support the hypothesis that at least a part of the athletes with an abnormal ET in absence of obstructive CAD have an attenuated SV response at high-intensity exercise.

Akıncı Özyürek B; Savaş Bozbaş Ş; Aydınalp A; Bozbaş H; Ulubay G;

Tuberkuloz Ve Toraks [Tuberk Toraks] 2019 Jun; Vol. 67 (2), pp. 102-107.

Introduction: Respiratory and cardiac functions in association with skeletal and neurophysiologic systems can be evaluated with cardiopulmonary exercise testing (CPET). Compared to treadmill exercise test, CPET provides more comprehensive data about the hemodynamic response to exercise.
Materials and Methods: We aimed to evaluate the relationship with CPET findings and coronary lesions identified on angiography in patients with angina pectoris who underwent teradmill exercise, CPET and coronary angiography (CAG). By this way we sought to examine the CPET parameters that might be predictive for coronary artery disease (CAD) before diagnostic exercise test results and ischemia symptoms develop. Thirty patients in whom CAG was planned because of symptoms and exercise test results were enrolled in the study. Oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation (VE), maximum work rate (WR), DVO2/DWR and O2 pulse (VO2/HR) values were calculated. Significant CAD was defined as ≥ 50% narrowing in at least one of the coronary arteries.
Result: The mean age was 60.4 ± 8.9 years ve 21 (65.6%) of subjects were male. On CAG, CAD was detected in 19 (59.4%) patients. Maximum heart rate, heart rate reserve (HRR), VE/VCO2 measured at anaerobic threshold (AT) and VO2(mL/kg/min) were significantly differed in patients with CAD than those without (p= 0.031; p= 0.041; p= 0.028; p= 0.03 respectively). Peak VO2, VO2/WR and O2 pulse values were higher in patients with normal angiographic results than those with CAD but the difference did not reach to statistical significance.
Conclusions: The findings of our study indicate that among CPET parameters AT VE/VCO2, ATVO2 (mL/kg/dk) and HRR can have predictive value in the diagnosis of CAD. We think that these parameters might be used in the evaluation of patients with angina and dyspnea suspected of CAD. In conclusion parameters obtained during the test that are not influenced by patient’s effort might increase the value of CPET in the diagnosis CAD.

Woodfield JC; Baldi C; Clifford K;

Scandinavian Journal Of Medicine & Science In Sports [Scand J Med Sci Sports] 2019 Aug 13. Date of Electronic Publication: 2019 Aug 13.

We read with interest the article by Boereboom et al. in the Scandinavian Journal of Medicine Science in Sport1 . This well-performed study showed that a short (8 sessions over 19 days) pre-operative exercise training program increased exercise time and work-load in the second cardiopulmonary exercise test (CPET), but did not lead to a change in participants’ peak VO2. We agree with the statement in the discussion that “Further work should be undertaken to explore exercise modality, training intensity, interval length and session frequency to try and determine an optimal HIIT protocol to improve the cardiorespiratory fitness (CRF) of preoperative patients in the short time-frame available”.

Lamotte MX, Chimenti S, Deboeck G, Gillet A, Kacelenenbogen R,
Strapart J, Vandeneynde F, Van Nooten G, Antoine M.

Acta Cardiol. 2018 Jun;73(3):248-255. doi: 10.1080/00015385.2017.1368947. Epub
2017 Aug 28.

BACKGROUND: With more than 15,000 implanted patients worldwide and a survival
rate of 80% at 1-year and 59% at 5-years, left ventricular assist device (LVAD)
implantation has become an interesting strategy in the management of heart
failure patients who are resistant to other kinds of treatment. There are limited
data in the literature on the change over time of exercise capacity in LVAD
patients, as well as limited knowledge about the beneficial effects that
rehabilitation might have on these patients. Therefore, the aim of our study was
to evaluate the evolution of exercise capacity on a cohort of patients implanted
with the same device (HeartWare©) and to analyse the potential impact of
rehabilitation.
METHODS: Sixty-two patients implanted with a LVAD between June 2011 and June 2015
were screened. Exercise capacity was evaluated by cardiopulmonary exercise
testing at 6 weeks, 6 and 12 months after implantation.
RESULTS: We have observed significant differences in the exercise capacity and
evolution between the trained and non-trained patients. Some of the trained
patients nearly normalised their exercise capacity at the end of the
rehabilitation programme.
CONCLUSIONS: Exercise capacity of patient implanted with a HeartWare© LVAD
increased in the early period after implantation. Rehabilitation allowed
implanted patients to have a significantly better evolution compared to
non-rehabilitated patients.

Duminda N Wijeysundera, Rupert M Pearse, Mark A Shulman, Tom E F Abbott, Elizabeth Torres, Althea Ambosta, Bernard L Croal, John T Granton, Kevin E Thorpe, Michael P W Grocott, Catherine Farrington, Paul S Myles, Brian H Cuthbertson, on behalf of the METS study investigators

www.thelancet.com Vol 391 June 30, 2018

Summary
Background Functional capacity is an important component of risk assessment for major surgery. Doctors’ clinical
subjective assessment of patients’ functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery.
Methods We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4 ), moderate (4–10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification.
Findings Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2–25) and 94·7% specificity (93·2–95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83–0·99; p=0·03).
Interpretation Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment.