Castello-Simões V; Karsten M;Minatel V; Simões RP; Silva E; Tamburús NY; Arena R; Borghi-Silva A; Catai AM;

Cardiology research and practice [Cardiol Res Pract] 2020 May 21; Vol. 2020, pp. 4629548. Date of Electronic Publication: 2020 May 21 (Print Publication: 2020).

Introduction: Expiratory flow limitation (EFL) during moderate intensity exercise is present in patients with myocardial infarction (MI), whereas in healthy subjects it occurs only at a high intensity. However, it is unclear whether this limitation already manifests in those with stable coronary artery disease (CAD) (without MI).
Materials and Methods: Forty-one men aged 40-65 years were allocated into (1) recent MI (RMI) group ( n  = 8), (2) late MI (LMI) group ( n  = 12), (3) stable CAD group ( n  = 9), and (4) healthy control group (CG) ( n  = 12). All participants underwent two cardiopulmonary exercise tests at a constant workload (moderate and high intensity), and EFL was evaluated at the end of each exercise workload.
Results: During moderate intensity exercise, the RMI and LMI groups presented with a significantly higher number of participants with EFL compared to the CG ( p < 0.05), while no significant difference was observed among groups at high intensity exercise ( p > 0.05). Moreover, EFL was only present in MI groups during moderate intensity exercise, whereas at high intensity all groups presented EFL. Regarding the degree of EFL, the RMI and LMI groups showed significantly higher values at moderate intensity exercise in relation to the CG. At high intensity exercise, significantly higher values for the degree of EFL were observed only in the LMI group.
Conclusion: The ventilatory limitation at moderate intensity exercise may be linked to the pulmonary consequences of the MI, even subjects with preserved cardiac and pulmonary function at rest, and not to CAD per se.

Bailey DM; Berg R; Davies RG; Appadurai IR; Lewis MH;

Annals of the Royal College of Surgeons of England [Ann R Coll Surg Engl] 2020 Jun 15, pp. 1-4. Date of Electronic Publication: 2020 Jun 15.

Introduction: Preoperative cardiopulmonary exercise testing aids surgical risk stratification and is an established predictor of mid- to long-term survival in patients undergoing elective open abdominal aortic aneurysm repair. Whether cardiopulmonary exercise testing also predicts 30-day mortality in this population remains to be established.
Materials and Methods: Data for 109 patients (mean age 72 years) who underwent cardiopulmonary exercise testing to assess risk for surgical abdominal aortic aneurysm repair was analysed. Patients were classified according to cardiopulmonary fitness as fit (peak oxygen uptake ≥ 15ml O ₂ .kg ^-1 .min ^-1 ) or unfit (peak oxygen uptake less than 15ml O ₂ .kg ^-1 .min ^-1 ) and further stratified according to clamp position (infrarenal or suprarenal). Between-group postoperative outcomes were compared for in-hospital 30-day mortality, postoperative morbidity scale scores (day 5) and hospital length of stay.
Results: Seventy-nine patients underwent open surgery and 30 patients were treated conservatively. No deaths were recorded at 30 days post-surgery. Unfit patients with infrarenal clamping exhibited higher postoperative morbidity scale scores (64% vs 26%) and longer length of stay (four days) than fit patients ( p < 0.05). Conversely, with suprarenal clamping, postoperative morbidity scale scores were similar and length of stay longer (three days) in fit compared with unfit patients ( p < 0.05).
Discussion and Conclusion: Preoperative fitness level defined by peak oxygen uptake failed to identify patients at risk of 30-day mortality when undergoing elective abdominal aortic aneurysm repair. Postoperative morbidity and length of stay in patients with suprarenal clamping was high independent of cardiopulmonary fitness. These findings suggest that cardiopulmonary exercise testing may be a useful predictor of complications following infrarenal rather than suprarenal clamping but may not be a good predictor of 30-day mortality.

Steinmetz C; Bjarnason-Wehrens B; Baumgarten H; Walther T; Mengden T; Walther C;

Clinical rehabilitation [Clin Rehabil] 2020 Jun 16, pp. 269215520933950. Date of Electronic Publication: 2020 Jun 16.

Objective: To determine the impact of an exercise-based prehabilitation (EBPrehab) program on pre- and postoperative exercise capacity, functional capacity (FC) and quality of life (QoL) in patients awaiting elective coronary artery bypass graft surgery (CABG).
Design: A two-group randomized controlled trail.
Setting: Ambulatory prehabilitation.
Subjects: Overall 230 preoperative elective CABG-surgery patients were randomly assigned to an intervention (IG, n  = 88; n  = 27 withdrew after randomization) or control group (CG, n  = 115).
Intervention: IG: two-week EBPrehab including supervised aerobic exercise. CG: usual care.
Main Measures: At baseline (T1), one day before surgery (T2), at the beginning (T3) and at the end of cardiac rehabilitation (T4) the following measurements were performed: cardiopulmonary exercise test, six-minute walk test (6MWT), Timed-Up-and-Go Test (TUG) and QoL (MacNew questionnaire).
Results: A total of 171 patients (IG, n  = 81; CG, n  = 90) completed the study. During EBPrehab no complications occurred. Preoperatively FC (6MWT _IG : 443.0 ± 80.1 m to 493.5 ± 75.5 m, P  = 0.003; TUG _IG : 6.9 ± 2.0 s to 6.1 ± 1.8 s, P  = 0.018) and QoL (IG: 5.1 ± 0.9 to 5.4 ± 0.9, P  < 0.001) improved significantly more in IG compared to CG. Similar effects were observed postoperatively in FC (6MWD _IG : Δ-64.7 m, p _T1-T3 = 0.013; Δ+47.2 m, p _T1-T4 < 0.001; TUG _IG : Δ+1.4 s, p _T1-T3 = 0.003).
Conclusions: A short-term EBPrehab is effective to improve perioperative FC and preoperative QoL in patients with stable coronary artery disease awaiting CABG-surgery.

Shandhi MMH; Hersek S; Fan J; Sander E; Marco T; Heller JA; Etemadi M; Klein L; Inan OT;

Journal of cardiac failure [J Card Fail] 2020 May 27. Date of Electronic Publication: 2020 May 27.

Objective: To estimate oxygen uptake (VO ₂ ) from cardiopulmonary exercise testing (CPX) using simultaneously recorded seismocardiogram (SCG) and electrocardiogram (ECG) signals captured with a small wearable patch.
Background: CPX is an important risk stratification tool for patients with heart failure (HF) due to the prognostic value of the features derived from the gas exchange variables such as VO ₂ . However, CPX requires specialized equipment, as well as trained professionals to conduct the study.
Methods: We have conducted a total of 68 CPX tests on 59 subjects with HF with reduced ejection fraction (31% women, mean age 55±13 years, ejection fraction 0.27±0.11, 79% stage C). The subjects were fitted with a wearable sensing patch and underwent treadmill CPX. We divided the dataset into a training-testing (N=44) and a separate validation set (N=24). We developed globalized (population) regression models to estimate VO ₂ from the SCG and ECG signals measured continuously with the patch. We further classified the patients as stage D or C using the SCG and ECG features to assess the ability to detect clinical state from the wearable patch measurements alone. We developed the regression and classification model with cross-validation on the training-testing set and validated the models on the validation set.
Results: The regression model to estimate VO ₂ from the wearable features yielded a moderate correlation (R ² of 0.64) with a root-mean-square-error (RMSE) of 2.51±1.12 ml.kg ^-1 .min ^-1 on the training-testing set, whereas R ² and RMSE on the validation set were 0.76 and 2.28±0.93 ml.kg ^-1 .min ^-1 respectively. Furthermore, the classification of clinical state yielded accuracy, sensitivity, specificity, and an area under the receiver operating characteristic curve values of 0.84, 0.91, 0.64, and 0.74 respectively for the training-testing set, and 0.83, 0.86, 0.67, and 0.92 respectively for the validation set.
Conclusion: Wearable SCG and ECG can assess CPX oxygen uptake and thereby classify clinical status for patients with HF. These methods may provide value in risk stratification of patients with HF by tracking cardiopulmonary parameters and clinical status outside of specialized settings, potentially allowing for more frequent assessments to be performed during longitudinal monitoring and treatment.

Magrì D; Gallo G; Zachara E; Re F; Agostoni P; Giordano D; Rubattu S; Forte M; ICotugno M; Torrisi MR; Petrucci S; Germani A; Savio C; Maruotti A; Volpe M; Autore C; Piane M; Musumeci B;

Journal of clinical medicine [J Clin Med] 2020 May 28; Vol. 9 (6). Date of Electronic Publication: 2020 May 28.

The role of genetic testing over the clinical and functional variables, including data from the cardiopulmonary exercise test (CPET), in the hypertrophic cardiomyopathy (HCM) risk stratification remains unclear. A retrospective genotype-phenotype correlation was performed to analyze possible differences between patients with and without likely pathogenic/pathogenic (LP/P) variants. A total of 371 HCM patients were screened at least for the main sarcomeric genes MYBPC3 (myosin binding protein C), MYH7 (β-myosin heavy chain), TNNI3 (cardiac troponin I) and TNNT2 (cardiac troponin T): 203 patients had at least an LP/P variant, 23 patients had a unique variant of uncertain significance (VUS) and 145 did not show any LP/P variant or VUS. During a median 5.4 years follow-up, 51 and 14 patients developed heart failure (HF) and sudden cardiac death (SCD) or SCD-equivalents events, respectively. The LP/P variant was associated with a more aggressive HCM phenotype. However, left atrial diameter (LAd), circulatory power (peak oxygen uptake*peak systolic blood pressure, CP%) and ventilatory efficiency (C-index = 0.839) were the only independent predictors of HF whereas only LAd and CP% were predictors of the SCD end-point (C-index = 0.738). The present study reaffirms the pivotal role of the clinical variables and, particularly of those CPET-derived, in the HCM risk stratification.

Neder JA; Berton DC; Nery LE; Tan WC; Bourbeau J; O’Donnell DE;

The European respiratory journal [Eur Respir J] 2020 May 29. Date of Electronic Publication: 2020 May 29.

Assessment of dyspnoea severity during incremental cardiopulmonary exercise testing (CPET) has long been hampered by the lack of reference ranges as a function of work rate (WR) and ventilation (V̇E). This is particularly relevant to cycling, a testing modality which overtaxes the leg muscles leading to a heightened sensation of leg discomfort.Reference ranges based on dyspnoea percentiles (0-10 Borg scale) at standardised WRs and V̇E were established in 275 apparently healthy subjects aged 20-85 (131 men). They were compared with values recorded in a randomly selected “validation” sample (N=451, 224 men). Their usefulness in properly uncovering the severity of exertional dyspnoea were tested in 167 subjects under investigation for chronic dyspnoea (“testing sample”) who terminated CPET due to leg discomfort (86 men).Iso-WR and, to a lesser extent, iso-V̇E reference ranges (5th-25th, 25th-50th, 50-75th and 75th-95th percentiles) increased as a function of age, being systematically higher in women (p<0.01). There was no significant differences in percentiles distribution between “reference” and “validation” samples (p>0.05). Submaximal dyspnoea-WR scores lied within the 75th-95th or >95th percentiles in 108/118 (91.5%) subjects of the “testing” sample who showed physiological abnormalities known to elicit exertional dyspnoea i.e. , ventilatory inefficiency and/or critical inspiratory constraints. In contrast, dyspnoea scores typically lied in the 5th-50th range in subjects without those abnormalities (p<0.001).This frame of reference might prove useful to uncover the severity of exertional dyspnoea in subjects who otherwise would be labeled as “non-dyspneic” while providing mechanistic insights into the genesis of this distressing symptom

Noury JB; Zagnoli F; Petit F; Marcorelles P; Rannou F;

Scientific reports [Sci Rep] 2020 May 29; Vol. 10 (1), pp. 8765. Date of Electronic Publication: 2020 May 29.

Metabolic myopathies are muscle disorders caused by a biochemical defect of the skeletal muscle energy system resulting in exercise intolerance. The primary aim of this research was to evaluate the oxygen cost (∆V’O ₂ /∆Work-Rate) during incremental exercise in patients with metabolic myopathies as compared with patients with non-metabolic myalgia and healthy subjects. The study groups consisted of eight patients with muscle glycogenoses (one Tarui and seven McArdle diseases), seven patients with a complete and twenty-two patients with a partial myoadenylate deaminase (MAD) deficiency in muscle biopsy, five patients with a respiratory chain deficiency, seventy-three patients with exercise intolerance and normal muscle biopsy (non-metabolic myalgia), and twenty-eight healthy controls. The subjects underwent a cardiopulmonary exercise test (CPX Medgraphics) performed on a bicycle ergometer. Pulmonary V’O ₂ was measured breath-by-breath throughout the incremental test. The ∆V’O ₂ /∆Work-Rate slope for exercise was determined by linear regression analysis. Lower oxygen consumption (peak percent of predicted, mean ± SD; p < 0.04, one-way ANOVA) was seen in patients with glycogenoses (62.8 ± 10.2%) and respiratory chain defects (70.8 ± 23.3%) compared to patients with non-metabolic myalgia (100.0 ± 15.9%) and control subjects (106.4 ± 23.5%). ∆V’O ₂ /∆Work-Rate slope (mLO ₂ .min ^-1 .W ^-1 ) was increased in patients with MAD absent (12.6 ± 1.5), MAD decreased (11.3 ± 1.1), glycogenoses (14.0 ± 2.5), respiratory chain defects (13.1 ± 1.2), and patients with non-metabolic myalgia (11.3 ± 1.3) compared with control subjects (10.2 ± 0.7; p < 0.001, one-way ANOVA). In conclusion, patients with metabolic myopathies display an increased oxygen cost during exercise and therefore can perform less work for a given VO ₂ consumption during daily life-submaximal exercises.

Sivakumar J; Sivakumar H; Read M; Snowden CP; Hii MW;

Annals of surgical oncology [Ann Surg Oncol] 2020 Jun 02. Date of Electronic Publication: 2020 Jun 02.

Introduction: Cardiopulmonary exercise testing (CPET) is an objective method of assessing functional capacity to meet the metabolic demands of surgery and has been adopted as a preoperative risk-stratification tool for patients undergoing major procedures. The two main measures are the peak rate of oxygen uptake during exercise ([Formula: see text]O ₂ peak) and anaerobic threshold (AT), the point at which anaerobic metabolism exceeds aerobic metabolism during exercise. This systematic review and meta-analysis evaluates the predictive value of CPET for patients undergoing oesophagectomy.
Methods: A systematic literature search was conducted in databases of CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, and Scopus to identify studies that examined associations between preoperative CPET variables and postoperative outcomes following oesophagectomy. Results were presented as standardised mean difference (SMD) with 95% confidence interval.
Results: Seven studies were included in this review. Preoperative [Formula: see text]O ₂ peak moderately correlated with cardiopulmonary complications [SMD = - 0.43; 95% confidence interval (CI) - 0.77 to - 0.09; p = 0.013; I ²  = 80.4%], unplanned ICU admissions (SMD = - 0.34; 95% CI - 0.60 to - 0.08; p = 0.011; I ²  = 0.0%), and 1-year survival (SMD = 0.31; 95% CI 0.02-0.61; p = 0.045; I ²  = 0.0%). Preoperative AT values moderately correlated with unplanned ICU admissions (SMD = - 0.34; 95% CI - 0.61 to - 0.07; p = 0.014; I ²  = 0.0%), and 1-year survival (SMD = 0.34; 95% CI 0.00-0.68; p = 0.049; I ²  = 7.4%). Neither [Formula: see text]O ₂ peak nor AT demonstrated prognostic value for noncardiopulmonary complications.
Conclusions: [Formula: see text]O ₂ peak and AT, where measured by preoperative CPET testing, are inversely associated with postoperative cardiopulmonary complications, unplanned ICU admissions, and 1-year survival following oesophagectomy. This meta-analysis was not able to identify an absolute cutoff value for CPET variables to discriminate between patients of varying levels of operative risk.

Pucci G; Alessio S; Russo A; Cerasari A; Dominioni I; Sanesi L; Filippucci L; Vaudo G;

Minerva cardioangiologica [Minerva Cardioangiol] 2020 Apr; Vol. 68 (2), pp. 72-80.

Background: HF patients typically show effort intolerance due to a reduction in peak exercise oxygen (peak VO2) consumption, which is related to inability to adapt systolic function to increased demand. Left ventricular ejection fraction (EF) is a surrogate marker of cardiac contractility and a powerful predictor of adverse prognosis in chronic heart failure (HF). The aim of the study was to explore the relationship between EF and other echocardiographic findings with peak VO2 in a population of HF individuals undergoing cardiopulmonary exercise testing (CPX).
Methods: We evaluated 101 patients (61% hypertensives, 74% with documented coronary artery disease) undergoing both resting echocardiography and symptom-limited CPX.
Results: Mean age was 58±13 years, 83% were males. Mean EF was 55±12%; 20% of the patients showed EF<40%. Mean test duration was 9.4±2.2 min. Average peak VO2 was 21±6 mL/kg/min. Peak VO2 showed a robust positive correlation with EF (R=0.42, P<0.001). Other independent predictors of peak VO2 were age, male sex, height and tricuspidal anular plane systolic excursion (TAPSE), this latter reflecting right ventricular dysfunction. When subjects were dichotomized according to predicted peak VO2values, those with higher-than-predicted peak VO2 showed significantly lower VE/VCO2 slope, and higher values of both oxygen pulse and VO2/WR slope.
Conclusions: EF and TAPSE are associated with peak VO2 in HF patients independently from age, sex and height. The evaluation of potentially relevant mechanisms affecting exercise capacity in HF patients requires further investigation.

Magrì D; Piepoli M; Corrà U;  et al, MECKI score Research Group

Journal of cardiac failure [J Card Fail] 2020 May 16. Date of Electronic Publication: 2020 May 16

Background: Heart failure with midrange ejection fraction (HFmrEF) represents a heterogeneous category where phenotype, as well as prognostic assessment, remains still debated. The present study explores a specific HFmrEF subset, namely those who recovered from a reduced EF (rec-HFmrEF) and, particularly, it focuses on the possible additive prognostic role of cardiopulmonary exercise testing (CPET).
Methods and Results: We analyzed data of 4,535 HF with reduced EF (HFrEF) and 1,176 rec-HFmrEF outpatients from the Metabolic Exercise combined with Cardiac and Kidney Indexes (MECKI) database. The end-point was cardiovascular death at 5 years. The median follow-up was 1,343 days (25th-75th range, 627-2,403 days). Cardiovascular death occurred in 552 HFrEF and 61 rec-HFmrEF patients. The multivariate analysis confirmed an independent role of the MECKI score’s variables in HFrEF (C-index=0.744) whereas, in the rec-HFmrEF group, only age and peak oxygen uptake (pVO ₂ ) remained associated to the end-point (C-index=0.745). A pVO ₂ ≤55% of predicted and a ventilatory efficiency ≥31 resulted as the most accurate cut-off values in the outcome prediction.
Conclusions: Present data support the CPET and, particularly, the pVO ₂ , as a useful tool in the rec-HFmrEF prognostic assessment. Peak VO ₂ ≤55% predicted and ventilatory efficiency ≥31 might help to identify a high risk rec-HFmrEF subgroup.