Franssen WMA; Beyens M; Hatawe TA; Frederix I; Verboven K; Dendale P; Eijnde BO; Massa G; Hansen D;

International Journal Of Obesity (2005) [Int J Obes (Lond)] 2018 Dec 19. Date of Electronic Publication: 2018 Dec 19.

Objective: To gain greater insights in the etiology and clinical consequences of altered cardiac function in obese adolescents. Therefore, we aimed to examine cardiac structure and function in obese adolescents, and to examine associations between altered cardiac function/structure and cardiometabolic disease risk factors or cardiopulmonary exercise capacity.
Methods: In 29 obese (BMI 31.6 ± 4.2 kg/m², age 13.4 ± 1.1 years) and 29 lean (BMI 19.5 ± 2.4 kg/m², age 14.0 ± 1.5 years) adolescents, fasted blood samples were collected to study hematology, biochemistry, liver function, glycemic control, lipid profile, and hormones, followed by a transthoracic echocardiography to assess cardiac structure/function, and a cardiopulmonary exercise test (CPET) to assess cardiopulmonary exercise parameters. Regression analyses were applied to examine relations between altered echocardiographic parameters and blood parameters or CPET parameters in the entire group.
Results: In obese adolescents, left ventricular septum thickness, left atrial diameter, mitral A-wave velocity, E/e’ ratio were significantly elevated (p < 0.05), as opposed to lean controls, while mitral e’-wave velocity was significantly lowered (p < 0.01). Elevated homeostatic model assessment of insulin resistance and blood insulin, c-reactive protein, and uric acid concentrations (all significantly elevated in obese adolescents) were independent risk factors for an altered cardiac diastolic function (p < 0.01). An altered cardiac diastolic function was not related to exercise tolerance but to a delayed heart rate recovery (HRR; p < 0.01).
Conclusions: In obese adolescents, an altered cardiac diastolic function was independently related to hyperinsulinemia and whole-body insulin resistance, and only revealed by a delayed HRR during CPET. This indicates that both hyperinsulinemia, whole-body insulin resistance, and delayed HRR could be regarded as clinically relevant outcome parameters.

Stringer W; Marciniuk D;

COPD [COPD] 2018 Dec 30, pp. 1-11. Date of Electronic Publication: 2018 Dec 30.

Chronic obstructive pulmonary disease (COPD) is a common multisystem inflammatory disease with ramifications involving essentially all organ systems. Pulmonary rehabilitation is a comprehensive program designed to prevent and mitigate these disparate systemic effects and improve patient quality of life, functional status, and social functioning. Although initial patient assessment is a prominent component of any pulmonary rehabilitation (PR) program, cardiopulmonary exercise testing (CPET) is not regularly performed as a screening physiologic test prior to PR in COPD patients. Further, CPET is not often used to assess or document the improvement in exercise capacity related to completion of PR. In this review we will describe the classic physiologic abnormalities related to COPD on CPET parameters, the role of CPET in Risk Stratification/Safety prior to PR, the physiologic changes that occur in CPET parameters with PR, and the literature regarding the use of CPET to assess PR results. Finally, we will compare CPET to 6MW in COPD PR, the common minimal clinically important difference (MCID) is associated with CPET, and the potential future roles of CPET in PR and Research.

Nemoto S; Kasahara Y; Izawa KP; Watanabe S; Yoshizawa K; Takeichi N; Kamiya K; Suzuki N; Omiya K; Matsunaga A; Akashi YJ;

Heart And Vessels [Heart Vessels] 2019 Jan 02. Date of Electronic Publication: 2019 Jan 02.

Resting heart rate (HR) plus 20 or 30 beats per minute (bpm), i.e., a simplified substitute for HR at the anaerobic threshold (AT), is used as a tool for exercise prescription without cardiopulmonary exercise testing data. While resting HR plus 20 bpm is recommended for patients undergoing beta-blocker therapy, the effects of specific beta blockers on HR response to exercise up to the AT (ΔAT HR) in patients with subacute myocardial infarction (MI) are unclear. This study examined whether carvedilol treatment affects ΔAT HR in subacute MI patients. MI patients were divided into two age- and sex-matched groups [carvedilol (+), n = 66; carvedilol (-), n = 66]. All patients underwent cardiopulmonary exercise testing at 1 month after MI onset. ΔAT HR was calculated by subtracting resting HR from HR at AT. ΔAT HR did not differ significantly between the carvedilol (+) and carvedilol (-) groups (35.64 ± 9.65 vs. 34.67 ± 11.68, P = 0.604). Multiple regression analysis revealed that old age and heart failure after MI were significant predictors of lower ΔAT HR (P = 0.039 and P = 0.013, respectively), but not carvedilol treatment. Our results indicate that carvedilol treatment does not affect ΔAT HR in subacute MI patients. Therefore, exercise prescription based on HR plus 30 bpm may be feasible in this patient population, regardless of carvedilol use, without gas-exchange analysis data.

Ackland G, Abbott TEF, Pearse RM, Karmali SN, Whittle J, Minto
G; POM-HR Study Investigators.

Br J Anaesth. 2018 Jan;120(1):94-100. doi: 10.1016/j.bja.2017.11.009. Epub 2017
Nov 21.

BACKGROUND: Systemic arterial pulse pressure (systolic minus diastolic pressure)
≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke
volume and is independently associated with accelerated morbidity and mortality.
Given that deconditioned surgical and heart failure patients share similar
cardiopulmonary physiology, we examined whether lower pulse pressure is
associated with excess morbidity after major surgery.
METHODS: This was a prospective observational cohort study of patients deemed by
their preoperative assessors to be at higher risk of postoperative morbidity.
Preoperative pulse pressure was calculated before cardiopulmonary exercise
testing. The primary outcome was any morbidity (PostOperative Morbidity Survey)
occurring within 5 days of surgery, stratified by pulse pressure threshold ≤53 mm
Hg. The relationship between pulse pressure, postoperative morbidity, and oxygen
pulse (a robust surrogate for left ventricular stroke volume) was examined using
logistic regression analysis (accounting for age, sex, BMI, cardiometabolic
co-morbidity, and operation type).
RESULTS: The primary outcome occurred in 578/660 (87.6%) patients, but
postoperative morbidity was more common in 243/ 660 patients with preoperative
pulse pressure ≤53 mm Hg{odds ratio (OR): 2.24 [95% confidence interval (CI):
1.29-3.38]; P<0.001). Pulse pressure ≤53 mm Hg [OR:1.23 (95% CI: 1.03-1.46);
P=0.02] and type of surgery were independently associated with all-cause
postoperative morbidity (multivariate analysis). Oxygen pulse <90% of
population-predicted normal values was associated with pulse pressure ≤ 53 mm Hg
[OR: 1.93 (95% CI: 1.32-2.84); P=0.007].
CONCLUSIONS: In deconditioned surgical patients, lower preoperative systemic
arterial pulse pressure is associated with excess morbidity. These data are
strikingly similar to meta-analyses identifying low pulse pressure as an
independent risk factor for adverse outcomes in cardiac failure. Low preoperative
pulse pressure is a readily available measure, indicating that detailed
physiological assessment may be warranted.

Mizumi S; Goda A; Takeuchi K; Kikuchi H; Inami T; Soejima K; Satoh T;

Physiological Reports [Physiol Rep] 2018 Dec; Vol. 6 (23), pp. e13945.

Cardiopulmonary exercise testing (CPX) with right heart catheterization (RHC) widely used for early diagnosis and evaluation of pulmonary vascular disease in patients with pulmonary arterial hypertension and early stage heart failure with preserved ejection fraction, who display normal hemodynamics at rest. The aim of this study was to investigate that whether body position affects pulmonary hemodynamics, pulmonary arterial wedge pressure (PAWP), and CPX parameters during invasive CPX. Seventeen patients (58 ± 14 years; 5/12 male/female) with chronic thromboembolic pulmonary hypertension treated with percutaneous transluminal pulmonary angioplasty and near-normal pulmonary artery pressure (PAP) underwent invasive CPX twice in supine and upright position using a cycle ergometer with 6 months interval. The mean PAP (peak: 45 ± 7 vs. 40 ± 11 mmHg, P = 0.006) and PAWP (peak: 17 ± 4 vs. 11 ± 7 mmHg, P = 0.008, supine vs. upright, respectively) throughout the test in supine position were significantly higher compared with in upright position, because of preload increase. However, transpulmonary pressure gradient, pulmonary vascular resistance, and mPA-Q slope during exercise were of no significant difference between two positions. There were no differences between the results of two positions in peak VO2 (15.9 ± 4.0 vs. 16.6 ± 3.2 mL/min per kg, P = 0.456), the VE versus VCO2 slope (37.8 ± 9.2 vs. 35.9 ± 8.0, P = 0.397), or the peak work-rate (79 ± 29 vs. 84 ± 27W, P = 0.118). Body position had a significant influence on PAP and PAWP during exercise, but no influence on the pulmonary circulation, or peak VO2 , or VE vs.VCO2 slope.

Sato Y, Yoshihisa A, Kimishima Y, Kiko T, Watanabe S, Kanno Y,
Abe S, Miyata M, Sato T, Suzuki S, Oikawa M, Kobayashi A,
Yamaki T, Kunii H, Nakazato K, Ishida T, Takeishi Y.

Can J Cardiol. 2018 Jan;34(1):80-87. doi: 10.1016/j.cjca.2017.10.021. Epub 2017
Nov 8.
Comment in:
Can J Cardiol. 2018 Jan;34(1):11-12.

BACKGROUND: It is widely recognized that overt hyper- as well as hypothyroidism
are potential causes of heart failure (HF). Additionally it has been recently
reported that subclinical hypothyroidism (sub-hypo) is associated with
atherosclerosis, development of HF, and cardiovascular death. We aimed to clarify
the effect of sub-hypo on prognosis of HF, and underlying hemodynamics and
exercise capacity.
METHODS: We measured the serum levels of thyroid stimulating hormone (TSH) and
free thyroxine (FT4) in 1100 consecutive HF patients. We divided these patients
into 5 groups on the basis of plasma levels of TSH and FT4, and focused on
euthyroidism (0.4 ≤ TSH ≤ 4 μIU/mL and 0.7 ≤ FT4 ≤ 1.9 ng/dL; n = 911; 82.8%) and
sub-hypo groups (TSH > 4 μIU/mL and 0.7 ≤ FT4 ≤ 1.9 ng/dL; n = 132; 12.0%). We
compared parameters of echocardiography, cardiopulmonary exercise testing, and
cardiac catheterization, and followed up for cardiac event rate and all-cause
mortality between the 2 groups.
RESULTS: Although left ventricular ejection fraction did not differ between the 2
groups, the sub-hypo group had lower peak breath-by-breath oxygen consumption and
higher mean pulmonary arterial pressure than the euthyroidism group (peak
breath-by-breath oxygen consumption, 14.0 vs 15.9 mL/min/kg; P = 0.012; mean
pulmonary arterial pressure, 26.8 vs 23.5 mm Hg, P = 0.020). In Kaplan-Meier
analysis (mean 1098 days), the cardiac event rate and all-cause mortality were
significantly higher in the sub-hypo group than those in the euthyroidism group
(log rank, P < 0.01, respectively). In Cox proportional hazard analysis, sub-hypo
was a predictor of cardiac event rate and all-cause mortality in HF patients (P <
0.05, respectively).
CONCLUSIONS: Sub-hypo might be associated with adverse prognosis, accompanied by
impaired exercise capacity and higher pulmonary arterial pressure, in HF
patients.

Zhang LY, Liu ZJ, Shen L, Huang YG

快速康复外科(ERAS)旨在通过多种优化措施减少患者的围术期应激反应,加速患者术后康复过程。随着ERAS理念的推广,如何更有效地实施ERAS方案成为新的挑战。心肺
运动试验在ERAS术前评估、制定优化措施和术后康复环节都具有良好的应用价值。本文主要综述心肺运动试验在ERAS中的应用进展,为制定更细致、更全面的ERAS方案提供
依据。.

Enhanced recovery after surgery (ERAS) is a new perioperative concept that aims
to reduce perioperative stress response and accelerate rehabilitation of patients
through a variety of optimized management. With the wider application of this
concept,the effective implementation of ERAS program has become a new challenge.
Cardiopulmonary exercise testing (CPET) has shown promising value in the
preoperative assessment,perioperative optimization,and postoperative
rehabilitation of ERAS. This article reviews the application of CPET in ERAS,with
an attempt to provide evidence for more detailed and comprehensive ERAS program.

Kurpaska M – mkurpaska@wim.mil.pl. – Krzesiński P; Gielerak G; Uziębło-Życzkowska B; Banak M; Stańczyk A;Piotrowicz K;

Hypertension Research: Official Journal Of The Japanese Society Of Hypertension [Hypertens Res] 2018 Nov 30. Date of Electronic Publication: 2018 Nov 30.

Patients with arterial hypertension (AH), especially women, often report exercise intolerance and dyspnea. However, these symptoms are not frequently reflected in standard assessments. The aim of the study was to evaluate the clinical value of impedance cardiography (ICG) in the hemodynamic assessment of patients with AH during exercise, particularly the differences between subgroups based on sex and the presence of dyspnea. Ninety-eight patients with AH (52 women; 54.5 ± 8.2 years of age) were evaluated for levels of N-terminal pro-B-type brain natriuretic peptide (NT-proBNP), exercise capacity (cardiopulmonary exercise testing (CPET) and the 6-min walk test (6MWT)), and exercise ICG. Patients with AH were stratified into the following four subgroups: males without dyspnea (MnD, n = 38); males with dyspnea (MD, n = 8); females without dyspnea (FnD, n = 27); and females with dyspnea (FD, n = 25). In comparison with the MnD subgroup, the FnD subgroup demonstrated significantly higher NT-proBNP levels; lower exercise capacity (shorter 6MWT distance, lower peak oxygen uptake (VO2), lower O2 pulse); higher peak stroke volume index (SVI); and higher SVI at the anaerobic threshold (AT). In comparison with the other subgroups, the FD subgroup walked a shorter distance during the 6MWT distance; had a steeper VE/VCO2 slope; had lower values of peak stroke volume (SV) and peak cardiac output (CO); and had a smaller change in CO from rest to peak. However, no other differences were identified (NT-proBNP, left ventricular diastolic dysfunction, or CPET parameters). Exercise impedance cardiography revealed an impaired hemodynamic response to exercise in hypertensive females with dyspnea. In patients with unexplained exercise intolerance, impedance cardiography may complement traditional exercise tests.

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

Rheumatology (Oxford, England) [Rheumatology (Oxford)] 2018 Nov 30. Date of Electronic Publication: 2018 Nov 30.

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.

Muller PT; Utida KAM; Augusto TRL; Spreafico MVP; Mustafa RC; Xavier AW; Saraiva EF;

Respiratory Medicine [Respir Med] 2018 Dec; Vol. 145, pp. 101-109. Date of Electronic Publication: 2018 Oct 30.

Background: Left ventricular diastolic dysfunction (LVDD) is highly prevalent in COPD and conflicting results have emerged regarding the consequences on exercise capacity in the 6MWT. We sought to examine the ventilatory efficiency and variability metrics as the primary endpoint and aerobic capacity (V’O2) as the secondary endpoint.
Methods: Forty subjects were included and submitted to comprehensive lung function tests, detailed pulsed-Doppler echocardiography, and cardiopulmonary exercise testing. Four subjects were excluded due to concomitant cardiac disease and two owing to COPD exacerbation.
Results: Seventeen COPD/LVDD+ and seventeen COPD/LVDD-individuals were closely matched for baseline characteristics. Throughout the exercise, there was no difference between-groups for primary (V’E/V’CO2slope and V’E/V’CO2nadir, p > 0.05 for both) or secondary endpoints (V’O2peak%pred, p > 0.05). Ventilatory variability remained unchanged. However, after very well age- and sex-matched subgroup analysis, five-moderate and three-mild COPD/LVDD + subjects with elevated left ventricular filling pressure (E/e’>13, n = 8), presented a downward-shifted V’E/V’CO2slope (25.7 ± 5.1 vs 33.4 ± 7.1, p = 0.031) and V’E/V’CO2nadir reduction (29.7 ± 3.9 vs 36.3 ± 7.2, p = 0.042) besides significantly better V’O2peak%pred (92.1 ± 21.6% vs 75.8 ± 13.1%, p = 0.045) compared to 8 COPD/LVDD-controls. Ventilatory variability remained once again unchanged.
Conclusions: COPD/LVDD overlap is not associated with worse exercise tolerance and/or wasted ventilation in excess compared to controls, even when suspected for elevated left ventricular filling pressure. Further studies are warranted to study specifically if augmented pulmonary blood transit time can allow better gas-exchange, thus preserving exercise capacity under specific conditions in COPD patients without heart failure.