Computerized Cardiopulmonary Exercise Testing

The images obtained are similar to the ones obtained during a full surface echocardiogram, commonly referred to as transthoracic echocardiogram. The patient is subjected to stress in the form of exercise or chemically usually dobutamine.

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After the target heart rate is achieved, 'stress' echocardiogram images are obtained. The two echocardiogram images are then compared to assess for any abnormalities in wall motion of the heart. This is used to detect obstructive coronary artery disease. The best known example of a nuclear stress test is myocardial perfusion imaging. Typically, a radiotracer Tc sestamibi , Myoview or thallous chloride may be injected during the test. After a suitable waiting period to ensure proper distribution of the radiotracer, scans are acquired with a gamma camera to capture images of the blood flow.

Scans acquired before and after exercise are examined to assess the state of the coronary arteries of the patient. Showing the relative amounts of radioisotope within the heart muscle, the nuclear stress tests more accurately identify regional areas of reduced blood flow. Stress and potential cardiac damage from exercise during the test is a problem in patients with ECG abnormalities at rest or in patients with severe motor disability. Pharmacological stimulation from vasodilators such as dipyridamole or adenosine, or positive chronotropic agents such as dobutamine can be used.

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The typical dose of radiation received during this procedure can range from 9. The American Heart Association recommends ECG treadmill testing as the first choice for patients with medium risk of coronary heart disease according to risk factors of smoking, family history of coronary artery stenosis, hypertension, diabetes and high cholesterol. The common approach for stress testing by American College of Cardiology and American Heart Association indicates the following: Sensitivity is the percentage of sick people who are correctly identified as having the condition.

Specificity indicates the percentage of healthy people who are correctly identified as not having the condition. To arrive at the patient's post-test likelihood of disease, interpretation of the stress test result requires integration of the patient's pre-test likelihood with the test's sensitivity and specificity. This approach, first described by Diamond and Forrester in the s, [8] results in an estimate of the patient's post-test likelihood of disease.

The value of stress tests has always been recognized as limited in assessing heart disease such as atherosclerosis , a condition which mainly produces wall thickening and enlargement of the arteries. This is because the stress test compares the patient's coronary flow status before and after exercise and is suitable to detecting specific areas of ischemia and lumen narrowing, not a generalized arterial thickening.

Stress tests, carried out shortly before these events, are not relevant to the prediction of infarction in the majority of individuals tested. These detection methods include anatomical and physiological methods. The anatomic methods directly measure some aspects of the actual process of atherosclerosis itself and therefore offer the possibility of early diagnosis but are often more expensive and may be invasive in the case of IVUS, for example.

The physiological methods are often less expensive and safer but are not able to quantify the current status of the disease or directly track progression. Stress cardiac imaging is not recommended for asymptomatic, low-risk patients as part of their routine care. A cardiac stress test should be terminated before completion under the following circumstances: Pharmacologic stress testing relies on coronary steal. Vasodilators are used to dilate coronary vessels, which causes increased blood velocity and flow rate in normal vessels and less of a response in stenotic vessels.

This difference in response leads to a steal of flow and perfusion defects appear in cardiac nuclear scans or as ST-segment changes. The choice of pharmacologic stress agents used in the test depends on factors such as potential drug interactions with other treatments and concomitant diseases. Pharmacologic agents such as Adenosine, Lexiscan Regadenoson , or dipyridamole is generally used when a patient cannot achieve adequate work level with treadmill exercise, or has poorly controlled hypertension or left bundle branch block.

However, an exercise stress test may provide more information about exercise tolerance than a pharmacologic stress test. Lexiscan Regadenoson or Dobutamine is often used in patients with severe reactive airway disease asthma or COPD as adenosine and dipyridamole can cause acute exacerbation of these conditions. If the patient's Asthma is treated with an inhaler then it should be used as a pre-treatment prior to the injection of the pharmacologic stress agent. In addition, if the patient is actively wheezing then the physician should determine the benefits versus the risk to the patient of performing a stress test especially outside of a hospital setting.

Jaeger Computerized CardioPulmonary Exercise Testing System, 1974

Caffeine is usually held 24 hours prior to an adenosine stress test, as it is a competitive antagonist of the A2A adenosine receptor and can attenuate the vasodilatory effects of adenosine. The test has relatively high rates of false positives and false negatives compared with other clinical tests.

Forshaw and associates stated that CPET may identify patients at high risk of post-operative cardiopulmonary morbidity and mortality. These investigators evaluated the utility of CPET before esophagectomy. Measured variables included anaerobic threshold AT and VO2peak. Outcome measures were post-operative morbidity and mortality, length of hospital stay, and unplanned intensive therapy unit admission.

One in-hospital death 1. The area under a receiver operating characteristic curve was 0. The authors concluded that although the VO2peak was significantly lower in those patients who developed cardiopulmonary complications, CPET is of limited value in predicting post-operative cardiopulmonary morbidity in patients undergoing esophagectomy. However, the extent of impairment in these tests as well as the correlation of these tests with each other and lung function in advanced emphysema is not well characterized. Correlation coefficients and multi-variable regression models were used to determine the association between lung function, quality of life QOL scores, and exercise measures.

Both exercise tests had similar correlation with measures of QOL, but maximum exercise capacity was better correlated with lung function measures than 6-min walk distance. Pulmonary arterial hypertension PAH is a debilitating chronic disorder of the pulmonary vasculature. Symptoms progress from shortness of breath and decreasing exercise tolerance to right heart failure, with peripheral edema and marked functional limitation.

Exercise-induced syncope, worsening symptoms at rest, and intractable right heart failure indicate critical disease. Familial or genetically mediated PAH accounts for a small percentage of cases. Guazzi and Opasich noted that the importance of studying the pathophysiological bases and clinical correlates of exercise limitation in patients with PAH is well-established.

Two modes of exercise testing, the 6MWT and CPET, are currently proposed for diagnostic, therapeutic, as well as prognostic finalities. The 6MWT is inexpensive, feasible and is thought to better reproduce daily life activities and to reliably detect therapeutic benefits.

On the other hand, CPET requires the patients' maximal effort and does not provide a reliable quality of life measure. However, it is highly reproducible and provides insights into the pathophysiological mechanisms that lead to exercise intolerance. Research in this area should continue to more firmly establish the clinical role of CPET in the evaluation of ischemic heart disease macrovascular or microvascular for the purpose of improving preventive cardiac care and thus reducing long-term health are costs". VO2 at maximal exercise is considered the best index of aerobic capacity and cardiorespiratory function.

Estimation of maximal aerobic capacity using published formulas without direct measurement is limited by physiological and methodological inaccuracies. Data derived from exercise testing with ventilatory gas analysis have proved to be reliable and important in evaluation of patients with heart failure. Such data are only partly influenced by resting left ventricular dysfunction. Maximal exercise capacity does not necessarily reflect the daily activities of patients with heart failure. Use of this technique in stratification of ambulatory heart failure patients has improved ability to identify those with the poorest prognosis, who should be considered for heart transplantation.

The low power recommendation grades are reflective not so much of well-powered statistical judgments as they are of weakness in the density of the relevant evidence base. Such areas should be regarded as important priorities for future investigation. In addition, more studies are needed to assess the increasing number of variables that can be derived from CPET, as well as their utility in many conditions that affect the cardiovascular and pulmonary systems.

Young and colleagues performed a systematic review of CPET in the pre-operative evaluation of patients with abdominal aortic aneurysm or peripheral vascular disease requiring surgery. Studies were eligible if they reported CPET-derived physiological parameters in patients undergoing abdominal aortic aneurysm repair or lower extremity arterial bypass. Data were extracted regarding patient populations and correlation between CPET and surgical outcomes including mortality, morbidity, critical care bed usage and length of hospital stay.

These researchers identified a total of 1, articles. There were no data from randomized controlled trials. Data from prospective studies did not comprehensively correlate CPET and surgical outcomes in patients with abdominal aortic aneurysms. There were no studies reporting CPET in patients undergoing lower extremity arterial bypass. Major limitations included small sample sizes, lack of blinding, and an absence of reporting standards.

The authors concluded that the paucity of robust data precludes routine adoption of CPET in risk-stratifying patients undergoing major vascular surgery. They stated that the use of CPET should be restricted to clinical trials and experimental registries, reporting to consensus-defined standards.

Marzolini et al noted that despite the importance of exercise training in mitigating cardiovascular risk, the development of exercise programs for people post-stroke has been limited by lack of feasibility data concerning CPET to inform the exercise prescription. These researches examined the feasibility of CPETs for developing an exercise prescription in people greater than or equal to 3 months post-stroke.

Cardiopulmonary exercise testing results from 98 consecutively enrolled patients post-stroke with motor impairments and 98 age- and sex-matched patients with coronary artery disease were examined at baseline and after 6 months of exercise training. The proportion of patients with stroke and coronary artery disease attaining an intensity sufficient for prescribing exercise at baseline was A clinically relevant abnormality occurred in No serious cardiovascular events occurred during CPETs.

The authors concluded that most patients after stroke achieved a level of exertion during the CPET sufficient to inform an exercise prescription. At least 1 of 10 patients post-stroke developed a clinically relevant abnormality on baseline and post-program CPETs with no serious cardiovascular events. Moreover, they state that these data supported the feasibility and safety of CPETs for prescribing exercise post-stroke; and strategies to improve use of baseline CPETs for women post-stroke require further investigation.

The clinical value of CPET for prescribing exercise to people after stroke needs to be ascertained in well-designed studies. Predicted post-operative PPO lung functions should be calculated. The authors concluded that a careful pre-operative physiologic assessment is useful for identifying those patients at increased risk with standard lung cancer resection and for enabling an informed decision by the patient about the appropriate therapeutic approach to treating his or her lung cancer. This pre-operative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment of this disease.

A European Respiratory Society Task Force stated that clear evidence now exists for the utility of CPET in children and adolescents with congenital heart diseases.

The authors state that CPET has been used to evaluate improvements in exercise tolerance after heart surgery. The guidelines note that the use of exercise testing to assess the long-term prognosis of children with CHD have not been reported. In a pilot study, Bartels et al determined exercise response during CPET in children and adolescents with dystrophinopathies. Exercise response on CPET was compared with a standard care test protocol. A total of 9 boys aged The feasibility of the CPET was similar to a standard care test protocol, and no serious adverse events occurred.

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The authors concluded that CPET appeared to be a promising outcome measure for cardiopulmonary exercise limitations in youth with mild functional limitations. They stated that further research with larger samples is needed to confirm current findings and investigate the additional value of the CPET to longitudinal follow-up of cardiomyopathy and the development of safe exercise programs for youth with dystrophinopathies. References from retrieved articles were examined to identify additional relevant studies.

Inclusion of original studies was on the basis of performance of maximal CPET, description of the protocol, and participants with definite MS aged greater than or equal to 18 years. No language restrictions were applied. The quality of CPET reporting in included studies was scored according to a structured checklist considering 10 feasibility e.

Structured data extraction was performed for these feasibility and safety features of CPET. Quality of reporting on CPET varied from 3 to 13 out of a possible 22 quality points. The percentage of test abnormalities feasibility was The percentage of adverse events safety was 2. Furthermore, CPET is safe when recommended precautions and safety measures are implemented. Moreover, they stated that future optimization of CPET will require protocolized testing and the implementation of standard reporting procedures.

All adverse events were temporary. The authors concluded that based on the available data, CPET is feasible provided that the CPET modality is tailored to the physical abilities of the patient. However, they stated that f future optimization of CPET will require protocolized testing and the implementation of standard reporting procedures.

Kasivisvanathan et al examined if CPET may predict which patients are at risk for adverse outcomes after undergoing hepatic resection surgery. High-risk patients undergoing elective, 1-stage, open hepatic resection were pre-operatively assessed using CPET. Morbidity, as defined by the post-operative morbidity survey POMS , was assessed on post-operative day 3.

A total of patients underwent pre-operative CPET and were included in the analysis.

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Of these, 73 patients These findings need to be validated by well-designed studies. There is substantial literature confirming the relationship between physical fitness and peri-operative outcome in general.

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The few small studies in patients undergoing surgery within an ERAS program described less fit individuals having a greater incidence of morbidity and mortality. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of peri-operative care as well as to screen for uncommon co-morbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain.

Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies chemo- and radio-therapy prior to surgery. Preliminary data suggested that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggested that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery i. The impact of such interventions on clinical outcomes remains uncertain.

The authors concluded that peri-operative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of pre-habilitation. A symptom-limited maximal CPET was performed on each patient. Multi-variable Cox proportional hazards regression modelling was used to identify risk factors associated with reduced survival.

The study included patients with a mean age of The in-hospital mortality was 2. The median follow-up was 26 months. The 3-year survival for patients with 0 or 1 sub-threshold CPET value was The authors concluded that CPET variables are independent predictors of reduced survival after elective AAA repair and can identify a cohort of patients with reduced survival at 3 years post-procedure.

Cardiac stress test

In a systematic review, Moran and colleagues evaluated the ability of CPET to predict post-operative outcome. The following databases were searched: A total of 37 full-text articles were included. Data extraction included the following: Cardio-pulmonary exercise testing-derived cut-points, peak oxygen consumption and anaerobic threshold AT predicted the following post-operative outcomes: The authors concluded that CPET is a useful pre-operative risk-stratification tool that can predict post-operative outcome.

Moreover, they stated that further research is needed to justify the ability of CPET to predict post-operative outcome in renal transplant, colorectal, upper GI, and bariatric surgery. Warnakulasuriya and co-workers examined if CPET has additive value to other scoring systems in predicting post-operative outcomes following bariatric surgery. Data was analyzed to examine the relationship between CPET and other scoring systems with post-operative outcome. A total of patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. The authors concluded that CPET did not add any incremental value in predicting post-operative outcomes in the bariatric population compared to the obesity surgery mortality risk score OSMRS , which is strongly predictive of LOS and complication following bariatric surgery.

Levy and colleagues stated that risk stratification in asymptomatic patients with severe aortic stenosis AS is based on exercise test results. However, differentiating between pathological and physiological breathlessness during exercise is sometimes challenging. Cardiopulmonary exercise testing may improve quantification of cardiopulmonary exercise capacity in patients with valve diseases. In a pilot study, these researchers evaluated the ability of CPET to detect abnormal responses to exercise and a clinical end-point occurrence of European Society of Cardiology guidelines surgical class I triggers.

The authors concluded that CPET is a useful tool for characterizing breathlessness during an exercise test in apparently asymptomatic patients with AS. The findings of this pilot study need to be validated by well-designed studies. Indeed, the development of symptoms during exercise or an abnormal BP response are associated with poor outcome and should be considered as an indication for surgery, as suggested by the most recently updated European Society of Cardiology guidelines.

Exercise stress echocardiography may also improve the risk stratification and identify asymptomatic patients at higher risk of a cardiac event. When the test is combined with imaging, echocardiography during exercise should be recommended rather than post-exercise echocardiography. During exercise, an increase greater than 18 to 20 mm Hg in mean pressure gradient, absence of improvement in left ventricular ejection fraction i.

Hence, exercise stress test may identify resting asymptomatic patients who develop exercise abnormalities and in whom surgery is recommended according to current guidelines. Exercise stress echocardiography may further unmask a subset of asymptomatic patients i. In these patients, early surgery could be beneficial, whereas regular follow-up seems more appropriate in patients without echocardiographic abnormalities during exercise.

This review does not mention the use of CPET. Patients with a pre-operative mean gradient of less than 40 mm Hg across the aortic valve, with the presence of AF or who have a permanent pacemaker, post-operatively appeared to benefit less from AVR, whereas the benefit appeared larger in those with more severe AS and a decreased pO2pulse.

These findings may be of importance for decisions and information of patients before AVR. The author stated that this study was the first in its field and therefore the cut-offs for CPET measures were not clearly established earlier, and that some of the predictors were defined post-hoc. Thus, the present study may be seen as a pilot study. Also, the follow-up was only from 1 to 3 years. To evaluate the prognostic value of CPET, a longer follow-up may be optimal. These investigators stated that CPET therefore has potential as a useful tool for serial monitoring. A total of 30 patients were enrolled.

All participants had no adverse effects during the exercise test. Mean peak double product was 26, Significant differences were observed in the normal group with VO2 peak mean of The authors concluded that these findings indicated that CPET in leukemia patients before stem cell transplantation was very safe, and was an efficient method to screen for patients with poor cardiac functions. They stated that as CPET presented parameters that revealed cardiopulmonary functions, including VO2 peak, double product and exercise capacity, CPET would help to predict the physical performance or general condition of the leukemia patients.

Moreover, they stated that larger prospective trials in homogenous populations are needed to further clarify the use of CPET in this setting.