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Harada T, Kagami K, Kato T, Ishii H, Obokata M. Exercise Stress Echocardiography in the Diagnostic Evaluation of Heart Failure with Preserved Ejection Fraction. J Cardiovasc Dev Dis 2022; 9:jcdd9030087. [PMID: 35323635 PMCID: PMC8950754 DOI: 10.3390/jcdd9030087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 02/01/2023] Open
Abstract
More than half of patients with heart failure have a preserved ejection fraction (HFpEF). The prevalence of HFpEF has been increasing worldwide and is expected to increase further, making it an important health-care problem. The diagnosis of HFpEF is straightforward in the presence of obvious objective signs of congestion; however, it is challenging in patients presenting with a low degree of congestion because abnormal elevation in intracardiac pressures may occur only during physiological stress conditions, such as during exercise. On the basis of this hemodynamic background, current consensus guidelines have emphasized the importance of exercise stress testing to reveal abnormalities during exercise, and exercise stress echocardiography (i.e., diastolic stress echocardiography) may be used as an initial diagnostic approach to HFpEF owing to its noninvasive nature and wide availability. However, evidence supporting the use of this method remains limited and many knowledge gaps exist with respect to diastolic stress echocardiography. This review summarizes the current understanding of the use of diastolic stress echocardiography in the diagnostic evaluation of HFpEF and discusses its strengths and limitations to encourage future studies on this subject.
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Affiliation(s)
- Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Gunma, Japan; (T.H.); (K.K.); (T.K.); (H.I.)
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Gunma, Japan; (T.H.); (K.K.); (T.K.); (H.I.)
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa 359-8513, Saitama, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Gunma, Japan; (T.H.); (K.K.); (T.K.); (H.I.)
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Gunma, Japan; (T.H.); (K.K.); (T.K.); (H.I.)
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Gunma, Japan; (T.H.); (K.K.); (T.K.); (H.I.)
- Correspondence: ; Tel.: +81-27-220-8145
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Arterial Hypertension and Cardiopulmonary Function: The Value of a Combined Cardiopulmonary and Echocardiography Stress Test. High Blood Press Cardiovasc Prev 2022; 29:145-154. [PMID: 35107808 PMCID: PMC8942964 DOI: 10.1007/s40292-021-00494-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022] Open
Abstract
Arterial hypertension (AH) is a global burden and the leading risk factor for mortality worldwide. Haemodynamic abnormalities, longstanding neurohormonal and inflammatory activation, which are commonly observed in patients with AH, promote cardiac structural remodeling ultimately leading to heart failure (HF) if blood pressure values remain uncontrolled. While several epidemiological studies have confirmed the strong link between AH and HF, the pathophysiological processes underlying this transition remain largely unclear. The combined cardiopulmonary-echocardiography stress test (CPET-ESE) represents a precious non-invasive aid to detect alterations in patients at the earliest stages of HF. The opportunity to study the response of the cardiovascular system to exercise, and to differentiate central from peripheral cardiovascular maladaptations, makes the CPET-ESE an ideal technique to gain insights into the mechanisms involved in the transition from AH to HF, by recognizing alterations that might be silent at rest but influence the response to exercise. Identifications of these subclinical alterations might allow for a better risk stratification in hypertensive patients, facilitating the recognition of those at higher risk of evolution towards established HF. This may also lead to the development of novel preventive strategies and help tailor medical treatment. The purpose of this review is to summarise the potential advantages of using CPET-ESE in the characterisation of hypertensive patients in the cardiovascular continuum.
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3
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Seferović PM, Polovina M, Veljić I. Embracing the unknown: risk stratification in heart failure with preserved ejection fraction with the EPYC score. Eur J Prev Cardiol 2021; 28:1662-1664. [PMID: 34339494 DOI: 10.1093/eurjpc/zwab054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Petar M Seferović
- Serbian Academy of Sciences and Arts, Belgrade 11000, Serbia.,University of Belgrade, Faculty of Medicine, Belgrade 11000, Serbia
| | - Marija Polovina
- University of Belgrade, Faculty of Medicine, Belgrade 11000, Serbia.,Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Veljić
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
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4
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Pugliese NR, Fabiani I, Mandoli GE, Guarini G, Galeotti GG, Miccoli M, Lombardo A, Simioniuc A, Bigalli G, Pedrinelli R, Dini FL. Echo-derived peak cardiac power output-to-left ventricular mass with cardiopulmonary exercise testing predicts outcome in patients with heart failure and depressed systolic function. Eur Heart J Cardiovasc Imaging 2020; 20:700-708. [PMID: 30476026 DOI: 10.1093/ehjci/jey172] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/26/2018] [Accepted: 10/18/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS Peak cardiac power output-to-mass (CPOM) represents a measure of the rate at which cardiac work is delivered respect to the potential energy stored in left ventricular (LV) mass. We studied the value of CPOM and cardiopulmonary exercise test (CPET) in risk stratification of patients with heart failure (HF). MATERIALS AND RESULTS We studied 159 patients with chronic HF (mean rest LV ejection fraction 30%) undergoing CPET and exercise stress echocardiography. CPOM was calculated as the product of a constant (K = 2.22 × 10-1) with cardiac output (CO) and the mean blood pressure (MBP), divided by LV mass (M), and expressed in the unit of W/100 g: CPOM = [K × CO (L/min) × MBP (mmHg)]/LVM(g). Patients were followed-up for the primary endpoint, including all-cause death, ventricular assist device implantation, and heart transplantation, and the secondary endpoint that comprised hospitalization for HF. In multivariate Cox regression analyses, peak CPOM was selected as the most powerful independent predictor of both primary and secondary endpoint [hazard ratio (HR) 0.004, 95% confidence interval (CI) 0.004-0.3; P = 0.002 and HR 0.09, 95% CI 0.02-0.55; P = 0.009]. Sixty-month survival free from the combined endpoint was 85% in those exhibiting oxygen consumption (VO2) > 14 mL/min/kg and peak CPOM > 0.6 W/100 g. Peak VO2 ≤ 14 mL/min/kg provided incremental prognostic value over demographic and clinical variables, brain natriuretic peptide, and resting echocardiographic parameters (χ2 from 58 to 64; P = 0.04), that was further increased by peak CPOM ≤ 0.6 W/100 g (χ2 77; P < 0.001). CONCLUSION Peak CPOM and peak VO2 showed independent and incremental prognostic values in patients with chronic HF.
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Affiliation(s)
- Nicola Riccardo Pugliese
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Iacopo Fabiani
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Giulia Elena Mandoli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Giacinta Guarini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Gian Giacomo Galeotti
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Alberto Lombardo
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Anca Simioniuc
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Giovanni Bigalli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Roberto Pedrinelli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
| | - Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa, Italy
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Arena R, Canada JM, Popovic D, Trankle CR, Del Buono MG, Lucas A, Abbate A. Cardiopulmonary exercise testing - refining the clinical perspective by combining assessments. Expert Rev Cardiovasc Ther 2020; 18:563-576. [PMID: 32749934 DOI: 10.1080/14779072.2020.1806057] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Cardiorespiratory fitness (CRF) is now established as a vital sign. Cardiopulmonary exercise testing (CPX) is the gold-standard approach to assessing CRF. AREAS COVERED A body of literature spanning several decades clearly supports the clinical utility of CPX in those who are apparently health and at risk for chronic disease as well as numerous patient populations. While CPX, in and of itself, is a valid and reliable clinical assessment, combining findings with other available assessments may provide a more comprehensive perspective that enhances clinical decision making and outcomes. The current review will accomplish the following: (1) define key CPX measures based upon current evidence; and (2) describe the current evidence addressing the relationships between CPX and echocardiography, serum biomarkers, and cardiovascular magnetic resonance. EXPERT OPINION Cardiopulmonary exercise testing provides prognostic and diagnostic information in apparently healthy individuals, those at risk for one or more chronic conditions, as well as numerous patient populations. Moreover, if the goal of an intervention is to improve one or more systems integral to the physiologic response to exercise, CPX should be considered as a central assessment to gauge therapeutic efficacy. To further refine the information obtained from CPX, combining other assessments has demonstrated promise.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois , Chicago, IL, USA
| | - Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University , Richmond, VA, USA.,Department of Kinesiology & Health Sciences, Virginia Commonwealth University , Richmond, Virginia, USA
| | - Dejana Popovic
- Division of Cardiology, Faculty of Medicine, University of Belgrade , Belgrade, Serbia.,Department of Physiology, Faculty of Pharmacy, University of Belgrade , Belgrade, Serbia
| | - Cory R Trankle
- VCU Pauley Heart Center, Virginia Commonwealth University , Richmond, VA, USA
| | | | - Alexander Lucas
- Department of Health Behavior and Policy and Department of Internal Medicine, Division of Cardiology, VCU Pauley Heart Center, Virginia Commonwealth University , Richmond, VA, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University , Richmond, VA, USA
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Huang YC, Tsai HH, Fu TC, Hsu CC, Wang JS. High-Intensity Interval Training Improves Left Ventricular Contractile Function. Med Sci Sports Exerc 2020; 51:1420-1428. [PMID: 30829901 DOI: 10.1249/mss.0000000000001931] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Improved myocardial contractility is a critical circulatory adaptation to exercise training. However, the types of exercise that enhance left ventricular (LV) contractile and diastolic functions have not yet been established. This study investigated how high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) influence LV mechanics during exercise. METHODS Fifty-four healthy sedentary men were randomized to engage in either HIIT (3-min intervals at 40% and 80% of V˙O2max, n = 18) or MICT (sustained 60% of V˙O2max, n = 18) for 30 min·d, 5 d·wk for 6 wk or to a control group (n = 18) that did not engage in exercise intervention. LV mechanics during semiupright bicycle exercise tests were measured by two-dimensional speckle-tracking echocardiography. RESULTS Before the interventions, acute bicycle exercise increased (i) peak basal/apical radial and circumferential and peak longitudinal strains and strain rates, (ii) peak basal/apical rotations and torsion, and (iii) peak systolic twisting and early diastolic untwisting velocities in the LV. After the interventions, the HIIT group exhibited greater LV mass and diastolic internal diameter as well as higher ratio of E wave to A wave and early diastolic propagation velocity than did the MICT group. Despite decreased peak apical rotation and torsion, HIIT enhanced peak apical radial strain and strain rate as well as shortened the time to reach peak untwisting velocity in the LV during exercise. However, the LV mechanics during exercise were unchanged in the control group. CONCLUSION HIIT but not MICT induces eccentric myocardial hypertrophy. Moreover, HIIT effectively improves the LV mechanics during exercise by increasing contractile and diastolic functions.
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Affiliation(s)
- Yu-Chieh Huang
- Healthy Aging Research Center, Graduate Institute of Rehabilitation Science, Medical Collage, Chang Gung University, Tao-Yuan, TAIWAN
| | - Hsing-Hua Tsai
- Healthy Aging Research Center, Graduate Institute of Rehabilitation Science, Medical Collage, Chang Gung University, Tao-Yuan, TAIWAN
| | - Tieh-Cheng Fu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, TAIWAN.,Heart Failure Center, Chang Gung Memorial Hospital, Keelung, TAIWAN
| | - Chih-Chin Hsu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, TAIWAN.,Heart Failure Center, Chang Gung Memorial Hospital, Keelung, TAIWAN
| | - Jong-Shyan Wang
- Healthy Aging Research Center, Graduate Institute of Rehabilitation Science, Medical Collage, Chang Gung University, Tao-Yuan, TAIWAN.,Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, TAIWAN.,Heart Failure Center, Chang Gung Memorial Hospital, Keelung, TAIWAN
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7
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Eysenck W, van Zalen J, Freemantle N, Lloyd G, Furniss S, Sulke N. The hemodynamic effects of a central iliac arteriovenous anastomosis at 6 months in patients with resistant and uncontrolled hypertension. J Clin Hypertens (Greenwich) 2019; 21:1399-1405. [PMID: 31347773 DOI: 10.1111/jch.13646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/27/2019] [Accepted: 07/08/2019] [Indexed: 11/27/2022]
Abstract
A central iliac arteriovenous anastomosis, termed the "coupler" (ROX Medical), results in a significant reduction in blood pressure (BP) in hypertensive patients. This study assessed functional and hemodynamic changes induced by the device. Twenty-one patients with resistant and/or uncontrolled hypertension underwent stress echocardiography and cardiopulmonary exercise testing (CPET) at baseline and 6 months post-coupler implantation. End points were selected to best evaluate cardiac function including Doppler stroke volume (SV), septal and lateral E/E', and right ventricular systolic velocity S' (RV S'). CPET VO2 peak demonstrated total cardiopulmonary performance. SV increased from 76.4 SD12.2 mL to 92.1 SD22.7 mL 6 months post-coupler insertion; P = .002. No changes in RV S', septal or lateral E/E', or VO2 peak were observed. Five patients experienced increased diuretic requirement ≥3 times baseline. RV S' fell from 19.0 SD1.87 cm/s to 16.80 SD3.43 cm/s in these patients (P > .05). A significant increase in SV 6 months post-coupler insertion was observed. In patients with increased diuretic requirement, the device was associated with a lower RV S' suggesting occult RV dysfunction as the mechanism of this pre-specified adverse outcome.
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Affiliation(s)
- William Eysenck
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| | - Jet van Zalen
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Guy Lloyd
- Heart Valve Clinic & Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,William Harvey Research Institute, QMUL, London, UK.,Institute of Cardiovascular Sciences, UCL, London, UK
| | - Stephen Furniss
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
| | - Neil Sulke
- Cardiology Research Department, Eastbourne General Hospital, East Sussex, UK
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8
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Pearson MJ, Mungovan SF, Smart NA. Effect of exercise on diastolic function in heart failure patients: a systematic review and meta-analysis. Heart Fail Rev 2018; 22:229-242. [PMID: 28229273 DOI: 10.1007/s10741-017-9600-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diastolic dysfunction contributes to the development and progression of heart failure. Conventional echocardiography and tissue Doppler imaging are widely utilised in clinical research providing a number of indices of diastolic function valuable in the diagnosis and prognosis of heart failure patients. The aim of this meta-analysis was to quantify the effect of exercise training on diastolic function in patients with heart failure. Exercise training studies that investigate different indices of diastolic function in patients with heart failure have reported that exercise training improves diastolic function in these patients. We sought to add to the current literature by quantifying, where possible, the effect of exercise training on diastolic function. We conducted database searches (PubMed, EBSCO, EMBASE, and Cochrane Trials Register to 31 July 2016) for exercise based rehabilitation trials in heart failure, using the search terms 'exercise training, diastolic function and diastolic dysfunction'. Data from six studies, with a total of 266 heart failure with reduced ejection fraction (HFrEF) participants, 144 in intervention groups and 122 in control groups, indicated a significant reduction in the ratio of early diastolic transmitral velocity (E) to early diastolic tissue velocity (E') (E/E' ratio) with exercise training, exercise vs. control mean difference (MD) of -2.85 (95% CI -3.66 to -2.04, p < 0.00001). Data from five studies in heart failure with preserved ejection fraction (HFpEF) patients, with a total of 204 participants, 115 in intervention groups and 89 in control groups, also demonstrated a significant improvement in E/E' in exercise vs. control MD of -2.38 (95% CI -3.47 to -1.28, p < 0.0001).
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Affiliation(s)
- M J Pearson
- School of Science and Technology, University of New England, Armidale, NSW, 2351, Australia
| | - S F Mungovan
- Westmead Private Physiotherapy Services and The Clinical Research Institute, Sydney, Australia.,Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - N A Smart
- School of Science and Technology, University of New England, Armidale, NSW, 2351, Australia.
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Guazzi M. The ultimate diagnosis of unexplained dyspnoea on exertion: Stay tuned on invasive cardiopulmonary exercise testing and beyond. Eur J Prev Cardiol 2017; 24:1308-1310. [DOI: 10.1177/2047487317713330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Sanna GD, Masia SL. Time to change approach - from morphology to function and pathophysiology: The lesson of postoperative tricuspid regurgitation. Eur J Prev Cardiol 2016; 24:70-71. [PMID: 27708070 DOI: 10.1177/2047487316673899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Stefano L Masia
- U.O. Riabilitazione Cardiologica, Ospedale "SS Annunziata" Sassari, Italy
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Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J 2016; 39:1144-1161. [DOI: 10.1093/eurheartj/ehw180] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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12
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Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 Focused Update: Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations. Circulation 2016; 133:e694-711. [PMID: 27143685 DOI: 10.1161/cir.0000000000000406] [Citation(s) in RCA: 239] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In the past several decades, cardiopulmonary exercise testing (CPX) has seen an exponential increase in its evidence base. The growing volume of evidence in support of CPX has precipitated the release of numerous scientific statements by societies and associations. In 2012, the European Association for Cardiovascular Prevention & Rehabilitation and the American Heart Association developed a joint document with the primary intent of redefining CPX analysis and reporting in a way that would streamline test interpretation and increase clinical application. Specifically, the 2012 joint scientific statement on CPX conceptualized an easy-to-use, clinically meaningful analysis based on evidence-vetted variables in color-coded algorithms; single-page algorithms were successfully developed for each proposed test indication. Because of an abundance of new CPX research in recent years and a reassessment of the current algorithms in light of the body of evidence, a focused update to the 2012 scientific statement is now warranted. The purposes of this update are to confirm algorithms included in the initial scientific statement not requiring revision, to propose revisions to algorithms included in the initial scientific statement, to propose new algorithms based on emerging scientific evidence, to further clarify the application of oxygen consumption at ventilatory threshold, to describe CPX variables with an emerging scientific evidence base, to describe the synergistic value of combining CPX with other assessments, to discuss personnel considerations for CPX laboratories, and to provide recommendations for future CPX research.
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