Clinical application of cardiac output during ramp exercise calculated using the Fick equation--comparison with the 2-stage bicycle ergometer exercise protocol in the supine position

Evaluation of two methods for continuous cardiac output assessment during exercise in chronic heart failure patients

The purpose of this study was to evaluate the accuracy of two techniques for the continuous assessment of cardiac output in patients with chronic heart failure (CHF): a radial artery pulse contour analysis method that uses an indicator dilution method for calibration (LiDCO) and an impedance cardiography technique (Physioflow), using the Fick method as a reference. Ten male CHF patients (New York Heart Association class II–III) were included. At rest, cardiac output values obtained by LiDCO and Physioflow were compared with those of the direct Fick method. During exercise, the continuous Fick method was used as a reference. Exercise, performed on a cycle ergometer in upright position, consisted of two constant-load tests at 30% and 80% of the ventilatory threshold and a symptom-limited maximal test. Both at rest and during exercise LiDCO showed good agreement with reference values [bias ± limits of agreement (LOA), −1% ± 28% and 2% ± 28%, respectively]. In contrast, Physioflow overestimated reference values both at rest and during exercise (bias ± LOA, 48% ± 60% and 48% ± 52%, respectively). Exercise-related within-patient changes of cardiac output, expressed as a percent change, showed for both techniques clinically acceptable agreement with reference values (bias ± LOA: 2% ± 26% for LiDCO, and −2% ± 36% for Physioflow, respectively). In conclusion, although the limits of agreement with the Fick method are pretty broad, LiDCO provides accurate measurements of cardiac output during rest and exercise in CHF patients. Although Physioflow overestimates cardiac output, this method may still be useful to estimate relative changes during exercise.

Blood Flow Redistribution During Exercise Contributes to Exercise Tolerance in Patients With Chronic Heart Failure

BACKGROUND

It is widely known that blood flow redistribution is impaired in patients with chronic heart failure (CHF). However, the relationship between exercise tolerance and the degree of blood flow redistribution is not fully understood. Whole-body thallium-201 chloride ((201)Tl) scintigraphy can estimate blood flow distribution. This study will evaluate the relationship between exercise tolerance and blood flow redistribution using whole-body scintigraphy in patients with CHF.

METHODS AND RESULTS

Exercise stress whole-body thallium scintigraphy was performed in 19 patients with CHF (mean ejection fraction: 33.0%; peak oxygen uptake: 15.5 ml x min(-1) x kg(-1)). Blood flow redistribution was quantified by comparing the regional thallium count (count/pixel) in the thigh and arm. We then assessed the relationship between these parameters and parameters obtained from cardiopulmonary exercise testing. (201)Thallium-chloride uptake in the thigh increased during exercise compared to rest (p<0.05), while its uptake in the arm was not different between exercise and rest. Increased (201)Tl uptake in the thigh during exercise was positively correlated with exercise tolerance (r=0.689). In contrast, (201)Tl uptake in the arm was not correlated with exercise tolerance.

CONCLUSIONS

By using this method, it is concluded that blood flow redistribution to the exercising muscle increases as the exercise tolerance increases in patients with CHF.

Is there an Optimal Training Intensity for Enhancing the Maximal Oxygen Uptake of Distance Runners?

The maximal oxygen uptake (V-dotO(2max)) is considered an important physiological determinant of middle- and long-distance running performance. Little information exists in the scientific literature relating to the most effective training intensity for the enhancement of V-dotO(2max) in well trained distance runners. Training intensities of 40-50% V-dotO(2max) can increase V-dotO(2max) substantially in untrained individuals. The minimum training intensity that elicits the enhancement of V-dotO(2max) is highly dependent on the initial V-dotO(2max), however, and well trained distance runners probably need to train at relative high percentages of V-dotO(2max) to elicit further increments. Some authors have suggested that training at 70-80% V-dotO(2max) is optimal. Many studies have investigated the maximum amount of time runners can maintain 95-100% V-dotO(2max) with the assertion that this intensity is optimal in enhancing V-dotO(2max). Presently, there have been no well controlled training studies to support this premise. Myocardial morphological changes that increase maximal stroke volume, increased capillarisation of skeletal muscle, increased myoglobin concentration, and increased oxidative capacity of type II skeletal muscle fibres are adaptations associated with the enhancement of V-dotO(2max). The strength of stimuli that elicit adaptation is exercise intensity dependent up to V-dotO(2max), indicating that training at or near V-dotO(2max) may be the most effective intensity to enhance V-dotO(2max) in well trained distance runners. Lower training intensities may induce similar adaptation because the physiological stress can be imposed for longer periods. This is probably only true for moderately trained runners, however, because all cardiorespiratory adaptations elicited by submaximal training have probably already been elicited in distance runners competing at a relatively high level.Well trained distance runners have been reported to reach a plateau in V-dotO(2max) enhancement; however, many studies have demonstrated that the V-dotO(2max) of well trained runners can be enhanced when training protocols known to elicit 95-100% V-dotO(2max) are included in their training programmes. This supports the premise that high-intensity training may be effective or even necessary for well trained distance runners to enhance V-dotO(2max). However, the efficacy of optimised protocols for enhancing V-dotO(2max) needs to be established with well controlled studies in which they are compared with protocols involving other training intensities typically used by distance runners to enhance V-dotO(2max).

Hemodynamic characteristics during treadmill and bicycle exercise in chronic heart failure: mechanism for different responses of peak oxygen uptake

The exercise capacity of patients with chronic heart failure (CHF) is greater when assessed by the treadmill rather than the bicycle ergometer, but the mechanism of this difference has not been clarified. The present study aimed to determine the difference between the hemodynamics of these exercise modes and the mechanism underlying the different peak oxygen uptake (VO2). Patients (n = 18) underwent a bicycle test and treadmill test using individual ramp protocols. Respiratory gas analysis and hemodynamic measurements with an opti-catheter were performed during both exercise tests. The peak VO2 was significantly larger in the treadmill test than the bicycle test (1410+/-292 vs. 1630+/-331 ml/min, p<0.001). Both the peak cardiac output (Q; 10.2+/-2.2 vs. 10.9+/-2.1 L/min, p<0.001) and the peak arteriovenous oxygen difference (a-v 02 diff; 13.9+/-1.5 vs. 15.0+/-1.2 vol%, p<0.001) were also significantly higher in the treadmill test. The relative contribution of Q and a-v O2 diff to the increased peak VO2 was equivalent, which suggests that both Q and a-v O2 diff. Contribute equally to the different peak VO2 responses in CHF.