Validity and reliability of cardiac output by CO2 rebreathing

Non-Invasive Cardiac Output Measurement Using Inert Gas Rebreathing Method during Cardiopulmonary Exercise Testing-A Systematic Review

BACKGROUND

The use of inert gas rebreathing for the non-invasive cardiac output measurement has produced measurements comparable to those obtained by various other methods. However, there are no guidelines for the inert gas rebreathing method during a cardiopulmonary exercise test (CPET). In addition, there is also a lack of specific standards for assessing the non-invasive measurement of cardiac output during CPET, both for healthy patients and those suffering from diseases and conditions.

AIM

This systematic review aims to describe the use of IGR for a non-invasive assessment of cardiac output during cardiopulmonary exercise testing and, based on the information extracted, to identify a proposed CPET report that includes an assessment of the cardiac output using the IGR method.

METHODS

This systematic review was conducted by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) guidelines. PubMed, Web of Science, Scopus, and Cochrane Library databases were searched from inception until 29 December 2022. The primary search returned 261 articles, of which 47 studies met the inclusion criteria for this review.

RESULTS AND CONCLUSIONS

This systematic review provides a comprehensive description of protocols, indications, technical details, and proposed reporting standards for a non-invasive cardiac output assessment using IGR during CPET. It highlights the need for standardized approaches to CPET and identifies gaps in the literature. The review critically analyzes the strengths and limitations of the studies included and offers recommendations for future research by proposing a combined report from CPET-IGR along with its clinical application.

Cardiovascular strain impairs prolonged self-paced exercise in the heat

It has been proposed that self-paced exercise in the heat is regulated by an anticipatory reduction in work rate based on the rate of heat storage. However, performance may be impaired by the development of hyperthermia and concomitant rise in cardiovascular strain increasing relative exercise intensity. This study evaluated the influence of thermal strain on cardiovascular function and power output during self-paced exercise in the heat. Eight endurance-trained cyclists performed a 40 km simulated time trial in hot (35°C) and thermoneutral conditions (20°C), while power output, mean arterial pressure, heart rate, oxygen uptake and cardiac output were measured. Time trial duration was 64.3 ± 2.8 min (242.1 W) in the hot condition and 59.8 ± 2.6 min (279.4 W) in the thermoneutral condition (P < 0.01). Power output in the heat was depressed from 20 min onwards compared with exercise in the thermoneutral condition (P < 0.05). Rectal temperature reached 39.8 ± 0.3 (hot) and 38.9 ± 0.2°C (thermoneutral; P < 0.01). From 10 min onwards, mean skin temperature was ~7.5°C higher in the heat, and skin blood flow was significantly elevated (P < 0.01). Heart rate was ~8 beats min(-1) higher throughout hot exercise, while stroke volume, cardiac output and mean arterial pressure were significantly depressed compared with the thermoneutral condition (P < 0.05). Peak oxygen uptake measured during the final kilometre of exercise at maximal effort reached 77 (hot) and 95% (thermoneutral) of pre-experimental control values (P < 0.01). We conclude that a thermoregulatory-mediated rise in cardiovascular strain is associated with reductions in sustainable power output, peak oxygen uptake and maximal power output during prolonged, intense self-paced exercise in the heat.

Muscle oxygenation trends during constant work rate cycle exercise in men and women

PURPOSE

To examine the relationship between muscle oxygenation and arteriovenous oxygen difference [(a - v)O2diff)] at four constant rate workloads in healthy men and women and to compare these responses between the genders.

METHODS

Nineteen men and 14 women consented to perform an incremental test to identify the lactic acidosis threshold (LAT) and maximal aerobic power (VO2max) and an intermittent constant work rate test at an oxygen uptake corresponding to 40% LAT, 80% LAT, 25% LAT-VO2max, and 50% LAT-VO2max. Each exercise interval was 5 min long followed by 2 min of recovery. Cardiac output was measured by CO2 rebreathing at each workload from which (a - v)O2diff was computed. Tissue absorbency was measured from the vastus lateralis in both the test sessions using near infrared spectroscopy (NIRS). Muscle oxygenation during constant work rate exercise and recovery was expressed as a percentage (%Mox) of the maximum range observed during incremental exercise and recovery.

RESULTS

A systematic decrease was observed in %Mox with increasing intensity, followed by a proportional increase during recovery from each exercise bout. Significant inverse relationships were observed between %Mox and (a - v)O2diff in men (r = -0.34) and women (r = -0.31) across the four intensities. Mean %Mox was significantly higher (P < 0.05) in women compared with men, suggesting lesser deoxygenation at the same relative exercise intensity.

CONCLUSIONS

%Mox was not an accurate predictor of mixed (a - v)O2diff during exercise because of the low common variance between these two variables, and it is unclear whether the gender difference in %Mox is a true physiological phenomenon or whether it is an artifact of the NIRS technique.

Age and cardiac output during cycle exercise in thermoneutral and warm environments

To determine whether chronological age, independent of changes in aerobic capacity, alters cardiac output (Qc), the central hemodynamic responses to intermittent incremental cycle exercise were studied in two groups of men. Qc was measured at rest and during exercise at 35%, 60%, 75%, and 85% peak aerobic capacity (VO2peak) using a CO2 rebreathing method in seven trained older (65 +/- 2 yr) and eight normally active but untrained young men (26 +/- 1 yr) matched for VO2peak and anthropometric measures. Subjects were tested in both a thermoneutral (22 degrees C) and a warm (36 degrees C) environment to investigate possible differential cardiovascular responses to exercise in the heat. Only subjects with no history of pulmonary, cardiac, neuromuscular, or endocrine disease and a normal electrocardiogram were studied. The older men had significantly lower (P < 0.05) Qc relative to the younger men at intensities greater than 60% VO2peak in both environmental conditions. At these higher intensities, the older men had a significantly higher stroke volume (SV) and lower heart rate (HR) (P < 0.05). A higher arteriovenous oxygen difference ((a-v)O2)) compared with their younger counterparts enabled the older men to exercise at the same absolute intensity, most likely because of training induced changes in left-ventricular performance and oxygen extraction. The addition of an exogenous heat source did not alter the Qc response in either group of men; however, a higher HR (P < 0.05) and smaller SV (P > 0.05) were observed in the young men during exercise in the heat. This may reflect previously reported differences in the skin blood flow response of VO2peak-matched young and older men during exercise. It is suggested that endurance trained older men can enhance left-ventricular performance to augment SV, but not sufficiently to maintain Qc in light of an attenuated HR response during exercise at intensities above 60% VO2peak.

Responses to arm exercise in patients with compensated heart failure

PURPOSE

This study compares the responses of 20 male patients (mean age 51 +/- 11 years) with stable heart failure during peak and submaximal arm and leg exercise.

METHODS

On day 1, subjects completed two symptom-limited graded exercise tests, one with their arms and one with their legs. On day 2, subjects performed arm only and leg only exercise at a matched power output of 30 Watts (W). Ten age-matched healthy subjects served as controls.

RESULTS

During peak arm exercise power output, oxygen consumption (VO2), ventilation, and rate-pressure product were higher in healthy subjects than in patients with heart failure. However, when a subject's peak VO2 or power output during arm exercise was expressed as a percentage of that achieved during peak leg exercise, no significant differences were noted between patients with heart failure and healthy subjects. Among both groups, rate-pressure product, VO2, ventilation, the ventilatory equivalent for O2, and respiratory exchange ratio were all higher when exercising at 30 W with the arms versus 30 W with the legs. Also, in patients with heart failure heart rate was higher (+6 min-1) and stroke volume index lower (-4 mL/m2) during submaximal arm than leg exercise.

CONCLUSIONS

Although peak exercise capacity (Watts, VO2) during arm exercise is lower in patients with heart failure than healthy subjects, when expressed as a percentage of peak leg capacity, the extent of the exercise intolerance they experience during arm exercise does not differ from healthy subjects.

The equilibrium CO2 rebreathing method does not affect resting or exercise blood pressure

The equilibrium CO2 rebreathing technique has been widely used for the noninvasive determination of cardiac output. Recently, several investigators have used this technique in conjunction with auscultatory blood pressure measurements to calculate total peripheral resistance. To examine the validity of this approach, we attempted to determine whether the CO2 rebreathing procedure has a significant effect on blood pressure. The participants in the present study were 10 male subjects, 24 +/- 1 yr of age (mean +/- SE). Each subject performed two trials-one with CO2 rebreathing and one without. Both trials consisted of three stages (rest, 25%, and 50% VO2peak), each stage lasting 15 min. During the rebreathing trial, the CO2 rebreathing technique was administered at 10 min into each stage. There were no statistically significant differences in the heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure responses between the two trials. These results indicate that the equilibrium CO2 rebreathing technique does not alter auscultatory blood pressures at rest and during exercise up to intensities of 50% VO2peak.

Prediction of stroke volume during upper and lower body exercise in men and women

In this study, regression equations were derived to predict cardiac stroke volume (SV, mL/beat), measured by carbon dioxide rebreathing, from oxygen pulse (O2 pulse, mL/beat) measurements in healthy men (n = 25) and women (n = 12) during upper and lower body exercise at the ventilatory threshold. The equations for upper body exercise were as follows: men, Y = 10.21X - 1.0, SE = 13.0; r = 0.85; women, Y = 12.70X - 4.8, SE = 15.4, r = 0.78. The equations for lower body exercise were as follows: men, Y = 5.22X + 53.0, SE = 17.9, r = 0.76; women, Y = 7.41X + 27.1, SE = 13.5, r = 0.78. No significant differences (p > .05) were observed between the exercise modes for the slopes and intercepts of the regression equations in both genders. The relationships between O2 pulse and SV were indirectly validated by using raw data from previous studies that had used the direct Fick method to determine cardiac output (Q) for each exercise mode and gender. Comparisons between the values of SV reported in several studies that used direct and indirect methods to determine Q and those predicted from the current equations indicated an error that was usually within 10% of the reported values. These observations suggest that the equations derived for predicting SV from O2 pulse measurements at the ventilatory threshold are quite accurate and can be generalized to a variety of techniques currently used to determine Q.

Physiological correlates of simulated wheelchair racing in trained quadriplegics

This study examined the physiological responses during a 7.5-km simulated wheelchair race (SR) performed on rollers by 8 male quadriplegic marathon racers and analyzed the factors associated with SR time. Cardiac output (Q) was estimated during the SR using carbon dioxide rebreathing, from which stroke volume (SV) and (alpha-v)O2 diff were calculated. Subjects raced at 90 and 93% of peak oxygen uptake (VO2) and peak heart rate, respectively. SR time was inversely related (p < 0.05) to peak VO2, and VO2, Q, and SV during the SR, but not (alpha-v)O2 diff, age, and lesion level. Multiple regression analysis included only absolute SR VO2 in the equation to predict SR time: Y = -29.7X + 65.9; SE = 5.8. SR VO2 was significantly (p < 0.05) related to Q and SV but not to (alpha-v)O2 diff. These descriptive data suggest that SR performance in trained male quadriplegics might be limited by central, as opposed to peripheral, factors that determine VO2.

Effect of body training position on outcomes of an aerobic training study on individuals with quadriplegia

The use of the supine training position to enhance aerobic training was evaluated in a 10-week upper-body exercise study. Fourteen subjects with quadriplegia (QD) were matched on initial peak power output (PO) values and then randomly assigned to either a supine (SUP, n = 7) or sitting (SIT, n = 7) training group. Peak VO2 and PO were measured pretraining and posttraining in both the supine and sitting positions. There were significant (p < .01) increases in peak VO2 (720 to 780 mL.min-1) and PO (29.3 to 33.3W) with training. Although the SIT group exhibited a small training effect size (0.1), while the SUP group exhibited a moderate effect size (0.6), the interaction between time and training group failed to reach significance (p = .07) because of a large injury level-related variation in VO2. The training effect achieved by the SUP group generalized to the sitting position, as their peak VO2 increased 80mL.min-1 in the sitting position. Endurance improved (p < .0001) in all subjects, with time to exhaustion increasing from 52min to 135min over the 10 weeks of training. The sum of 4 skinfolds decreased (p < .05) from 67.5 to 61.0mm. The lack of change in stroke volume at rest and at 50% of peak PO suggests that an inotropic adaptation of the heart, commonly observed in subjects without SCI, did not occur in this population. However, a 4.7bpm increase (p < .01) in resting heart rate (HR) and a near significant increase (p = .07) in peak HR from pretraining to posttraining suggests a training-induced chronotropic adaptation of the heart. Although improvements in aerobic capacity can be achieved by training in either supine or sitting positions, the training effect size was larger in the supine position. Improvements in SV were not observed in either training position; this may be because of low absolute workloads were used. Central cardiovascular adaptation may occur in subjects with QD but changes are reflected as chronotropic and not inotropic adaptations.

Prediction of stroke volume from oxygen pulse measurements in untrained and trained men

This study examined the relationship of oxygen pulse (O2 pulse) to stroke volume (SV) and arterio-venous oxygen difference [(a-v)O2 diff] during submaximal cycle exercise in untrained (UG) and trained (TG) males. Fourteen volunteers in each group completed an incremental VO2 max test and a submaximal test at 60% VO2 max to determine cardiac output (Q) via CO2 rebreathing. VO2, Q, and heart rate (HR) were used to calculate SV and (a-v)O2 diff. There were no significant differences (p > .05) between the two groups for O2 pulse, SV, and (a-v)O2 diff during submaximal exercise. Stroke volume index (SVI) was significantly higher (p < .05) in the TG. O2 pulse was significantly related to SV and SVI (p < .05) but not to (a-v)O2 diff in both groups. Regression equations for predicting SV from O2 pulse for UG and TG were Y = 6.81X + 26.7, SE = 21.4, r = 0.84, and Y = 10.33X - 32.3, SE = 14.2, r = 0.71, respectively. These results suggest that O2 pulse can be used to predict SV during submaximal cycle exercise in untrained and trained men.

Cardiovascular responses of cardiac transplant patients to arm and leg exercise

This investigation compares the cardiovascular responses of normal (n = 10) and cardiac transplant (n = 14) subjects to peak arm and leg exercise. It also tests the hypothesis that the higher heart rate (fc) in normal subjects during light (30 W) submaximal arm versus leg exercise is due to cardiac innervation. In cardiac transplant patients, power output, oxygen consumption (VO2), fc and rate pressure product were 54%, 28%, 7%, and 8% lower during peak arm than leg exercise, respectively. In normal subjects, power output, VO2, fc and rate pressure product were 61%, 33%, 8%, and 11% lower during peak arm than leg exercise, respectively. In cardiac transplant patients there was no significant difference in absolute fc during submaximal arm and leg exercise. In normal subjects, absolute fc during arm and leg exercise was [mean (SD)] 97 (4) beats.min-1 and 92 (4) beats.min-1, respectively (P = 0.07). Plasma noradrenaline was increased more during arm than leg exercise in both cardiac transplant and normal subjects. Maximal leg testing is useful when determining the capacity of cardiac transplant patients to perform arm work. The higher absolute fc reported by other investigators for normal subjects during submaximal arm versus leg exercise may be mediated by cardiac innervation.

Stroke volume response to progressive exercise in athletes engaged in different types of training

Using the impedance cardiography method, heart rate (fc) matched changes on indexed stroke volume (SI) and cardiac output (CI) were compared in subjects engaged in different types of training. The subjects consisted of untrained controls (C), volleyball players (VB) who spent about half of their training time (360 min.week-1) doing anaerobic conditioning exercises and who had a maximal oxygen uptake (VO2max) 41% higher than the controls, and distance runners (D) who spent all their training time (366 min.week-1) doing aerobic conditioning exercises and who had a VO2max 26% higher than VB. The subjects performed progressive submaximal cycle ergometer exercise (10 W.min-1) up to fc of 150 beats.min-1. In group C, SI had increased significantly (P < 0.05) at fc of 90 beats.min-1 (+32%) and maintained this difference up to 110 beats.min-1, only to return to resting values on reaching 130 beats.min-1 with no further changes. In group VB, SI peaked (+54%) at fc of 110 beats.min-1, reaching a value significantly higher than that of group C, but decreased progressively to 22% of the resting value on reaching 150 beats.min-1. In group D, SI peaked at fc of 130 beats.min-1 (+54%), reaching a value significantly higher than that of group VB, and showed no significant reduction with respect to this peak value on reaching 150 beats.min-1. As a consequence, the mean CI increase per fc unit was progressively higher in VB than in C (+46%) and in D than in VB (+105%).(ABSTRACT TRUNCATED AT 250 WORDS)

Improved ventilatory response to exercise after cardioversion of chronic atrial fibrillation to sinus rhythm

The purpose of this study was to assess hemodynamic and respiratory measures of submaximal and maximal exercise performance in patients with chronic atrial fibrillation, before and one month after cardioversion to sinus rhythm. Restoration of sinus rhythm (n = 16) produced significant reductions in resting and exercise heart rates, 14 percent to 20 percent (p < 0.01). Due to a proportionately larger increase in stroke volume, cardiac output increased by 9 percent during low-level exercise (p < 0.01) and by 7 percent during exercise above the anaerobic threshold (p < 0.05). Minute ventilation was reduced by 7 percent during low-level exercise (p < 0.01) and by 9 percent above the anaerobic threshold (p < 0.05). The ratio between minute ventilation and carbon dioxide elimination was significantly reduced (p < 0.01). Maximum oxygen uptake (+8 percent; p < 0.01) and maximal tolerated work load (+6 percent; p < 0.05) increased. Hemodynamic changes during exercise were similar in patients with (n = 7) or without (n = 9) disopyramide prophylaxis. Restoration of sinus rhythm induced improvement in hemodynamics and in efficiency of ventilation, thereby reducing the ventilatory demand during submaximal exercise.

Sham-feeding decreases cardiac output in normal subjects

The cardiovascular effect of sham-feeding was measured in seven healthy non-obese human subjects by the Fick principle using the carbon dioxide rebreathing method. The subjects were resting in the sitting position and were exposed to the sight and smell but not the taste of a breakfast meal. Cardiac output decreased significantly from a mean value of 4.0 1 min-1 to 3.5 1 min-1 during sham-feeding (Friedman, P = 0.004). The cardiac output returned to basal values in all seven subjects when the sensory stimulus was removed. The decrease in cardiac output was due to a decreased stroke volume, whereas heart rate and blood pressure did not change. The mechanism of the decrease in cardiac output during sham-feeding remains to be established.