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PubMed1995

An evaluation of integrated cardiopulmonary exercise testing in a pulmonary function laboratory.

Clinical exercise testing has been used mainly to assess the cardiac response to exercise. Integrative cardiopulmonary exercise tests (CPET) involving the measurement of the ventilatory, circulatory and metabolic response to exercise has largely been a research tool. We analysed the results of one hundred tests randomly chosen from a total of 472 exercise tests performed between January 1992 and June 1993 as clinical investigation in a pulmonary function laboratory. CPET was used (a) to identify the cause of effort limitation in patients where more than one illness could be relevant (26); (b) to obtain an objective measure of the exercise capacity of patients with respiratory or cardiac disease (31); (c) as monitor of response to treatment (11) and (d) in the investigation of unexplained dyspnoea (32). In 94 of the 100 cases CPET was able to provide an answer to the specific clinical question posed. In patients with unexplained dyspnoea (CPET identified a group who exhibit an inappropriate hyperventilatory response to exercise with no supportive evidence of cardiopulmonary disease. In a small minority of cases CPET gave non-specific results. We conclude that CPET is a useful investigation in the management of patients with cardiopulmonary disease and complements the various other investigations offered by a pulmonary function laboratory.

Adolescent↗
PubMed2005

Exercise testing in aortic stenosis.

Physician-supervised exercise testing in asymptomatic patients with aortic stenosis allows an objective assessment of the hemodynamic response to exercise and it provides a measure of exercise capacity. Exercise testing cannot be used to determine the presence or absence of coronary artery disease, but limited data indicate that exercise testing can provide prognostic information. The results of such testing can be used to provide an exercise prescription and to reassure the patient who might otherwise excessively limit his or her activity.

Aortic Valve Stenosis↗
PubMed2005

Functional capacity and cardiovascular assessment: submaximal exercise testing and hidden candidates for pharmacologic stress.

Submaximal exercise testing is often used to estimate functional capacity in non-athletes, to assess cardiovascular disease in elderly or frail patients, to demonstrate exercise equipment, or to risk-stratify patients after myocardial infarction. However, submaximal exercise testing is not sufficiently sensitive, specific, or predictive to have widespread clinical utility, except in post-myocardial infarction protocols. Many patients for whom submaximal exercise testing is not useful are unable to exercise sufficiently for maximal testing and are referred for imaging with pharmacologic stress. Although some patients who are unable to exercise adequately are easily recognized, many are not. The identification of such patients before they fail a maximal exercise test attempt is beneficial to both the patient and the imaging laboratory.

Aged↗
PubMed2004

Mood changes after maximal exercise testing in subjects with symptoms of exercise dependence.

Considering exercise has positive and negative reinforcing properties, the mood states of sedentary, nonexercise-dependent and exercise-dependent volunteers were compared after maximal exercise testing. Mood status was evaluated by the Beck Depression Inventory, Trait-State Anxiety Inventory, and Profile of Mood States (POMS). No differences were detected before the test or after it, indicating little possibility of positive reinforcement. However, a significant reduction in the POMS Tension-Anxiety scores was observed in both exerciser groups (greater in the exercise-dependent group) but not in the sedentary group. Only in the exercise-dependent group were significant reductions in Anger and Total Mood Disorders scores observed compared with their pre-exercise scores. These data suggest that exercising has stronger negative reinforcement properties for exercise-dependent volunteers and is a factor which could increase the odds of their becoming dependent on exercise.

Adolescent↗
PubMed1998

Can computerization of the exercise test replace the cardiologist?

BACKGROUND: The type of practitioners who use the standard exercise test is changing. Once a tool of the cardiologist, the standard exercise test is now being performed by internists and other noncardiologists. Because this change could be facilitated by computerization similar to the computerized interpretation programs available for the resting electrocardiograph (ECG), we performed this analysis. A secondary aim was to demonstrate the effects of medication status and resting ECG abnormalities on test diagnostic characteristics because these factors affect utility of the exercise test by the generalist. METHODS AND RESULTS: A retrospective analysis was performed of consecutive patients referred at 2 university-affiliated Veteran's Affairs Medical Centers and a Hungarian Hospital for evaluation of chest pain and possible ischemic heart disease. There were 1384 consecutive male patients without a prior myocardial infarction with complete data who had exercise tests and coronary angiography between 1987 and 1997. Measurements included clinical, exercise test data, and visual interpretation of the ECG recordings as well as more than 100 computed measurements from the digitized ECG recordings and compilation of angiographic data from clinical reports. The computer measurements had similar diagnostic power compared with visual interpretation. Computerized measurements from maximal exercise or recovery were equivalent or superior to all other measurements. Prediction equations applied by computer were superior to single ECG measurements. Beta-blockers had no effect on test characteristics, whereas resting ST depression was associated with decreased specificity and increased sensitivity. CONCLUSIONS: Computerized exercise ST measurements are comparable to visual ST measurements by a cardiologist; computerized scores that included clinical and exercise test results exhibited the greatest diagnostic power. Applying scores with a computer allows the practicing physician to improve the diagnostic characteristics of the standard exercise test. This approach is successful even when there is resting ST depression, thus lessening the need for more expensive nuclear or imaging studies.

Adult↗
PubMed1978

The predictive value of anginal chest pain as an indicator of coronary disease during exercise testing.

To determine the significance of anginal chest pain during exercise testing, a series of 302 patients undergoing coronary arteriography with exercise testing was reviewed. Of the 302 patients, 85 had ischemic ECG changes and chest pain (Group I); 87 patients had ischemic ECG changes but no chest pain (Group II); 25 patients had chest pain but no ischemic ECG changes (Group III); 105 patients had neither chest pain nor ischemic ECG changes (Group IV). Coronary artery disease was present in 95% of Group I, 75% of Group II, 72% of Group III, and 28% of Group IV. Of those patients with coronary disease, multiple vessels were involved in 94% of Group I, 51% of Group II, 67% of Group III, and 21% of Group IV. The predictive value for presence and extent of coronary disease showed Group I greater than Groups II and III greater than Group IV (p less than 0.025). We conclude that (1) anginal chest pain during exercise testing predicts the presence and extent of coronary disease more accurately than its absence; (2) the presence of chest pain even without an ischemic ECG response during exercise testing appears to be as predictive of coronary disease as an ischemic ECG response alone; and (3) the combination of anginal chest pain during exercise testing and an ischemic ECG response is highly predictive of multivessel coronary artery disease.

Angina Pectoris↗
PubMed1992

[Exercise-induced left bundle branch block in treadmill exercise test: clinical significance and prognosis].

Exercise induced left bundle branch block (LBBB) is poorly understood. We investigated its clinical characteristics and prognosis. The records of 3,459 consecutive patients who underwent treadmill exercise testing were reviewed. Exercise induced LBBB was identified in 6 patients (0.17%). Three out of six patients had underlying cardiac disease; two had coronary artery disease and one dilated cardiomyopathy. Three out of five had redistribution on Tl-201 myocardial scintigraphy. In one of these three patients, however, coronary angiography demonstrated no significant narrowings. Tl-201 myocardial scintigraphy in patients with exercise induced LBBB may be undetermined for coronary artery disease. During follow-up, one of six patients had depressed left ventricular function and was diagnosed as having dilated cardiomyopathy. It is thus obvious that exercise induced LBBB without a specific underlying heart disease should be followed up carefully.

Aged↗
PubMed2001

Treadmill exercise testing with increasing inclination as exercise protocol for wheelchair athletes.

STUDY DESIGN: Treadmill testing on a progressive incline of 11 wheelchair athletes. OBJECTIVE: To determine if a novel treadmill exercise protocol which uses increments in inclination, rather than the standard increments in velocity, can be used to effectively determine maximum oxygen uptake VO2max for elite wheelchair athletes. SETTING: Nottwil, Switzerland. METHODS: Eleven elite wheelchair basketball players (29.3+/-6.3 years, 72.7+/-16.9 kg and 177+/-9.6 cm) performed an exercise protocol with increasing inclination on the treadmill. Eight players had a spinal cord injury (SCI), two had no lesion of the central nervous system and one had poliomyelitis. VO2max and heart rate were measured continuously, while serum lactate was determined immediately after the exercise protocol. RESULTS: Athletes reached a maximal heart rate of 185+/-11.4 bpm and maximal lactate of 10.2+/-2.1 mmol/l. VO2max was 35.1+/-4.9 ml/min/kg. The correlation between heart rate and VO(2) at different inclinations was statistically significant and comparable to able-bodied subjects. CONCLUSIONS: An exercise protocol with increasing inclination is a valid alternative to an exercise protocol with increasing velocity.

Adult↗
PubMed2005

Mobilization of cardiovascular function during the constant-load and all-out exercise tests.

The problem of evaluating the mobilization of body functioning during exercise combines two questions: first, the velocity of adaptation at onset of exercise, and second, to what extent the body function was mobilized. The aim of this study was to find out the peculiarities in mobilization of cardiovascular function during constant-load and all-out exercise tests in non-athletes and sportsmen: cohorts of sprinters, endurance and combat athletes. Every subject underwent a Roufier's test (30 squats per 45 seconds), a 30-second duration maximal vertical jump test, and a bicycle ergometry (graded stress). Indirect arterial blood pressure measurements were taken from the arm with a sphygmomanometer and standard-size arm cuff and various indices registered in 12-lead electrocardiogram (ECG) using a computerized ECG analysis system "Kaunas-load" were analyzed. The results obtained during the study showed that the change in ratio of JR/RR intervals of ECG allows assessing the dynamics of mobilization of cardiovascular system during the exercise tests or workouts. The greater mobilization of cardiovascular system when performing constant-load exercise tests is rather characteristic for non-athletes than sportsmen's cohorts. Constant-load exercise tests rather than all-out exercise tests are more suitable for assessments of individual peculiarities or differences between the cohorts. The individual peculiarities in velocity of adaptation of cardiovascular system at onset of exercise can be evaluated making use of the index of velocity of adaptation (V(Ad)), which represents the difference between the relative changes of JT and RR intervals of ECG. Velocity of adaptation at onset of exercise depends on the residual effects of training but not on the type of exercise test.

Adaptation, Physiological↗
PubMed1987

The role of exercise testing in impairment evaluation.

To examine the usefulness of exercise testing in impairment evaluation, we reviewed the evaluation of 348 asbestos-exposed shipyard workers. We compared work capacity predicted from history, physical examination, chest roentgenogram, resting electrocardiogram, and resting pulmonary function tests with measured work capacity during an incremental cycle exercise test. The predicted work capacity was often incorrect when compared with measured maximal oxygen uptake (VO2). One third (22 of 66) of those predicted to have reduced work capacity had normal measured work capacity, and 46 of 148 workers (31%) predicted to have normal work capacity were found to have low maximal VO2 during exercise. Of 134 men for whom predicted work capacity was uncertain, maximal VO2 during exercise was low in 49 (37%), normal in 81 (60%), and remained indeterminate in 4 (3%). Thus, of the 138 workers who had low measured VO2, 43 were correctly predicted to have normal work capacity, 46 were incorrectly predicted, and the prediction was uncertain in 49. Only a few were limited by respiratory disease, and cardiovascular disorders limited 69% of those with a low maximal VO2 during exercise. Accordingly, resting VC, FEV1, and DLCO had a poor correlation with exercise performance. Finally, we found that resting DLCO was a poor predictor of abnormal exercise AaPO2, dead-space/tidal volume ratio, or arterial end-tidal PCO2 difference. We conclude that exercise testing is needed for accurate work capacity assessment in impairment evaluation. Exercise testing also facilitates the identification of the major limiting system in those with low work capacity.

Asbestosis↗
PubMed1981

Digoxin-induced positive exercise tests: their clinical and prognostic significance.

To evaluate the influence of digoxin on the results of exercise testing and the prognostic significance of digoxin-induced positive exercise tests, 98 healthy men, aged 22 to 70 years, were studied. All had normal initial exercise test results. All took digoxin, 0.25 mg daily, for 14 days, and then performed daily exercise tests until each had a negative test response. Five years after these initial tests, a medical history was obtained from 92 of the 98 subjects, and 76 subjects performed repeat exercise tests. Six subjects were lost to follow-up study. Twenty-five percent of subjects (22 of 98) had a digoxin-induced positive exercise test. There was a direct relation between age and the incidence of digoxin-positive tests. The incidence of digoxin-positive tests in men over age 60 years was 100 percent. By 30 seconds after exercise no subject had greater than 1.9 mm S-T depression. No test remained positive for more than 6 minutes after exercise was discontinued. No test was positive 12 days after digoxin was withdrawn. With logistic regression analysis, it was possible to estimate the probability that a subject would have a digoxin-induced positive test. No subject had had a cardiovascular event at follow-up study, but five subjects had a positive repeat exercise test. Four of these subjects had had a digoxin-positive test initially. It is concluded that (1) useful information can be obtained from exercise studies of patients who receive digoxin, (2) the probability that a positive exercise test is due to digoxin can be estimated, (3) to remove the exercise-induced electrocardiographic effect, the drug should be withdrawn for 12 days, and (4) digoxin may unmask subclinical coronary arterial stenosis.

Adult↗
PubMed1994

Exercise limitation and clinical exercise testing in chronic obstructive pulmonary disease.

Clinical exercise testing is an important tool in assessment of exercise limitation in COPD patients, in assessment of physiologic and psychological factors that contribute to exercise limitation, and in the differential diagnosis of cardiorespiratory disease. Further studies that examine the clinical utility of exercise testing are needed because there are currently insufficient data regarding the utility of many exercise variables.

Acidosis, Respiratory↗
PubMed2000

Use of transcutaneous oxygen and carbon dioxide tensions for assessing indices of gas exchange during exercise testing.

The slow response characteristics of the combined transcutaneous electrode have been viewed as a major disadvantage when compared with other types of non-invasive assessment of gas exchange during exercise testing. We have previously shown that by using the highest recommended temperature of 45 degrees C to reduce response times, and combining this with an exercise protocol of gradual work load increments, that this allows changes in arterial blood gases to be closely followed by transcutaneous values. In the present study we have validated the use of a transcutaneous electrode for estimation of alveolar-arterial oxygen gradient (AaO2) and dead space to tidal volume ratio (V(D)/V(T)) during exercise, against values calculated from direct arterial blood gas analysis. One hundred measurements were made in 20 patients with various cardiopulmonary disorders who underwent exercise testing. Exercise testing was performed by bicycle ergometry with a specific protocol involving gradual work load increments at 2 min intervals. Transcutaneous gas tensions were measured by a heated combined O2 and CO2 electrode. Arterial blood was sampled at the midpoint of each stage of exercise and transcutaneous tensions noted at the end of each stage. The mean difference of the AaO2 gradient calculated from blood gas tensions obtained by the two methods was 0.14 kPa. The limits of agreement were -0.26 and 0.63 kPa. The same values for V(D)/V(T) calculated from gas tensions measured by the two methods were: mean difference 0001; limits of agreement -0.0242 and 0.0252. For both these parameters there was an even scatter around the mean value on Bland and Altman analysis. The findings of this study suggest that estimation of parameters of gas exchange using transcutaneous values during exercise testing is reliable, provided the electrode is heated to a slightly higher temperature than usual and the work load increments are gradual, allowing for the latency in the response time of the system. This system allows the assessment of the contribution of ventilation/perfusion inequality to breathlessness on exertion in patients, provided an initial arterial or ear lobe capillary sample is obtained for calibration purposes. This technique is particularly valuable in patients undergoing repeat exercise tests as it circumvents the need for arterial cannulation.

Adult↗
PubMed2003

The influence of exercise test protocol on perceived exertion at submaximal exercise intensities in children.

This study examined ratings of perceived exertion (RPE) using Borg's 6-20 scale at 50 W, 80 W, and ventilatory threshold (VT) in 10-year-old children (n = 15) during two different graded exercise tests. Power output was increased by 10 W.min(-1) in one protocol and by 30 W.3 min(-1) in the other. The cardiorespiratory responses at VT and peak exercise were similar between protocols. At 50 W and 80 W the cardiorespiratory responses were generally lower (P < 0.05) in the 10W trial. However, RPE was 11.5 +/- 2.9 and 12.1 +/- 3.2 at 50 W and 15.1 +/- 2.7 and 15.3 +/- 2.8 at 80 W in the 10-W and 30-W trials, respectively (P > 0.05). The RPE at VT was 13.9 +/- 2.4 in the 10-W trial and 12.4 +/- 2.4 in the 30-W trial (P < 0.05). In that variations in submaximal RPE did not coincide with variations in central mediators of exertion, locals cues of exertion may have provided the dominate sensory signal.

Analysis of Variance↗
PubMed2000

Exercise testing in clinical medicine.

Exercise-induced changes in the electrocardiogram have been used to identify coronary artery disease for almost a century. Over the past decade, however, clinicians have increasingly focused on more expensive diagnostic tools believing them to offer improved diagnostic accuracy. In fact, by incorporating historical data, the simple exercise test can in most cases outperform the newer tests. The use of prediction equations and non-staged exercise protocols can improve the test still further, while advances in the use of the test for prognosis, with the discovery of novel risk factors and the addition of gas analysis, may in the future shift the primary emphasis away from diagnosis. Brief, inexpensive, and done in most cases without the presence of a cardiologist, the exercise test offers the highest value for predictive accuracy of any of the non-invasive tests for coronary artery disease.

Coronary Disease↗
PubMed1979

[Clinical and epidemiological criteria of evaluation of the exercise test (author's transl)].

Exercise test diagnostic and prognostic value depends on the purpose for which is performed and on the population studied. In typical angina patients the test is usefull for choosing between medical and surgical therapy and for evaluating treatment efficacy. In patients with atypical chest pain a diagnostic value is recognized. In asymptomatic subjects results of a number of epidemiological studies suggest that this test is recommended only in selected groups or for research purpose. In the appendix definitions of epidemiological measures used in screening tests evaluation are given with examples.

Adolescent↗
PubMed1988

Cardiopulmonary exercise testing in congestive heart failure.

Cardiopulmonary exercise testing includes the monitoring of respiratory gases and airflow to determine oxygen uptake, carbon dioxide (CO2) production, respiratory rate, tidal volume, and minute ventilation during a graded maximal exercise test. A plateau in oxygen uptake, which occurs despite an increase in work load, and which is termed maximal oxygen uptake (VO2 max), correlates with the maximal exercise cardiac output and can therefore be used to grade the severity of heart failure. The anaerobic threshold occurs at 60 to 70% of VO2 max and is another indicator of the severity of heart failure and, when attained, indicates that the patient is close to performing a maximal test. We have found VO2 max and anaerobic threshold to be objective measures of efficacy of both investigational and noninvestigational therapy in patients with heart failure. A pulmonary limitation to exercise can be identified by the failure to attain anaerobic threshold or VO2 max, as well as exhaustion of the ventilatory reserve, as estimated by maximal voluntary ventilation. Thus, cardiopulmonary exercise testing can be used to (1) grade the severity of heart failure, (2) objectively follow the response to therapy, and (3) differentiate a cardiac from a pulmonary limitation to exercise.

Carbon Dioxide↗
PubMed2002

The prognostic value of exercise testing in elderly men.

PURPOSE: Our purposes were to compare the responses to exercise testing in elderly (> or =65 years of age) and younger men, and to investigate whether exercise testing has similar prognostic value in the two age groups. METHODS: We included all elderly (n = 1185) and younger (n = 2789) male veterans without established coronary heart disease who underwent routine clinical exercise testing between 1987 and 2000 at two academically affiliated Veteran's Affairs medical center laboratories. Measurements included a standardized medical history, exercise testing, and all-cause mortality. RESULTS: Compared with younger patients, elderly patients achieved a lower workload (a mean [+/- SD] of 7 +/- 3 vs. 10 +/- 4 metabolic equivalents [METs], P <0.001) and were more likely to have abnormal ST depression (27% [n = 324] vs. 16% [n = 436], P <0.001). During the mean follow-up of 6 years, annual mortality was twice as high among elderly patients as among younger patients (4% vs. 2%, P <0.001). The only exercise test variable that was associated significantly with time to death in both age groups was maximal METs achieved: each 1 MET increase in exercise capacity was associated with an 11% reduction in annual mortality. Exercise-induced ST depression was more common in those who subsequently died, but was not an independent predictor of mortality. CONCLUSION: In elderly men, exercise testing provided prognostic information incremental to clinical data. Achieved workload (in METs) was the major exercise testing variable associated with all-cause mortality. Its prognostic importance was the same in elderly as in younger men.

Age Factors↗