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PubMed1989

Cardiopulmonary exercise testing.

Cardiopulmonary exercise testing is an objective method of assessing the functional capacity of a patient. In contrast to clinical assessment and resting investigations, exercise testing is useful in detecting early changes in patients with cardiac or respiratory disease. Although a number of different types of ergometers can be used for testing, the ones used commonly are the cycle and treadmill. Comparison of these two modes of exercise shows no significant clinical difference between them; therefore, either can be used for routine cardiopulmonary exercise testing. There are various types of exercise protocols, but generally the protocol should involve large muscle groups and should be tolerated by the population being tested. The main goal when selecting an exercise protocol is to strike a balance between workload increments that do not prematurely fatigue the subject and at the same time allow the subject to reach a maximum power output within 8 to 15 minutes. Whatever the exercise test protocol used, the intensity should be increased to a symptom-limited maximum. This procedure is safe as long as contraindications for starting a test and indications for terminating a test are adhered to strictly. The assessment of cardiorespiratory responses during exercise ranges from simple and noninvasive techniques to those that are invasive and complex. In the majority of cases all the information needed for proper assessment of the patient can be acquired with simple noninvasive techniques.

Electrocardiography↗
PubMed1984

The cardiokymography exercise test compared to the thallium-201 perfusion exercise test in the diagnosis of coronary artery disease.

To determine the usefulness of exercise cardiokymography (CKG) compared to thallium-201 perfusion scanning in the diagnosis of coronary artery disease (CAD), 179 patients with a mean age of 54 +/- 10 years (73% men) were studied. Previously documented CAD was present in 73 patients (41%); 13 (7%) were asymptomatic and 93 (53%) had chest pain syndrome. Exercise stress testing, CKG, and thallium-201 perfusion scanning were independently correlated with coronary angiographic data. Treadmill exercise stress test alone without CKG had a sensitivity of 68% and specificity of 62%. CKG showed a sensitivity of 76% and a specificity of 90%, and easily interpreted cardiokymograms were obtained in 78% of patients studied. Thallium-201 scans had a sensitivity of 79% and a specificity of 88%. However, when the CKG and treadmill exercise test results were concordant (both positive or both negative), the CKG exercise test had a sensitivity of 87% and specificity of 100%. Thus, when the CKG and exercise test results are concordant, the sensitivity and specificity are equal to or better than thallium-201 perfusion scanning for the prediction of CAD. Since CKG is an inexpensive and noninvasive test, its adjunctive use with routine exercise stress testing may be of great value.

Adolescent↗
PubMed2006

[Cardiopulmonary exercise testing in exercise-induced pulmonary hypertension].

OBJECTIVE: To determine the accuracy of cardiopulmonary exercise-testing (CPET) in detecting exercise-induced pulmonary hypertension. BACKGROUND: CPET plays a key role in the investigation of exertional breathlessness. Exercise-induced pulmonary hypertension has been recently demonstrated to be a cause of exertional dyspnea. However, the features of CPET associated with the condition are still unknown. METHODS: We prospectively studied CPET and exercise echo-cardiography characteristics in 39 patients complaining of exertional breathlessness. Patients could be divided into 3 groups as follows: 1) control subjects having normal pulmonary arterial pressure at rest [pulmonary arterial systolic pressure < 35 mmHg] and at peak exercise [pulmonary arterial systolic pressure < 45 mmHg]; 2) patients having exercise-induced PH; 3) patients having resting PH. Results from CPET have been analyzed within each group. RESULTS: Patients developing exercise-induced PH revealed an increased VD/VT ratio and CO2 gradient (P[a-ET]CO2) at peak exercise compared to controls (VD/VT at 0.38 +/- 0.1 vs 0.29 +/- 0.11 and P[a-ET]CO2 at 4,6 +/- 3,1 vs 1 +/- 3,8 mmHg). VD/VT and P[a-ET]CO2 were increased in patients with resting PH. A VD/VT ratio at peak exercise higher than 0.34 was 72.7% sensitive and 71% specific in predicting exercise-induced PH. Positive and negative predictive values were 72.7% and 70.1% respectively. CONCLUSION: Patients with exercise-induced PH did not decrease or may increase dead space during exercise. Therefore CPET may be a useful tool in selecting patients who need to undergo further exercise haemodynamic investigations.

Adaptation, Physiological↗
PubMed1996

[Advancement of management of arrhythmias associated with exercise testing].

Exercise-induced isolated premature contractions occur in healthy subjects, as well as in patients with cardiac disease. On the other hand, the prevalence of exercise-induced supraventricular or ventricular tachycardia is uncommon among most healthy subjects in usual clinical laboratory settings. Significant coronary heart disease may be found in patients who reveals ventricular arrhythmias during the phase of graded exercise testing. The absence of increase of heart rate during submaximal exercise usually suggests sinus node dysfunction. Exercise testing is of value when it comes to assessing the site of AV block in patients with atrioventricular (AV) block. Exercise testing is also useful to clarify arrhythmic implications for various exercise-related complaints and may help to assess risk strafication and effects of interventions. The clinical significance of induction or suppression of arrhythmia during exercise still remains to be investigated.

Arrhythmias, Cardiac↗
PubMed1988

Comparison of dipyridamole-handgrip test and bicycle exercise test for thallium tomographic imaging.

Seventy-three patients with angina pectoris and 20 with atypical chest pain, who underwent coronary angiography, were examined by single-photon emission computed thallium tomography (TI-SPECT) using a combined dipyridamole-handgrip stress test. Perfusion defects were detected in 78 of 81 patients with angiographically significant coronary artery disease (CAD) (sensitivity 96%). In 9 of 12 patients without CAD, the thallium images were normal (specificity 75%). Thirty-five patients with CAD were reexamined by TI-SPECT using a dynamic bicycle exercise stress test. The sensitivity of the dipyridamole-handgrip test did not differ from the bicycle exercise test in diagnosing the CAD (97% vs 94%). Multiple thallium defects were seen in 19 of 22 (86%) patients with multivessel CAD by the dipyridamole-handgrip test but only in 14 of 22 (64%) by the bicycle exercise test. Noncardiac side-effects occurred in 17 of 93 (18%) patients after dipyridamole infusion. Cardiac symptoms were less common during the dipyridamole-handgrip test than during the bicycle exercise (15% vs 76%, p less than 0.01). These data suggest that the dipyridamole-handgrip test is a useful alternative stress method for thallium perfusion imaging, particularly in detecting multivessel CAD.

Angina Pectoris↗
PubMed1998

Transient global amnesia: a complication of incremental exercise testing.

Incremental exercise testing is routinely used for diagnosis, rehabilitation, health screening, and research. We report the case of a 71-yr-old patient with chronic obstructive pulmonary disease (COPD) who suffered an episode of transient global amnesia (TGA) several minutes after successfully completing an incremental exercise test on a cycle ergometer. TGA, which is known to be precipitated by physical or emotional stress in about one-third of cases, is a transient neurological disorder in which memory impairment is the prominent deficit. TGA has a benign course and requires no treatment although 24-h observation is recommended. Recognition of TGA as a potential complication of incremental graded exercise testing is important to both aid diagnosis of the amnesia and to spare a patient unnecessary evaluation.

Aged↗
PubMed1993

A primer in cardiopulmonary exercise testing.

Cardiopulmonary exercise testing is useful in diagnosing the cause of exercise intolerance, in evaluating disability, and in defining the response to therapy. This testing modality is firmly founded on physiological principles. An efficient interaction of the body's systems is required to transport oxygen to the exercising muscles; failure of any system will yield characteristic changes in the ventilatory and gas exchange responses to exercise. An important measurement to make during exercise testing is the work rate at which oxygen transport begins to be inadequate. This work rate, known as the anaerobic threshold, is marked by a rise in blood lactate, and can be estimated noninvasively by examination of gas exchange responses during incremental exercise. In recent years, computerized systems and improved transducers have been introduced to facilitate breath-by-breath measurements during exercise testing. These systems also facilitate calibration, data presentation and report generation, making cardiopulmonary exercise testing a practical testing modality.

Anaerobic Threshold↗
PubMed2004

One-minute heart rate recovery after cycloergometer exercise testing as a predictor of mortality in a large cohort of exercise test candidates: substantial differences with the treadmill-derived parameter.

BACKGROUND: Previous work showed a strong inverse association between 1-min heart rate recovery (HRR) after exercising on a treadmill and all-cause mortality. The aim of this study was to determine whether the results could be replicated in a wide population of real-world exercise ECG candidates in our center, using a standard bicycle exercise test. METHODS: Between 1991 and 1997, 1420 consecutive patients underwent ECG exercise testing performed according to our standard cycloergometer protocol. Three pre-specified cut-point values of 1-min HRR, derived from previous studies in the medical literature, were tested to see whether they could identify a higher-risk group for all-cause mortality; furthermore, we tested the possible association between 1-min HRR as a continuous variable and mortality using logistic regression. RESULTS: Both methods showed a lack of a statistically significant association between 1-min HRR and all-cause mortality. A weak trend toward an inverse association, although not statistically significant, could not be excluded. CONCLUSIONS: We could not validate the clear-cut results from some previous studies performed using the treadmill exercise test. The results in our study may only "not exclude" a mild inverse association between 1-min HRR measured after cycloergometer exercise testing and all-cause mortality. The 1-min HRR measured after cycloergometer exercise testing was not clinically useful as a prognostic marker.

Adult↗
PubMed2002

The relationship between left ventricular function assessed by multigated radionuclide test and cardiopulmonary exercise test in patients with ischemic heart disease.

STUDY OBJECTIVES: To compare the oxygen pulse curve (O(2)P-C) as measured during cardiopulmonary exercise testing (CPET) with left ventricular (LV) ejection fraction (LVEF) rest-exercise response as measured by multigated equilibrium (99m)Tc radionuclide cineangiography (MUGA) in patients with different degrees of ischemic heart disease (IHD). PATIENTS: Forty-six patients (39 men and 7 women; mean plus minus 1 SD age, 59.2 plus minus 11 years) with IHD, with no hypertrophic, valvular, or pericardial disease. METHODS: A supine bicycle ergometer with increments of 25 W every 2 min was used for MUGA, and an electronically braked cycle ergometer was used for upright symptoms-limited CPET. Exercise was increased by 10 to 20 W/min until the target heart rate (HR) was reached (similar peak HR for both studies). MEASUREMENTS AND RESULTS: The O(2)P-C was scored on a 10-point scale as follows: type A, normal curve (10 points); type B, normal-shaped curve with low values (8 points); type C, low and flat curve (5 points); type D, descending curve (3 points). Findings for the MUGA study were classified into four groups by the degree of ischemic response: group 1 (control), normal diastolic function (n = 10), LVEF > 55%, LVEF during exercise minus LVEF at rest [DeltaLVEF] greater-than-or-equal 5%; group 2, mild ischemia (n = 10), LVEF > 55%, < 0 DeltaLVEF < 5%, diastolic dysfunction at exercise (prominent "A" waves); group 3, LV dysfunction (n = 9), LVEF < or = 35% at rest; and group 4, significant ischemia (n = 17), LVEF > 55%, DeltaLVEF < 0, diastolic dysfunction. A highly significant relationship between the O(2)P-C score and the MUGA grouping was observed by Fisher's Exact Test and Pearson's linear regression line (p < 0.001; R = - 0.89). CONCLUSIONS: Exercise-responded O(2)P-C might serve as a good noninvasive, physiologically based, parameter to distinguish between IHD patients with normal and impaired LV function.

Adult↗
PubMedDate not supplied

Comparative value of arm and leg exercise testing.

Arm exercise test (AET) is described as an alternative to the classical leg exercise test (LET). The value of these two types of exercise was studied in a group of 32 patients aged 34 to 65 years. The patients performed LET for several reasons and, after 24 hrs, AET under the same conditions. The effort level reached under LET was always greater than that achieved under AET and the calculated functional aerobic impairment (FAI) was 50% greater during AET thus supporting the idea that AET cannot be used instead of LET in determining the functional capacity (NYHA) of cardiac patients. However, AET remains useful for the determination of the occupational working capacity in certain occupational categories. The double product (DP) (or index tension time (ITT) calculated after AET represented 85% of the calculated value after LET. The results proved that MVO2 is similar for both LET and AET, but in the latter at lower levels of exercise (VO2). The LET-DP was greater than the AET-DP in 66.5% of our cases, thus suggesting that AET should be reserved for situations in which LET cannot be performed. This is also supported by the presence of ST depression during AET in only 66% of the 18 subjects with ST depression during LET and in five of the six patients without ST depression, DP-AET was lower than DP-LET.

Adult↗
PubMed1988

A real-time data-logger system using an optical disk WORM for archiving continuous 12-lead ECG data during exercise testing.

An exercise ECG analysis program was developed over 15 years on a number of mainframes, minicomputers and, most recently, microcomputer-based systems. It has been rehosted into both Motorola MC68000 and Intel 80286 microprocessor-based development systems and is currently used with a removable 200 Mbyte optical disk (Write-Once-Read-Many, WORM) based data-logger system that can record and store all 12 leads simultaneously and continuously for an entire exercise test (up to 38 minutes). Data is acquired with 12-bit A/D resolution at 500 samples/sec. All ECG data and patient information are archived on the optical disk for later off-line recall and analysis on a PC or real-time replay through a D/A converter. Recorded ECG signals are at patient levels so they can be replayed through the patient cable box on any commercial system. Current development includes both simultaneous on-line processing and storage of 12-lead ECG data and off-line processing and development performed on the long-term, continuous ECG data being archived on optical disk. Patient medical histories and clinical information are separately entered into an applications database, where ECG measures and test results are later included. This new optical disk based exercise ECG database contains more than 600 complete exercise tests and is projected to increase to nearly 3,000 within 2 years.

Computer Systems↗
PubMed1991

Prediction of the frequency and duration of ambulatory myocardial ischemia in patients with stable coronary artery disease by determination of the ischemic threshold from exercise testing: importance of the exercise protocol.

The relation between ambulatory myocardial ischemia and the results of exercise testing in patients with ischemic heart disease remains undefined, because of the dissimilar results of previous reports. To further investigate this issue and, in particular, to ascertain the importance of the exercise protocol in determining that relation, 70 patients with stable coronary artery disease underwent 48 h ambulatory electrocardiographic (ECG) monitoring and treadmill exercise tests after withdrawal of medications. Patients exercised using two different protocols with slow (National Institutes of Health [NIH] combined protocol) and brisk (Bruce protocol) work load increments. Exercise duration was longer with the NIH combined protocol (14.1 +/- 5 versus 6.8 +/- 2 min; p less than 0.0001), but the maximal work load and peak heart rate achieved were greater with the Bruce protocol (9.8 +/- 2 versus 6.5 +/- 2 METs, and 142 +/- 19 versus 133 +/- 22 beats/min, respectively; p less than 0.0001). A close inverse correlation between exercise testing and the results of ambulatory ECG monitoring was observed using the NIH combined protocol; the strongest correlation was observed between time of exercise at 1 mm of ST segment depression and number of ischemic episodes (r = -0.86; p less than 0.0001). With the Bruce protocol a significantly weaker inverse correlation was found (r = -0.35). The mean heart rate at the onset of ST segment depression was similar during monitoring and during exercise testing with the NIH combined protocol (97.2 +/- 13 versus 101.0 +/- 17 beats/min, respectively) but it was significantly higher (110.4 +/- 13) when using the Bruce protocol (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2005

Anginal threshold between stress tests: exercise versus dobutamine stress echocardiography.

PURPOSE: Dobutamine echocardiography (DOB) can be substituted to exercise testing when necessary for clinical reasons. Current literature suggests DOB is maximal when 85% of maximal predicted heart rate (%PHR) is achieved (similar to EX), but there is little evidence to determine whether this target has the same clinical significance as during EX. We therefore performed this study to compare the ischemic threshold between EX and DOB. METHODS: Twenty men with stable angina underwent in a random order DOB and EX echocardiograms after being weaned off their cardiac medications. Electrocardiography, heart rate (HR), and systolic blood pressure were recorded every minute. Ischemic threshold was defined as the precise time at which clinical angina occurred. RESULTS: Anginal threshold appeared consistently at a higher level for DOB than EX as evidenced by the higher rate-pressure product (RPP) values (22,492 +/- 4,300 vs 20,371 +/- 5,367 bpm x mm Hg, DOB vs EX, respectively, P = 0.02), HR (126 +/- 23 vs 119 +/- 15 bpm, P = 0.01), and %PHR (79 +/- 15% vs 74 +/- 10%, P < 0.01). Thirty-two percent of the subjects presented an ischemic HR above 85% of PHR and 60% had a higher ischemic HR during DOB versus EX. CONCLUSIONS: This study shows that estimation of anginal threshold during DOB is feasible and is slightly higher (approximately 10%) than during EX. Extrapolation of a cut off target heart rate from an exercise modality to a pharmaceutical one may not be valid.

Angina Pectoris↗
PubMed2000

[Guidelines of the Spanish Society of Cardiology for clinical practice in exercise testing].

Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain. This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.

Adult↗
PubMed2002

Impact of periodic breathing on measurement of oxygen uptake and respiratory exchange ratio during cardiopulmonary exercise testing.

Metabolic exercise testing is valuable in patients with chronic heart failure (CHF), but periodic breathing may confound the measurements. We aimed to examine the effects of periodic breathing on the measurement of oxygen uptake ( V*O(2)) and respiratory exchange ratio (RER). First, we measured the effects of different averaging procedures on peak V*O(2) and RER values in 122 patients with CHF undergoing cardiopulmonary exercise testing. Secondly, we studied the effects of periodic breathing on V*O2) and RER in healthy volunteers performing computer-guided periodic breathing. Thirdly, we used a Fourier analysis to study the effects of periodic breathing on gas exchange measurements. The first part of the study showed that 1 min moving window gave a mean peak V*O(2) of 13.8 ml.min(-1).kg(-1) for the CHF patients. A 15 s window gave significantly higher values. The difference averaged 1.0 ml.min(-1).kg(-1) ( P <0.0001), but varied widely: 41% of subjects showed a difference greater than 1.0 ml.min(-1).kg(-1). RER values were also higher by an average of 0.09 ( P <0.0001); in 20% of subjects the difference was greater than 0.10. In the second part of the study, we found artefactual elevations of peak V*O(2) (without averaging) of 2.9 ml.min(-1).kg(-1) ( P <0.01) and of peak RER of 0.13 ( P <0.001), which were still significant when 30 s averaging was applied [delta(peak V*O(2))=1.8 ml.min(-1).kg(-1), P <0.01; deltaRER=0.08, P <0.001]. The third, theoretical, part of the study showed that values of carbon dioxide output and V*O(2) oscillate with different phases and amplitudes, resulting in oscillations in their ratio, RER. Averaging over 15 s or 30 s can be expected to give only 10% or 36% attenuation respectively. Thus periodic breathing causes variable artefactual elevations of measured peak V*O(2) and RER, which can be attenuated by using longer averaging periods. Clinical reports and research publications describing peak V*O(2) in CHF should be accompanied by details of the averaging technique used.

Adult↗
PubMed1988

Exercise testing after myocardial infarction: relative values of the low level predischarge and the postdischarge exercise test.

This study was undertaken to compare the relative values of the low level predischarge exercise test and the postdischarge (6 weeks) symptom-limited test in 518 consecutive patients admitted with an acute myocardial infarction. Of the patients who did not develop significant ST segment depression or angina during the predischarge test, the symptom-limited test also remained negative in 91.5 and 91.9% of the patients, respectively. Similar results were obtained with ST segment elevation and the systolic blood pressure response during the two exercise tests with only 2.1 and 11.4% changing from normal to abnormal, respectively. Discriminant function analysis was done to predict the occurrence of coronary events (unstable angina, reinfarction, cardiac failure, cardiac death) with use of the data from the exercise tests together with other clinical and investigational data. The jackknife method correctly classified 71.9 and 71.4% of the patients with the data from the predischarge exercise test and symptom-limited test, respectively. Combining the data from the two tests improved the overall predictive accuracy to only 75.0%. It is concluded that the routine performance of a symptom-limited test 6 to 8 weeks after infarction does not reveal any significant additional information in those patients who have undergone a predischarge low level exercise test. Thus the 6 to 8 week test should be restricted to selected patients after myocardial infarction.

Adult↗