Cardiopulmonary Stress Testing: Beyond Transplant Evaluation
Ross Arena, PhD, PT, FAHA, FESC, FACSM
Professor and Head
College of Applied Health Sciences
University of Illinois at Chicago
Left Atrium-Ventricle
Skeletal Muscle
Right Atrium-Ventricle
Cardio-
Pulmonary
Interface
CO
2
CO2
O2
O2
CO2
O2
Pu
lmon
ary
Art
eria
l C
ircu
it
Pulmonary Venous Circuit
Systemic Venous Circuit
System
ic Arteria
l Circu
it
Chemo/
Ergo Receptor and ANS Balance
Myers et al, Curr Prob in Card, In Press
Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a
Clinical Vital Sign: A Scientific Statement From the American Heart Association
by Robert Ross, Steven N. Blair, Ross Arena, Timothy S. Church, Jean-Pierre Després, Barry A. Franklin, William L. Haskell, Leonard
A. Kaminsky, Benjamin D. Levine, Carl J. Lavie, Jonathan Myers, Josef Niebauer, Robert Sallis, Susumu S. Sawada, Xuemei Sui, and
Ulrik Wisløff
CirculationVolume 134(24):e653-e699
December 13, 2016
Copyright © American Heart Association, Inc. All rights reserved.
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The value of gas exchange beyond aerobic capacity
The real why.
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Ventilatory Efficiency
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Pinkstaff SO, Burger CD, Daugherty J, Bond S, Arena R. Guidelines for the Use
of Cardiopulmonary Exercise Testing in Patients with Pulmonary Hypertension:
Evidence-Based Recommendations. Expert Review of Respiratory Medicine.
2016;10(3):279-95.
The relationship between pulmonary hypertension pathophysiology and cardiopulmonary exercise testing markers
Comparison between normal and abnormal pulmonary arterial vessel
response to exercise: implications for cardiac output with an acute
exercise stimulus and right ventricular function with chronic exercise
Arena R, Lavie CJ, Borghi-Silva A, Daugherty J, Bond S, Phillips SP, Guazzi M. Exercise training in group 2 pulmonary hypertension: Which intensity and what modality. Progress in Cardiovascular Disease. 2016 Jul-Aug;59(1):87-94.
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What is limiting clinical application and value?
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Normal
PAH
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One dimensional Three dimensional
VO2VO2VCO2VEMore
Copyright © American Heart Association
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The Essentials
Aerobic Performance
Ventilatory Efficiency
Pulmonary Function
Hemodynamics
ECG
Subjective Scales
Universal CPX Reporting Form
Normal (dashed line) and abnormal (solid line) example of oxygen pulse and ΔVo2/ΔW plots
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
Examples of normal ventilatory pattern (top panel) and exercise oscillatory ventilation pattern (bottom panel)
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
Flow Volume Loops
21Copyright © American Heart Association
Heart Failure
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
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Unexplained Exertional Dyspnea
Guazzi M et al. Circulation and EHJ 2016
Copyright © American Heart Association
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Improved Resolution for Unexplained Dyspnea
Flow limitation: Flow rate during exercise = PFT flow rate
Dynamic Hyperinflation: Increase in end expiratory lung volume (i.e. exercise induced air trapping)
Suspected or Confirmed PAH/Secondary PH
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
Confirmed or Suspected HCM
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
Prognostic and Diagnostic Stratification for Patients With COPD or ILD.
Guazzi M et al. Circulation 2016 Circulation and EHJ
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Suspected Myocardial Ischemia
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
Suspected Mitochondrial Myopathy
Guazzi M et al. Circulation 2012;126:2261-2274
Copyright © American Heart Association
Presurgical Assessment
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Guazzi M et al. Circulation 2016 Circulation and EHJ
Valvular Heart Disease/Dysfunction
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Guazzi M et al. Circulation 2016 Circulation and EHJ
Apparently Healthy Individuals
37Guazzi M et al. Circulation 2016 Circulation and EHJ
Rating Evidence and Clinical Recommendations
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Level of Prognostic SignificanceE
vid
en
ce
of
Ce
rta
inty
(P
rec
isio
n)
of
Pro
gn
os
tic
Va
lue
Class I
Assessment/Measure(s)
clearly prognostic
Assessment SHOULD be
performed or administered
Class IIa
Assessment/Measure(s) likely
prognostic
Several Additional Level A
studies needed
IT IS REASONABLE to perform
or administer assessment
Class IIb
Assessment/Measure(s)
may be prognostic
Greater number of additional
Level A and B (preferably A)
studies needed
Assessment MAY BE be
performed or administered
Class III No benefit or
Class III Harm
No Benefit:Assessment/measure(s)
not prognostic
Harm: Assessment/measure(s)
excess cost without prognostic
insight or harmful
LEVEL A
Multiple populations
evaluated
Data derived from
multiple prospective
outcomes databases
or meta-analyses
Recommendation that
assessment/measure(s) is
useful/effective
Sufficient evidence from
multiple prospective
outcomes databases or
meta-analyses
Recommendation in favor of
assessment/measure(s) being
useful/effective
Some conflicting evidence from
multiple prospective outcomes
databases or meta-analyses
Recommendation’s
usefulness/efficacy less well
established
Greater conflicting evidence
from multiple prospective
outcomes databases or
meta-analyses
Recommendation that
assessment/measures(s) not
useful/effective and may be harmful
Sufficient evidence from multiple
prospective outcomes databases or
meta-analyses
LEVEL B
Limited populations
evaluated
Data derived from
single prospective
outcomes database or
retrospective
databases
Recommendation that
assessment/measure(s) is
useful/effective
Evidence from single
prospective outcomes
databases or retrospective
outcomes databases
Recommendation in favor of
assessment/measure(s) being
useful/effective
Some conflicting evidence from
single prospective outcomes
databases or retrospective
outcomes databases
Recommendation’s
usefulness/efficacy less well
established
Greater conflicting evidence
from single prospective
outcomes databases or
retrospective outcomes
databases
Recommendation that
assessment/measures(s) not
useful/effective and may be harmful
Evidence from single prospective
outcomes databases or
retrospective outcomes databases
LEVEL C
Very limited
populations evaluated
Only consensus
opinion of experts,
small outcomes
databases, or standard
of care
Recommendation that
assessment/measure(s) is
useful/effective
Only expert opinion, small
outcomes databases, or
standard of care
Recommendation in favor of
assessment/measure(s) being
useful/effective
Only diverging expert opinion,
small outcomes databases, or
standard of care
Recommendation’s
usefulness/efficacy less well
established
Only diverging expert
opinion, small outcomes
databases, or standard of
care
Recommendation that
assessment/measures(s) not
useful/effective and may be harmful
Only expert expert opinion, small
outcomes databases, or standard of
care
Suggested phrases
for writing
recommendations
Should
Is recommended
Is indicated
Is useful/effective/beneficial
Is reasonable
Can be
useful/effective/beneficial
Is probably recommended or
indicated
May/might be considered
May/might be reasonable
Usefulness/effectiveness is
unknown/unclear/uncertain
or not well established
No Benefit
Is not recommended
Is not indicated
Should not be
performed/administered/other
In not useful/beneficial/effective
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Class I Class IIa Class IIb Class III
CPX is clearly:
prognostic/diagnostic
CPX clearly:
gauges therapeutic
efficacy
CPX:
- Should be performed
- Is recommended
- Is Indicated
- Is Useful
- Is Effective
- Is Beneficial
CPX is likely:
prognostic/diagnostic
CPX likely:
gauges therapeutic
efficacy
CPX:
- Is probably
recommended
- Is probably indicated
- Can be useful
- Can be effective
- Can be beneficial
CPX may be:
prognostic/diagnostic
CPX may:
gauge therapeutic efficacy
CPX:
- May be considered
- May be reasonable
- Usefulness is unknown
- Usefulness is unclear
- Usefulness is uncertain
- Usefulness is not well
established
CPX is not:
prognostic/diagnostic
CPX does not:
gauge therapeutic
efficacy
CPX:
- Has no benefit
- Is not recommended
- Is not indicated
- Should not be performed
- Should not be
administered
- Is not useful
- Is not beneficial
- Is not effective
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Future Considerations
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Refining the Algorithms
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Based of Hazard RatioVE/VCO2 slope = 7HRR = 5OUES = 3PETCO2 = 2Peak VO2 = 2
Submaximal Testing
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OUES
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Translation from Science to Practice
http://www.ncats.nih.gov/research/cts/cts.html
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Lab of the Future: Comprehensive Functional Assessment
IMS&E
MFP&E
CPX
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