Individuals who contract coronavirus disease 2019 (COVID-19) can suffer with persistent and debilitating symptoms long after the initial acute illness. Heart rate (HR) profiles determined during ...cardiopulmonary exercise testing (CPET) and delivered as part of a post-COVID recovery service may provide insight into the presence and impact of dysautonomia on functional ability.
Using an active, working-age, post-COVID-19 population, the purpose of this study was to (1) determine and characterize any association between subjective symptoms and dysautonomia; and (2) identify objective exercise capacity differences between patients classified "with" and those "without" dysautonomia.
Patients referred to a post-COVID-19 service underwent comprehensive clinical assessment, including self-reported symptoms, CPET, and secondary care investigations when indicated. Resting HR >75 bpm, HR increase with exercise <89 bpm, and HR recovery <25 bpm 1 minute after exercise were used to define dysautonomia. Anonymized data were analyzed and associations with symptoms, and CPET outcomes were determined.
Fifty-one of the 205 patients (25%) reviewed as part of this service evaluation had dysautonomia. There were no associations between symptoms or perceived functional limitation and dysautonomia (P >.05). Patients with dysautonomia demonstrated objective functional limitations with significantly reduced work rate (219 ± 37 W vs 253 ± 52 W; P <.001) and peak oxygen consumption (V̇o
: 30.6 ± 5.5 mL/kg/min vs 35.8 ± 7.6 mL/kg/min; P <.001); and a steeper (less efficient) V̇e/V̇co
slope (29.9 ± 4.9 vs 27.7 ± 4.7; P = .005).
Dysautonomia is associated with objective functional limitations but is not associated with subjective symptoms or limitation.
Chronic obstructive pulmonary disease (COPD) is characterised by reduced exercise tolerance and improving physical performance is an important therapeutic goal. A variety of exercise tests are ...commonly used to assess exercise tolerance, including laboratory and field-based tests. The responsiveness of these tests to common COPD interventions is yet to be compared, but may inform test selection in clinical and research settings.
What exercise test possesses the greatest sensitivity to change pre- to post-intervention in patients with COPD?
154 patients with symptomatic COPD were recruited and randomised (2:1:1) to six weeks of long-acting muscarinic antagonist (LAMA), pulmonary rehabilitation (PR), or usual care (UC). Pre- and post-intervention, participants performed a ramp-incremental and constant work rate cycle ergometer exercise test (ICET and CWRCT), incremental and endurance shuttle walk test (ISWT and ESWT), six-minute walk test (6MWT), and a four metre gait speed test (4MGS).
103 participants (67 ± 8 y; 75 73% males; FEV1: 50.6 ± 16.8 % predicted) completed the study. Significant improvements in the ICET, CWRCT, ISWT, ESWT, and 6MWT were observed following PR (p<0.05), with the greatest improvements seen in the constant work rate protocols (% change: CWRCT: 42%; ESWT: 41%).
The ESWT and CWRCT appeared to be the most responsive exercise test protocols to LAMA and PR. The magnitude of change was much greater after a programme of rehabilitation compared to bronchodilator therapy.
Skeletal muscle power has been demonstrated to be a stronger predictor of functional limitations than any other physical capability. However, no validated alternatives exist to the usually expensive ...instruments and/or time-consuming methods to evaluate muscle power in older populations. Our aim was to validate an easily applicable procedure to assess muscle power in large cohort studies and the clinical setting and to assess its association with other age-related outcomes.
Forty community dwelling older adults (70–87 years) and 1804 older subjects (67–101 years) participating in the Toledo Study for Healthy Aging were included in this investigation. Sit-to-stand (STS) velocity and muscle power were calculated using the subject's body mass and height, chair height and the time needed to complete five STS repetitions, and compared with those obtained in the leg press exercise using a linear position transducer. In addition, STS performance, physical (gait speed) and cognitive function, sarcopenia (skeletal muscle index (SMI)) and health-related quality of life (HRQoL) were recorded to assess the association with the STS muscle power values.
No significant differences were found between STS velocity and power values and those obtained from the leg press force-velocity measurements (mean difference ± 95% CI = 0.02 ± 0.05 m·s−1 and 6.9 ± 29.8 W, respectively) (both p > 0.05). STS muscle power was strongly associated with maximal muscle power registered in the leg press exercise (r = 0.72; p < 0.001). In addition, cognitive function and SMI, and physical function, were better associated with absolute and relative STS muscle power, respectively, than STS time values after adjusting by different covariates. In contrast, STS time was slightly more associated with HRQoL than STS muscle power measures.
The STS muscle power test proved to be a valid, and in general, a more clinically relevant tool to assess functional trajectory in older people compared to traditional STS time values. The low time, space and material requirements of the STS muscle power test, make this test an excellent choice for its application in large cohort studies and the clinical setting.
•Sit-to-stand power was calculated from: sit-to-stand time, chair height, body mass and height.•Sit-to-stand power was similar to that obtained from a validated instrument in the leg press exercise.•Sit-to-stand power was independently associated with physical and cognitive function, sarcopenia and quality of life.
There is a consistent relationship between physical activity, physical fitness, and health across almost all clinical contexts, including the perioperative setting. Physiological measurements ...obtained during physical exercise may be used to infer the risk of adverse outcome after major surgery. In particular, data obtained from perioperative cardiopulmonary exercise testing have an expanding role in perioperative care. Such information may be used to inform a variety of changes in clinical practice, including interventions that may reduce the risk of perioperative adverse events. Specifically, for patients undergoing major cancer surgery there is a complex interplay between different cancer treatments, including neoadjuvant therapies (chemo- and chemo- plus radiotherapy), surgery, and physical fitness, and the modulation of these relationships by perioperative exercise interventions. Preoperative cardiopulmonary exercise testing provides an objective evaluation of physical fitness and has been used to provide an individualized risk profile in order to guide collaborative decision-making, inform the consent process, characterize and optimize co-morbidities, and to triage patients to perioperative care. Furthermore, studies evaluating exercise interventions aimed at increasing preoperative exercise capacity have established that training improves physical fitness. However, to date, this literature is largely composed of feasibility and pilot studies with small sample sizes, which are in general underpowered to assess clinical outcomes. Adequately powered prospective multicentre studies are needed to characterize the most effective means of improving patient fitness before surgery and to evaluate the impact of such improvements on surgical and disease-specific (e.g. cancer) outcomes.
To improve preoperative risk stratification in lung cancer lobectomy by identifying and comparing optimal thresholds for peak oxygen uptake (VO2peak) presented as weight-indexed and percent of ...predicted values, respectively.
This was a longitudinal cohort study including national registry data on patients scheduled for cancer lobectomy that used available data from preoperative cardiopulmonary exercise testing. The measured VO2peak was indexed by body mass (mL/kg/min) and also compared with 2 established reference equations (Wasserman-Hansen and Study of Health in Pomerania, respectively). By receiver operating characteristic analysis, a lower 90% specificity and an upper 90% sensitivity threshold were determined for each measure, in relation to the outcome of any major complication or death. For each measure and based on these thresholds, patients were categorized as low risk, intermediate risk, or high risk. The frequency of complications was compared between groups using χ2.
The frequency of complications differed significantly between the proposed low-, intermediate-, and high-risk groups when using % predicted Study of Health in Pomerania (5%, 21%, 35%, P = .007) or % predicted Wasserman-Hansen (5%, 25%, 35%, P = .002) but not when using the weight-indexed VO2peak groups (7%, 23%, 15%, P = .08). Nonsignificant differences were found using the threshold <15 mL/kg/min (P = .34).
This study showed that weight-indexed VO2peak was of less use as a marker of risk at the lower range of exercise capacity, whereas % predicted VO2peak was associated with a continuously increasing risk of major complications, also at the lower end of exercise capacity. As identifying subjects at high risk of complications is important, % predicted VO2peak is therefore preferable.
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Invasive cardiopulmonary exercise testing (iCPET) combines traditional cardiopulmonary exercise testing with invasive hemodynamic measurements to assess exercise intolerance, which can be caused by ...preload insufficiency (PI), characterized by low ventricular filling pressures and reduced cardiac output during exertion. We hypothesize that plasma catecholamine levels at rest and during exercise correlate with hemodynamic parameters in PI.
We included adult patients who underwent iCPET for exercise intolerance and had plasma catecholamines measured at rest and peak exercise.
Among 84 patients, PI was identified in 57 (67.8%). Compared to patients without PI, those with PI were younger median (IQR) 37 (28, 46) vs 47 (39,55) years, p=0.005 and had lower workload at peak exercise 81 (66, 96) vs 95 (83.5, 110.50) Watts, p=0.006. Patients with PI had higher heart rates at rest and peak exercise 87 (78, 97) vs 79 (74, 87) bpm, p=0.04; and 167 (154, 183) vs 156 (136, 168) bpm, p=0.01, respectively. In all patients, epinephrine and norepinephrine at peak exercise directly correlated with peak workload (r:0.41, p<0.001 and r:0.47, p<0.001, respectively). Resting epinephrine was higher in patients with PI 136 (60, 210) vs 77 (41, 110) pg/mL, p=0.02. There was no significant difference in the change in catecholamines from rest to peak exercise between patients with or without PI.
PI patients exhibited elevated heart rate and epinephrine at rest, indicating increased sympathetic activity. We did not find strong associations between catecholamines and cardiac filling pressures, suggesting that catecholamine levels are predominantly influenced by peak workload.
•Preload insufficiency (PI) is a growingly recognized cause of exercise intolerance•Invasive cardiopulmonary exercise testing can help diagnose PI•Epinephrine and norepinephrine levels correlate with peak workload during exercise•PI patients have higher resting epinephrine levels, indicating sympathetic activity•Catecholamine levels at peak exercise were similar in those with or without PI
•People with COPD had higher levels of all breathlessness sensations during exercise.•Intensity of breathlessness sensations was related to inspiratory reserve volume.•Critically low levels of ...inspiratory reserve volume occurred at low minute ventilation in COPD.•All groups rated work/effort of breathing higher than unsatisfied inspiration.•Only people with COPD reported moderate breathlessness-related fear and anxiety.
This study compared the multidimensional breathlessness response to incremental cardiopulmonary cycle exercise testing (CPET) in people with chronic obstructive pulmonary disease (COPD; n = 14, aged 69 ± 9 years, forced expiratory volume in 1-sec = 54 ± 16 % predicted) and healthy older (OA) (n = 35, aged 68 ± 5 years) and younger (YA) (n = 19, aged 28 ± 8 years) adults. Participants performed CPET and successively rated overall breathlessness intensity, unsatisfied inspiration, breathing too shallow, work/effort of breathing, and breathlessness-related unpleasantness, fear, and anxiety using the 0−10 Borg scale. At any given percent predicted peak minute ventilation, people with COPD rated all breathlessness sensations higher than OA and YAs, who were similar. Most between group differences disappeared when examined in relation to inspiratory reserve volume, except people with COPD reported higher levels of unsatisfied inspiration and breathing too shallow (vs YA), and breathlessness-related fear and anxiety (vs OA and YAs). Multidimensional ratings of breathlessness sensations during CPET provides further insight into differences in exertional symptom perceptions among people with COPD and without COPD.
Peak exercise cardiac output (CO) increase is associated with an increase of peak oxygen uptake (VO2), provided that arteriovenous O2 difference Δ(Ca−Cv)O2 does not decrease. At anaerobic threshold, ...VO2, is related to CO.
We tested the hypothesis that, in heart failure (HF) patients with left ventricular assistance device (LVAD), an acute increase of CO obtained through changes in LVAD pump speed is associated with peak exercise and anaerobic threshold VO2 increase.
Fifteen of 20 patients bearing LVAD (Jarvik 2000) enrolled in the study successfully performed peak exercise evaluation. All patients had severe HF as shown by clinical evaluation, laboratory tests, echocardiography, spirometry with alveolar-capillary diffusion, and maximal cardiopulmonary exercise testing (CPET). CPETs with non-invasive CO measurements at rest and peak exercise were done on 2days at LVAD pump speed set randomly at 2 and 4.
Increasing LVAD pump speed from 2 to 4 increased CO from 3.4±0.9 to 3.8±1.0L/min (ΔCO 0.4±0.6L/min, p=0.04) and from 5.3±1.3 to 5.9±1.4L/min (ΔCO 0.6±0.7L/min, p<0.01) at rest and peak exercise, respectively. Similarly, VO2 increased from 788±169 to 841±152mL/min (ΔVO2 52±76mL/min, p=0.01) and from 568±116 to 619±124mL/min (ΔVO2 69±96mL/min, p=0.02) at peak exercise and at anaerobic threshold, respectively. Δ(Ca−Cv)O2 did not change significantly, while ventilatory efficiency improved (VE/VCO2 slope from 39.9±5.4 to 34.9±8.3, ΔVE/VCO2 −5.0±6.4, p<0.01).
In HF, an increase in CO with a higher LVAD pump speed is associated with increased peak VO2, postponed anaerobic threshold, and improved ventilatory efficiency.
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