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Cardiopulmonary Exercise Testing
Mahesh J. Patel, MD
Case Presentation	
  
•  41 y/o WM presents with DOE x 2 months. 2 ER visits with
negative work-ups. Ruled out for MI, PE,...
Exercise Test	
  
•  Exercise Time – 10 minutes, 54 seconds
•  Test stopped due to SOB
•  Max HR 164 bpm and BP 211/89 mmH...
Is his fitness level normal ?	
  
•  41 y/o man with BMI 30.1 kg/m2
•  Peak estimated METs – 10.9
CPET	
  
•  Peak VO2 was 74% of predicted norms.
•  Mild impairment due to deconditioning
•  Norms in this case are from a...
•  Exercise Physiology
•  Basics of CPX interpretation
Outline	
  
Cardiopulmonary Exercise Testing
•  Standard EKG stress test
combined with metabolic gas
exchange analysis
•  Gold standar...
Oxygen Uptake (VO2)
•  Coupling cellular to ventilatory respiration
•  VO2 = Cardiac Output * (CaO2 – CvO2)
The Fick Principle
VO2	
 (Oxygen	
 Uptake)	
 =	
 Cardiac	
 Output	
 *	
 Hb	
 *	
 AVO2	
 
	
 
Resting	
 VO2	
 =	
 3.5	
 mL	...
Approximate
Metabolic Equivalents (METs)
Physical	
  ac*vity	
   	
   	
   	
   	
   	
   	
   	
   	
  METs	
  
	
  
Ligh...
Cardiorespiratory Fitness (VO2Max)
Range of Max VO2
	
 
	
 
	
 
Rest	
  
3.5	
  
HF	
  
10-­‐15	
  
CABG	
  
20-­‐25	
  
60	
  yr.	
  Fit	
  
30-­‐35	
  
Col...
CPX Test can be used to discriminate
between circulatory, pulmonary, and
peripheral etiologies of DOE
•  Coupling cellular...
VO2 = CO • AVO2 difference
VO2 = SV • HR • AVO2 difference
VO2 = EDV • EF • HR • AVO2 difference
VO2 = EDV – ESV • HR •Hb ...
Skeletal Muscle Physiology	
  
Comparing	
  equa*ons	
  for	
  es*ma*ng	
  
peak	
  VO2	
  
•  ACSM: [(mph)(26.8)](0.1) = “x”
“x” * 0.1 = “y”
(Grade)(x)(...
Case	
  Study	
  for	
  Comparison	
  
	
  
•  63 y.o male
•  Achieved 5 mph with 9.5% grade
Direct Wasserman Myers Astran...
VO2 pattern on a fixed workload
of exercise	
  
Start	
  
exercise	
  
Stop	
  
exercise	
  
VO2 pattern on increasing levels
of workload	
  
	
  
VO2	
  
	
  
Exercise Time on fixed workload	
  
What Does Fitness Info Tell Us ?
•  A reflection of overall physiological health
and function, especially the cardiovascula...
Fitness & CV Mortality
Blair JAMA 1989
0
1
2
3
4
5
6
7
8
9
10
1st 2nd 3rd 4th 5th
Women
Men
Increasing cardiopulmonary fitn...
VCO2 / VO2
•  Respiratory	
 exchange	
 ratio	
 (RER)	
 
•  Reflects	
 %	
 aerobic	
 vs.	
 %	
 anaerobic	
 
metabolism	
 by	...
Anaerobic Threshold
•  Class I indications - (good evidence)
–  1. Evaluate exercise capacity and response to therapy in
heart failure patient...
Gas	
  Exchange	
  Report	
  
Nine	
  Panel	
  Plot	
  
Circulation 122:191-225, 2010
AHA Evaluation Paradigm	
  
Circulation 122:191-225, 2010
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Cardiopulmonary Exercise Testing / Exercise Physiology

Mahesh Patel, MD
Duke University Medical Center

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Cardiopulmonary Exercise Testing / Exercise Physiology

  1. 1. Cardiopulmonary Exercise Testing Mahesh J. Patel, MD
  2. 2. Case Presentation   •  41 y/o WM presents with DOE x 2 months. 2 ER visits with negative work-ups. Ruled out for MI, PE, and CHF. •  No regular exercise but he is a paramedic and has 2 kids and so tells me he is very active and on his feet all the time. •  PMH: HTN, OSA, & Dyslipidemia (low HDL-C) •  Meds: losartan and metoprolol •  PE – BP 142/72, HR 70, height 68 inches, weight 202 lbs, BMI 30.9 kg/m2 with increased waist circumference •  Testing – EKG, CXR, cardiac MRI all normal
  3. 3. Exercise Test   •  Exercise Time – 10 minutes, 54 seconds •  Test stopped due to SOB •  Max HR 164 bpm and BP 211/89 mmHg •  Peak speed 3.6 mph & 18 degree incline •  No ischemia by ECG •  Peak estimated METs - 10.9
  4. 4. Is his fitness level normal ?   •  41 y/o man with BMI 30.1 kg/m2 •  Peak estimated METs – 10.9
  5. 5. CPET   •  Peak VO2 was 74% of predicted norms. •  Mild impairment due to deconditioning •  Norms in this case are from a population of sedentary men •  What would you tell him his fitness level should be ? •  What would be your physical activity recommendation to him ?
  6. 6. •  Exercise Physiology •  Basics of CPX interpretation Outline  
  7. 7. Cardiopulmonary Exercise Testing •  Standard EKG stress test combined with metabolic gas exchange analysis •  Gold standard for assessments of functional capacity •  Can help determine the cause of dyspnea on exertion: circulatory vs. pulmonary vs. peripheral etiologies
  8. 8. Oxygen Uptake (VO2) •  Coupling cellular to ventilatory respiration •  VO2 = Cardiac Output * (CaO2 – CvO2)
  9. 9. The Fick Principle VO2 (Oxygen Uptake) = Cardiac Output * Hb * AVO2 Resting VO2 = 3.5 mL of O2 consumption/kg/min = 1 MET Conservation of Mass
  10. 10. Approximate Metabolic Equivalents (METs) Physical  ac*vity                  METs     Light  intensity  ac*vi*es                    <  3    sleeping                        0.9    watching  television                    1.0    wri7ng,  desk  work,  typing                  1.8    walking,  1.7  mph  (2.7  km/h),  level  ground,  strolling,  very  slow        2.3    walking,  2.5  mph  (4  km/h)                  2.9     Moderate  intensity  ac*vi*es                  3  to  6    bicycling,  sta7onary,  50  waHs,  very  light  effort            3.0    walking  3.0  mph  (4.8  km/h)                  3.3    calisthenics,  home  exercise,  light  or  moderate  effort,  general        3.5    walking  3.4  mph  (5.5  km/h)                  3.6    bicycling,  <10  mph  (16  km/h),  leisure,  to  work  or  for  pleasure        4.0    bicycling,  sta7onary,  100  waHs,  light  effort              5.5     Vigorous  intensity  ac*vi*es                  >  6    jogging,  general                      7.0    calisthenics  (e.g.  pushups,  situps,  pull-­‐ups,  jumping  jacks)      8.0    heavy,  vigorous  effort                    8.0    running  jogging,  in  place                    8.0    rope  jumping                      10.0  
  11. 11. Cardiorespiratory Fitness (VO2Max)
  12. 12. Range of Max VO2 Rest   3.5   HF   10-­‐15   CABG   20-­‐25   60  yr.  Fit   30-­‐35   College  Male   40-­‐45   Greg  LeMond   90  
  13. 13. CPX Test can be used to discriminate between circulatory, pulmonary, and peripheral etiologies of DOE •  Coupling cellular to ventilatory respiration
  14. 14. VO2 = CO • AVO2 difference VO2 = SV • HR • AVO2 difference VO2 = EDV • EF • HR • AVO2 difference VO2 = EDV – ESV • HR •Hb * ([O2]a – [O2]v) Fick  Equa*on  
  15. 15. Skeletal Muscle Physiology  
  16. 16. Comparing  equa*ons  for  es*ma*ng   peak  VO2   •  ACSM: [(mph)(26.8)](0.1) = “x” “x” * 0.1 = “y” (Grade)(x)(1.8) = “z” VO2 = x + y + z = 3.5 •  Wasserman: [56.36 – (0.413 * Age)] •  Myers: [14.7 – 0.11(Age)] * 3.5 •  Astrand: 60 – 0.55 (Age)
  17. 17. Case  Study  for  Comparison     •  63 y.o male •  Achieved 5 mph with 9.5% grade Direct Wasserman Myers Astrand ACSM 37.0 ml/kg/min 27.3 ml/kg/min 51.2 ml/kg/min 25.35 ml/kg/min 39.8 ml/kg/min
  18. 18. VO2 pattern on a fixed workload of exercise   Start   exercise   Stop   exercise  
  19. 19. VO2 pattern on increasing levels of workload     VO2     Exercise Time on fixed workload  
  20. 20. What Does Fitness Info Tell Us ? •  A reflection of overall physiological health and function, especially the cardiovascular system.   •  Marker of disease severity •  Marker of subclinical disease •  Marker of physical activity  
  21. 21. Fitness & CV Mortality Blair JAMA 1989 0 1 2 3 4 5 6 7 8 9 10 1st 2nd 3rd 4th 5th Women Men Increasing cardiopulmonary fitness RR of CV Death -  Aerobic Center Longitudinal Study -  Cooper Clinic in Dallas, TX
  22. 22. VCO2 / VO2 •  Respiratory exchange ratio (RER) •  Reflects % aerobic vs. % anaerobic metabolism by skeletal muscle •  Also reflects % substrate utilization –  Fats –  Proteins –  Carbohydrates •  Max test: RER > 1.1 –  better estimation than HR 220 – age or RPE
  23. 23. Anaerobic Threshold
  24. 24. •  Class I indications - (good evidence) –  1. Evaluate exercise capacity and response to therapy in heart failure patients being considered for transplantation. –  2. Differentiate cardiac versus pulmonary limitation for dyspnea on exertion. •  Class IIa - (weight of opinion) –  1. Evaluate exercise capacity when indicated for medical reasons when subjective estimates (exercise test time or work rate) are unreliable. •  Class IIb - (efficacy less established) –  1. Evaluate response to intervention in which improvement of exercise tolerance is an important end point. –  2. Determine exercise training intensity for cardiac rehab. Indica*ons  for  CPET  
  25. 25. Gas  Exchange  Report  
  26. 26. Nine  Panel  Plot  
  27. 27. Circulation 122:191-225, 2010 AHA Evaluation Paradigm  
  28. 28. Circulation 122:191-225, 2010

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