Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation

Abstract

Symptom-limited (maximal) exercise testing before cardiac rehabilitation (CR) was once an unambiguous standard of care. In particular, it served as an important screen for residual ischemia and instability before initiating a progressive exercise training regimen. However, improved revascularization and therapy for coronary heart disease has led many clinicians to downplay this application of exercise testing, especially because such testing is also a potential encumbrance to CR enrollment (delaying ease and efficiency of enrollment after procedures and hospitalizations) and patient burden (eg, added costs, logistic hassle, and anxiety). Nonetheless, exercise testing has enduring value for CR, especially because it reveals dynamic physiological responses as well as ischemia, arrhythmias, and symptoms pertinent to exercise prescription and training and to overall stability and prognosis. Moreover, as indications for CR have expanded, the value of exercise testing and functional assessment is more relevant than ever in the growing population of eligible patients, including those with heart failure, valvular heart disease, and posttransplantation, especially as current patients also tend to be more clinically complex, with advanced ages, multimorbidity, frailty, and obesity. This review focuses on the appropriate use of exercise testing in the CR setting. Graded exercise tests, cardiopulmonary exercise tests, submaximal walking tests, and other functional assessments (strength, frailty) for CR are discussed.

WITHDRAWN: Screened microRNAs related to endothelial progenitor cells and verified the target gene of microRNA-126-3p

“…Several randomized trials have verified that aerobic exercise (AE) produced possibly the greatest improvements in peak oxygen consumption (Vo 2 ) and left ventricular ejection fraction [8]. Furthermore, after systematically analyzing studies on exercise-based CR, Taylor et al [9,10] found that CR could decrease total mortality by 20% and cardiac mortality by 30%, and could decrease cardiovascular risk factors. Currently, AE-based CR is a class I recommendation for increasing survival in many guidelines for patients with ASCVD, whether acute cardiac syndrome or stable angina pectoris [11,12].…”

The importance of physical function as a clinical outcome: Assessment and enhancement

“…Cardiopulmonary exercise testing (CPET) presumes that a patient has requisite capacities of strength and balance that in many cases are too limited for CRF testing. Therefore, a broader range of physical function assessments is an important goal . Ideally, functional assessments for older adults need to gauge a wide range of capacities in this heterogeneous population, with prognostic sensitivity, and capacity to track changes over time (ie, sufficiently sensitive to delineate decrements or improvements).…”

“…Cardiorespiratory fitness (CRF) is a powerful indicator of morbidity and mortality. It is best measured using graded symptom‐limited CPET and directly quantified as peak oxygen uptake (VO 2 ) . Although standard exercise testing can be used to estimate metabolic equivalents (METs) a metabolic index conceptually related to peak VO 2 , METs are calculated and are relatively less precise than VO 2 assessments.…”

“…Many exercise testing labs default to the Bruce treadmill protocol (a treadmill protocol that entails the rapid progression of speeds and inclines over a few minutes to demarcate exercise limitations). Similarly, many use high rapid progressions of resistances for their bicycle testing (25 watts/min) . Rationale to use these protocols is based on their diagnostic and prognostic efficacy in younger populations .…”

Brugada syndrome: new concepts and algorithms in management (RCD code: V 1A.1)

“…In a recently reported case, the BrS ECG pattern was likely induced by ischemia (Brugada phenocopy) [34]. ExT and cardiopulmonary exercise testing may provide information on exercise safety and may reveal or augment the BrS ECG pattern [29,35,36]. The specific role of these tests in the management of BrS patients requires further studies.…”