Recommendations on the use of exercise testing in clinical practice

Palange, Paolo; Ward, Susan A.; Carlsen, K-H.; Casaburi, Richard; Gallagher, CG; Gosselink, Rik; O’Donnell, Denis E.; Puente-Maestu, Luís; Schols, A.M.W.J.; Singh, Sally; Whipp, Brian J.

doi:10.1183/09031936.00046906

Cited by 534 publications

(428 citation statements)

References 296 publications

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“…Direct measurement of oxygen consumption during an incremental exercise stress test is the most accurate method to determine VO 2max . 23,24 The use of a non-weightbearing form of exercise should minimize the risk for confounding by body weight. We use an electrically braked cycle ergometer, the preferred device for exercise testing in clinical practice.…”

Section: Discussionmentioning

confidence: 99%

The current standard measure of cardiorespiratory fitness introduces confounding by body mass: the DR's EXTRA study

et al. 2011

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OBJECTIVE: Cardiorespiratory fitness is currently estimated by dividing maximal oxygen consumption (VO 2max ) by body weight (per-weight standard). However, the statistically correct way to neutralize the effect of weight on VO 2max in a given population is adjustment for body weight by regression techniques (adjusted standard). Our objective is to quantify the bias introduced by the per-weight standard in a population distributed across different categories of body mass. DESIGN: This is a cross-sectional study. SUBJECTS AND METHODS: Baseline measures from participants of the Dose-Responses to Exercise Training Study (DR's EXTRA), 635 men (body mass index (BMI): 19--47 kg m À2 ) and 638 women (BMI: 16--49 kg m À2 ) aged 57--78 years who performed oral glucose tolerance tests and maximal exercise stress tests with direct measurement of VO 2max . We compare the increase in VO 2max implied by the per-weight standard with the real increase of VO 2max per kg body weight. A linear logistic regression model estimates odds for abnormal glucose metabolism (either impaired fasting glycemia or impaired glucose tolerance or Type 2 diabetes) of the least-fit versus most-fit quartile according to both per-weight standard and adjusted standard. RESULTS: The per-weight standard implies an increase of VO 2max with 20.9 ml min À1 in women and 26.4 ml min À1 in men per additional kg body weight. The true increase per kg is only 7.0 ml min À1 (95% confidence interval: 5.3--8.8) and 8.0 ml min À1 (95% confidence interval: 5.3--10.7), respectively. Risk for abnormal glucose metabolism in the least-fit quartile of the population is overestimated by 52% if the per-weight standard is used. CONCLUSIONS: In comparisons across different categories of body mass, the per-weight standard systematically underestimates cardiorespiratory fitness in obese subjects. Use of the per-weight standard markedly inflates associations between poor fitness and co-morbidities of obesity.

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Section: Discussionmentioning

confidence: 99%

The current standard measure of cardiorespiratory fitness introduces confounding by body mass: the DR's EXTRA study

et al. 2011

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“…Cardiopulmonary exercise testing (CPX) is the gold standard for evaluating the cause of exercise intolerance in patients with pulmonary and cardiac disease (Palange et al 2007). CPX can provide an objective measure of exercise capacity, identify the mechanisms limiting exercise tolerance, establish indices of the patient's prognosis, and monitor disease progression and/or the response to interventions (Palange et al 2007).…”

Section: Introductionmentioning

confidence: 99%

“…CPX can provide an objective measure of exercise capacity, identify the mechanisms limiting exercise tolerance, establish indices of the patient's prognosis, and monitor disease progression and/or the response to interventions (Palange et al 2007). Incremental ramp exercise (IRE), the most widely used CPX protocol in clinical practice (American Thoracic Society; American College of Chest Physicians 2003), is used to calculate aerobic threshold (AT), respiratory compensation point, peak work rate (WR peak ), and maximal oxygen uptake (V 4 O 2max ).…”

Section: Introductionmentioning

confidence: 99%

Muscle Oxygen Extraction Is Higher during Constant Work Exercise than during Incremental Ramp Exercise

Yamamoto

Tabira

2014

Tohoku J. Exp. Med.

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A cardiopulmonary exercise test (CPX) can provide objective measures of exercise capacity. Specifically, incremental ramp exercise (IRE) and constant work-rate exercise (CWE) protocols are frequently used in clinical practice and for research. The CWE endurance time has shown larger increases than other indexes assessed by IRE after rehabilitation intervention. Muscle oxygen extraction is one of the important physiological factors of exercise capacity; however, the differences in muscle oxygen kinetics between IRE and CWE remain unclear. The purpose of this study was to compare the muscle oxygen kinetics during IRE and CWE. Each of the 15 participants performed IRE and CWE to exhaustion on a cycle ergometer. Ventilatory and muscle deoxygenation responses were measured during the tests; muscle deoxygenation was determined using near-infrared spectroscopy. No differences in oxygen uptake and heart rate were observed between the two tests. A comparison of the muscle deoxygenation kinetics between the two tests indicated significantly greater deoxygenation during the CWE than during the IRE at all time points (p < 0.05). The muscle deoxygenation kinetics, as percentages of maximal oxygen uptake (V 4 O 2max ), were higher during CWE than during IRE, except at 80% of V 4 O 2max (p < 0.05). These results suggest that skeletal muscle during CWE extracts oxygen at a rate comparable to that during IRE, and that exercise capacity assessed using CWE might be linked to a higher overall O 2 extraction. The fact that endurance time during CWE is more sensitive to rehabilitation intervention may be due to improvements in muscle oxygen extraction.

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“…During incremental physical workload, the physiological reserve of the heart, lungs and skeletal muscles can be quantified by monitoring ECG changes, heart rate and blood pressure responses, respiratory volumes, oxygen consumption and carbon dioxide production, as well as by grading dyspnoea and subjective feelings. Accordingly, interpretation of abnormal results during CPET is helpful for detecting significant coronary artery disease, ventricular or valvular dysfunction, gas exchange or ventilation abnormalities as well as skeletal muscle deconditioning [8,11].…”

mentioning

confidence: 99%

“…Besides imaging techniques and lung functional investigations, cardiopulmonary exercise testing (CPET) has recently emerged as a noninvasive tool providing valuable diagnostic and prognostic information [8][9][10]. During incremental physical workload, the physiological reserve of the heart, lungs and skeletal muscles can be quantified by monitoring ECG changes, heart rate and blood pressure responses, respiratory volumes, oxygen consumption and carbon dioxide production, as well as by grading dyspnoea and subjective feelings.…”

mentioning

confidence: 99%

Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery

Licker¹,

Schnyder²,

Frey³

et al. 2010

European Respiratory Journal

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Over the past decades, major progress in patient selection, surgical techniques and anaesthetic management have largely contributed to improved outcome in lung cancer surgery. The purpose of this study was to identify predictors of post-operative cardiopulmonary morbidity in patients with a forced expiratory volume in 1 s ,80% predicted, who underwent cardiopulmonary exercise testing (CPET).In this observational study, 210 consecutive patients with lung cancer underwent CPET with completed data over a 9-yr period (2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009).Cardiopulmonary complications occurred in 46 (22%) patients, including four (1.9%) deaths. On logistic regression analysis, peak oxygen uptake (peak V9O 2 ) and anaesthesia duration were independent risk factors of both cardiovascular and pulmonary complications; age and the extent of lung resection were additional predictors of cardiovascular complications, whereas tidal volume during one-lung ventilation was a predictor of pulmonary complications. Compared with patients with peak V9O 2 .17 mL?kg, those with a peak V9O 2 ,10 mL?kg -1 ?min -1 had a four-fold higher incidence of cardiac and pulmonary morbidity. Our data support the use of pre-operative CPET and the application of an intra-operative protective ventilation strategy. Further studies should evaluate whether pre-operative physical training can improve post-operative outcome.

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Recommendations on the use of exercise testing in clinical practice

Cited by 534 publications

References 296 publications

The current standard measure of cardiorespiratory fitness introduces confounding by body mass: the DR's EXTRA study

The current standard measure of cardiorespiratory fitness introduces confounding by body mass: the DR's EXTRA study

Muscle Oxygen Extraction Is Higher during Constant Work Exercise than during Incremental Ramp Exercise

Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery

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