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CARDIOPULMONARY EXERCISE TESTING –INTERACTIVE CASE DISCUSSION
The Cardiologist’s point of viewLukas Trachsel
Oxygen uptake in response to acute exercise
COCardiacoutput
SVStrokevolume
HRHeart rate
Wassermann, Principles of Exercise Testing, 5th Edition
Perip.Circ.Dilate
Recruit
Pulm.Circ.RecruitDilate
C(a-v)o2Arterial-mixedvenous O2 diff. x10x2-3
VO2 = CO x C(a-v) O2
‘Fick equation’
9 – Panel – Plot (Wassermann)
Motivation / exercisecapacity
Ventilatory mechanicalrelevant panels
Cardio-circulatoryrelevant panels
VO2 = SV x HR x C(a-v) O2
VO2/HR = SV x C(a-v) O2
VO2/WR-Slope
9 – Panel – Plot (Wassermann)
Cooperation / exercisecapacity
Ventilatory mechanicalrelevant panels
Cardio-circulatoryrelevant panels
Gas exchange
Case Report• 61 year old male• 3-vessel CAD (12/2010)
– Non-STE-MI inferior 12/2010– CABG 12/2010 – Ejection fraction normal– Risk factors: cholesterol, BMI 30, familial history, former
smoker
• Suspected exercise induced asthma 07/2012– Body plethysmography 20.7.2012: borderline restriction
(TLC 76% predicted), dynamic lung volume normal, C0 diffusion capacity normal
• Annual ‘follow-up’: – Exercise intolerance for months, exertional dyspnoe
(NYHA II)
CAD, post-CABGExercise intolerance, NYHA II
VE/VCO2-Slope 35 (<30)
RER 1.15
BR 20%
VO2/WR-Slope 8.2 (> 8.6) O2 pulse 77% pred
CRF 77% pred
WR 76% pred
QUIZ QUESTION:
What is the most likely reason for the symptoms and for the reduced exercise capacity/CRF?
a) Respiratory limitationb) Cardio-circulatory limitation (unspecific)c) Cardio-circulatory limitation (suggestive ofischemia)d) Limitation of peripheral musclese) Others
CAD, post-CABGExercise intolerance, NYHA II
VO2/WR-Slope 8.2 (> 8.6) O2 pulse 77% pred
BR 20%
RER 1.15
CRF 77% pred
WR 76% pred
VE/VCO2-Slope 35 (<30)
Case Report• 53 year old male
• Hypertensive heart disease
• Metabolic syndrome
• Syncope 2012
• Sent for disability evaluation by the insurance(‘IV-Abklärung’)
• Symptoms: dyspnoe on exertion (NYHA II-III), periodic chest pain (at rest, on exertion)
Hypertensive HD, metabolic syndromeNYHA II-III VO2/WR-Slope 8.9 (> 8.6)
O2 pulse 59% predVE/VCO2-Slope 38(<30)
CRF 64% pred
WR 54% pred
RER 1.29
BR 16%
QUIZ QUESTION:
What is the most unlikely reason for the reduced exercise capacity?
a) Heart failure with preserved ejection fractionb) Subacute pulmonary embolismc) Chronic thrombo-embolic pulmonary hypertension (CTEPH)d) Previously undetected aortic stenosise) COPD
RER 1.29
Hypertensive HD, metabolic syndromeNYHA II-III
VE/VCO2-Slope 38 (<30)
VO2/WR-Slope 8.9 (> 8.6)
PET Co2 32mm Hg(Rest: > 35mm Hg)
bath tub?
O2 pulse 59% pred
CRF 64% pred
WR 54% pred
BR 16%
RER 1.29
European Heart Journal (2012) 33, 2917–2927
“Several CPX statements have been published by well-respected organizations in both the US and Europe. Despite these prominent reports and the plethora of pertinent medical literature
which they feature, underutilization of CPX persists.”
• New CPX indications and algorithms:
– CPX to assess perisurgical and postsurgical risk and long-term prognosis
– CPX to assess valvular disease/dysfunction
European Heart Journal doi:10.1093/eurheartj/ehw180