cardiopulmonary stress testing: beyond transplant evaluation

Cardiopulmonary Stress Testing: Beyond Transplant Evaluation

Ross Arena, PhD, PT, FAHA, FESC, FACSM

Professor and Head

College of Applied Health Sciences

University of Illinois at Chicago

Left Atrium-Ventricle

Skeletal Muscle

Right Atrium-Ventricle

Cardio-

Pulmonary

Interface

CO

2

CO2

O2

O2

CO2

O2

Pu

lmon

ary

Art

eria

l C

ircu

it

Pulmonary Venous Circuit

Systemic Venous Circuit

System

ic Arteria

l Circu

it

Chemo/

Ergo Receptor and ANS Balance

Myers et al, Curr Prob in Card, In Press

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a

Clinical Vital Sign: A Scientific Statement From the American Heart Association

by Robert Ross, Steven N. Blair, Ross Arena, Timothy S. Church, Jean-Pierre Després, Barry A. Franklin, William L. Haskell, Leonard

A. Kaminsky, Benjamin D. Levine, Carl J. Lavie, Jonathan Myers, Josef Niebauer, Robert Sallis, Susumu S. Sawada, Xuemei Sui, and

Ulrik Wisløff

CirculationVolume 134(24):e653-e699

December 13, 2016

Copyright © American Heart Association, Inc. All rights reserved.

The value of gas exchange beyond aerobic capacity

The real why.

7

Ventilatory Efficiency

8

Pinkstaff SO, Burger CD, Daugherty J, Bond S, Arena R. Guidelines for the Use

of Cardiopulmonary Exercise Testing in Patients with Pulmonary Hypertension:

Evidence-Based Recommendations. Expert Review of Respiratory Medicine.

2016;10(3):279-95.

The relationship between pulmonary hypertension pathophysiology and cardiopulmonary exercise testing markers

Comparison between normal and abnormal pulmonary arterial vessel

response to exercise: implications for cardiac output with an acute

exercise stimulus and right ventricular function with chronic exercise

Arena R, Lavie CJ, Borghi-Silva A, Daugherty J, Bond S, Phillips SP, Guazzi M. Exercise training in group 2 pulmonary hypertension: Which intensity and what modality. Progress in Cardiovascular Disease. 2016 Jul-Aug;59(1):87-94.

What is limiting clinical application and value?

14

Normal

PAH

15

One dimensional Three dimensional

VO2VO2VCO2VEMore

17

The Essentials

Aerobic Performance

Ventilatory Efficiency

Pulmonary Function

Hemodynamics

ECG

Subjective Scales

Universal CPX Reporting Form

Normal (dashed line) and abnormal (solid line) example of oxygen pulse and ΔVo2/ΔW plots

Guazzi M et al. Circulation 2012;126:2261-2274


Examples of normal ventilatory pattern (top panel) and exercise oscillatory ventilation pattern (bottom panel)



Flow Volume Loops

21Copyright © American Heart Association

Heart Failure



Unexplained Exertional Dyspnea

Guazzi M et al. Circulation and EHJ 2016


Improved Resolution for Unexplained Dyspnea

Flow limitation: Flow rate during exercise = PFT flow rate

Dynamic Hyperinflation: Increase in end expiratory lung volume (i.e. exercise induced air trapping)

Suspected or Confirmed PAH/Secondary PH



Confirmed or Suspected HCM



Prognostic and Diagnostic Stratification for Patients With COPD or ILD.

Guazzi M et al. Circulation 2016 Circulation and EHJ

Suspected Myocardial Ischemia



Suspected Mitochondrial Myopathy



Presurgical Assessment

35


Valvular Heart Disease/Dysfunction

36


Apparently Healthy Individuals

37Guazzi M et al. Circulation 2016 Circulation and EHJ

Rating Evidence and Clinical Recommendations

38

40

Level of Prognostic SignificanceE

vid

en

ce

of

Ce

rta

inty

(P

rec

isio

n)

of

Pro

gn

os

tic

Va

lue

Class I

Assessment/Measure(s)

clearly prognostic

Assessment SHOULD be

performed or administered

Class IIa

Assessment/Measure(s) likely

prognostic

Several Additional Level A

studies needed

IT IS REASONABLE to perform

or administer assessment

Class IIb

Assessment/Measure(s)

may be prognostic

Greater number of additional

Level A and B (preferably A)

studies needed

Assessment MAY BE be

performed or administered

Class III No benefit or

Class III Harm

No Benefit:Assessment/measure(s)

not prognostic

Harm: Assessment/measure(s)

excess cost without prognostic

insight or harmful

LEVEL A

Multiple populations

evaluated

Data derived from

multiple prospective

outcomes databases

or meta-analyses

Recommendation that

assessment/measure(s) is

useful/effective

Sufficient evidence from

multiple prospective

outcomes databases or

meta-analyses

Recommendation in favor of

assessment/measure(s) being

useful/effective

Some conflicting evidence from

multiple prospective outcomes

databases or meta-analyses

Recommendation’s

usefulness/efficacy less well

established

Greater conflicting evidence

from multiple prospective


meta-analyses

Recommendation that

assessment/measures(s) not

useful/effective and may be harmful

Sufficient evidence from multiple

prospective outcomes databases or

meta-analyses

LEVEL B

Limited populations

evaluated

Data derived from

single prospective

outcomes database or

retrospective

databases

Recommendation that


useful/effective

Evidence from single

prospective outcomes

databases or retrospective

outcomes databases



useful/effective

Some conflicting evidence from

single prospective outcomes

databases or retrospective

outcomes databases

Recommendation’s


established

Greater conflicting evidence

from single prospective


retrospective outcomes

databases

Recommendation that



Evidence from single prospective


retrospective outcomes databases

LEVEL C

Very limited

populations evaluated

Only consensus

opinion of experts,

small outcomes

databases, or standard

of care

Recommendation that


useful/effective

Only expert opinion, small

outcomes databases, or

standard of care



useful/effective

Only diverging expert opinion,

small outcomes databases, or

standard of care

Recommendation’s


established

Only diverging expert

opinion, small outcomes

databases, or standard of

care

Recommendation that



Only expert expert opinion, small

outcomes databases, or standard of

care

Suggested phrases

for writing

recommendations

Should

Is recommended

Is indicated

Is useful/effective/beneficial

Is reasonable

Can be

useful/effective/beneficial

Is probably recommended or

indicated

May/might be considered

May/might be reasonable

Usefulness/effectiveness is

unknown/unclear/uncertain

or not well established

No Benefit

Is not recommended

Is not indicated

Should not be

performed/administered/other

In not useful/beneficial/effective

41

Class I Class IIa Class IIb Class III

CPX is clearly:

prognostic/diagnostic

CPX clearly:

gauges therapeutic

efficacy

CPX:

- Should be performed

- Is recommended

- Is Indicated

- Is Useful

- Is Effective

- Is Beneficial

CPX is likely:


CPX likely:

gauges therapeutic

efficacy

CPX:

- Is probably

recommended

- Is probably indicated

- Can be useful

- Can be effective

- Can be beneficial

CPX may be:


CPX may:

gauge therapeutic efficacy

CPX:

- May be considered

- May be reasonable

- Usefulness is unknown

- Usefulness is unclear

- Usefulness is uncertain

- Usefulness is not well

established

CPX is not:


CPX does not:

gauge therapeutic

efficacy

CPX:

- Has no benefit

- Is not recommended

- Is not indicated

- Should not be performed

- Should not be

administered

- Is not useful

- Is not beneficial

- Is not effective

45

Future Considerations

Refining the Algorithms

48

Based of Hazard RatioVE/VCO2 slope = 7HRR = 5OUES = 3PETCO2 = 2Peak VO2 = 2

Submaximal Testing

49

OUES

50

51

Translation from Science to Practice

http://www.ncats.nih.gov/research/cts/cts.html

52

Lab of the Future: Comprehensive Functional Assessment

IMS&E

MFP&E

CPX

55

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cardiopulmonary stress testing: beyond transplant evaluation

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