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Aims: Pulmonary capillary wedge pressure (PAWP) ≥25 mmHg during bicycle ergometry is recommended to uncover occult heart failure with preserved ejection fraction. We hypothesized that PAWP increase would differ in available diastolic stress tests and that the margin of PAWP ≥25 mmHg would only be reliably achieved through ergometry. Methods and results: We conducted a prospective, single‐arm study in patients with an intermediate risk for heart failure with preserved ejection fraction according to the ESC HFA‐PEFF score. A total of 19 patients underwent four stress test modalities in randomized order: leg raise, fluid challenge, handgrip, and bicycle ergometry. The primary outcome was the difference (Δ) between resting and exercise PAWP in each modality. Secondary outcomes were differences (Δ) in mean pulmonary artery pressure (mPAP), cardiac output (CO), as well as the ratios between mPAP and PAWP to CO. Compared to resting values, passive leg raise (Δ7.7 ± 8.0 mmHg, p = 0.030), fluid challenge (Δ9.2 ± 6.4 mmHg, p = 0.003), dynamic handgrip (Δ9.6 ± 7.5 mmHg, p = 0.002), and bicycle ergometry (Δ22.3 ± 5.0 mmHg, p < 0.001) uncovered increased PAWP during exercise. Amongst these, bicycle ergometry also demonstrated the highest ΔmPAP (27.2 ± 7.1 mmHg, p < 0.001), ΔCO (3.3 ± 2.6 L/min, p < 0.001), ΔmPAP/CO ratio (2.3 ± 2.0 mmHg/L/min, p < 0.001), and ΔPAWP/CO ratio (2.2 ± 1.4 mmHg/L/min, p < 0.001) compared to other modalities. PAWP ≥25 mmHg was only reliably achieved in bicycle ergometry (31.1 ± 3.9 mmHg). In all other modalities only 10.5% of patients achieved PAWP ≥25 mmHg (handgrip 18.4 ± 6.6 mmHg, fluid 18.1 ± 5.6 mmHg, leg raise 16.5 ± 7.0 mmHg). Conclusions: We demonstrate that bicycle ergometry exhibits a distinct haemodynamic response with higher increase of PAWP compared to other modalities. This finding needs to be considered for valid detection of exercise PAWP ≥25 mmHg when non‐bicycle tests remain inconclusive. [ABSTRACT FROM AUTHOR]

Aims: Phosphodiesterase‐5 inhibitors (PDE5I) are frequently implemented after left ventricular assist device (LVAD) implantation to improve haemodynamics in patients with early postoperative right ventricular (RV) failure. It is unknown if long‐term PED5I therapy beyond the early post‐operative period provides any clinical benefit in stable outpatients, who have recovered from post‐operative RV failure under univentricular device support. This study aimed to investigate the impact of PDE5I discontinuation on RV function and cardiopulmonary exercise capacity in patients on durable LVAD support. Methods and results: We enrolled 31 clinically stable LVAD recipients on long‐term oral PDE5I therapy. The mean age was 53 years, and 90% were male. Patients discontinued PDE5I and underwent cardiopulmonary exercise testing, echocardiography, LVAD interrogation, and biomarker analysis at baseline and 4 weeks after PDE5I withdrawal. At 4 weeks, no significant changes were observed in echocardiographic indices of RV morphology and function but an increase in peak tricuspid regurgitation velocity (2.1 vs. 2.4 m/s, P = 0.01). Peak oxygen consumption (11.4 vs. 11.8 mL/min/kg, P = 0.52), minute ventilation/carbon dioxide production slope (33 vs. 35, P = 0.56), N‐terminal pro‐brain natriuretic peptide (1455 vs. 1399 pg/mL, P = 0.55), flow and power readings of the device, and quality of life (Kansas City Cardiomyopathy Questionnaire score 78.3% vs. 77.5%, P = 0.62) exhibited no significant changes. We observed an increase in 6‐min walking distance (346 vs. 364 m, P = 0.03). Two patients were hospitalized for non‐cardiac reasons (subtherapeutic INR, driveline infection). No patient was hospitalized for cardiac decompensation. Conclusions: In LVAD patients with a history of early post‐operative RV failure, discontinuation of long‐term PDE5I therapy was not associated with deterioration of RV function, exercise capacity, and quality of life. PDE5I should be critically evaluated until more evidence regarding the net clinical benefit of this pharmacologic intervention becomes available. [ABSTRACT FROM AUTHOR]

(1) Background: Cardiopulmonary exercise testing (CPET) has been suggested by the European Society of Cardiology (ESC) for assessing the exercise limitations of apparently healthy individuals, but data on elite athletes regarding this test are scarce. (2) Methods: We analyzed CPET in elite (n = 43, 21.9 ± 3.7 years) and recreational (n = 40, 34.7 ± 13.0 years) athletes with persistent subjective exercise intolerance and post-exertional malaise (PEM) after COVID-19 infection. The primary outcome was the point prevalence of the adequate cardiopulmonary response (ACPR), defined by the presence of all of the following ESC criteria for apparently healthy individuals: (1) >100% of predicted peak oxygen consumption (predVO2peak), (2) VE/VCO2 < 30, (3) no exercise oscillatory ventilation (EOV), and (4) heart rate recovery of ≥12 beats/minute 1 min after exercise termination (HRR1). Results: ACPR occurred more frequently in elite athletes than in recreational athletes (70.0% vs. 39.5%; p = 0.005), mainly driven by the lower VE/VCO2 (<30: 97.7% vs. 65%, p < 0.001). Elite (11.6%) and recreational athletes (22.5%) showing a plateau of O2 pulse did not display ACPR. Conclusions: ACPR was not observed in all recreational and elite athletes with PEM. In particular, perturbed VE/VCO2 and the plateauing of O2 pulse are suitable for quantifying exercise limitations and may identify a high-risk population with long-COVID-19 syndrome who require their training intensities to be adapted. [ABSTRACT FROM AUTHOR]

(1) Background: The exercise capacity of patients with a left ventricular assist device (LVAD) remains limited despite mechanical support. Higher dead space ventilation (VD/VT) may be a surrogate for right ventricular to pulmonary artery uncoupling (RV–PA) during cardiopulmonary exercise testing (CPET) to explain persistent exercise limitations. (2) Methods: We investigated 197 patients with heart failure and reduced ejection fraction with (n = 89) and without (HFrEF, n = 108) LVAD. As a primary outcome NTproBNP, CPET, and echocardiographic variables were analyzed for their potential to discriminate between HFrEF and LVAD. As a secondary outcome CPET variables were evaluated for a composite of hospitalization due to worsening heart failure and overall mortality over 22 months. (3) Results: NTproBNP (OR 0.6315, 0.5037–0.7647) and RV function (OR 0.45, 0.34–0.56) discriminated between LVAD and HFrEF. The rise of endtidal CO2 (OR 4.25, 1.31–15.81) and VD/VT (OR 1.23, 1.10–1.40) were higher in LVAD patients. Group (OR 2.01, 1.07–3.85), VE/VCO2 (OR 1.04, 1.00–1.08), and ventilatory power (OR 0.74, 0.55–0.98) were best associated with rehospitalization and mortality. (4) Conclusions: LVAD patients displayed higher VD/VT compared to HFrEF. Higher VD/VT as a surrogate for RV–PA uncoupling could be another marker of persistent exercise limitations in LVAD patients. [ABSTRACT FROM AUTHOR]

Background: Exercise oscillatory ventilation (EOV), indicating pathological fluctuations on pulmonary arterial pressure, is associated with mortality in patients with heart failure (HF). Whether left ventricular assist device (LVAD)‐induced ventricular unloading can reverse EOV and may prevent short‐term rehospitalization has not been investigated. Methods: We performed a retrospective single‐center in‐ and outpatient analysis of patients with (n = 20, LVAD) and without (n = 27, HF) circulatory support and reduced ejection fraction (EF, 22.8 ± 7.9%). The association of cardiopulmonary exercise testing (CPET) variables and 3 months‐rehospitalization (3MR) as a primary outcome was analyzed. Furthermore, CPET variables were compared regarding the presence of EOV (+/−). Results: Lower VO2peak (11.6 ± 4.9 ml/kg/min vs. 14.4 ± 4.3 ml/kg/min, p = 0.039), lower increase of PETCO2 (CI = 0.049–1.127; p = 0.068), and higher VE/VCO2 (43.8 ± 9.5 vs. 38.3 ± 10.6; p = 0.069) were associated with 3MR. Flattening of O2 pulse (CI = 0.139–2.379; p = 0.487) had no impact on 3MR. EOV was present in 59.5% (n = 28/47) of patients, without a significant difference between LVAD and HF patients (p = 0.959). Patients with HF/EOV+ demonstrated significantly lower VO2peak compared with HF/EOV− (p = 0.039). LVAD/EOV+ displayed significantly lower EF (p = 0.004) and fewer aortic valve opening than LVAD/EOV− (p = 0.027). Conclusions: Lower VO2peak, but not EOV, was associated with 3MR. EOV occurred at a similar rate in LVAD and HF patients, which may illustrate insufficient unloading during exercise in chronic LVAD therapy and may contribute to the limited exercise capacity following LVAD implantation. Simultaneous CPET and right heart catheterization studies are needed to elucidate whether EOV may serve as a non‐invasive predictor of insufficient LV unloading necessitating LVAD reprograming. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to assess associations between depressive symptoms, lifestyle, and somatic symptoms during the COVID-19 pandemic. Design: A prospective, observational study using a self-designed questionnaire. Setting: Three general practitioners' (GP) offices in rural Germany. Participants: 271 adult patients without manifest cardiovascular or pulmonary disease with (n = 82) and without (n = 189) hypertension reporting to our GP offices. Main outcome measures: The reported increase of depressive symptoms (loneliness, sleeplessness, joylessness, listlessness) prior to the first documented case in Germany on 27.01.2020 (t0) as opposed to patients' health perception during the Corona pandemic (t1) was the primary outcome measure. The secondary outcome measures were changes in physical activity (PA), dyspnea and angina in the two groups. Results: Out of 271 patients (50.8 ± 16.8 years, 55.1% females), 1.5% were tested positive for COVID-19. Overall, listlessness (8.5%, p = 0.001), sleeplessness (5.2%, p = 0.001) and joylessness (4.2%, p = 0.003) were increased. Dyspnea significantly increased (9.2%, p < 0.001) and employment status worsened (6.5%, p < 0.001). There were significant associations between the increase of depressive symptoms, weight increase (p = 0.017), and reduction in physical activity (p = 0.046). However, after adjusting for age, hypertensive patients did not show more depressive symptoms (p = 0.704), dyspnea (p = 0.063) or angina (p = 0.432), nor was there any difference in PA (p = 0.906) compared to healthy individuals. Conclusions: We demonstrate an association between the deterioration of depressive symptoms, weight gain, and reduced physical activity during COVID-19, both in hypertensives and healthy controls. Hypertension is no driver of symptom deterioration during the pandemic. The trial was registered in the German Clinical Trials Registry (DRKS00022157). [ABSTRACT FROM AUTHOR]

Introduction: Exercise pulmonary hypertension (exPH) has been defined as total pulmonary resistance (TPR) >3 mm Hg/L/min and mean pulmonary artery pressure (mPAP) >30 mm Hg, albeit with a considerable risk of false positives in elderly patients with lower cardiac output during exercise. Methods: We retrospectively analysed patients with unclear dyspnea receiving right heart catheterisation at rest and exercise (n=244) between January 2015 and January 2020. Lung function testing, blood gas analysis, and echocardiography were performed. We elaborated a combinatorial score to advance the current definition of exPH in an elderly population (mean age 67.0 years±11.9). A stepwise regression model was calculated to non-invasively predict exPH. Results: Analysis of variables across the achieved peak power allowed the creation of a model for defining exPH, where three out of four criteria needed to be fulfilled: Peak power ≤100 Watt, pulmonary capillary wedge pressure ≥18 mm Hg, pulmonary vascular resistance >3 Wood Units, and mPAP ≥35 mm Hg. The new scoring model resulted in a lower number of exPH diagnoses than the current suggestion (63.1% vs. 78.3%). We present a combinatorial model with vital capacity (VCmax) and valvular dysfunction to predict exPH (sensitivity 93.2%; specificity 44.2%, area under the curve 0.73) based on our suggested criteria. The odds of the presence of exPH were 2.1 for a 1 l loss in VCmax and 3.6 for having valvular dysfunction. Conclusion: We advance a revised definition of exPH in elderly patients in order to overcome current limitations. We establish a new non-invasive approach to predict exPH by assessing VCmax and valvular dysfunction for early risk stratification in elderly patients. [ABSTRACT FROM AUTHOR]

Objective: Right heart catheterization (RHC) is associated with a higher procedural risk in older adults, but non-invasive estimation of pulmonary hypertension (PH) is a challenge. We aimed to elaborate a non-invasive prediction model to estimate PH. Methods and design: We retrospectively analysed 134 older adults (70.0 years ±12.3; 44.9% males) who reported to our clinic with unclear dyspnea between 01/2015 and 01/2020 and had received RHC as a part of their diagnostic workup. Lung function testing, analysis of blood gas samples, 6 min walk distance and echocardiography were performed within 24 hours of RHC. Main outcome measures: In a stepwise statistical approach by using an in/exclusion algorithm (using the AIC criterion) we analysed non-invasive parameters to test their value in predicting PH (defined as mean pulmonary artery pressure, PAmean, >25mmHg). Discrimination capability of the final model was measured by the AUC (area under curve) from an ROC (receiver operating characteristics) analysis. Results: We yielded a sensitivity of 87.2% and a specificity of 62.5% in a combinatorial logistical model with systolic pulmonary artery pressure (sPAP) and forced vital capacity (VCmax), the discrimination index was 86.7%. The odds ratios for an increase of 10 mmHg of sPAP were 2.99 (2.08–4.65) and 1.86 (1.11–3.21) for a 1 l decrease in VCmax. On their own, VCmax proved to be specific (83.3%), while sPAP was a sensitive (79.1%) predictor for PH. Conclusions: We provide a combinatorial model to predict PH from sPAP and VCmax in older adults, which may help to avoid invasive procedures. [ABSTRACT FROM AUTHOR]

Exaggerated blood pressure response during exercise is a risk factor for cardiovascular disease, but is inhomogeneously defined in the literature. We used a novel approach by taking into account both workload and blood pressure to define exercise hypertension (systolic values > 200 mmHg at 100W). We examined medically controlled hypertensives (n = 373; mean age 56.7 ± 14.8 years) and their blood pressure response during bicycle ergometry. Exercise hypertension was inversely associated with E/A wave ratio but not E/E' during resting echocardiography (p = 0.045; p = 0.293). Functional air trapping (residual volume/total lung capacity, RV/TLC) was significantly higher in the group of exercise hypertensives (43.6% ± 11.6 vs. 38.1% ± 10.0; p = 0.005). Patients treated with renin-angiotensin aldosterone system (RAAS) blockers showed lower blood pressure response during exercise than those treated with calcium channel blockers (CCBs) and thiazides (both <0.001) and also displayed higher E/A (p = 0.023) and lower E/E' values (p = 0.042). We provide evidence that the easily accessible parameters E/A inversion and air trapping at rest could be used in clinical routine to screen for exercise-induced hypertension in medically controlled hypertensives. We also show that RAAS blockers have a more favorable effect on blood pressure response during exercise than CCBs and thiazides. [ABSTRACT FROM AUTHOR]

Beta-blocker (BB) therapy is a main pillar in treating patients with heart failure and reduced ejection fraction and has shown a prognostic benefit. However, evidence for application of BB in heart failure with preserved ejection fraction (HFpEF), especially in the absence of coronary artery disease, atrial fibrillation or arterial hypertension, is scarce. HFpEF is characterized by elevations in left atrial pressure and reduced compliance of the left ventricle leading to a hampered increase of cardiac output (CO) during exercise, which results in exertional dyspnea. This may be due to either a limited increase in stroke volume or reduced chronotropy during physical activity. We critically discuss the pathophysiological background of HFpEF, current data on BB in heart failure therapy, as well as the potential benefits and harms of BB therapy in HFpEF. Furthermore, we argue that non-cardio selective BB with peripheral activity to reduce afterload may be more suitable in this population than cardio-selective BB. Although preliminary data on BB in HFpEF are available, multicenter prospective trials to assess a reduction of cardiovascular morbidity are warranted. Future trials need to focus on phenotyping HFpEF patients and assess who may benefit most from tailored BB therapy. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted in an effort to examine tennis players' ability to perceive fine and coarse information and to examine their ability to predict serve direction under three levels of visual blur. Researchers found that there was a significant interaction between anticipation skill and level of blur and that players' anticipation skill was drawn from the perception of fine grained information.

A well-established characteristic of expertise in many sport skills is the ability to process biological motion to anticipate the actions of an opponent. Presently, it is unclear whether anticipation skill is based on the processing of local, featural information or more global, configural information. In the present study, we attempted to address this question by manipulating the level of visual blur. Expert, skilled, and novice tennis players (N = 56) attempted to judge serve direction in 96 video clips depicting two intermediate-club-level players serving to the deuce court. Each clip was temporally occluded at one of four levels relative to ball-racquet impact (-320 ms, -160 ms, 0 ms, +160 ms) and was shown with one of three levels of blur (no blur, 20% blur, 40% blur). The results revealed a significant effect of blur, such that judgment accuracy decreased as the level of blur increased. There was no interaction with skill level, suggesting that successful judgments were based upon the processing of featural rather than configural information in all three groups. Intriguingly, the novice players performed better than the skilled players who in turn performed better than the experts and this was consistent across all three levels of blur. Analysis of the proportion of correct responses for each trial (item solution probabilities) revealed evidence of greater susceptibility to deception in expert players. Specifically, the expert group had a total of 26 trials (out of 96) on which fewer than 20% of the group members were correct, compared with 15 trials for the skilled group and only 7 trials for the novice group. Finally, the number of deceptive trials was greatest in the 40% blur condition, suggesting that the serve motions depicted in the test trials violated the configural rules to which expert players have become sensitive. [ABSTRACT FROM AUTHOR]

Background: Peak oxygen consumption (VO2peak), which depends on maximal exertion and is reduced in adults with congenital heart disease (ACHD), is associated with lesion severity. The lowest ventilatory equivalent for oxygen (the minimum value of VE/VO2) reflects the cardiorespiratory optimal point (COP) as best possible respiration-circulatory interaction and may discriminate between lesion types without the need for maximal exertion. However, data on COP in ACHD is scarce., Methods: We retrospectively analyzed stable ACHD with moderate (N.=13) and severe lesions (N.=17) reporting to our outpatient clinic undergoing cardiopulmonary exercise testing. The primary outcome of the study was the difference of COP between moderate and severe lesions. Secondary outcomes were between group differences of the submaximal variable exercise oxygen uptake efficiency slope (OUES) and peak O2 pulse (O2pulsemax) as a surrogate for peripheral oxygen extraction and stroke volume increase during exercise., Results: The group of severe lesions displayed higher COP (29.5±7.0 vs. 25.2±6.2, P=0.028) as well as lower O2pulsemax (13.3±8.4 vs. 14.9±3.4 mL/beat/kg 10 2 , P=0.038). VO2peak (17.4±6.5 vs. 20.8±8.5 mL/kg/min, P=0.286) and OUES (1.5±0.7 vs. 1.8±0.9, P=0.613) showed a trend towards lower values in severe lesions. COP was a better between group discriminator than O2pulsemax (area under the curve 73.8% vs. 72.4%)., Conclusions: As a submaximal variable, COP discriminated between moderate and severe lesions and may prove beneficial in a highly vulnerable population that is often unable to undergo exertional testing.