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In patients with cardiovascular, pulmonary, muscular and neurological diseases, cardiopulmonary exercise testing (CPET) is a valuable tool providing clinically-relevant diagnostic and prognostic information by evaluation of exercise response. CPET requires to be performed in dedicated centers able to correctly carry out the examination and to carefully evaluate the results. CPET analyzes functional capacity revealing both symptomatic and asymptomatic intolerance to exercise. One of the most important advantages for clinicians derived by the use of CPET, beyond standard exercise electrocardiography testing, is the capability not only to grade the severity of the disease, but also to distinguish between different causes of dyspnea and exercise impairment. Indications for CPET use in clinical practice are increasing in the last decades, evolving beyond the routine use as a training tool in athletes. In fact, CPET represents an important step in the management of patients with heart failure or pulmonary hypertension, as suggested by international guidelines. CPET role in helping for the selection of patients candidate to heart transplantation is also well known. Beyond its clinical usefulness, scientific interest in CPET is constantly expanding, mainly due to the safety of the exam and to the huge size of the pathophysiological information that it offers. The aim of this paper is to simply explain everyday applications and potential further purposes of CPET in clinical practice. Our review is intended both for physicians approaching CPET for the first time and for clinicians with an interest in expanding their knowledge in this field.

Background: Pathological changes were observed in the diaphragm due to abnormal renal function in chronic kidney disease (CKD). Inspiratory muscle training (IMT) has been suggested for patients with CKD; however, the most appropriate intensity for IMT has not been determined. Therefore, this study aimed to investigate the effects of different IMT protocols on respiratory muscle strength, quadriceps femoris muscle strength (QMS), handgrip muscle strength (HGS), functional exercise capacity, quality of life (QoL), pulmonary function, dyspnoea, fatigue, balance, and physical activity (PA) levels in patients with CKD., Methods: This randomized, controlled, single-blind study included 47 patients and they were divided into three groups: Group 1 (n = 15, IMT with 10% maximal inspiratory pressure (MIP)), Group 2 (n = 16, IMT with 30% MIP), and Group 3(n = 16; IMT with 60% MIP). MIP, maximal expiratory pressure (MEP), 6-min walking test (6-MWT), QMS, HGS, QoL, pulmonary function, dyspnoea, fatigue, balance, and PA levels were assessed before and after eight weeks of IMT., Results: Increases in MIP, %MIP, 6-MWT distance, and %6-MWT were significantly higher in Groups 2 and 3 than in Group 1 after IMT (p < 0.05). MEP, %MEP, FEF 25-75%, QMS, HGS, and QoL significantly increased; dyspnoea and fatigue decreased in all groups (p < 0.05). FVC, PEF, and PA improved only in Group 2, and balance improved in Groups 1 and 2 (p < 0.05)., Conclusions: IMT with 30% and 60% MIP similarly improves inspiratory muscle strength and functional exercise capacity. IMT with 30% is more effective in increasing PA. IMT is a beneficial method to enhance peripheral and expiratory muscle strength, respiratory function, QoL and balance, and reduce dyspnoea and fatigue. IMT with %30 could be an option for patients with CKD who do not tolerate higher intensities., Trial Registration: This study was retrospectively registered (NCT06401135, 06/05/2024)., (© 2024. The Author(s).)

Patients with advanced lung disease, especially patients with COPD, suffer from dyspnea at rest that worsens during the performance of even limited physical activities. The causes of dyspnea are multifactorial and are related to structural changes found in the parenchymal compartment of the lung as well as the airway and pulmonary vasculature. Alterations in any of the lung compartments may have negative consequences for the physiological performance of exercise. Respiratory assist devices that attenuate the pathophysiological derangements induced by the underlying lung disease, and/or unload the increased work of breathing, can enhance the performance of exercise, and help to produce more robust training effects in patients with lung disease. Herein we review the data that examines these approaches using respiratory assist devices to improve exercise outcomes in patients with COPD., Competing Interests: The author has disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Exercise limitation is a characteristic feature of chronic respiratory diseases such as COPD and is associated with poor outcomes including decreased functional status and health-related quality of life and increased mortality. The mechanisms responsible for exercise limitation are complex and include ventilatory limitation, cardiovascular impairment, and skeletal muscle dysfunction. In addition, comorbidities such as cardiovascular disease are common in this population and can further impact exercise capacity. Exercise training, a core component of pulmonary rehabilitation, improves exercise capacity by addressing many of these mechanisms that, in turn, can potentially slow the decline of lung function, reduce the frequency of exacerbations, and decrease mortality. This article will discuss the mechanisms of exercise limitation in individuals with chronic respiratory disease, primarily focusing on COPD, and provide an overview of exercise training and its benefits in this patient population., Competing Interests: Dr Nici has disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: Due to their relationship with clinical progression, follow-up of exercise capacity and muscle strength is important for optimal disease management in patients who have undergone the Fontan procedure. We aimed to retrospectively analyze exercise capacity and muscle strength trajectory over approximately 2 years., Methods: Exercise capacity was assessed using an exercise stress test with the modified Bruce protocol on a treadmill, hand grip and knee extensor strength using a hand dynamometer, and body composition using a bioelectrical impedance device. Exercise capacity, muscle strength, and body composition follow-up data recorded between 2020 and 2022 were compared., Results: Fifteen patients [median age from 17 (first assessment) to 18 years (last assessment), 5 females)] with a 20-month median follow-up time were analyzed retrospectively. There was an increase in weight, height, body mass index, and body fat weight (p<0.05). There was a tendency for increased handgrip strength (%) (p=0.069), but no significant difference was observed in the knee extensor strength of patients during the follow-up period (p>0.05). The changes in heart rate (HR) and oxygen saturation were higher in the last test than in the first test (p<0.05). Maximum HR (HRmax), % predicted HRmax and HR reserve recorded during the test and HR 1 minute after the test were similar between the first and last tests (p>0.05)., Conclusions: After 20 months of follow-up, exercise capacity and muscle strength did not decline; instead, the body mass index and fat weight increased. Patients who have undergone the Fontan procedure may not be experiencing a decline in exercise capacity and muscle strength over relatively short time periods during childhood, adolescence, and early adulthood., Competing Interests: The authors declare that there is no conflict of interest.

This technique-focused observational study explores the impact of a 6-week Nordic Walking (NW) program on physiological and biomechanical aspects in ischemic heart disease (IHD) patients. Twelve male IHD patients (66.2 ± 5.2 years, 12.2 ± 7.5 years of disease duration) were evaluated pre- and post-training for (i) gait parameters, (ii) exercise tolerance using electrocardiographic (ECG) stress test, (iii) a 6-min walk test (6MWT). The NW training, adhering to IHD patient guidelines, involved a 100-m walk at a self-selected, preferred speed without sticks, with classic NW sticks and mechatronic sticks. A mechatronic measuring system, specifically engineered for measuring, diagnosing and monitoring the patient's gait, was integrated into mechatronic sticks. Post-training, significant enhancements were observed in ECG stress test duration, metabolic equivalency, and 6MWT distance, irrespective of the stick type. However, no significant changes were noted in spatiotemporal parameters concerning the measured side, stick utilisation, or type. The results suggest that NW training boosts exercise capacity and refines gait mechanics in male IHD patients. However, the improvement in exercise capacity was not linked to changes in gait mechanics from NW training but rather to the movement during NW gait. Hence, the key to enhancing exercise capacity in IHD patients is the movement during NW gait, not the quality of gait mechanics., (© 2024. The Author(s).)

The global temperature rise will have extensive consequences on our organ systems, but hypohydration caused by reduced water intake or increased water loss through sweating plays the most relevant role. Many studies have already demonstrated the association between hypohydration and impaired exercise performance, but data related to the cardiac burden of hypohydration are scarce. This study is a sub-investigation of our large, prospective, self-controlled trial on the effects of hypohydration on cardiopulmonary exercise capacity with previously published results. In the current sub-study, we analyzed the impact of hypohydration on cardiac burden in this cohort of fifty healthy, recreational athletes during cardiopulmonary exercise test.Therefore, each participant underwent cardiopulmonary exercise test with a standardized ramp protocol twice, once in hypohydrated state and once in euhydrated state as control, and the cardiac markers Troponin T, NT-pro-BNP and Chromogranin A were measured before and after the exercise test at each state. Mean age was 29.7 years and 34% of probands were female. Hypohydration led to a reduced body water, a significant decrease in oxygen uptake and lower levels of power output. Yet, Troponin T, NT-proBNP, Chromogranin A and lactate levels did not significantly differ between the two conditions.In this study cohort, decreased exercise capacity during hypohydration was more likely due to impaired cardiac output with diminished plasma volume rather than measurable cardiac stress from fluid deprivation. However, whether these data are generalizable to a diseased cohort is left unanswered and should be addressed in future randomized controlled trials.

Post-acute COVID-19 syndrome, or long COVID, presents with persistent symptoms, including cough, dyspnea, and fatigue, extending beyond one month after SARS-CoV-2 infection. Cardiac complications such as chest pain and arrhythmias have raised concerns, with chronotropic incompetence (CI), an inadequate heart rate increase during exercise, emerging as a significant condition contributing to diminished exercise tolerance and quality of life. This study estimated the prevalence of CI and explored its association with aerobic capacity and physical activity levels in long COVID patients. A cross-sectional study was conducted at a private hospital in Sergipe, Brazil, involving 93 patients over 18 years old with persistent post-COVID-19 symptoms after confirmed SARS-CoV-2 infections. Exclusion criteria included beta-blocker use, inadequate respiratory exchange ratio, and inability to complete cardiopulmonary exercise testing (CPET). Clinical histories, CPET results, and chronotropic index calculation were used to identify CI, with logistic regression analyzing associated factors. Of the participants (mean age 45 years; average duration since COVID-19 diagnosis 120 days), 20.4% were diagnosed with CI. Logistic regression identified a strong association between CI and sedentary behavior (OR 11.80; 95% CI 2.54 to 54.78; p=0.001). Patients with CI showed lower predicted peak heart rates and maximal oxygen uptake. The prevalence of CI among long COVID patients in this study was approximately 20%, associated with decreased aerobic capacity and increased sedentary behavior. These findings highlight the need for timely diagnosis and therapeutic interventions, including cardiopulmonary rehabilitation, to enhance the quality of life in post-COVID patients with CI. The study's cross-sectional design and its specific context have limited causality inference and generalizability, underscoring the importance of further research in diverse settings.

Background: Skeletal muscle wasting is critical in patients with heart failure (HF). Whereas prior studies have employed appendicular lean mass (ALM) normalized by height squared to identify low skeletal muscle mass, the potential of ALM normalized to body mass index (ALM/BMI) remains unexplored in patients with HF. In this study, we compared the use of 2 skeletal muscle mass indices in patients with HF to examine their sex-specific correlations with measures of physical capacity, quality of life, and daily physical activity., Methods and Results: A total of 111 patients with HF underwent dual x-ray absorptiometry, physical capacity tests, and accelerometry and answered a quality-of-life questionnaire. ALM normalized by height squared and ALM/BMI indices disagreed in classifying low muscle mass (Cohen's κ, -0.008 [95% CI, -0.094 to 0.177]; P =0.93). ALM/BMI correlated well with 6-minute walking distance in women and men ( R =0.67 and 0.49; P <0.001), with maximal oxygen uptake in women and men ( R =0.41 and 0.48; P <0.05), and with maximal muscle strength in women and men ( R =0.54 and 0.43; P <0.01). Inversely, ALM normalized by height squared did not correlate significantly with 6-minute walking distance or maximal oxygen uptake and correlated with maximal muscle strength only in men ( R =0.43; P <0.001). Only ALM/BMI allowed for identification of a low-muscle-mass group characterized by poor quality of life (Minnesota Living With Heart Failure Questionnaire score of 33±21 versus 25±16; P =0.027) and less daily time spent in moderate to vigorous physical activity (8 [3-17] versus 15 [9-37] minutes; P <0.001)., Conclusions: ALM/BMI was superior for identifying clinically significant muscle dysfunction in both female and male patients with HF.

Background: Pulmonary rehabilitation (PR) is recommended for the treatment of people with idiopathic pulmonary fibrosis (IPF). Physical activity is an important health behaviour, closely linked to survival in people with IPF. Little is known about the impact of virtual (V) PR on physical activity in people with IPF., Objective: To explore the feasibility of conducting a trial to explore effect of virtual PR on objectively measured physical activity in people with IPF., Methods: All patients with a diagnosis of IPF in a stable phase of the disease were invited to participate in VPR: a 10 week exercise programme delivered twice-weekly for one hour. Data were collected at baseline (BL) and post VPR (10 weeks): Kings Brief Interstitial Lung Disease (K-BILD), Exercise capacity (6-minute walk test (6MWT) or 1-minute sit-to-stand (STS)) and Physical Activity. Physical activity was measured with a triaxial accelerometer for seven days. Screening, recruitment, adherence and safety data were collected., Results: 68 people were screened for this study. N = 16 participants were recruited to the study. There was one dropout. N = 15 completed VPR. All results reported in mean (standard deviation) (SD). Participants attended 18.1(2.0) of the 20 sessions. No adverse events were detected. The mean age of participants was 71.5(11.5) years, range: 47-95 years; 7 M:9 F. Mean (SD) FEV 1 2.3(0.3)L, FVC 2.8(0.7)L. No statistically significant changes were observed in outcome measures apart from exercise capacity. Light physical activity increased from 152(69.4) minutes per day (n = 16) to 161.9(88.7) minutes per day (n = 14), mean change (SD) (CI) p-value: 9.9 (39.8) [-12.3 to 30.9] p = 0.4. Moderate-to-vigorous physical activity increased from 19.1(18.6) minutes per day (n = 16) to 25.7(28.3) minutes per day (n = 14), mean change (SD) (CI) p-value: 6.7 (15.5) [-2.1 to 15.1] p = 0.1. Step count increased from 3838(2847) steps per day (n = 16) to 4537(3748) steps per day (n = 14), mean change (SD) (CI) p-value: 738 (1916) [-419.3 to 1734.6] p = 0.2. K-BILD (n = 15) increased from 55.1(7.4) at BL to 55.7(7.9) post VPR mean change (SD) [95% confidence interval] (CI) p-value: 1.7(6.5) [-1.7 to 5.3], p = 0.3. 6MWT (n = 5) increased from 361.5(127.1) to 452.2(136.1) meters, mean change (SD) (CI) p-value: 63.7 (48.2) [-3.8 to 123.6], p = 0.04 and 1-minute STS increased from 17.6(3.0) (n = 11) to 23.7(6.3) (n = 10), mean change (SD) (CI) p-value 5.8 (4.6) [2.6 to 9.1], p = 0.003., Conclusion: VPR can improve physical activity in people with IPF. A number of important feasibility issues included recruitment, retention, adherence and safety have been reported which are crucial for future research in this area. A fully powered trial is needed to determine the response of people with IPF to PR with regard to physical activity., (© 2024. The Author(s).)

Voluntary or forced exercise training in mice is used to assess functional capacity as well as potential disease-modifying effects of exercise over a range of cardiovascular disease phenotypes. Compared to voluntary wheel running, forced exercise training enables precise control of exercise workload and volume, and results in superior changes in cardiovascular performance. However, the use of a shock grid with treadmill-based training is associated with stress and risk of injury, and declining compliance with longer periods of training time for many mouse strains. With these limitations in mind, we designed a novel, high-intensity interval training modality (HIIT) for mice that is carried out on a rotarod. Abbreviated as RotaHIIT, this protocol establishes interval workload intensities that are not time or resource intensive, maintains excellent training compliance over time, and results in improved exercise capacity independent of sex when measured by treadmill graded exercise testing (GXT) and rotarod specific acceleration and endurance testing. This protocol may therefore be useful and easily implemented for a broad range of research investigations. As RotaHIIT training was not associated cardiac structural or functional changes, or changes in oxidative capacity in cardiac or skeletal muscle tissue, further studies will be needed to define the physiological adaptations and molecular transducers that are driving the training effect of this exercise modality., (© 2024 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Background: This systematic review and meta-analysis aims to explore in heart failure (HF) patients with reduced ejection fraction (EF) undergoing exercise-based cardiac rehabilitation the following: 1) the comparison of temporal changes between peak oxygen uptake (VO2peak) and first ventilatory threshold (VO2VT1), 2) the association of VO2peak and VO2VT1 changes with physiological factors, and 3) the differential effects of continuous aerobic exercise (CAE) and interval training (IT) on VO2peak and VO2VT1., Methods: A systematic literature search was conducted in PubMed, CENTRAL, and Scopus. Inclusion criteria were 1) original research articles using exercise-based cardiac rehabilitation, 2) stable HF patients with reduced EF, 3) available values of VO2peak and VO2VT1 (in mL/kg/min) both at baseline and after exercise training with comparison between these time points., Results: Among the 30 eligible trials, 24 used CAE, 5 IT, and one CAE and IT. Multivariable meta-regression with duration of exercise training and percentage of males as independent variables and the change in VO2peak as a dependent variable showed that the change in VO2peak was negatively associated with duration of exercise training (coefficient=-0.061, p=0.027), implying the possible existence of a waning effect of exercise training on VO2peak in the long term. Multivariable meta-regression demonstrated that both age (coefficient=-0.140, p<0.001) and EF (coefficient=-0.149, p<0.001) could predict the change in VO2VT1, whereas only age (coefficient=-0.095, p=0.022), but not EF (coefficient = 0.082, p = 0.100), could predict the change in VO2peak. The posttraining peak respiratory exchange ratio, as an index of maximum effort during exercise testing, correlated positively with the change in VO2peak (coefficient=-0.021, p=0.044). The exercise-induced changes of VO2peak (p = 0.438) and VO2VT1 (p = 0.474) did not differ between CAE and IT groups., Conclusions: Improvement of endurance capacity during cardiac rehabilitation may be detected more accurately with the assessment of VO2VT1 rather than VO2peak., Competing Interests: Declaration of Competing Interest Declarations of interest: none., (Copyright © 2024 Hellenic Society of Cardiology. All rights reserved.)

INTRODUCTION: There is a current belief in aviation suggesting that aerobic training may reduce G-tolerance due to potential negative impacts on arterial pressure response. Studies indicate that increasing maximal aerobic capacity (INLINEMATHo₂-max testing for insights into fitness, risks, and tailored exercise. Zeigler Z, Acevedo AM. Re-evaluating the need for routine maximal aerobic capacity testing within fighter pilots . Aerosp Med Hum Perform. 2024; 95(5):273-277.

This study investigates the association between maximal functional capacity (peakVO 2 ) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in 133 ambulatory patients with heart failure with preserved ejection fraction (HFpEF), focusing on patients with obesity. Across all participants, NT-proBNP inversely correlated with peakVO 2 . However, this association varied based on obesity status. In patients without obesity, there was an inverse relationship between NT-proBNP and peakVO 2 , while no significant correlation was observed in patients with obesity. These findings suggest that in stable ambulatory HFpEF, NT-proBNP did not predict peakVO 2 in patients with obesity., Competing Interests: Declaration of Competing Interest Authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aims: We aimed to assess physical activity (PA) levels, adherence to PA guidelines, and fitness capacity in individuals with type 1 diabetes (T1D) and control population., Methods: This cross-sectional study included 232 T1D and 248 controls. PA levels (IPAQ-SF questionnaire), adherence to guidelines (>150 min/week of moderate-to-vigorous PA), fitness capacity (VO 2 max, maximal incremental test on a cycle ergometer and 1RM test) were assessed, along with other clinical variables., Results: Total PA levels (T1D 2202 ± 1839 vs. controls 2357 ± 2189 METs/min/week), adherence (T1D 53.1 % vs controls 53.2 %), and sedentariness (T1D 27.3 % vs. controls 25.1 %) were similar between groups. However, participants with T1D exhibited significantly lower levels of VO 2 max (29.1 ± 10.5 vs. 32.5 ± 11.5 mlO 2 /kg/min, p < 0.001), work capacity (2.73 ± 1.03 vs. 3 ± 10 W/kg of body weight, p = 0.004) and strength capacity (2.29 ± 0.53 vs. 2.41 ± 0.79 kg/kg body weight in 1RM, p = 0.01) than controls, after adjusting for sex and age., Conclusions: Individuals with T1D exhibit lower fitness capacity compared to a control population, regardless of age and sex, even when presenting similar levels of total physical activity and adherence to guidelines., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Purpose: Dietary nitrate (NO 3 - ) supplementation can lower systolic blood pressure (SBP) and improve exercise performance. Salivary flow rate (SFR) and pH are key determinants of oral NO 3 - reduction and purported to peak in the afternoon. We tested the hypotheses that NO 3 - -rich beetroot juice (BR) would increase plasma [nitrite] ([NO 2 - ]), lower SBP and improve exercise performance to a greater extent in the afternoon (AFT) compared to the morning (MORN) and evening (EVE)., Method: Twelve males completed six experimental visits in a repeated-measures, crossover design. NO 3 - -depleted beetroot juice (PL) or BR (~ 13 mmol NO 3 - ) were ingested in the MORN, AFT and EVE. SFR and pH, salivary and plasma [NO 3 - ] and [NO 2 - ], brachial SBP and central SBP were measured pre and post supplementation. A severe-intensity exercise tolerance test was completed to determine cycling time to exhaustion (TTE)., Results: There were no between-condition differences in mean SFR or salivary pH. The elevation in plasma [NO 2 - ] after BR ingestion was not different between BR-MORN, BR-AFT and BR-EVE. Brachial SBP was unchanged following BR supplementation in all conditions. Central SBP was reduced in BR-MORN (- 3 ± 4 mmHg), BR-AFT (- 4 ± 3 mmHg), and BR-EVE (- 2 ± 3 mmHg), with no differences between timepoints. TTE was not different between BR and PL at any timepoint., Conclusion: Acute BR supplementation was ineffective at improving TTE and brachial SBP and similarly effective at increasing plasma [NO 2 - ] and lowering central SBP across the day, which may have implications for informing NO 3 - supplementation strategies., (© 2023. The Author(s).)

Rationale: A COPD Foundation working group sought to identify measures of exercise endurance, a meaningful aspect of physical functioning in everyday life among patients with chronic obstructive pulmonary disease (COPD) that is not fully accepted in regulatory decision making, hampering drug development. Objectives: To demonstrate, as we previously asserted (Casaburi COPD 2022;9:252), that constant work rate cycling endurance time is an appropriate exercise endurance measure in patients with COPD. Methods: To validate this assertion, we assembled an integrated database of endurance time responses, including 8 bronchodilator (2,166 subjects) and 15 exercise training (3,488 subjects) studies (Casaburi COPD 2022;9:520). Results: Construct validity was demonstrated: 1 ) peak physiologic and perceptual responses were similar for constant work rate and incremental cycling; 2 ) after bronchodilator therapy, there were greater increases in endurance time in patients with more severe airflow limitation; 3 ) after exercise training, endurance time increases were similar across airflow limitation severities; and 4 ) there were correlations between changes in endurance time and changes in mechanistically related physiologic and perceptual variables. Test-retest reliability was demonstrated, with consistency of changes in endurance time at two time points after the intervention. Responsiveness was confirmed, with significant increases in endurance time after active (but not placebo) bronchodilator therapy, with greater increases seen with more severe airflow limitation and after exercise training. On the basis of regression analysis using multiple anchor variables, the minimum important difference for endurance time increase is estimated to be approximately 1 minute. Conclusions: Constant work rate cycling endurance time is a valid exercise endurance measure in COPD, suitable for contributing to the evaluation of treatment benefit supporting regulatory decision making and evidence-based therapeutic recommendations.

Objective: This study examined the relationship between changes in physical activity and their impact on exercise capacity and health-related quality of life over a 3-year span in patients with CHD., Methods: We evaluated 99 young patients with CHD, aged 13-18 years at the outset. Physical activity, health-related quality of life, and exercise capacity were assessed via questionnaires and peak oxygen uptake measurements at baseline and after 3 years; changes in measures were estimated between the two time points and categorised into quartiles. Participants were stratified according to achieved (active) or not-achieved (inactive) recommended levels of physical activity (≥150 minutes/week) at both time points., Results: Despite increases in physical activity, exercise capacity, and health-related quality of life over 3 years, the changes were not statistically significant (all p > 0.05). However, a positive association was found between physical activity changes and exercise capacity (ß = 0.250, p = 0.040) and health-related quality of life improvements (ß = 0.380, p < 0.001). Those with the most pronounced physical activity increase showed notable exercise capacity (p < 0.001) and health-related quality of life increases (p < 0.001) compared with patients with the largest decline in physical activity. The active-inactive category demonstrated a notable decline in exercise capacity compared to the active-active group, while the inactive-active group showed health-related quality of life improvements., Conclusions: Over 3 years, increased physical activity was consistently linked to increases in exercise capacity and health-related quality of life in patients with CHD, highlighting the potential of physical activity augmentation as an intervention strategy.

Background: Substance use disorder (SUD) causes conditions such as cognitive and behavioral disorders, anxiety, depression, and social isolation it also causes acute airway inflammation by affecting airway bronchial dynamics. The current study aimed to investigate the lung function, respiratory muscle strength, and exercise capacity in patients with SUD., Methods: One hundred-eighty three patients with SUD, a total of 119 healthy controls, 54 of whom were cigarette smokers and 65 of whom were non-smokers were included in the study. Spirometric tests, respiratory muscle strength (MIP and MEP), and the 6-Minute Walk Test (6-MWT) were assessed. The III National Health and Nutrition Examination Survey were used to evaluate respiratory symptoms in patients with SUD and cigarette smokers., Results: 86.3% of the SUD patients included in the study were using heroin, 9.2% were cannabis, and 5.5% were spice. The most common symptom in both SUD patients and cigarette smokers was shortness of breath, wheezing, and sputum production. After post-hoc tests, the FVC (p = 0.002), FVC (%predicted) (p < 0.0001), FEV 1 (p = 0.002), FEV1 (%predicted) (p < 0.0001), FEV 1 /FVC (%) (p < 0.0001), PEF (p < 0.0001) and FEF %25-75 (p < 0.0001) lung function parameters were significantly lower in SUD patients than non-smokers. In addition, it was found that MIP (p < 0.0001), MIP (%predicted) (p < 0.0001), MEP (p < 0.0001), and MEP (%predicted) (p < 0.0001) values of SUD patients were significantly lower than non-smokers., Conclusion: The study findings indicate that substance use has an effect on lung functions and the most commonly reported symptoms are shortness of breath, wheezing, and sputum production. In addition, respiratory muscle strength and exercise capacity were decreased in SUD patients compared to non-smokers., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2022 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)

Background: We sought to evaluate the influence of the rudimentary ventricle on long-term outcomes after the Fontan operation, focusing on exercise capacity and cardiac performance. Methods: Between 1995 and 2021, 290 patients underwent a total cavopulmonary connection. "Two-ventricle" Fontan circulation was defined as a rudimentary ventricle >30% of the dominant ventricle or >50% of its predicted normal value. This cohort was compared with patients with single-ventricle Fontan circulation. The primary endpoint was Fontan failure, and the secondary endpoints were VO 2 and cardiac catheterization data at ten years postoperatively. Results: The median follow-up after the Fontan operation was 7.9 years (interquartile range: 1.9-13.9). No significant difference was found in Fontan failure-free survival between the "two-ventricle" Fontan circulation group and the single-ventricle Fontan circulation group (83/91, 93% vs 156/199, 78%), respectively at 20 years; P  = .11). No significant difference was found in VO 2 or cardiac performance except cardiac index, with 2.9 (2.3-4.8) versus 2.5 (2.3-4.3) L/min/m 2 ( P  = .047). Fifty-one patients in the "two-ventricle" Fontan circulation group were followed up for over ten years after the Fontan operation. In the subgroup analysis of this cohort, the rudimentary ventricular end-diastolic volume/dominant ventricular end-diastolic volume ratio showed a significant positive correlation with dominant ventricular end-diastolic pressure (r = 0.58 [95% CI 0.35-0.74], P  = .002) and a significant negative correlation with VO 2 (r = -0.61 [95% CI -0.80 to -0.28], P  = .001). Conclusions: The rudimentary ventricle was not significantly associated with any clinical disadvantages regarding Fontan failure. However, a large rudimentary ventricle was significantly associated with higher end-diastolic pressure and lower exercise capacity., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Submaximal functional tests of endurance are ubiquitous in clinical practice. This investigation compared cardiovascular responses, perceived exertion, and performance measures following the completion of three self-paced, 2-minute, functional tests of endurance. A pilot prospective, observational, cross-sectional design with 16 community-dwelling older participants compared heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), rating of perceived exertion (RPE), and performance measures following the completion of three randomly allocated self-paced activities. The three activities included 2 minutes of stepping in standing (2MSTD), 2 minutes of seated stepping (2MSIT), and a 2-minute walk test (2MWT). A within-subjects repeated measures ANOVA analyzed differences in change scores for cardiovascular and RPE responses. Pearson's correlations assessed associations in performance measures between the three tests. Standing stepping compared to seated stepping produced statistically higher change scores in HR, SBP, DBP, and RPE (p < .05). Further, 2MSTD revealed statistically higher SBP and RPE scores compared to 2MWT (p < .05). Large and moderate correlations were observed between number of steps completed in sitting and standing (r = 0.83, p < .01) and between standing steps and distance walked (r = 0.56, p = .02), respectively. This pilot investigation informs home care physical therapists that 2 minutes of self-paced stepping in standing produced the greatest change scores in all cardiovascular and perceived exertion responses. No significant differences were noted in HR between self-paced walking and standing stepping, and between standing and seated stepping. For patients unable to walk or step in standing, self-paced seated stepping may be a viable alternative., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Adolescents living with obesity (AlwO) can have limited exercise capacity. Exercise capacity can be predicted by a 2-factor model comprising lung function and leg muscle function, but no study has looked at cycling leg muscle function and its contribution to cycling exercise capacity in AlwO., Methods: Twenty-two nonobese adolescents and 22 AlwO (BMI > 95 percentile) were studied. Anthropometry, body composition (dual-energy X-ray absorptiometry), spirometry, 30-s isokinetic work capacity, and maximal exercise (cycle ergometry) were measured., Results: AlwO had greater total body mass, lean body mass, and lean leg mass (LLM). Lung function trended higher in AlwO. Leg 30-s work did not differ in absolute terms or per allometrically scaled LLM. Peak oxygen consumption did not differ between the groups in absolute terms or as percent predicted values (79.59 ± 14.6 vs. 82.3 ± 11.2% predicted control versus ALwO) but was lower in AlwO when expressed per kg body mass, kg lean body mass, scaled lean body mass, and LLM. Peak oxygen consumption related to both lung function and 30-s work, with no observed group effect. 30-s leg work related to the scaled LLM, with a small group effect. There was some correlation between leg work and time spent in moderate to vigorous physical activity in AlwO (r s  = 0.39, p = .07)., Conclusion: AlwO have larger LLM and preserved exercise capacity, when expressed as percentage of predicted, but not per allometrically scaled LLM. Increasing time spent in moderate to vigorous activity may benefit AlwO., (© 2024 Wiley Periodicals LLC.)

Background: This study aimed to determine the effect of different carbohydrate (CHO) doses on exercise capacity in patients with McArdle disease-the paradigm of "exercise intolerance", characterized by complete muscle glycogen unavailability-and to determine whether higher exogenous glucose levels affect metabolic responses at the McArdle muscle cell (in vitro) level., Methods: Patients with McArdle disease (n = 8) and healthy controls (n = 9) underwent a 12-min submaximal cycling constant-load bout followed by a maximal ramp test 15 min after ingesting a non-caloric placebo. In a randomized, double-blinded, cross-over design, patients repeated the tests after consuming either 75 g or 150 g of CHO (glucose:fructose = 2:1). Cardiorespiratory, biochemical, perceptual, and electromyographic (EMG) variables were assessed. Additionally, glucose uptake and lactate appearance were studied in vitro in wild-type and McArdle mouse myotubes cultured with increasing glucose concentrations (0.35, 1.00, 4.50, and 10.00 g/L)., Results: Compared with controls, patients showed the "classical" second-wind phenomenon (after prior disproportionate tachycardia, myalgia, and excess electromyographic activity during submaximal exercise, all p < 0.05) and an impaired endurance exercise capacity (-51% ventilatory threshold and -55% peak power output, both p < 0.001). Regardless of the CHO dose (p < 0.05 for both doses compared with the placebo), CHO intake increased blood glucose and lactate levels, decreased fat oxidation rates, and attenuated the second wind in the patients. However, only the higher dose increased ventilatory threshold (+27%, p = 0.010) and peak power output (+18%, p = 0.007). In vitro analyses revealed no differences in lactate levels across glucose concentrations in wild-type myotubes, whereas a dose-response effect was observed in McArdle myotubes., Conclusion: CHO intake exerts beneficial effects on exercise capacity in McArdle disease, a condition associated with total muscle glycogen unavailability. Some of these benefits are dose dependent., (Copyright © 2024. Production and hosting by Elsevier B.V.)

Background: While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance., Methods: We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves., Results: On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48-0.54 versus 0.38) and peak VO 2 percentage predicted (0.23-0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO 2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11-0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16-0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53-1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082)., Conclusions: In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes., Competing Interests: Disclosures None.

Background: Currently, excess ventilation has been grounded under the relationship between minute-ventilation/carbon dioxide output ( V ˙ E - V ˙ CO 2 ). Alternatively, a new approach for ventilatory efficiency ( η E V ˙ ) has been published., Objective: Our main hypothesis is that comparatively low levels of η E V ˙ between chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are attainable for a similar level of maximum and submaximal aerobic performance, conversely to long-established methods ( V ˙ E - V ˙ CO 2 slope and intercept)., Methods: Both groups performed lung function tests, echocardiography, and cardiopulmonary exercise testing. The significance level adopted in the statistical analysis was 5%. Thus, nineteen COPD and nineteen CHF-eligible subjects completed the study. With the aim of contrasting full values of V ˙ E - V ˙ CO 2 and η V ˙ E for the exercise period (100%), correlations were made with smaller fractions, such as 90% and 75% of the maximum values., Results: The two groups attained matched characteristics for age (62±6 vs. 59±9 yrs, p>.05), sex (10/9 vs. 14/5, p>0.05), BMI (26±4 vs. 27±3 Kg m2, p>0.05), and peak V ˙ O 2 (72±19 vs. 74±20 %pred, p>0.05), respectively. The V ˙ E - V ˙ CO 2 slope and intercept were significantly different for COPD and CHF (27.2±1.4 vs. 33.1±5.7 and 5.3±1.9 vs. 1.7±3.6, p<0.05 for both), but η V ˙ E average values were similar between-groups (10.2±3.4 vs. 10.9±2.3%, p=0.462). The correlations between 100% of the exercise period with 90% and 75% of it were stronger for η V ˙ E (r>0.850 for both)., Conclusion: The η V ˙ E is a valuable method for comparison between cardiopulmonary diseases, with so far distinct physiopathological mechanisms, including ventilatory constraints in COPD.

Competing Interests: Competing interests: None declared.

Background: Field-based walk tests conducted remotely may provide an alternative method to a facility-based assessment of exercise capacity for people with advanced lung disease. This prospective study evaluated the level of agreement in the distance walked between a 6-min walk test (6MWT) and an incremental shuttle walk test performed by using standard in-person procedures and test variations and settings., Methods: Adults with advanced lung disease underwent 4 study visits: (i) one in-person standard 6MWT (30-m corridor) and one in-person treadmill 6MWT, (ii) a remote 6MWT in a home setting (10-m corridor), (iii) 2 in-person standard incremental shuttle walk tests (10-m corridor), and (iv) a remote incremental shuttle walk test in a home setting (10-m corridor). A medical-grade oximeter measured heart rate and oxygen saturation before, during, and for 2 min after the tests., Results: Twenty-eight participants were included (23 men [82%]; 64 (57-67) y old; 19 with interstitial lung disease [68%] and 9 with COPD [32%]; and 26 used supplemental oxygen (93%) [exertional [Formula: see text] of 0.46 ± 0.1]). There was no agreement between the tests. Greater walking distances were achieved with standard testing procedures: in-person 6MWT versus treadmill 6MWT (355 ± 68 vs 2 96 ± 97; P = .001; n = 28), in-person 6MWT versus remote 6MWT (349 ± 68 vs 293 ± 84; P = .001; n = 24), and in-person incremental shuttle walk test versus remote incremental shuttle walk test (216 ± 62 vs 195 ± 63; P = .03; n = 22)., Conclusions: Differences in the distance walked may have resulted from different track lengths, widths, and walking surfaces. This should be considered in test interpretation if tests are repeated under different conditions., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: Despite being a prognostic predictor, cardiac autonomic dysfunction (AD) has not been well investigated in chronic obstructive pulmonary disease (COPD). We aimed to characterise computed tomography (CT), spirometry, and cardiopulmonary exercise test (CPET) features of COPD patients with cardiac AD and the association of AD with CT-derived vascular and CPET-derived ventilatory efficiency metrics., Methods: This observational cohort study included stable, non-severe COPD patients. They underwent clinical evaluation, spirometry, CPET, and CT. Cardiac AD was determined based on abnormal heart rate responses to exercise, including chronotropic incompetence (CI) or delayed heart rate recovery (HRR) during CPET., Results: We included 49 patients with FEV1 of 1.2-5.0 L (51.1-129.7%), 24 (49%) had CI, and 15 (31%) had delayed HRR. According to multivariate analyses, CI was independently related to reduced vascular volume (VV; VV ≤ median; OR [95% CI], 7.26 [1.56-33.91]) and low ventilatory efficiency (nadir VE/VCO2 ≥ median; OR [95% CI], 10.67 [2.23-51.05]). Similar results were observed for delayed HRR (VV ≤ median; OR [95% CI], 11.46 [2.03-64.89], nadir VE/VCO2 ≥ median; OR [95% CI], 6.36 [1.18-34.42])., Conclusions: Cardiac AD is associated with impaired pulmonary vascular volume and ventilatory efficiency. This suggests that lung blood perfusion abnormalities may occur in these patients. Further confirmation is required in a large population-based cohort., (© 2024. The Author(s).)

Aims: Carotid baroreflex activation therapy (BAT) restores baroreflex sensitivity and modulates the imbalance in cardiac autonomic function in patients with heart failure with reduced ejection fraction (HFrEF). We tested the hypothesis that treatment with BAT significantly reduces cardiovascular mortality and heart failure morbidity and provides long-term safety and sustainable symptomatic improvement., Methods and Results: BeAT-HF was a prospective, multicentre, randomized, two-arm, parallel-group, open-label, non-implanted control trial. New York Heart Association (NYHA) class III subjects, ejection fraction ≤35%, previous heart failure hospitalization or N-terminal pro-B-type natriuretic peptide (NT-proBNP) >400 pg/ml, no class I indication for cardiac resynchronization therapy and NT-proBNP <1600 pg/ml were randomized to BAT plus optimal medical management (BAT group) or optimal medical management alone (control). The primary endpoint was cardiovascular mortality and HF morbidity; additional pre-specified endpoints included durability of safety, quality of life (QOL), exercise capacity (6-min hall walk distance [6MHWD]), functional status (NYHA class), hierarchical composite win ratio, freedom from all-cause death, left ventricular assists device (LVAD) implantation, heart transplant. Overall, 323 patients had 332 primary events, median follow-up was 3.6 years/patient. Both primary endpoint (rate ratio 0.94, 95% confidence interval [CI] 0.57-1.57; p = 0.82) and components of the primary endpoints were not significantly different between BAT and control. The system- and procedure-related major adverse neurological and cardiovascular event-free rate remained 97% throughout the trial. Symptom improvement (QOL, 6MHWD, NYHA class, all nominal p < 0.001) in the BAT group was durable in time, sustainable in extent. Win ratio (1.26, 95% CI 1.02-1.58) and freedom from all-cause death, LVAD implantation, heart transplant (hazard ratio 0.66, 95% CI 0.43-1.01) favoured the BAT group but did not reach statistical significance., Conclusion: The BeAT-HF primary endpoint was neutral; however, BAT provided safe, effective, and sustainable improvements in HFrEF patient's functional status, 6MHWD and QOL., (© 2024 CVRx and The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background and Objective: Reduced functional capacity, dyspnea, fatigue, and changes in body composition are common in patients with post-COVID-19 syndrome (PCS), and cardiopulmonary rehabilitation may improve these parameters. Thus, the present study verified the effects of cardiopulmonary rehabilitation (respiratory, aerobic, and resistance muscle training) on submaximal exercise tolerance, dyspnea, fatigue, and body composition., Methods: This controlled and randomized clinical trial applied a six-week outpatient intervention protocol in individuals over 18 years old (n = 33) with a diagnosis of COVID-19 confirmed by polymerase chain reaction. These individuals were allocated to cardiopulmonary rehabilitation (n = 17) or control groups (i.e., educational lectures; n = 16). The cardiopulmonary rehabilitation group performed respiratory, aerobic, and resistance muscle training. Submaximal exercise tolerance, dyspnea, fatigue, and body composition were assessed before and after the protocol., Results: After 6 weeks, the cardiopulmonary rehabilitation group increased the tolerance to submaximal exercise, with a difference of 100.46 m (95% confidence interval [CI]: 7.40-193 m) in the distance walked on the six-minute walk test, reduced dyspnea (-1.45, 95% CI: -1.98--0.92) in the modified Medical Research Council, and increased 0.63 kg (95% CI: 0.09-1.18 kg) of muscle mass in the upper limbs compared with the control group., Conclusion: The six-week cardiopulmonary rehabilitation protocol improved functional capacity, reduced dyspnea, and increased muscle mass in the upper limbs in individuals with PCS. Thus, these results supported the protocol use in this population and encourage further studies to assess its effectiveness in a large sample., (© 2024 John Wiley & Sons Ltd.)

Reduced exercise tolerance is one of the hallmarks of patients with cardiac amyloidosis (CA), but detailed biological responses during exercise were not investigated. The purpose of this study was to compare the cardiopulmonary exercise test (CPX) parameters between CA patients and propensity-matched heart failure patients. This was a single-center, retrospective, observational study of patients diagnosed with CA. The control group was extracted by propensity score matching from patients who underwent CPX for chronic heart failure during the same period. Clinical data including assessment of biological responses during CPX were compared between the patients with CA (CA group, n = 16) and the control group (non-CA group, n = 16). Echocardiography suggested more impaired diastolic function in the CA group than in the non-CA group. There was no significant difference between groups in the fraction of end-tidal carbon dioxide (FETCO 2 ) at rest. However, the difference between the FETCO 2 at rest and the FETCO 2 at the respiratory compensation point (ΔFETCO 2 ) was significantly smaller in the CA group than in the non-CA group (0.40% ± 0.37% vs. 0.82% ± 0.33%; p = 0.002). Only in the CA group, there was a significant negative correlation between the ΔFETCO 2 and the E/e' ratio on echocardiography (r = - 0.521; p = 0.039) and the serum high-sensitivity troponin T concentration (r = - 0.501; p = 0.048). In conclusion, patients with CA may find it difficult to increase cardiac output during exercise due to severe diastolic dysfunction., (© 2023. Springer Nature Japan KK, part of Springer Nature.)

Introduction: Physical activity is recognised as an important intervention in patients with CHD. However, more data on the actual magnitude of physical training impact on functional capacity in this group of patients are still warranted. We aim to assess effort tolerance in a contemporary cohort of patients with congenital heart disease, regularly following a training programme, in comparison with a matched control group., Methods: Patients with CHD followed at the sports medicine department, who had undergone cardiopulmonary exercise test between 2011 and 2019, were included. Variables recorded were maximum workload, absolute and indexed maximum oxygen consumption, maximum heart rate, absolute and indexed maximum O2 pulse, ventilatory equivalent of CO2 and oxygen consumption/Work. Trend of cardiopulmonary parameters was analysed over time. Maximal workload, maximum oxygen consumption and ventilatory equivalent of CO2 were compared with a control group of patients with a more sedentary lifestyle, matched for diagnosis, gender, age, and body mass index., Results: Among one hundred and eleven patients, 73 males (66%) were analysed. Median age was 14 (12-17) years. Twenty-nine patients (27%) were practising sports at competitive level. Maximum oxygen consumption and oxygen consumption % of maximum predicted were not significantly different at follow-up as compared with baseline. Follow-up of maximum oxygen consumption was 38.2 ± 9 ml/kg/min versus 38.6 ± 9.2 ml/kg/min (p = NS) and follow-up of %oxygen consumption was 88 ± 20 versus 87 ± 15 (p = NS). Ventilatory equivalent of CO2 significantly improved in the last test as compared with the baseline: 30 ± 4 versus 33 ± 5 (p = 0.002). As compared with the control group, trained patients displayed a significantly higher maximum workload and oxygen consumption, while ventilatory equivalent of CO2 was not significantly different., Conclusions: In our cohort, patients following a regular training programme displayed a significantly higher functional capacity as compared with not trained control group, irrespective of NYHA class. Objective functional capacity was stable over a median follow-up of 3 years.

Patients with heart failure with preserved ejection fraction (HFpEF) often receive β-blocker (BB) therapy for management of co-morbidities. However, the association of BB therapy with exercise capacity and health-related quality of life (HRQL) in HFpEF is not well-studied. In this post hoc analysis of the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF (RELAX) trial, which included patients with chronic stable HFpEF with peak exercise capacity assessment at baseline and at 12 and 24 weeks of follow-up, we evaluated the association of BB use with the measures of exercise capacity (peak exercise oxygen uptake), anaerobic threshold, and HRQL (Minnesota living with heart failure questionnaire). Separate linear mixed-effect models were constructed for each outcome with adjustment for treatment arm, demographics, medical history, left ventricular ejection fraction, and duration of heart failure. Of the 216 study participants (median age 69 years, 48.2% women), 76% reported BB use at baseline. Participants with (vs without) BB therapy were older (70 vs 63.5 years, p = 0.001) and had a higher prevalence of ischemic heart disease (44% vs 23%, p = 0.01). In the adjusted linear mixed model, BB use over time was not associated with peak exercise oxygen uptake (β 95% confidence interval [CI] 0.2 (-0.31 to 0.7), p = 0.5) and 6-minute walk distance (β 95% CI 14.69 [-14.25 to 43.63], p = 0.3). However, BB use was associated with a higher anaerobic threshold (β 95% CI 0.32 (0.02 to 0.62), p = 0.036) and better HRQL (lower quality of life as assessed by Minnesota living with heart failure questionnaire score) (β 95% CI -6.68 [-10.96 to -2.4], p = 0.002). Future trials are needed to better evaluate the effects of BB on exercise capacity in patients with chronic stable HFpEF., Competing Interests: Declaration of competing interest Dr. Chandra has received grant funding outside the present study from August Health. Dr. Pandey has received grant funding outside the present study from Applied Therapeutics and Gilead Sciences; has received honoraria outside the present study as an advisor/consultant for Tricog Health Inc and Lilly, Rivus, and Roche Diagnostics; and has received nonfinancial support from Pfizer and Merck. Dr. Segar reports speaker fees from Merck & Co and grant support from the American Heart Association outside the present study. The remaining authors have no competing interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Heart failure with preserved ejection fraction (HFpEF) accounts for over 50% of all heart failure cases nationwide and continues to rise in its prevalence. The complex, multi-organ involvement of the HFpEF clinical syndrome requires clinicians and investigators to adopt an integrative approach that considers the contribution of both cardiac and non-cardiac function to HFpEF pathophysiology. Thus, this symposium review outlines the key points from presentations covering the contributions of disease-related changes in cardiac function, arterial stiffness, peripheral vascular function, and oxygen delivery and utilization to exercise tolerance in patients with HFpEF. While many aspects of HFpEF pathophysiology remain poorly understood, there is accumulating evidence for a decline in vascular health in this patient group that may be remediable through pharmacological and lifestyle interventions and could improve outcomes and clinical status in this ever-growing patient population., (© 2023 The Authors. Experimental Physiology published by John Wiley & Sons Ltd on behalf of The Physiological Society.)

Introduction: Cardiopulmonary responses during unsupported upper limb function assessment may vary in chronic obstructive pulmonary disease (COPD)., Objective: To compare the cardiopulmonary responses during the function assessment with the Six-Minute Pegboard and Ring Test (6PBRT) and the incremental Unsupported Upper Limb Exercise (UULEX) test in COPD and to investigate the correlations with muscle strength and the limitations on activity of daily living (ADLs)., Methods: This was a cross-sectional study. Cardiopulmonary variables were recorded during tests using a breath-by-breath analyzer. Muscle strength was assessed using a hand-held dynamometer. Self-reported ADL was evaluated using the modified Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M). Paired t-test, Wilcoxon signed rank test, and Spearman correlation coefficients were used., Results: Fifteen individuals with moderate-to-severe COPD participated (66 ± 9 years old, forced expiratory volume in the first second [FEV 1 ]: 48%±14% of predicted). The UULEX induced higher oxygen consumption (0.54 ± 0.20 vs . 0.44 ± 0.09 L/min, p = .01) and dyspnea (4.0 [2.6 to 6.9] vs . 0.5 [0.9 to 5.1], p < .01) than 6PBRT. The performance in both tests was correlated with self-reported ADL limitations on PFSDQ-M (6PBRT: r = -0.69, p < .01; UULEX: r = -0.62, p = .01)., Conclusion: The UULEX promoted greater cardiopulmonary responses than 6PBRT, and performance in 6PBRT and UULEX was correlated with ADL limitations in individuals with COPD.

Objective: In Fontan circulation, pulmonary arterial hypertension (PAH)-targeted therapies could improve the patients' exercise capacity. This study aimed to investigate the effects of PAH agents on different exercise parameters in stable Fontan patients by synthesising evidence of randomised controlled trials (RCTs)., Methods: A systematic search of PubMed, Cochrane Central Register of Controlled Trials and Web of Science databases, as well as of ClinicalTrials.gov, was performed. Primary outcomes were specific cardiopulmonary exercise test parameters: peak oxygen uptake (peak VO 2 ), peak heart rate (peak HR), the minute ventilation/produced carbon dioxide (VE/VCO 2 ) slope and the oxygen uptake, both measured at the anaerobic threshold (VO 2 @AT)., Results: Five RCTs were included in the analysis including 573 Fontan patients (mean age 21.2 years, 60% male). PAH-targeted therapies did not affect peak VO 2 (mean difference (MD) 0.72, 95% CI -0.25 to 1.70) or peak HR (MD -0.67, 95% CI -3.81 to 2.47), but resulted in a small, significant improvement in VO 2 @AT (standardised MD 0.24, 95% CI 0.02 to 0.47). VE/VCO 2 slope at the anaerobic threshold was also reduced (MD -1.13, 95% CI -2.25 to -0.01)., Conclusions: Although PAH-targeted therapies did not affect exercise parameters at maximal effort, they induced slight improvements in indices of submaximal effort, measured at the anaerobic threshold. Pharmacological improvement of submaximal exercise seems to be a more suitable indicator of Fontan individuals' exercise capacity. Larger RCTs, recruiting specific subpopulations and focusing also on the anaerobic threshold, are warranted to draw more robust conclusions., Prospero Registration Number: CRD42022306674., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cardiopulmonary exercise test (CPET) with supine bicycle echocardiography (SBE) enables comprehensive physiologic assessment during exercise. We characterized cardiopulmonary fitness by integrating CPET-SBE parameters and evaluated its prognostic value in patients presenting with dyspnea., Methods and Results: We retrospectively reviewed 473 consecutive patients who underwent CPET-SBE for dyspnea evaluation. A dimensionality reduction process was applied, transforming 24 clinical and CPET-SBE parameters into a 2-dimensional feature map, followed by patient clustering based on the data distribution. Clinical and exercise features were compared among the clusters in addition to the 5-year risk of clinical outcome (a composite of cardiovascular death and heart failure hospitalization). Maximum exercise effort ( R >1) was achieved in 95% of cases. Through dimensionality reduction, 3 patient clusters were derived: Group 1 (n=157), 2 (n=104), and 3 (n=212). Median age and female proportion increased from Group 1 to 2, and 3, although resting echocardiography parameters showed no significant abnormalities among the groups. There was a worsening trend in the exercise response from Group 1 to 2 and 3, including left ventricular diastolic function, oxygen consumption, and ventilatory efficiency. During follow-up (median 6.0 [1.6-10.4] years), clinical outcome increased from Group 1 to 2 and 3 (5-year rate 3.7% versus 7.0% versus 13.0%, respectively; log-rank P =0.02), with higher risk in Group 2 (hazard ratio, 1.94 [95% CI, 0.52-7.22]) and Group 3 (3.92 [1.34-11.42]) compared with Group 1., Conclusions: Comprehensive evaluation using CPET-SBE can reveal distinct characteristics of cardiopulmonary fitness in patients presenting with dyspnea, potentially enhancing outcome prediction.

Aim: We aim to analyze past literature to evaluate the efficacy of coenzyme Q10 (CoQ-10) in the population with heart failure (HF). Methods: A systematic literature search was conducted through MEDLINE (via PubMed) and Cochrane Library. The outcomes analyzed were a reduction in HF-related mortality, an improvement in exercise capacity, and the left ventricular ejection fraction (LVEF). Results: Among 16 studies, CoQ-10 significantly reduced HF-related mortality by 40% and improved exercise capacity in patients with HF, but demonstrated no significant difference in LVEF however, the potential of its efficacy on LVEF could not be ruled out. Conclusion: CoQ-10 significantly enhances exercise capacity and reduces HF-related mortality; however, its impact on patients with reduced LVEF requires further investigation.

Aims: Effective therapy to improve exercise capacity in Fontan patients is lacking. Leg-focused high-weight resistance training might augment the peripheral muscle pump and thereby improve exercise capacity., Methods and Results: This randomized semi-cross-over controlled trial investigated the effects of a 12-week leg-focused high-weight resistance training plus high-protein diet, on (sub)maximal exercise capacity, cardiac function (assessed with cardiovascular magnetic resonance), muscle strength, and quality of life in paediatric Fontan patients. Twenty-eight paediatric Fontan patients were included, 27 patients, (median age 12.9 [10.5-15.7]), and successfully completed the programme. Peak oxygen uptake (PeakVO2) at baseline was reduced [33.3 mL/kg/min (27.1-37.4), 73% (62-79) of predicted]. After training PeakVO2/kg and Peak workload improved significantly with +6.2 mL/kg/min (95%CI: 3.4-9.0) (+18%) P < 0.001 and +22 Watts (95%CI: 12-32) (+18%) P < 0.001, respectively, compared to the control period. Indexed single ventricle stroke volume increased significantly [43 mL/beat/m2 (40-49) vs. 46 (41-53), P = 0.014], as did inferior vena cava flow [21 mL/beat/m2 (18-24) vs. 23 (20-28), P = 0.015], while superior vena cava flow remained unchanged. The strength of all measured leg-muscles increased significantly compared to the control period. Self-reported quality of life improved on the physical functioning and change in health domains of the child health questionnaire, parent-reported quality of life improved the bodily pain, general health perception, and change in health domains compared to the control period., Conclusion: In a relatively large group of 27 older Fontan children, 12-weeks of leg-focused high-weight resistance training improved exercise capacity, stroke volume, (sub)maximal exercise capacity, muscle strength, and domains of quality of life., Registration: International Clinical Trials: Trial NL8181., Competing Interests: Conflict of interest: Authors have no conflicts of interest to declare that are relevant to the content of this article., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: We aimed to clarify the extent to which cardiac and peripheral impairments to oxygen delivery and utilization contribute to exercise intolerance and risk for adverse events, and how this relates to diversity and multiplicity in pathophysiologic traits., Methods and Results: Individuals with heart failure with preserved ejection fraction (HFpEF) and non-cardiac dyspnoea (controls) underwent invasive cardiopulmonary exercise testing and clinical follow-up. Haemodynamics and oxygen transport responses were compared. HFpEF patients were then categorized a priori into previously-proposed, non-exclusive descriptive clinical trait phenogroups, including cardiometabolic, pulmonary vascular disease, left atrial myopathy, and vascular stiffening phenogroups based on clinical and haemodynamic profiles to contrast pathophysiology and clinical risk. Overall, patients with HFpEF (n = 643) had impaired cardiac output reserve with exercise (2.3 vs. 2.8 L/min, p = 0.025) and greater reliance on peripheral oxygen extraction augmentation (4.5 vs. 3.8 ml/dl, p < 0.001) compared to dyspnoeic controls (n = 219). Most (94%) patients with HFpEF met criteria for at least one clinical phenogroup, and 67% fulfilled criteria for multiple overlapping phenogroups. There was greater impairment in peripheral limitations in the cardiometabolic group and greater cardiac output limitations and higher pulmonary vascular resistance during exertion in the other phenogroups. Increasing trait multiplicity within a given patient was associated with worse exercise haemodynamics, poorer exercise capacity, lower cardiac output reserve, and greater risk for heart failure hospitalization or death (hazard ratio 1.74, 95% confidence interval 1.08-2.79 for 0-1 vs. ≥2 phenogroup traits present)., Conclusions: Though cardiac output response to exercise is limited in patients with HFpEF compared to those with non-cardiac dyspnoea, the relative contributions of cardiac and peripheral limitations vary with differing numbers and types of clinical phenotypic traits present. Patients fulfilling criteria for greater multiplicity and diversity of HFpEF phenogroup traits have poorer exercise capacity, worsening haemodynamic perturbations, and greater risk for adverse outcome., (© 2023 European Society of Cardiology.)

Aims: Heart failure with preserved ejection (HFpEF) and diabetes mellitus (DM) commonly co-exist. However, it is unclear if DM modifies the haemodynamic and cardiometabolic phenotype in patients with HFpEF. We aimed to interrogate the haemodynamic and cardiometabolic effects of DM in HFpEF., Methods: We compared the haemodynamic and metabolic profiles of non-DM patients and patients with DM-HFpEF at rest and during exercise using right heart catheterisation and mixed venous blood gas analysis., Results: Of 181 patients with HFpEF, 37 (20%) had DM. Patients with DM displayed a more adverse exercise haemodynamic response vs HFpEF alone (mean pulmonary arterial pressure: 47 mmHg [interquartile range {IQR} 42-55] vs 42 [38-47], p<0.001; workload indexed pulmonary capillary wedge pressure indexed: 0.80 mmHg/W [0.44-1.23] vs 0.57 [0.43-1.01], p=0.047). HFpEF-DM patients had a lower mixed venous oxygen saturation at rest (70% [IQR 66-73] vs 72 [69-75], p=0.003) and were unable to enhance O 2 extraction to the same extent (Δ-28% [-33 to -15] vs -29 [-36 to -21], p=0.029), this occurred at a 22% lower median workload. Resting mixed venous lactate levels were higher in those with DM (1.5 mmol/L [IQR 1.1-1.9] vs 1 [0.9-1.3], p<0.001), and during exercise indexed to workload (0.09 mmol/L/W [0.06-0.13] vs 0.08 [0.05-0.11], p=0.018)., Conclusion: Concurrent diabetes and HFpEF was associated with greater metabolic responses at rest, with enhanced wedge driven pulmonary hypertension and relative lactataemia during exercise without appropriate augmentation of oxygen consumption., Competing Interests: Conflicts of Interest There are no conflicts of interest to disclose., (Copyright © 2024 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background and Objective: Earlier reviews of exercise in people during exacerbation of chronic obstructive pulmonary disease (COPD) included studies where exercise training was initiated late during hospital admission or shortly following hospital discharge. Our question was: in adults hospitalised with an exacerbation of COPD, does initiating exercise training early during an admission versus not initiating exercise training during admission, change outcomes measured at discharge?, Methods: Systematic review and meta-analysis. Database searches of PubMed, the Cochrane Library, PEDro and EMBASE conducted in December 2021 and updated in January 2024. Studies were included if they had at least one group that was prescribed exercise training within 48 h of hospital admission (experimental) and at least one group that received usual care which did not include prescribed exercise training (control). Outcomes included exercise capacity, physical function, adverse events and uptake of outpatient pulmonary rehabilitation programs., Results: Ten studies (423 participants; mean FEV 1 ranging from 26 % to 50 % predicted) were included. At discharge, compared to the control group, the experimental group demonstrated better exercise capacity (standardised mean difference (SMD) 0.58, 95 % confidence interval (CI) 0.32 to 0.83; five studies, moderate effect, low certainty evidence) and physical function (SMD -0.54, 95 % CI -0.86 to -0.22; four studies, moderate effect, low certainty evidence). No observed serious adverse events were reported. None of the studies reported uptake of pulmonary rehabilitation following discharge., Conclusion: In adults with an exacerbation of COPD, exercise training prescribed within 48 h of hospitalisation was safe and improved exercise capacity and physical function., Competing Interests: Declaration of competing interest None of the authors have any conflict of interest to declare with the contents of this manuscript., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Extrapulmonary changes also occur in COPD. Resistance training can increase muscle strength and exercise capacity., Objective: The objective of this systematic review was to examine and compare the effectiveness of high and low-moderate load lower limb resistance training on muscle strength and exercise capacity in individuals with stable chronic obstructive pulmonary disease (COPD)., Methods: The PubMed/Medline, Scopus, Cochrane Library, ClinicalTrials.gov, Web of Science, EBSCO, and CINAHL databases were searched to identify the articles published in English between January 1970 and July 2023., Results: Seven randomized controlled trials with a total of 188 individuals with COPD (RT: 100, CG: 88) met the inclusion criteria. A significant difference was revealed (favoring high load) in the change in knee extensor muscle strength and leg press strength in the high load resistance training group compared to the low-moderate load resistance training group (MD 21.90 Nm, 95 % CI 17.46-26.34 Nm, p < 0.00001; MD 5.80 kg, 95 % CI 3.87-7.73 kg, p < 0.00001). A significant difference was observed in the change in 6 MWT (six minute walk test) distance (favoring low-moderate load) and VO 2peak (peak oxygen uptake) (favoring high load) in the high load resistance training group compared to the low-moderate load resistance training group (MD -16.90 m, 95 % CI -29.76- -4.04 m, p < 0.010; MD 3.10 ml/kg/min, 95 % CI 2.65-3.55 ml/kg/min, p < 0.00001)., Conclusion: This systematic review and meta-analysis demonstrated that both high-load and low-moderate load resistance training increased muscle strength and might increase exercise capacity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO 2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Heart failure with preserved ejection fraction (HFpEF) has become an emerging concern. The protective effect of bradycardia in patients with reduced ejection fraction using beta-blockers or ivabradine does not improve symptoms in HFpEF. This review aims to assess current data regarding the impact of anti-bradycardia pacing in patients with HFpEF. A search was conducted on PubMed, ScienceDirect, Springer, and Wiley Online Library, selecting studies from 2013 to 2023. Relevant and eligible prospective studies and randomized controlled trials were included. Functional status, quality of life, and echocardiographic parameters were assessed. Six studies conformed to the selection criteria. Four were prospective studies with a total of 90 patients analyzed. Two were randomized controlled trials with a total of 129 patients assessed. The 6-min walk test (6MWT) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score improved in all prospective studies. My-PACE trial showed improvements in MLHFQ score (p < 0.001), significant relative lowering in NT-proBNP levels (p = 0.02), and an increased mean daily activity in the personalized accelerated pacing group compared to usual care. RAPID-HF trial proved that pacemaker implantation to enhance exercise heart rate (HR) did not improve exercise capacity and was associated with increased adverse events. HFpEF requires a more individualized approach and quality of life management. This review demonstrates that higher resting HR by atrial pacing may improve symptoms and even outcomes in HFpEF, while a higher adaptive rate during exertion has not been proven beneficial., (© 2024. The Author(s).)