CARDIOPULMONARY EXERCISE TESTING –INTERACTIVE CASE DISCUSSION

The Cardiologist’s point of viewLukas Trachsel

9 – Panel – Plot (Wassermann)

9 – Panel – Plot (Wassermann)

Motivation / exercisecapacity

9 – Panel – Plot (Wassermann)

Motivation / exercisecapacity

Ventilatory mechanicalrelevant panels

Oxygen uptake in response to acute exercise

COCardiacoutput

SVStrokevolume

HRHeart rate

Wassermann, Principles of Exercise Testing, 5th Edition

Perip.Circ.Dilate

Recruit

Pulm.Circ.RecruitDilate

C(a-v)o2Arterial-mixedvenous O2 diff. x10x2-3

VO2 = CO x C(a-v) O2

‘Fick equation’

9 – Panel – Plot (Wassermann)

Motivation / exercisecapacity

Ventilatory mechanicalrelevant panels

Cardio-circulatoryrelevant panels

VO2 = SV x HR x C(a-v) O2

VO2/HR = SV x C(a-v) O2

VO2/WR-Slope

9 – Panel – Plot (Wassermann)

Cooperation / exercisecapacity

Ventilatory mechanicalrelevant panels

Cardio-circulatoryrelevant panels

Gas exchange

Case Report• 61 year old male• 3-vessel CAD (12/2010)

– Non-STE-MI inferior 12/2010– CABG 12/2010 – Ejection fraction normal– Risk factors: cholesterol, BMI 30, familial history, former

smoker

• Suspected exercise induced asthma 07/2012– Body plethysmography 20.7.2012: borderline restriction

(TLC 76% predicted), dynamic lung volume normal, C0 diffusion capacity normal

• Annual ‘follow-up’: – Exercise intolerance for months, exertional dyspnoe

(NYHA II)

Spirometry

CAD, post-CABGExercise intolerance, NYHA II

CAD, post-CABGExercise intolerance, NYHA II

CAD, post-CABGExercise intolerance, NYHA II

VE/VCO2-Slope 35 (<30)

RER 1.15

BR 20%

VO2/WR-Slope 8.2 (> 8.6) O2 pulse 77% pred

CRF 77% pred

WR 76% pred

QUIZ QUESTION:

What is the most likely reason for the symptoms and for the reduced exercise capacity/CRF?

a) Respiratory limitationb) Cardio-circulatory limitation (unspecific)c) Cardio-circulatory limitation (suggestive ofischemia)d) Limitation of peripheral musclese) Others

CAD, post-CABGExercise intolerance, NYHA II

VO2/WR-Slope 8.2 (> 8.6) O2 pulse 77% pred

BR 20%

RER 1.15

CRF 77% pred

WR 76% pred

VE/VCO2-Slope 35 (<30)

PCI LAD distal LIMA-RIVA graft 15.09.2014

CAD, post-CABGSymptoms resolved

09.09.14Before PCI

23.09.14After PCI

European Heart Journal (2003) 24, 1304–1313

European Heart Journal (2003) 24, 1304–1313

European Heart Journal (2003) 24, 1304–1313Int J Cardiol 174 (2014) 337–342

Case Report• 53 year old male

• Hypertensive heart disease

• Metabolic syndrome

• Syncope 2012

• Sent for disability evaluation by the insurance(‘IV-Abklärung’)

• Symptoms: dyspnoe on exertion (NYHA II-III), periodic chest pain (at rest, on exertion)

Spirometry

Hypertensive HD, metabolic syndromeNYHA II-III

Hypertensive HD, metabolic syndromeNYHA II-III

Hypertensive HD, metabolic syndromeNYHA II-III VO2/WR-Slope 8.9 (> 8.6)

O2 pulse 59% predVE/VCO2-Slope 38(<30)

CRF 64% pred

WR 54% pred

RER 1.29

BR 16%

QUIZ QUESTION:

What is the most unlikely reason for the reduced exercise capacity?

a) Heart failure with preserved ejection fractionb) Subacute pulmonary embolismc) Chronic thrombo-embolic pulmonary hypertension (CTEPH)d) Previously undetected aortic stenosise) COPD

RER 1.29

Hypertensive HD, metabolic syndromeNYHA II-III

VE/VCO2-Slope 38 (<30)

VO2/WR-Slope 8.9 (> 8.6)

PET Co2 32mm Hg(Rest: > 35mm Hg)

bath tub?

O2 pulse 59% pred

CRF 64% pred

WR 54% pred

BR 16%

RER 1.29

Ventilation-/Perfusion-Szintigraphy

Subsegmentary bilateral pulmonary emboli

Heart. 2007 Oct;93(10):1285-92.

European Heart Journal (2012) 33, 2917–2927

“Several CPX statements have been published by well-respected organizations in both the US and Europe. Despite these prominent reports and the plethora of pertinent medical literature

which they feature, underutilization of CPX persists.”

• New CPX indications and algorithms:

– CPX to assess perisurgical and postsurgical risk and long-term prognosis

– CPX to assess valvular disease/dysfunction

European Heart Journal doi:10.1093/eurheartj/ehw180

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