Cardiopulmonary Exercise Testing: Mitchell Horowitz

Cardiopulmonary Exercise Testing
MITCHELL HOROWITZ
Outline
Description of CPET
Who should and who should not get CPET
When to terminate CPET
Exercise physiology
Define terms: respiratory exchange ratio, ventilatory
equivalent, heart rate reserve, breathing reserve, oxygen
pulse
Pattern of CPET results COPD vs CHF
Rationale for Exercise Testing
Cardiopulmonary measurements
obtained at rest may not estimate
functional capacity reliably
Clinical Exercise Tests
6-min walk test

Submaximal
Shuttle walk test

Incremental, maximal, symptom-limited
Exercise bronchoprovocation
Exertional oximetry
Cardiac stress test
CPET
Karlman Wasserman
Coupling of External Ventilation
and Cellular Metabolism
Adaptations of Wassermans Gears
General Mechanisms of Exercise Limitation
Pulmonary Peripheral
Ventilatory Inactivity
Respiratory muscle Atrophy
dysfunction Neuromuscular dysfunction
Impaired gas exchange Reduced oxidative capacity
Cardiovascular of skeletal muscle
Reduced stroke volume Malnutrition
Abnormal HR response Perceptual
Circulatory abnormality Motivational
Blood abnormality Environmental
What is CPET?
Symptom-limited exercise
test
Measure airflow, SpO2, and
expired oxygen and carbon
dioxide
Allows calculation of peak
oxygen consumption,
anaerobic threshold
Components of Integrated CPET
Symptom-limited
ECG
HR
Measure expired gas

Oxygen consumption
CO2 production
Minute ventilation
SpO2 or PO2
Perceptual responses
Breathlessness
Leg discomfort
Modified Borg CR-10 Scale
Indications for CPET
Evaluation of dyspnea
Distinguish cardiac vs pulmonary vs peripheral limitation vs other
Detection of exercise-induced bronchoconstriction
Detection of exertional desaturation
Pulmonary rehabilitation
Exercise intensity/prescription
Response to participation
Pre-op evaluation and risk stratification
Prognostication of life expectancy
Disability determination
Fitness evaluation
Diagnosis
Assess response to therapy
Mortality in CF Patients
Nixon et al; NEJM 327: 1785; 1992.

Followed 109 patients with CF for 8 yrs from CPET
Peak VO2 >81% predicted: 83% survival
Peak VO2 59-81% predicted: 51% survival
Peak VO2 <59% predicted: 28% survival

Mortality in CHF Patients
Mancini et al; Circulation 83: 778; 1991.

Peak VO2 >14 ml/kg/min:
1-yr survival 94%
2-yr survival 84%
Peak VO2 14 ml/kg/min:

1-yr survival 47%
2-yr survival 32%

CPET to Predict Risk of Lung Resection in Lung Cancer
Lim et al; Thorax 65:iii1, 2010

Alberts et al; Chest 132:1s, 2007
Balady et al; Circulation 122:191, 2010
Peak VO2 >15 ml/kg/min

No significant increased risk of complications or death
Peak VO2 <15 ml/kg/min
Increased risk of complications and death
Peak VO2 <10 ml/kg/min
40-50% mortality
Consider non-surgical management
Absolute Contraindications to CPET
Acute MI
Unstable angina
Unstable arrhythmia
Acute endocarditis, myocarditis, pericarditis
Syncope
Severe, symptomatic AS
Uncontrolled CHF
Acute PE, DVT
Respiratory failure
Uncontrolled asthma
SpO2 <88% on RA
Acute significant non-cardiopulmonary disorder that may affect or be
adversely affected by exercise
Significant psychiatric/cognitive impairment limiting cooperation
Relative Contraindications to CPET
Left main or 3-V CAD

Severe arterial HTN (>200/120)
Significant pulmonary HTN
Tachyarrhythmia, bradyarrhythmia
High degree AV block
Hypertrophic cardiomyopathy
Electrolyte abnormality
Moderate stenotic valvular heart disease
Advanced or complicated pregnancy
Orthopedic impairment
Indications for Early Exercise Termination
Patient request
Ischemic ECG changes
2 mm ST depression
Chest pain suggestive of ischemia
Significant ectopy
2nd or 3rd degree heart block
Bpsys >240-250, Bpdias >110-120
Fall in BPsys >20 mmHg
SpO2 <81-85%
Dizziness, faintness
Onset confusion
Onset pallor
CPET Measurements
Work R
VO2 SpO2
VCO2 ABG
AT Lactate
HR CP
ECG Dyspnea
BP Leg fatigue
Exercise Modality
Advantages of cycle ergometer

Cheaper
Safer
Less danger of fall/injury
Can stop anytime
Direct power calculation
Independent of weight
Holding bars has no effect
Little training needed
Easier BP recording, blood draw
Requires less space
Less noise
Advantages of treadmill
Attain higher VO2
More functional
Incremental vs Ramp Exercise Test Protocol
INCREMENTAL RAMP
WORK WORK
TIME TIME
Physiology and Chemistry
Slow vs fast twitch fibers

Buffering of lactic acid by bicarbonate
CO2 production from carbonic acid
Respiratory exchange ratio
Ventilatory equivalent of oxygen
Ventilatory equivalent of carbon dioxide
Graphical determination of AT
Fick Equation
Oxygen pulse
Properties of Skeletal Muscle Fibers
Red = Slow twitch = Type I White = Fast twitch = Type II

Sustained activity Rapid burst exercise
High mitochondrial density Few mitochondria
Metabolize glucose Metabolize glucose
aerobically anaerobically
1 glucose yields 36 ATP 1 glucose yields
Rapid recovery 2 ATP and 2 lactic acid
Slow recovery
Lactic Acid is Buffered by Bicarbonate
Lactic acid + HCO3 H2CO3 + Lactate

H2O + CO2
Respiratory Exchange Ratio
RER= CO2 produced / O2 consumed

= VCO2 / VO2
Ventilatory Equivalents
Ventilatory equivalent for carbon dioxide =

Minute ventilation / VCO2
Efficiency of ventilation
Liters of ventilation to eliminate 1 L of CO2
Ventilatory equivalent for oxygen =

Minute ventilation / VO2
Liters of ventilation per L of oxygen uptake
Relationship of AT to RER and Ventilatory Equiv for O2
Below the anaerobic threshold, with carbohydrate

metabolism, RER=1 (CO2 production = O2 consumption).
Above the anaerobic threshold, lactic acid is generated.
Lactic acid is buffered by bicarbonate to produce lactate,
water, and carbon dioxide.
Above the anaerobic threshold, RER >1 (CO2 production > O2
consumption).
Carbon dioxide regulates ventilation.
Ventilation will disproportionately increase at lactate
threshold to eliminate excess CO2.
Increase in ventilatory equivalent for oxygen demarcates the
anaerobic threshold.
Lactate Threshold
Determination of AT from RER Plot (V Slope Method)
Determination of AT from Ventilatory Equivalent Plot
Wasserman 9-Panel Plot
Oxygen Consumption: Fick Equation
Fick Equation: Arterial oxygen content =

(1.34)(SaO2)(Hgb)
Q = VO2 / C(a-v)O2 Venous oxygen content =

(1.34)(SvO )(Hgb) 2
VO2 = Q x C(a-v)O2
VO2 = SV x HR x C(a-v)O2
Heart disease Anemia
Heart disease
Lung disease Lung disease (low SaO2)
Muscle disease
Deconditioning
Oxygen Pulse
Oxygen Pulse:
. . .the amount of oxygen
consumed by the body from
the blood of one systolic
discharge of the heart.
Henderson and Prince
Am J Physiol 35:106, 1914
Oxygen Pulse = VO2 / HR

Fick Equation:
VO2 = SV x HR x C(a-v)O2
VO2/HR = SV x C(a-v)O2
Oxygen Pulse ~ SV
Interpretation of CPET
Peak oxygen consumption

Peak HR
Peak work
Peak ventilation
Anaerobic threshold
Heart rate reserve
Breathing reserve
Heart Rate Reserve
Comparison of actual peak HR and predicted peak HR

= (1 Actual/Predicted) x 100%
Normal <15%
Estimation of Predicted Peak HR
220 age
For age 40: 220 - 40 = 180
For age 70: 220 - 70 = 150
210 (age x 0.65)

For age 40: 210 - (40 x 0.65) = 184
For age 70: 210 - (70 x 0.65) = 164

Breathing Reserve
Comparison of actual peak ventilation and predicted peak

ventilation
Predicted peak ventilation = MVV, or FEV1 x 35
= (1 Actual/Predicted) x 100%
Normal >30%
Comparison CPET results
Normal CHF COPD

Predicted Peak HR 150 150 150
Peak HR 150 140 120
MVV 100 100 50
Peak VO2 2.0 1.2 1.2
AT 1.0 0.6 1.0
Peak VE 60 40 49
Breathing Reserve 40% 60% 2%
HR Reserve 0% 7% 20%
Borg Breathlessness 5 4 8
Borg Leg Discomfort 8 8 5
Cardiac vs Pulmonary Limitation
Heart Disease
Breathing reserve >30%
Heart rate reserve <15%
Pulmonary Disease
Breathing reserve <30%
Heart rate reserve >15%

CPET Interpretation
Peak VO2 HRR BR AT/VO2max A-a

Normal >80% <15% >30% >40% normal
Heart disease <80% <15% >30% <40% normal
Pulm vasc dis <80% <15% >30% <40% increased
Pulm mech dis <80% >15% <30% >40% increased
Deconditioning <80% >15% >30% >40% normal
SUMMARY
Cardiopulmonary measurements obtained at rest may

not estimate functional capacity reliably.
CPET includes the measurement of expired oxygen and
carbon dioxide.
The Borg scale is a validated instrument for
measurement of perceptual responses.
CPET may assist in pre-op evaluation and risk
stratification, prognostication of life expectancy, and
disability determination.
SUMMARY
Cycle ergometer permits direct power calculation.

Peak VO2 is higher on treadmill than cycle ergometer.
Peak VO2 may be lower than VO2max.
Absolute contraindications to CPET include unstable
cardiac disease and SpO2 <88% on RA.
Fall in BPsys >20 mmHg is an indication to terminate CPET.
1 glucose yields 36 ATP in slow twitch fiber, and 2 ATP + 2
lactic acid in fast twitch fiber.
RER= CO2 produced / O2 consumed
SUMMARY
Above the anaerobic threshold, CO2 production exceeds

O2 consumption.
Ventilation will disproportionately increase at lactate
threshold to eliminate excess CO2.
AT may be determined graphically from V slope method or
from ventilatory equivalent for CO2.
Derived from the Fick equation, Oxygen Pulse = VO2 / HR,
and is proportional to stroke volume.
In pure heart disease, BR is >30% and HRR <15%.
In pure pulmonary disease, BR is <30% and HRR >15%.

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Cardiopulmonary Exercise Testing

6-min walk test

Shuttle walk test

Measure expired gas

Nixon et al; NEJM 327: 1785; 1992.

Peak VO2 <59% predicted: 28% survival

Mancini et al; Circulation 83: 778; 1991.

2-yr survival 84%

Peak VO2 14 ml/kg/min:

2-yr survival 32%

Lim et al; Thorax 65:iii1, 2010

Peak VO2 >15 ml/kg/min

Left main or 3-V CAD

Advantages of cycle ergometer

Slow vs fast twitch fibers

Red = Slow twitch = Type I White = Fast twitch = Type II

Lactic acid + HCO3 H2CO3 + Lactate

RER= CO2 produced / O2 consumed

Ventilatory equivalent for carbon dioxide =

Ventilatory equivalent for oxygen =

Below the anaerobic threshold, with carbohydrate

Fick Equation: Arterial oxygen content =

Q = VO2 / C(a-v)O2 Venous oxygen content =

Oxygen Pulse = VO2 / HR

Peak oxygen consumption

Comparison of actual peak HR and predicted peak HR

For age 70: 220 - 70 = 150

210 (age x 0.65)

For age 70: 210 - (70 x 0.65) = 164

Comparison of actual peak ventilation and predicted peak

Normal CHF COPD

Heart rate reserve <15%

Heart rate reserve >15%

Peak VO2 HRR BR AT/VO2max A-a

Cardiopulmonary measurements obtained at rest may

Cycle ergometer permits direct power calculation.

Above the anaerobic threshold, CO2 production exceeds

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