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. 2023 Apr 26;25(Suppl C):C319-C325.
doi: 10.1093/eurheartjsupp/suad057. eCollection 2023 May.

Cardiopulmonary exercise testing and heart failure: a tale born from oxygen uptake

Massimo Mapelli  1   2 , Elisabetta Salvioni  1 , Irene Mattavelli  1 , Carlo Vignati  1   2 , Arianna Galotta  1 , Damiano Magrì  3 , Anna Apostolo  1 , Susanna Sciomer  4 , Jeness Campodonico  1   2 , Piergiuseppe Agostoni  1   2
Affiliations

Cardiopulmonary exercise testing and heart failure: a tale born from oxygen uptake

Massimo Mapelli et al. Eur Heart J Suppl. .

Abstract

Since 50 years, cardiopulmonary exercise testing (CPET) plays a central role in heart failure (HF) assessment. Oxygen uptake (VO2) is one of the main HF prognostic indicators, then paralleled by ventilation to carbon dioxide (VE/VCO2) relationship slope. Also anaerobic threshold retains a strong prognostic power in severe HF, especially if expressed as a percent of maximal VO2 predicted value. Moving beyond its absolute value, a modern approach is to consider the percentage of predicted value for peak VO2 and VE/VCO2 slope, thus allowing a better comparison between genders, ages, and races. Several VO2 equations have been adopted to predict peak VO2, built considering different populations. A step forward was made possible by the introduction of reliable non-invasive methods able to calculate cardiac output during exercise: the inert gas rebreathing method and the thoracic electrical bioimpedance. These techniques made possible to calculate the artero-venous oxygen content differences (ΔC(a-v)O2), a value related to haemoglobin concentration, pO2, muscle perfusion, and oxygen extraction. The role of haemoglobin, frequently neglected, is however essential being anaemia a frequent HF comorbidity. Finally, peak VO2 is traditionally obtained in a laboratory setting while performing a standardized physical effort. Recently, different wearable ergo-spirometers have been developed to allow an accurate metabolic data collection during different activities that better reproduce HF patients' everyday life. The evaluation of exercise performance is now part of the holistic approach to the HF syndrome, with the inclusion of CPET data into multiparametric prognostic scores, such as the MECKI score.

Keywords: Cardiac output; Cardiopulmonary exercise test; Heart failure prognosis; Oxygen uptake; Prognostic score.

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Conflict of interest statement

Conflict of interest: None declared.

Figures

Figure 1
Figure 1
Survival rate according to peak VO2 in a heart failure population with severe exercise impairment.
Figure 2
Figure 2
Graphical analysis of risk of the study outcome according to peak oxygen uptake (VO2) risk was the composite of cardiovascular death, urgent heart transplantation, and left ventricular assist device implantation. (Reproduced from Paolillo et al., Eur J Heart Fail. 2019.).
Figure 3
Figure 3
Example of the combined effects of three different HF therapeutic interventions, cardiac rehabilitation, edge to edge mitral valve repair, and cardiac resynchronization, on VO2 and its components at rest and at peak exercise. PRE = basal evaluation pre-intervention; POST = evaluation after intervention.
Figure 4
Figure 4
(A) The correlation between oxygen uptake (peakV̇O2) at cardiopulmonary exercise test (CPET) and 6 min walking test-V̇O2 expressed as a percent of the CPET peak V̇O2 (6MWT-V̇O2%) is shown. In (B), we show the percentage of subjects overcoming the 110% of CPET peak V̇O2 for each subgroup (healthy, Group 1 = peak V̇O2 < 12 mL/kg/min, Group 2 = peak V̇O2 12–16 mL/kg/min, and Group 3 = peak V̇O2 > 16 mL/kg/min). (C) The correlation between peak ventilation (V̇E) and 6MWT-V̇E expressed as % of peak V̇E at CPET (6MWT-V̇E %) is shown. In (D), the percentage of subjects overcoming the 100% of CPET peak V̇E for each subgroup is reported. (E) The correlation between peak heart rate (HR) and 6MWT-HR as % of peak HR at CPET (6MWT-HR%). In (F), the percentage of subjects overcoming the 100% of CPET peak HR for each subgroup. (Reproduced from Mapelli et al., ESC Heart Fail. 2022.).
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