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New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (15 March 2025) | Viewed by 11492

Special Issue Editor

Dr. Gaia Cattadori

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Guest Editor
IRCCS Multimedica, Cardiovascular Research Unit, Milan, Italy
Interests: rehabilitation; exercise physiology; exercise performance; exercise testing; physical activity assessment; exercise; physical activity; oxygen consumption; cardiac rehabilitation; cardiopulmonary exercise testing; cardiovascular rehabilitation
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

In October 2020, our Special Issue "New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation" was launched (https://www.mdpi.com/journal/jcm/special_issues/Cardiopulmonary_Exercise_Testing_and_Cardiac_Rehabilitation).

Several epidemiological studies have consistently reported inverse associations between cardiorespiratory fitness and the risk of cardiovascular disease and mortality, leading to an improvement in physical activity in the general population and growing interest in a scientific approach to this topic. Moreover, representing a profound change to the historical prescription of rest in cardiac patients, exercise training is now considered the main therapy. Consequently, cardiac rehabilitation with exercise training integrated as a core component is being widely proposed for primary and secondary cardiovascular prevention. Cardiopulmonary exercise testing permits the simultaneous evaluation of the cardiovascular and respiratory systems’ ability to perform gas exchange in order to support the increase in the muscle respiration required when exercising. Knowing the physiology, or even the pathophysiology, of exercise performance and/or limitations is crucial in achieving safe cardiac rehabilitation, establishing exercise training protocols, and assessing the final response. On the basis of the abovementioned points, we consider novel insights regarding cardiopulmonary exercise testing and cardiac rehabilitation to be a very current topic.

An abundance of manuscripts in regard to various topics related to cardiopulmonary exercise testing and cardiac rehabilitation was published, accomplishing the enormous success of the first Special Issue. Thus, we have decided to move forward with the creation of Part II of the Special Issue, collecting additional insight into cardiopulmonary exercise testing and cardiac rehabilitation. We are very keen to attract a global audience, welcoming any contributions on this subject from around the world, and encouraging both solicited and unsolicited submissions contributing to our goal.

Dr. Gaia Cattadori
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • cardiac rehabilitation
  • exercise physiology
  • exercise performance
  • exercise testing
  • physical activity assessment
  • exercise
  • physical activity
  • oxygen consumption
  • cardiopulmonary exercise testing

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Published Papers (7 papers)

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Research

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13 pages, 1147 KiB  
Article
Antiarrhythmic Effects of SGLT2 Inhibitors on Supraventricular Tachyarrhythmias in Patients with HFrEF
by Lyuboslav Katov, Jonas Rostan, Yannick Teumer, Federica Diofano, Carlo Bothner, Wolfgang Rottbauer and Karolina Weinmann-Emhardt
J. Clin. Med. 2025, 14(3), 786; https://doi.org/10.3390/jcm14030786 - 25 Jan 2025
Viewed by 1245
Abstract
Background: In recent years, sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated significant cardiovascular and renal benefits in patients with heart failure (HF), in addition to their established antidiabetic effects. However, their role in arrhythmia prevention remains unclear. This study aimed to assess the [...] Read more.
Background: In recent years, sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated significant cardiovascular and renal benefits in patients with heart failure (HF), in addition to their established antidiabetic effects. However, their role in arrhythmia prevention remains unclear. This study aimed to assess the effect of SGLT2 inhibitors on the incidence of supraventricular tachycardia (SVT) and ventricular tachycardia (VT) in patients with HF with reduced ejection fraction (HFrEF) during an extended follow-up period. Methods: This retrospective cohort study was conducted between January 2019 and November 2024 at the Ulm University Heart Center. All patients exhibited severely reduced left ventricular function and underwent primary prophylactic implantable cardioverter-defibrillator (ICD) implantation. Half of the cohort initiated SGLT2 inhibitor therapy alongside optimal medical HF treatment (the SGLT2 group). Patients were followed for approximately three years (846.2 ± 520.0 days) and the incidence of SVT and VT was analyzed using intracardiac Holter records of the ICD. Results: The study population consisted of 78 patients with a mean age of 66.6 ± 12.9 years. Over the follow-up period, a significant prolongation in the time to first occurrence of SVT was observed in the SGLT2 group (Log-Rank p = 0.03), suggesting a potential protective effect of SGLT2 inhibitors. However, regarding VT, additional SGLT2 inhibitor therapy did not show an additional benefit to optimal medical HF treatment. Conclusions: This study suggests that SGLT2 inhibitors may play a beneficial role in reducing the incidence of SVT in patients with HFrEF. These results highlight the importance of further investigating the antiarrhythmic potential of SGLT2 inhibitors through large-scale, prospective studies to better understand their clinical implications and mechanisms of action. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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10 pages, 1274 KiB  
Article
Calculation of Oxygen Uptake during Ambulatory Cardiac Rehabilitation
by Holger Stephan, Nils Klophaus, Udo F. Wehmeier, Fabian Tomschi and Thomas Hilberg
J. Clin. Med. 2024, 13(8), 2235; https://doi.org/10.3390/jcm13082235 - 12 Apr 2024
Cited by 1 | Viewed by 1079
Abstract
Background: Cardiopulmonary exercise testing is not used routinely. The goal of this study was to determine whether accurate estimates of VO2 values can be made at the beginning and at the end of a rehabilitation program. Methods: A total of [...] Read more.
Background: Cardiopulmonary exercise testing is not used routinely. The goal of this study was to determine whether accurate estimates of VO2 values can be made at the beginning and at the end of a rehabilitation program. Methods: A total of 91 cardiac rehabilitation patients were included. Each participant had to complete cardiopulmonary exercise testing at the beginning and at the end of a rehabilitation program. Measured VO2 values were compared with estimates based on three different equations. Results: Analyses of the means of the differences in the peak values showed very good agreement between the results obtained with the FRIEND equation or those obtained with a combination of rules of thumb and the results of the measurements. This agreement was confirmed with the ICCs and with the standard errors of the measurements. The ACSM equation performed worse. The same tendency was seen when considering the VO2 values at percentage-derived work rates. Conclusions: The FRIEND equation and the more easily applicable combination of rules of thumb are suitable for estimating the peak VO2 and the VO2 at a percentage-derived work rate in cardiac patients both at the beginning and at the end of a cardiac rehabilitation program. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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10 pages, 1216 KiB  
Article
Exploring the Prognostic Performance of MECKI Score in Heart Failure Patients with Non-Valvular Atrial Fibrillation Treated with Edoxaban
by Massimo Mapelli, Irene Mattavelli, Elisabetta Salvioni, Nicolò Capra, Alice Bonomi, Gaia Cattadori, Beatrice Pezzuto, Jeness Campodonico, Arianna Piotti, Alessandro Nava, Massimo Piepoli, Damiano Magrì, Stefania Paolillo, Ugo Corrà, Rosa Raimondo, Rocco Lagioia, Carlo Vignati, Roberto Badagliacca, Pasquale Perrone Filardi, Michele Senni, Michele Correale, Mariantonietta Cicoira, Marco Metra, Marco Guazzi, Giuseppe Limongelli, Gianfranco Parati, Fabiana De Martino, Francesco Bandera, Maurizio Bussotti, Federica Re, Carlo M. Lombardi, Angela B. Scardovi, Susanna Sciomer, Andrea Passantino, Michele Emdin, Caterina Santolamazza, Enrico Perna, Claudio Passino, Gianfranco Sinagra and Piergiuseppe Agostoniadd Show full author list remove Hide full author list
J. Clin. Med. 2024, 13(1), 94; https://doi.org/10.3390/jcm13010094 - 23 Dec 2023
Viewed by 2148
Abstract
Introduction: Risk stratification in heart failure (HF) is essential for clinical and therapeutic management. The Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score is a validated prognostic model for assessing cardiovascular risk in HF patients with reduced ejection fraction [...] Read more.
Introduction: Risk stratification in heart failure (HF) is essential for clinical and therapeutic management. The Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score is a validated prognostic model for assessing cardiovascular risk in HF patients with reduced ejection fraction (HFrEF). From the validation of the score, the prevalence of HF patients treated with direct oral anticoagulants (DOACs), such as edoxaban, for non-valvular atrial fibrillation (NVAF) has been increasing in recent years. This study aims to evaluate the reliability of the MECKI score in HFrEF patients treated with edoxaban for NVAF. Materials and Methods: This study included consecutive outpatients with HF and NVAF treated with edoxaban (n = 83) who underwent a cardiopulmonary exercise test (CPET). They were matched by propensity score with a retrospective group of HFrEF patients with NVAF treated with vitamin K antagonists (VKAs) from the MECKI score registry (n = 844). The study endpoint was the risk of cardiovascular mortality, urgent heart transplantation, or Left Ventricle Assist Device (LVAD) implantation. Results: Edoxaban patients were treated with a more optimized HF therapy and had different clinical characteristics, with a similar MECKI score. After propensity score, 77 patients treated with edoxaban were successfully matched with the MECKI-VKA control cohort. In both groups, MECKI accurately predicted the composite endpoint with similar area under the curves (AUC = 0.757 vs. 0.829 in the MECKI-VKA vs. edoxaban-treated group, respectively, p = 0.452). The two populations’ survival appeared non-significantly different at the 2-year follow-up. Conclusions: this study confirms the prognostic accuracy of the MECKI score in HFrEF patients with NVAF treated with edoxaban, showing improved predictive power compared to VKA-treated patients. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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10 pages, 1924 KiB  
Article
The Interpretation of Standard Cardiopulmonary Exercise Test Indices of Cardiac Function in Chronic Kidney Disease
by Shanmugakumar Chinnappa, Ming-Chieh Shih, Yu-Kang Tu and Andrew Mooney
J. Clin. Med. 2023, 12(23), 7456; https://doi.org/10.3390/jcm12237456 - 1 Dec 2023
Viewed by 1519
Abstract
Background and Aims: As there is growing interest in the application of cardiopulmonary exercise test (CPX) in chronic kidney disease (CKD), it is important to understand the utility of conventional exercise test parameters in quantifying the cardiopulmonary fitness of patients with CKD. Merely [...] Read more.
Background and Aims: As there is growing interest in the application of cardiopulmonary exercise test (CPX) in chronic kidney disease (CKD), it is important to understand the utility of conventional exercise test parameters in quantifying the cardiopulmonary fitness of patients with CKD. Merely extrapolating information from heart failure (HF) patients would not suffice. In the present study, we evaluated the utility of CPX parameters such as the peak O2-pulse and the estimated stroke volume (SV) in assessing the peak SV by comparing with the actual measured values. Furthermore, we compared the anaerobic threshold (AT), peak circulatory power, and ventilatory power with that of the measured values of the peak cardiac power (CPOpeak) in representing the cardiac functional reserve in CKD. We also performed such analyses in patients with HF for comparison. Method: A cross sectional study of 70 asymptomatic male CKD patients [CKD stages 2–5 (pre-dialysis)] without primary cardiac disease or diabetes mellitus and 25 HF patients. A specialized CPX with a CO2 rebreathing technique was utilized to measure the peak cardiac output and peak cardiac power output. The peak O2 consumption (VO2peak) and AT were also measured during the test. Parameters such as the O2-pulse, stroke volume, arteriovenous difference in O2 concentration [C(a-v)O2], peak circulatory power, and peak ventilatory power were all calculated. Pearson’s correlation, univariate, and multivariate analyses were applied. Results: Whereas there was a strong correlation between the peak O2-pulse and measured peak SV in HF, the correlation was less robust in CKD. Similarly, the correlation between the estimated SV and the measured SV was less robust in CKD compared to HF. The AT only showed a modest correlation with the CPOpeak in HF and only a weak correlation in CKD. A stronger correlation was demonstrated between the peak circulatory power and CPOpeak, and the ventilatory power and CPOpeak. In HF, the central cardiac factor was the predominant determinant of the standard CPX-derived surrogate indices of cardiac performance. By contrast, in CKD both central and peripheral factors played an equally important role, making such indices less reliable markers of cardiac performance per se in CKD. Conclusion: The results highlight that the standard CPX-derived surrogate markers of cardiac performance may be less reliable in CKD, and that further prospective studies comparing such surrogate markers with directly measured cardiac hemodynamics are required before adopting such markers into clinical practice or research in CKD. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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Review

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28 pages, 1272 KiB  
Review
Exercise Pulmonary Hypertension and Beyond: Insights in Exercise Pathophysiology in Pulmonary Arterial Hypertension (PAH) from Invasive Cardiopulmonary Exercise Testing
by Elizabeth S. Tarras, Inderjit Singh, Joan Kreiger and Phillip Joseph
J. Clin. Med. 2025, 14(3), 804; https://doi.org/10.3390/jcm14030804 - 26 Jan 2025
Viewed by 1306
Abstract
Pulmonary arterial hypertension (PAH) is a rare, progressive disease of the pulmonary vasculature that is associated with pulmonary vascular remodeling and right heart failure. While there have been recent advances both in understanding pathobiology and in diagnosis and therapeutic options, PAH remains a [...] Read more.
Pulmonary arterial hypertension (PAH) is a rare, progressive disease of the pulmonary vasculature that is associated with pulmonary vascular remodeling and right heart failure. While there have been recent advances both in understanding pathobiology and in diagnosis and therapeutic options, PAH remains a disease with significant delays in diagnosis and high morbidity and mortality. Information from invasive cardiopulmonary exercise testing (iCPET) presents an important opportunity to evaluate the dynamic interactions within and between the right heart circulatory system and the skeletal muscle during different loading conditions to enhance early diagnosis, phenotype disease subtypes, and personalize treatment in PAH given the shortcomings of contemporary diagnostic and therapeutic approaches. The purpose of this review is to present the current applications of iCPET in PAH and to discuss future applications of the testing methodology. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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Other

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7 pages, 5045 KiB  
Case Report
“Under the Bridge”: Looking for Ischemia in a Patient with Intramyocardial Coronary Artery Course—The Role of the Cardiopulmonary Exercise Test
by Massimo Mapelli, Gaia Cattadori, Elisabetta Salvioni, Irene Mattavelli, Emanuele Pestrin, Umberto Attanasio, Damiano Magrì, Pietro Palermo and Piergiuseppe Agostoni
J. Clin. Med. 2023, 12(17), 5764; https://doi.org/10.3390/jcm12175764 - 4 Sep 2023
Viewed by 1643
Abstract
Many variables obtained during cardiopulmonary exercise test (CPET), including O2 uptake (VO2) versus heart rate (HR, O2-pulse) and work rate (VO2/Watt), provide quantitative patterns of responses to exercise when left ventricular dysfunction is an effect of [...] Read more.
Many variables obtained during cardiopulmonary exercise test (CPET), including O2 uptake (VO2) versus heart rate (HR, O2-pulse) and work rate (VO2/Watt), provide quantitative patterns of responses to exercise when left ventricular dysfunction is an effect of myocardial ischemia (MI). Therefore, CPET offers a unique approach to evaluate exercise-induced MI in the presence of fixed or dynamic coronary arteries stenosis. In this paper, we examined the case of a 74-year-old patient presenting with an ischemic CPET and a normal stress cardiac magnetic resonance (CMR) with dipyridamole. A coronary angiography demonstrated the presence of myocardial bridging (MB), a well-known congenital coronary anomaly that is able to generate MI during exercise (but not in provocative testing using coronary artery vasodilators, such as dipyridamole). Despite the good diagnostic accuracy of the imaging methods (i.e., stress CMR) in MI detection, this case shows that exercise should be the method of choice in elicit ischemia in specific cases, like MB. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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9 pages, 1550 KiB  
Brief Report
Real-Time Estimation of Anaerobic Threshold during Exercise Using Electrocardiogram in Heart Failure Patients
by Toshinobu Ryuzaki, Yasuyuki Shiraishi, Kotaro Miura, Hidehiko Ikura, Yuta Seki, Koichiro Azuma, Kazuki Sato, Keiichi Fukuda and Yoshinori Katsumata
J. Clin. Med. 2023, 12(16), 5225; https://doi.org/10.3390/jcm12165225 - 11 Aug 2023
Viewed by 1397
Abstract
Exercise therapy at the aerobic level is highly recommended to improve clinical outcomes in patients with heart failure, in which cardiopulmonary exercise testing (CPX) is required to determine anaerobic thresholds (ATs) but is not available everywhere. This study aimed to validate a method [...] Read more.
Exercise therapy at the aerobic level is highly recommended to improve clinical outcomes in patients with heart failure, in which cardiopulmonary exercise testing (CPX) is required to determine anaerobic thresholds (ATs) but is not available everywhere. This study aimed to validate a method to estimate the AT using heart rate variability (HRV) analysis from electrocardiography data in patients with heart failure. Between 2014 and 2019, 67 patients with symptomatic heart failure underwent CPXs in a single university hospital. During the CPX, RR intervals was measured continuously and the HRV threshold (HRVT), defined as the inflection point of <5 ms2 of a high-frequency component (HFC) using the power spectrum analysis, was determined. Patients were divided into two groups according to the mean HFC at rest (high-HFC group, n = 34 and low-HFC group, n = 33). The high-HFC group showed good correlation between the VO2 at AT and HRVT (r = 0.63, p < 0.001) and strong agreement (mean difference, −0.38 mL/kg, p = 0.571). The low-HFC group also showed modest correlation (r = 0.41, p = 0.017) but poor agreement (mean differences, 3.75 mL/kg, p < 0.001). In conclusion, the HRVT obtained from electrocardiography may be a useful indicator for estimating AT in patients with heart failure. Full article
(This article belongs to the Special Issue New Insights from Cardiopulmonary Exercise Testing and Cardiac Rehabilitation: 2nd Edition)
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