1. Cardiopulmonary Exercise Testing Essentials Tool
Abdurahman M. AL-Howikan
Specialist in CPET
(CPET)

2. Definition :
Heart
Cardiopulmonary exercise testing ( CPET ) is defined as diagnostic procedure that analyzes the responses and cooperation of the heart, circulation, respiration, and metabolism during continuously increase muscular stress
 non- invasive procedure

3. ►Obisity
►airflow obstruction
►Obstruction
►Restriction
►Chestwall
►infiltrative
►Heart disease
- coronary
-Valvular
►Anemia

4. Other Fields of CPET: Pulmonary ……. ►physical performance
►exercise prescription
►quality of trainning
Cardiology ………
Sports medicine
►occupational exercise
tolerance (Air traveler,
diving, fireman)
Occupational medicine
Intensive care
Rehabilitation
►Risk assessment prior
to surgery
►Nutrition
►design of Reh. programs
►assessed the improvement

5. Indications for Exercise Testing
Diseases that affect the heart, lungs, circulation, or blood
shortness of breath that otherwise cannot be determined at
rest or through conventional lung function testing
exercise capacity and anaerobic threshold of the individual
abnormal blood pressure response to exercise
Follow responses to therapy in patients with cardiopulmonary disease
poor circulation

6. Information of CPET oxygen intake: Power At rest 3.5ml/kg = MET
symptom intensity
Ventilation
from7 liter at rest to 100 liter
VE 70% of mvv
Arterial O2 saturation
systemic blood pressure
heart rate
HRSV= CO
HRmaxfor each 10 yrs
HRmax=220-age
HRmax=194.8-(0.504age
carbon dioxide output
At the begininng of test < 1.0
(0.7 fat), ( mix),(>1.0 carbohydrate

7. SAFETY OF EXERCISE TESTING
Complications: 1 per 2,000
Death: 1 per 20,000
Reference: The Safety of Exercise Testing. Gibbons, LW et al. Primary Care (1994) 21; 3;

8. Maximal Oxygen Uptake (VO2 -- ml/kg)
CLASSIFYING FITNESS
Maximal Oxygen Uptake (VO2 -- ml/kg)
MEN WOMEN
AGE LOW FAIR AVG GOOD HIGH LOW FAIR AVG GOOD HIGH
< > < > 48
< > < > 44
< > < > 41
< > < > 37
< > < > 34
HOW CAN I ASSESS THE EXERCISE TEST RESULTS AGAINST NORMAL POPULATIONS ? The American College of Sports Medicine utilizes a Fitness Classification scheme that was originally published by the AHA as far back as These guidelines relate the individual’s test results (VO2max) to age and sex. As a result, the patient can clearly see how he/she performed against others in the same group. This also gives the physician an appropriate reference to work against when making clinical decisions. Reference: Exercise Testing and Training of Apparently Healthy Individuals: A Handbook for Physicians. American Heart Assoc., 1972 p. 15 WHAT IS THE VALUE OF USING THE EXERCISE TEST RESULTS TO DETERMINE AN EXERCISE PRESCRIPTION ? “Recommended exercise intensity based on either 80% peak HR exceeded [anaerobic] threshold % of the time. Intensity based on 85% peak HR resulted in a large percentage (46%) of patients with a heart rate above the [anaerobic] threshold, whereas target HR derived from 75% peak HR resulted in many patients (38%) with a heart rate below the lower limit. Exercise Prescription based on predicted maximal HR was of little value, regardless of the percentage used to determine target HR. Exercise Prescription based on direct assessment of the [anaerobic] threshold is therefore preferred.” “Indiscriminate use of age-predicted maximal HR in making exercise prescriptions or in setting goals for treadmill performance should be avoided.” Reference: Cardiopulmonary Exercise Testing. Froehlicher VF. Publisher unknown at this time. Pp

9. Comparative between direct measurement VO2 max( ml/min) and estimate according to Wasserman equation
Age (years)
P ‹ 0.01
AL- Howikan A, AL- Hazzaa H, Al- Mobeireek F, Al- Majed S. peak cardiorespiratory exercise data for healthy Saudi males
(abstract) proceeding of the 12th annual meeting of the Saudi Heart Association. Riyadh (KSA): the Saudi Heart Association; 2002

10. Logical strategy to approach cardiopulmonary exercise testing
Identification of the clinical problem, Clinical history
Physical examination, Pulmonary function tests, E C G
Indication for CPET
Ensure quality of results
Select appropriate reference values
to establish patterns of abnormal response
Compare with characteristic patterns
of relevant diseases

11. Cardiopulmonary response
To effort

12. ►the response is linear
►slope (DV’O2/change in work rate (DWR)) approximately 10 mL·min1·W-1
►oxygen cost of breathing per unit ventilation (COPD), (ILD).

13. ►Oxygen pulse Vo2/HR= SV C(a–v)O2
►reduced SV  low, unchanging or flatO2 pulse  deconditioning, cardiovascular disease

14. ►Vt usually plateaus at 50 to 60% of vital capacity (VC)
►both Vt, fr increase until 70 to 80% of peak exercise

15. healthy adults, peak exercise ventilation approaches 70% of the MVV
MVV=(FEV1 35–40).
healthy adults, peak exercise ventilation approaches 70% of the MVV
VE=(tidal volume, Vt, time respiratory frequency, fr)
►Lung disease typically increases both ventilation at rest and given level of exercise COPD, ILD, PVD So, an abnormal level of ventilation is required to maintain normal Pa,CO2,

16. ► less accurate at saturations below about 88%
►good for monitoring trending phenomenon but not reliable for determining absolute magnitude of change in hemoglobin transmit
► less accurate at saturations below about 88%
►Dark skin color can interfere with signal detection

17. ► hyperventilation producing extra CO2 (aerobically)
►Vco2 reaction between hydrogen ion (from lactate) and dissolved CO2
► [H] [HCO3 ] ←→ [H2CO3] ←→ [CO2] [H2O]
► hyperventilation producing extra CO2
(aerobically)

18. without hyperventilation
► V-slope method, in turn, determines the point of the change in slope of the relationship of V˙ co2 versus V˙ o2
►V˙ co2 increases faster than V˙ o2
without hyperventilation
► AT increased rate of rise of arterial [lactate] during exercise.
► occurs at about 50–60% V˙ o2max
► low 40% ➽ cardiac, pulmonary (desaturation)
► limitation in O2 supply to the tissues, (mitochondrial myopathies)
► level of fitness,

19. As exercise intensity increases
► vasodilatation ➽ metabolic demands.
►vasoconstricted ➽ nonworking muscle
►excessive rise➽abnormal BP control
►BP does not increase ➽ abnormality of
sympathetic
►BP falls ➽ heart failure, ischemi aortic
stenosis, pulmonary vascular disease,
central venous obstruction

20. DIAGNOSIS NORMAL VO2 max LOW LOW LOW VO2-AT OBESITY NORMAL NORMAL
BR %
WHAT IS INVOLVED IN MAKING A DIAGNOSTIC INTERPRETATION OF THE CARDIOPULMONARY EXERCISE TEST ? The above Flow Chart simplifies the diagnostic interpretation of the Exercise Test in such a way that it is possible to separate out the primary cause of unexplained dyspnea (shortness of breath). As you can see, there are 5 diagnostic categories to place the results: 1. NORMAL or OBESE 2. DECONDITIONED 3. POOR EFFORT 4. CARDIOVASCULAR LIMITATION 5. RESPIRATORY LIMITATION A 6th category can be included to include those with more than one abnormality, but even in that case the test lends itself to identifying which component is the primary limiting factor. Reference: Adapted from Zavala, DC. Manual on Exercise Training: A Training Handbook. U. of Iowa Publishers (1993).
CARDIOVASC.
LIMITATION
DECONDITIONED
LOW
RESPIRATORY
LIMITATION
POOR
EFFORT

21. Mortality worsened if Angina and ST depression occur during Test
(Impairment) (No Impairment)
TREATMENT OF RISK FACTORS AND SYMPTOMS;
IF PATHOLOGY PRESENT, YEARLY VISIT WITH SPECIALIST
NON-SPECIALIST MANAGEMENT;
SEVERE MODERATE MILD NORMAL
SPECIALIST INPUT NEEDED;
CONSIDER INVASIVE INTERVENTIONS;
CHRONIC CARE CAN BE DIRECTED BY A SPECIALIST
TO A PRACTITIONER
ACCUGRAPH
High
SSA 18
ALL-CAUSE MORTALITY
Mortality worsened if Angina and ST depression occur during Test IV
III II I
FUNCTIONAL
CLASS
<1%
/yr
WHAT IS INVOLVED IN MAKING A PROGNOSTIC INTERPRETATION OF THE CARDIOPULMONARY EXERCISE TEST ? The above graph (copyright ASI Accumed Systems, Inc. 1998) brings together the significant information needed to assess PROGNOSIS (Risk Assessment). We have found that this is a meaningful way to discuss test results with the patient. For example, the patient depicted above has a VO2max of13, which corresponds to the following information gathered from the graph: 1. Functional Class 3 (Moderate to Severe Functional Limitation) 2. Less than 5 METS (Poor Prognosis - cannot perform all Activities of Daily Living) 3. Less than 15 ml/kg - THE MAGIC NUMBER AS DEFINED BY DR. ZAVALA (Aggressive interventions should be considered since chronic pathology is suspected) --- SPECIALIST CONSULT ? 4. Predicted value is 27. This is where the patient should be to be in average condition Social Security considers values < 18 ml/kg (5 METS) as an independent criteria for disability The bar on the X-axis from ml/kg represents mortality and morbidity statistics that approximate 0. This is a “zone” that we aim to reach for obvious reasons The CURVED RED LINE represents All-Cause Mortality and Morbidity. As you can see, when the VO2 drops below ml/kg (5 METS), annualized mortality starts to increase rapidly The question the patient will have is how can he/she move the Actual VO2 number to the right on the graph? Exercise, risk factor modification, and medical interventions are the primary methods. Now the patient has a visual motivation and a number to put his/her health in it’s proper perspective. Follow up testing gives objectivity to improvement. P R E D
VO2 5 10 A C T 15 20 25 30 35
ACTUAL
METS 1 2 3 4 5 6 7 8 9 10 13 27
BRUCE
1.7 / 10%
2.5 / 12%
3.4 / 14%
WATTS (70 Kg bwt) 50 75
100
125
150

22. WORK TREADMILL BIKE RAMP WORK WORK (Watts) ( ? ) TIME TIME
WHY USE A BIKE ERGOMETER? Accurate measurement of POWER Ramping protocols allow for assessment of physiologic function across all work levels. Staged protocols only assess partial physiologic function Independent of patient’s weight (Treadmill results are influenced by weight) Less danger of fall and injury to patient Easier to take accurate B/P at high work rates (Patient arm is steady and there is far less noise - no treadmill motor) Patient can stop at anytime Holding handle bars does not effect test (Holding treadmill handrails can significantly effect results) Fits into smaller space and is portable Patients with knee or hip problems tend to perform better and report being more comfortable on the bike Bike ramp protocols are designed to last 6-10 minutes, resulting in less fatigue (yet peak work is maximized) HR, Work, and VO2 (Cardiac Output) are linearly related. Bike ramp protocols produce linear increases in Work, thereby mimicking the expected physiologic response in health and disease Determination of the Anaerobic Threshold (AT) by the most popular methods (V-slope and VE/VO2 nadir) were developed and proven through the use of bike ramp protocols. To use another method means to lose AT detection accuracy Bike ramp protocols are used by many of the leading clinical and research cardiopulmonary exercise testing labs (UCLA, Duke, Mayo, Stanford, Bowman-Gray, Johns Hopkins, UAB, Temple to name a few). Recently, treadmills capable of performing ramp protocols have been developed.
TIME
TIME

23. Patterns of abnormal response to exercise in different diseases COPD
ILD
PVD
Obesity
Deconditioned
Heart failure
V’O2,peak
Reduced
Normal LT
Indeter.
Nor. Low
Normal Low
Low
VE,reserve
Reduced or none
Reduced or Normal
HRR
normal increased
normal
O2 pul .pa
Fall in SaO2
Present Absent
Present
Absent

24. Interpretation Case 2
Sex: male
age: 46 years
weight: 81 kg
% of ideal Wt: 64 kg
height: 167 cm
BMI: BSA:1.93 sm

25. Start Peak vo2 Low 1-Normal 2-Early heart or lung disease 3- Obesity
Abnormal
ECG
O2 Pulse
Obese
81kg
167 cm
Normal
Normal ( anxiety)
AT (Normal)

26. Compare Maximal oxygen consumption with other population
Reference
(20-29) y
(30-39) y
(40-50) y
German medical staff
46.3
40.4
36.1
Canadian
Sedentary
51.7
47.4
42.3
Saudi
sedentary
31.55
28.88
23.9

27. Variables Age (years) (20-29) (30-39) (40-50) 2.22 ±0.32 2.23 ± 0.29
Peak cardiopulmonary function in healthy Saudi males (mean ± SD). (103)
Variables
Age (years)
(20-29)
(30-39)
(40-50)
VO2 peak (L. min-1)
2.22 ±0.32
2.23 ± 0.29
1.93± 0.27
VO2 peak (ml. kg.-1 min-1)
31.6±5.9
28.9± 5.5
23.9± 3.6
HR peak (bpm)
183 ± 8
178±8
172 ± 8
HR reserve (bpm)
12±9
8 ±8
4±9 ** ** * * ** **

28. Peak cardiopulmonary function in healthy Saudi males (mean ± SD). (103)
Variables
Age (years)
(20-29)
(30-39)
(40-50)
VE peak
(L. min-1)
89.6±14.6
90.2±15
82.3 ± 14.2
VT peak (L)
1.9 ± 0.26
1.9 ± 0.3
1.9 ±0.28
fb peak (min)
48 ± 7.3
47.9 ± 8
44.5 ± 7.9
B R (L)
41.2±19
37.9±17.8
24.9±17 * **

29. Peak cardiopulmonary function in healthy Saudi males
(mean ± SD). (103)
Variables
Age (years)
(20-29)
(30-39)
(40-50)
Maximal work load (watts)
153.7± 19.8
156.4± 20
140.8±17.9
Exercise time (min)
14.2 ± 1.9
14.2 ±1.9
12.2 ± 1.6
VAT (L.min-1)
16±3.9
14.5 ±3.6
13.2 ±1.9
VAT
(% VO2 peak)
%51
%56 ** * **

30. SUGGESTED NORMAL GUIDELINES FOR INTERPRETATION OF CARDIOPULMONARY
EXERCISE TESTING RESULTS
Variables
Criteria of Normality
VO2max or VO2peak
> 84% predicted
Anaerobic threshold
range of normal (40–80%)
Heart rate (HR)
HRmax 90% age predicted
Heart rate reserve (HRR)
HRR <15 beats/min
O2 pulse (VO2/HR)
> 80%
Ventilatory reserve (VR)
MVV -VEmax:11(L )
Respiratory frequency (fR)
< 60 breaths/min
VE/VCO2 (at AT)
< 34
VD/VT
< 0.28; < 0.30 for age > 40 y
P(A–a)O2
< 35 mm Hg

31. ---------------------- Patient can not stop in emergency case
TREADMILL
Disadvantage
Advantage
More cooperation from patients
Similar to walking
Noisy
Setting of speed and graded for all size
Patient hold handrail
Patient can not stop in emergency case

32. BIKE Disadvantage Advantage Local muscles fatigue
Some measurement can be taken
VO2 max less, but AT, VE higher
Less noisy, coast, size, weight