Cardiopulmonary exercise testing (CPET)

MUDr. Kryštof Slabý

Klinika rehabilitace a tělovýchovného lékařství UK 2.LF a FN Motol

Typical patient groups

• Athletes – fitness assessment

• Healthy – weight reduction, fitness improvement

• Patients

– exercise therapy

– exercise testing

• circulation, respiration, before surgery, musculoskeletal sys.

– nutritional counseling

CPET 3

Types of stress

• Physical

– Physical (heat, cold)

– Postural (HUTT, standing)

– Physical exercise

• Dynamic

• Static

• Pharmacological

• Psychological

• “Nutritional” or “Metabolic” (glucose, fasting) CPET 4

Stress testing

Stress testing – indications

• Stress test as provocation for specific conditions

• Symptoms/pathology related to exercise

• Assessment of exercise capacity, functional reserve, limitation, prognosis, risk stratification

• Exercise therapy (e.g. cardiac rehabilitation)

• Legal (insurance, specific professions)

• Sports

CPET 5

Contraindications of stress testing

• Acute disesases, recent exacerbation or decompensation of chronic diseases

• Insufficient cooperation

• If the risk of performing test exceeds benefits

CPET 6

Contraindications of stress ECG

• Absolute: AIM (4 days), unstable angina, known LCA

stenosis, electrical instability/dysrhytmia, acute heart failure, aortic dissection, perimyocarditis, pulmonary embolism, (severe valve stenosis), (heart failure), acute infection, stroke (3 months), severe anemia

• Relative: pulmonary hypertension, less significatn

dysrhythmia, mild or moderate valve disease, significant arterial hypertension (>200/115), hypertrophic cardiomyopathy, higher degree AV blockade

CPET 7

Chaloupka: Zátěžové testy v kardiologii. Zátěžová elektrokardiografie. Cor et vasa, 2000; 42(3)

Complications of stress testing

• Safe diagnostic method*

– Death in 1-10/100000 tests in adults

• Recently withdrawal of some contraindications

– Severe asympt. Aortic valve stenosis, stable abdominal aortic aneurysm <5cm, chronic heart failure, hypertrophic cardiomyopathy, genet. arythmia ...

• Risks as in normal physical stress

– hypotension, hypoglycemia, bronchospasm

– infrequently dysrhythmia, bleeding, trauma

CPET 8

*Clinician's Guide to cardiopulmonary exercise testing in adults. Circulation. 2010; 122(2):191-225

Stress ECG

• Bicycle ergometr (alt. treadmill, arm crank)

• Rest ECG, BP

• Stress ECG, BP

• Results: symptoms, ECG (signs of ischemia, dysrhythmia), reaction of BP

• Advantages: easy, not so expensive equipment

• Disadvantage: not for functional capacity

CPET 9

CPET

• Like stress ECG + expired air analysis, saturation

• Advantages: exercise capacity, ventilatory anaerobic threshold, advanced hemodynamic and metabolic parameters, differential diagnosis of exertional dyspnoea

CPET 10

Other stress testing methods

• Stress ECHO

• Perfusion SPECT

• Stress cardiac MRI

CPET 11

Exertional dyspnoea

• Respiratory etiology

• Cardiac etiology

• Low fitness

• Hyperventilation

• Increased work of breathing (breathing pattern)

• (Anemia, pulmonary embolism, ...)

CPET 12

NYHA functional class

CPET 13

Zátěžové testy v kardiologii - Zátěžová elektrokardiografie.

http://www.kardio-cz.cz/index.php?&desktop=clanky&action=view&id=95

Braunwalds’s Heart Disease, 9ed

Other exercise related symptoms

• Palpitation, arrhythmia

• Syncope, colaps

• Hypotension

• Hypoglycemia

• Mismatch between symptoms in exercise and examination at rest

CPET 14

Examination before surgery

• In case of known disease (CAD, hypertension, COPD, ...)

• Risk stratification in major surgery

• Lung resection viability

• Heart Tx indication

CPET 15

Metabolic syndrome

• In case of known disease (see other slides)

• Exercise therapy

CPET 16

Specific provocation

• Genetic arhythmia – LQTS, CPVT

• Wolf-Parkinson-White sy. (preexcitation)

• Exercise induced bronchospasm

• Flow-limitation/dyn. hyperinflation

• Hypertrophic cardiomyopathy – LVOTO • Exercise induces hypoxemia

• Autonomic failure

• Mitochondrial disease

CPET 17

Handgrip test

• Handgrip – sustained contraction >2 min on 30% maximal contraction

• Blood pressure reaction – measurement on opposite arm

• Exaggerated response – increased risk of future hypertension/progression

CPET 18

Head-up tilt test

• Dif. dg. of syncope

• Orthostatic challenge ± baroreflex provocation ± pharmacologic challenge

• Different protocols

CPET 19

Checking effect of therapy

• Betablockers (bradins?)

• Pacemaker/ICD/CRT

• Claudication interval

• Treatment for exercise induced bronchospasm

• Antihypertensives

CPET 20

Indication criteria

• Prosthesis, assistive devices (ergometry, strength testing)

• Home oxygen therapy (6MWT)

• Occupational medicine

CPET 21

Serial testing

• Congenital heart disease

• Cardiomyopathy

• Some dysrhythmia

• Exercise therapy

• Athletes

CPET 22

Sports

• Preparticipation screening

• Fitness assessment

• Training optimization

• Sports eligibility, license

• Return to competitive sports after years of lower activity (masters category)

• Patients-athletes (HT, CAD, DM, CHD, ...)

CPET 23

Instructions to patients

• Sufficient hydration 30min before, light meal 1-2 hours before, comfortable clothes and shoes

• Without strenuous physical activity day before

• Refrain from alcohol, cigarettes, stimulants 12 hours before test

• Drugs – only b-blockers and nitrates 5 halftimes before test

CPET 24