The role of CPX testing in the rehabilitation of cardiac patients.

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1 Cardiopulmonary exercise testing (CPX) for comprehensive cardiac evaluations The role of CPX testing in the rehabilitation of cardiac patients. Viviane M Conraads, MD, PhD Department of Cardiology Cardiac Rehabilitation Centre Antwerp University Hospital University of Antwerp, Belgium NO DISCLOSURES

2 What do the guidelines say? After myocardial revascularization (PCI, CABG) Chronic Heart Failure

3 functional evaluation training prescription evaluation of ischemia or in-stent stenosis (imaging)

4 to detect reversible ischaemia as part of the evaluation of patients for heart transplantation and mechanical circulatory support training prescription to obtain prognostic information

5 CPX; what is extra? 1. Diagnosis Ischemia Dyspnea ex intolerance 2. Prognosis and guidance for treatment 3. Exercise prescription 4. Optimization of devices/patients with devices

6 Ischemic Cascade Ischemia Clinically recognized New ECG abnormalities Systolic dysfunction Strain abnormalities Clinically silent Diastolic dysfunction Perfusion abnormalities Normal function Time/Magnitude Ischemia

7 Ischemia Which are the arguments pro-ischemia? Fick Lower formula: peakvo 2 Lower VAT O 2 Lower O 2 pulse VO 2 = cardiac output x arteriovenous O 2 difference VO 2 = SV x Heart rate x arteriovenous O 2 difference Flattening O 2 pulse and VO 2 / W trajectory Caveat: depending on area at risk O 2 pulse (SV) = VO 2 /Heart rate

8 Contribution of cardiopulmonary indices in the assessment of patients with silent and symptomatic ischemia during exercise testing. Klainman E, et al. Int J Cardiol 1996;53:257 Lower O 2 pulse

9 Exercise-induced myocardial ischaemia detected by cardiopulmonary exercise testing. Belardinelli R, et al. Eur Heart J 2003;24:1304 Flattening O 2 pulse and VO 2 / W trajectory

10 Exercise-induced myocardial ischaemia detected by cardiopulmonary exercise testing. Belardinelli R, et al. Eur Heart J 2003;24:1304

11 Diagnosis

12 Diagnosis MVV: maximal voluntary ventilation during 1 min = FEV 1 x 35

13 MVV = FEV 1 x 35 = 2 l x 35 = 70l/min Breathing reserve = 0% 55 yr-old man Peak VO 2 predicted = 32.5ml/kg/min

14 CPX; what is extra? 1. Diagnosis 2. Prognosis and guidance for R/ 3. Exercise prescription Prognostic parameters CRT VAD HTX 4. Optimization of devices/patients with devices

15 Prognostic parameters CPX variables Ischemia % predicted VO 2 O 2 pulse/ W trajectory VO 2 / W trajectory Systolic Bloodpressure ECG abnormalities

16 Prognostic parameters CPX variables CHF peakvo 2 VE/VCO 2 slope Oscillatory breathing P ET CO2 HRRecovery OUES Circulatory power VO 2 t1/2 Systolic Bloodpressure ECG abnormalities

17 CPX; what is extra? 1. Diagnosis 2. Prognosis and guidance for R/ 3. Exercise prescription Safety Efficacy 4. Optimization of devices/patients with devices

18 Exercise training in heart failure: practical guidance. Conraads VM & Beckers PJ. Heart 2010;96:2025 Training Heart Rate (THR) = HR at x% VO 2 peak

19 VAT RCP Ventilation CO 2 production Moderate continuous training Higher intensity training VO 2 (ml/kg/min) High intensity aerobic interval training High intensity anaerobic interval training

20 Arbitrary units Ventilation RCP CO 2 production VAT VO 2 (ml/kg/min) Rest Exercise Peak Exercise intensity Peak HR RCP VO 2 plateau RER > Conraads VM & Beckers PJ. Heart 2010;96:2025

21 Arbitrary units Ventilation RCP CO 2 production VAT VO 2 (ml/kg/min) Rest Exercise Peak Exercise intensity Peak HR RCP VO 2 plateau RER > Conraads VM & Beckers PJ. Heart 2010;96:2025

22 CPX; what is extra? 1. Diagnosis 2. Prognosis and guidance for R/ 3. Exercise prescription 4. Optimization of devices/patients with devices

23 Rate-response and cardiac resynchronisation therapy in chronic heart failure: higher cardiac output does not acutely improve exercise performance: a pilot trial. Van Thielen, et al. Eur J Cardiovasc Prev & Rehabil 2008;15:197

24 The effect of endurance training on exercise capacity following cardiac resynchronization therapy in chronic heart failure patients: a pilot trial. Conraads VMA, et al. Eur J Cardiovasc Prev & Rehabil 2007;14:99

25 CPX; just do it?

26 Safety of symptom limited cardiopulmonary exercise testing in patients with chronic heart failure due to severe left ventricular systolic dysfunction. Keteyian S, et al. Am Heart J 2009;158 (4 Suppl): S72 N=4411 CPET 40% ICD (932) no deaths no HF exacerbation requiring hospital. no angina requiring hospital. no MI no sustained VT no stroke or TIA 293 ICDs fired once 688 discharges/2.5yr 1 VFib - next day 1 Sust. VTach - next day No ex-related discharge 27 tests stopped because 3-5 beats SVT or VT runs Precautions: 5-10 beats below treatment zone, deactivate ICD or increase ventricular discharge rate

27 CPX & rehabilitation: conclusions 1. Provides information (far) beyond classical exercise testing 2. Is feasible and safe even in high risk/debilitated patients 3. Useful to optimize therapy and exercise prescription 4. Requires equipment/time/expertise/money

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