Peak Ventilation Reference Standards from Exercise Testing: From the FRIEND Registry

Peak Ventilation Reference Standards from Exercise Testing: From the FRIEND Registry. Med. Sci. Sports Exerc., Vol. 50, No. 12, pp. 2603–2608, 2018. Purpose: Cardiopulmonary exercise testing (CPX) provides valuable clinical information, including peak ventilation (V˙ Epeak), which has been shown to have diagnostic and prognostic value in the assessment of patients with underlying pulmonary disease. This report provides reference standards for V˙ Epeak derived from CPX on treadmills in apparently healthy individuals. Methods: Nine laboratories in the United States experienced in CPX administration with established quality control procedures contributed to the Fitness Registry and the Importance of Exercise National Database from 2014 to 2017. Data from 5232 maximal exercise tests from men and women without cardiovascular or pulmonary disease were used to create percentiles ofV˙ Epeak for both men and women by decade between 20 and 79 yr. Additionally, prediction equations were developed for V˙ Epeak using descriptive information. Results: V˙ Epeak was found to be significantly different between men and women and across age groups (P G 0.05). The rate of decline in V˙ Epeak was 8.0% per decade for both men and women. A stepwise regression model of 70% of the sample revealed that sex, age, and height were significant predictors ofV˙ Epeak. The equation was cross-validated with data from the remaining 30% of the sample with a final equation developed from the full sample (r = 0.73). Additionally, a linear regression model revealed forced expiratory volume in 1 s significantly predicted V˙ Epeak (r = 0.73). Conclusions: Reference standards were developed for V˙ Epeak for the United States population. Cardiopulmonary exercise testing laboratories will be able to provide interpretation of V˙ Epeak from these age and sex-specific percentile reference values or alternatively can use these nonexercise prediction equations incorporating sex, age, and height or with a single predictor of forced expiratory volume in 1 s

Impaired myocardial relaxation with exercise determines peak aerobic exercise capacity in heart failure with preserved ejection fraction

Background Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by impaired exercise capacity due to shortness of breath and/or fatigue. Assessment of diastolic dysfunction at rest and with exercise may provide insight into the pathophysiology of exercise intolerance in HFpEF. Aims To measure echocardio-Doppler-derived parameters of diastolic function as they relate to various indices of aerobic exercise capacity in HFpEF. Methods We selected 16 subjects with clinically stable HFpEF, no evidence of volume overload, but impaired functional capacity by cardiopulmonary exercise testing [peak oxygen consumption (VO2)]. We measured the transmitral E and A flow velocities, E/A ratio, and E deceleration time (DT) and tissue Doppler E′ velocity. We also indexed the E′ to the DT, as additional measure of impaired relaxation (E′DT), and calculated the diastolic functional reserve index (DFRI), as the product of E′ at rest and change in E′ with exercise. Results E′ velocity, at rest and peak exercise, as well as the DFRI positively correlated with peak VO2, whereas DT, E′DT, and E/E′ with exercise inversely correlated with peak VO2. Of note, the E′DT at rest also significantly predicted E′ velocity at peak exercise (R = +0.81, P \u3c 0.001). Exercise E′ was the only independent predictor of peak VO2 at multivariable analysis (R = +0.67, P = 0.005). Conclusions The E′ velocity at peak exercise is a strong and independent predictor of aerobic exercise capacity as measured by peak VO2 in patients with HFpEF, providing the link between abnormal myocardial relaxation with exercise and impaired aerobic exercise capacity in HFpEF

Test-Retest Reliability and Validity of the Plank Exercise

Purpose: The plank exercise is a popular and widely used exercise to increase core strength. We previously established normative values for the plank exercise that may be used for fitness classification to identify gaps in core muscular strength and endurance. Whether the plank exercise can be confidently added to current fitness appraisal protocols will depend on its reliability and validity in the fitness testing environment. This study sought to examine test-retest reliability of the plank exercise and to compare plank performance with established normative values for the curl up test. The role of verbal encouragement cues during plank performance testing was also assessed. Methods: Collegiate male (n=14) and female participants (n=19) performed the plank exercise in two separate sessions separated by a minimum of 72 hr. Participants maintained the plank position until complete fatigue was reached. Verbal cues were given to half of the participants in one of the two sessions. Performance on the curl up exercise was measured in a third, separate session. Results: Intraclass correlation showed that mean time held in the plank position was not significantly different between the two plank testing sessions (108.15 + 49.38 versus 111.39 + 56.87 seconds, p=0.556). Verbal encouragement cues did not improve performance time (between group effect, p=0.940). The curl up test was not significantly correlated with either plank session (r=0.410 and 0.276 for plank session one and two, respectively). Surprisingly, the curl up test was positively correlated with participant height (r=0.578). Conclusion: This study suggests that the plank exercise is a reliable test; plank performance was comparable across testing sessions and not influenced by verbal encouragement. Further testing is needed to confirm validity of the plank exercise as a measure of core muscular endurance. We show here that plank performance was not correlated with the standard curl up test. However, the curl up test may not adequately measure core strength, given that increased body height was associated with higher curl up completion scores

Methods and protocols for incremental exercise testing in tetraplegia, using arm-crank ergometry assisted by Functional Electrical Stimulation

Cervical spinal cord injury (SCI) leads to tetraplegia, with paralysis and loss of sensation in the upper and lower limbs. The associated sedentary lifestyle results in an increased risk of cardiovascular disease. To address this, we require the design of exercise modalities aimed specifically at tetraplegia and methods to assess their efficacy. This paper describes methods for arm-crank ergometry (ACE) assisted by Functional Electrical Stimulation (FES) applied to the biceps and triceps. The instrumented ergometer enables work-rate control during exercise, implemented here for incremental exercise testing during FES-ACE. Detailed protocols for the tests are given. Experimental data collected during exercise tests with tetraplegic volunteers are provided to illustrate the feasibility of the proposed approach to testing and data analysis. Incremental tests enabled calculation of peak power output and peak oxygen uptake. We propose that the high-precision exercise testing protocols described here are appropriate to assess the efficacy of the novel exercise modality, FES-ACE, in tetraplegia

Effect of gender on P-wave dispersion in asymptomatic populations

Background: Exercise testing is a diagnostic tool for evaluating the induction of stress-induced paroxysmal atrial fibrillation (PAF). Resting P-wave dispersion has been suggested to be greater in males versus females but if used by clinicians, gender difference in response to exercise must be determined. Methods: Sixteen healthy subjects (n=8 male, age: 21±0.3; n=8 female, age: 23±1.4) performed an incremental exercise test using the Bruce protocol. Electrocardiograms were recorded at rest, end-exercise, 1, 3, and 5 mins recovery. P-waves were measured in each lead with the maximum (P-max) and minimum (P-min) P-wave durations and dispersion calculated. Results: There was a significant decrease in P-max from rest to end-exercise in males and females [males, 118.3±7.4 (95%CI: 109.7 to 126.8ms) vs. 97.9±6.2 (89.3 to 106.4ms); females, 109.4±4.5 (100.8 to 117.9ms) vs. 94.3±4.6 (85.7 to 102.8ms); p=0.001 (5.7 to 29.8ms)]. Similarly, for P-min [males, 65.6±5.6 (57.4 to 73.9ms) vs. 50.8±2.7 (42.5 to 59.0ms); females, 58.4±3.3 (50.1 to 66.6ms) vs. 45.6±2.7 (37.4 to 53.9ms); p=0.01 (2.2 to 25.4ms)]. Irrespective of gender there was limited change in P-wave dispersion in response to exercise. Males had a longer P-max versus females during the protocol [109.6±2.3 (105.8 to 113.4ms) vs. 103.6±1.8 (99.8 to 107.4ms); p=0.03] but this was not stage-specific. There was no gender differences in either P-min (p=0.12) or P-wave dispersion (p=0.64) across the protocol or stage-specific. Conclusions: Results from this study indicate that in contrast to P-max and P-min, the P-wave dispersion may not be significantly influenced by the sympathetic nervous system in males and females. Therefore, this study suggests males and females should be evaluated in the same way using the P-wave dispersion for predicting the development of stress-induced PAF at rest and during exercise testing protocols

Recommendations for high intensity upper body exercise testing

Introduction: For given submaximal and maximal peak power outputs aerobic responses to upper body exercise are different to those for lower body exercise (Sawka, 1986: Exercise & Sport Sciences Reviews, 14, 175-211). However, much less is known regarding responses to exercise intensities at and around peak oxygen up take (VO2peak). Purpose: The purpose of this study was to determine the metabolic responses during arm crank ergometry (ACE) below, at and above peak oxygen uptake and to help establish exercise testing guidelines for high intensity upper body exercise. Methods: Following institutional ethical approval fourteen male students (Age 21.1, s = 6.1 years and 2.44 s=0.44 VO2peak) volunteered to take part in this study. Each participant exercised on a table mounted cycle ergometer (Monark 894E, Monark Exercise AB, Sweden). After habituation peak minute power (PMP) was calculated from an incremental test. Subsequently each participant completed four continuous work tests (CWT) to volitional exhaustion at 80%, 90%, 100% and 110% of PMP. All tests were completed at 70 rev∙min-1 with a minimum of 48-h between tests and the order was counterbalanced. Each CWT was preceded by a 5 min warm-up, loaded with a mass corresponding to the participants 80% PMP for 20 s at minutes 2, 3 and 4. Oxygen uptake (VO2), respiratory exchange ratio (RER), heart rate (HR) and ratings of perceived exertion for the arms (local (RPEL) and cardiorespiratory strain (RPECR) were recorded at 1 min, 2 min and at volitional exhaustion. The EMG responses at three sites (flexor carpi ulnaris, biceps brachii and triceps brachii lateral) were recorded using double-differential (16-3000 Hz bandwidth, x300 gain), bipolar, active electrodes (MP-2A, Linton, Norfolk, UK). Electromyographic data were sampled at 1000 Hz and filtered using a 20 to 500 Hz band-pass filter (MP150 Data Acquisition and AcqKnowledge 4.0, Biopac, Goleta, CA). The EMG signals for each muscle were root mean squared (RMS) with a 500-ms sample window. The signal was then normalised, prior to each CWT, as a percentage of the mean of 3 sets of 10 duty cycles completed during the warm-up (see above) when the participants 80% PMP for 20 s was applied. Time to exhaustion (Tlim) was recorded as the performance outcome measure. Data for Tlim were analysed using one-way analysis of variance. Differences in EMG, VO2, RER, HR, RPEL and RPECR were analysed using separate two-way analysis of variance with repeated measures (trial x time). All analyses were performed using the Statistical Package for Social Sciences ( 17.0; SPSS Inc., Chicago, IL). Individual differences in means were located using Bonferroni post-hoc correction. Significance was accepted at P < 0.05. Results: As resistive load increased Tlim decreased (611 s=194, 397 s=99, 268 s=90, 206 s=67s, respectively; P < 0.001, ES = 0.625). Post-hoc analysis revealed that Tlim using 80%PMP was longer than for 90%, 100% and 110% PMP trials (P < 0.001) and 90% was longer than both 100% and 110% PMP trials (P = 0.079, P = 0.001). At exhaustion VO2 was similar across trials (P = 0.413, ES = 0.053), although 80% PMP VO2 tended to be less (2.10 s=0.32 l·min-1) than for 90% (2.29 s=0.37), 100% (2.33 s=0.49) and 110% (2.26 s=0.34). Also, 80% PMP VO2 was less than VO2peak (P = 0.013). There were differences in RER at Tlim (P < 0.001, ES = 0.593) with values increasing with % PMP (1.15 s=0.07, 1.26 s=0.07, 1.36 s=0.10, 1.40 s=0.09, respectively). There were no differences across trials for HR at Tlim (~173 (12); P = 0.834, ES = 0.016) and HR was proportional to %PMP at 1 min, and 2 min. For flexor carpi ulnaris there was an increase in activation as exercise intensity increased (P < 0.001, ES = 0.245). There were a similar responses for biceps brachii and triceps brachii demonstrating an increase in activation with exercise intensity (P <0.001, ES = 0.137, P < 0.001, ES = 0.163, respectively). No differences for RPEL and RPECR were observed at Tlim. Discussion: There was a clear response of Tlim with intensity as expected for lower body exercise (Hill et al., 2002: Medicine and Science in Sports and Exercise, 34(4), 709-714). Despite differences in Tlim across exercise intensities VO2, HR and RPE were similar at exhaustion indicating a functional cardiorespiratory maximum had been reached. As indicated by the RER an increased activation of the anaerobic metabolism with greater exercise intensities (100% and 110%) is likely and therefore this may represent a greater anaerobic component at these two intensities. The increase in EMG activity with intensity could indicate an increase activity with an increase in exercise intensity. Conclusion: It is recommended that due to the combination of muscle activation, oxygen uptake and Tlim that an exercise intensity of 90% or 100% of PMP could be used for high intensity upper body exercise testing

Applying stress-testing on value at risk (VaR) methodologies

In recent years, Value at Risk (VaR) methodologies, i. e., Parametric VaR, Historical Simulation and the Monte Carlo Simulation have experienced spectacular growth within the new regulatory framework which is Basle II. Moreover, complementary analyses such a Stress-testing and Back-testing have also demonstrated their usefulness for financial risk managers. In this paper, we develop an empirical Stress-Testing exercise by using two historical scenarios of crisis. In particular, we analyze the impact of the 11-S attacks (2001) and the Latin America crisis (2002) on the level of risk, previously calculated by different statistical methods. Consequently, we have selected a Spanish stock portfolio in order to focus on market risk

Systemic Exercise-Induced Hypoalgesia Following Isometric Exercise Reduces Conditioned Pain Modulation

Objective Physically active individuals show greater conditioned pain modulation (CPM) compared with less active individuals. Understanding the effects of acute exercise on CPM may allow for a more targeted use of exercise in the management of pain. This study investigated the effects of acute isometric exercise on CPM. In addition, the between-session and within-session reliability of CPM was investigated. Design Experimental, randomized crossover study. Setting Laboratory at Marquette University. Subjects Thirty healthy adults (19.3±1.5 years, 15 males). Methods Subjects underwent CPM testing before and after isometric exercise (knee extension, 30% maximum voluntary contraction for three minutes) and quiet rest in two separate experimental sessions. Pressure pain thresholds (PPTs) at the quadriceps and upper trapezius muscles were assessed before, during, and after ice water immersions. Results PPTs increased during ice water immersion (i.e., CPM), and quadriceps PPT increased after exercise (P \u3c 0.05). CPM decreased similarly following exercise and quiet rest (P \u3e 0.05). CPM within-session reliability was fair to good (intraclass correlation coefficient [ICC] = 0.43–0.70), and the between-session reliability was poor (ICC = 0.20–0.35). Due to the variability in the systemic exercise-induced hypoalgesia (EIH) response, participants were divided into systemic EIH responders (N = 9) and nonresponders (N = 21). EIH responders experienced attenuated CPM following exercise (P = 0.03), whereas the nonresponders showed no significant change (P \u3e 0.05). Conclusions Isometric exercise decreased CPM in individuals who reported systemic EIH, suggesting activation of shared mechanisms between CPM and systemic EIH responses. These results may improve the understanding of increased pain after exercise in patients with chronic pain and potentially attenuated CPM

Which diagnostic tests are most useful in a chest pain unit protocol?

Background The chest pain unit (CPU) provides rapid diagnostic assessment for patients with acute, undifferentiated chest pain, using a combination of electrocardiographic (ECG) recording, biochemical markers and provocative cardiac testing. We aimed to identify which elements of a CPU protocol were most diagnostically and prognostically useful. Methods The Northern General Hospital CPU uses 2–6 hours of serial ECG / ST segment monitoring, CK-MB(mass) on arrival and at least two hours later, troponin T at least six hours after worst pain and exercise treadmill testing. Data were prospectively collected over an eighteen-month period from patients managed on the CPU. Patients discharged after CPU assessment were invited to attend a follow-up appointment 72 hours later for ECG and troponin T measurement. Hospital records of all patients were reviewed to identify adverse cardiac events over the subsequent six months. Diagnostic accuracy of each test was estimated by calculating sensitivity and specificity for: 1) acute coronary syndrome (ACS) with clinical myocardial infarction and 2) ACS with myocyte necrosis. Prognostic value was estimated by calculating the relative risk of an adverse cardiac event following a positive result. Results Of the 706 patients, 30 (4.2%) were diagnosed as ACS with myocardial infarction, 30 (4.2%) as ACS with myocyte necrosis, and 32 (4.5%) suffered an adverse cardiac event. Sensitivities for ACS with myocardial infarction and myocyte necrosis respectively were: serial ECG / ST segment monitoring 33% and 23%; CK-MB(mass) 96% and 63%; troponin T (using 0.03 ng/ml threshold) 96% and 90%. The only test that added useful prognostic information was exercise treadmill testing (relative risk 6 for cardiac death, non-fatal myocardial infarction or arrhythmia over six months). Conclusion Serial ECG / ST monitoring, as used in our protocol, adds little diagnostic or prognostic value in patients with a normal or non-diagnostic initial ECG. CK-MB(mass) can rule out ACS with clinical myocardial infarction but not myocyte necrosis(defined as a troponin elevation without myocardial infarction). Using a low threshold for positivity for troponin T improves sensitivity of this test for myocardial infarction and myocardial necrosis. Exercise treadmill testing predicts subsequent adverse cardiac events

Healthcare professional’s guide to cardiopulmonary exercise testing

Cardiopulmonary exercise testing (CPEX) is a valuable clinical tool that has proven indications within the fields of cardiovascular, respiratory and pre-operative medical care. Validated uses include investigation of the underlying mechanism in patients with breathlessness, monitoring functional status in patients with known cardiovascular disease and pre-operative functional state assessment. An understanding of the underlying physiology of exercise, and the perturbations associated with pathological states, is essential for healthcare professionals to provide optimal patient care. Healthcare professionals may find performing CPEX to be daunting, yet this is often due to a lack of local expertise and guidance with testing. We outline the indications for CPEX within the clinical setting, present a typical protocol that is easy to implement, explain the key underlying physiological changes assessed by CPEX, and review the evidence behind its use in routine clinical practice. There is mounting evidence for the use of CPEX clinically, and an ever-growing utilisation of the test within research fields; a sound knowledge of CPEX is essential for healthcare professionals involved in routine patient care