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