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Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement From the American Heart Association
Open accessAbstract
Arteriovenous oxygen difference EOB Exercise oscillatory breathing FECO 2 Fraction of carbon dioxide in expired air FEO 2 Fraction of oxygen in expired air FEV 1 Forced expiratory volume in 1 second MET Metabolic equivalent MVV Maximum voluntary ventilation O 2 Oxygen OUES Oxygen-uptake efficiency slope P ET CO 2 Partial pressure of end-tidal carbon dioxide P ET O 2 Partial pressure of end-tidal oxygen RER Respiratory exchange ratio V ˙CO 2 Carbon dioxide output VD Volume of dead space V ˙E Minute ventilation V ˙E/V ˙CO 2 Ventilatory equivalent of carbon dioxide V ˙E/V ˙O2 Ventilatory equivalent of oxygen V ˙O2 Oxygen uptake VT Ventilatory threshold 192
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“Cardiologists have tended to regard peak V˙o2 as a particularly valuable index for heart function because V˙o2 can be applied as a proxy for cardiac output,8 and this is most commonly used as part of heart failure (HF) management.”
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“From an evidence-based perspective, cardiopulmonary exercise testing (CPX) is a well-supported assessment technique in both the United States (US) and Europe.”
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Self-citationExercise Intolerance in Patients With Heart Failure
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“regular ‘biological quality control’ (conducted monthly or more frequently), utilizing responses of a ‘standard’ subject (typically a member of the laboratory staff familiar with testing procedures).(13,39,47,48) It is recommended that the subject performs two sub-anaerobic threshold (AT) constant WR tests, each of at…”
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Self-citationCardiopulmonary Exercise Testing in Heart Failure
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“Peak VO2 is an important predictor of prognosis in HF patients (2).”
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Guazzi, M., Bandera, F., Ozemek, C., Systrom, D. M., & Arena, R. A. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.08.012 · Cited by 450
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“The gold standard method is cardiopulmonary exercise testing (CPX) with directly measured VO2max, which has a known biological variability of 3%–4%.(30) As shown in Table 2, this methodology was only used in one study that examined”
MethodSelf-citationUse of exercise testing in the evaluation of interventional efficacy: an official ERS statement
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“The peak oxygen consumption (pVO2) determined by CPET can be used to stratify risk and assess treatment response as well as to identify candidates for device, pharmacologic, and advanced HF therapies.(37,38) For example, a pVO2 of <14 mL/kg/minute is associated with a 1-year survival of 48% and has been adopted as a s…”
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“Cardiopulmonary exercise testing, including determination of peak oxygen uptake, is an objective method used to determine the functional capacity of a patient with HF and for determination of disease severity (12).”
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“1 was targeted as a high effort standard (1).”
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“17 age)] (weight 43))/weight] for females (10,11).”
IL-1 Blockade in Patients With Heart Failure With Preserved Ejection Fraction
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Self-citationLong-term change in cardiorespiratory fitness and all-cause mortality
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“0 at peak exercise, an indication of good exercise effort.(1)”
BackgroundSelf-citationUse of Cardiopulmonary Exercise Testing to Evaluate Long COVID-19 Symptoms in Adults
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“Cardiorespiratory fitness was measured during a maximal exercise test on an electronically braked cycle ergometer according to a ramp protocol, aiming to achieve peak oxygen uptake (peakVO2, in mL/kg/min) within 8– 12 minutes [14].”
MethodStatement on Exercise Testing in Cystic Fibrosis
Hebestreit, H. U., Arets, H. G. M., Aurora, P., Boas, S., Cerny, F., Hulzebos, E. H. J., Karila, C., Lands, L. C., Lowman, J. D., Swisher, A. K., et al. (2015) · Respiration · doi:10.1159/000439057 · Cited by 165
Nadruz, W., West, E., Sengeløv, M., Santos, M., Groarke, J. D., Forman, D. E., Claggett, B. L., Skali, H., & Shah, A. M. (2017) · Journal of the American Heart Association · doi:10.1161/jaha.117.006000 · Cited by 165
Self-citationCardiopulmonary Exercise Testing and Prognosis in Hypertrophic Cardiomyopathy
Coats, C. J., Rantell, K., Bartnik, A., Patel, A., Mist, B., McKenna, W. J., & Elliott, P. M. (2015) · Circulation: Heart Failure · doi:10.1161/circheartfailure.114.002248 · Cited by 148
“Cardiopulmonary exercise testing (CPX) provides a non-invasive method for assessing the cardiovascular, pulmonary and skeletal muscle components of exercise performance.(5) In cardiovascular disease, CPX has many applications including the evaluation of patients with systolic”
MethodSmart, N. A., Haluska, B. A., Jeffriess, L., & Leung, D. Y. (2012) · Congestive Heart Failure · doi:10.1111/j.1751-7133.2012.00295.x · Cited by 155
Ukena, C., Mahfoud, F., Kindermann, I., Barth, C., Lenski, M., Kindermann, M., Brandt, M. C., Hoppe, U. C., Krum, H., Esler, M., et al. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2011.05.036 · Cited by 147
“With a ignificant number of patients being on beta-blockers 91%), the prevalence of chronotropic incompetence (CI) efined as failure to achieve 80% of the maximum ageredicted heart rate (7), was 78% (n 28) in the treatment roup and 44% (n 4) in the control group, respectively.”
BackgroundMethodInfluentialHasselberg, N. E., Haugaa, K. H., Sarvari, S. I., Gullestad, L. L., Andreassen, A. K., Smiseth, O. A., & Edvardsen, T. (2014) · European Heart Journal - Cardiovascular Imaging · doi:10.1093/ehjci/jeu277 · Cited by 146
“(Figure 3) In patients with HFpEF, GLS was correlated to exercise capacity and to NT-proBNP, both of which have prognostic impact in HFpEF.3,29 A few studies have shown correlations between myocardial strain and exercise capacity in patients with heart failure with reduced EF , 40%.16,30 Our study is the first study s…”
MethodInfluentialCahalin, L. P., Chase, P. J., Arena, R. A., MYERS, J. N., Bensimhon, D., Peberdy, M. A., Ashley, E. A., West, E., Forman, D. E., Pinkstaff, S. O., et al. (2012) · Heart Failure Reviews · doi:10.1007/s10741-012-9332-0 · Cited by 145
“analysis, these variables should be used to guide clinical management strategies (pharmacologic, lifestyle, surgical) with the hope of reducing the risk of future adverse CV events [4, 24].”
BackgroundInfluentialSelf-citationExercise blood pressure: Clinical relevance and correct measurement
Sharman, J. E., & LaGerche, A. (2015) · Journal of Human Hypertension · doi:10.1038/jhh.2014.84 · Cited by 142
Macías-Rodríguez, R. U., Ilarraza-Lomelí, H., Ruiz-Margáin, A., Ponce-de-León-Rosales, S., Vargas-Vorácková, F., García-Flores, O., Torre, A., & Duarte-Rojo, A. (2016) · Clinical and Translational Gastroenterology · doi:10.1038/ctg.2016.38 · Cited by 142
Longitudinal Algorithms to Estimate Cardiorespiratory Fitness
Artero, E. G., Jackson, A. S., Sui, X., Lee, D.-C., O’Connor, D. P., Lavie, C. J., Church, T. S., & Blair, S. N. (2014) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2014.03.008 · Cited by 128
“The most valid measure of CRF is cardiopulmonary exercise testing (CPX) with maximal oxygen uptake (VO2max) measured by ventilatory expired gas analysis (5).”
MethodSelf-citationLinks Between Osteoarthritis and Diabetes
Piva, S. R., Bove, A. M., Khoja, S. S., Josbeno, D. A., Fitzgerald, G. K., & Toledo, F. G. S. (2014) · Clinics in Geriatric Medicine · doi:10.1016/j.cger.2014.08.019 · Cited by 142
“For a complete review on the relative and absolute contraindications to exercise in the general population the reader is referred elsewhere.(93,94)”
Physiological Stress Elicits Impaired Left Ventricular Function in Preterm-Born Adults
Huckstep, O. J., Williamson, W., Telles, F., Burchert, H. H., Bertagnolli, M., Herdman, C., Arnold, L., Smillie, R. W., Mohamed, A. B., Boardman, H., et al. (2018) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2018.01.046 · Cited by 129
“Resting echocardiography was performed per clinical standards with subjects scanned in the lateral decubitus position (12); however, upright cycle ergometry and treadmill are the most common clinical exercise stress modalities (29).”
MethodPorta, A., Faes, L., Bari, V., Marchi, A., Bassani, T., Nollo, G., Perseguini, N. M., Milan, J. C., Minatel, V., Borghi‐Silva, A., et al. (2014) · PLoS ONE · doi:10.1371/journal.pone.0089463 · Cited by 127
“The criteria for exercise interruption were based on [37] and the assessment was made according to [38].”
MethodYap, J. J. L., Lim, F. Y., Gao, F., Teo, L. L., Lam, C. S. P., & Yeo, K. K. (2015) · Clinical Cardiology · doi:10.1002/clc.22468 · Cited by 127
Increased Oxidative Metabolism in the Li–Fraumeni Syndrome
Wang, P., Ma, W., Park, J., Celi, F. S., Arena, R. A., Choi, J. W., Ali, Q. A., Tripodi, D., Zhuang, J., Lago, C. U., et al. (2013) · New England Journal of Medicine · doi:10.1056/nejmoa1214091 · Cited by 128
Self-citationMaking Patients Fit for Surgery
van Rooijen, S. J., Molenaar, C. J. L., Schep, G., van Lieshout, R., Beijer, S., Dubbers, R., Rademakers, N., Papen‐Botterhuis, N. E., van Kempen, S., Carli, F., et al. (2019) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000001221 · Cited by 131
Cardiopulmonary Exercise Testing: Relevant but Underused
Forman, D. E., MYERS, J. N., Lavie, C. J., Guazzi, M., Celli, B. R., & Arena, R. A. (2010) · Postgraduate Medicine · doi:10.3810/pgm.2010.11.2225 · Cited by 121
Self-citationZheng, X., Zheng, Y., Ma, J., Zhang, M., Zhang, Y., Liu, X., Chen, L., Yang, Q., Sun, Y., Wu, J., et al. (2018) · Heart & Lung · doi:10.1016/j.hrtlng.2018.09.011 · Cited by 120
“The aim of CR is to ensure the best possible social, psychological and physical conditions for patients living with cardiac disease.(40,41) A previous meta-analysis found that exercise-based CR could reduce depressive symptoms in patients with coronary artery disease (CAD).”
BackgroundAerobic Exercise in Subacute Stroke Improves Cardiovascular Health and Physical Performance
Billinger, S. A., Mattlage, A. E., Ashenden, A. L., Lentz, A. A., Harter, G., & Rippee, M. A. (2012) · Neurology Report · doi:10.1097/npt.0b013e318274d082 · Cited by 119
Skalski, J. H., Allison, T. G., & Miller, T. D. (2012) · Circulation · doi:10.1161/circulationaha.112.110460 · Cited by 119
Optimizing Outcomes in Cardiac Rehabilitation: The Importance of Exercise Intensity
Taylor, J. L., Bonikowske, A. R., & Olson, T. P. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.734278 · Cited by 128
Guazzi, M., Vicenzi, M., & Arena, R. A. (2011) · European Journal of Heart Failure · doi:10.1093/eurjhf/hfr147 · Cited by 115
Self-citationSupervision of Exercise Testing by Nonphysicians
MYERS, J. N., Forman, D. E., Balady, G. J., Franklin, B. A., Worel, J. N., Martin, B., Herbert, W. G., Guazzi, M., & Arena, R. A. (2014) · Circulation · doi:10.1161/cir.0000000000000101 · Cited by 115
Self-citationScott, J. M., Iyengar, N. M., Nilsen, T. S., Michalski, M., Thomas, S. M., Herndon, J. E., SASSO, J. P., Yu, A. F., Chandarlapaty, S., Dang, C. T., et al. (2018) · Cancer · doi:10.1002/cncr.31368 · Cited by 115
“Cardiorespiratory fitness (VO2peak) was assessed with a symptom-limited CPET on an electronic motorized treadmill test with 12-lead electrocardiogram monitoring (Mac 5000; GE Healthcare) according to standard procedures.(8) All CPETs were conducted at a dedicated research laboratory at both institutions.”
MethodCardiopulmonary Responses and Prognosis in Hypertrophic Cardiomyopathy
Finocchiaro, G., Haddad, F., Knowles, J. W., Caleshu, C. A., Pavlović, A., Homburger, J. R., Shmargad, Y., Sinagra, G., Magavern, E. F., Wong, M., et al. (2015) · JACC Heart Failure · doi:10.1016/j.jchf.2014.11.011 · Cited by 115
“Other variables derived from CPET have also been linked to mortality in heart failure, including peak VO2 and ventilatory inefficiency expressed as the VE/VCO2 slope (7,32,33).”
Self-citationCardiopulmonary Exercise Testing in Systolic Heart Failure in 2014: The Evolving Prognostic Role
Corrà, U., Piepoli, M. F., Adamopoulos, S. N., Agostoni, P., Coats, A. J. S., Conraads, V. M., Lambrinou, E., Pieske, B. M., Piotrowicz, E., Schmid, J., et al. (2014) · European Journal of Heart Failure · doi:10.1002/ejhf.156 · Cited by 114
Assessing Exercise Limitation Using Cardiopulmonary Exercise Testing
Stickland, M. K., Butcher, S. J., Marciniuk, D. D., & Bhutani, M. (2012) · Pulmonary Medicine · doi:10.1155/2012/824091 · Cited by 119
“The data gathered from a CPET can provide valuable information to differentiate between these causes [5], as progressive incremental exercise testing provides the most comprehen-”
BackgroundMacKay-Lyons, M. J., McDonald, A. C., Matheson, J. E., Eskes, G. A., & Klus, M.-A. (2013) · Neurorehabilitation and neural repair · doi:10.1177/1545968313484809 · Cited by 112
“11), indicative of consistent physical effort exerted across tests, thus ensuring comparability of test results.(38) Although peak RPE 0-10 values were also consistent across tests (5.”
ResultChaudhry, S., & Stewart, G. C. (2016) · Heart Failure Clinics · doi:10.1016/j.hfc.2016.03.001 · Cited by 117
Snell, C. R., Stevens, S. R., Davenport, T. E., & Ness, J. M. V. (2013) · Physical Therapy · doi:10.2522/ptj.20110368 · Cited by 109
Evaluation of Cardiorespiratory Fitness and Respiratory Muscle Function in the Obese Population
Arena, R. A., & Cahalin, L. P. (2013) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2013.08.001 · Cited by 117
“Detection of ventilatory threshold allows for a more precise workload and heart rate where exercise training intensity may be optimal.(21)”
InfluentialSelf-citationSharma, A., Stevens, S. R., Lucas, J., Fiuzat, M., Adams, K. F., Whellan, D. J., Donahue, M., Kitzman, D. W., Piña, I. L., Zannad, F. M., et al. (2017) · JACC Heart Failure · doi:10.1016/j.jchf.2017.07.013 · Cited by 107
Impact of Different Exercise Modalities on the Human Gut Microbiome
Bycura, D. K., Santos, A. C., Shiffer, A., Kyman, S., Winfree, K. N., Sutliffe, J. T., Pearson, T., Sonderegger, D. L., Cope, E. K., & Caporaso, J. G. (2021) · Sports · doi:10.3390/sports9020014 · Cited by 112
“To further investigate changes in aerobic capacity across the study period, subjects’ ventilatory thresholds (VT) were identified post hoc by V-slope plots [21] of O2 uptake (VO2) and CO2 output (VCO2) in mL·min−1 over pre- and post-test treadmill test times (s).”
BackgroundMethodInfluentialThe Oxygen Uptake Response to Incremental Ramp Exercise
Boone, J., & Bourgois, J. (2012) · Sports Medicine · doi:10.2165/11599690-000000000-00000 · Cited by 104
“VO2/DW is often unaffected by the disease.([78,79]) In these patients, the”
Keller, B. A., Pryor, J. L., & Giloteaux, L. (2014) · Journal of Translational Medicine · doi:10.1186/1479-5876-12-104 · Cited by 102
“99) [20,22,23] in healthy active [21] and inactive adults [19,23], children [24] and many patient populations [25-30].”
BackgroundGraded Maximal Exercise Testing to Assess Mouse Cardio-Metabolic Phenotypes
Petrosino, J. M., Silfee, V., Maurya, S. K., Kalyanasundaram, A., Periasamy, M., LaFountain, R. A., Wilson, J. M., Simonetti, O. P., & Ziouzenkova, O. (2016) · PLoS ONE · doi:10.1371/journal.pone.0148010 · Cited by 103
“Furthermore, they have shown that tests lasting over 12 minutes provide data that is impacted by skeletal muscle fatigue and orthopedic issues [2].”
BackgroundMethodInfluentialTseng, T.-H., Chen, H., Wang, L., & Chien, M. (2020) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.8560 · Cited by 119
“The ventilation threshold was determined using the V-slope method.(31)”
The relationship between obesity and coronary artery disease
Jahangir, E., Schutter, A. D., & Lavie, C. J. (2014) · Translational research · doi:10.1016/j.trsl.2014.03.010 · Cited by 105
“Higher BMI is associated with lower levels of high-density lipoprotein cholesterol (HDL-C), high levels of triglycerides, in addition to small, dense, atherogenic M AN US CR IP T AC CE PT ED low-density lipoprotein cholesterol (LDL-C), all potentially increasing the risk for CAD.”
InfluentialSelf-citationShafiq, A., Brawner, C. A., Aldred, H. A., Lewis, B., Williams, C. T., Tita, C., Schairer, J. R., Ehrman, J. K., Velez, M., Selektor, Y., et al. (2016) · American Heart Journal · doi:10.1016/j.ahj.2015.12.020 · Cited by 102
Self-citationHeart failure with preserved ejection fraction: Refocusing on diastole
Abbate, A., Arena, R. A., Abouzaki, N. A., Tassell, B. W. V., Canada, J. M., Shah, K. B., Biondi‐Zoccai, G., & Voelkel, N. F. (2014) · International Journal of Cardiology · doi:10.1016/j.ijcard.2014.11.106 · Cited by 104
Self-citation
Metadata
- Authors
- Balady, G. J., Arena, R., Sietsema, K., Myers, J., Coke, L., Fletcher, G. F., Forman, D., Franklin, B., Guazzi, M., Gulati, M., Keteyian, S. J., Lavie, C. J., Macko, R., Mancini, D., Milani, R. V., Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, & Interdisciplinary Council on Quality of Care and Outcomes Research
- Affiliations
- IRCCS Policlinico San Donato (IT)
- ORCID
- Venue
- Circulation
- Published
- 2010-07-13
- Volume
- 122
- Issue
- 2
- Pages
- 191-225
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2074602210
- Cited by
- 1,964
- References
- 255
- Citations by year
- 2026: 148 · 2025: 128 · 2024: 177 · 2023: 138 · 2022: 156 · 2021: 150 · 2020: 138 · 2019: 139 · 2018: 125 · 2017: 140 · 2016: 122 · 2015: 90 · 2014: 100 · 2013: 78 · 2012: 70
- FWCI
- 177.95
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs (IK6 RX002477)
- Topics
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
- Keywords
- cardiopulmonary exercise testing, oxygen consumption, ventilatory threshold, oxygen uptake efficiency slope, respiratory exchange ratio, ventilatory equivalents, end-tidal carbon dioxide, end-tidal oxygen, arteriovenous oxygen difference, carbon dioxide output, dead space, forced expiratory volume, metabolic equivalents, maximal voluntary ventilation, adults
- MeSH terms
- Adult, American Heart Association, Cardiovascular Diseases, Exercise Test, Female, Humans, Lung Diseases, Male, United States
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