Cited by 1,964Cardiovascular and exercise physiologyChronic Obstructive Pulmonary Disease (COPD) ResearchPhysical Activity and Health

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Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement From the American Heart Association

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Balady, Gary J., Arena, Ross, Sietsema, Kathy, Myers, Jonathan, Coke, Lola, Fletcher, Gerald F., Forman, Daniel, Franklin, Barry, Guazzi, Marco, Gulati, Martha, Keteyian, Steven J., Lavie, Carl J., Macko, Richard, Mancini, Donna, Milani, Richard V., Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, Interdisciplinary Council on Quality of Care and Outcomes Research·2010·Circulation

DOI 10.1161/cir.0b013e3181e52e69

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Abstract

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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“Since the seminal study by Mancini and colleagues (5) in which they showed the prognostic significance of low peak oxygen uptake (V̇O2) in patients with compensated HF awaiting heart transplant, several other measures from the CPET have been shown to be related to prognosis in these patients (1,2,4,6).”
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Riksfjord, S. M., Brændvik, S. M., Røksund, O. D., & Aamot, I. (2017) · SAGE Open Medicine · doi:10.1177/2050312117743672 · Cited by 8
Physiological responses in different intensities of resistance exercise – Critical load and the effects of aging process
Arakelian, V. M., Goulart, C. D. L., Mendes, R. G., de Sousa, N. M. F., Trimer, R., Guizilini, S., Sampaio, L. M. M., Baldissera, V., Arena, R. A., Reis, M. S., et al. (2018) · Journal of Sports Sciences · doi:10.1080/02640414.2018.1561389 · Cited by 8
Self-citation
The importance of contractile reserve in predicting exercise tolerance in asymptomatic patients with severe aortic stenosis
van Zalen, J., Badiani, S., Hart, L., Marshall, A. J., Beale, L., Brickley, G., Bhattacharyya, S., Patel, N., & Lloyd, G. (2019) · Echo Research and Practice · doi:10.1530/erp-19-0005 · Cited by 8
Impact of pericardiectomy on exercise capacity and sleep of patients with chronic constrictive pericarditis
de Melo, D. T. P., Nerbass, F. B., Sayegh, A. L. C., de Souza, F. R., Hotta, V. T., Salemi, V. M. C., Ramires, F. J. A., Dias, R. R., Lorenzi‐Filho, G., Mady, C., et al. (2019) · PLoS ONE · doi:10.1371/journal.pone.0223838 · Cited by 8
High INtensity Interval Training In pATiEnts with intermittent claudication (INITIATE): protocol for a multicentre, proof-of-concept, prospective interventional study
Pymer, S., Harwood, A. E., Ibeggazene, S., McGregor, G., Huang, C., Twiddy, M., Nicholls, A. R., Ingle, L., Carroll, S., Long, J. A., et al. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-038825 · Cited by 8
Considering the Feasibility, Tolerability, and Safety of High-Intensity Interval Training as a Novel Treatment for Patients With Intermittent Claudication
Pymer, S., Ibeggazene, S., Palmer, J., Smith, G., Harwood, A. E., Carroll, S., Ingle, L., & Chetter, I. C. (2020) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000551 · Cited by 8
Exercise Ventricular Rates, Cardiopulmonary Exercise Performance, and Mortality in Patients With Heart Failure With Atrial Fibrillation
Elshazly, M. B., Wilkoff, B. L., Tarakji, K. G., Wu, Y., Donnellan, E., Khalil, C. A., Asaad, N., Jaber, W. A., Wazni, O. M., & Cho, L. (2021) · Circulation Heart Failure · doi:10.1161/circheartfailure.120.007451 · Cited by 8
Cardiopulmonary Exercise Testing in Combined Pulmonary Fibrosis and Emphysema
Westhoff, M., Litterst, P., & Ewert, R. (2021) · Respiration · doi:10.1159/000513848 · Cited by 8
Heart rate response and chronotropic incompetence during cardiopulmonary exercise testing in childhood acute lymphoblastic leukemia survivors
Bertrand, É., Caru, M., Lemay, V., Andelfinger, G., Laverdière, C., Krajinović, M., Sinnett, D., & Curnier, D. Y. (2021) · Pediatric Hematology and Oncology · doi:10.1080/08880018.2021.1894279 · Cited by 8
All-Cause Mortality Predicted by Peak Oxygen Uptake Differs Depending on Spirometry Pattern in Patients with Heart Failure and Reduced Ejection Fraction
Iterson, E. H. V., Cho, L., Tonelli, A. R., Finet, J. E., & Laffin, L. J. (2021) · ESC Heart Failure · doi:10.1002/ehf2.13342 · Cited by 8
The validation of oxygen uptake efficiency slope in patients with stroke
Han, S.-C., Fu, T., Hsu, C., Huang, S., Lin, H.-Y., & Wang, J. (2021) · Medicine · doi:10.1097/md.0000000000027384 · Cited by 8
“with the V-slope method, defined as the point at which a linear relationship between VCO2 and VO2 is lost ([18,19]); oxygen uptake efficiency slope (OUES): derived from the slope of the natural logarithm plot of VE (l/min) vs VO2(ml/min), which indicates the constant representing the rate at which oxygen consumption i…”
Method
A Brief, Individualized Exercise Program at Intensities Below the Ventilatory Threshold Exerts Therapeutic Effects for Depression: A Pilot Study
Sakai, Y., Chen, C., Toyomaki, A., Hashimoto, N., Kitagawa, K., Inoue, T., Sato, A., Makihara, K., Kameyama, R., Wakatsuki, Y., et al. (2021) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2021.787688 · Cited by 8
Peak Circulatory Power during Maximal Cardiopulmonary Exercise Testing: Reference Standards from the FRIEND Registry
Busque, V., MYERS, J. N., Arena, R. A., Kaminsky, L. A., & Peterman, J. E. (2022) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000002985 · Cited by 8
“Copyright © 2022 by the American College of Sports Medicine and DBP, and peak RER were recorded according to published standards (22).”
MethodSelf-citation
Coronary stenosis is a risk marker for impaired cardiac function on cardiopulmonary exercise test
Li, S., Yuan, Y., Zhao, L., Lv, T., She, F., Liu, F., Xue, Y., Zhou, B., Xie, Y., Geng, Y., et al. (2022) · BMC Cardiovascular Disorders · doi:10.1186/s12872-022-02935-9 · Cited by 8
“10 or HR peak ⩾ 85% predicted HR peak [22].”
BackgroundMethod
Prognostic value of cardiopulmonary exercise testing in patients with transthyretin cardiac amyloidosis
Silverii, M. V., Argirò, A., Baldasseroni, S., Fumagalli, C., Zampieri, M., Guerrieri, L., Bartolini, S., Mazzoni, C., Bürgisser, C., Tomberli, A., et al. (2022) · Internal and Emergency Medicine · doi:10.1007/s11739-022-03125-3 · Cited by 8
The role of cardiopulmonary exercise testing in risk stratification and prognosis of atrial fibrillation: a scoping review of the literature
Boulmpou, A., Teperikidis, E., Papadopoulos, C. E., Patoulias, D., Charalampidis, P. E., Mouselimis, D., Tsarouchas, A., Boutou, A., Giannakoulas, G., & Vassilikos, V. P. (2022) · Acta cardiologica. Supplementum · doi:10.1080/00015385.2022.2148894 · Cited by 8
Exercise oscillatory ventilation reflects diminished quality of life and perceived functional capacity in patients with heart failure
Arena, R. A., Guazzi, M., MYERS, J. N., Chase, P. J., Bensimhon, D., Cahalin, L. P., Peberdy, M. A., Ashley, E. A., West, E., & Forman, D. E. (2011) · International Journal of Cardiology · doi:10.1016/j.ijcard.2011.09.072 · Cited by 8
“Exercise oscillatory ventilation (EOV) has garnered great attention in recent years, demonstrating a robust ability to predict increased risk for adverse events and reflect disease severity [5,6].”
BackgroundSelf-citation
A comparison of the diagnostic performance of the ST/HR hysteresis with cardiopulmonary stress testing parameters in detecting exercise-induced myocardial ischemia
Zimarino, M., Barnabei, L., Madonna, R., Palmieri, G., Radico, F., Tatasciore, A., Bellisarii, F. I., Perrucci, G. M., Corazzini, A., & Caterina, R. D. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2012.12.007 · Cited by 8
“The better ability of treadmill protocols to obtain higher workloads and consequently induce a greater and more easily detectable degree of myocardial ischemia [11,21] might at least partially explain the higher sensitivity of the ST/HR hysteresis compared with”
Background
Physiology and Clinical Applications of Cardiopulmonary Exercise Testing in Lung Cancer Surgery
Voduc, N. (2013) · Thoracic surgery clinics/Thorac. surg. clin. · doi:10.1016/j.thorsurg.2013.01.005 · Cited by 8
The prognostic relevance of oxygen uptake in inoperable chronic thromboembolic pulmonary hypertension
Richter, M. J., Pader, P., Gall, H. J., Reichenberger, F., Seeger, W., Mayer, E., Guth, S., Kramm, T., Grimminger, F., Ghofrani, H. A., et al. (2015) · The Clinical Respiratory Journal · doi:10.1111/crj.12399 · Cited by 9
“The limited exercise capacity was shown by means of a reduced peak VO2 and VO2@AT during CPET.”
MethodInfluential
A study of the 200-metre fast walk test as a possible new assessment tool to predict maximal heart rate and define target heart rate for exercise training of coronary heart disease patients
Casillas, J.-M., Joussain, C., Grémeaux, V., Hannequin, A., Rapin, A., Laurent, Y., & Benaïm, C. (2014) · Clinical Rehabilitation · doi:10.1177/0269215514540922 · Cited by 8
Clinical assessment before hepatectomy identifies high-risk patients
Ulyett, S., Wiggans, M. G., Bowles, M. J., Aroori, S., Briggs, C. D., Erasmus, P., Minto, G., & Stell, D. A. (2015) · Journal of Surgical Research · doi:10.1016/j.jss.2015.05.044 · Cited by 8
“[9] Balady GJ, Arena R, Sietsema K, et al.”
Background
ULTIMATE-SHF trial (UdenafiL Therapy to Improve symptoMAtology, exercise Tolerance and hEmodynamics in patients with chronic systolic heart failure): study protocol for a randomized, placebo-controlled, double-blind trial
Kim, K., Kim, H., Hwang, I., Lee, S., Cho, H., Kang, H., Kim, Y.-J., & Sohn, D. (2013) · Trials · doi:10.1186/1745-6215-14-188 · Cited by 8
“CPET and combined exercise echocardiography will be performed on a stationary cycle ergometer, since echocardiography should be performed at peak exercise [19].”
Noninvasive Ventilation Before Maximum Exercise Test Increases Exercise Tolerance in Subjects With Heart Failure: A Crossover Study
Carvalho, L., Brandão, D. C., Campos, S. L., Vidal, T. M. D. S., de Aguiar, M. I. R., Martins, S. M., & de Andrade, A. D. (2016) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2016.09.129 · Cited by 9
Cardiopulmonary Exercise Testing in Patients With Heart Failure and a Preserved Ejection Fraction: Filling the Prognostic Knowledge Gap
Ozemek, C., & Arena, R. A. (2017) · Revista Española de Cardiología (English Edition) · doi:10.1016/j.rec.2017.08.012 · Cited by 8
“This is in line with epidemiologic characterization studies of HFpEF patients, who have been identified to be older and to consist of a higher proportion of women than patients with HFrEF.”
MethodInfluentialSelf-citation
Troponin‐I levels as a potential prognostic biomarker of sacubitril/valsartan treatment response in heart failure with reduced ejection fraction: Who will benefit most?
Nakou, E. S., Marketou, M. E., CHLOUVERAKIS, G. I., Patrianakos, A. P., Vardas, P. E., & PARTHENAKIS, F. I. (2018) · Clinical Cardiology · doi:10.1002/clc.23099 · Cited by 8
Assessment for Exercise Prescription in Heart Failure
Guazzi, M. (2015) · Cardiac failure review · doi:10.15420/cfr.2015.01.01.46 · Cited by 8
Self-citation
Decreased Aerobic Exercise Capacity After Long-Term Remission From Cushing Syndrome: Exploration of Mechanisms
Roerink, S. H. P. P., Cocks, M. S., Wagenmakers, M. A. E. M., Rodighiero, R. P., Strauss, J. A., Shepherd, S. O., Plantinga, T. S., Thijssen, D. H. J., Hopman, M. T. E., Pereira, A. M., et al. (2019) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgz286 · Cited by 8
Beneficial Molecular Adaptations in BRCA-Mutation Carriers by Combined HIT/HIRT Intervention: Results from a Pilot Study
Bizjak, D. A., Schulz, S. V. W., Schümann, U., Otto, S., Kirsten, J., Ebner, F. K., Leinert, E., Huober, J., Janni, W., & Steinacker, J. M. (2020) · Cancers · doi:10.3390/cancers12061526 · Cited by 8
“A bicycle cardiopulmonary exercise test was completed according to international standards to determine VO2peak for HIT training load [49].”
Method
Effect of three different Pilates sessions on energy expenditure and aerobic metabolism in healthy females
Almeida, I. D. S., Andrade, L. D. S., Mochizuki, L., Sousa, C. V., Neto, J. H. F., Kennedy, M. D., Maciel, L. A., Durigan, J. L. Q., & Mota, Y. L. (2020) · Sport Sciences for Health · doi:10.1007/s11332-020-00676-w · Cited by 8
VO2peak prior to transplant differentiates survival post kidney transplant
Chakkera, H. A., Kaplan, B. E., Budhiraja, P., Behmen, S., Fitz‐Patrick, D., & Butterfield, R. J. (2021) · Clinical Transplantation · doi:10.1111/ctr.14517 · Cited by 8
“Median (Range) 45 (1,100) Type of dialysis (at baseline) None 111 (37.”
Background
Equipment, measurements and quality control
Pórszász, J., Stringer, W. W., & Casaburi, R. H. (2018) · European Respiratory Society eBooks · doi:10.1183/2312508x.10011117 · Cited by 8
Cardiopulmonary exercise testing and impedance cardiography in the assessment of exercise capacity of patients with coronary artery disease early after myocardial revascularization
Kurpaska, M., Krzesiński, P., Gielerak, G. G., Gołębiewska, K., & Piotrowicz, K. (2022) · BMC Sports Science Medicine and Rehabilitation · doi:10.1186/s13102-022-00527-w · Cited by 8
“Each patient underwent maximum CPET, which was stopped if severe symptoms (fatigue, dyspnea) appeared or at the patient’s request [16].”
Background
Increased ventilatory response to exercise in symptomatic and asymptomatic LMNA mutation carriers: a follow‐up study
Ollila, L., Heliö, T. M., Sovijärvi, A. R., Jalanko, M., Kaartinen, M., Kuusisto, J., Kärkkäinen, S., Jurkko, R., Reissell, E., Palojoki, E., et al. (2015) · Clinical Physiology and Functional Imaging · doi:10.1111/cpf.12260 · Cited by 8
“Ventilatory anaerobic threshold was assessed at the slope change of _VCO2 exceeding _VO2, increase of _VE/ _VO2 compared to _VE/ _VCO2 and increase of PetO2 versus PetCO2 (partial pressures of O2 and CO2 in expiratory air) (Balady et al., 2010).”
BackgroundMethod
DNA damage in mononuclear cells following maximal exercise in sedentary and physically active lean and obese men
Peres, A., da Silva, I. M., Santos, M. A., Beretta, Â. C. D. L., de Andrade, V. M., Romão, P. R. T., & Dorneles, G. P. (2020) · European Journal of Sport Science · doi:10.1080/17461391.2020.1801850 · Cited by 8
“Participants performed Cardiopulmonary exercise testing (CPX) on an electric treadmill (Centurion 300, Micromed, Brazil) using a ramp protocol (Balady et al., 2010).”
Method
Non‐invasive markers of pulmonary hypertension in interstitial lung disease: Is cardiopulmonary exercise testing the H oly G rail?
Boutou, A., Pitsiou, G., & Argyropoulou, P. (2014) · Respirology · doi:10.1111/resp.12321 · Cited by 8
CardioPulse Articles
Guazzi, M., & Arena, R. A. (2012) · European Heart Journal · doi:10.1093/eurheartj/ehs319 · Cited by 8
Self-citation
Exercise Stress Echocardiography in Degenerative Mitral Regurgitation
Lancellotti, P., & Garbi, M. (2018) · Circulation Cardiovascular Imaging · doi:10.1161/circimaging.118.008263 · Cited by 8
Role of Cardiorespiratory Fitness and Mitochondrial Oxidative Capacity in Reduced Walk Speed of Older Adults With Diabetes
Ramos, S. V., Distéfano, G., Lui, L., Cawthon, P. M., Kramer, P. A., SIPULA, I. J., Bello, F. M., Mau, T., Jurczak, M. J., Molina, A. J. A., et al. (2024) · Diabetes · doi:10.2337/db23-0827 · Cited by 7
Effects of a Tai Chi rehabilitation program implemented using a hybrid online and offline mode on oxidative stress and inflammatory responses in patients with coronary heart disease: a randomized controlled trial
Cui, M., Wei, Q., Li, Y., Liu, M., Sun, L., Liu, X., Chen, Z., Fang, H., Liu, L., Fu, J., et al. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1369675 · Cited by 7
“…recommended by the American College of Cardiology (ACC) and the American College of Sports Medicine (ACSM), the cardiopulmonary exercise test in this study utilized a graded ascending exercise protocol (Ramp protocol), with a total exercise test time expected to fall within 8–12 min (19, 20).”
Method
Feasibility of performing the 3‐minute step test with remote supervision in children and adolescents with cystic fibrosis: A comparative study
Vendrusculo, F. M., da Costa, G. A., Bagatini, M. A., Lemes, B. M. H. M., Faria, C. A., de Oliveira, L. C., Aquino, E. D. S., & Donadio, M. V. F. (2024) · Pediatric Investigation · doi:10.1002/ped4.12436 · Cited by 7
Effects of volume-matched once-weekly and thrice-weekly high-intensity interval training (HIIT) on body adiposity in adults with central obesity: Study protocol for a randomized controlled trial
Leung, C. K., Bernal, J. D. K., Yu, A. P., Recchia, F., Tam, B. T., Fong, D., Chan, D. K. C., Ngai, H. H. Y., Lee, C., Yung, P. S., et al. (2024) · Journal of Exercise Science & Fitness · doi:10.1016/j.jesf.2024.05.001 · Cited by 9
Protocol for the San Diego Nathan Shock Center Clinical Cohort: a new resource for studies of human aging
Phang, H. J., Heimler, S., Scandalis, L., Wing, D., Moran, R. J., Nichols, J. F., Moreno, D., Shadel, G. S., Gage, F. H., & Molina, A. J. A. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-082659 · Cited by 7
“27 28 Indirect calorimetry remains the gold-standard method for assessing Peak VO 2 .”
Method
The patient with dyspnea
Brenner, S., & Güder, G. (2014) · Herz · doi:10.1007/s00059-014-4057-6 · Cited by 7
Effects of Exercise Mode on Improving Cardiovascular Function and Cardiorespiratory Fitness After Bariatric Surgery
Mahmoud, A. M., da Silva, A. L. G., André, L. D., Hwang, C.-L., Severin, R. S., Sanchez-Johnsen, L., Borghi‐Silva, A., Elokda, A., Arena, R. A., & Phillips, S. A. (2022) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000001946 · Cited by 7
Self-citation
The association between variables of cardiopulmonary exercise test and quality of life in patients with chronic Chagas cardiomyopathy (Insights from the PEACH STUDY)
Vieira, M. C., Mendes, F. D. S. N. S., da Silva, P. S., da Silva, G. M. S., Mazzoli‐Rocha, F., de Sousa, A. S., Saraiva, R. M., Quintana, M. D. S. B., Costa, H. S., Paravidino, V. B., et al. (2022) · PLoS ONE · doi:10.1371/journal.pone.0279086 · Cited by 7
Cardiopulmonary exercise testing criteria for advanced therapies in patients with heart failure
Brawner, C. A., & Lazar, M. H. (2023) · Heart Failure Reviews · doi:10.1007/s10741-023-10337-y · Cited by 10

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: Balady, Gary J.
Arena, Ross
Myers, Jonathan
Forman, Daniel
Franklin, Barry
Guazzi, Marco
Gulati, Martha
Lavie, Carl J.
Macko, Richard
Mancini, Donna
Milani, Richard V.
Venue: Circulation
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2010-07-13
Volume: 122
Issue: 2
Pages: 191-225
ISSN: 0009-7322 (ISSN-L)
1524-4539
DOI: 10.1161/cir.0b013e3181e52e69
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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Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement From the American Heart Association

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