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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Young, E., Karthikesalingam, A., Huddart, S., Pearse, R. M., Hinchliffe, R. J., Loftus, I. M., THOMPSON, M. M., & Holt, P. (2012) · European Journal of Vascular and Endovascular Surgery · doi:10.1016/j.ejvs.2012.03.022 · Cited by 56
Cardiopulmonary exercise testing reflects similar pathophysiology and disease severity in heart failure patients with reduced and preserved ejection fraction
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“There is a rather compelling body of research to support this view point in patients with HFrEF, although the consensus is both VE/VCO2 slope and peak VO2 should be assessed in combination to improve prognostic resolution.(3) While the current investigation supports a similar pattern in HFpEF with respect to VE/VCO2 s…”
ResultSelf-citation
Exercise-based cardiac rehabilitation in surgically treated type-A aortic dissection patients
Fuglsang, S., Heiberg, J., Hjortdal, V. E., & Laustsen, S. (2016) · Scandinavian Cardiovascular Journal · doi:10.1080/14017431.2016.1257149 · Cited by 55
“position papers from Corra et al.[9,10] The training sessions”
Background
Clinical Correlates and Outcome Associated with Changes in 6-Minute Walking Distance in Patients with Heart Failure: Findings from the BIOSTAT-CHF Study
Ferreira, J. P., Metra, M., Anker, S. D., Dickstein, K., Lang, C. C., Ng, L. L., Samani, N. J., Cleland, J. G. F., van Veldhuisen, D. J., Voors, A. A., et al. (2019) · European Journal of Heart Failure · doi:10.1002/ejhf.1380 · Cited by 56
Biomarkers of aging: from molecules and surrogates to physiology and function
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Low skeletal muscle mass is associated with low aerobic capacity and increased mortality risk in patients with coronary heart disease – a CARE CR study
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“guidelines and recommendations (American Thoracic Society/ American College of Chest Physicians 2003; Balady et al., 2010; Nichols et al., 2015; Taylor et al., 2015) and was per-”
New insights into resting and exertional right ventricular performance in the healthy heart through real‐time pressure‐volume analysis
Cornwell, W. K., Tran, T., Cerbin, L. P., Coe, G., Muralidhar, A., Hunter, K. S., Altman, N. L., Ambardekar, A. V., TOMPKINS, C. M., Zipse, M. M., et al. (2020) · The Journal of Physiology · doi:10.1113/jp279759 · Cited by 55
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Maximal and submaximal aerobic tests for wheelchair-dependent persons with spinal cord injury: a systematic review to summarize and identify useful applications for clinical rehabilitation
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Does exercise prescription based on estimated heart rate training zones exceed the ventilatory anaerobic threshold in patients with coronary heart disease undergoing usual-care cardiovascular rehabilitation? A United Kingdom perspective
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“according to manufacturers’ instructions and current recommendations.(25) Peak values were averaged over the final 30 s of the CPET.”
Method
The relationship between cardiorespiratory fitness, cardiovascular risk factors and atherosclerosis
Chu, D. J., Rifai, M. A., Virani, S. S., Brawner, C. A., Nasir, K., & Al-Mallah, M. H. (2020) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2020.04.019 · Cited by 56
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“[18] The peak oxygen uptake and oxygen uptake at the VT was also reported as a percentage of the predicted maximal oxygen consumption.[19] Ventilatory efficiency was assessed by the slope of the min ventilation to the carbon dioxide production (VE/VCO2 slope) calculated over the linear phase of the response up to the…”
Method
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Davenport, T. E., Lehnen, M., Stevens, S. R., VanNess, J. M., Stevens, J., & Snell, C. R. (2019) · Frontiers in Pediatrics · doi:10.3389/fped.2019.00082 · Cited by 53
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“According to recent scientific statements issued by the American Heart Association, it was both important and feasible to measure CRF in the clinical environment [3, 6–10].”
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Klaassen, S. H. C., Liu, L. C. Y., Hummel, Y. M., Damman, K., van der Meer, P., Voors, A. A., Hoendermis, E. S., & van Veldhuisen, D. J. (2017) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2017.07.397 · Cited by 52
“In addition to standard diagnostic tests, cardiopulmonary exercise testing (CPX) provides useful information regarding the clinical condition of patients.(4) Although peak VO2 is the criterion standard in patients with heart failure, HFpEF patients often do not achieve peak VO2 owing to elderly age and the presence of…”
Method
Effects and tolerability of exercise therapy modality on cardiorespiratory fitness in lung cancer: a randomized controlled trial
Scott, J. M., Thomas, S. M., Herndon, J. E., Douglas, P. S., Yu, A. F., Rusch, V. W., Huang, J. G., Capaci, C., Harrison, J., Stoeckel, K., et al. (2021) · Journal of Cachexia Sarcopenia and Muscle · doi:10.1002/jcsm.12828 · Cited by 57
“(%) I 1 (1) 1 (4) 0 (0) 0 (0) 0 (0) IA 35 (39) 10 (42) 8 (35) 9 (45) 8 (35) IB 22 (24) 4 (17) 6 (26) 5 (25) 7 (30) IIA 10 (11) 2 (8) 4 (17) 2 (10) 2 (9) IIB 8 (9) 3 (12) 1 (4) 1 (5) 3 (13) IIIA 11 (12) 3 (12) 3 (13) 2 (10) 3 (13) IIIB 2 (2) 0 (0) 1 (4) 1 (5) 0 (0) Limited stage 1 (1) 1 (4) 0 (0) 0 (0) 0 (0) Adjuvant t…”
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“Physical Repeated cardiopulmonary exercise tests, 24 h apart (Katch et al., 1982; Amann et al., 2004; Bensimhon et al., 2008; Balady et al., 2010) VanNess et al., 2006; Patrick Neary et al., 2008; Vermeulen et al., 2010; Snell et al., 2013 Cognitive Specific neurocognitive tests* (Wechsler, 1981;…”
Background
Prognostic respiratory parameters in heart failure patients with and without exercise oscillatory ventilation — A systematic review and descriptive meta-analysis
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Wagner, J., Agostoni, P., Arena, R. A., Belardinelli, R., Dumitrescu, D., Hager, A., MYERS, J. N., Rauramaa, R., Riley, M., Takken, T., et al. (2018) · American Heart Journal · doi:10.1016/j.ahj.2018.05.009 · Cited by 51
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Self-citation
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Elshazly, M. B., Senn, T. N., Wu, Y., Lindsay, B. A., Saliba, W. I., Wazni, O. M., & Cho, L. (2017) · Journal of the American Heart Association · doi:10.1161/jaha.117.006662 · Cited by 50
“The increase in SBP during exercise is a normal physiologic process in healthy individuals, reflecting an increase in cardiac output for the most part and peripheral vascular resistance to a lesser extent.(12) Although most studies have shown AF association with lower peak SBP attributable to loss of atrial contractil…”
BackgroundMethodResultInfluential
High-intensity interval training in people with Parkinson’s disease: a randomized, controlled feasibility trial
Harvey, M., Weston, K. L., Gray, W. K., O’Callaghan, A., Oates, L. L., Davidson, R., & Walker, R. W. (2018) · Clinical Rehabilitation · doi:10.1177/0269215518815221 · Cited by 52
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“Ventilatory threshold (VT) was defined as the point of intersection between the line of departure of VO2 from the line of identity drawn through a plot of VCO2 versus VO2 (the v-slope method) (14).”
Method
Effects of home-based cardiac telerehabilitation programs in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis
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“The Peak oxygen consumption (VO2 peak) in the cardiopulmonary exercise test (CPET) is the gold standard for reflecting the patient’s cardiorespiratory fitness and exercise capacity [38].”
Background
Muscular pre-conditioning using light-emitting diode therapy (LEDT) for high-intensity exercise: a randomized double-blind placebo-controlled trial with a single elite runner
Ferraresi, C., Beltrame, T., Fabrizzi, F., do Nascimento, E. S. P., Karsten, M., Francisco, C. D. O., Borghi‐Silva, A., Catai, A. M., Cardoso, D. R., Ferreira, A. G., et al. (2015) · Physiotherapy Theory and Practice · doi:10.3109/09593985.2014.1003118 · Cited by 50
“The gas analyzer system was calibrated before the test following standard procedures (Balady et al, 2010).”
Method
Recumbent Stepper Submaximal Exercise Test to Predict Peak Oxygen Uptake
Billinger, S. A., SWEARINGEN, E. V., MCCLAIN, M., Lentz, A. A., & GOOD, M. B. (2012) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0b013e31824f5be4 · Cited by 48
Associations of cardiovascular and all-cause mortality events with oxygen uptake at ventilatory threshold
Kunutsor, S. K., Kurl, S., Khan, H., Zaccardi, F., & Laukkanen, J. A. (2017) · International Journal of Cardiology · doi:10.1016/j.ijcard.2017.01.156 · Cited by 53
6MWT Performance and its Correlations with VO2 and Handgrip Strength in Home-Dwelling Mid-Aged and Older Chinese
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“The VO2 test method was designed based on usual cardiovascular exercise test protocol [18,28] and on our trial tests (unpublished data).”
MethodResult
The Role of Moderate Aerobic Exercise as Determined by Cardiopulmonary Exercise Testing in ALS
Braga, A. C., Pinto, A. C., Pinto, S., & de Carvalho, M. A. (2018) · Neurology Research International · doi:10.1155/2018/8218697 · Cited by 48
“The former refers to the use of oxygen to adequately meet energy demands during exercise via aerobic metabolism, which is critically related to the cardiorespiratory and vascular system’s capacity to supply oxygen to the muscles, and the ability to clear carbon dioxide from the blood via the lungs [4].”
Background
Post-Exercise Oxygen Uptake Recovery Delay
Bailey, C. S., Wooster, L. T., Buswell, M. D., Patel, S., Pappagianopoulos, P. P., Bakken, K., White, C., Tanguay, M., Blodgett, J. B., Baggish, A. L., et al. (2018) · JACC Heart Failure · doi:10.1016/j.jchf.2018.01.007 · Cited by 48
“Peak oxygen uptake (VO2) measured during cardiopulmonary exercise testing (CPET) reflects exercise capacity and is utilized to grade severity of HF (1).”
Left Atrial Strain Predicts Exercise Capacity in Heart Failure Independently of Left Ventricular Ejection Fraction
Maffeis, C., Rossi, A., Cannata, L., Zocco, C., Belyavskiy, E., Radhakrishnan, A. K., Feuerstein, A., Morris, D. A., Pieske‐Kraigher, E., Pieske, B. M., et al. (2022) · ESC Heart Failure · doi:10.1002/ehf2.13788 · Cited by 48
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“To assess the exercise capacity of each patient, a bicycle cardiopulmonary exercise test was completed according to international standards [28].”
Method
Peak Oxygen Uptake Prediction From a Moderate, Perceptually Regulated, 1-km Treadmill Walk in Male Cardiac Patients
Chiaranda, G., MYERS, J. N., Mazzoni, G., Terranova, F., Bernardi, E., Grossi, G., Codecà, L., Conconi, F., & Grazzi, G. (2012) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0b013e3182663507 · Cited by 49
Self-citation
Supervised Short-term High-intensity Training on Plasma Irisin Concentrations in Type 2 Diabetic Patients
Dünnwald, T., Melmer, A., Gatterer, H., Salzmann, K., Ebenbichler, C. F., Burtscher, M., Schobersberger, W., & Grander, W. (2019) · International Journal of Sports Medicine · doi:10.1055/a-0828-8047 · Cited by 47
“fined as the average value of VO2 over the last 30 sec before exhaustion [4], whereas the highest HR achieved in the test was taken as HRmax.”
Background
Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review
Stubbs, D. J., Grimes, L. A., & Ercole, A. (2020) · PLoS ONE · doi:10.1371/journal.pone.0226480 · Cited by 47
Cardiorespiratory Reference Data in Older Adults: The Generation 100 Study
STENSVOLD, D., BUCHER SANDBAKK, S., VIKEN, H., ZISKO, N., REITLO, L. S., NAUMAN, J., GAUSTAD, S. E., HASSEL, E., MOUFACK, M., BRØNSTAD, E., et al. (2017) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000001343 · Cited by 46
“Breathing reserve was calculated as the difference between maximum voluntary ventilation (FEV1 40) and peak ventilation, and presented as percentage of maximum voluntary ventilation (3).”
Method
A Non Invasive Estimate of Dead Space Ventilation from Exercise Measurements
Gargiulo, P., Apostolo, A., Filardi, P. P., Sciomer, S., Palange, P., & Agostoni, P. (2014) · PLoS ONE · doi:10.1371/journal.pone.0087395 · Cited by 46
“to analyze the ratio of the relationship [31], others the slope [32].”
Background
A randomised trial comparing weight loss with aerobic exercise in overweight individuals with coronary artery disease: The CUT-IT trial
Pedersen, L. R., Olsen, R. H., Jürs, A., Astrup, A. V., Chabanova, E., Simonsen, L., Wisløff, U., Haugaard, S. B., & Prescott, E. (2014) · European Journal of Preventive Cardiology · doi:10.1177/2047487314545280 · Cited by 46
“Our assertion that the increase in VO2peaktotal and VO2peakffm is due to AIT per se and not familiarisation to the test is supported by the constant peak RER in this group.(18) Thus, the increase in peak RER after the LED could reflect a more efficient test with increased physical performance due to loss of body weigh…”
Background
Effects of continuous vs interval exercise training on oxygen uptake efficiency slope in patients with coronary artery disease
do Prado, D. M. L., Rocco, E. A., Silva, A. G., Rocco, D. F. M., Pacheco, M. T. T., Silva, P. F., & Furlan, V. (2016) · Brazilian Journal of Medical and Biological Research · doi:10.1590/1414-431x20154890 · Cited by 46
Nonexercise Estimated Cardiorespiratory Fitness and Mortality Due to All Causes and Cardiovascular Disease
Zhang, Y., Zhang, J., Zhou, J., Ernstsen, L., Lavie, C. J., Hooker, S. P., & Sui, X. (2017) · Mayo Clinic Proceedings Innovations Quality & Outcomes · doi:10.1016/j.mayocpiqo.2017.04.007 · Cited by 46
“The measurement of CRF often requires specialized equipment and trained personnel, and it is time-consuming and relatively expensive, especially in clinical settings.(11) The development of nonexercise algorithms provides a cost-effective way to estimate CRF from easily obtained health indicators.”
BackgroundSelf-citation
Exercise capacity in diabetes mellitus is predicted by activity status and cardiac size rather than cardiac function: a case control study
Roberts, T. J., Burns, A., MacIsaac, R. J., MacIsaac, A. I., Prior, D., & Gerche, A. L. (2018) · Cardiovascular Diabetology · doi:10.1186/s12933-018-0688-x · Cited by 46
“Respiratory exchange ratio (RER), ventilatory threshold (VT) and ventilatory efficiency (V̇E/V̇CO2) were calculated by standard measures [8].”
Method
Review article: comprehensive analysis of cirrhotic cardiomyopathy
Chahal, D., Liu, H., Shamatutu, C., Sidhu, H., Lee, S. S., & Marquez, V. (2021) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.16305 · Cited by 48
Reduced Exercise Capacity, Chronotropic Incompetence, and Early Systemic Inflammation in Cardiopulmonary Phenotype Long Coronavirus Disease 2019
Durstenfeld, M. S., Peluso, M. J., Kaveti, P., Hill, C. A., Li, D., Sander, E., Swaminathan, S., Arechiga, V. M., Lu, S., Goldberg, S. A., et al. (2023) · The Journal of Infectious Diseases · doi:10.1093/infdis/jiad131 · Cited by 45
Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness
Guerra‐Londono, C. E., Cata, J. P., Nowak, K., & Gottumukkala, V. N. R. (2024) · Current Oncology · doi:10.3390/curroncol31040162 · Cited by 52
“Other measures of CRF include the anaerobic threshold and the ventilatory equivalents of oxygen and carbon dioxide [47].”
BackgroundMethod
Impact of a cardiac rehabilitation program and inflammatory state on endothelial progenitor cells in acute coronary syndrome patients
Cesari, F., Marcucci, R., Gori, A. M., Bürgisser, C., Francini, S., Sofi, F., Gensini, G. F., Abbate, R., & Fattirolli, F. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2012.04.157 · Cited by 45
Long-term effect of exercise training in patients after transcatheter aortic valve implantation: Follow-up of the SPORT:TAVI randomised pilot study
Preßler, A., Förschner, L., Hummel, J., Haller, B., Christle, J. W., & Halle, M. (2018) · European Journal of Preventive Cardiology · doi:10.1177/2047487318765233 · Cited by 45
Anandamide Is Related to Clinical and Cardiorespiratory Benefits of Aerobic Exercise Training in Migraine Patients: A Randomized Controlled Clinical Trial
Oliveira, A. B., Ribeiro, R. T., de Mello, M. T., Tufik, S. B., & Peres, M. F. P. (2019) · Cannabis and Cannabinoid Research · doi:10.1089/can.2018.0057 · Cited by 45
“output and musculoskeletal oxygen extraction/utilization.(31) Respiratory gas exchange measurements were obtained breath-by-breath by an open-circuit computerized spirometry system (Quark CPET; COSMED, Rome,”
Method
Cardiorespiratory fitness modulates the proportions of monocytes and T helper subsets in lean and obese men
Dorneles, G. P., da Silva, I., Boeira, M. C. R., Valentini, D., Fonseca, S. G., Lago, P. D., Peres, A., & Romão, P. R. T. (2019) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.13506 · Cited by 45
Exercise oscillatory ventilation: Mechanisms and prognostic significance
Dhakal, B. P., & Lewis, G. D. (2016) · World Journal of Cardiology · doi:10.4330/wjc.v8.i3.258 · Cited by 46
Reference Values for Peak Exercise Cardiac Output in Healthy Individuals
Agostoni, P., Vignati, C., Gentile, P., Boiti, C., Farina, S., Salvioni, E., Mapelli, M., Magrì, D., Paolillo, S., Corrieri, N., et al. (2017) · CHEST Journal · doi:10.1016/j.chest.2017.01.009 · Cited by 44
Myocardial Work Assessment for the Prediction of Prognosis in Advanced Heart Failure
Hedwig, F., Nemchyna, O., Stein, J., Knosalla, C., Merke, N., Knebel, F., Hagendorff, A., Schoenrath, F., Falk, V., & Knierim, J. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.691611 · Cited by 44
Clinical Usefulness of Response Profiles to Rapidly Incremental Cardiopulmonary Exercise Testing
Ramos, R. P., Alencar, M. C. N., Treptow, E. C., Arbex, F. F., Ferreira, E. V. M., & Neder, J. A. (2013) · Pulmonary Medicine · doi:10.1155/2013/359021 · Cited by 42
Cardiopulmonary exercise testing in the assessment of pulmonary hypertension
Arena, R. A., Guazzi, M., MYERS, J. N., Grinnen, D., Forman, D. E., & Lavie, C. J. (2011) · Expert Review of Respiratory Medicine · doi:10.1586/ers.11.4 · Cited by 43
Self-citation
Cardiac rehabilitation program in patients with Chagas heart failure: a single-arm pilot study
Mediano, M. F. F., Mendes, F. D. S. N. S., Pinto, V. L. M., da Silva, G. M. S., da Silva, P. S., Carneiro, F. M., Sangenis, L. H. C., Saraiva, R. M., Xavier, S. S., do Brasil, P. E. A. A., et al. (2016) · Revista da Sociedade Brasileira de Medicina Tropical · doi:10.1590/0037-8682-0083-2016 · Cited by 43
“symptoms, in order to provide a comprehensive assessment of tolerance and physiological responses during exercise(24).”
Background
Effect of Aerobic Exercise Training on Ventilatory Efficiency and Respiratory Drive in Obese Subjects
Chlif, M., Chaouachi, A., & Ahmaı̈di, S. (2017) · Respiratory Care · doi:10.4187/respcare.04923 · Cited by 44
Cardio-Oncology Rehabilitation and Telehealth: Rationale for Future Integration in Supportive Care of Cancer Survivors
Baťalík, L., Filáková, K., Radkovcova, I., Dosbaba, F., Winnige, P., Vlažná, D., Batalikova, K., Felšőci, M., Stefanakis, M., Líška, D., et al. (2022) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2022.858334 · Cited by 44
Effect of High‐Intensity Interval Training and Moderate‐Intensity Continuous Training in People With Poststroke Gait Dysfunction: A Randomized Clinical Trial
Marzolini, S., Robertson, A. D., MacIntosh, B. J., Corbett, D., Anderson, N. D., Brooks, D., Koblinsky, N. D., & OH, P. I. (2023) · Journal of the American Heart Association · doi:10.1161/jaha.123.031532 · Cited by 45
Effects of exercise training and Mediterranean diet on vascular risk reduction in post-menopausal women
AlKhatib, A. H., & Klonizakis, M. (2014) · Clinical Hemorheology and Microcirculation · doi:10.3233/ch-131770 · Cited by 43
PDE 5 inhibition with udenafil improves left ventricular systolic/diastolic functions and exercise capacity in patients with chronic heart failure with reduced ejection fraction; A 12-week, randomized, double-blind, placebo-controlled trial
Kim, K., Kim, H., Hwang, I., Cho, H., Je, N., Kwon, O.-M., Choi, S., Lee, S., Kim, Y.-J., & Sohn, D. (2015) · American Heart Journal · doi:10.1016/j.ahj.2015.03.018 · Cited by 43
Association between VO2 peak estimated by a 1-km treadmill walk and mortality. A 10-year follow-up study in patients with cardiovascular disease
Grazzi, G., MYERS, J. N., Bernardi, E., Terranova, F., Grossi, G., Codecà, L., Volpato, S., Conconi, F., Mazzoni, G., & Chiaranda, G. (2014) · International Journal of Cardiology · doi:10.1016/j.ijcard.2014.02.039 · Cited by 44
Self-citation
The current standard measure of cardiorespiratory fitness introduces confounding by body mass: the DR's EXTRA study
Savonen, K. P., Krachler, B., Hassinen, M., Komulainen, P., Kiviniemi, V. V., Lakka, T. A., & Rauramaa, R. (2011) · International Journal of Obesity · doi:10.1038/ijo.2011.212 · Cited by 42
Prognostic Value of Estimated Functional Capacity Incremental to Cardiac Biomarkers in Stable Cardiac Patients
Tang, W. H. W., Topol, E. J., Fan, Y., Wu, Y., Cho, L., Stevenson, C., Ellis, S. G., & Hazen, S. L. (2014) · Journal of the American Heart Association · doi:10.1161/jaha.114.000960 · Cited by 42
Cardiorespiratory Coordination after Training and Detraining. A Principal Component Analysis Approach
Balagué, N., González, J., Javierre, C. F., Hristovski, R., Aragonés, D., Álamo, J., Méndez, O. A. N., & Ventura, J. L. (2016) · Frontiers in Physiology · doi:10.3389/fphys.2016.00035 · Cited by 42
“It measures a broad range of variables related to cardiorespiratory function with the goal of quantitatively linking metabolic, cardiovascular, and pulmonary responses to exercise (Balady et al., 2010).”
Background
A Home- and Community-Based Physical Activity Program Can Improve the Cardiorespiratory Fitness and Walking Capacity of Stroke Survivors
Marsden, D. L., Dunn, A., Callister, R., McElduff, P., Levi, C. R., & Spratt, N. J. (2016) · Journal of Stroke and Cerebrovascular Diseases · doi:10.1016/j.jstrokecerebrovasdis.2016.06.007 · Cited by 44
Comparison Between the Kansas City Cardiomyopathy Questionnaire and New York Heart Association in Assessing Functional Capacity and Clinical Outcomes
Hawwa, N., Vest, A. R., Kumar, R., Lahoud, R. N., Young, J. B., Wu, Y., Gorodeski, E. Z., & Cho, L. (2016) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2016.12.002 · Cited by 42
Cardiopulmonary exercise testing: A contemporary and versatile clinical tool
Leclerc, K. M. (2017) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.84a.15013 · Cited by 42
Association of domain-specific physical activity and cardiorespiratory fitness with all-cause and cause-specific mortality in two population-based cohort studies
Bahls, M., Groß, S., Baumeister, S. E., Völzke, H., Gläser, S., Ewert, R., Markus, M. R. P., Medenwald, D., Kluttig, A., Felix, S. B., et al. (2018) · Scientific Reports · doi:10.1038/s41598-018-34468-7 · Cited by 42
Anaerobic Threshold and Respiratory Compensation Point Identification During Cardiopulmonary Exercise Tests in Chronic Heart Failure
Carriere, C., Corrà, U., Piepoli, M. F., Bonomi, A., Merlo, M., Barbieri, S., Salvioni, E., Binno, S. M., Mapelli, M., Righini, F. M., et al. (2019) · CHEST Journal · doi:10.1016/j.chest.2019.03.013 · Cited by 42
“The VO2 at AT has been suggested to have a prognostic value and to be a marker of HF severity.(6,7) Notably, even the absence of an identifiable AT, despite the achievement of exerciseinduced anaerobiosis, has a strong prognostic power.”
Background
Left Atrial Function and Maximal Exercise Capacity in Heart Failure with Preserved and Mid-Range Ejection Fraction
Maffeis, C., Morris, D. A., Belyavskiy, E., Kropf, M., Radhakrishnan, A. K., Zach, V., da Conceicao, C. R., Trippel, T. D., Pieske‐Kraigher, E., Rossi, A., et al. (2020) · ESC Heart Failure · doi:10.1002/ehf2.13143 · Cited by 41
Cardiopulmonary Exercise Testing in Athletes: Expect the Unexpected
Petek, B. J., Gustus, S. K., & Wasfy, M. M. (2021) · Current Treatment Options in Cardiovascular Medicine · doi:10.1007/s11936-021-00928-z · Cited by 46
“20 at peak exercise [5, 20], meaning this percentage of estimated total lung capacity remains untapped.”
BackgroundInfluential
High-intensity interval training versus progressive high-intensity circuit resistance training on endothelial function and cardiorespiratory fitness in heart failure: A preliminary randomized controlled trial
da Silva, N. T., Vale-Lira, A., Verboven, K., Durigan, J. L. Q., Hansen, D., & Cipriano, G. (2021) · PLoS ONE · doi:10.1371/journal.pone.0257607 · Cited by 47
Proteomic analysis of cardiorespiratory fitness for prediction of mortality and multisystem disease risks
Perry, A., Farber‐Eger, E. H., Gonzales, T. I., Tanaka, T., Robbins, J., Murthy, V. L., Stolze, L. K., Zhao, S., Huang, S., Colangelo, L. A., et al. (2024) · Nature Medicine · doi:10.1038/s41591-024-03039-x · Cited by 43
“This proteomic CRF score was then translated for use in the UKB in the same manner, and we observed directionally consistent results as our primary analysis with slightly decreased effect sizes (Supplementary Tables 9–12).”
Method
High-intensity interval training improves cardiovascular and physical health in patients with rheumatoid arthritis: a multicentre randomised controlled trial
Bilberg, A., Mannerkorpi, K., Börjesson, M., Svedlund, S., Sivertsson, J., Klingberg, E., & Bjersing, J. L. (2024) · British Journal of Sports Medicine · doi:10.1136/bjsports-2024-108369 · Cited by 41
Incorporating Patients With Chronic Heart Failure Into Outpatient Cardiac Rehabilitation
Keteyian, S. J., Squires, R. W., Ades, P. A., & Thomas, R. J. (2014) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000073 · Cited by 40
Self-citation
The Role of Cardiopulmonary Exercise Test in IPF Prognosis
Triantafillidou, C., Manali, E. D., Lyberopoulos, P., Kolilekas, L. F., Kagouridis, K., Gyftopoulos, S., Vougas, K. N., Kotanidou, A. N., Alchanatis, M., Karakatsani, A., et al. (2013) · Pulmonary Medicine · doi:10.1155/2013/514817 · Cited by 42
“In patients with chronic lung diseases, an elevated VE/VCO 2 slope is attributed to the effects of increased physiological dead space, ventilation-perfusion mismatching, and the abnormally elevated chemoreceptor and ergoreceptor sensitivity that are present at rest and deteriorate during exercise [27].”
Background
The septal bulge—an early echocardiographic sign in hypertensive heart disease
Gaudron, P. D., Liu, D., Scholz, F., Hu, K., Florescu, C., Herrmann, S., Bijnens, B. H., Ertl, G., Störk, S., & Weidemann, F. (2015) · Journal of the American Society of Hypertension · doi:10.1016/j.jash.2015.11.006 · Cited by 40
Cardiorespiratory Fitness and Body Composition Responses to Different Intensities and Frequencies of Exercise Training in Colorectal Cancer Survivors
Devin, J. L., Jenkins, D. G., Sax, A. T., Hughes, G. I., Aitken, J. F., Chambers, S. K., Dunn, J. C., Bolam, K. A., & Skinner, T. L. (2018) · Clinical Colorectal Cancer · doi:10.1016/j.clcc.2018.01.004 · Cited by 41
Exercise ventilatory irregularity can be quantified by approximate entropy to detect breathing pattern disorder
Bansal, T., Haji, G. S., Rossiter, H. B., Polkey, M. I., & Hull, J. H. (2018) · Respiratory Physiology & Neurobiology · doi:10.1016/j.resp.2018.05.002 · Cited by 40
Cardiac stunning during haemodialysis: the therapeutic effect of intra-dialytic exercise
McGuire, S., Horton, E., Renshaw, D., Chan, K., Jiménez, A., Maddock, H., Krishnan, N., & McGregor, G. (2019) · Clinical Kidney Journal · doi:10.1093/ckj/sfz159 · Cited by 35
Progress in Understanding, Diagnosing, and Managing Cardiac Complications of Systemic Sclerosis
Hung, G., Mercurio, V., Hsu, S., Mathai, S. C., Shah, A. A., & Mukherjee, M. (2019) · Current Rheumatology Reports · doi:10.1007/s11926-019-0867-0 · Cited by 40
Impaired myocardial reserve underlies reduced exercise capacity and heart rate recovery in preterm-born young adults
Huckstep, O. J., Burchert, H. H., Williamson, W., Telles, F., Tan, C., Bertagnolli, M., Arnold, L., Mohamed, A. B., McCormick, K. P., Hanssen, H., et al. (2020) · European Heart Journal - Cardiovascular Imaging · doi:10.1093/ehjci/jeaa060 · Cited by 41
Cardiopulmonary exercise testing in interstitial lung diseases and the value of ventilatory efficiency
Gille, T., & Laveneziana, P. (2021) · European Respiratory Review · doi:10.1183/16000617.0355-2020 · Cited by 42
Effects of different exercise intensities on prefrontal activity during a dual task
Kimura, D., Hosokawa, T., Ujikawa, T., & Ito, T. (2022) · Scientific Reports · doi:10.1038/s41598-022-17172-5 · Cited by 40
Targeting of High Peak Respiratory Exchange Ratio Is Safe and Enhances the Prognostic Power of Peak Oxygen Uptake for Heart Failure Patients
Nakanishi, M., Takaki, H., Kumasaka, R., Arakawa, T., Noguchi, T., Sugimachi, M., & Goto, Y. (2014) · Circulation Journal · doi:10.1253/circj.cj-14-0047 · Cited by 39
A Model of the Cardiorespiratory Response to Aerobic Exercise in Healthy and Heart Failure Conditions
Fresiello, L., Meyns, B. P., Molfetta, A. D., & Ferrari, G. (2016) · Frontiers in Physiology · doi:10.3389/fphys.2016.00189 · Cited by 39
Cardiopulmonary Response to Exercise Testing in People with Chronic Stroke: A Retrospective Study
Billinger, S. A., Taylor, J. M., & Quaney, B. M. (2011) · Stroke Research and Treatment · doi:10.1155/2012/987637 · Cited by 39
Functional Assessment of Heart Failure Patients
Kaminsky, L. A., & Tuttle, M. (2014) · Heart Failure Clinics · doi:10.1016/j.hfc.2014.08.002 · Cited by 39
Time-course of vascular adaptations during 8 weeks of exercise training in subjects with type 2 diabetes and middle-aged controls
Schreuder, T. H. A., GREEN, D. J., Nyakayiru, J., Hopman, M. T. E., & Thijssen, D. H. J. (2014) · European Journal of Applied Physiology · doi:10.1007/s00421-014-3006-7 · Cited by 38
Exercise Ventilatory Parameters for the Diagnosis of Reactive Pulmonary Hypertension in Patients With Heart Failure
Lim, H. S., & Theodosiou, M. (2014) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2014.06.355 · Cited by 38
Home-based interval training increases endurance capacity in adults with complex congenital heart disease
Sandberg, C., Hedström, M., Wadell, K., Dellborg, M., Ahnfelt, A., Zetterström, A.-K., Öhrn, A., & Johansson, B. H. (2017) · Congenital Heart Disease · doi:10.1111/chd.12562 · Cited by 38
“Peak VO2 derived from incremental CPET is frequently used and often considered the “gold standard” measure of peak aerobic exercise capacity.(25,26) When assessing the peak aerobic exercise capacity, it is important that the test is performed with maximum effort.”
Influential
Ventilatory threshold may be a more specific measure of aerobic capacity than peak oxygen consumption rate in persons with stroke
Boyne, P., Reisman, D. S., Brian, M. S., Barney, B., Franke, A., Carl, D., Khoury, J. C., & Dunning, K. K. (2016) · Topics in Stroke Rehabilitation · doi:10.1080/10749357.2016.1209831 · Cited by 38
Cardiorespiratory optimal point during exercise testing as a predictor of all-cause mortality
Ramos, P. S., & de Araújo, C. G. S. (2017) · Revista Portuguesa de Cardiologia · doi:10.1016/j.repc.2016.09.017 · Cited by 38
Telemonitored exercise-based cardiac rehabilitation improves physical capacity and health-related quality of life
Laustsen, S., Oestergaard, L. G., van Tulder, M. W., Hjortdal, V. E., & Petersen, A. K. (2018) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x18792808 · Cited by 39

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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