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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BackgroundSelf-citation
Physiologic decrease of ventilatory response to exercise in the second decade of life in healthy children
Giardini, A., Odendaal, D., Khambadkone, S., & Derrick, G. P. (2011) · American Heart Journal · doi:10.1016/j.ahj.2011.03.008 · Cited by 32
Exercise oscillatory ventilation in heart failure
Corrà, U. (2016) · International Journal of Cardiology · doi:10.1016/j.ijcard.2016.02.122 · Cited by 31
Exercise cardiac magnetic resonance imaging: a feasibility study and meta-analysis
Beaudry, R. I., Samuel, T. J., Wang, J., Tucker, W. J., Haykowsky, M. J., & Nelson, M. D. (2018) · American Journal of Physiology-Regulatory, Integrative and Comparative Physiology · doi:10.1152/ajpregu.00158.2018 · Cited by 32
Positive effect of yoga on cardiorespiratory fitness: A pilot study
Sovová, E., Čajka, V., Pastucha, D., Malinčíková, J., Radová, L., & Sovová, M. (2015) · International Journal of Yoga · doi:10.4103/0973-6131.158482 · Cited by 32
“The protocol started with a 3‐min workload of 1 W/kg and was followed by an incremental ramp protocol to a subjective maximal effort (a test duration of up to 12 min).[9] From all participants, a signed written informed consent was obtained.”
Method
Skeletal Muscle Changes in Chronic Cardiac Disease and Failure
Kennel, P. J., MANCINI, D. M., & Schulze, P. C. (2015) · Comprehensive physiology · doi:10.1002/cphy.c110003 · Cited by 36
Self-citation
Modified high-intensity interval training increases peak cardiac power output in patients with heart failure
Huang, S., Wong, M.-K., Lin, P.-J., Tsai, F., Fu, T., Wen, M., Kuo, C.-T., & Wang, J. (2014) · European Journal of Applied Physiology · doi:10.1007/s00421-014-2913-y · Cited by 31
“…Minnesota). the VO2peak was defined by the following criteria: (i) VO2 increased by less than 2 ml/kg/min over at least 2 min, (ii) Hr exceeded 85 % of its predicted maximum, (iii) the respiratory exchange ratio exceeded 1.15, or (iv) some other symptom/sign limitations (Balady et al. 2010).”
BackgroundMethodInfluential
Cross-Validation of the Recumbent Stepper Submaximal Exercise Test to Predict Peak Oxygen Uptake in Older Adults
Herda, A. A., Lentz, A. A., Mattlage, A. E., Sisante, J.-F. V., & Billinger, S. A. (2014) · Physical Therapy · doi:10.2522/ptj.20130307 · Cited by 31
Impact of diabetes and diastolic dysfunction on exercise capacity in normotensive patients without coronary artery disease
Gürdal, A., Kaşıkçıoğlu, E., Yakal, S., & Buğra, Z. (2015) · Diabetes and Vascular Disease Research · doi:10.1177/1479164114565631 · Cited by 31
Mediators of Exercise Effects on HRQoL in Cancer Survivors after Chemotherapy
Kalter, J., Kampshoff, C. S., Chinapaw, M. J. M., van Mechelen, W., Galindo‐Garre, F., Schep, G., Leeuw, I. M. V., Brug, J., & Buffart, L. M. (2016) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000000976 · Cited by 32
Cardiopulmonary Exercise Testing in Patients with Idiopathic Scoliosis
Shen, J., Lin, Y., Luo, J., & Xiao, Y. (2016) · Journal of Bone and Joint Surgery · doi:10.2106/jbjs.15.01403 · Cited by 31
Repeatability and Meaningful Change of CPET Parameters in Healthy Subjects
DeCato, T. W., Bradley, S. M., Wilson, E. L., & Hegewald, M. J. (2017) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000001474 · Cited by 31
“The mass flow sensor and gas analyzers were calibrated before each test and met current standards for accuracy, reproducibility, and response time (1,21).”
Method
The Role of Cardiopulmonary Exercise Testing as a Risk Assessment Tool in Patients Undergoing Oesophagectomy: A Systematic Review and Meta-analysis
Sivakumar, J., Sivakumar, H., Read, M. D., Sinclair, R. C. F., Snowden, C. P., & Hii, M. W. (2020) · Annals of Surgical Oncology · doi:10.1245/s10434-020-08638-9 · Cited by 31
Oxynet: A collective intelligence that detects ventilatory thresholds in cardiopulmonary exercise tests
Zignoli, A., Fornasiero, A., Rota, P., Muollo, V., Peyré‐Tartaruga, L. A., Low, D. A., Fontana, F. Y., Besson, D., Pühringer, M., Ring‐Dimitriou, S., et al. (2020) · European Journal of Sport Science · doi:10.1080/17461391.2020.1866081 · Cited by 29
“…include aerobic capacity/level and athletic assessment for performance purposes, medical diagnosis and prognosis of several chronic diseases and the individual prescription of adequate/symptom-limited exercise intensities for optimal physical training/rehabilitation (Balady et al., 2010).”
Background
Cardiopulmonary exercise testing during the COVID-19 pandemic
Mihalick, V. L., Canada, J. M., Arena, R. A., Abbate, A., & Kirkman, D. L. (2021) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2021.04.005 · Cited by 31
“Patients who had a mild case of COVID-19 should be 10 days out from their first test and symptom onset, and free of all symptoms experienced during the initial phase of their infection.(22) Patients who were severely ill, and immunocompromisedpatients, should also be symptom free and at least 20 days out from the firs…”
Self-citation
A Machine Learning Approach to the Interpretation of Cardiopulmonary Exercise Tests: Development and Validation
Inbar, O., Inbar, O., Reuveny, R., Segel, M., Greenspan, H. K., & Scheinowitz, M. (2021) · Pulmonary Medicine · doi:10.1155/2021/5516248 · Cited by 31
“This may be at the core of why such a valued and noninvasive procedure (CPET) is underused [2, 11].”
Background
Peak oxygen consumption and prognosis in heart failure
Corrà, U., Mezzani, A., Giordano, A., Pistono, M., Gnemmi, M., Caruso, R., & Giannuzzi, P. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2011.12.055 · Cited by 31
A Review of Cardiorespiratory Fitness in Adolescent and Young Adult Survivors of Childhood Cancer: Factors that Affect its Decline and Opportunities for Intervention
Berkman, A. M., & Gilchrist, S. C. (2015) · Journal of Adolescent and Young Adult Oncology · doi:10.1089/jayao.2015.0031 · Cited by 30
Very short/short‐term benefit of inpatient/outpatient cardiac rehabilitation programs after coronary artery bypass grafting surgery
Spiroski, D., Andjic, M., Stojanović, O., Lazovic, M. P., Dikić, A. D., Ostojić, M., Beleslin, B., Kostić, S., Zdravkovic, M. D., & Lović, D. B. (2017) · Clinical Cardiology · doi:10.1002/clc.22656 · Cited by 32
Influence of Baseline Physical Activity Level on Exercise Training Response and Clinical Outcomes in Heart Failure
Mediano, M. F. F., Leifer, E., Cooper, L. S., Keteyian, S. J., Kraus, W. E., Mentz, R. J., & Fleg, J. L. (2018) · JACC Heart Failure · doi:10.1016/j.jchf.2018.09.012 · Cited by 30
Self-citation
Effect of Physical Exercise Training in Patients With Chagas Heart Disease (from the PEACH STUDY)
Mendes, F. D. S. N. S., Mediano, M. F. F., Souza, F. C. D. C. E., da Silva, P. S., Carneiro, F. M., de Holanda, M. T., Saraiva, R. M., Xavier, S. S., do Brasil, P. E. A. A., & de Sousa, A. S. (2020) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2020.01.035 · Cited by 30
Cardiopulmonary exercise testing – refining the clinical perspective by combining assessments
Arena, R. A., Canada, J. M., Popović, D., Trankle, C. R., Buono, M. G. D., Lucas, A. R., & Abbate, A. (2020) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2020.1806057 · Cited by 30
“VE/VCO2 slope has been the most widely used index of ventilatory efficiency [5] and is attractive due to its high test–retest”
BackgroundSelf-citation
Exercise cardiovascular magnetic resonance reveals reduced cardiac reserve in pediatric cancer survivors with impaired cardiopulmonary fitness
Foulkes, S., Costello, B. T., Howden, E. J., Janssens, K., Dillon, H. T., Toro, C., Claus, P., Fraser, S. F., Daly, R. M., Elliott, D. A., et al. (2020) · Journal of Cardiovascular Magnetic Resonance · doi:10.1186/s12968-020-00658-4 · Cited by 30
Physical activity and cardiorespiratory fitness—A ten‐year follow‐up
Bahls, M., Ittermann, T., Ewert, R., Stubbe, B., Völzke, H., Friedrich, N., Felix, S. B., & Dörr, M. (2020) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.13882 · Cited by 31
A clinician's guide to cardiopulmonary exercise testing 1: an introduction
Taylor, C., Nichols, S., & Ingle, L. (2015) · British Journal of Hospital Medicine · doi:10.12968/hmed.2015.76.4.192 · Cited by 30
Relationship between inspiratory muscle capacity and peak exercise tolerance in patients post-myocardial infarction
Neves, L. M. T., Karsten, M., Neves, V. R., Beltrame, T., Borghi‐Silva, A., & Catai, A. M. (2011) · Heart & Lung · doi:10.1016/j.hrtlng.2011.07.010 · Cited by 30
Cardiopulmonary exercise testing in adults with congenital heart disease
Khan, A. M., Paridon, S. M., & Kim, Y. Y. (2014) · Expert Review of Cardiovascular Therapy · doi:10.1586/14779072.2014.919223 · Cited by 30
“Furthermore, the accuracy of pulse oximetry may be lower in individuals who are desaturated at baseline [3].”
BackgroundMethodInfluential
Effect of Exercise Training on Red Blood Cell Distribution Width as a Marker of Impaired Exercise Tolerance in Patients With Coronary Artery Disease
Nishiyama, Y., Niiyama, H., Harada, H., Katou, A., Yoshida, N., & Ikeda, H. (2016) · International Heart Journal · doi:10.1536/ihj.16-015 · Cited by 30
Clinical aspects of myocardial fibrosis in adults with Ebstein’s anomaly
Ciepłucha, A., Trojnarska, O., Kociemba, A., Łanocha, M., Barczynski, M., Rozmiarek, S., Kramer, L., & Pyda, M. (2018) · Heart and Vessels · doi:10.1007/s00380-018-1141-5 · Cited by 30
“Impaired exercise capacity was defined as %peak VO2 < 85% of predicted value [19].”
Background
Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomized, controlled, crossover trial
Radtke, T., Böni, L., Bohnacker, P., Maggi-Beba, M., Fischer, P., Kriemler, S., Benden, C., & Dressel, H. (2018) · BMC Pulmonary Medicine · doi:10.1186/s12890-018-0661-1 · Cited by 30
“One of the following criteria had to be fulfilled to ensure the test was maximal: 1) plateau in oxygen consumption (V’O2) despite an increase in workrate; 2) peak heart rate over 85% of predicted [25], 3) respiratory exchange ratio (RER) > 1.”
Background
Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy
Mapelli, M., Romani, S., Magrì, D., Merlo, M., Cittar, M., Masè, M., Muratori, M., Gallo, G., Sclafani, M., Carriere, C., et al. (2022) · Heart · doi:10.1136/heartjnl-2021-320569 · Cited by 29
Supervised exercise training versus usual care in ambulatory patients with left ventricular assist devices: A systematic review
Ganga, H. V., Leung, A., Jantz, J., Choudhary, G., Stabile, L. M., LEVINE, D. J., Sharma, S. C., & Wu, W. (2017) · PLoS ONE · doi:10.1371/journal.pone.0174323 · Cited by 29
Effects of inspiratory muscle-training intensity on cardiovascular control in amateur cyclists
de Abreu, R. M., Porta, A., Rehder‐Santos, P., Cairo, B., da Silva, C. D., Signini, É. D. F., Sakaguchi, C. A., & Catai, A. M. (2019) · American Journal of Physiology-Regulatory, Integrative and Comparative Physiology · doi:10.1152/ajpregu.00167.2019 · Cited by 29
Reference Standards for Ventilatory Threshold Measured With Cardiopulmonary Exercise Testing
Vainshelboim, B., Arena, R. A., Kaminsky, L. A., & MYERS, J. N. (2019) · CHEST Journal · doi:10.1016/j.chest.2019.11.022 · Cited by 29
Self-citation
Exercise Oscillatory Ventilation and Prognosis in Heart Failure Patients with Reduced and Mid-Range Ejection Fraction
Rovai, S., Corrà, U., Piepoli, M. F., Vignati, C., Salvioni, E., Bonomi, A., Mattavelli, I., Arcari, L., Scardovi, A. B., Filardi, P. P., et al. (2019) · European Journal of Heart Failure · doi:10.1002/ejhf.1595 · Cited by 29
Self-citation
A Fully Soft and Passive Assistive Device to Lower the Metabolic Cost of Sit-to-Stand
Lee, H., Kim, S. H., & Park, H. (2020) · Frontiers in Bioengineering and Biotechnology · doi:10.3389/fbioe.2020.00966 · Cited by 29
Cardiopulmonary exercise testing and efficacy of percutaneous coronary intervention: a substudy of the ORBITA trial
Ganesananthan, S., Rajkumar, C., Foley, M. J., Thompson, D., Nowbar, A. N., Seligman, H., Petraco, R., Sen, S., Nijjer, S. S., Thom, S., et al. (2022) · European Heart Journal · doi:10.1093/eurheartj/ehac260 · Cited by 29
“myocardial ischaemia in symptomatic patients with stable coronary artery disease (CAD).(5,6) Compared WITH exercise electrocardiography alone, assessments of work-rate trajectory (VO2/WR), oxygenpulse (O2-pulse), and ventilatory efficiency during CPET have been shown to offer enhanced sensitivity and specificity for t…”
Background
Severe heart failure prognosis evaluation for transplant selection in the era of beta-blockers: Role of peak oxygen consumption
Cattadori, G., Agostoni, P., Corrà, U., Lenarda, A. D., Sinagra, G., Veglia, F., Salvioni, E., Gioia, R. L., Scardovi, A. B., Emdin, M., et al. (2013) · International Journal of Cardiology · doi:10.1016/j.ijcard.2013.07.192 · Cited by 29
“Peak oxygen consumption (VO2) is used to define the severity of heart failure (HF) [1,2] and as a criteria for heart transplant (HT) listing [3–5].”
MethodSelf-citation
Cardiorespiratory fitness, respiratory function and hemodynamic responses to maximal cycle ergometer exercise test in girls and boys aged 9–11 years: the PANIC Study
Lintu, N., Viitasalo, A., Tompuri, T., Veijalainen, A., Hakulinen, M. A., Laitinen, T. P., Savonen, K. P., & Lakka, T. A. (2014) · European Journal of Applied Physiology · doi:10.1007/s00421-014-3013-8 · Cited by 29
Preoperative evaluation of the patient with lung cancer being considered for lung resection
Choi, H., & Mazzone, P. J. (2014) · Current Opinion in Anaesthesiology · doi:10.1097/aco.0000000000000149 · Cited by 29
“A real-time measurement of several parameters provides estimation of oxygen uptake (VO2), carbon dioxide output (VCO2), respiratory exchange ratio (VCO2/VO2), anaerobic threshold, and cardiac output [53].”
Background
Association Between Depressive Symptoms and Exercise Capacity in Patients With Heart Disease
Papasavvas, T., Alhashemi, M., & Micklewright, D. P. (2016) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000193 · Cited by 30
Myocardial remodelling and tissue characterisation by cardiovascular magnetic resonance (CMR) in endurance athletes
Pujadas, S., Doñate, M., Li, C.-H., Merchan, S., Cabanillas, A., Alomar, X., Pons-Llado, G., Serra-Grima, R., & Carreras, F. (2018) · BMJ Open Sport & Exercise Medicine · doi:10.1136/bmjsem-2018-000422 · Cited by 29
“VO 2 values shown in the athlete’s group were in the range of well highly trained subjects according to reference values.(11) CMR results are shown in table 2.”
Method
Cardiopulmonary Exercise Testing: Methodology, Interpretation, and Role in Exercise Prescription for Cardiac Rehabilitation
Kabbadj, K., Taiek, N., Hjouji, W. E., Karrouti, O. E., & Hangouche, A. J. E. (2024) · US Cardiology Review · doi:10.15420/usc.2024.37 · Cited by 28
Cardiopulmonary exercise testing
Stringer, W. W., Casaburi, R. H., & Older, P. (2012) · Current Opinion in Anaesthesiology · doi:10.1097/aco.0b013e32834f6c32 · Cited by 28
An Internet-Based Counseling Intervention With Email Reminders that Promotes Self-Care in Adults With Chronic Heart Failure: Randomized Controlled Trial Protocol
Nolan, R. P., Payne, A. Y. M., Ross, H. J., White, M., D’Antono, B., Chan, S., Barr, S. I., Gwadry-Sridhar, F. H., Nigam, A., Perreault, S., et al. (2014) · JMIR Research Protocols · doi:10.2196/resprot.2957 · Cited by 28
Is Cardiorespiratory Fitness Related to Cardiometabolic Health and All-Cause Mortality Risk in Patients with Coronary Heart Disease? A CARE CR Study
Nichols, S., Taylor, C., Page, R. M., Kallvikbacka‐Bennett, A., Nation, F., Goodman, T., Clark, A. L., Carroll, S., & Ingle, L. (2018) · Sports Medicine - Open · doi:10.1186/s40798-018-0138-z · Cited by 28
“After 3 min of seated rest, CPET was conducted following the modified Bruce treadmill protocol (GE Health-care, Buckinghamshire, UK) [16] in accordance with established guidelines [17 – 20].”
Wearable Patch-Based Estimation of Oxygen Uptake and Assessment of Clinical Status during Cardiopulmonary Exercise Testing in Patients With Heart Failure
Shandhi, M. M. H., Hersek, S., Fan, J., Sander, E., Marco, T. D., Heller, J. A., Etemadi, M., Klein, L., & Inan, O. T. (2020) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2020.05.014 · Cited by 30

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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