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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Method
Telerehabilitation Using Fitness Application in Patients with Severe Cystic Fibrosis Awaiting Lung Transplant: A Pilot Study
Layton, A. M., Irwin, A. M., Mihalik, E. C., Fleisch, E., Keating, C. L., DiMango, E., Shah, L., & Arcasoy, S. M. (2021) · International Journal of Telemedicine and Applications · doi:10.1155/2021/6641853 · Cited by 27
“Patients were excluded from the study if they demonstrated any of the following with exercise: severe oxyhemoglobin desaturation (SpO2) at rest or during exercise (SpO2 ≤ 85%), hypercapnia (ETCO2 ≥ 60mmHg), symptoms of dizziness, headache, nausea, or chest pain during the exercise, required > 6 L/min of supplemental o…”
BackgroundMethodInfluential
Cardiopulmonary Exercise Testing in Heart Failure
Juarez, M., Castillo‐Rodriguez, C., Soliman, D., Rio‐Pertuz, G. D., & NUGENT, K. M. (2024) · Journal of Cardiovascular Development and Disease · doi:10.3390/jcdd11030070 · Cited by 24
Validity of Reporting Oxygen Uptake Efficiency Slope from Submaximal Exercise Using Respiratory Exchange Ratio as Secondary Criterion
Williamson, W., Fuld, J. P., Westgate, K. L., Sylvester, K. P., Ekelund, U., & Brage, S. (2012) · Pulmonary Medicine · doi:10.1155/2012/874020 · Cited by 24
Comparison of the FRIEND and Wasserman‐Hansen Equations in Predicting Outcomes in Heart Failure
MYERS, J. N., Silva, C. G. D. S. E., Arena, R. A., Kaminsky, L. A., Christle, J. W., Busque, V., Ashley, E. A., & Moneghetti, K. J. (2021) · Journal of the American Heart Association · doi:10.1161/jaha.121.021246 · Cited by 24
Self-citation
Validity of the Maximal Heart Rate Prediction Models among Runners and Cyclists
Kasiak, P. S., Wiecha, S., Cieśliński, I., Takken, T., Łach, J., Lewandowski, M., Barylski, M., Mamcarz, A., & Śliż, D. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12082884 · Cited by 24
“Recently, endurance sports have been gaining popularity, hence the number of EAs with suspected CVD and veteran EAs increased.”
BackgroundInfluential
Consensus statement of Chinese experts on exercise prescription (2023)
Li, G.-P., Wang, Z., Hao, Y., Qian, J., Hu, B., Wang, Y., Luo, X., Ning, Y., & Lin, F. (2024) · Sports Medicine and Health Science · doi:10.1016/j.smhs.2024.02.003 · Cited by 24
Accurate diagnosis of myalgic encephalomyelitis and chronic fatigue syndrome based upon objective test methods for characteristic symptoms.
Twisk, F. N. M. (2015) · World Journal of Methodology · doi:10.5662/wjm.v5.i2.68 · Cited by 31
Obstructive Sleep Apnea Impairs Postexercise Sympathovagal Balance in Patients with Metabolic Syndrome
Cepeda, F. X., Toschi‐Dias, E., Maki‐Nunes, C., Rondon, M. U. P. B., Alves, M. J. N. N., Braga, A., Martinêz, D. G., Drager, L. F., Lorenzi‐Filho, G., Negrão, C. E., et al. (2015) · SLEEP · doi:10.5665/sleep.4812 · Cited by 25
Predicted values of exercise capacity in heart failure: where we are, where to go
Gargiulo, P., Olla, S., Boiti, C., Contini, M. C., Filardi, P. P., & Agostoni, P. (2013) · Heart Failure Reviews · doi:10.1007/s10741-013-9403-x · Cited by 24
Comparison of Predicted Exercise Capacity Equations and the Effect of Actual versus Ideal Body Weight among Subjects Undergoing Cardiopulmonary Exercise Testing
Ahmadian, H. R., Sclafani, J. J., Emmons, E. E., Morris, M. J., Leclerc, K. M., & Slim, A. M. (2013) · Cardiology Research and Practice · doi:10.1155/2013/940170 · Cited by 24
Does dexmedetomidine have a cardiac protective effect during non‐cardiac surgery? A randomised controlled trial
Xu, L., Hu, Z., Shen, J., & McQuillan, P. M. (2014) · Clinical and Experimental Pharmacology and Physiology · doi:10.1111/1440-1681.12296 · Cited by 24
“Standards for myocardial ischaemia improvements (ST segment decreasing for >1 mm (J + 60 msed) persisting for >1 min) including complete improvement, mild improvement and no improvement was set according to the standard of the Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults.21 Complete improvement was…”
MethodInfluential
The relationship between biventricular myocardial performance and metabolic parameters during incremental exercise and recovery in healthy adolescents
Pieles, G. E., Gowing, L., Forsey, J., Ramanujam, P., Miller, F., Stuart, G., & Williams, C. A. (2015) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.00627.2015 · Cited by 24
Association of serum myokines and aerobic exercise training in patients with spinal cord injury: an observational study
Han, D., Hsiao, M., Wang, T., Chen, S., & Yang, W. (2016) · BMC Neurology · doi:10.1186/s12883-016-0661-9 · Cited by 24
“Arm cranking was at 60–70 revolutions per min while the workload was gradually increased until volitional exhaustion or termination according to the guidelines of American College of Sports Medicine [22].”
Method
Exercise Training Adaptations in Metabolic Syndrome Individuals on Chronic Statin Treatment
Morales‐Palomo, F., Ramírez-Jiménez, M., ORTEGA, J. F., Moreno‐Cabañas, A., & Mora‐Rodríguez, R. (2019) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgz304 · Cited by 24
Physical fitness and activity level in Norwegian adults with achondroplasia
de Vries, O., Johansen, H., & Fredwall, S. O. (2020) · American Journal of Medical Genetics Part A · doi:10.1002/ajmg.a.62055 · Cited by 24
“To compare VO 2 values with the general population, we used the measurement unit ml/kg/min, and the relative VO 2 was calculated as the absolute value divided by weight (Balady et al., 2010; Bassett & Howley, 2000).”
Method
Interobserver variability of ventilatory anaerobic threshold in asymptomatic volunteers
Kaczmarek, S., Habedank, D., Obst, A., Dörr, M., Völzke, H., Gläser, S., & Ewert, R. (2019) · Multidisciplinary Respiratory Medicine · doi:10.1186/s40248-019-0183-6 · Cited by 25
“ment on CPET in adults [10] notes that confidence in determining AT may be increased by having two or three independent, experienced observers perform the calculation.”
BackgroundMethodResultInfluential
Smartphone-recorded physical activity for estimating cardiorespiratory fitness
Eades, M. T., Tsanas, A., Juraschek, S. P., Kramer, D. B., Gervino, E. V., & Mukamal, K. J. (2021) · Scientific Reports · doi:10.1038/s41598-021-94164-x · Cited by 23
Muscle and Bone Health in Young Chilean Adults with Phenylketonuria and Different Degrees of Compliance with the Phenylalanine Restricted Diet
Rojas-Agurto, E., Leal-Witt, M. J., Arias, C., Cabello, J. F., Bunout, D. C., & Cornejo, V. (2023) · Nutrients · doi:10.3390/nu15132939 · Cited by 23
Exercise systolic blood pressure response during cycle ergometry is associated with future hypertension in normotensive individuals
Carlén, A., Lindow, T., Cauwenberghs, N., Elmberg, V., Brudin, L. H., Ekström, M. P., & Hedman, K. (2024) · European Journal of Preventive Cardiology · doi:10.1093/eurjpc/zwae012 · Cited by 23
Serum levels of fatty acid binding protein 4 and fat metabolic markers in relation to catecholamines following exercise
Iso, T., Sunaga, H., Matsui, H., Kasama, S., Oshima, N., Haruyama, H., Furukawa, N., Nakajima, K., Machida, T., Murakami, M., et al. (2017) · Clinical Biochemistry · doi:10.1016/j.clinbiochem.2017.05.021 · Cited by 24
Design of wearable and wireless multi-parameter monitoring system for evaluating cardiopulmonary function
Li, S., Lin, B.-S., Wang, C.-A., Yang, C., & Lin, B.-S. (2017) · Medical Engineering & Physics · doi:10.1016/j.medengphy.2017.06.009 · Cited by 23
“[9] Balady GJ , Arena R , Sietsema K , Myers J , Coke L , Fletcher GF , et al.”
Background
Comparison of Effects of N95 Respirators and Surgical Masks to Physiological and Psychological Health among Healthcare Workers: A Randomized Controlled Trial
Su, C., Peng, C., Liu, H.-L., Yeh, I., & Lee, C. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182413308 · Cited by 23
“These might affect the balance of physiological and psychological conditions and deteriorate existing chronic diseases such as ischemic heart disease, chronic obstructive pulmonary disease, or cancer [35,36].”
Background
Objective methods for preoperative assessment of functional capacity
Silvapulle, E., & Darvall, J. N. (2022) · BJA Education · doi:10.1016/j.bjae.2022.03.003 · Cited by 23
Multimodal Exercise and Cognitive Training Program Improves Cognitive Function in Amnestic Mild Cognitive Impairment
Fairchild, J. K., MYERS, J. N., Louras, P., Jo, B., McNerney, M. W., Hallmayer, J. F., & Yesavage, J. A. (2023) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2023.12.002 · Cited by 23
Self-citation
Temporal changes in cardiorespiratory fitness and the incidence of hypertension in initially normotensive subjects
Jae, S. Y., Heffernan, K. S., Yoon, E. S., Park, S. H., Carnethon, M. R., Fernhall, B., Choi, Y., & Park, W. H. (2012) · American Journal of Human Biology · doi:10.1002/ajhb.22313 · Cited by 23
Novel Scoring System Using Postoperative Cardiopulmonary Exercise Testing Predicts Future Explantation of Left Ventricular Assist Device
Imamura, T., Kinugawa, K., Nitta, D., Fujino, T., Inaba, T., Maki, H., Hatano, M., Kinoshita, O., Nawata, K., Kyo, S., et al. (2014) · Circulation Journal · doi:10.1253/circj.cj-14-1058 · Cited by 23
Oxygen kinetics during 6-minute walk tests in patients with cardiovascular and pulmonary disease
Kern, L., Condrau, S., Baty, F., Wiegand, J., van Gestel, A. J. R., Azzola, A., Tamm, M., & Brutsche, M. H. (2014) · BMC Pulmonary Medicine · doi:10.1186/1471-2466-14-167 · Cited by 23
Metabolically Healthy Obesity and Carotid Intima-Media Thickness
Jae, S. Y., Franklin, B. A., Choi, Y.-H., & Fernhall, B. (2015) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2015.07.004 · Cited by 23
Self-citation
Effects of Cardiopulmonary Exercise Rehabilitation on Left Ventricular Mechanical Efficiency and Ventricular‐Arterial Coupling in Patients With Systolic Heart Failure
Aslanger, E. K., Assous, B., Bihry, N., Beauvais, F., Logeart, D., & Solal, A. C. (2015) · Journal of the American Heart Association · doi:10.1161/jaha.115.002084 · Cited by 23
Discriminating Circulatory Problems From Deconditioning
Rozenbaum, Z., Khoury, S., Aviram, G., Gura, Y., Sherez, J., Man, A., Shimiaie, J., Tourneau, T. L., Halkin, A., Biner, S., et al. (2016) · CHEST Journal · doi:10.1016/j.chest.2016.09.027 · Cited by 23
Feasibility of Exercise Testing in Patients Who Are Critically Ill: A Prospective, Observational Multicenter Study
Sommers, J., Klooster, E., Zoethout, S. B., van den Oever, H. L. A., Nollet, F., Tepaske, R., Horn, J., Engelbert, R., & van der Schaaf, M. (2018) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2018.07.430 · Cited by 23
Association between activity energy expenditure and peak oxygen consumption with sarcopenia
Bunout, D. C., Barrera, G., Hirsch, S., Jimenez, T., & de la Maza, M. P. (2018) · BMC Geriatrics · doi:10.1186/s12877-018-0993-y · Cited by 23
Validity of Cardiorespiratory Fitness Measured with Fitbit Compared to V˙O2max
KLEPIN, K., Wing, D., Higgins, M., Nichols, J. F., & Godino, J. (2019) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000002041 · Cited by 23
“The “gold standard” measure of CRF is maximal oxygen uptake, or V̇O2max, which is assessed during a graded exercise test typically conducted on a treadmill or cycling ergometer (3,13,14).”
Background
Effect of Normobaric Hypoxia on Exercise Performance in Pulmonary Hypertension
Schneider, S., Mayer, L. C., Lichtblau, M., Berlier, C., Schwarz, E. I., Saxer, S., Furian, M., Bloch, K. E., & Ulrich, S. (2020) · CHEST Journal · doi:10.1016/j.chest.2020.09.004 · Cited by 23
Characteristics and reference values for cardiopulmonary exercise testing in the adult Chinese population – The Xiangya hospital exercise testing project (the X-ET project)
Dun, Y., Olson, T. P., Li, C., Qiu, L., Fu, S., Cao, Z., Ripley-Gonzalez, J. W., You, B., Li, Q., Deng, L., et al. (2021) · International Journal of Cardiology · doi:10.1016/j.ijcard.2021.03.013 · Cited by 23
The Cardiovascular Physiology of Sports and Exercise
Opondo, M. A., Sarma, S., & Levine, B. D. (2015) · Clinics in Sports Medicine · doi:10.1016/j.csm.2015.03.004 · Cited by 26
Physiology in Medicine: Acute altitude exposure in patients with pulmonary and cardiovascular disease
Seccombe, L. M., & Peters, M. J. (2013) · Journal of Applied Physiology · doi:10.1152/japplphysiol.01013.2013 · Cited by 22
Peak oxygen pulse responses during maximal cardiopulmonary exercise testing: Reference standards from FRIEND (Fitness Registry and the Importance of Exercise: an International Database)
Arena, R. A., MYERS, J. N., Harber, M., Wisløff, U., Stensvold, D., & Kaminsky, L. A. (2019) · International Journal of Cardiology · doi:10.1016/j.ijcard.2019.11.106 · Cited by 24
Self-citation
Determinants of Cardiorespiratory Fitness After Bariatric Surgery: Insights From a Randomised Controlled Trial of a Supervised Training Program
Auclair, A., Harvey, J., Leclerc, J., Piché, M., O’Connor, K., Nadreau, É., Pettigrew, M., Haykowsky, M. J., Marceau, S., Biertho, L. D., et al. (2020) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2020.03.032 · Cited by 22
New Equations for Predicting Maximum Oxygen Uptake in Patients With Heart Failure
Kokkinos, P. F., Kaminsky, L. A., Arena, R. A., Zhang, J., Franklin, B. A., Kraus, W. E., Triantafyllidi, H., Benas, D., Whellan, D. J., & MYERS, J. N. (2020) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2020.04.049 · Cited by 22
Self-citation
[Retracted] Handgrip Strength‐Related Factors Affecting Health Outcomes in Young Adults: Association with Cardiorespiratory Fitness
Zhou, M., Zha, F., Chen, Y., Liu, F., Zhou, J., Long, J., Luo, W., Huang, M., Zhang, S.-H., Luo, D.-L., et al. (2021) · BioMed Research International · doi:10.1155/2021/6645252 · Cited by 22
“In accordance with the “Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement from the American Heart Association” [22], the graded, symptom-limited maximal cardiopulmonary exercise test (CPET) was used to measure CRF via an incremental cycle ergometer (MasterScreen; Ergoline, Germany…”
Method
Retracted
Cardiorespiratory Fitness After Open Repair for Acute Type A Aortic Dissection – A Prospective Study
Norton, E. L., Wu, K.-H., Rubenfire, M., Fink, S., Sitzmann, J., Hobbs, R. D., Saberi, S., Willer, C. J., Yang, B., & Hornsby, W. (2021) · Seminars in Thoracic and Cardiovascular Surgery · doi:10.1053/j.semtcvs.2021.05.017 · Cited by 22
Cardiopulmonary Exercise Testing Distinguishes between Post-COVID-19 as a Dysfunctional Syndrome and Organ Pathologies
Kersten, J., Hoyo, L., Wolf, A., Hüll, E., Nunn, S., Tadic, M. V., Scharnbeck, D., Rottbauer, W., & Buckert, D. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191811421 · Cited by 22
Cardiorespiratory fitness as a vital sign of CVD risk in the COVID-19 era
Harber, M. P., Peterman, J. E., Imboden, M. T., Kaminsky, L. A., Ashton, R. E. M., Arena, R. A., & Faghy, M. A. (2022) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2022.12.001 · Cited by 22
Self-citation
How Does the Method Used to Measure the VE/VCO2 Slope Affect Its Value? A Cross-Sectional and Retrospective Cohort Study
Chaumont, M., Forton, K., Gillet, A., Nzokou, D. T., & Lamotte, M. (2023) · Healthcare · doi:10.3390/healthcare11091292 · Cited by 22

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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