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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“1 [19].”
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Wang, H.-Y., Chen, Y.-H., Kuan, Y., Huang, S., Lin, L., & Chen, H. (2021) · Clinical Rehabilitation · doi:10.1177/02692155211056999 · Cited by 12
Exertional Cardiac and Pulmonary Vascular Hemodynamics in Patients With Heart Failure With Reduced Ejection Fraction
Edward, J. A., Parker, H., Stöhr, E. J., McDonnell, B. J., O'Gean, K., Schulte, M., Lawley, J. S., & Cornwell, W. K. (2023) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2023.01.010 · Cited by 12
Impact of altitude on worker health and project efficiency in tunnel construction
Zhao, S., Wen, S., Guo, Y., Sun, B., Chen, W., Wang, S., Guo, Y., & Guo, C. S. (2025) · International Journal of Industrial Ergonomics · doi:10.1016/j.ergon.2024.103694 · Cited by 13
Cardiovascular Drift during Training for Fitness in Patients with Metabolic Syndrome
Morales‐Palomo, F., Ramírez-Jiménez, M., ORTEGA, J. F., Pallarés, J. G., & Mora‐Rodríguez, R. (2016) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000001139 · Cited by 13
Comparison of Resistance-Based Walking Cardiorespiratory Test to the Bruce Protocol
Hurt, C. P., Bamman, M. M., Naidu, A., & Brown, D. A. (2017) · The Journal of Strength and Conditioning Research · doi:10.1519/jsc.0000000000002263 · Cited by 11
Cardiopulmonary exercise testing in the evaluation of liver disease in adults who have had the Fontan operation
Agarwal, A., Cunnington, C., Sabanayagam, A., Zier, L. S., McCulloch, C. E., Harris, I. S., Foster, E., Atkinson, D., Bryan, A., Jenkins, P., et al. (2017) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2017.09.001 · Cited by 12
Surgical closure of a ventricular septal defect in early childhood leads to altered pulmonary function in adulthood: A long-term follow-up
Rex, C. E., Eckerström, F., Heiberg, J., Maagaard, M., Rubak, S., Redington, A. N., & Hjortdal, V. E. (2018) · International Journal of Cardiology · doi:10.1016/j.ijcard.2018.06.109 · Cited by 12
Validación para Colombia del cuestionario para la “Medición de la capacidad funcional en pacientes con falla cardíaca”
Ropero, E. M. S., Vera-Giraldo, C. Y., Navas-Ríos, C. M., Ortiz-Rangel, S. D., Guevara, C. R., Vargas-Montoya, D. M., Aguirre-Acevedo, D. C., & Lugo‐Agudelo, L. H. (2018) · Revista Colombiana de Cardiología · doi:10.1016/j.rccar.2018.04.004 · Cited by 12
“Masculino 21 (65,6) 61 (70,1) 8 (50) 90 (66,7)”
Influential
Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing
Thomas, G., West, M. A., Browning, M., Minto, G., Swart, M., Richardson, K., McGarrity, L., Jack, S., Grocott, M. P. W., & Levett, D. Z. H. (2020) · Perioperative Medicine · doi:10.1186/s13741-020-00148-2 · Cited by 12
The Effect of Mat Pilates Training Combined With Aerobic Exercise Versus Mat Pilates Training Alone on Blood Pressure in Women With Hypertension: A Randomized Controlled Trial
Almeida, I. D. S., Andrade, L. D. S., de Sousa, A. M. M., Cipriano, G., da Silva, N. T., Nascimento, D. D. C., Mota, Y. L., & Durigan, J. L. Q. (2021) · Physical Therapy · doi:10.1093/ptj/pzab258 · Cited by 13
Introduction: CPET in clinical practice. Recent advances, current challenges and future directions
Neder, J. A., Laveneziana, P., Ward, S. A., & Palange, P. (2018) · European Respiratory Society eBooks · doi:10.1183/2312508x.10015318 · Cited by 12
Which high-intensity interval training program is more effective in patients with coronary artery disease?
Okur, İ., Aksoy, C. C., Yaman, F., & Sen, T. (2022) · International Journal of Rehabilitation Research · doi:10.1097/mrr.0000000000000524 · Cited by 12
Neural network methods for diagnosing patient conditions from cardiopulmonary exercise testing data
Brown, D. E., Sharma, S., Jablonski, J. A., & WELTMAN, A. L. (2022) · BioData Mining · doi:10.1186/s13040-022-00299-6 · Cited by 12
“Peak V̇O2 is also used in specific clinical scenarios such as the evaluation of response to therapies in heart failure patients being considered for transplant [16, 17, 18].”
Hemodynamic Gain Index Is Associated With Cardiovascular Mortality and Improves Risk Prediction
Laukkanen, J. A., Isiozor, N. M., Willeit, P., & Kunutsor, S. K. (2023) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000777 · Cited by 12
Adaptations of aortic and pulmonary artery flow parameters measured by phase-contrast magnetic resonance angiography during supine aerobic exercise
Pieles, G. E., Szantho, G. V., Rodrigues, J. C. L., Lawton, C. B., Stuart, G., Bucciarelli‐Ducci, C., Turner, M., Williams, C. A., Tulloh, R. M. R., & Hamilton, M. C. K. (2014) · European Journal of Applied Physiology · doi:10.1007/s00421-014-2833-x · Cited by 12
Delayed blood pressure recovery ratio might indicate increased arterial stiffness in hypertensive patients with reduced aerobic exercise capacity
Kontsas, K., Triantafyllidi, H., Trivilou, P., Ikonomidis, I., Tzortzis, S., Liazos, I., Alevras, P., PARASKEVAIDIS, I. A., Kremastinos, D. T., ANASTASIOU‐NANA, M. I., et al. (2013) · Blood Pressure · doi:10.3109/08037051.2012.759694 · Cited by 12
Effects of Resistance Band Exercise on Vascular Activity and Fitness in Older Adults
Smith, M. F., Ellmore, M., Middleton, G., Murgatroyd, P., & Gee, T. I. (2017) · International Journal of Sports Medicine · doi:10.1055/s-0042-121261 · Cited by 12
“0 and 85 % of age-predicted maximal heart rate, to avoid any presence of low peak RER [3].”
BackgroundInfluential
The Gas Sampling Interval Effect on V˙O2peak Is Independent of Exercise Protocol
Scheadler, C. M., Garver, M. J., & Hanson, N. (2017) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000001301 · Cited by 13
Moderate to Severe Obstructive Sleep Apnea in Military Personnel Is Not Associated With Decreased Exercise Capacity
Powell, T. A., Mysliwiec, V., Aden, J. K., & Morris, M. J. (2019) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.7828 · Cited by 12
“17–19 Given the normal cardiovascular response to exercise in our cohort, it would appear that these physiologic changes had not yet developed, potentially explaining their normal exercise tolerance.”
Prescripción de ejercicio en pacientes con cirrosis: recomendaciones para la atención clínica
Macías‐Rodríguez, R. U., Ruiz‐Margáin, A., Román-Calleja, B. M., Moreno-Tavarez, E., Weber-Sangri, L., González-Arellano, M. F., Fernández-del-Rivero, G., & Ramírez-Soto, K. (2019) · Revista de Gastroenterología de México · doi:10.1016/j.rgmx.2019.02.011 · Cited by 12
The role of cardiopulmonary exercise testing and training in patients with pulmonary hypertension: making the case for this assessment and intervention to be considered a standard of care
Sabbahi, A., Severin, R. S., Ozemek, C., Phillips, S. A., & Arena, R. A. (2019) · Expert Review of Respiratory Medicine · doi:10.1080/17476348.2020.1708196 · Cited by 12
Self-citation
Isolated Exercise-Induced Pulmonary Hypertension Associates with Higher Cardiovascular Risk in Scleroderma Patients
Madonna, R., Morganti, R., Radico, F., Vitulli, P., Mascellanti, M., Amerio, P., & Caterina, R. D. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9061910 · Cited by 12
“We defined O2 pulse as the oxygen uptake divided by the heart rate (HR), % O2 pulse as the percent of predicted O2 pulse [13,15], and VE/VCO2 and VE/VO2 were the slope of ventilation versus CO2 output and O2 uptake, respectively.”
Method
Prediction of Discontinuation of Structured Exercise Programme in Chronic Fatigue Syndrome Patients
Kujawski, S., Cossington, J., Słomko, J., Dawes, H., Strong, J. W. L., Estévez‐López, F., Murovska, M., Newton, J. L., Hodges, L. D., & Zalewski, P. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9113436 · Cited by 12
“In the presence of a physician, the patients undertook a cardiopulmonary exercise test (CPET) using the Bruce protocol (Cardiovit CS-200 Ergo-Spiro, Schiller AG, Baar, Switzerland) at baseline [25,26].”
BackgroundMethod
Eccentric Left Ventricular Hypertrophy and Left and Right Cardiac Function in Chronic Heart Failure with or without Coexisting COPD: Impact on Exercise Performance
dos Santos, P. B., Simões, R. P., Goulart, C. D. L., Roscani, M. G., Marinho, R. S., Camargo, P. F., Arbex, R. F., Casale, G., de Oliveira, C. R., Mendes, R. G., et al. (2021) · International Journal of COPD · doi:10.2147/copd.s285812 · Cited by 12
Self-citation
Two-year follow-up after a six-week high-intensity training intervention study with breast cancer patients: physiological, psychological and immunological differences
Schulz, S. V. W., Schümann, U., Otto, S., Kirsten, J., Treff, G., Janni, W., Huober, J., Leinert, E., Steinacker, J. M., & Bizjak, D. A. (2021) · Disability and Rehabilitation · doi:10.1080/09638288.2021.1921861 · Cited by 12
Physically Active Lifestyle Is Associated With Attenuation of Hippocampal Dysfunction in Cognitively Intact Older Adults
Eisenstein, T., Giladi, N., Hendler, T., Havakuk, O., & Lerner, Y. (2021) · Frontiers in Aging Neuroscience · doi:10.3389/fnagi.2021.720990 · Cited by 11
Cardiovascular Burden and Adverse Events in Patients With Esophageal Cancer Treated With Chemoradiation for Curative Intent
Søndergaard, M. M. A., Nordsmark, M., Nielsen, K. M., & Poulsen, S. H. (2021) · JACC CardioOncology · doi:10.1016/j.jaccao.2021.10.002 · Cited by 12
“1 is considered to indicate sufficient patient effort during cardiopulmonary stress testing (12).”
BackgroundMethodInfluential
Energetics and clinical factors for the time required to walk 400 m: The Study of Muscle, Mobility and Aging ( SOMMA )
Cummings, S. R., Lui, L., Glynn, N. W., Mau, T., Cawthon, P. M., Kritchevsky, S. B., Coen, P. M., Goodpaster, B., Marcinek, D. J., Hepple, R. T., et al. (2024) · Journal of the American Geriatrics Society · doi:10.1111/jgs.18763 · Cited by 12
Left atrial volume index is an independent predictor of hypertensive response to exercise in patients with hypertension
Lee, S., Youn, J., Lee, H. S., Park, S., Lee, S., Cho, I., Shim, C. Y., Hong, G., Choi, D., & Kang, S. (2014) · Hypertension Research · doi:10.1038/hr.2014.146 · Cited by 11
PATHway: Decision Support in Exercise Programmes for Cardiac Rehabilitation
Filos, D., Triantafyllidis, A. K., Chouvarda, I., Buys, R., Véronique, C., Werner, B., Walsh, D. M. J., Woods, C. B., Moran, K., & Nicos, M. (2016) · Studies in health technology and informatics · doi:10.3233/978-1-61499-653-8-40 · Cited by 11
“programmes [10].”
Design of Smart Brain Oxygenation Monitoring System for Estimating Cardiovascular Disease Severity
Chou, W., Wu, P.-J., Fang, C.-C., Yen, Y.-S., & Lin, B. (2020) · IEEE Access · doi:10.1109/access.2020.2997865 · Cited by 11
“Here, the cardiovascular disease severity is classified according to the peak metabolic equivalents (METs) of patients under CPET [11], [12].”
BackgroundMethodInfluential
Moderate- and High-Intensity Inspiratory Muscle Training Equally Improves Inspiratory Muscle Strength and Endurance—A Double-Blind Randomized Controlled Trial
Rehder‐Santos, P., de Abreu, R. M., Signini, É. D. F., da Silva, C. D., Sakaguchi, C. A., Dato, C. C., & Catai, A. M. (2021) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.2020-0189 · Cited by 12
Effects of bariatric surgery on cardiorespiratory fitness: A systematic review and meta‐analysis
Ibacache-Saavedra, P., Jerez‐Mayorga, D., Carretero‐Ruiz, A., Miranda‐Fuentes, C., Cano-Cappellacci, M. A., & Artero, E. G. (2021) · Obesity Reviews · doi:10.1111/obr.13408 · Cited by 11
“We aimed to examine postoperative changes in CRF (VO2max/peak) and its relationship with weight loss among adults undergoing BS.”
BackgroundInfluential
Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data
Sivakumar, J., Forshaw, M. J., Lam, S., Peters, C. J., Allum, W., Whibley, J., Sinclair, R. C. F., Snowden, C. P., Hii, M. W., Sivakumar, H., et al. (2022) · Diseases of the Esophagus · doi:10.1093/dote/doac005 · Cited by 11
Preventing the adverse cardiovascular consequences of allogeneic stem cell transplantation with a multi-faceted exercise intervention: the ALLO-Active trial protocol
Dillon, H. T., Saner, N. J., Ilsley, T., Kliman, D. S., Spencer, A. G., Avery, S., Dunstan, D. W., Daly, R. M., Fraser, S. F., Owen, N. G., et al. (2022) · BMC Cancer · doi:10.1186/s12885-022-09793-w · Cited by 13
Effectiveness of hospital-based low intensity and inspected aerobic training on functionality and cardiorespiratory fitness in unconditioned stroke patients: Importance of submaximal aerobic fitness markers
Horvath, J. E., Nagy, Á., Fülöp, P., & Jenei, Z. (2022) · Medicine · doi:10.1097/md.0000000000031035 · Cited by 11
“[28] The results showed the same outcomes with Sheng Chien at al.”
Result
Prognostic Value of 6-Minute Walk Test in Advanced Heart Failure With Reduced Ejection Fraction
Scrutinio, D., Guida, P., & Passantino, A. (2023) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2023.04.041 · Cited by 11
Clinical and invasively-measured predictors of high exercise capacity in Fontan patients
Ponder, R. D., Chez, L., Rosenthal, C. J., Bravo‐Jaimes, K., Lluri, G., Reardon, L. C., Lin, J. P., Levi, D. S., & Aboulhosn, J. (2023) · International Journal of Cardiology · doi:10.1016/j.ijcard.2023.131166 · Cited by 11
Do Clinical Exercise Tests Permit Exercise Threshold Identification in Patients Referred to Cardiac Rehabilitation?
Keltz, R. R., Hartley, T., Huitema, A., McKelvie, R. S., Suskin, N., & Keir, D. A. (2023) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2023.07.029 · Cited by 11
Cardiorespiratory coupling is associated with exercise capacity in athletes: A cross-sectional study
de Abreu, R. M., Cairo, B., Rehder‐Santos, P., da Silva, C. D., Signini, É. D. F., Milan‐Mattos, J. C., Sakaguchi, C. A., Catai, A. M., & Porta, A. (2023) · Respiratory Physiology & Neurobiology · doi:10.1016/j.resp.2023.104198 · Cited by 11
Racial Differences in Diabetic Cardiomyopathy
Batista, J. L., Liu, Y., Butler, J., Prato, S. D., Ezekowitz, J. A., Lam, C. S. P., Marwick, T. H., Rosenstock, J., Tang, W. H. W., Perfetti, R., et al. (2024) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2024.04.053 · Cited by 11
V o 2 kinetics associated with moderate-intensity exercise in heart failure: impact of intrathecal fentanyl inhibition of group III/IV locomotor muscle afferents
Iterson, E. H. V., Johnson, B. D., Joyner, M. J., Curry, T. B., & Olson, T. P. (2017) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.00014.2017 · Cited by 11
Osteopathic treatment leads to significantly greater reductions in chronic thoracic pain after CABG surgery: A randomised controlled trial
Roncada, G. (2020) · Journal of Bodywork and Movement Therapies · doi:10.1016/j.jbmt.2020.03.004 · Cited by 11
Ventilatory and chronotropic incompetence during incremental and constant load exercise in end-stage renal disease: a comparative physiology study
McGuire, S., Horton, E., Renshaw, D. W., Chan, K., Krishnan, N. S., & McGregor, G. (2020) · American Journal of Physiology-Renal Physiology · doi:10.1152/ajprenal.00258.2020 · Cited by 11
Observational case series describing features of cardiopulmonary exercise testing in Postural Tachycardia Syndrome (PoTS)
Loughnan, A., Gall, N. P., & James, S. (2020) · Autonomic Neuroscience · doi:10.1016/j.autneu.2020.102762 · Cited by 11

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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