Cardiopulmonary exercise testing in patients with pulmonary hypertension: clinical recommendations based on a review of the evidence

Abstract

Pulmonary hypertension (PH) remains an ominous diagnosis despite advances in pharmacological and surgical therapy. Early and effective diagnosis is important for clinicians making treatment determinations and patients wishing to understand the prognostic implications of their illness. Cardiopulmonary exercise testing (CPX) has the power to reveal the underlying pathophysiological consequences of the disease process. Research, especially over the last 10-15 years, has demonstrated the utility of this tool. Several CPX variables have been shown to be consistently altered in patients with PH and more so as severity of disease increases. However, to further enhance clinical application, additional research is needed to better define optimal CPX measures and associated cutoff values. This paper gives class-based recommendations with associated levels of evidence for the use of CPX in the PH patient population.

Cardiopulmonary exercise testing improves diagnostic specificity in patients with echocardiography‐suspected pulmonary hypertension

“…Cardiopulmonary exercise testing (CPET) is a well‐established assessment tool for evaluation of disease severity in PH patients . Pinkstaff et al go even further by making class recommendations CPET for diagnostic evaluation (level B, class IIa), prognostication (level B, class IIb), and determining therapeutic efficiency (level C, class IIb) . Among patients with unexplained exertional dyspnea, a minute ventilation/carbon dioxide output (VE/VCO 2 ) ≥60 and peak partial pressure of end‐tidal CO 2 (P ET CO 2 ) <20 mm Hg at ventilatory threshold are highly suggestive of PH .…”

“…[11][12][13] Pinkstaff et al go even further by making class recommendations CPET for diagnostic evaluation (level B, class IIa), prognostication (level B, class IIb), and determining therapeutic efficiency (level C, class IIb). 14 Among patients with unexplained exertional dyspnea, a minute ventilation/carbon dioxide output (VE/VCO 2 ) ≥60 and peak partial pressure of end-tidal CO 2 (P ET CO 2 ) <20 mm Hg at ventilatory threshold are highly suggestive of PH. 15 CPET is also a useful noninvasive diagnostic tool for detection of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with a normal echocardiogram.…”

Exercise-based evaluations and interventions for pulmonary hypertension with connective tissue disorders

“…The prognostic role of CPX variables in assessing survival in PAH has also been demonstrated with a building evidence base. [48,62] ; P = 0.003). [67] This suggests that in addition to measurement of the distance covered during the 6MWT, desaturation and heart rate recovery (a surrogate marker of autonomic function) may need to be measured and documented.…”

“…Furthermore, the use of CPX has recently been considered a Level B, class IIb recommendation for prognostication [62]. The most commonly obtained variable from CPX, peakVȮ2 has shown the highest diagnostic accuracy (sensitivity 87.5%, specificity 74.8% at a threshold level of 13.8 mL/min/kg [64].…”

Oxygen Uptake Efficiency Slope Predicts Poor Outcome in Patients With Idiopathic Pulmonary Arterial Hypertension

“…It is important to identify patients with a higher risk of poor outcome early in order to treat them with optimal drugs, such as initial combination therapy for patients with a higher risk of mortality . Several key parameters obtained from cardiopulmonary exercise testing (CPET), including peak oxygen uptake (peak ), end tidal partial pressure of carbon dioxide at anaerobic threshold, ventilation ()/carbon dioxide output () slope or ratio at anaerobic threshold, and heart rate recovery have been widely used to assess disease severity, therapeutic responses, and prognosis estimation in patients with PAH …”