A fundamental requirement for many of the activities of daily living is the ability to perform predominantly aerobic, ie, oxygen-using, work. Such activities require the integrated efforts of the heart, lungs, and circulation to deliver oxygen to the metabolically active muscle mass. Thus, the assessment of functional or aerobic exercise time or peak oxygen consumption provides important diagnostic and prognostic information in a wide variety of clinical settings. Furthermore, numerous clinical trials, especially those in patients with heart failure, have used aerobic exercise time or peak oxygen consumption as a primary or secondary end point. This brief advisory will highlight the major clinical and research applications of functional capacity assessment. For a comprehensive review of exercise testing, the reader is referred to the American College of Cardiology/American Heart Association Guidelines for Exercise Testing. 1
Physiology and TerminologyThe maximal capacity of an individual to perform aerobic work is defined by the maximal oxygen consumption (V O 2 max), the product of cardiac output (CO) and arteriovenous oxygen (AV O 2 ) difference at exhaustion. Although V O 2 max is measured in liters per minute, it is usually expressed per kilogram of body weight to facilitate intersubject comparisons. Functional capacity, particularly when estimated rather than measured directly, is often expressed in metabolic equivalents (METs); 1 MET represents resting energy expenditure and approximates 3.5 mL O 2 ⅐ kg Ϫ1 ⅐ min
Ϫ1. Because V O 2 max is typically achieved by exercise that involves only about half of the total body musculature, it is generally believed that V O 2 max is limited by maximal CO rather than peripheral factors. 2 V O 2 max is affected by age, sex, conditioning status, and the presence of diseases or medications that influence its components. V O 2 max in a young world-class male endurance athlete can exceed 80 mL ⅐ kg Ϫ1 ⅐ min
Ϫ1, whereas a value of 15 mL ⅐ kg Ϫ1 ⅐ min Ϫ1 is typical for a sedentary but healthy 80-year-old woman. Aerobic capacity declines 8% to 10% per decade in nonathletic subjects, 3 mediated largely by decreases in maximal heart rate and AV O 2 difference. Earlier studies suggested that the age-associated decline in V O 2 max may be attenuated to Ϸ5% per decade in endurance-trained subjects who continue to exercise vigorously. However, recent longitudinal observations with Ͼ20 years of follow-up have demonstrated declines of 10% to 15% per decade in such individuals, 4 mediated in part by a reduction in training intensity. At any age, V O 2 max in men is 10% to 20% greater than in women, in part because of a higher hemoglobin concentration, a larger proportion of muscle mass, and a greater stroke volume in men. These age and sex differences in V O 2 max must be considered in interpretations of functional capacity in individuals. Endurance training augments V O 2 max by 10% to 30% primarily by increasing maximal stroke volume and the AV O 2 difference. 5 True V O 2 max is usual...