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

References

• Baldi F, Fuso L, Arrighi E, et al. Optimal management of pulmonary arterial hypertension: prognostic indicators to determine treatment course. Ther Clin Risk Manag. 2014;10:825–839. doi:10.2147/TCRM.S48920.
   PubMed Web of Science ®Google Scholar
• McLaughlin VV, Gaine SP, Howard LS, et al. Treatment goals of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D73–D81. doi:10.1016/j.jacc.2013.10.034.
   PubMed Web of Science ®Google Scholar
• Galiè N, Rubin L, Hoeper M, et al. Treatment of patients with mildly symptomatic pulmonary arterial hypertension with bosentan (EARLY study): a double-blind, randomised controlled trial. Lancet (London, England). 2008;371(9630):2093–2100. doi:10.1016/S0140-6736(08)60919-8.
   PubMed Web of Science ®Google Scholar
• Myers J, Voodi L, Umann T, et al. A survey of exercise testing: methods, utilization, interpretation, and safety in the VAHCS. J Cardiopulm Rehabil. 20(4):251–258[ cited 2013 Nov 29]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/10955267.
   PubMedGoogle Scholar
• Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: develope. Circulation. 2009;119(14):e391–e479. doi:10.1161/CIRCULATIONAHA.109.192065.
   PubMedGoogle Scholar
• McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College. Circulation. 2009;119(16):2250–2294. doi:10.1161/CIRCULATIONAHA.109.192230.
   PubMed Web of Science ®Google Scholar
• Galiè N, Humbert M, Vachiery J-L, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2015:ehv317. doi:10.1093/eurheartj/ehv317.
   Google Scholar
• Arena R, Lavie CJ, Milani RV, et al. Cardiopulmonary exercise testing in patients with pulmonary arterial hypertension: an evidence-based review. J Heart Lung Transplant. 2010;29(2):159–173. doi:10.1016/j.healun.2009.09.003.
   PubMed Web of Science ®Google Scholar
• Arena R, Guazzi M, Cahalin LP, et al. Revisiting cardiopulmonary exercise testing applications in heart failure: aligning evidence with clinical practice. Exerc Sport Sci Rev. 2014;42(4):153–160. doi:10.1249/JES.0000000000000022.
   PubMed Web of Science ®Google Scholar
• Paolillo S, Farina S, Bussotti M, et al. Exercise testing in the clinical management of patients affected by pulmonary arterial hypertension. Eur J Prev Cardiol. 2012;19(5):960–971 [cited 2015 Jun 24]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/23126000.
   PubMed Web of Science ®Google Scholar
• Fowler RM, Gain KR, Gabbay E. Exercise intolerance in pulmonary arterial hypertension. Pulm Med. 2012;2012:359204. doi:10.1155/2012/359204.
   PubMedGoogle Scholar
• Low AT, Medford ARL, Millar AB, et al. Lung function in pulmonary hypertension. Respir Med. 2015. doi:10.1016/j.rmed.2015.05.022.
   PubMed Web of Science ®Google Scholar
• Zhai Z. Differences in ventilatory inefficiency between pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Chest J. 2011;140(5):1284. doi:10.1378/chest.10-3357.
   PubMed Web of Science ®Google Scholar
• Woods PR, Frantz RP, Taylor BJ, et al. The usefulness of submaximal exercise gas exchange to define pulmonary arterial hypertension. J Heart Lung Transplant. 2011;30(10):1133–1142. doi:10.1016/j.healun.2011.03.021.
   PubMed Web of Science ®Google Scholar
• Nishio R, Tanaka H, Tsuboi Y, et al. Differences in hemodynamic parameters and exercise capacity between patients with pulmonary arterial hypertension and chronic heart failure. J Cardiopulm Rehabil Prev. 2012;32(6):379–385. doi:10.1097/HCR.0b013e318272bc0b.
   PubMed Web of Science ®Google Scholar
• Boerrigter BG. Ventilatory and cardiocirculatory exercise profiles in COPD. Chest J. 2012;142(5):1166. doi:10.1378/chest.11-2798.
   PubMed Web of Science ®Google Scholar
• Armstrong HF, Thirapatarapong W, Dussault NE, et al. Distinguishing pulmonary hypertension in interstitial lung disease by ventilation and perfusion defects measured by cardiopulmonary exercise testing. Respiration. 2013;86(5):407–413. doi:10.1159/000350445.
   PubMed Web of Science ®Google Scholar
• Guazzi M, Cahalin LP, Arena R. Cardiopulmonary exercise testing as a diagnostic tool for the detection of left-sided pulmonary hypertension in heart failure. J Card Fail. 2013;19(7):461–467. doi:10.1016/j.cardfail.2013.05.005.
   PubMed Web of Science ®Google Scholar
• McCabe C, Deboeck G, Harvey I, et al. Inefficient exercise gas exchange identifies pulmonary hypertension in chronic thromboembolic obstruction following pulmonary embolism. Thromb Res. 2013;132(6):659–665. doi:10.1016/j.thromres.2013.09.032.
   PubMed Web of Science ®Google Scholar
• Thirapatarapong W, Armstrong HF, Bartels MN. Comparing cardiopulmonary exercise testing in severe COPD patients with and without pulmonary hypertension. Heart Lung Circ. 2014;23(9):833–840. doi:10.1016/j.hlc.2013.12.015.
   PubMed Web of Science ®Google Scholar
• Valois FM, Nery LE, Ramos RP, et al. Contrasting cardiopulmonary responses to incremental exercise in patients with schistosomiasis-associated and idiopathic pulmonary arterial hypertension with similar resting hemodynamic impairment. PLoS One. 2014;9(2):e87699. doi:10.1371/journal.pone.0087699.
   Google Scholar
• Held M, Grün M, Holl R, et al. Cardiopulmonary exercise testing to detect chronic thromboembolic pulmonary hypertension in patients with normal echocardiography. Respiration. 2014;87(5):379–387. doi:10.1159/000358565.
   PubMed Web of Science ®Google Scholar
• Liu W-H, Luo Q, Liu Z-H, et al. Pulmonary function differences in patients with chronic right heart failure secondary to pulmonary arterial hypertension and chronic left heart failure. Med Sci Monit. 2014;20:960–966. doi:10.12659/MSM.890409.
   PubMed Web of Science ®Google Scholar
• Liu W-H, Luo Q, Liu Z-H, et al. Differences in pulmonary function and exercise capacity in patients with idiopathic dilated cardiomyopathy and idiopathic pulmonary arterial hypertension. Heart Lung. 2014;43(4):317–321. doi:10.1016/j.hrtlng.2014.04.001.
   PubMed Web of Science ®Google Scholar
• Tan X, Yang W, Guo J, et al. Usefulness of decrease in oxygen uptake efficiency to identify gas exchange abnormality in patients with idiopathic pulmonary arterial hypertension. PLoS One. 2014;9(6):e98889. doi:10.1371/journal.pone.0098889.
   Google Scholar
• Xi Q, Zhao Z, Liu Z, et al. The lowest VE/VCO₂ ratio best identifies chronic thromboembolic pulmonary hypertension. Thromb Res. 2014;134(6):1208–1213. doi:10.1016/j.thromres.2014.09.025.
   PubMed Web of Science ®Google Scholar
• Guo J, Shi X, Yang W, et al. Exercise physiology and pulmonary hemodynamic abnormality in PH patients with exercise induced venous-to-systemic shunt. PLoS One. 2014;10(4):e0121690. doi:10.1371/journal.pone.0121690.
   Google Scholar
• Shi X, Guo J, Gong S, et al. Oxygen uptake is more efficient in idiopathic pulmonary arterial hypertension than in chronic thromboembolic pulmonary hypertension. Respirology. 2015. doi:10.1111/resp.12648.
   Web of Science ®Google Scholar
• Oudiz RJ, Midde R, Hovanesyan A, et al. Usefulness of right-to-left shunting and poor exercise gas exchange for predicting prognosis in patients with pulmonary arterial hypertension. Am J Cardiol. 2010;105(8):1186–1191. doi:10.1016/j.amjcard.2009.12.024.
   PubMed Web of Science ®Google Scholar
• Deboeck G, Scoditti C, Huez S, et al. Exercise testing to predict outcome in idiopathic versus associated pulmonary arterial hypertension. Eur Respir J. 2012;40(6):1410–1419. doi:10.1183/09031936.00217911.
   PubMed Web of Science ®Google Scholar
• Ramos RP, Arakaki JSO, Barbosa P, et al. Heart rate recovery in pulmonary arterial hypertension: relationship with exercise capacity and prognosis. Am Heart J. 2012;163(4):580–588. doi:10.1016/j.ahj.2012.01.023.
   PubMed Web of Science ®Google Scholar
• Schwaiblmair M, Faul C, Von Scheidt W, et al. Ventilatory efficiency testing as prognostic value in patients with pulmonary hypertension. BMC Pulm Med. 2012;12(1):23. doi:10.1186/1471-2466-12-23.
   PubMed Web of Science ®Google Scholar
• Gläser S, Obst A, Koch B, et al. Pulmonary hypertension in patients with idiopathic pulmonary fibrosis - the predictive value of exercise capacity and gas exchange efficiency. PLoS One. 2013;8(6):e65643. doi:10.1371/journal.pone.0065643.
   Google Scholar
• Groepenhoff H, Vonk-Noordegraaf A, van de Veerdonk MC, et al. Prognostic relevance of changes in exercise test variables in pulmonary arterial hypertension. PLoS One. 2013;8(9):e72013. doi:10.1371/journal.pone.0072013.
   PubMed Web of Science ®Google Scholar
• Grünig E, Tiede H, Enyimayew EO, et al. Assessment and prognostic relevance of right ventricular contractile reserve in patients with severe pulmonary hypertension. Circulation. 2013;128(18):2005–2015. doi:10.1161/CIRCULATIONAHA.113.001573.
   PubMed Web of Science ®Google Scholar
• Bozbaş SS, Bozbaş H, Atar A, et al. Comparative effects of losartan and nifedipine therapy on exercise capacity, Doppler echocardiographic parameters and endothelin levels in patients with secondary pulmonary hypertension. Anadolu Kardiyol Derg. 2010;10(1):43–49. cited 2015 Jun 24]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/20150004.
   PubMedGoogle Scholar
• Fox BD, Kassirer M, Weiss I, et al. Ambulatory rehabilitation improves exercise capacity in patients with pulmonary hypertension. J Card Fail. 2011;17(3):196–200. doi:10.1016/j.cardfail.2010.10.004.
   PubMed Web of Science ®Google Scholar
• Andreassen AK, Ragnarsson A, Gude E, et al. Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. Heart. 2013;99(19):1415–1420. doi:10.1136/heartjnl-2012-303549.
   PubMed Web of Science ®Google Scholar
• Chan L, Chin LMK, Kennedy M, et al. Benefits of intensive treadmill exercise training on cardiorespiratory function and quality of life in patients with pulmonary hypertension. Chest J. 2013;143(2):333. doi:10.1378/chest.12-0993.
   PubMed Web of Science ®Google Scholar
• Hirashiki A, Adachi S, Nakano Y, et al. Cardiopulmonary exercise testing to evaluate the exercise capacity of patients with inoperable chronic thromboembolic pulmonary hypertension: an endothelin receptor antagonist improves the peak PETCO2. Life Sci. 2014;118(2):397–403. doi:10.1016/j.lfs.2014.03.009.
   PubMed Web of Science ®Google Scholar
• Claessen G, La Gerche A, Wielandts J-Y, et al. Exercise pathophysiology and sildenafil effects in chronic thromboembolic pulmonary hypertension. Heart. 2015;101(8):637–644. doi:10.1136/heartjnl-2014-306851.
   PubMed Web of Science ®Google Scholar
• De Groote P, El Asri C, Fertin M, et al. Sildenafil in heart transplant candidates with pulmonary hypertension. Arch Cardiovasc Dis. 2015. doi:10.1016/j.acvd.2015.01.013.
   PubMed Web of Science ®Google Scholar
• Pandey A, Garg S, Knunger M, et al. Efficacy and safety of exercise training in chronic pulmonary hypertension: systematic review and meta-analysis. Circ Heart Fail. 2015;8(6):1032–1043. doi:10.1161/CIRCHEARTFAILURE.115.002130.
   PubMed Web of Science ®Google Scholar
• Reybrouck T, Mertens L, Schulze-Neick I, et al. Ventilatory inefficiency for carbon dioxide during exercise in patients with pulmonary hypertension. Clin Physiol. 1998;18(4):337–344. [cited 2015 Jun 24]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9715760.
   PubMedGoogle Scholar
• Yasunobu Y, Oudiz RJ, Sun X-G, et al. End-tidal PCO2 abnormality and exercise limitation in patients with primary pulmonary hypertension. Chest. 2005;127(5):1637–1646. doi:10.1378/chest.127.5.1637.
   PubMed Web of Science ®Google Scholar
• Holverda S, Bogaard HJ, Groepenhoff H, et al. Cardiopulmonary exercise test characteristics in patients with chronic obstructive pulmonary disease and associated pulmonary hypertension. Respiration. 2008;76(2):160–167. doi:10.1159/000110207.
   PubMed Web of Science ®Google Scholar
• Gläser S, Noga O, Koch B, et al. Impact of pulmonary hypertension on gas exchange and exercise capacity in patients with pulmonary fibrosis. Respir Med. 2009;103(2):317–324. doi:10.1016/j.rmed.2008.08.005.
   PubMed Web of Science ®Google Scholar
• Rausch CM, Taylor AL, Ross H, et al. Ventilatory efficiency slope correlates with functional capacity, outcomes, and disease severity in pediatric patients with pulmonary hypertension. Int J Cardiol. 2013;169(6):445–448. doi:10.1016/j.ijcard.2013.10.012.
   PubMed Web of Science ®Google Scholar
• Arena R, Myers J, Hsu L, et al. The minute ventilation/carbon dioxide production slope is prognostically superior to the oxygen uptake efficiency slope. J Card Fail. 2007;13(6):462–469. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17675060.
   PubMed Web of Science ®Google Scholar
• Sun X-G, Hansen JE, Oudiz RJ, et al. Gas exchange detection of exercise-induced right-to-left shunt in patients with primary pulmonary hypertension. Circulation. 2002;105(1):54–60. [cited 2013 Nov 29]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/11772876.
   PubMed Web of Science ®Google Scholar
• Held M, Hesse A, Gött F, et al. A symptom-related monitoring program following pulmonary embolism for the early detection of CTEPH: a prospective observational registry study. BMC Pulm Med. 2014;14:141. doi:10.1186/1471-2466-14-141.
   PubMed Web of Science ®Google Scholar
• Sun X-G, Hansen JE, Stringer WW. Oxygen uptake efficiency plateau: physiology and reference values. Eur J Appl Physiol. 2012;112(3):919–928. doi:10.1007/s00421-011-2030-0.
   PubMed Web of Science ®Google Scholar
• Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the internat. Eur Heart J. 2009;30(20):2493–2537. doi:10.1093/eurheartj/ehp297.
   PubMed Web of Science ®Google Scholar
• Woods PR, Taylor BJ, Frantz RP, et al. A pulmonary hypertension gas exchange severity (PH-GXS) score to assist with the assessment and monitoring of pulmonary arterial hypertension. Am J Cardiol. 2012;109(7):1066–1072. doi:10.1016/j.amjcard.2011.11.042.
   PubMed Web of Science ®Google Scholar
• Wensel R, Opitz CF, Anker SD, et al. Assessment of survival in patients with primary pulmonary hypertension: importance of cardiopulmonary exercise testing. Circulation. 2002;106(3):319–324. [cited 2015 Jun 24]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/12119247.
   PubMed Web of Science ®Google Scholar
• Groepenhoff H, Vonk-Noordegraaf A, Boonstra A, et al. Exercise testing to estimate survival in pulmonary hypertension. Med Sci Sports Exerc. 2008;40(10):1725–1732. doi:10.1249/MSS.0b013e31817c92c0.
   PubMed Web of Science ®Google Scholar
• Enderby CY, Burger C. Medical treatment update on pulmonary arterial hypertension. Ther Adv Chronic Dis. 2015;6(5):264–272. doi:10.1177/2040622315590757.
   PubMed Web of Science ®Google Scholar
• Macchia A, Marchioli R, Tognoni G, et al. Systematic review of trials using vasodilators in pulmonary arterial hypertension: why a new approach is needed. Am Heart J. 2010;159(2):245–257. doi:10.1016/j.ahj.2009.11.028.
   PubMed Web of Science ®Google Scholar
• Torres F. Systematic review of randomised, double-blind clinical trials of oral agents conducted in patients with pulmonary arterial hypertension. Int J Clin Pract. 2007;61(10):1756–1765. doi:10.1111/j.1742-1241.2007.01545.x.
   PubMed Web of Science ®Google Scholar
• Barst RJ, Langleben D, Frost A, et al. Sitaxsentan therapy for pulmonary arterial hypertension. Am J Respir Crit Care Med. 2004;169(4):441–447. doi:10.1164/rccm.200307-957OC.
   PubMed Web of Science ®Google Scholar
• Oudiz RJ, Barst RJ, Hansen JE, et al. Cardiopulmonary exercise testing and six-minute walk correlations in pulmonary arterial hypertension. Am J Cardiol. 2006;97(1):123–126. doi:10.1016/j.amjcard.2005.07.129.
   PubMed Web of Science ®Google Scholar
• Oudiz RJ, Roveran G, Hansen JE, et al. Effect of sildenafil on ventilatory efficiency and exercise tolerance in pulmonary hypertension. Eur J Heart Fail. 2007;9(9):917–921. doi:10.1016/j.ejheart.2007.06.013.
   PubMed Web of Science ®Google Scholar
• Lewis GD, Shah R, Shahzad K, et al. Sildenafil improves exercise capacity and quality of life in patients with systolic heart failure and secondary pulmonary hypertension. Circulation. 2007;116(14):1555–1562. doi:10.1161/CIRCULATIONAHA.107.716373.
   PubMed Web of Science ®Google Scholar
• Desai SA, Channick RN. Exercise in patients with pulmonary arterial hypertension. J Cardiopulm Rehabil Prev. 2008;28(1):12–16. doi:10.1097/01.HCR.0000311502.57022.73.
   PubMed Web of Science ®Google Scholar
• Buys R, Avila A, Cornelissen VA. Exercise training improves physical fitness in patients with pulmonary arterial hypertension: a systematic review and meta-analysis of controlled trials. BMC Pulm Med. 2015;15:40. doi:10.1186/s12890-015-0031-1.
   PubMed Web of Science ®Google Scholar