Cardiopulmonary exercise test (CPEX)- Clinical Populations
Integrative exercise responses involving the pulmonary, cardiovascular, hematopoietic,
neuropsychological, and skeletal muscle systems, which are not adequately reflected through
the measurement of individual organ system function. Relatively noninvasive, dynamic
physiologic overview permits the evaluation of both submaximal and peak exercise responses,
providing the physician with relevant information for clinical decision making.
Its use in patient management is increasing with the understanding that resting pulmonary
and cardiac function testing cannot reliably predict exercise performance, functional capacity
and overall health status correlates better with exercise tolerance than with resting
measurements.
Most patients with cardiac or respiratory problems have symptoms which are worse on
exertion, the use of CPET in patient management is increasing with the understanding that
resting pulmonary and cardiac function testing cannot reliably predict exercise performance
and functional capacity, furthermore, overall health status correlates better with exercise
tolerance rather than with resting measurements.
It makes much more sense to make some measurements when they are exercising. A CPEX
also puts the cardiac and respiratory systems under stress, so that the reserve capacity of the
body can be assessed, particularly in terms of its ability to deliver oxygen to peripheral tissues
Patients with known or suspected coronary artery disease runs on a treadmill whilst their
electrocardiogram (ECG) is monitored for ST segment changes. Changes develop on ECG,
strong pointer to the presence of heart disease
Patients are often symptom limited, and may stop exercise before reaching physiologic limits
of metabolic or gas transport capacity. Evaluation of undiagnosed exercise intolerance and for
the objective determination of functional capacity and impairment.
INDICATIONS OF CPET
ACC/AHA Update of Practice Guidelines for Exercise Testing, published in 2002, listed the
indications for ordering a functional VO2 exercise test (table 3).
Contraindications for CPET (table 4).
CPET provides excellent risk stratification in primary pulmonary hypertension, caution is
advised when exercising these patients owing to the increased risk of sudden death as
pulmonary pressure increases with exercise.
CPEX is a useful tool for: Clinical populations
1. Assessing the contribution of cardiac or respiratory pathologies to incapacity
2. Quantifying the extent of the impairment
3. Preoperative evaluation
4. Planning of post-operative care.
5. Measuring the response to an intervention.
6. Finding out what is wrong with patients who are short of breath
7. Diagnosing heart and lung disease.
8. Quantifying fitness.
9. Post-surgical mortality rate can be reduced.
10. Evaluation of undiagnosed exercise intolerance
11. Objective determination of functional capacity and impairment.
12. Evaluation of patients with cardiovascular diseases
13. Evaluation of patients with respiratory diseases/symptoms
14. Exercise evaluation and prescription for pulmonary rehabilitation
15. Evaluation of impairment/disability
16. Evaluation for lung, heart, and heart–lung transplantation
Respiratory Medicine
1. Obstructive and restrictive ventilatory disorders
2. Interstitial disorders
3. Pulmonary hypertension
4. Diffusion and distribution disorders
5. Flow limitations
6. Exercise related dyspnea of unknown origin
7. Suspected limited exercise capacity due to circulatory or pulmonary vascular disorders
8. Suspected exercise-induced asthma
9. Trending for subtle respiratory disease changes
10. Pre-operative risk assessment for lung transplant patients
Intensive Care
1. Pre-operative risk assessment
2. Nutrition control (adjusting parenteral nutrition of intensive care patients)
Occupational Medicine
1. Exercise-related career proficiency tests
2. Determining the degree of disability or work limitation/inability
3. Fitness checkups (high altitude, air travel, tropical climate, diving)
Cardiology
1. Coronary heart disease
2. Cardiomyopathy
3. Heart disease, valvular heart failure
4. Congenital cardiac defects
5. Pre-operative risk assessment for heart transplant patients
6. Cardiac insufficiency
Protocols
Incremental ramp protocol to a volitional maximum (mostly patients)
Allow the patient to approach the maximum load within an acceptable time range before the
need to terminate the test due to exhaustion (not due to max exercise capacity).
Aim of a standard CPET protocol is for the individual to be exposed to a load using a bike
ergometer or a treadmill and incrementally increase workload for about 8 to 12 minutes until
they can go no further.
Constant work rate protocols
Gaining popularity because of clinical applicability (monitoring response(s) to therapy)
Initial workload usually 20–25 W and increased by 15–25 W every 2 minutes until maximal
exertion is reached. Workload can be computer controlled for electronically braked bicycle
ergometers, ramp protocol (eg, 10 W/min) is often used.
Modified Naughton protocol is recommended for treadmill exercise testing in patients with
heart failure. Protocol is designed to increase the workload by approximately 1 MET (3.5 ml O2/
kg/min) for each 2-minute stage
Patients with heart disease require continuous ECG monitoring and frequent blood pressure
measurements during exercise testing. Since verbal communication is usually not possible
with the mouthpiece apparatus, hand signals are usually used by the patient during exercise.
Patients with mitral stenosis, for instance, often stop exercising before reaching VAT, while on
the other hand patients with chronic obstructive pulmonary disease commonly pass the VAT.
CPET AND HEART FAILURE (HF)
VO2 plateau
Clear plateau may not be achieved before symptom limitation of exercise. Peak VO2 (PVO2) is
often used as an estimate of VO2max.
Factors limiting VO2max in patients with congestive heart failure (CHF),
1. Marked reduction in SV response to exercise
2. Smaller reductions in MHR
3. Maximal arterial minus mixed venous oxygen content (CaO2max 2 CvO2max).
4. Diseases of the lungs
5. Skeletal muscles, hematological system often have a profound effect on VO2max by
affecting arterial or mixed venous oxygen content.
Heart rate (HR)
1. HR is expected to rise with the increasing workload
2. Patients with cardiac impairment usually show larger increase
3. Patients with poor cardiac function, oxygen transport can only be increased by
additional oxygen extraction.
Panel 1
Minute ventilation (V‘E) & workload (Watts) against time.
1. Subjects suffering from pulmonary disease it is useful to display the subject‘s
maximum ventilation obtained by means of a forced spirometry measurement (usually
calculated from 35 x FEV1) or a maximal voluntary ventilation maneuver (MVV) in order
to detect ventilation limitation.
VE/VO2
Normal subjects, initial increase in ventilation will be direct proportion to oxygen uptake
Until the subjects reaches the anaerobic threshold
AT or first VT1
Beyond this point the fuel shifts to primarily glucose, increased Co2 production
Drives ventilation higher
Increased O2 demand
Indicating that ventilation is no longer simply following CO₂ production but is compensating
for metabolic acidosis (due to lactate buildup).
Point where ventilation starts rising faster than VO₂
RCP is the intersection or noticeable change in the slope where VE begins to rise
disproportionately relative to both VO₂ and VCO₂.
Respiratory Compensation Point (RCP): This occurs after the anaerobic threshold, usually
when RER exceeds 1.1–1.2, indicating hyperventilation to expel excess CO₂ due to metabolic
acidosis.
Respiratory Exchange Ratio (RER) reaches 1.0, it typically corresponds to Anaerobic
Threshold (AT) or Ventilatory Threshold 1 (VT1). Both terms refer to a similar physiological
event, where there is a noticeable shift in metabolism and ventilation.
VT1 (or AT) occurs at a point where RER approaches or reaches 1.0.
At this stage, the body shifts from predominantly using fat for energy to relying more on
carbohydrates.
The increase in ventilation (disproportionate to oxygen consumption) helps expel the extra
CO₂ produced during the buffering of lactate, marking this as the first ventilatory threshold
(VT1).
As exercise intensity increases beyond VT1, you reach Ventilatory Threshold 2 (VT2), or the
Respiratory Compensation Point (RCP), where ventilation increases even more drastically
to expel excess CO₂ due to significant lactic acid buildup.
Given that the VO2 max is 60.0 ml/kg/min, we can estimate the ventilatory thresholds:
1. VT1:
○ Range: 60% to 75% of VO2 max
○ 60% of VO2 max = 0.60 × 60.0 = 36.0 ml/kg/min
○ 75% of VO2 max = 0.75 × 60.0 = 45.0 ml/kg/min
○ This athlete's VT1 is likely to be between 36.0 ml/kg/min and 45.0 ml/kg/min,
meaning they can sustain a moderate level of intensity for extended periods up
to this point.
2. VT2:
○ Range: 80% to 90% of VO2 max
○ 80% of VO2 max = 0.80 × 60.0 = 48.0 ml/kg/min
○ 90% of VO2 max = 0.90 × 60.0 = 54.0 ml/kg/min
○ This athlete's VT2 is likely to be between 48.0 ml/kg/min and 54.0 ml/kg/min,
meaning they can maintain high-intensity effort close to these values for
shorter durations.
Percentage of VO2 Max Achieved:
● Since the cricketer's VO2 max is 60.0 ml/kg/min and no specific VT1/VT2 data is
provided, if we estimate based on general guidelines:
○ He likely achieved 75%–90% of VO2 max during the exercise, given his maximal
heart rate (96.46% of predicted HR max) and the duration of the test.
Interpretation:
● VT1 Interpretation: The cricketer can perform moderate-intensity aerobic exercise,
like sustained running or long fielding sessions, efficiently up to a VO2 of 36.0–45.0
ml/kg/min. Beyond this point, lactate production begins to increase.
● VT2 Interpretation: The athlete reaches higher-intensity efforts around 48.0–54.0
ml/kg/min. This indicates his capacity to maintain high-intensity efforts for shorter
bursts, as seen in sprinting between the wickets, fast bowling, or fielding in cricket.
VT1 Identification:
● RER ~1.0: This indicates the shift from primarily aerobic to mixed aerobic/anaerobic
metabolism, where lactate production begins to rise.
● VO₂ at VT1: The first occurrence of an RER of ~1.0 occurs when VO₂ = 3961.8 mL/min,
which suggests this is the athlete's VT1.
VT2 (RCP) Identification:
● RER >1.05: This marks the Respiratory Compensation Point (RCP), where lactate
accumulates more rapidly, and the body compensates by increasing ventilation
sharply.
● VO₂ at VT2/RCP: RER exceeds 1.05 when VO₂ = 4375.8 mL/min, indicating this is the
athlete's VT2 (or RCP).
Percentage of VO2 Max at VT1 and VT2:
Given the athlete’s VO2 max = 60.0 ml/kg/min, we can calculate the percentages of VO2 max
at VT1 and VT2.
1. VT1:
○ VO₂ at VT1 = 3961.8 mL/min
○ Relative VO₂ (ml/kg/min) = 3961.8 mL/min ÷ 97.2 kg = 40.76 ml/kg/min
○ Percentage of VO₂ max at VT1: (40.76 ÷ 60.0) × 100 = 67.9% of VO₂ max
2. VT2 (RCP):
○ VO₂ at VT2 = 4375.8 mL/min
○ Relative VO₂ (ml/kg/min) = 4375.8 mL/min ÷ 97.2 kg = 45.02 ml/kg/min
○ Percentage of VO₂ max at VT2: (45.02 ÷ 60.0) × 100 = 75.03% of VO₂ max
Summary:
● VT1 occurs at approximately 67.9% of VO2 max when VO₂ = 3961.8 mL/min,
corresponding to an RER of ~1.0.
● VT2 (RCP) occurs at around 75.03% of VO2 max when VO₂ = 4375.8 mL/min,
corresponding to an RER exceeding 1.05.
This indicates that the cricketer reaches VT1 at a relatively high intensity (close to 68% of VO2
max), allowing for sustained moderate-intensity activity, while VT2 (RCP) occurs at around 75%
of VO2 max, where high-intensity efforts are reached and maintained for shorter durations.
Poor cardiovascular efficiency
Deconditioning
Delivering less O2 per heart beat
