1. ALFIO STUTO SEAL WHEALTH TEAM SIRACUSA - ITALY
CPET VS ET TO ESTIMATE THE ACTUAL CHANGES OF FUNCTIONAL CAPACITY AFTER CARDIAC REHABILITATION
ALFIO STUTO
SEAL WHEALTH TEAM SIRACUSA - ITALY

2. Assessment of functional capacity
Reflects ability to perform activity of daily living that require sustained aerobic metabolism
Directly measured VO2 is more precise and is the preferred measure clinically.
When estimated from the work rate achieved rather than directly measured VO2 is frequently expressed in metabolic equivalents (METs).
1 MET = 3.5 mlO2/Kg/min
Reflects ability to perform activity of daily living that require sustained aerobic metabolism
When estimated from the work rate achieved rather than directly measured VO2 is frequently expressed in metabolic equivalents (METs). In this instance, functional capacity is commonly expressed as a multiple of the resting metabolic rate
Directly measured VO2 is more precise and is the preferred measure clinically.

3. INTRODUCTION
The ACC/AHA 2002 guideline update for exercise testing discourage the use of the cardiopulmonary exercise testing (CPET) as a routine part of the cardiac rehabilitation.
Aggiungere riferimento bibliografico ACC/AHA 2002 su guideline exercise testing and CR
Gibbons RJ, Balady GJ, Bricker JT, et al. Circulation 106:1883, 2002

4. PURPOSE
1) to assess the inaccuracy of the standard exercise testing (ET) in the estimation of the functional capacity (VO2max) from the work rate achieved on a treadmill or cycle ergo meter and
2) to sustain the importance of the CPET as a routine part of the CR.

5. CARDIOPULMONARY EXERCISE TESTING (CPET)
PROVIDES A GLOBAL ASSESSMENT OF THE INTEGRATIVE EXERCISE RESPONSE INVOLVING
….involving all the transport chain of The O2 & CO2 from the air to the cell and back-- throught (a) several primary variables and derived (calculated variables) measures
Wasserman K. Priciples Exercise Testing and Interpretation. Fourth Edition 2005 by Lippincott Williams & Wilkins

6. CARDIOPULMONARY EXERCISE TESTING: MISURES
Devices and analyzer used to measures variables during exercise on a cycle ergometer. Devices and analyzer individually or collectively may measure a single or several primary variables. The variables in the right-hand column are usually calculated from two or more primary variables
Wasserman K. Priciples Exercise Testing and Interpretation. Fourth Edition 2005 by Lippincott Williams & Wilkins

7. MATERIAL & METHODS
. from April 2007 to December 2010, three hundred thirty coronary patients, referred to physician-supervised outpatient CR were enrolled for this study.
. All patients underwent a CPET at the moment of the enrolment to individualize the exercise prescription and at the end of 12 weeks CR program.
from April 2007 to December 2010, three hundred thirty coronary patients, mean age / years, referred to physician-supervised outpatient CR were consecutively enrolled for this study. …….
……the PWL and the peak VO2 measured during the initial and final CPET were collected and comparatively analyzed..> and on the basis of the results the pts were subdivided in two groups….>next slides

8. CARDIOPULMONARY EXERCISE TESTING: MISURES
All patients underwent a CPET at the moment of the enrolment to individualize the exercise prescription and at the end of 12 weeks CR program.
The peak workloads (PWL) and the peak oxygen uptake (VO2peak) achieved during the initial and final CPET, were collected and comparatively analyzed..> and on the basis of the results the pts were subdivided in two groups….>next slide
Devices and analyzer used to measures variables during exercise on a cycle ergometer. Devices and analyzer individually or collectively may measure a single or several primary variables. The variables in the right-hand column are usually calculated from two or more primary variables
Wasserman K. Priciples Exercise Testing and Interpretation. Fourth Edition 2005 by Lippincott Williams & Wilkins

9. peak VO2 before-after CR
RESULTS (1)
Group
peak VO2 before-after CR
P value
PWL
before-after CR A
230
18.5+/ vs
23.2+/- 6.09
0.000
103.3+/ vs
126.1+/-38.85 B
100
16.7+/-5.7 vs
21.13+/- 6.09
111.9+/-28.58
107+/
0.202
On the basis of the data the pts were subdivided in two groups:
A: 230 (31.03%) pts, aged / years, in to whom PWL did not increase and VO2peak were increased, and
B: 100 (68.97%) pts, aged / years, in to whom the PWL as well as the VO2peak were both increased.
Now we come to consider the functional capacity expressed as METs estimated from PWLs achieved vs METs estimated from the directly measured peak VO2next slide
Similarly the alternative approach expressing the functional capacity (F.C.) as METs estimated from PWL vs METs from the directly measured peak VO2confirm the “disparity” (??) between the two groups (you can see a mirror image of the first table): “in eithers” the F.C. expressed as METs estimated from PWL were actually unchanged in group A pts and significantly improved in group B pts after CR; whereas the FC expressed as METs estimated from the directly measured peak VO2 show a significant improvement in both groups (A and B) of pts after CR. and zooming on the group A pts (next slide)

10. RESULTS (2) Group METs from peak VO2 P value METs from PWL A 230
before-after CR
P value
METs from PWL A
230
5.15+/-1.7 vs
6.63+/- 1.72
0.000
5.16+/-1.4
6.05+/-1.5 B
100
4.7+/-1.6
6.03+/-1.7
5.5+/-1.4
5.37+/-1.32
0.396
On the basis of the data the pts were subdivided in two groups:
A: 230 (31.03%) pts, aged / years, in to whom PWL did not increase and VO2peak were increased, and
B: 100 (68.97%) pts, aged / years, in to whom the PWL as well as the VO2peak were both increased.
Now we come to consider the functional capacity expressed as METs estimated from PWLs achieved vs METs estimated from the directly measured peak VO2next slide
Similarly the alternative approach expressing the functional capacity (F.C.) as METs estimated from PWL vs METs from the directly measured peak VO2confirm the “disparity” (??) between the two groups (you can see a mirror image of the first table): “in eithers” the F.C. expressed as METs estimated from PWL were actually unchanged in group A pts and significantly improved in group B pts after CR; whereas the FC expressed as METs estimated from the directly measured peak VO2 show a significant improvement in both groups (A and B) of pts after CR. and zooming on the group A pts (next slide)

11. Group B: METs from VO2 vs METs from Watt
Before CR
After CR
METs
4.9
6.3
5.5
5.4
VO2
WATT
Without the CPET and the directly measured peak VO2, looking only to the WR sustained the F.C. expressed as METs estimated from the PWL achived seem actually unchanged after CRand based only on these results we could misled in prognostic evaluation and the ex. Prescription based on the energy requirements of activities….
Prognostic Judgment
Exercise Prescription (Energy Requirements of Activities)

12. CONCLUSIONS (I)
after cardiac rehabilitation the changes in functional capacity were consistently witnessed by both tests, respectively ET (PWL) and CPET (PWL+VO2peak), in about sixty nine percent of the pts.
However in the residual thirty one per cent of the patients, without the CPET, we could miss to detect any evidence of the actual changes in functional capacity.

13. CONCLUSIONS (II)
In these pts the CPET will be irreplaceable to avoid misleading endings on the exercise prescription for the everyday life after completion of the CR program.

14. Tanks for Your attention
Ognina Siracusa
Ognina Siracusa

15. EQUATIONS TO ESTIMATE VO2MAX FOR CYCLE ERGOMETRY
MALES:
VO2max (ml/Kg/min)* = (power in W) (body mass in Kg) – (age in y)
SEE = 212 ml/min
. FEMALES:
VO2max (ml/Kg/min)* = 9.39 (power in W) (body mass in Kg) – 5.88 (age in y)
SEE = 147 ml/min
*Divide for Kg to obtain the value in ml/Kg/min
ACSM’S guideline for exercise testing and prescription. 6° edition 2000 by LWW, p. 306

16. RESULTS Group peak VO2 before-after CR P value PWL before-after CR
18.5+/-5.9 vs 23.2+/-
6.09
0.000
103.3+/ /-
126.1+/-38.85
B 100
16.7+/-5.7 vs /-
111.9+/ vs 107+/-
25.46
0.202
METs from peak VO2
before-after CR
METs from PWL
5.15+/-1.7 vs 6.63+/-
1.72
5.16+/-1.4 vs 6.05+/-1.5
4.7+/-1.6 vs 6.03+/-1.7
5.5+/-1.4 vs 5.37+/-1.32
0.396
On the basis of the data the pts were subdivided in two groups:
A: 230 (31.03%) pts, aged / years, in to whom PWL did not increase and VO2peak were increased, and
B: 100 (68.97%) pts, aged / years, in to whom the PWL as well as the VO2peak were both increased.
Now we come to consider the functional capacity expressed as METs estimated from PWLs achieved vs METs estimated from the directly measured peak VO2next slide
Similarly the alternative approach expressing the functional capacity (F.C.) as METs estimated from PWL vs METs from the directly measured peak VO2confirm the “disparity” (??) between the two groups (you can see a mirror image of the first table): “in eithers” the F.C. expressed as METs estimated from PWL were actually unchanged in group A pts and significantly improved in group B pts after CR; whereas the FC expressed as METs estimated from the directly measured peak VO2 show a significant improvement in both groups (A and B) of pts after CR. and zooming on the group A pts (next slide)