Ventilatory threshold during exercise in patients with mild to moderate chronic heart failure: determination, relation with lactate threshold and reproducibility

doi:10.1016/0167-5273(91)90010-M

International Journal of Cardiology

Volume 30, Issue 3, March 1991, Pages 321-327

https://doi.org/10.1016/0167-5273(91)90010-M Get rights and content

Abstract

Detection of the ventilatory threshold during exercise has been proposed in order to assess exercise tolerance in patients with chronic heart failure. The relation between the different methods of detecting the ventilatory threshold and the lactate threshold, however, and their reproducibility, have not really been assessed. Forty-three patients with chronic heart failure underwent an exercise test with respiratory gas analysis. A lactate threshold could be determined in 36 patients and a ventilatory threshold in 27 to 38 patients, depending on the method of determination of the ventilatory threshold. The greatest number of determinations (38) and the best correlation coefficient with the lactate threshold (r = 0.87 and 0.88, respectively) were obtained with the method of the ventilatory equivalent for oxygen and by averaging the different methods of determination. Reproducibility of the ventilatory threshold was only moderately good (r = 0.83) and less satisfactory than that of the peak oxygen uptake (r = 0.97). We conclude that unless the way of detecting the ventilatory threshold is improved in patients with chronic heart failure, the peak oxygen uptake will remain more reproducible.

References (31)

JI Matthews et al.
Microprocessor exercise physiology systems vs a nonautomated system. A comparison of data output
Chest
(1987)
CA Simonton et al.
The ventilatory threshold: quantitative analysis of reproducibility and relation to arterial lactate concentration in normal subjects and in patients with chronic congestive heart failure
Am J Cardiol
(1988)
BM Massie et al.
³¹P nuclear magnetic resonance evidence of abnormal skeletal muscle metabolism in patients with congestive heart failure
Am J Cardiol
(1987)
JR Wilson et al.
Use of maximal bicycle exercise testing with respiratory gas analysis to assess exercise performance in patients with congestive heart failure secondary to coronary artery disease or to idipathic dilated cardiomyopathy
Am J Cardiol
(1986)
JE Eldridge et al.
Computerized detection of the lactate threshold in coronary artery disease
Am J Cardiol
(1986)
KT Weber et al.
Oxygen utilisation and ventilation during exercise in patients with chronic cardiac failure
Circulation
(1982)
K Wasserman et al.
Exercise physiology in health and disease
Am Rev Resp Dis
(1975)
DP Lipkin et al.
Respiratory gas exchange in the assessment of patients with impaired ventricular function
Br Heart J
(1985)
K Wasserman et al.
Anaerobic threshold and respiratory gas exchange during exercise
J Appl Physiol
(1973)
T Reybrouck et al.
Validation and determination of the “anaerobic threshold” (Letters to the Editor)
J Appl Physiol
(1983)

GA Brooks

“Anaerobic threshold”: review of the concept and direction for future research

Med Sci Sports Exercise

(1985)

JA Davis

Anaerobic threshold: review of the concept and direction for future research

Med Sci Sports Exercise

(1985)

HJ Green et al.

Anaerobic threshold, blood lactate, and muscle metabolites in progressive exercise

J Appl Physiol

(1983)

EF Hughes et al.

Effect of glycogen depletion and pedalling speed on “anaerobic threshold”

J Appl Physiol

(1982)

J Hagberg et al.

Exercise hyperventilation in patients with Mc Ardle's disease

J Appl Physiol

(1982)

Cited by (36)

Prognostic usefulness of the functional aerobic reserve in patients with heart failure
2010, American Heart Journal
Citation Excerpt :
However, in both of these studies, the researchers were not able to identify VT in a significant proportion of patients (8%7 and 23%21), and these patients were excluded from many of the analyses. It has been reported that the VT is not detectable in up to 30% of patients with HF tested.8 Our data resulted in only 13% of the overall group without a detectable VT and are within the range previously reported.7,8,19-21
Peak oxygen consumption derived from cardiopulmonary exercise (CPX) testing provides important prognostic information in patients with heart failure (HF). The oxygen consumption at the ventilatory threshold (VT) has also been shown to be prognostic. However, the VT cannot always be detected in patients with HF. Other variables such as the difference between peak oxygen consumption and oxygen consumption at the VT (termed the functional aerobic reserve [FAR]) may also provide prognostic information. The purpose of this study was to determine the prognostic value of an undetectable VT and FAR.
Eight hundred seventy-four patients with chronic, systolic HF (70% male, age 54 ± 14 years, ejection fraction 29% ± 12%) underwent CPX and were tracked for 2 years for major events (death, transplant, and left ventricular assist device implantation).
Patients were divided into 2 subgroups based on whether VT could be detected or not. There were 141 major events during the 2-year follow-up. Kaplan-Meier analysis for the 2 VT subgroups demonstrated worse prognoses for patients with a nondetectable VT versus those with a detectable VT (P < .001). Based on receiver operating characteristic curve analysis (FAR = 0 mlO₂ kg⁻¹ min⁻¹ for patients with undetectable VT), the optimal cut-point for FAR was ≤/>3 mlO₂ kg⁻¹ min⁻¹ (sensitivity/specificity 69%/60%). Cox regression analysis identified the FAR as a significant univariate predictor of risk and was retained in multivariate analysis.
In conclusion, these data reveal that an undetectable VT and the FAR during CPX testing can provide useful prognostic information in patients with HF.
Prospective evaluation of the oxygen uptake efficiency slope as a submaximal predictor of peak oxygen uptake in aged patients with ischemic heart disease
2006, American Heart Journal
The purpose of this study was to evaluate the oxygen uptake efficiency slope (OUES) as a predictor of peak oxygen consumption (Vo₂) in aged patients with coronary artery disease (CAD) and to compare its predictive value to that of ventilatory anaerobic threshold (VAT).
A total of 160 aged (>60 years) patients with stable CAD performed a maximal cardiopulmonary exercise test. The equations were computed by using data of 85 randomly selected patients and were validated in the remaining 75 patients. Bland-Altman (BA) analysis was used to assess the agreement between measured and predicted peak Vo₂.
In the first 85 patients, peak Vo₂ correlated best with VAT and OUES per kilogram (P < .001). The linear regression to predict peak Vo₂ for OUES per kilogram was peak Vo₂ = 4.591 + 0.64 × OUES/kg (SEE = 2.61 mL kg⁻¹ min⁻¹). The BA 95% limits of agreement were −29% and +30% of the predicted value. For VAT, the linear regression to predict peak Vo₂ was peak Vo₂ = 2.995 + 1.251 × VAT (SEE = 2.26 mL kg⁻¹ min⁻¹). The BA 95% limits of agreement were −23% and +33% of the predicted value. Cross-tabulation analysis in 3 subgroups with different exercise capacities showed significant relationship between predicted and measured peak Vo₂ (all P < .001). OUES per kilogram showed the best measure of agreement with measured peak Vo₂, resulting in high sensitivity and specificity scores.
OUES is not able to acceptably predict peak Vo₂ in aged patients with CAD but is at least as performant as VAT in categorizing patients into subgroups with different exercise capacities. Therefore, the objectively measurable OUES is the preferred submaximal predictor of functional capacity in the assessment of aged patients with CAD.
Early exercise training after mitral valve repair: A multicentric prospective french study
2005, Chest
Surgical mitral valve (MV) repair is now the best technique to correct mitral regurgitation (MR). However, clinical studies have shown that without exercise training (ET), there is no significant postoperative exercise tolerance improvement. Moreover, healing duration of the MV wound is not well known; thus, the feasibility of an early ET program (ETP) may be discussed.
To evaluate safety and feasibility of an early ETP after MV repair.
All patients hospitalized in 13 postoperative centers after MV repair from September 2002 to June 2003 were included in this prospective study. They underwent an ETP during 3 weeks on average. Transthoracic echocardiography and a cardiopulmonary exercise test were performed before and after the ETP.
Two hundred fifty-one consecutive patients (male gender, 70%; mean age, 59 ± 14 years [± SD]) were included 16 ± 10 days after MV repair. There was no MR occurrence or worsening after the ETP. Left ventricular ejection fraction slightly increased (53 ± 10% vs 55 ± 9%, p = 0.004). Peak oxygen consumption and anaerobic threshold increased from 16.3 ± 4.5 to 20.0 ± 6.0 mL/kg/min (22% increase) and from 12.2 ± 3.8 to 14.2 ± 4.3 mL/kg/min (16% increase) respectively, (p < 0.0001).
ET after MV repair does not deteriorate the outcome of recent surgery and seems efficient.
Oxygen uptake efficiency slope, a new submaximal parameter in evaluating exercise capacity in chronic heart failure patients
2005, American Heart Journal
Citation Excerpt :
As demonstrated in our and previous studies,17 this index significantly correlates with peakVO2 and is able to identify a subset of patients at high risk for early death from congestive heart failure. However, there are various methods to calculate this index, making it subject to high interobserver and intraobserver variability and lower reproducibility.18–22 Baba et al11 introduced OUES, a novel index derived from the logarithmic relation between oxygen uptake and minute ventilation during incremental exercise.
The oxygen uptake efficiency slope (OUES) is a new submaximal parameter which objectively predicts the maximal exercise capacity in children and healthy subjects. However, the usefulness of OUES in adult patients with and without advanced heart failure remains undetermined. The present study investigates the stability and the usefulness of OUES in adult cardiac patients with and without heart failure.
Forty-five patients with advanced heart failure (group A) and 35 patients with ischemic heart disease but normal left ventricular ejection fraction (group B) performed a maximal exercise test. PeakVO₂ and percentage of predicted peakVO₂ were markers of maximal exercise capacity, whereas OUES, ventilatory anaerobic threshold (VAT), and slope VE/VCO₂ were calculated as parameters of submaximal exercise.
Group A patients had lower peakVO₂ (P < .001), lower percentage of predicted peakVO₂ (P = .001), lower VAT (P < .05), steeper slope VE/VCO₂ (P < .001), and lower OUES (P < .02). Within group A, significant differences were found for VAT, slope VE/VCO₂, and OUES (all P < .01) between patients with peakVO₂ above and below 14 mL O₂/kg/min. Of all the submaximal parameters, VAT correlated best with peakVO₂ (r =.814, P < .01) followed by OUES/kg (r = .781, P < .01), and slope VE/VCO₂ (r = −.492, P < .001). However, VAT could not be determined in 18 (23%) patients.
OUES remains stable over the entire exercise duration and is significantly correlated with peakVO₂ in adult cardiac patients with and without impaired LVEF. Therefore, OUES could be helpful to assess exercise performance in advanced heart failure patients unable to perform a maximal exercise test. Further studies are needed to confirm our hypothesis.
Oxygen uptake should be measured and not estimated in patients with heart failure
2002, International Journal of Cardiology
Oxygen uptake efficiency slope: An index of exercise performance and cardiopulmonary reserve requiring only submaximal exercise
2000, Journal of the American College of Cardiology
OBJECTIVES
We sought to evaluate, in adults, the efficacy of the Oxygen Uptake Efficiency Slope (OUES), an index of cardiopulmonary functional reserve that can be based upon a submaximal exercise effort.
BACKGROUND
Maximal oxygen uptake (O_{2 max}), the most reliable measure of exercise capacity, is seldom attained in standard exercise testing. The OUES, which relates oxygen uptake to total ventilation during exercise, was proposed by Baba and coworkers (7) in a study of pediatric cardiac patients. They felt this submaximal index of cardiopulmonary reserve might be more practical than O_{2 max} and more appropriate than the commonly used peak oxygen consumption (O_{2 peak}).
METHODS
Treadmill exercise tests with simultaneous respiratory gas measurement were performed in 998 older subjects free of clinically recognized cardiovascular disease and 12 male patients with congestive heart failure. During incremental exercise, oxygen uptake was plotted against the logarithm of total ventilation, and the OUES was determined.
RESULTS
The OUES, when calculated only from the first 75% of the exercise test, differed by 1.9% from the OUES calculated from 100% of exercise time in subjects with a peak respiratory exchange rate ≥1.10. On serial tests the OUES was less variable than exercise duration or O_{2 peak}. It correlated strongly with O_{2 max}, with forced expiratory volume in 1 s and negatively with a history of current smoking. The OUES declined linearly with age in both women and men. A small sample of patients with congestive heart failure had OUES values much lower than those of older subjects without cardiovascular disease.
CONCLUSIONS
The OUES is an objective, reproducible measure of cardiopulmonary reserve that does not require a maximal exercise effort. It integrates cardiovascular, musculoskeletal and respiratory function into a single index that is largely influenced by pulmonary dead space ventilation and exercise-induced lactic acidosis.

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Original studyVentilatory threshold during exercise in patients with mild to moderate chronic heart failure: determination, relation with lactate threshold and reproducibility

Abstract

Chest

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Oxygen utilisation and ventilation during exercise in patients with chronic cardiac failure

Circulation

Exercise physiology in health and disease

Am Rev Resp Dis

Respiratory gas exchange in the assessment of patients with impaired ventricular function

Br Heart J

Anaerobic threshold and respiratory gas exchange during exercise

J Appl Physiol

Validation and determination of the “anaerobic threshold” (Letters to the Editor)

J Appl Physiol

“Anaerobic threshold”: review of the concept and direction for future research

Med Sci Sports Exercise

Anaerobic threshold: review of the concept and direction for future research

Med Sci Sports Exercise

Anaerobic threshold, blood lactate, and muscle metabolites in progressive exercise

J Appl Physiol

Effect of glycogen depletion and pedalling speed on “anaerobic threshold”

J Appl Physiol

Exercise hyperventilation in patients with Mc Ardle's disease

J Appl Physiol

Original study
Ventilatory threshold during exercise in patients with mild to moderate chronic heart failure: determination, relation with lactate threshold and reproducibility