Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, accounting for over 9 million deaths annually. The prevalence of CAD continues to rise, driven by ageing and the increasing prevalence of risk factors such as hypertension, diabetes, and obesity. Current clinical guidelines emphasize the importance of functional tests in the diagnostic pathway, particularly for assessing the presence and severity of ischemia. While recommended tests are valuable, they may not fully capture the complex physiological responses to exercise or provide the necessary detail to tailor personalized treatment plans. Cardiopulmonary exercise testing (CPET) offers a comprehensive assessment of the cardiovascular, pulmonary, and muscular systems under stress, potentially addressing these gaps and providing a more precise understanding of CAD, particularly in settings where traditional diagnostics may be insufficient. By enabling more personalized and precise treatment strategies, CPET could play a central role in the future of CAD management. This narrative review examines the current evidence supporting the use of CPET in CAD diagnosis and management and explores the potential for integrating CPET into existing clinical guidelines, considering its diagnostic and prognostic capabilities, cost-effectiveness, and the challenges associated with its adoption.

An 𝗲𝘅𝗰𝗶𝘁𝗶𝗻𝗴 𝗹𝗮𝗻𝗱𝗺𝗮𝗿𝗸 𝘀𝘁𝘂𝗱𝘆 just published in the highly prestigious journal 𝗡𝗮𝘁𝘂𝗿𝗲 demonstrates for the  first time a direct link between microvascular heart disease and cardiac dysfunction detected by cardiopulmonary exercise testing (𝗖𝗣𝗘𝗧). This has enormous implications for heart disease prevention as well as women's heart disease. CPET is the only modality that offers a safe, non-invasive and effective way to detect subclinical heart disease in patients without “blocked arteries”. Women with symptoms typically have normal routine testing in cardiology offices and can now get a definitive diagnosis and treatment plan. Asymptomatic individuals can use the information to develop customized exercise prescriptions with our without medical therapy. Everyone can closely follow their progress and make adjustments accordingly to optimize their long-term health.

Cardiopulmonary exercise testing (CPET) is the gold standard for directly assessing cardiorespiratory fitness (CRF) and has a relatively new and evolving role in evaluating atherosclerotic heart disease, particularly in detecting cardiac dysfunction caused by ischemic heart disease. The purpose of this review is to assess the current literature on the link between cardiovascular (CV) risk factors, cardiac dysfunction and CRF assessed by CPET.

Although selected CPET parameters relate to severity of angina symptoms and quality of life, only an oxygen-pulse plateau detects the severity of myocardial ischaemia and predicts the placebo-controlled efficacy of PCI in patients with single-vessel CAD.

Past studies have documented the ability of cardiopulmonary exercise testing to detect cardiac dysfunction in symptomatic patients with coronary artery disease. Firefighters are at high risk for work-related cardiac events. This observational study investigated the association of subclinical cardiac dysfunction detected by cardiopulmonary exercise testing with modifiable cardiometabolic risk factors in asymptomatic firefighters.

There is a well-established inverse relationship between cardiorespiratory fitness (CRF) and mortality. However, this relationship has almost exclusively been studied using estimated CRF.

Few studies have investigated long-term changes in cardiorespiratory fitness (CRF), defined by indirect measures of CRF, and all-cause mortality. We aimed to investigate whether long-term change in CRF, as assessed by the gold standard method of respiratory gas exchange during exercise, is associated with all-cause mortality. A population-based sample of 579 men aged 42 to 60 years with no missing data at baseline examination (V1) and at reexamination at 11 years (V2) were included. Maximal oxygen uptake (VO2max) was measured at both visits using respiratory gas exchange during maximal exercise testing, and the difference (ΔVO2max) was calculated as VO2max (V2) − VO2max (V1). Deaths were ascertained annually using national death certificates during 15 years of follow-up after V2.

The change in CRF over time was inversely related to mortality outcomes, and mortality was better predicted by CRF measured at subsequent test than CPX1 CRF. These findings emphasize the importance of adopting lifestyle behaviors that promote CRF, as well as support the need for routine assessment of CRF in clinical practice to better assess risk.

The majority of previous research on the association between cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) is based on indirect assessment of CRF in clinically referred predominantly male populations. Therefore, our aim was to examine the associations between VO2peak measured by the gold-standard method of cardiopulmonary exercise testing and fatal and non-fatal coronary heart disease (CHD) in a healthy and fit population.

Preliminary evidence suggests that peak exercise oxygen pulse – peak oxygen uptake/heart rate-, a variable obtained during maximal cardiopulmonary exercise testing and a surrogate of stroke volume, is a predictor of mortality. We aimed to assess the associations of peak exercise oxygen pulse with sudden cardiac death, fatal coronary heart disease and cardiovascular disease and all-cause mortality.

In total, 753 athletes were included in the study during the period between October 2014 and March 2017. In 651 (86.5%) of these athletes, normal ET results were observed, whereas 102 athletes (13.5%) showed abnormal ET results. Twentytwo of these 102 athletes were excluded from analysis, as 10 were female athletes, 8 athletes did not undergo CPET, and 4 athletes were referred to other hospitals for further diagnostic evaluation. The remaining 79 athletes with abnormal ET results were diagnostically evaluated by MPS (n = 51) or CCTA (n = 28). Five athletes showed reversible ischemic perfusion defects on MPS with a mean of 1.2 T 0.2 segments.

None of these athletes showed obstructive CAD during CAG.

The purpose of this study was to examine the individual and combined associations of cardiorespiratory fitness (fitness) and body mass index (BMI) with the risk of sudden cardiac death (SCD) in middle-aged men. This prospective study was based on a Population sample of 2,357 men aged 42-60 years, who were followed up in the Kuopio Ischemic Heart Disease cohort study. Fitness was directly measured by peak oxygen uptake (VO2peak) during progressive exercise testing to volitional fatigue. Participants were divided into 4 groups (fit-normal weight, unfit-normal weight, fit-overweight/obese, and unfit-overweight/obese) based on the median values of fitness and BMI. A total of 253 (10.7%) SCDs occurred during an average follow-up of 22 years.

A robust literature demonstrates that coronary artery calcification (CAC) and cardiorespiratory fitness (CRF) are independent predictors of cardiovascular disease (CVD) events. Much less is known about the joint associations of CRF and CAC with CVD risk. In the setting of high CAC, high versus low CRF has been associated with decreased CVD events. The goal of this study was to assess the effect of continuous levels of CRF on CVD risk in the setting of increasing CAC burden.

In this pilot study, mpagliflozin was associated with 1-month improvement in exercise capacity in T2DM patients with symptomatic HF. This beneficial effect was also found for other surrogates of severity.

Prospective study examining the relationship between cardiorespiratory fitness level and incidence of medical treatments during a 1-yr period before each of two examinations. A subset was also evaluated to assess whether improvement in fitness affected incidence of treatments.

Low CRF is associated with higher health care costs. Efforts to improve CRF may not only

improve health but also result in lower health care costs.

CPET can enhance outpatient evaluation and management of CAD. Diagnostically, it can help to identify physiologically significant obstructive-CAD and NO-CAD in patients with normal routine cardiac testing. CPET may be of particular value in symptomatic women with NO-CAD. rognostically, precise quantification of improvements in exercise capacity may help to improve long-term lifestyle and medication adherence for this chronic condition.

PMI is a common complication after noncardiac surgery

and, despite early detection during routine clinical screening, is associated

with substantial short- and long-term mortality. Mortality seems comparable

in patients with PMI not fulfilling any other of the additional criteria required

for spontaneous acute myocardial infarction versus those patients who do.

In cardiopulmonary disorders, exercise intolerance is a major clinical feature from early stages, and becomes a source of symptoms and the reason for referral to a physician. Exercise limitation is one of the most disabling problems experienced by patients with heart failure (HF) (1). Its quantification may be approximated by several methods, but a thorough analysis of the organ systems and pathways involved in the impaired physiological response is obtained by exercise gas exchange analysis with cardiopulmonary exercise testing (CPET). This technique enables the clinician  . . 

Journal of The American College of Cardiology VOL.70, NO. 13, 2017 

Purpose of Review Improving patient outcomes from major urological surgery requires not only advancement in surgical technique and technology, but also the practice of patient-centered, multidisciplinary, and integrated medical care of these patients from the moment of contemplation of surgery until full recovery. This review examines the evidence for recent developments in preoperative assessment and optimization that is of relevance to major urological surgery . .

Curr Urol Rep (2017) 18:54  

"His surgery was urgent and there wasn't time to see him in clinic. In the end, I didn't meet him until the morning of surgery, when I realised that he had lots of other medical problems. Cancelling the case just wasn't an option, so we went ahead and did our best. We got him through surgery without too many problems, but a few days later he developed pneumonia and ended up on intensive care. I can't help but feel he would have coped better if we had been able to also offer more basic medical care. "

The Royal College of Anaesthetists - 2017 

Despite intensive risk factor management, cardiovascular disease (CVD) remains a major cause of morbidity and mortality in diabetes raising the question of whether diabetes prevention interventions may be important in reducing CVD risk in diabetes x We found that men, but not women with prediabetes treated with metformin for an average duration of 14 years in the Diabetes Prevention Program Outcome Study had lower coronary calcium scores than their placebo group counterparts. x No difference in coronary calcium scores was observed in the group receiving a lifestyle intervention as compared to the placebo group.  

Long Term Effect of Metformin on CAC_Circulation_2017

The Nuclear Cardiology Laboratory at Mayo Clinic in Rochester, Minnesota, began offering combined CPET/SPECT MPI in January of 2011 as a standard clinical study. From January 2011 to December 2015, 435 consecutive patients underwent combined CPETMPI. Inclusion criteria were patients who were clinically referred for CPET/MPI testing at a single institution and had given consent for their records to be included in research studies.  

Journal of Nuclear Cardiology - Published Online: 15 May 2017 

The patient’s condition started deteriorating immediately and he became more tachypnoeic and dyspnoeic, with an oxygen saturation of 88%. A chest drain was inserted on the left side, but the patient became increasingly hypoxic, had seizures and progressed to a Pulseless Electrical Activity cardiac arrest. Cardiopulmonary resuscitation was started and the trachea . .

Journal of the Association of Anaesthetists - Case Study

Mounting evidence has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease, all-cause mortality, and mortality rates attributable to various cancers. A growing body of epidemiological and clinical evidence demonstrates not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension,high cholesterol, and type 2 diabetes mellitus, but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes.