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. 1999 Aug;75(886):453–458. doi: 10.1136/pgmj.75.886.453

The role of exercise testing in the evaluation and management of heart failure

D Wright 1, L Tan 1
PMCID: PMC1741331  PMID: 10646020

Abstract

The clinical syndrome of heart failure has been investigated so extensively that it may now almost be regarded as a metabolic disorder. Although an initial insult reduces cardiac pump efficacy, the resultant physiological response culminates in complex neurohormonal dysfunction. This has created confusion and prevented the acceptance of a universal definition of cardiac failure. With much current research concentrating on the pharmacological modification of neuro-endocrine imbalance, it is easy to lose sight of the fundamental principles behind heart failure management, namely, to improve cardiac function. In attempting to achieve this, the issues of morbidity and mortality must be addressed jointly; they are not mutually exclusive entities. Discrepant results between mortality studies and changes in exercise capacity have undermined the value of exercise testing. Because a treatment enhances longevity we should not ignore its effect on symptomatic status, and likewise we should not discard a therapy, which improves function because adverse events result in occasional premature deaths. Informed patient choice must exist.
Historically, exercise testing has been quintessential in our understanding and evaluation of heart failure. Peak oxygen consumption remains the best overall indicator of symptomatic status, exercise capacity, prognosis and hospitalisation. Unfortunately, muddling of surrogate and true end-points has confused many of these issues. Improved comprehension may be gained by applying the concept of cardiac reserve which has been described in a variety of heart conditions and used in cardiac failure patients to provide an indication of prognosis and functional capacity.


Keywords: exercise testing; heart failure

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Selected References

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  1. Adamopoulos S., Coats A. J., Brunotte F., Arnolda L., Meyer T., Thompson C. H., Dunn J. F., Stratton J., Kemp G. J., Radda G. K. Physical training improves skeletal muscle metabolism in patients with chronic heart failure. J Am Coll Cardiol. 1993 Apr;21(5):1101–1106. doi: 10.1016/0735-1097(93)90231-o. [DOI] [PubMed] [Google Scholar]
  2. Arnold S. B., Byrd R. C., Meister W., Melmon K., Cheitlin M. D., Bristow J. D., Parmley W. W., Chatterjee K. Long-term digitalis therapy improves left ventricular function in heart failure. N Engl J Med. 1980 Dec 18;303(25):1443–1448. doi: 10.1056/NEJM198012183032503. [DOI] [PubMed] [Google Scholar]
  3. Bain R. J., Tan L. B., Murray R. G., Davies M. K., Littler W. A. The correlation of cardiac power output to exercise capacity in chronic heart failure. Eur J Appl Physiol Occup Physiol. 1990;61(1-2):112–118. doi: 10.1007/BF00236703. [DOI] [PubMed] [Google Scholar]
  4. Belardinelli R., Georgiou D., Scocco V., Barstow T. J., Purcaro A. Low intensity exercise training in patients with chronic heart failure. J Am Coll Cardiol. 1995 Oct;26(4):975–982. doi: 10.1016/0735-1097(95)00267-1. [DOI] [PubMed] [Google Scholar]
  5. Benjamin I. J., Jalil J. E., Tan L. B., Cho K., Weber K. T., Clark W. A. Isoproterenol-induced myocardial fibrosis in relation to myocyte necrosis. Circ Res. 1989 Sep;65(3):657–670. doi: 10.1161/01.res.65.3.657. [DOI] [PubMed] [Google Scholar]
  6. Bittner V., Weiner D. H., Yusuf S., Rogers W. J., McIntyre K. M., Bangdiwala S. I., Kronenberg M. W., Kostis J. B., Kohn R. M., Guillotte M. Prediction of mortality and morbidity with a 6-minute walk test in patients with left ventricular dysfunction. SOLVD Investigators. JAMA. 1993 Oct 13;270(14):1702–1707. [PubMed] [Google Scholar]
  7. Bocchi E. A., Guimarães G. V., Moreira L. F., Bacal F., de Moraes A. V., Barreto A. C., Wajngarten M., Bellotti G., Stolf N., Jatene A. Peak oxygen consumption and resting left ventricular ejection fraction changes after cardiomyoplasty at 6-month follow-up. Circulation. 1995 Nov 1;92(9 Suppl):II216–II222. doi: 10.1161/01.cir.92.9.216. [DOI] [PubMed] [Google Scholar]
  8. COLLIER C. R. Determination of mixed venous CO2 tensions by rebreathing. J Appl Physiol. 1956 Jul;9(1):25–29. doi: 10.1152/jappl.1956.9.1.25. [DOI] [PubMed] [Google Scholar]
  9. Cahalin L. P., Mathier M. A., Semigran M. J., Dec G. W., DiSalvo T. G. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest. 1996 Aug;110(2):325–332. doi: 10.1378/chest.110.2.325. [DOI] [PubMed] [Google Scholar]
  10. Chomsky D. B., Lang C. C., Rayos G. H., Shyr Y., Yeoh T. K., Pierson R. N., 3rd, Davis S. F., Wilson J. R. Hemodynamic exercise testing. A valuable tool in the selection of cardiac transplantation candidates. Circulation. 1996 Dec 15;94(12):3176–3183. doi: 10.1161/01.cir.94.12.3176. [DOI] [PubMed] [Google Scholar]
  11. Chua T. P., Ponikowski P., Harrington D., Anker S. D., Webb-Peploe K., Clark A. L., Poole-Wilson P. A., Coats A. J. Clinical correlates and prognostic significance of the ventilatory response to exercise in chronic heart failure. J Am Coll Cardiol. 1997 Jun;29(7):1585–1590. doi: 10.1016/s0735-1097(97)00078-8. [DOI] [PubMed] [Google Scholar]
  12. Clark A. L., Poole-Wilson P. A., Coats A. J. Effects of motivation of the patient on indices of exercise capacity in chronic heart failure. Br Heart J. 1994 Feb;71(2):162–165. doi: 10.1136/hrt.71.2.162. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Cohen-Solal A., Aupetit J. F., Gueret P., Kolsky H., Zannad F. Can anaerobic threshold be used as an end-point for therapeutic trials in heart failure? Lessons from a multicentre randomized placebo-controlled trial. The VO2 French Study Group. Eur Heart J. 1994 Feb;15(2):236–241. doi: 10.1093/oxfordjournals.eurheartj.a060482. [DOI] [PubMed] [Google Scholar]
  14. Cohen-Solal A., Benessiano J., Himbert D., Paillole C., Gourgon R. Ventilatory threshold during exercise in patients with mild to moderate chronic heart failure: determination, relation with lactate threshold and reproducibility. Int J Cardiol. 1991 Mar;30(3):321–327. doi: 10.1016/0167-5273(91)90010-m. [DOI] [PubMed] [Google Scholar]
  15. Cohn J. N., Johnson G., Ziesche S., Cobb F., Francis G., Tristani F., Smith R., Dunkman W. B., Loeb H., Wong M. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991 Aug 1;325(5):303–310. doi: 10.1056/NEJM199108013250502. [DOI] [PubMed] [Google Scholar]
  16. Colucci W. S., Ribeiro J. P., Rocco M. B., Quigg R. J., Creager M. A., Marsh J. D., Gauthier D. F., Hartley L. H. Impaired chronotropic response to exercise in patients with congestive heart failure. Role of postsynaptic beta-adrenergic desensitization. Circulation. 1989 Aug;80(2):314–323. doi: 10.1161/01.cir.80.2.314. [DOI] [PubMed] [Google Scholar]
  17. Cooke G. A., Marshall P., al-Timman J. K., Wright D. J., Riley R., Hainsworth R., Tan L. B. Physiological cardiac reserve: development of a non-invasive method and first estimates in man. Heart. 1998 Mar;79(3):289–294. doi: 10.1136/hrt.79.3.289. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Costanzo M. R., Augustine S., Bourge R., Bristow M., O'Connell J. B., Driscoll D., Rose E. Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. Circulation. 1995 Dec 15;92(12):3593–3612. doi: 10.1161/01.cir.92.12.3593. [DOI] [PubMed] [Google Scholar]
  19. Cowley A. J., Fullwood L., Stainer K., Hampton J. R. Exercise tolerance in patients with heart failure--how should it be measured? Eur Heart J. 1991 Jan;12(1):50–54. doi: 10.1093/oxfordjournals.eurheartj.a059824. [DOI] [PubMed] [Google Scholar]
  20. DEFARES J. G. Determination of PvCO2 from the exponential CO2 rise during rebreathing. J Appl Physiol. 1958 Sep;13(2):159–164. doi: 10.1152/jappl.1958.13.2.159. [DOI] [PubMed] [Google Scholar]
  21. Depeursinge F. B., Depeursinge C. D., Boutaleb A. K., Feihl F., Perret C. H. Respiratory system impedance in patients with acute left ventricular failure: pathophysiology and clinical interest. Circulation. 1986 Mar;73(3):386–395. doi: 10.1161/01.cir.73.3.386. [DOI] [PubMed] [Google Scholar]
  22. DiBianco R., Shabetai R., Kostuk W., Moran J., Schlant R. C., Wright R. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989 Mar 16;320(11):677–683. doi: 10.1056/NEJM198903163201101. [DOI] [PubMed] [Google Scholar]
  23. Elborn J. S., Stanford C. F., Nicholls D. P. Reproducibility of cardiopulmonary parameters during exercise in patients with chronic cardiac failure. The need for a preliminary test. Eur Heart J. 1990 Jan;11(1):75–81. doi: 10.1093/oxfordjournals.eurheartj.a059596. [DOI] [PubMed] [Google Scholar]
  24. Feinstein A. R., Fisher M. B., Pigeon J. G. Changes in dyspnea-fatigue ratings as indicators of quality of life in the treatment of congestive heart failure. Am J Cardiol. 1989 Jul 1;64(1):50–55. doi: 10.1016/0002-9149(89)90652-8. [DOI] [PubMed] [Google Scholar]
  25. Franciosa J. A. Exercise testing in chronic congestive heart failure. Am J Cardiol. 1984 May 15;53(10):1447–1450. doi: 10.1016/s0002-9149(84)91041-5. [DOI] [PubMed] [Google Scholar]
  26. Franciosa J. A., Leddy C. L., Wilen M., Schwartz D. E. Relation between hemodynamic and ventilatory responses in determining exercise capacity in severe congestive heart failure. Am J Cardiol. 1984 Jan 1;53(1):127–134. doi: 10.1016/0002-9149(84)90696-9. [DOI] [PubMed] [Google Scholar]
  27. Franciosa J. A., Park M., Levine T. B. Lack of correlation between exercise capacity and indexes of resting left ventricular performance in heart failure. Am J Cardiol. 1981 Jan;47(1):33–39. doi: 10.1016/0002-9149(81)90286-1. [DOI] [PubMed] [Google Scholar]
  28. Franciosa J. A., Wilen M., Ziesche S., Cohn J. N. Survival in men with severe chronic left ventricular failure due to either coronary heart disease or idiopathic dilated cardiomyopathy. Am J Cardiol. 1983 Mar 1;51(5):831–836. doi: 10.1016/s0002-9149(83)80141-6. [DOI] [PubMed] [Google Scholar]
  29. Franciosa J. A., Ziesche S., Wilen M. Functional capacity of patients with chronic left ventricular failure. Relationship of bicycle exercise performance to clinical and hemodynamic characterization. Am J Med. 1979 Sep;67(3):460–466. doi: 10.1016/0002-9343(79)90794-0. [DOI] [PubMed] [Google Scholar]
  30. Ghali J. K., Cooper R., Ford E. Trends in hospitalization rates for heart failure in the United States, 1973-1986. Evidence for increasing population prevalence. Arch Intern Med. 1990 Apr;150(4):769–773. [PubMed] [Google Scholar]
  31. Guyatt G. H., Sullivan M. J., Thompson P. J., Fallen E. L., Pugsley S. O., Taylor D. W., Berman L. B. The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J. 1985 Apr 15;132(8):919–923. [PMC free article] [PubMed] [Google Scholar]
  32. Higginbotham M. B., Morris K. G., Conn E. H., Coleman R. E., Cobb F. R. Determinants of variable exercise performance among patients with severe left ventricular dysfunction. Am J Cardiol. 1983 Jan 1;51(1):52–60. doi: 10.1016/s0002-9149(83)80010-1. [DOI] [PubMed] [Google Scholar]
  33. Ho K. K., Anderson K. M., Kannel W. B., Grossman W., Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation. 1993 Jul;88(1):107–115. doi: 10.1161/01.cir.88.1.107. [DOI] [PubMed] [Google Scholar]
  34. Hogg J. C., Agarawal J. B., Gardiner A. J., Palmer W. H., Macklem P. T. Distribution of airway resistance with developing pulmonary edema in dogs. J Appl Physiol. 1972 Jan;32(1):20–24. doi: 10.1152/jappl.1972.32.1.20. [DOI] [PubMed] [Google Scholar]
  35. Ingram R., Jr, McFadden E. R., Jr Respiratory changes during exercise in patients with pulmonary venous hypertension. Prog Cardiovasc Dis. 1976 Sep-Oct;19(2):109–115. doi: 10.1016/0033-0620(76)90019-0. [DOI] [PubMed] [Google Scholar]
  36. Jondeau G., Katz S. D., Toussaint J. F., Dubourg O., Monrad E. S., Bourdarias J. P., LeJemtel T. H. Regional specificity of peak hyperemic response in patients with congestive heart failure: correlation with peak aerobic capacity. J Am Coll Cardiol. 1993 Nov 1;22(5):1399–1402. doi: 10.1016/0735-1097(93)90549-g. [DOI] [PubMed] [Google Scholar]
  37. Kiilavuori K., Sovijärvi A., Näveri H., Ikonen T., Leinonen H. Effect of physical training on exercise capacity and gas exchange in patients with chronic heart failure. Chest. 1996 Oct;110(4):985–991. doi: 10.1378/chest.110.4.985. [DOI] [PubMed] [Google Scholar]
  38. Kraemer M. D., Kubo S. H., Rector T. S., Brunsvold N., Bank A. J. Pulmonary and peripheral vascular factors are important determinants of peak exercise oxygen uptake in patients with heart failure. J Am Coll Cardiol. 1993 Mar 1;21(3):641–648. doi: 10.1016/0735-1097(93)90096-j. [DOI] [PubMed] [Google Scholar]
  39. Kremser C. B., O'Toole M. F., Leff A. R. Oscillatory hyperventilation in severe congestive heart failure secondary to idiopathic dilated cardiomyopathy or to ischemic cardiomyopathy. Am J Cardiol. 1987 Apr 1;59(8):900–905. doi: 10.1016/0002-9149(87)91116-7. [DOI] [PubMed] [Google Scholar]
  40. Liang C. S., Stewart D. K., LeJemtel T. H., Kirlin P. C., McIntyre K. M., Robertson H. T., Brown R., Moore A. W., Wellington K. L., Cahill L. Characteristics of peak aerobic capacity in symptomatic and asymptomatic subjects with left ventricular dysfunction. The Studies of Left Ventricular Dysfunction (SOLVD) Investigators. Am J Cardiol. 1992 May 1;69(14):1207–1211. doi: 10.1016/0002-9149(92)90937-t. [DOI] [PubMed] [Google Scholar]
  41. Lipkin D. P., Bayliss J., Poole-Wilson P. A. The ability of a submaximal exercise test to predict maximal exercise capacity in patients with heart failure. Eur Heart J. 1985 Oct;6(10):829–833. doi: 10.1093/oxfordjournals.eurheartj.a061768. [DOI] [PubMed] [Google Scholar]
  42. Lipkin D. P., Perrins J., Poole-Wilson P. A. Respiratory gas exchange in the assessment of patients with impaired ventricular function. Br Heart J. 1985 Sep;54(3):321–328. doi: 10.1136/hrt.54.3.321. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Mancini D. M., Eisen H., Kussmaul W., Mull R., Edmunds L. H., Jr, Wilson J. R. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. Circulation. 1991 Mar;83(3):778–786. doi: 10.1161/01.cir.83.3.778. [DOI] [PubMed] [Google Scholar]
  44. Marmor A., Raphael T., Marmor M., Blondheim D. Evaluation of contractile reserve by dobutamine echocardiography: noninvasive estimation of the severity of heart failure. Am Heart J. 1996 Dec;132(6):1195–1201. doi: 10.1016/s0002-8703(96)90463-9. [DOI] [PubMed] [Google Scholar]
  45. Marmor A., Schneeweiss A. Prognostic value of noninvasively obtained left ventricular contractile reserve in patients with severe heart failure. J Am Coll Cardiol. 1997 Feb;29(2):422–428. doi: 10.1016/s0735-1097(96)00493-7. [DOI] [PubMed] [Google Scholar]
  46. Massie B. M., Berk M. R., Brozena S. C., Elkayam U., Plehn J. F., Kukin M. L., Packer M., Murphy B. E., Neuberg G. W., Steingart R. M. Can further benefit be achieved by adding flosequinan to patients with congestive heart failure who remain symptomatic on diuretic, digoxin, and an angiotensin converting enzyme inhibitor? Results of the flosequinan-ACE inhibitor trial (FACET). Circulation. 1993 Aug;88(2):492–501. doi: 10.1161/01.cir.88.2.492. [DOI] [PubMed] [Google Scholar]
  47. Massie B. M., Conway M., Rajagopalan B., Yonge R., Frostick S., Ledingham J., Sleight P., Radda G. Skeletal muscle metabolism during exercise under ischemic conditions in congestive heart failure. Evidence for abnormalities unrelated to blood flow. Circulation. 1988 Aug;78(2):320–326. doi: 10.1161/01.cir.78.2.320. [DOI] [PubMed] [Google Scholar]
  48. Metra M., Raddino R., Dei Cas L., Visioli O. Assessment of peak oxygen consumption, lactate and ventilatory thresholds and correlation with resting and exercise hemodynamic data in chronic congestive heart failure. Am J Cardiol. 1990 May 1;65(16):1127–1133. doi: 10.1016/0002-9149(90)90326-v. [DOI] [PubMed] [Google Scholar]
  49. Meyer K., Samek L., Schwaibold M., Westbrook S., Hajric R., Lehmann M., Essfeld D., Roskamm H. Physical responses to different modes of interval exercise in patients with chronic heart failure--application to exercise training. Eur Heart J. 1996 Jul;17(7):1040–1047. doi: 10.1093/oxfordjournals.eurheartj.a015000. [DOI] [PubMed] [Google Scholar]
  50. Meyer K., Stengele E., Westbrook S., Beneke R., Schwaibold M., Görnandt L., Lehmann M., Roskamm H. Influence of different exercise protocols on functional capacity and symptoms in patients with chronic heart failure. Med Sci Sports Exerc. 1996 Sep;28(9):1081–1086. doi: 10.1097/00005768-199609000-00001. [DOI] [PubMed] [Google Scholar]
  51. Milani R. V., Mehra M. R., Reddy T. K., Lavie C. J., Ventura H. O. Ventilation/carbon dioxide production ratio in early exercise predicts poor functional capacity in congestive heart failure. Heart. 1996 Nov;76(5):393–396. doi: 10.1136/hrt.76.5.393. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Minotti J. R., Christoph I., Oka R., Weiner M. W., Wells L., Massie B. M. Impaired skeletal muscle function in patients with congestive heart failure. Relationship to systemic exercise performance. J Clin Invest. 1991 Dec;88(6):2077–2082. doi: 10.1172/JCI115537. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Minotti J. R., Johnson E. C., Hudson T. L., Zuroske G., Murata G., Fukushima E., Cagle T. G., Chick T. W., Massie B. M., Icenogle M. V. Skeletal muscle response to exercise training in congestive heart failure. J Clin Invest. 1990 Sep;86(3):751–758. doi: 10.1172/JCI114771. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Myers J., Salleh A., Buchanan N., Smith D., Neutel J., Bowes E., Froelicher V. F. Ventilatory mechanisms of exercise intolerance in chronic heart failure. Am Heart J. 1992 Sep;124(3):710–719. doi: 10.1016/0002-8703(92)90282-z. [DOI] [PubMed] [Google Scholar]
  55. Narang R., Swedberg K., Cleland J. G. What is the ideal study design for evaluation of treatment for heart failure? Insights from trials assessing the effect of ACE inhibitors on exercise capacity. Eur Heart J. 1996 Jan;17(1):120–134. doi: 10.1093/oxfordjournals.eurheartj.a014670. [DOI] [PubMed] [Google Scholar]
  56. Nugent A. M., McParland J., McEneaney D. J., Steele I., Campbell N. P., Stanford C. F., Nicholls D. P. Non-invasive measurement of cardiac output by a carbon dioxide rebreathing method at rest and during exercise. Eur Heart J. 1994 Mar;15(3):361–368. doi: 10.1093/oxfordjournals.eurheartj.a060504. [DOI] [PubMed] [Google Scholar]
  57. Packer M., Carver J. R., Rodeheffer R. J., Ivanhoe R. J., DiBianco R., Zeldis S. M., Hendrix G. H., Bommer W. J., Elkayam U., Kukin M. L. Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group. N Engl J Med. 1991 Nov 21;325(21):1468–1475. doi: 10.1056/NEJM199111213252103. [DOI] [PubMed] [Google Scholar]
  58. Packer M., Narahara K. A., Elkayam U., Sullivan J. M., Pearle D. L., Massie B. M., Creager M. A. Double-blind, placebo-controlled study of the efficacy of flosequinan in patients with chronic heart failure. Principal Investigators of the REFLECT Study. J Am Coll Cardiol. 1993 Jul;22(1):65–72. doi: 10.1016/0735-1097(93)90816-j. [DOI] [PubMed] [Google Scholar]
  59. Page E., Cohen-Solal A., Jondeau G., Douard H., Roul G., Kantelip J. P., Bussière J. L. Comparison of treadmill and bicycle exercise in patients with chronic heart failure. Chest. 1994 Oct;106(4):1002–1006. doi: 10.1378/chest.106.4.1002. [DOI] [PubMed] [Google Scholar]
  60. Paintal A. S. Mechanism of stimulation of type J pulmonary receptors. J Physiol. 1969 Aug;203(3):511–532. doi: 10.1113/jphysiol.1969.sp008877. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Parameshwar J., Keegan J., Sparrow J., Sutton G. C., Poole-Wilson P. A. Predictors of prognosis in severe chronic heart failure. Am Heart J. 1992 Feb;123(2):421–426. doi: 10.1016/0002-8703(92)90656-g. [DOI] [PubMed] [Google Scholar]
  62. Piña I. L., Karalis D. G. Comparison of four exercise protocols using anaerobic threshold measurement of functional capacity in congestive heart failure. Am J Cardiol. 1990 May 15;65(18):1269–1271. doi: 10.1016/0002-9149(90)90989-e. [DOI] [PubMed] [Google Scholar]
  63. Piña I. L. Optimal candidates for heart transplantation: is 14 the magic number? J Am Coll Cardiol. 1995 Aug;26(2):436–437. doi: 10.1016/0735-1097(95)80019-d. [DOI] [PubMed] [Google Scholar]
  64. Poole-Wilson P. A. Exercise as a means of assessing heart failure and its response to treatment. Cardiology. 1989;76(5):347–356. doi: 10.1159/000174518. [DOI] [PubMed] [Google Scholar]
  65. Rector T. S., Cohn J. N. Prognosis in congestive heart failure. Annu Rev Med. 1994;45:341–350. doi: 10.1146/annurev.med.45.1.341. [DOI] [PubMed] [Google Scholar]
  66. Reed J. W., Ablett M., Cotes J. E. Ventilatory responses to exercise and to carbon dioxide in mitral stenosis before and after valvulotomy: causes of tachypnoea. Clin Sci Mol Med. 1978 Jan;54(1):9–16. doi: 10.1042/cs0540009. [DOI] [PubMed] [Google Scholar]
  67. Riley M., McParland J., Stanford C. F., Nicholls D. P. Oxygen consumption during corridor walk testing in chronic cardiac failure. Eur Heart J. 1992 Jun;13(6):789–793. doi: 10.1093/oxfordjournals.eurheartj.a060258. [DOI] [PubMed] [Google Scholar]
  68. Roul G., Moulichon M. E., Bareiss P., Gries P., Sacrez J., Germain P., Mossard J. M., Sacrez A. Exercise peak VO2 determination in chronic heart failure: is it still of value? Eur Heart J. 1994 Apr;15(4):495–502. doi: 10.1093/oxfordjournals.eurheartj.a060533. [DOI] [PubMed] [Google Scholar]
  69. Scriven A. J., Lipkin D. P., Anand I. S., Sutton G. C., Poole-Wilson P. A. Double-blind, randomised, cross-over comparison of oral captopril and enoximone added to diuretic treatment in patients with severe heart failure. J Cardiovasc Pharmacol. 1988 Jan;11(1):45–50. doi: 10.1097/00005344-198801000-00007. [DOI] [PubMed] [Google Scholar]
  70. Shimizu M., Myers J., Buchanan N., Walsh D., Kraemer M., McAuley P., Froelicher V. F. The ventilatory threshold: method, protocol, and evaluator agreement. Am Heart J. 1991 Aug;122(2):509–516. doi: 10.1016/0002-8703(91)91009-c. [DOI] [PubMed] [Google Scholar]
  71. Stelken A. M., Younis L. T., Jennison S. H., Miller D. D., Miller L. W., Shaw L. J., Kargl D., Chaitman B. R. Prognostic value of cardiopulmonary exercise testing using percent achieved of predicted peak oxygen uptake for patients with ischemic and dilated cardiomyopathy. J Am Coll Cardiol. 1996 Feb;27(2):345–352. doi: 10.1016/0735-1097(95)00464-5. [DOI] [PubMed] [Google Scholar]
  72. Sullivan M. J., Green H. J., Cobb F. R. Altered skeletal muscle metabolic response to exercise in chronic heart failure. Relation to skeletal muscle aerobic enzyme activity. Circulation. 1991 Oct;84(4):1597–1607. doi: 10.1161/01.cir.84.4.1597. [DOI] [PubMed] [Google Scholar]
  73. Sullivan M. J., Green H. J., Cobb F. R. Skeletal muscle biochemistry and histology in ambulatory patients with long-term heart failure. Circulation. 1990 Feb;81(2):518–527. doi: 10.1161/01.cir.81.2.518. [DOI] [PubMed] [Google Scholar]
  74. Sullivan M. J., Hawthorne M. H. Exercise intolerance in patients with chronic heart failure. Prog Cardiovasc Dis. 1995 Jul-Aug;38(1):1–22. doi: 10.1016/s0033-0620(05)80011-8. [DOI] [PubMed] [Google Scholar]
  75. Sullivan M. J., Higginbotham M. B., Cobb F. R. Exercise training in patients with severe left ventricular dysfunction. Hemodynamic and metabolic effects. Circulation. 1988 Sep;78(3):506–515. doi: 10.1161/01.cir.78.3.506. [DOI] [PubMed] [Google Scholar]
  76. Sullivan M. J., Higginbotham M. B., Cobb F. R. Increased exercise ventilation in patients with chronic heart failure: intact ventilatory control despite hemodynamic and pulmonary abnormalities. Circulation. 1988 Mar;77(3):552–559. doi: 10.1161/01.cir.77.3.552. [DOI] [PubMed] [Google Scholar]
  77. Swedberg K. Exercise testing in heart failure. A critical review. Drugs. 1994;47 (Suppl 4):14–24. doi: 10.2165/00003495-199400474-00004. [DOI] [PubMed] [Google Scholar]
  78. Swedberg K., Gundersen T. The role of exercise testing in heart failure. J Cardiovasc Pharmacol. 1993;22 (Suppl 9):S13–S17. [PubMed] [Google Scholar]
  79. Tan L. B. Cardiac pumping capability and prognosis in heart failure. Lancet. 1986 Dec 13;2(8520):1360–1363. doi: 10.1016/s0140-6736(86)92006-4. [DOI] [PubMed] [Google Scholar]
  80. Tan L. B. Clinical and research implications of new concepts in the assessment of cardiac pumping performance in heart failure. Cardiovasc Res. 1987 Aug;21(8):615–622. doi: 10.1093/cvr/21.8.615. [DOI] [PubMed] [Google Scholar]
  81. Tan L. B., Jalil J. E., Pick R., Janicki J. S., Weber K. T. Cardiac myocyte necrosis induced by angiotensin II. Circ Res. 1991 Nov;69(5):1185–1195. doi: 10.1161/01.res.69.5.1185. [DOI] [PubMed] [Google Scholar]
  82. Tan L. B., Littler W. A. Measurement of cardiac reserve in cardiogenic shock: implications for prognosis and management. Br Heart J. 1990 Aug;64(2):121–128. doi: 10.1136/hrt.64.2.121. [DOI] [PMC free article] [PubMed] [Google Scholar]
  83. Wasserman K., Casaburi R. Dyspnea: physiological and pathophysiological mechanisms. Annu Rev Med. 1988;39:503–515. doi: 10.1146/annurev.me.39.020188.002443. [DOI] [PubMed] [Google Scholar]
  84. Weber K. T., Kinasewitz G. T., Janicki J. S., Fishman A. P. Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure. Circulation. 1982 Jun;65(6):1213–1223. doi: 10.1161/01.cir.65.6.1213. [DOI] [PubMed] [Google Scholar]
  85. Wiener D. H., Fink L. I., Maris J., Jones R. A., Chance B., Wilson J. R. Abnormal skeletal muscle bioenergetics during exercise in patients with heart failure: role of reduced muscle blood flow. Circulation. 1986 Jun;73(6):1127–1136. doi: 10.1161/01.cir.73.6.1127. [DOI] [PubMed] [Google Scholar]
  86. Wilson J. R., Ferraro N. Exercise intolerance in patients with chronic left heart failure: relation to oxygen transport and ventilatory abnormalities. Am J Cardiol. 1983 May 1;51(8):1358–1363. doi: 10.1016/0002-9149(83)90312-0. [DOI] [PubMed] [Google Scholar]
  87. Wilson J. R., Martin J. L., Schwartz D., Ferraro N. Exercise intolerance in patients with chronic heart failure: role of impaired nutritive flow to skeletal muscle. Circulation. 1984 Jun;69(6):1079–1087. doi: 10.1161/01.cir.69.6.1079. [DOI] [PubMed] [Google Scholar]
  88. Wilson J. R., Rayos G., Yeoh T. K., Gothard P., Bak K. Dissociation between exertional symptoms and circulatory function in patients with heart failure. Circulation. 1995 Jul 1;92(1):47–53. doi: 10.1161/01.cir.92.1.47. [DOI] [PubMed] [Google Scholar]
  89. Wilson J. R., Rayos G., Yeoh T. K., Gothard P. Dissociation between peak exercise oxygen consumption and hemodynamic dysfunction in potential heart transplant candidates. J Am Coll Cardiol. 1995 Aug;26(2):429–435. doi: 10.1016/0735-1097(95)80018-c. [DOI] [PubMed] [Google Scholar]
  90. Ziesche S., Cobb F. R., Cohn J. N., Johnson G., Tristani F. Hydralazine and isosorbide dinitrate combination improves exercise tolerance in heart failure. Results from V-HeFT I and V-HeFT II. The V-HeFT VA Cooperative Studies Group. Circulation. 1993 Jun;87(6 Suppl):VI56–VI64. [PubMed] [Google Scholar]
  91. van den Broek S. A., van Veldhuisen D. J., de Graeff P. A., Landsman M. L., Hillege H., Lie K. I. Comparison between New York Heart Association classification and peak oxygen consumption in the assessment of functional status and prognosis in patients with mild to moderate chronic congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992 Aug 1;70(3):359–363. doi: 10.1016/0002-9149(92)90619-a. [DOI] [PubMed] [Google Scholar]

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