HEART-RATE VARIABILITY THRESHOLD AS AN
ALTERNATIVE FOR SPIRO-ERGOMETRY TESTING:
A VALIDATION STUDY
ROBERT T. MANKOWSKI,1 SCOTT MICHAEL,2 ROBERT ROZENBERG,1 SEBASTIAAN STOKLA,1
HENK J. STAM,1 AND STEPHAN F.E. PRAET1
1
Department of Rehabilitation Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands; and 2Faculty of
Health Sciences, Cumberland Campus, The University of Sydney, Sydney, Australia
ABSTRACT
Mankowski, RT, Michael, S, Rozenberg, R, Stokla, S, Stam, HJ,
and Praet, SFE. Heart-rate variability threshold as an alternative for
spiro-ergometry testing: a validation study. J Strength Cond Res
31(2): 474–479, 2017—Although spiro-ergometry is the estab-
lished “gold standard” for determination of the second ventilatory
threshold (VT2), it is a costly and rather time-consuming method.
Previous studies suggest that assessing the second anaerobic
threshold (AT2) on the basis of heart rate variability (HRV) during
exercise may be a more cost-effective and noninvasive manner.
However, appropriate validation studies, are still lacking. Eleven
healthy, moderately trained subjects underwent 3 incremental
exercise tests. Ventilation, oxygen uptake (V _ O2), CO2 production
(V_ CO2), and HRV were measured continuously. Exercise testing
was performed in 3 oxygen (FiO2) conditions of inspired air (14,
21, and 35% of oxygen). Participants and assessors were blinded
to the FiO2 conditions. Two research teams assessed VT2s and
HRVT2s independently from each other. Mean workloads
corresponding to VT2 and HRVT2 in hypoxia were, respectively,
19 6 17% (p = 0.01) and 15 6 15% (p = 0.1) lower in com-
parison with hyperoxic conditions. Bland-Altman analysis showed
low estimation bias (2.2%) and acceptably precise 95% limits of
agreement for workload 215.7% to 20.1% for all FiO2 condi-
tions. Bias was the lowest under normoxic conditions (1.1%) in
comparison with hypoxia (3.7%) and hyperoxia (4.7%). Heart rate
variability–based AT2 assessment had a most acceptable agree-
ment with VT2 under normoxic conditions. This simple HRVT2
assessment may have potential applications for exercise monitor-
ing in commercial fitness settings.
KEY WORDS exercise, maximal testing, cost-effective, healthy
subjects, hypoxia, hyperoxia
Address correspondence to Robert T. Mankowski, r.mankowski@
erasmusmc.nl.
31(2)/474–479
Journal of Strength and Conditioning Research
Ó 2016 National Strength and Conditioning Association
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474 Journal of Strength and Conditioning Research
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INTRODUCTION
T
he second anaerobic threshold (AT2) is frequently
used to design and monitor exercise training pro-
grams for healthy people, athletes, and patients
with chronic diseases (9,18,30). Specifically, prop-
erly determined AT2 (;90% HRmax) is crucial for estab-
lishing appropriate training workloads and intensity needed
to effectively improve exercise performance and to prevent
injuries and overtraining (12). However, the “gold standard”
assessments of AT2 can only be determined through costly,
time-consuming spiro-ergometry testing often in combina-
tion with invasive methods such as multiple blood sampling
for the determination of lactate concentration [La] (5,6).
Recently, heart-rate variability threshold (HRVT) was
introduced as a noninvasive, cost-effective, and more
straightforward method than the currently practiced “gold
standard” to assess AT1 and AT2 in an individual (4). The
method has also been proposed to design and monitor indi-
vidualized training programs in athletes and patients under-
going cardiac and pulmonary rehabilitation (13). However,
appropriate validation and sensitivity analyses to detect
changes in individual training status are still lacking.
The HRVT represents a transition point between lower
and higher activity of the sympathetic nervous system
(SNS), which is strongly correlated with an increase in
[La], catecholamine concentrations, and minute ventilation
(Ve) that occurs at the AT1 (11).
One of the most commonly used methods for determining
HRVT is the root mean square of the successive differences
(HRVT-RMSSD) (20). Another method is based on the
Poincaré plotting technique, from which the instantaneous
variability of beat-to-beat data is derived by means of disper-
sion of points perpendicular to the axis of line-of-identity
(HRVT-SD1) (26,29).
In healthy subjects, Sales et al. (26) reported strong
correlations between the HRVT1 and the “gold standard”
AT1 assessments (HRVT-RMSSD r = 0.91 and HRVT-SD1
r = 0.93). Thus far, most comparative studies have used
single measurements to investigate agreement between
these 2 AT determination methods (6,11,26). These
 the TM

Journal of Strength and Conditioning Research | www.nsca.com

group-based validation studies, however, do not provide ethics advisory board of Swansea University) and required
information on the sensitivity of HRVT method to detect, subjects to provide informed consent before participation.
e.g., changes in an individual’s AT. Furthermore, there is
evidence that determination of AT2 is more reproducible Experimental Approach to the Problem
than AT1 in trained cyclists (31). Therefore, a comparison Subjects completed 3 incremental exercise tests until exhaustion
of second ventilatory threshold (VT2) and HRVT2 was on the same cycle ergometer (Jaeger ER800; CareFusion,
selected for the purpose of this validation study. To test Houten, The Netherlands, workload accuracy 3%) on
the sensitivity of HRVT for detecting an acute change in different days. Each test was performed under hypoxic
physiological stress, we propose a new validation method (14.04% O2), normoxic (21.2% O2), or hyperoxic (35.08% O2)
based on an acute shift in AT2 by manipulating inspiratory conditions. The tests were separated by at least 72 hours and
oxygen fraction (FiO2). For a given workload, SNS activity performed in a randomized order at the same time of the day.
level will be increased during hypoxic exercise (33) and Randomization occurred by drawing opaque sealed envelopes
lower under hyperoxic conditions (15). In accordance, containing the order of the 3 FiO2 conditions. Both tempera-
AT2 should be reached at a lower workload during hypoxic ture (218 C) and humidity (35–45%) in the laboratory were held
as opposed to a normoxic or hyperoxic exercise stress test. constant. Subjects were asked to refrain from strenuous exercise
To our knowledge, this is the first study to validate the on the day before the test. Furthermore, they were asked to
sensitivity of HRVT2 assessment relative to that of AT2 on refrain from caffeinated drinks at least 12 hours before the
the basis of the breath-by-breath gas analysis method during exercise test.
multiple incremental exercise tests under decreased and
increased FiO2 conditions. Testing Procedures
In accordance, we hypothesized that HRVT2-based Incremental Exercise Test. All the exercise tests were per-
workload is strongly associated with the spiro-ergometry formed at the Clinical Exercise Performance Laboratory
VT2-based workload during incremental exercise test per- from the Erasmus University Medical Center in Rotter-
formed under low, normal, and high FiO2 conditions. In dam, the Netherlands, in the presence of an exercise
addition, we hypothesized that a shift in HRVT2 is associ- physiologist and a sports physician. All subjects were
ated with a shift in VT2. scheduled to perform a symptom-limited exercise stress
test. This standard ramp test started with a 2-minute rest
METHODS period followed by 4 minutes of unloaded cycling as warm-
Subjects up. Next, the workload increased with a slope of 1.8 W/6
A total of 11 (8 males and 3 females, age range 20–28 years) seconds (men) or a 1.2 W/6 seconds (women). Subjects
healthy and medium-trained young adults volunteered to were instructed to cycle until exhaustion with a pedal
participate in this study. The study protocol was approved by frequency of 60–80 rpm. The loaded phase was termi-
the regional Medical Ethics Committee of the Erasmus nated when pedaling frequency dropped below 60 rpm.
University Medical Centre in Rotterdam, the Netherlands A 5-minute unloaded recovery phase ended the exercise
(number: 2012-128 [NTR3777]). All participants provided stress test. During the warm-up, workload, and recovery
written informed consent. The study conforms to the Code phases of the exercise protocol, V_ O2, V_ CO2, minute venti-
of Ethics of the World Medical Association (approved by the lation (Ve) (Oxycon Pro; Carefusion; accuracy: volume
sensor 2%, O2 and CO2 ana-
lyzers 0.5%, CO2) were moni-
tored. Peak oxygen uptake,
TABLE 1. Subjects’ characteristics.* workload, heart rate (HR), and
respiratory exchange ratio
Hypoxia Normoxia Hyperoxia
(RER) were documented.
(N = 11), (N = 11), (N = 9),
N = 11 mean 6 SD mean 6 SD mean 6 SD Immediately after each exer-
cise, test subjects were asked
Age (yrs) 23.6 6 2.2 to rate their perceived exertion
Weight (kg) 69.1 6 9.8 on a scale from 6 to 20 using
Height (cm) 177.9 6 8.2
22 the Borg scale (1).
BMI (kg$m ) 22.0 6 1.7
V_ O2peak (ml$kg21$min21) 46.8 6 5.3 54.6 6 7.0 54.2 6 6.7
Wmax (W) 289 6 48 324 6 54 336 6 55 Heart Rate and Heart Rate Vari-
Borg score 16.4 6 0.7 16.3 6 0.8 16.2 6 0.8 ability. Beat-to-beat HR was
measured continuously using an
*The results in boldface (hypoxia) were significantly different from normoxia and hyperoxia
(p # 0.05). HR monitor (Zephyr BioHar-
ness 3; Zephyr, Annapolis, MD,
USA, HR accuracy 63 bpm).

VOLUME 31 | NUMBER 2 | FEBRUARY 2017 | 475

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 HRV & VT

independent researchers also

blinded to the different FiO2
TABLE 2. Comparison of the mean second anaerobic thresholds between 3
different oxygen conditions.* test conditions. The values of
nRMSSD were displayed
FiO2 conditions every 30 seconds. The second
heart-rate variability threshold
Mean 6 SD (W)
was determined by visual
Hypoxia Normoxia Hyperoxia inspection. It was defined as
the breakpoint representing
VT2 218.5 6 39.0 251.3 6 44.7 257.5 6 37.2 the start of a substantial
HRVT2 222.9 6 48.9 243.6 6 44.2 263.0 6 47.8
increase in nRMSSD, after
*Mean VT2 in boldface (hypoxia) was significantly different (p = 0.01) from VT2 under having reached a minimum
hyperoxic conditions. value. The threshold was ex-
VT2 = second variability threshold.
pressed as workload (Watt)
corresponding with the
HRVT2. Inflection points
(HRVT2) that could not be
The real-time HR data were recorded on an external server determined visually be the independent assessors were
(through a laptop and Bluetooth2.0 connection) with dedi- excluded from the analysis.
cated software (AppSolute Training, ADTS, 1.2 beta version;
Vital BV, Hazerswoude-Rijndijk, the Netherlands). Heart Statistical Analyses
rate variability (HRV) was quantified every 30 seconds by The subjects were characterized by descriptive analysis of
first calculating the root mean square of successive differ- the data (mean 6 SD). Bland-Altman plot analysis was used
ences of R-R intervals (RMSSD), then dividing this by the for comparing workload values obtained from the 2 AT
average R-R interval over the corresponding 30-second assessment methods (agreement between VT2 and
period, to calculate normalized RMSSD (nRMSSD). HRVT2). The obtained AT2s under the 3 FiO2 conditions
were compared using a General Linear Model with
Medical Gasses. According to legal requirements in the repeated measures. According to an anticipated difference
Netherlands, each test was performed using medically of at least 40 W between hypoxic and hyperoxic exercise–
certified oxygen/nitrogen mixtures stored in 50-L, 200-bar related ventilatory threshold, 11 subjects would be sufficient
gas cylinders (Linde Gas Benelux/BOC Morden, London, to perform this validation study (effect size 0.9, alpha of
United Kingdom). The 3 different air mixtures were blinded 0.05) (21). For all statistical tests, p # 0.05 were considered
to the subject and inspired through a Douglas bag (20 L) significant. Bonferroni adjustment was applied accordingly
connected to an oro-nasal 7400 Vmask and a 2730 2-way Y- (IBM SPSS Statistics, version 20).
shape non-rebreathing valve (Hans Rudolph, Inc., Shawnee,
KS, USA).

Data analysis
Determination of the Second Variability Threshold. Obtained
values of V_ O2, V_ CO2, RER, and (Ve) were averaged for
each 30-second time window. Second ventilatory thresh-
old was determined independently by 2 sports physicians,
both having more than 5 years of experience with clinical
assessment of cardiopulmonary exercise tests. All tests
results were encoded and both assessors were blinded
to the 3 different FiO2 test conditions. For the present
study, VT2 was defined by the second nonlinear increase
of the Ve/V_ CO2 curve (24). When VT2s differed between
the 2 assessors, consensus on VT2 was obtained by re- Figure 1. Bland-Altman scatter plot. Mean workload values of second
variability threshold (VT2) and the second heart-rate variability threshold
viewing each other’s assessment. Ventilatory threshold (HRVT2) are plotted on X axis. Empty circles—hypoxia; half-filled circles—
was expressed as workload (W) level corresponding normoxia; filled circles—hyperoxia; LoA = limit of agreement. Heart rate
with VT2. variability (HRV) was quantified every 30 seconds by first calculating the
root mean square of successive differences of R-R intervals (RMSSD),
then dividing this by the average R-R interval over the corresponding 30-
Determination of Second Heart Rate Variability Threshold. The second period, to calculate the normalized RMSSD (nRMSSD).
second heart-rate variability threshold was determined by 2
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476 Journal of Strength and Conditioning Research

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TABLE 3. Bland-Altman calculations for each
FiO2 condition.*
FiO2 conditions
Hypoxia Normoxia Hyperoxia
Bias (%) 3.7 1.1 4.7
Lower LoA (%) 217.7 215.2 217.7
Upper LoA (%) 25.2 17.3 27.1
*LoA = level of agreement.
RESULTS
Table 1 presents subjects’ characteristics. Participants were
moderately trained (V_ O2peak 54.6 6 7.0 ml$min21$kg21). A
total of 2 HRVT2 inflection points during hyperoxic exercise
could not be determined and were excluded from our anal-
ysis. Mean workloads corresponding to VT2 and HRVT2
(Table 2) in hypoxia, were respectively, 19 6 17% (p =
0.01) and 15 6 15% (p = 0.1) lower in comparison with
hyperoxic conditions. The mean (6SD) workload of the
VT2 methods was 242.4 6 42.8 W, compared with 246.7
6 49 W for the HRVT2 method. Figure 1 shows the Bland-
Altman plot with the bias and 95% limits of agreement
(LoA) of VT2 and HRVT2 comparison under all FiO2 con-
ditions. The LoA for workload (W) were 215.7 to 20.1%.
Although HRVT2 gives an acceptably precise agreement of
2.2% (bias) with VT2, the positive bias (systematic error)
occurred in 17 out of 31 cases. Additionally, Table 3 presents
Bland-Altman analyses of VT2 and HRVT2 comparison for
each FiO2 condition separately. This “subgroup” analysis in-
dicates the most acceptably precise agreement under nor-
moxic conditions (1.1%) in comparison with hypoxia (3.7%)
and hyperoxia (4.7%).
DISCUSSION
To the best of our knowledge, this is the first study that
investigated the level of agreement between 2 independent
methods for assessing AT2 based on spiro-ergometry (VT2)
and HRV (HRVT2) under different FiO2 conditions. The
main finding is that the agreement between VT2 and HRVT2
was most acceptably precise under normoxic conditions.
Additionally, the VT method showed significant sensitivity
for detecting a shift in AT2 when comparing hypoxic with
hyperoxic exercise conditions. Difference between HRVT2
placement in hypoxia and hyperoxia were insignificant; how-
ever, there was a trend (p = 0.1) for HRVT2 to be higher
during hyperoxic vs. hypoxic conditions. The outcome of the
present study supports our hypothesis that the proposed
HRVT2 method can serve as a potential alternative method
for detecting AT2 without having to use costly spiro-
ergometry equipments in commercial fitness settings.
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Our Bland-Altman concordance analysis shows an accept-
ably precise agreement between the VT2 and HRVT2
assessment methods. These results are in line with other
studies (4,5,27). For example, Quinart et al. also reported
a good agreement between VT2 and HRVT2 (VT2 ex-
pressed in Watts). Quinart et al. (22) investigated 20 obese
adolescents (14 girls and 6 boys) who underwent 2 mixed
protocols (combining exercise stages of 3-minute duration at
the start of the test, and then 1-minute duration) before and
after a 9-month exercise intervention program . Despite the
fact that their Bland-Altman analysis demonstrated a low
estimation bias and overall good agreement between the 2
measures (22), their mixed protocol was regarded a study
limitation potentially impairing their VT2 accuracy (22). In
accordance with their recommendations, we performed lin-
ear incremental exercise tests till exhaustion, allowing for
optimal detection of VT2 through spiro-ergometry.
Although our Bland-Altman analysis shows sufficient agree-
ment between VT2 and HRVT2 under normoxic conditions,
future studies using different exercise loading protocols are
probably warranted to establish the best protocol for assess-
ing HRVT2.
In the current study, VT2 based on the spiro-ergometry
data was used as a “gold standard” and compared with the
HRVT2 results under all FiO2 conditions. The bias (2.2%),
mean absolute difference (7.2%), and LoA (215.7–20.1%) do
not confirm a perfect agreement between those 2 methods
(Figure 1) in comparison with other authors (4,22). How-
ever, it has been shown previously that an interobserver
error in VT assessments on the basis of ventilatory equiva-
lents for oxygen was ;15% (7). In contrast, Sinclair et al. (28)
and others have shown that the interobserver error between
assessed VT based on the V-slope method data ranged
between 5.6 and 8.1%, which was considered clinically
acceptable . In the present study, 22 cases out of 31 (71%)
showed a difference #8.1%. Therefore, the level of error in
other spiro-ergometry VT assessments suggests that accept-
ably precise HRVT2 results may support relevance of the
HRVT concept to replace costly VT measurements in a clin-
ical setting.
Additionally, we conducted a Bland-Altman analysis for
each FiO2 condition. Both HRVT2 and VT between hypoxia
and hyperoxia tend to be different, indicating that both VT
and HRVT2 methods seem to be responsive to change in
oxygen conditions Accordingly, comparison of the AT2
methods under normoxic conditions seems to be the most
acceptable (bias 1.1%). This may suggest that HRVT2 assess-
ments may be valid for exercise tests under normoxic
conditions.
As far as we know, only 1 study previously investigated
the sensitivity of the HRVT method to detect training
adaptations (14). Exercise training modifies anthropometric
features, improves cardiorespiratory variables, and lowers
the activity of the SNS during submaximal exercise (26).
In accordance, Quinart et al. were able to observe an
VOLUME 31 | NUMBER 2 | FEBRUARY 2017 | 477
 HRV & VT
improvement in training status. In particular, they observed
similarly increased workload corresponding to VT2
(;17.5%) and HRVT2 (;15%). The present study extends
on their results by showing a rather similar difference in
workload capacity for VT2 when manipulating FiO2 con-
ditions. Higher FiO2 (hyperoxia) decreases and lower FiO2
(hypoxia) increases the activity of SNS during exercise
(15,33). In comparison with a medium- or long-term train-
ing intervention study, our approach was intended as a more
direct method to test the sensitivity of the HRVT assess-
ment method in response to a change of physiological
stress. The shift in VT2 under hypoxic and hyperoxic con-
ditions is well in line with previous reports (27). In particu-
lar, supplementary oxygen may also improve oxygen
delivery and consumption, and hence exercise tolerance
(V_ O2max). Therefore, time to exhaustion is extended and
activation of SNS is lower during a maximal test under
hyperoxic conditions in comparison with hypoxic condi-
tions (23,25). The HRVT2 method seems less sensitive as
the shift in HRVT2 did not reach statistical significance.
The latter result may also be explained by a type II error
as we had to exclude 2 HRVT measurements under hyper-
oxic conditions because of difficulties to determine a clear
inflection point. The lack of statistical difference between
normoxia and hypoxia may also be caused by limited sta-
tistical power in our study. Another explanation, in line with
the high SDs of our measurements is the recently described
variation in the individual response to hypoxia/hyperoxia
(8,16,19). Therefore, HRVT2 assessments may be valid for
tests under normoxic conditions.
In the present study, an upward inflection in the time-
domain HRV measure nRMSSD (RMSSD:RRI ratio) was
used to determine HRVT2 as opposed to frequency domain
measures (3,4). By comparison, frequency domain measures
should not be applied to a time window of less than 10 times
the lower bound of the frequency band (i.e., 67 seconds for
a high-frequency lower bound of 0.15 Hz) (10).
Therefore, the present study used the time-domain
measure nRMSSD (RMSSD:RRI ratio), using 30-second
windows, which was perhaps the simplest to perform (10).
Heart rate variability measurements are sensitive to the
autonomic nervous system disturbances in pathologies (e.g.,
Parkinson’s disease, diabetes-related autonomic neuropathy)
(32) and to exercise performance improvement. Especially,
during exercise, the HRV signal can also be influenced by
nonneural factors (17). In particular, the nonneural influences
of respiration on the sino-atrial node, particularly during
exercise at and above VT2, likely contribute to the upward
inflection of nRMSSD (10). This makes the time-domain
method practically useful as a proxy measure for VT2 detec-
tion. The present study used visual determination of break-
points for HRVT and VT. Although this approach is widely
used in a range of physiological contexts, mathematical
models have been shown to be useful to objectively identify
threshold breakpoints (2). Accordingly, future studies on
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478 Journal of Strength and Conditioning Research
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HRVT may benefit from the application of objective break-
point determination methods.
The current study has some limitations. In particular,
regarding the identification of HRVT2, a clear upward
inflection point could not always be identified. Therefore, 2
measurements were excluded, as both the 2 independent
assessors could not detect an inflection point corresponding
to HRVT2.
The currently used, and as far we know, best available
VT and HRV methods both require a visual assessment of
inflection points in both ventilation and HRV data. As
there is no gold standard for determining VT, either of the
methods may have introduced some level of bias or error.
Based on the results of this study, it is suggested that
HRVT2 assessment method may give valid results under
normoxic conditions and not under hypoxic or hyperoxic
conditions. Although all exercise tests were performed
according to exercise testing guidelines, the equipment
required to perform a precise ramp test on a cycle
ergometer at 1.8 and 1.2 W$s21 is not trivial. In accor-
dance, future HRV-VT validation studies should preferably
also include an exercise testing protocol using a graded
step test (30 seconds to 3 minutes at a constant workload)
on a commercially available cycle ergometer under nor-
moxic conditions.
Although computationally simple and achieving a high
temporal resolution, time-domain HRV measures such as
nRMSSD have not previously been validated for determin-
ing VT2. Previously, frequency-domain measures such as the
product of HF power and HF frequency (3,4) have been
used. Future research could be directed toward refining the
application of time-domain or alternative HRV analysis to
estimate ventilatory thresholds.
In conclusion, the present study showed that there is
a most acceptably precise agreement between the VT2
and HRVT2 assessment methods under normoxic con-
ditions. This simple HRVT2 assessment may have poten-
tial applications for exercise monitoring in commercial
fitness settings.
PRACTICAL APPLICATIONS
These results open up new avenues for a cost-efficient and
noninvasive HRVT method that could be easily applied to
determine, monitor, and individualize the appropriate work-
load intensity in different types of aerobic exercise training
modalities in commercial fitness settings.
ACKNOWLEDGMENTS
We acknowledge Mr. Bert Bannink and the pulmonology
department at the Erasmus University Medical Centre for
access to measuring devices and constant technical support.
We thank Mr. Oskar de Kuijer from Vital B.V. for the HRV
measuring equipment and software. Finally, this study
would not have been possible without our flexible and
committed subjects.

REFERENCES
1. Borg, GA. Psychophysical bases of perceived exertion. Med Sci
Sports Exerc 14: 377–381, 1982.
2. Cheuvront, SN, Bearden, SE, Kenefick, RW, Ely, BR, Degroot, DW,
Sawka, MN, and Montain, SJ. A simple and valid method to
determine thermoregulatory sweating threshold and sensitivity. J
Appl Physiol (1985) 107: 69–75, 2009.
3. Cottin, F, Medigue, C, Lepretre, PM, Papelier, Y, Koralsztein, JP, and
Billat, V. Heart rate variability during exercise performed below and
above ventilatory threshold. Med Sci Sports Exerc 36: 594–600, 2004.
4. Cottin, F, Medigue, C, Lopes, P, Lepretre, PM, Heubert, R, and
Billat, V. Ventilatory thresholds assessment from heart rate
variability during an incremental exhaustive running test. Int J Sports
Med 28: 287–294, 2007.
5. Di Michele, R, Gatta, G, Di Leo, A, Cortesi, M, Andina, F, Tam, E,
Da Boit, M, and Merni, F. Estimation of the anaerobic threshold
from heart rate variability in an incremental swimming test. J
Strength Cond Res 26: 3059–3066, 2012.
6. Dourado, VZ, Banov, MC, Marino, MC, de Souza, VL, Antunes, LC,
and McBurnie, MA. A simple approach to assess VT during a field
walk test. Int J Sports Med 31: 698–703, 2010.
7. Garrard, CS and Das, R. Sources of error and variability in the
determination of anaerobic threshold in healthy humans. Respiration
51: 137–145, 1987.
8. Gore, CJ, Sharpe, K, Garvican-Lewis, LA, Saunders, PU,
Humberstone, CE, Robertson, EY, Wachsmuth, NB, Clark, SA,
McLean, BD, Friedmann-Bette, B, Neya, M, Pottgiesser, T,
Schumacher, YO, and Schmidt, WF. Altitude training and
haemoglobin mass from the optimised carbon monoxide
rebreathing method determined by a meta-analysis. Br J Sports
Med 47(Suppl 1): i31–i39, 2013.
9. Hansen, D, Stevens, A, Eijnde, BO, and Dendale, P. Endurance
exercise intensity determination in the rehabilitation of coronary
artery disease patients: A critical re-appraisal of current evidence.
Sports Med 42: 11–30, 2012.
10. Heart rate variability. Standards of measurement, physiological
interpretation and clinical use. Task Force of the European Society
of Cardiology and the North American Society of Pacing and
Electrophysiology. Circulation 93: 1043–1065, 1996.
11. Karapetian, GK, Engels, HJ, Gretebeck, KA, and Gretebeck, RJ. Effect
of caffeine on LT, VT and HRVT. Int J Sports Med 33: 507–513, 2012.
12. Kendall, KL, Smith, AE, Graef, JL, Kendall, KL, Smith, AE,
Graef, JL, Fukuda, DH, Moon, JR, Beck, TW, Cramer, JT, and
Stout, JR. Effects of four weeks of high-intensity interval training
and creatine supplementation on critical power and anaerobic
working capacity in college-aged men. J Strength Cond Res 23: 1663–
1669, 2009.
13. Keteyian, SJ, Hibner, BA, Bronsteen, K, Kerrigan, D, Aldred, HA,
Reasons, LM, Saval, MA, Brawner, CA, Schairer, JR,
Thompson, TM, Hill, J, McCulloch, D, and Ehrman, JK. Greater
improvement in cardiorespiratory fitness using higher-intensity
interval training in the standard cardiac rehabilitation setting. J
Cardiopulm Rehabil Prev 34: 98–105, 2014.
14. Lima-Silva, AE, Bertuzzi, RC, Pires, FO, Fronchetti, L,
Gevaerd, MS, and De-Oliveira, FR. A low carbohydrate diet affects
autonomic modulation during heavy but not moderate exercise. Eur
J Appl Physiol 108: 1133–1140, 2010.
15. Loredo, JS, Clausen, JL, Nelesen, RA, Ancoli-Israel, S, Ziegler, MG,
and Dimsdale, JE. Obstructive sleep apnea and hypertension: Are
peripheral chemoreceptors involved? Med Hypotheses 56: 17–19, 2001.
16. MacNutt, MJ, Peters, CM, Chan, C, Moore, J, Shum, S, and
Sheel, AW. Day-to-day variability in cardiorespiratory responses to
hypoxic cycle exercise. Appl Physiol Nutr Metab 40: 155–161, 2015.
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
the TM
Journal of Strength and Conditioning Research | www.nsca.com
17. Maetzler, W, Karam, M, Berger, MF, Heger, T, Maetzler, C,
Ruediger, H, Bronzova, J, Lobo, PP, Ferreira, JJ, Ziemssen, T, and
Berg, D. Time- and frequency-domain parameters of heart rate
variability and sympathetic skin response in Parkinson’s disease. J
Neural Transm 122: 419–425, 2015.
18. Mann, T, Lamberts, RP, and Lambert, MI. Methods of prescribing
relative exercise intensity: Physiological and practical
considerations. Sports Med 43: 613–625, 2013.
19. Masschelein, E, Puype, J, Broos, S, Van Thienen, R, Deldicque, L,
Lambrechts, D, Hespel, P, and Thomis, M. A genetic predisposition
score associates with reduced aerobic capacity in response to acute
normobaric hypoxia in lowlanders. High Alt Med Biol 16: 34–42, 2015.
20. Paschoal, MA and Fontana, CC. Method of heart rate variability
threshold applied in obese and non-obese pre-adolescents. Arq Bras
Cardiol 96: 450–456, 2011.
21. Peltonen, JE, Tikkanen, HO, and Rusko, HK. Cardiorespiratory
responses to exercise in acute hypoxia, hyperoxia and normoxia.
Eur J Appl Physiol 85: 82–88, 2001.
22. Quinart, S, Mourot, L, Nègre, V, Simon-Rigaud, ML, Nicolet-
Guénat, M, Bertrand, AM, Meneveau, N, and Mougin, F. Ventilatory
thresholds determined from HRV: Comparison of 2 methods in
obese adolescents. Int J Sports Med 35: 203–208, 2014.
23. Queiroga, F Jr, Nunes, M, Meda, E, Chiappa, G, Machado, MC,
Nery, LE, and Neder, JA. Exercise tolerance with helium-hyperoxia
versus hyperoxia in hypoxaemic patients with COPD. Eur Respir J
42: 362–370, 2013.
24. Reinhard, U, Muller, PH, and Schmulling, RM. Determination of
anaerobic threshold by the ventilation equivalent in normal
individuals. Respiration 38: 36–42, 1979.
25. Richardson, RS, Grassi, B, Gavin, TP, Haseler, LJ, Tagore, K, Roca, J,
and Wagner, PD. Evidence of O2 supply-dependent VO2 max in the
exercise-trained human quadriceps. J Appl Physiol (1985) 86: 1048–
1053, 1999.
26. Sales, MM, Campbell, CS, Morais, PK, Ernesto, C, Soares-
Caldeira, LF, Russo, P, Motta, DF, Moreira, SR, Nakamura, FY, and
SimÕes, HG. Noninvasive method to estimate anaerobic threshold
in individuals with type 2 diabetes. Diabetol Metab Syndr 3: 1, 2011.
27. Schmitt, L, Hellard, P, Millet, GP, Roels, B, Richalet, JP, and
Fouillot, JP. Heart rate variability and performance at two different
altitudes in well-trained swimmers. Int J Sports Med 27: 226–231,
2006.
28. Sinclair, RC, Danjoux, GR, Goodridge, V, and Batterham, AM.
Determination of the anaerobic threshold in the pre-operative
assessment clinic: Inter-observer measurement error. Anaesthesia 64:
1192–1195, 2009.
29. Tulppo, MP, Makikallio, TH, Takala, TE, Seppanen, T, and
Huikuri, HV. Quantitative beat-to-beat analysis of heart rate dynamics
during exercise. Am J Physiol 271(1 Pt 2): H244–H252, 1996.
30. Walter, AA, Smith, AE, Kendall, KL, Stout, JR, and Cramer, JT. Six
weeks of high-intensity interval training with and without beta-
alanine supplementation for improving cardiovascular fitness in
women. J Strength Cond Res 24: 1199–1207, 2010.
31. Weston, SB and Gabbett, TJ. Reproducibility of ventilation of
thresholds in trained cyclists during ramp cycle exercise. J Sci Med
Sport 4: 357–366, 2001.
32. Wulsin, LR, Horn, PS, Perry, JL, Massaro, J, and D’Agostino, R.
Autonomic imbalance as a predictor of metabolic risks, cardiovascular
disease, diabetes, and mortality autonomic imbalance predicts CVD,
DM, Mortality. J Clin Endocrinol Metab jc20144123, 2015. doi: 10.
1519/JSC.000000000001202. Epub ahead of print.
33. Yamamoto, Y, Hoshikawa, Y, and Miyashita, M. Effects of acute
exposure to simulated altitude on heart rate variability during
exercise. J Appl Physiol (1985) 81: 1223–1229, 1996.
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