Departments of Anaesthesia,

Intensive Care and Pain

Medicine
Western Hospital
Gordon Street
Footscray VIC 3011
Tel: +61 3 8345.6639
Fax: +61 3 8345.6572

A  quick  guide  to  interpreta1on  of  pre-­‐opera1ve  

Cardiopulmonary  Exercise  Test  results    

Cardiopulmonary  Exercise  Tes4ng  (CPx)  provides  an  integra4ve  objec4ve  marker  of  cardiac,  
respiratory  and  muscle  performance  during  exercise.  A  CPx  test  produces  a  vast  amount  of  
informa4on  and  this  informa4on  can  allow  you  to  risk  stra4fy  your  pa4ents.  This  guide  aims  to  assist  
your  interpreta4on  of  the  data  produced  on  a  CPx  report  to  allow  you  to  beDer  iden4fy  your  pa4ent’s  
pathology.  

Cardiac  markers:  
• Oxygen  pulse  (seen  in  plot  2  of  the  9  panel  plot):  is  a  marker  of  oxygen  extrac4on  with  each  
beat  of  the  heart,  and  is  a  surrogate  marker  of  stroke  volume  changes  with  exercise.  It  is  
calculated  by  dividing  the  oxygen  consump4on  (VO2)  by  the  heart  rate.  The  es4mated  stroke  
volume  seen  on  the  report  is  indexed  for  the  pa4ent’s  haemoglobin.  It  should  show  a  rapid  rise  
with  exercise  followed  by  a  plateau,  with  further  increases  in  cardiac  output  reached  by  
increases  in  heart  rate.  An  early  flaDening  or  decrease  in  the  slope  with  ongoing  exercise  
indicates  either  cardiogenic  or  peripheral  vascular  pathology.  The  predicted  level  for  your  
pa4ent  is  represented  by  the  dashed  purple  line  on  plot  2.    
• VO2  work  rate  slope  (seen  in  plot  3  of  the  9  panel  plot):  this  represents  the  rela4onship  
between  the  increase  in  VO2  with  increasing  work.  The  slope  represents  the  ability  of  
exercising  muscle  to  extract  O2  to  produce  energy.  In  normal  condi4ons,  the  slope  should  be  
9-­‐11mls  O2/min/W.  A  reduc4on  in  this  slope  <9  indicates  a  failure  in  oxygen  delivery,  and  
likely  represents  a  cardiac,  vascular  or  rarely,  mitochondrial  issue.    
• Peak  heart  rate  (seen  in  plots  2  and  5  of  the  9  panel  plot):  a  rough  approxima3on  of  
predicted  peak  heart  rate  is  220-­‐age  and  is  also  seen  as  the  dashed  brown  line  on  plot  2.  It  
should  increase  in  a  linear  fashion.  Failure  to  reach  predicted  levels  indicates  a  degree  of  
chronotropic  incompetence  and  may  be  due  to  the  presence  of  B-­‐blockade.  
• ECG  changes:  any  relevant  stress  ECG  changes  with  incremental  exercise  will  be  documented  
on  the  report.  

Respiratory  markers:  
• Minute  Ven1la1on/Carbon  dioxide  produc1on  rela1onship  VE/VCO2  (seen  in  plots  4  and  6  
of  the  9  panel  plot):    represents  the  slope  of  minute  ven4la4on  to  the  produc4on  of  carbon  
dioxide  and  is  a  marker  of  the  efficiency  of  ven4la4on.  A  normal  value  is  <30,  with  values  
greater  than  30  reflec4ng  perfusion/ven4la4on  mismatch  and  reduced  chemoreceptor  
sensi4vity,  and  is  elevated  in  pathology  such  as  pulmonary  hypertension,  COPD  and  heart  
failure.      
Dr. Hugh Taylor
Department Anaesthesia and Pain Medicine
August, 2015
 Departments of Anaesthesia,
Intensive Care and Pain
Medicine
Western Hospital
Gordon Street
Footscray VIC 3011
Tel: +61 3 8345.6639
Fax: +61 3 8345.6572

• Oxygen  satura1ons  during  exercise  (seen  in  plot  9  of  the  9  panel  plot):  Any  significant  fall  
will  be  noted  in  the  report.  

Cardiac  and  Respiratory  pathology:  

• Maximal  aerobic  capacity  or  VO2  peak  (seen  in  plot  3  of  the  9  panel  plot):  represents  the  
maximal  oxygen  consump4on  and  reflects  the  limit  of  the  cardiopulmonary  system  to  deliver  
oxygen  to  the  working  muscles.  It  is  expressed  as  L/min  and  then  indexed  for  the  pa4ents  
weight  as  mls/kg/min.  The  predicted  level  for  your  pa4ent  is  represented  as  the  dashed  red  
line  in  plot  3.  Currently  at  WH  we  only  test  those  pa4ents  scheduled  to  undergo  lung  resec4on  
to  VO2  peak,  the  remaining  pre-­‐opera4ve  pa4ents  are  just  tested  to  beyond  their  anaerobic  
threshold.  Failure  to  reach  the  predicted  peak  likely  represents  a  degree  of  cardiac  or  
respiratory  pathology.  Performance  will  also  be  reduced  in  the  presence  of  anaemia.    
• Anaerobic  threshold  or  AT  (seen  on  plots  3,5,6  and  9  of  the  9  panel  plot):    This  represents  
the  point  where  ongoing  incremental  exercise  can  not  be  maintained  using  aerobic  
metabolism  alone  and  will  require  anaerobic  supplementa4on  in  order  to  con4nue.  It  is  effort  
independent  and  usually  occurs  at  45-­‐65%  of  the  VO2  peak  in  healthy  untrained  subjects  and  
demonstrates  high  test-­‐retest  reliability.    Determina4on  of  how  this  is  calculated  is  beyond  the  
scope  of  this  summary.  An  AT  of  <11mls/kg/min  remains  a  reliable  marker  of  elevated  post-­‐
opera4ve  morbidity.    

Suggested  Reading:  
1. Agnew  N.  Preopera4ve  cardiopulmonary  exercise  tes4ng.  Con4nuing  Educa4on  in  Anaesthesia,  
Cri4cal  Care  &  Pain.  2010  Mar  12;10(2):33–7.  
2. American  Thoracic  Society/American  College  of  Chest  Physicians.  ATS/ACCP  Statement  on  
Cardiopulmonary  Exercise  Tes4ng.  Am  J  Respir  Crit  Care  Med.  2003  Jan  15;167(2):211–77.  
3. LeveD  DZH,  GrocoD  MPW,  Cardiopulmonary  Exercise  Tes4ng  for  Risk  Predic4on  in  Major  
Abdominal  Surgery.  Anesthesiology  Clinics.  Elsevier;  2015  Mar  1;33(1):1–16.  
4. Smith  TB,  Stonell  C,  Purkayastha  S,  Paraskevas  P.  Cardiopulmonary  exercise  tes4ng  as  a  risk  
assessment  method  in  non  cardio-­‐pulmonary  surgery:  a  systema4c  review.  Anaesthesia.  2009  
Aug;64(8):883–93.  
 

Dr. Hugh Taylor

Department Anaesthesia and Pain Medicine
August, 2015