Karlman Wasserman MD PhD - Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications

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Library of Congress Cataloging-in-Publication Data

9781609138998

1609138996

Principles of exercise testing and interpretation : including pathophysiology and clinical applications / Karlman Wasserman [et al.]. 5th ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-60913-899-8 (hardback : alk. paper)

I. Wasserman, Karlman.

[DNLM: 1. Exercise Test. 2. Physical Exertion-physiology. WG 141.5.F9]

616.1'20754dc23

2011036549

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To Our Families

I n this fifth edition of Principles of Exercise Testing and Interpretation, as in earlier editions, we attempt to develop conceptual advances in the physiology and pathophysiology of exercise, particularly as related to the practice of medicine. The underlying theme of the book continues to be the recognition that the most important requirement for exercise performance is transport of oxygen to support the bioenergetic processes in the muscle cells (including, of course, the heart) and elimination of the carbon dioxide formed as a byproduct of exercise metabolism. Thus, appropriate cardiovascular and ventilatory responses are required to match those of muscle respiration in meeting the energy demands of exercise.

As depicted by the logo on the book cover, normal exercise performance requires an efficient coupling of external to internal (cellular) respiration. Appropriate treatment of exercise intolerance requires that patients' symptoms be thought of in terms of a gas exchange defect between the cell and the environment. The defect may be in the lungs, heart, peripheral or pulmonary circulations, the muscles themselves, or there may be a combination of defects. Thus, we describe the pathophysiology in gas transport and exchange that affect any site in the cardiorespiratory coupling between the lungs and the muscles.

We illustrate how cardiopulmonary exercise testing can provide the means for a critical evaluation by the clinician-scientist of the functional competency of each component in the coupling of cellular to external respiration, including the cardiovascular system. To achieve this, clinical cases are used to illustrate the wide spectrum of pathophysiology capable of causing exercise intolerance.

The primary symptoms causing exercise intolerance, typically dyspnea and/or fatigue, are shown to have a rational pathophysiological basis. Without cardiopulmonary exercise testing, the treatment of patients with exercise intolerance may be improperly focused because the pathophysiology causing the exercise intolerance may not be well understood by the physician working within the diagnostic spectrum of his or her subspecialty. Exertional dyspnea and/or fatigue at unusually low levels of exercise can often be traced to abnormal coupling of the cardiopulmonary mechanisms required for normal gas exchange. Therefore, by measuring gas exchange during cardiopulmonary exercise tests, not only can the exercise limitation be quantified, but the functional adequacy of the heart, circulatory system, and lungs also can be established. Fortunately, this can usually be done noninvasively.

We believe that each chapter of this book makes original contributions to the understanding of exercise physiology. In particular, provide extensive information about changes in arterial, mixed venous, and femoral vein blood gases and arterial lactate during lower extremity exercise. These chapters are valuable for differentiating the function of the peripheral from central circulations and describe mechanisms that enable favorable shifts in the oxyhemoglobin and CO2 dissociation curves to optimize arterial-venous differences and minimize changes in muscle capillary PO2 and PCO2.

The gas exchange responses to exercise can indicate to the investigator which organ(s) are functioning poorly and which are functioning well. Because the pattern of the gas exchange response is characteristic of the disease process, it can enable a clinical diagnosis. For instance, cardiopulmonary exercise testing might not only detect cardiovascular limitation, but could also be used to distinguish which cardiovascular disease restricts the patient's exercise performance when several might coexist, such as coronary artery disease, chronic heart failure, and peripheral vascular disease. describes a flowchart approach to assist in making a clinical diagnosis, using the physiological data obtained during cardiopulmonary exercise testing. It is likely that no test in medicine can be used to diagnose the broad spectrum of diseases, while quantifying severity of organ dysfunction or improvement in the pathophysiology of exercise intolerance, better and more cheaply than cardiopulmonary exercise testing. As a referral center for problematic cases, we are often impressed with the revelations of pathophysiology provided by cardiopulmonary exercise testing.