Cardiopulmonary exercise test in patients with subacute pulmonary emboli

Yan Topilsky, Courtney L Hayes, Amber D Khanna, Thomas G Allison
Heart & Lung: the Journal of Critical Care 2012, 41 (2): 125-36

OBJECTIVE: Patients presenting with suspected pulmonary embolism (PE) may present a challenge, particularly if diagnostic testing is not immediately available or clinically not indicated (iodine allergy, pregnancy, renal dysfunction). These patients have abnormal regional gas exchange that can be recognized by a cardiopulmonary exercise test (CPET), which may become helpful in their evaluation.

METHODS: A retrospective analysis was performed of outpatients evaluated for subacute exertional dyspnea of 2 to 12 weeks duration with a test for PE and CPET. A total of 108 patients met inclusion criteria. Thirty patients (27.8%) had confirmed PE.

RESULTS: The patients with PE had increased nadir ventilatory equivalent ratio for carbon dioxide (VE/VCO(2)), decreased peak oxygen uptake/predicted, and decreased end exercise saturation (P < .005 for all). All patients but 1 had normal breathing reserve (>15%). A normal nadir VE/VCO(2) excluded PE with 100% sensitivity. By using a "flow chart strategy," the exercise test had 92.8% sensitivity and 92.1% specificity for PE. Eight patients with PE died during follow-up (3.8 ± 4.6 years), 6 of PE-related causes. Peak VO(2)/kg was the best predictor of all-cause mortality and nadir VE/VCO(2) for PE-related mortality. There were no serious complications from any of the exercise tests.

CONCLUSION: PE may be excluded by a normal nadir VE/VCO(2) in patients presenting with subacute dyspnea. A combination of decreased peak VO(2)/kg, increased nadir VE/VCO(2), normal breathing reserve, and exercise-induced desaturation may be sensitive and specific for PE. CPET may assist in identifying subacute PE in patients with contraindications to use of computed tomography angiography or ventilation perfusion scans.

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