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PubMed2006

[Ironman and cardiac transplantation. High sporting exercise capacity before and after cardiac transplantation].

The case of a 45-year-old man is reported who was an active competitive sportsman up to his 38th year. In fall of 1998, exercise limitation was noted. The cardiologic work-up revealed dilated cardiomyopathy. In spite of intensive medical therapy clinical course deteriorated within the next 3 years, cardiologic findings and a follow-up in CPET (cardiopulmonary exercise testing) showed a rapid decline. In May 2002, he was listed for cardiac transplantation. In August 2003, an orthotopic bicaval cardiac transplantation was performed at the University of Göttingen, Germany. The patient was followed regularly in the office. Physical exercise capacity increased significantly and he was able to participate in the 10-km New Year's run of 2003. Since 2004, he has been working very successfully as a coach for competitive swimmers. Based on CPET findings, actual views and concepts regarding the pathophysiology and training of chronic heart failure are discussed and the question is raised whether and in which respect a sportive predisposition favors the clinical outcome.

Cardiomyopathy, Dilated↗

PubMed2000

Relation of changes over time in ventricular size and function to those in exercise capacity in patients with chronic heart failure.

BACKGROUND: We studied the direction and magnitude of changes in left ventricular (LV) cavity size and mass over time and whether these changes were related to those in exercise performance in patients with chronic heart failure (CHF). METHODS AND RESULTS: The study group was composed of 59 patients (55 men aged 58 +/- 10 years) with CHF and LV end-diastolic diameter (EDD) >55 mm. All underwent echocardiography and a treadmill cardiopulmonary exercise test within a 4-week interval (baseline) and again after a period of >/=4 months (median of 14 months). At baseline, the group as a whole had moderate to severe LV dysfunction with an EDD of 70 +/- 9 mm, end-systolic diameter (ESD) of 60 +/- 11 mm, and LV mass of 500 +/- 200 g. The mean peak oxygen consumption (Vo (2), 18 +/- 6 mL/kg per minute) was unrelated to LV cavity size or mass. EDD increased in 37 (63%) of the patients and fell in 22 (37%) patients from the initial to the second test. The absolute magnitude of changes over time averaged 7 mm for EDD, 125 g for mass, and 6 mL/kg per minute for peak Vo(2). Changes in LV size and mass per year were significantly related to those in peak Vo(2) (r = -0.49 for EDD, r = -0.56 for ESD, and r = -0.44 for LV mass, respectively, all P <.001) and ventilatory response to exercise (r = 0.60, r = 0.58, and r = 0.72 for EDD, ESD, and LV mass; respectively, all P <.001). CONCLUSIONS: Changes over time in objective measures of LV dimensions and mass, in patients with CHF are significantly related to those in exercise capacity and respiratory efficiency.

Adult↗

PubMed1992

Reduced cardiac output and exercise capacity in patients after MI.

This article summarizes the literature and suggests directions for future research concerning rehabilitation potential, impairment, and reduced cardiac output after myocardial infarction (MI). Current evidence suggests that cardiac output and maximal exercise capacity are reduced in some post-MI patients. The conceptual model of rehabilitation potential presented emphasizes the need for careful assessment of the state of underlying pathology present after MI when evaluating the response to exercise or exercise training.

Cardiac Output↗

PubMed1998

Analysis of impaired exercise capacity in patients with cirrhosis.

Exercise limitation in cirrhosis is typically attributed to a cirrhotic myopathy (without impaired oxygen utilization) and/or a cardiac chronotropic dysfunction. We performed symptom-limited cardiopulmonary exercise testing in 19 cirrhotics without confounding variables (cardiopulmonary disease, beta blockade, anemia, smoking). Twelve concurrently exercised patients without cirrhosis and with normal resting pulmonary function were controls. Oxygen consumption (VO2) at peak exercise, at anaerobic threshold (VO2-AT), work rate (WR), and heart rate (HR) were measured. Cirrhotics had significantly lower peak WR (73+/-4 vs 107+/-7% predicted, p < 0.001), VO2 (72+/-4 vs 98+/-5% predicted, P < 0.001), VO2-AT (53+/-4 vs 71+/-5% predicted peak VO2, P < 0.01), HR (83+/-2 vs 91+/-2% predicted, P < 0.01) and were more likely to have chronotropic dysfunction (peak HR < 85% predicted). Six cirrhotics had normal aerobic capacity (peak VO2 > 80% predicted), while 13 were abnormal. The abnormals had an earlier AT (46+/-2 vs 67+/-3% predicted peak VO2, P < 0.05) but no difference in peak HR percent predicted was found. In conclusion, two thirds of cirrhotics, without confounding factors, have significantly reduced aerobic capacity. Cirrhotic myopathy (without impaired O2 utilization) and cardiac chronotropic dysfunction do not adequately account for the observed decrease in aerobic capacity.

Adult↗

PubMed1999

Arterial blood oxygenation, maximum exercise capacity and oxygen transport in patients before and after autologous peripheral blood progenitor cell transplantation.

Several studies have reported a reduced pulmonary diffusion capacity for carbon monoxide after total body irradiation (TBI) and/or high-dose chemotherapy (HDCT) and autologous peripheral blood progenitor transplantation (APBPC). The present study describes the oxygenation of arterial plasma (paO2), the maximum exercise capacity (Wmax) and maximum oxygen transport (VO2max) before and after such treatment. Pulmonary gas exchange and paO2 were measured in 15 patients at maximum dynamic bicycle exercise, performed before and at 8+/-0.9 (s.e.m.) months after TBI/HDCT (n = 12) and HDCT (n = 3) followed by APBPC. Wmax was 169+/-14 and 157+/-15 watts (P>0.05) before and after therapy, respectively. VO2max, 1.8+/-0.1 l/min before treatment, fell to 1.6+/-0.1 l/min (P<0.05) after therapy. The maximum exercise paO2 was 13.2+/-0.4 kPa before and 13.6+/-0.4 kPa (P>0.05) after the treatment period. The findings indicate no significant reduction of Wmax or pulmonary diffusion capacity for O2 after TBI/HDCT and APBPC while VO2max fell modestly by approximately 11%. The study was restricted to patients who remained in remission.

Adult↗

PubMed1994

Effect of increasing doses of beta agonists on spirometric parameters, exercise capacity, and quality of life in patients with chronic airflow limitation.

BACKGROUND: A study was undertaken to determine the impact of different doses of inhaled terbutaline on peak flow rates, spirometric parameters, functional exercise capacity, and quality of life in patients with chronic airflow limitation. METHODS: A double blind, randomised, placebo controlled, multiple crossover trial was conducted with treatment periods of one week. Patients with a clinical diagnosis of chronic airflow limitation and FEV1 below 70% predicted after administration of bronchodilator were recruited from secondary care respiratory practices, and the effect of 500, 1000, and 1500 micrograms inhaled terbutaline four times daily on spirometric parameters (FEV1, FVC), maximum inspiratory pressures, six minute walking distance, and health-related quality of life (Chronic Respiratory Disease Questionnaire, Quality of Well Being, Standard Gamble) was measured. RESULTS: Twenty five patients completed the trial. Peak flow rates and FEV1 showed statistically significant but clinically trivial improvement on the higher drug doses. Results of maximum inspiratory pressure measurements, walk test distance, and quality of life measures showed minimal differences on the different dosages, and none of the differences approached conventional statistical significance. CONCLUSIONS: Regular use of beta agonists in doses higher than two puffs four times a day is very unlikely to provide additional functional or symptomatic benefit to patients with chronic airflow limitation.

Aged↗

PubMed1992

Ascending aortic Doppler velocity and the prediction of exercise capacity in post-infarction left ventricular dysfunction.

A system to improve analysis of the aortic pulsed Doppler velocity signal has been developed and used to study cardiac performance during a 4 min, 25 W incremental stage supine bicycle exercise to exhaustion. Twenty-two male subjects with stable chronic ischaemic heart disease were studied (15 with NYHA class II/III heart failure, and seven age-matched class I subjects). None had evidence of reversible ischaemia. Peak velocity (PV) from the intensity weighted mean velocity profile, early acceleration (eA) and stroke distance (SD) were all significantly lower at rest in class II/III compared to class I. For the change from rest to 50 W, PV did not alter, eAC increased significantly (P less than 0.05) and to a similar extent in both groups (18.6% class II/III vs 16.4% class I) and SD was reduced from 7.8 to 5.9 in class II/III (P less than 0.01) but did not change in class I (12.4 vs 11.8, ns). There was also a greater increase in heart rate (HR) in class II/III subjects (P less than 0.05). The duration of exercise was correlated with resting PV (r = 0.48, P less than 0.025) but was correlated best with the change in blood momentum (PV x Stroke volume x HR) between rest and peak exercise (r = 0.80, P less than 0.001). Thus Doppler velocimetry can give quantitative information on the response to exercise which discriminates between grades of ventricular dysfunction and is predictive of exercise capacity.

Adult↗

PubMed2000

Effects of simulated altitude-induced hypoxia on exercise capacity in patients with chronic heart failure.

PURPOSE: Patients with stable heart failure often wish to spend time at altitudes above those of their residence. However, it is not known whether they can safely tolerate ascent to high altitudes or what its effects on work capacity may be. SUBJECTS AND METHODS: We studied 14 normal subjects and 38 patients with clinically stable heart failure, 12 of whom had normal workload [peak exercise oxygen consumption (VO(2)) greater than 20 mL/min/kg], 14 of whom had slightly diminished workload (peak VO(2) 20 to 15 mL/min/kg), and 12 of whom had markedly diminished workload (peak VO(2) less than 15 mL/min/kg) at baseline. All performed cardiopulmonary exercise tests with inspired oxygen fractions equal to those at 92, 1,000, 1,500, 2,000, and 3,000 m, and maximum achieved work rates (mean +/- SD) were measured. RESULTS: All subjects completed the trial; no test was interrupted because of arrhythmia, angina, or ischemia. Maximum work rate decreased in parallel with increasing simulated altitude. The percentage decrease was greater for patients with heart failure and was most marked among those with the lowest workload at baseline. Maximum achieved work rate declined by 3% +/- 4% per 1,000 m in normal subjects, by 5% +/- 3% (P <0.01) in patients with heart failure with normal workload, by 5% +/- 4% (P <0.01) in patients with slightly diminished workload, and by 11% +/- 5% (P <0.01 vs normal subjects and vs the other patients with heart failure) in patients with markedly reduced workload. CONCLUSION: Patients with stable heart failure who ascend to higher altitudes should expect to have a reduction in maximum physical activity in proportion to their exercise capacity at sea level.

Aged↗

PubMed1989

Exercise capacity following pulmonary rehabilitation in the elderly.

Pulmonary rehabilitation has proven beneficial for patients with chronic airway obstruction. In this study, the authors evaluate the effect of rehabilitation in elderly patients. Results show that the change in exercise capacity was not related to the patients' age, and suggest that age alone should not be an exclusionary criterion.

Adult↗

PubMed1996

The effect of cigarette smoking on exercise capacity in patients with intermittent claudication.

The purposes of this study were: (1) to determine whether peripheral arterial occlusive disease (PAOD) patients who smoked had more severe claudication pain, reduced peripheral circulation, and poorer cardiopulmonary measurements at peak exercise than non-smoking patients, and (2) to determine whether the differences between the smoking and non-smoking patients persisted after controlling for the resting ankle/brachial systolic pressure index (ABI). Thirty-eight PAOD patients (ABI = 0.59 +/- 0.15, mean +/- SD) who smoked an average of 1.5 packs of cigarettes per day over 42 years and 100 PAOD patients (ABI = 0.74 +/- 26) who had quit smoking for an average of 7 years were recruited. Smokers refrained from smoking on the day of testing. Claudication pain times, oxygen uptake, ventilation, leg oximetry, and ankle systolic pressure responses to peak exercise were recorded. The smoking group had more severe claudication pain, as maximal pain occurred 1:37 min:s sooner during exercise (p < 0.05), and the pain took 2:21 min:s longer to subside (p < 0.01) compared to the non-smoking group. Additionally, at peak exercise the smoking group had a lower oxygen uptake (12.8 +/- 2.6 vs 13.9 +/- 2.4 ml/kg/min, p < 0.01), a higher ventilation (31.7 +/- 9.2 vs 27.9 +/- 7.1 liters/min, p < 0.05), and a higher oximeter electrode power (409 +/- 55 vs 385 +/- 37 mW, p < 0.01) than the non-smoking group. Differences between the groups persisted (p < 0.05) after adjusting for resting ABI. It is concluded that cigarette smokers with PAOD had more severe claudication pain, reduced peripheral circulation, and poorer cardiopulmonary measurements at peak exercise than non-smoking patients. These differences were independent of resting ABI. Thus, cigarette smoking reduces the exercise capacity of claudicants, placing patients who smoke at an even greater risk of living a functionally dependent lifestyle.

Adult↗

PubMed1994

Early impairment of the cardiopulmonary exercise capacity of hypertensive patients.

A reduction of functional capacity has been reported in severe hypertension. However, the reduced peripheral vasodilation observed in the early stages of hypertension, could also impair the blood supply to exercising muscles in mild hypertensives presenting a normal left ventricular mass. In this paper the cardiopulmonary exercise capacity of early hypertensives has been investigated. Thirty mild hypertensives (9 in stage I and 21 in stage II according to WHO) and 36 normotensives divided into two age and weight-matched groups, were investigated. All subjects underwent a stress test according to the modified Bruce protocol with contemporary assessment of breath-by-breath expiratory gas analysis and measurement of the anaerobic threshold (AT) and of the oxygen consumption at peak exercise (PVO2). Exercise duration and maximal workload, in stage I hypertensives, were similar to controls but the O2 consumption was significantly reduced in comparison to controls (P = 0.043). On the contrary, in stage II patients exercise duration, maximal workload, PVO2 and AT were significantly lower than in normotensives. No relationship between myocardial hypertrophy and ergometric or ventilatory (PVO2, AT, VE) parameters was found. In conclusion an early impairment of the aerobic exercise performance is detectable in uncomplicated (stage I WHO) mild hypertensives.

Adult↗

PubMed1987

Value of predischarge data for the prediction of exercise capacity after cardiac rehabilitation in patients with recent myocardial infarction.

The aim of this study was to assess whether data related to predischarge clinical examinations, resting radionuclide ventriculography and symptom-limited bicycle ergometry can predict the achievement of a normal exercise capacity after a rehabilitation program in patients with a recent myocardial infarction. The study population consists of 141 consecutive patients who completed a 3-month training program. Patients with heart failure and/or severe angina were excluded. The rehabilitation program included two training sessions weekly during the 3 months. Working capacity (WC) increased from 79 +/- 17% at hospital discharge to 105 +/- 21% of normal values after rehabilitation (P less than 0.001), by 33% on average. Ninety-five patients achieved a normal WC. Conventional predischarge clinical evaluation, resting left ventricular ejection fraction, exercise induced angina, or ST segment depression were not predictive of normal WC after rehabilitation. Predischarge WC was the single best predictor of a normal WC after rehabilitation compared to those with a persistently low WC (84 +/- 15% in patients with normal WC vs 69 +/- 14% in those with persistently low WC, P less than 0.001). Nevertheless, 49% of patients with a baseline WC of less than 80% achieved a normal WC after rehabilitation. No correlation was found between the change of WC after rehabilitation and predischarge WC or ejection fraction. Therefore, the selection of patients for cardiac rehabilitation after a myocardial infarction should be based primarily on clinical grounds. Exclusion based on exercise induced angina, ST segment depression or low resting ejection fraction at hospital discharge or at entry in the rehabilitation program is not justified.

Adult↗

PubMed1984

Exercise capacity as a predictor of post-thoracotomy morbidity.

Although severe impairment on routine pulmonary function tests will identify patients with a high post-thoracotomy morbidity, cardiopulmonary complications often develop in patients with only a mild-to-moderate impairment in pulmonary function. To determine whether the preoperative exercise capacity can prospectively identify those at risk of developing complications, 22 patients scheduled for thoracotomy (mean age, 55.7 +/- 2 yr) underwent an incremental exercise test on a cycle ergometer to determine their maximal O2 uptake (VO2max) prior to thoracotomy. Routine pulmonary function tests were performed and postoperative forced expiratory volume in one second (FEV1) was predicted from split function perfusion lung scan in all subjects. Eleven of the 22 patients had no cardiopulmonary complications postoperatively. The age, history of prior cardiovascular disease, degree of impairment on routine pulmonary function tests, and predicted postoperative FEV1 were similar in those who did and those who did not experience complications. However, those without complications had a significantly higher VO2max than did those who experienced complications (22.4 +/- 1.4 versus 14.9 +/- 0.9 ml/kg/min, p less than 0.001). Only 1 of 10 patients with a VO2max greater than 20 ml/kg/min had a complication, whereas all 6 patients with a VO2max less than 15 ml/kg/min had a complication. We conclude that exercise testing is a useful adjunct in the evaluation of operative risk for thoracotomy.

Adult↗

PubMed2001

Independent contribution of myocardial perfusion defects to exercise capacity and heart rate recovery for prediction of all-cause mortality in patients with known or suspected coronary heart disease.

OBJECTIVES: The goal of this study was to determine the value of thallium201 single photon emission computed tomography (SPECT) imaging for prediction of all-cause mortality when considered along with functional capacity and heart rate recovery. BACKGROUND: Myocardial perfusion defects identified by thallium201 SPECT imaging are predictive of cardiac events. Functional capacity and heart rate recovery are exercise measures that also have prognostic implications. METHODS: We followed 7,163 consecutive adults referred for symptom-limited exercise thallium SPECT (mean age 60 +/- 10, 25% women) for 6.7 years. Using information theory, we identified a probable best model relating nuclear findings to outcome to calculate a prognostic nuclear score. RESULTS: There were 855 deaths. Intermediate- and high-risk prognostic nuclear scores were noted in 28% and 10% of patients. Compared with those with low-risk scans, patients with an intermediate-risk score were at increased risk for death (14% vs. 9%, hazard ratio: 1.67, 95% confidence interval [CI]: 1.44 to 1.95, p < 0.0001), while those with high-risk scores were at greater risk (24%, hazard ratio: 2.98, 95% CI: 2.49 to 3.56, p < 0.0001). In multivariable analyses that adjusted for clinical characteristics, functional capacity and heart rate recovery, an intermediate-risk nuclear score remained predictive of death (adjusted hazard ratio: 1.50, 95% CI: 1.28 to 1.76, p < 0.0001), as did a high-risk score (adjusted hazard ratio: 2.76, 95% CI: 2.13 to 2.56, p < 0.0001). Impaired functional capacity and decreased heart rate recovery provided additional prognostic information. CONCLUSIONS: Myocardial perfusion defects detected by thallium SPECT imaging are independently predictive of long-term all-cause death, even after accounting for exercise capacity, heart rate recovery and other potential confounders.

Activities of Daily Living↗

PubMed2002

Partial loading of the left ventricle during mechanical assist device support is associated with improved myocardial function, blood flow and metabolism and increased exercise capacity.

BACKGROUND: Myocardial recovery has been observed after placement of left ventricular assist devices in some patients awaiting cardiac transplantation. Left ventricular assist devices provide profound volume and pressure unloading while restoring systemic blood flow. However, the optimal degree of left ventricular unloading during left ventricular assist device support is unknown. The purpose of this study was to assess the effect of the degree of left ventricular decompression, during left ventricular assist device support, on myocardial function and exercise capacity. METHODS: Twenty patients with a left ventricular assist device performed cardiopulmonary exercise testing with simultaneous echocardiographic and hemodynamic measurements during full, and then partial, device support. Eleven patients underwent positron emission tomographic scanning for measurement of myocardial blood flow and oxygen consumption. RESULTS: Patients were divided into two groups based on the degree of left ventricular decompression as assessed by echocardiographic measurements. Patients with partially decompressed ventricles (n = 13, LVEDD = 4.8 +/- 1.0 cm) as compared to those with fully decompressed ventricles (n = 10, LVEDD = 3.0 +/- 0.3 cm) demonstrated significant improvements in: peak oxygen consumption (16.8 +/- 4.3 versus 12.8 +/- 3.0 ml/kg.min), native left ventricular index during exercise (2.5 +/- 1.4 versus 0.8 +/- 0.8 liters/min.m(2)); ability to exercise with the device weaned (10 of 13 versus 1 of 10 patients); resting myocardial blood flow (0.55 +/- 0.11 versus 0.21 +/- 0.13 ml/g.min); and myocardial oxygen consumption (0.04 +/- 0.01 versus 0.02 +/- 0.001 min-1) (all p < 0.05). CONCLUSIONS: These results suggest that partial loading of the left ventricle during left ventricular assist device support may be beneficial. Further study of optimal ventricular decompression during device support is needed, as this may be important in improving myocardial recovery.

Adult↗

PubMed1989

Arterial vasodilator therapy in heart failure: haemodynamic response patterns predictive of changes in exercise capacity.

When the peripheral vascular resistance is abnormally high, the heart can be considered to be pumping inefficiently in that much of its effort is wasted in overcoming the extra high load. Patients with such conditions are liable to have reduced exercise capacity (ExC). It is unclear whether selective arterial vasodilation in these patients can improve ExC. In a double-blind crossover comparative study of the effects of felodipine versus placebo in 10 patients with heart failure in NYHA class III, all patients decreased systemic vascular resistance (SVR) and increased cardiac index (CI), not only at rest but also during exercise. Since heart rate (HR) did not change, the increase in CI was due to increased stroke volume (SV). This beneficial haemodynamic response did not, however, correlate with functional response to the drug. A mixed exercise response was obtained, with 3 patients showing an increase, 3 a decrease, and 4 no change in ExC with felodipine. Therefore, we investigated whether an alternative way of characterizing haemodynamic response would explain why individual patients responded differently to the same drug. We tested the hypothesis that vasodilator therapy would enhance ExC if it were able to alter the load facing the heart in such a way that the cardiac pump needed to impart less hydraulic power output to maintain the same degree of physical exercise. Patients who could perform with felodipine the same submaximal exercise for less cardiac effort than with placebo were the ones who could increase their ExC during the vasodilator therapy. The converse was also true. We conclude that exercise response to vasodilator therapy depended on whether the failing heart was rendered able to pump more efficiently by the drug.

Aged↗

PubMed1991

Acute and chronic effects of once-daily isosorbide-5-mononitrate on the exercise capacity of patients with angina pectoris treated with a beta-blocking drug.

Forty-four patients with stable effort angina pectoris were included in a double-blind, randomised, placebo-controlled, parallel group study to compare the effect of two slow-release forms of isosorbide-5-mononitrate ('Ismo-Retard' 40 mg and 'Imdur' 60 mg) on exercise capacity when given as an adjunctive treatment to beta adrenoreceptor blocking therapy. In a symptom-limited exercise test performed three hours after the first dose, Ismo-retard increased the total duration of exercise by 92 seconds (confidence interval (CI) 5.1-116.9) p less than 0.006, and the time of onset to anginal pain by 117 seconds (CI 27.8, 156.1) p less than 0.004. A similar improvement in total duration of exercise (by 87 seconds) was noted three hours following 15 consecutive once-daily doses (CI 16.8-128) p less than 0.02, and in the time of onset to anginal pain by 101 seconds (CI 19.8-139.6) p less than 0.01. For Imdur the corresponding results were 53 seconds (CI 12.7-56.3), 84 seconds (CI 15.4-103.7), p less than .02, 54 seconds (CI 1.4-78.4) and 85 seconds (CI 6.9-120.5) respectively. These results would suggest that both active treatments were effective anti-anginal agents.

Adrenergic beta-Antagonists↗

PubMed1991

Short-term effects of oral enoximone on hemodynamics, exercise capacity, anaerobic threshold, and arrhythmias in congestive heart failure.

Enoximone, a phosphodiesterase-inhibitor, is a potent inotropic vasodilator agent that causes a marked improvement in hemodynamics in patients with congestive heart failure. The acute effects of oral enoximone on rest and exercise hemodynamics, ejection fraction, aerobic metabolism, exercise capacity, and arrhythmias were studied in 11 patients with moderate to moderately severe dilative cardiomyopathy after 8 days of enoximone (100 mg tid) in addition to baseline therapy (diuretics and digitalis). The cardiac index increased from 2.44 +/- 0.45 to 2.72 +/- 0.50 l/min/m2 (p less than 0.01) at rest and from 4.00 +/- 0.96 to 4.75 +/- 0.95 l/min/m2 (p less than 0.005) during exercise. Pulmonary wedge pressure decreased from 16.8 +/- 7.3 to 12.5 +/- 6.5 mmHg (p less than 0.005) at rest and from 28.2 +/- 8.0 to 24.5 +/- 10.3 mmHg (p less than 0.05) during exercise. Systemic vascular resistance decreased from 1608 +/- 243 to 1495 +/- 300 dynes*sec*cm-5 (p less than 0.05) at rest and from 1152 +/- 155 to 1027 +/- 236 dynes*sec*cm-5 (ns) during exercise. The anaerobic threshold, which was recorded simultaneously, increased from 13.2 +/- 2.7 to 15.5 +/- 2.5 ml/kg/min VO2 (p less than 0.02). The radionuclide ventriculography ejection fraction improved from 21.7 +/- 5.0 to 28.1 +/- 9.1% (p less than 0.01) during exercise; the changes at rest were not significant (20.8 +/- 6.2 vs 25.8 +/- 8.4%). Exercise tolerance showed an increase of 16% (492 +/- 133 to 573 +/- 135 sec, p less than 0.005). The resting heart rate remained unchanged (81.8 +/- 13.4 vs 81.8 +/- 11.9). Interestingly, 24-h Holter monitoring revealed more or new repetitive arrhythmias in 9/11 patients.

Adult↗