Cardiopulmonary exercise testing in contemporary cardiology: physiological insights, novel applications and evolving algorithms

Cardiopulmonary exercise testing (CPET) allows for the study of the pathophysiology of exercise intolerance through assessment of exercise integrative physiology of the pulmonary, cardiovascular, muscular and cellular oxidative systems. Over the years, key gas exchange variables have shown a role in the interpretative translation of physiology to clinical decision making. CPET is a standard when approaching all forms of exercise intolerance, with a predominant evidence for heart failure and hypertrophic cardiomyopathy. As impaired cardiac output and peripheral oxygen diffusion are the main determinants of the abnormal functional response in patients with cardiac issues, invasive CPET (iCPET) has been gaining popularity, especially in confirming the diagnosis of heart failure with preserved ejection fraction (HFpEF) and exercise-induced pulmonary hypertension. Impactful advancements come from the application of CPET combined with echocardiography, or CPET imaging, which shows less accuracy in the left and right haemodynamic assessment compared with iCPET but adds information on atrial and biventricular cardiac valve functional perturbations. While gas exchange classifications and scores are predominant for heart failure with reduced ejection fraction, algorithms are growing on refining exercise unexplained dyspnoea categorisation in HFpEF. The implementation of wearable systems and artificial intelligence to estimate peak oxygen consumption is part of the novel applications. This review focuses on CPET use and perspectives focusing on the most modern advancements in cardiology.