During the COVID-19 pandemic, the use of protective masks has been essential to reduce contagions. However, public opinion is that there is an associated subjective shortness of breath. We evaluated cardiorespiratory parameters at rest and during maximal exertion to highlight any differences with the use of protective masks.12 healthy subjects performed three identical cardiopulmonary exercise tests, one without wearing a protective mask, one wearing a surgical mask and one with a filtering face piece particles class 2 (FFP2) mask. Dyspnoea was assessed using the Borg scale. Standard pulmonary function tests were also performed.All the subjects (40.8±12.4 years; six male) completed the protocol with no adverse events. Spirometry showed a progressive reduction of forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) from no mask to surgical to FFP2 (FEV₁: 3.94±0.91 L, 3.23±0.81 L, 2.94±0.98 L; FVC: 4.70±1.21 L, 3.77±1.02 L, 3.52±1.21 L; p<0.001). Rest ventilation, O₂uptake (V˙O₂) and CO₂production (V˙CO₂) were progressively lower, with a reduction in respiratory rate. At peak exercise, subjects had a progressively higher Borg scale when wearing surgical and FFP2 masks. Accordingly, at peak exercise,V˙O₂(31.0±23.4 mL·kg⁻¹·min⁻¹, 27.5±6.9 mL·kg⁻¹·min⁻¹, 28.2±8.8 mL·kg⁻¹·min⁻¹; p=0.001), ventilation (92±26 L, 76±22 L, 72±21 L; p=0.003), respiratory rate (42±8 breaths·min⁻¹, 38±5 breaths·min⁻¹, 37±4 breaths·min⁻¹; p=0.04) and tidal volume (2.28±0.72 L, 2.05±0.60 L, 1.96±0.65 L; p=0.001) were gradually lower. There was no significant difference in oxygen saturation.Protective masks are associated with significant but modest worsening of spirometry and cardiorespiratory parameters at rest and peak exercise. The effect is driven by a ventilation reduction due to increased airflow resistance. However, because exercise ventilatory limitation is far from being reached, their use is safe even during maximal exercise, with a slight reduction in performance.

SUMMARY: Aim: To assess the effect of chronotropic incompetence on functional capacity in chronic heart failure (CHF) patients, as evaluated as NYHA and peak oxygen consumption (pVO₂), focusing on the presence and dose of β‐blocker treatment. Methods: Nine hundred and sixty‐seven consecutive CHF patients were evaluated, 328 of whom were discarded because they failed to meet the study criteria. Of the 639 analyzed, 90 were not treated with β‐blockers whereas the other 549 were. The latter were further subdivided in high (n = 184) and low (n = 365) β‐blockers daily dose group in accordance with an arbitrary cut‐off of 25 mg for carvedilol and of 5 mg for bisoprolol. Failure to achieve 80% of the percentage of maximum age predicted peak heart rate (%Max PHR) or of HR reserve (%HRR) constituted chronotropic incompetence. Results: No differences were found in NYHA or pVO2 between patients with and without β‐blockers and, similarly, between high and low β‐blocker dose groups. Twenty and sixty‐nine percent of not β‐blocked patients showed chronotropic incompetence according to %Max PHR and %HRR, respectively, whereas this prevalence rose to 61% and 84% in those on β‐blocker therapy. Patients taking β‐blockers without chronotropic incompetence, as inferable from both %Max PHR and %HRR, showed higher NYHA and pVO2 regardless of drug dose, whereas, in not β‐blocked patients, only %HRR revealed a difference in functional capacity. At multivariable analysis, HR increase during exercise (ΔHR) was the variable most strongly associated to pVO2 (β: 0.572; SE: 0.008; P < 0.0001) and NYHA class (β: −0.499; SE: 0.001; P < 0.0001). Conclusions: ΔHR is a powerful predictor of CHF severity regardless of the presence of β‐blocker therapy and of β‐blocker daily dose.

Rehabilitation in patients with advanced cardiac and pulmonary disease has been shown to increase survival and improve quality of life, among many other benefits. Exercise training is the fundamental ingredient in these rehabilitation programs. However, determining the amount of exercise is not straightforward or uniform. Most rehabilitation and training programs fix the time of exercise and set the exercise intensity to the goals of the rehabilitation program and the exercise-related hurdles of the individual. The exercise training intensity prescription must balance the desired gain in conditioning with safety. Symptom-limited cardiopulmonary exercise testing is the fundamental tool to identify the exercise intensity and define the appropriate training. In addition, cardiopulmonary exercise testing provides an understanding of the systems involved in oxygen transport and utilization, making it possible to identify the factors limiting exercise capacity in individual patients.

Background: The RoMa classification, based on peak heart rate and oxygen pulse derived from cardiopulmonary exercise testing, was recently proposed to stratify patients with hypertrophic cardiomyopathy by physiological reserve during exercise. We aimed to externally validate RoMa in an independent multicenter cohort with hypertrophic cardiomyopathy and assess its association with long‐term clinical outcomes. Methods: In this retrospective multicenter cohort study patients with hypertrophic cardiomyopathy, undergoing cardiopulmonary exercise testing, were consecutively enrolled. Patients were enrolled regardless of left ventricular outflow tract obstruction and were naïve to disease‐specific therapy (eg, mavacamten). Patients were categorized into RoMa I to IV based on percentage of predicted heart rate and oxygen pulse. The primary end point was a composite of all‐cause and cardiovascular death, sudden cardiac death, or aborted sudden cardiac death, heart failure–related hospitalization, stroke, systemic embolism, surgical myectomy, and heart transplantation. Results: The study included 292 patients (age 51 [36–63] years, 70% male sex, 30% with obstructive left ventricular outflow tract). Functional capacity declined hierarchically across RoMa groups (peak oxygen uptake 29.2 to 17.9 mL/kg/min; P ‐trend <0.001). During follow‐up (≈6 years), 68 composite events occurred. Kaplan–Meier analysis showed significant differences in event‐free survival across groups (log‐rank P =0.019). In multivariable analysis, RoMa II to IV compared with RoMa I were independently associated with higher hazard ratios (HRs) for the composite outcome (HRs, 3.89–5.37; all P <0.05), whereas genotype, LVEF <50%, male sex, and left ventricular outflow tract obstruction were not predictive. Conclusions: The RoMa classification independently predicts long‐term, clinically relevant outcomes in hypertrophic cardiomyopathy regardless of left ventricular outflow tract obstruction and may provide a novel approach to risk stratification.

Many variables obtained during cardiopulmonary exercise test (CPET), including O₂ uptake (VO₂) versus heart rate (HR, O₂-pulse) and work rate (VO₂/Watt), provide quantitative patterns of responses to exercise when left ventricular dysfunction is an effect of myocardial ischemia (MI). Therefore, CPET offers a unique approach to evaluate exercise-induced MI in the presence of fixed or dynamic coronary arteries stenosis. In this paper, we examined the case of a 74-year-old patient presenting with an ischemic CPET and a normal stress cardiac magnetic resonance (CMR) with dipyridamole. A coronary angiography demonstrated the presence of myocardial bridging (MB), a well-known congenital coronary anomaly that is able to generate MI during exercise (but not in provocative testing using coronary artery vasodilators, such as dipyridamole). Despite the good diagnostic accuracy of the imaging methods (i.e., stress CMR) in MI detection, this case shows that exercise should be the method of choice in elicit ischemia in specific cases, like MB.

In patients at high cardiovascular risk, a low-density lipoprotein cholesterol (LDL-C) reduction of ≥50% from baseline and an LDL-C goal of <70 mg/dL (or <55 mg/dL in very high-risk patients) are recommended. Multiple registry and retrospective studies have shown that patients with high atherosclerotic cardiovascular risk often do not reach the targets defined by the European Society of Cardiology guidelines as a result of suboptimal management of LDL-C. Here, we report the data on lipid-lowering therapy and lipid targets from the Survey on Risk FactOrs and CardiovascuLar secondary prEvention and drug strategieS (SOFOCLES), an observational, prospective study designed to collect data on patients with ischemic heart disease treated at cardiac outpatient clinics across the Italian national territory. We included patients with known coronary heart disease (CHD) who underwent follow-up visits at various outpatient cardiology clinics. A total of 2532 patients were included (mean age: 67±17 years, 80% male). Among patients with available laboratory data (n=1712), 995 (58%) had LDL-C<70 mg/dL, 717 (42%) had LDL-C≥70 mg/dL, and 470 (27%) had LDL-C<55 mg/dL. Patients who more frequently achieved the recommended LDL-C levels were male, had diabetes, had a higher educational level, and performed intense physical activity. Statins were used in 2339 (92%) patients, high-intensity statins (e.g., rosuvastatin 20/40 mg or atorvastatin 40/80 mg) in 1547 patients (61% of the whole population and 66% of patients on statins), and ezetimibe in 891 patients (35%). Patients receiving high-intensity statins tended to be younger, not to have diabetes, and to have been included in a cardiac rehabilitation program. In a real-world sample of Italian patients with CHD, adherence to lipid-lowering therapy fell markedly short of optimal levels. Many patients did not achieve the LDL-C target of 70 mg/dL, and even fewer reached the LDL-C target of 55 mg/dL. Notably, patients with a lower educational level had a greater likelihood of being undertreated. Strategies aimed at improving preventive interventions for CHD and overcoming social disparities should be evaluated and optimized.