Fundamentals

of clinical cardiology

Maximal oxygen intake and nomographic assessment of

functional aerobic impairment in cardiovascular disease

R. A. Bruce, M.D.
F. Kusumi, U.S.
D. Hosmer, Ph.D.
Seattle, Wash.

M aximal oxygen intake (Vo,max)

the product of maximal cardiac
output and maximal arterial-mixed venous
is fatigue are reached and/or limiting symp-
toms or signs occur.
3. Be safe and acceptable to patients,
oxygen difference.’ In health it varies with especially when serial observations are
body weight, especially lean body mass.* desired.
Higher values are observed in men than in 4. Require minimal time for monitoring
women, in young adults than in older per- and supervising personnel yet provide sub-
sons, in athletes than in sedentary persons, stantial data.
even when corrected for differences in body 5. Have established normal standards of
weight.3-11 It diminishes with inactivity and submaximal oxygen requirements and high
increases with physical training.12 Since correlation of duration of exertion with
maximal AV-oxygen difference is not mark- Vo,max, to facilitate rapid and reliable
edly restricted by heart disease, reduction evaluation of Vozmax in relation to appro-
of Vozmax reveals the functional severity priate peer groups.
of disease in cardiac patients. A cumulative 9-year experience with over
Any test for *objective measurement and 10,000 tests on healthy persons and par-
evaluation of Vozmax for clinical applica- ticularly ambulatory cardiac patients with-
tion should meet certain basic require- out a fatality indicates that a multistage-
ments. More specifically, it should: treadmill testing procedure satisfies the
1. Utilize familiar dynamic exercise of first four requirements. Evidence to docu-
large muscles, which requires no special ment the fifth requirement is presented
skills or training and avoids pressor hazards here.
of isometric exercise.13,14
2. Begin with submaximal exertion, al- Material and methods
lowing time for physiologic adaptations, To provide normal standards for healthy
with progressive increments in workloads adults, measurements of oxygen intake at
until individually determined endpoints of various levels of submaximal, maximal,

From the Department of Medicine (Cardiology). and Department of Biostatistics, University of Washington, Seattle,
Wash.
This study has been supported in part by grants HE 09773. HE 13517-01, and HE 05281 from the National Heart
and Lung Institute. grant HS 00092 from the National Center for Health Services. United States Public Health
Service. and grant RR37 from the National Institutes of Health.
Received for publication May 16. 1972.
Reprint requests to: Dr. Robert A. Bruce, Co-Director, Division of Cardiology, Department of Medicine, RG-20,
University of Washington. Seattle, Wash. 98195.

546 American Heart Journal April, 1973 Vol. 85, No. 4, pp. 546-562
l’olsme 85
Ssmber 4 Maximal oxygen intake and functional aerobic impairment 547

l-7 mph, 10 “&grade 2.5mph. lZ%grade ,,, ;:iyk$ yo;;?‘ade IV Q6~;; ‘;o;6Tade
’ 2 74 kph, 5O43’ ” 4.02kph. 6’5’

c------- JOGGING - OR RUNNING .

50 r WALKING

-i?
Normal Men \io,submax-8.33 +2.94.(mIn), rz.936, ~~292 *
: 40
Normal Women ifozsubmax:8.05+ 2.74~(rrun), rz.926, N :509
9 Cardiac Men ~02submax~10.16~2.36~(m~n), rz.674, N~153
‘z F-l

1 2 3 4 5 6 7 8 9 10 11 12
MINUTES OF EXERCISE
t Unusually well tra,ned athletes

Fig. 1. Aerobic requirements of healthy adult men and women and cardiac men during first 12 minutes of
exercise testing, without support, on multistage treadmill (submaximal exercise only). Means are shown for
each minute. Data are expressed as ml./(Kg. min.) standard pressure and temperature, dry. Correlations on
l

regression equations are shown for each subgroup.

and in some instances transient supra-
maximal exercise were obtained from pre-
vious reports on 85 men,‘O 144 middle-aged
women,” and an additional 66 young men
and women. None was obtained from pa-
tient rosters of physicians or clinics. Physi-
cal activity of each person was dichoto-
mized into “physically active” and “seden-
tary” categories, depending upon partici-
pation in jogging, running games, or equiva-
lent levels of exertion regularly each week.
Physical characteristics of these 295 indi-
viduals are presented in Table I. Each had
been invited to participate voluntarily in
these studies. After being oriented about
purposes, methods, benefits, risks, rights,
and welfare to provide an adequate basis
for informed consent (see Appendix), each
was screened fa)r possible cardiovascular
disease or other contraindications to selec-
tion by history, physical examination,
12-lead resting electrocardiogram
For the purposes of this study, similar
data were obtained from ambulatory car-
diac patients with coronary or hyperten-
sive heart disease, to illustrate feasibility
of quantitative assessmentand magnitude
of impaired Vozmax as well as the modifi-
cations induced by treatment
glycerin. Each had been presented for
clinical evaluation and therapy of sympto-
matic disease; physical characteristics of
these patients are presented in Table II.
Again, each was screened prior to testing,
to exclude any with contraindications to
stress testing-specifically, active phase of
acute myocardial infarction or myocarditis,
pulmonary embolism, severe congestive
heart faiIure, ventricular tachycardia, or
marked digitalis intoxication, especially
with hypokalemia.
The multistage exercise test utilized a
calibrated treadmill to regulate energy
expenditure involuntarily and to attain the
highest possible level of i702.l~ This began
with walking slowly for 3 minutes at 1.7
mph at 10 per cent grade, with an energy
requirement equivalent to 4 “mets” or
multiples of VOW while sitting at rest; then
and speed and grade increased every 3 minutes
(ECG). without any intervening rest periods, as
indicated in Table III, to an individually
determined endpoint of fatigue and/or
other limiting symptoms or signs, when
exercise was stopped. Except for touching
the handrail with 1 or 2 fingers to maintain
body position near the center of the moving
with nitro- belt, not even partial support of body
 Am. Heart 1.
548 Bruce, Kusumi, and Homer April, 197.3

Table I. Physical and behavioral characteristics in healthy persons

Men

Physical Younger ( <45 years) Older (245 years)

status - -~ Total
/
Active Sedentary Active Sedentary
I

Sample size 13 25 69 138

Age hr.)” 35.1 * 7.4 36.3 * 7.1 52.?% 5.6 54.7 + 7.6 48.6* 11.1
Height (cm.)* 182.0 * 7.0 178.7 * 7.4 175.9 * 5.9 176.8 f 6.3 177.5 * 6.6
Weight (Kg.)* 79.5 f 7.4 79.2 * 9.1 77.1 * 9.0 78.9 f 8.6 78.6 + 8.6
Relative weight
(%Yt 96 A.5 98 +9 99 *8 100 f 10 98 * 9
Smokers (%) 14 16 10 16 14

*Means f standard deviations,

Observed weight
tRelative weight = x 100 where Predicted weight in Kg. for men = -60.7 + 0.79 (height in cm.)
Predicted weight for height by regression
andforwomen= -68,2+0,79(heightincm.).

Table II. Physical and behavioral characteristics in cardiac men

Sample size 52 21 10 15 98
Age hr.)* 46.7 * 10.6 48.3 * 7.8 53.4 * 8.8 52.9 * 7.9 48.7 * 9.8
Height (cm.)* 173.9 * 7.0 177.7 * 6.3 175.5 * 4.5 175.0 * 7.1 175.0 * 6.7
Weight (Kg.)* 81.4 * 12.5 74.8 * 11.3 80.1 * 13.8 80.1 * 7.0 79.6 * 11.8
Relative weight (%)*t 106 * 16 93 * 13 102 + 16 103 * 10 102 f 15

*Means * standard deviations.

Observed weight
tRelative weight = x 100 where Predicted weight in Kg. for men = -60.7 + 0.79 (height in
Predicted weight for height by regression
cm.) and far women = -68.2 i- 0.79 (height in cm.).
IAbbreviations: HMI = healed myocardial infarction; AP = angina pectoris.

weight was permitted. This precaution changes.“j ECG was recorded while the
greatly reduced the variability of exercise subject was sitting at rest, for each minute
duration in repeated tests. of exercise, and for 5 minutes of recovery
Mandatory indications for stopping ex- with the individual sitting again. Blood
ercise in the absence of other symptoms or pressure was recorded with a clinical
signs were the appearance of an ataxic sphygmomanometer before exercise, during
gait or of 3 or more consecutive ventricular each workload, and for 5 minutes of recov-
premature beats. ery. At high workloads during jogging,
A bipolar lead (from Vg position to pressure was often indeterminate, because
inferior tip of right scapula*) was used to of body motion and machine noise; then
monitor ECG for rhythm, rate, and ST-T initial recovery value was substituted as
the nearest approximation of pressure to
*Care was taken to reduce skin resistance. and to fix electrode maximal effort.
positions with adhesive rings around central point of elec-
trode jelly; another electrode elsewhere on the chest
With the patient’s nose occluded by a
wall grounded the individual to the electrocardiograph. clip, expired air was collected from a sili-
 l’otume 85
Number 4 Maximal oxygen intake and functionuE aerobic impairment 549

Women

Younger (<45 years) Older (245 years)

Total

Active Sedentary Active Sedentary

I I

20 67 24 46 157
36.3 f 7.7 33.3 * 7.9 52.4 * 4.6 50.1* 5.1 41.4 =t 11.2
167.5 f 7.1 166:l * 6.2 162.6 * 4.5 166.8 * 6.4 166.0 * 6.3
61.0 * 7.6 61.7 * 11.3 61.8 + 8.2 63.7 * 9.2 62.1 * 9.8

95 + 12 98 * 16 102 * 10 100 + 12 98 * 13
25 21 17 17 20

Table III. Absolute aerobic requirements of submaximal exercise observed at 1 or more minutes
prior to maximal oxygen intake, means f standard deviations in ml./(Kg.-min.) Voz

Healthy persons
Cardiac men
MiTl-
Stage utes Men Women
I

(N) Mean * SD (N) Mean * SD P* (N) Mean * SD Pi

I I

I. 1.7 mph (2.74 kmph) 1 (6) 12.4 * 2.2 (12) 9.0* 1.7 0.01 (5) 10.5 * 2.4
at 1O7o grade (5’ 43’) 2 (7) 16.7 * 1.8 (19) 15.4 * 1.5 NS (8) 15.8 * 3.1
3 (21) 17.4 * 1.4 (142) 16.9 * 1.5 NS (18) 17.8 * 2.7 NS

II. 2.5 mph (4.02 kmph) 4 (11) 19.6 * 2.1 (21) 19.2 * 2.0 NS (21) 19.9 * 3.7 N’s
at 125Yo grade (6” 51’) 5 (9) 24.1 * 1.2 (47) 21.7 * 1.7 0.001 (26) 22.1 * 2.6 0.01
6 (47) 24.8 + 2.1 (122) 23.2 * 1.8 0.001 (24) 23.1 * 2.9 0.01

III. 3.4 mph (5.47 kmph) 7 (29) 28.6 * 2.4 (57) 25.8 * 1.8 0.001 (13) 25.4 * 2.1 0.001
at 14% grade (7” 58’) 8 (46) 32.6 * 2.4 (41) 29.9 * 2.8 0.001 (16) 30.2 * 3.0 0.002
9 (69) 34.3 * 3.3 (31) 32.2 * 3.2 0.01 (16) 31.8 * 2.3 0.006

IV. 4.2 mph (6.76 kmph) 10 (29) 38.3 * 3.6 (9) 39.0 * 4.2 NS (6) 35.0 * 3.0 0.04
at 16% grade (9” 06’) 11 (12) 42.3 + 1.9 (3) 46.1 * 6.2 NS
12 (6) 43.8 * 4.0 (5) 49.1 * 5.4 NS

*Probability of observed differences between sexes being due to chance.

tProbability of observed differences between healthy and cardiac men being due to chance. (For the well-trained healthy person. there
are 3 additional stages of 5.0 mph and IS y0 grade. 5.5 mph and 20% grade, and 6.0 mph and 22% grade. Actually. it is exceedingly
uncommon for even an athlete to exceed the latter workload; if he does, a few additional seconds of effort produces maximal exer-
tion.)

cone rubber mouthpiece fitted with very minutes of strenuous exercise. Gasometric
low resistance valves (with a dead space measurements of volumes of expired air
of 0.1 L.) by plastic tubes of 4 cm. internal were corrected to standard pressure and
diameter into a series of evacuated neo- temperature, dry. Dual measurements of
prene balloons, where the inlet valve for oxygen concentrations were obtained with a
each bag was opened for exactly 60 seconds, Beckman paramagnetic analyzer, first with-
to sample various minutes of submaximal out and then with absorption of CO2
exercise and also sample the last 2 to 4 through a soda-lime column, to calculate
550 Bruce, Kusumi, and Hosmer Am. Heart J.
April, 1973

Table IV. Variations in maximal exercise performance in healthy persons*

Men
____--~-___-__ __--_____
Physical status Younger (< 45 years) Older (2 45 years)
___- _____-----__ ___---__~- Total

Active I Sedentary : Active Sedentary

Sample size 13 25 31 69 138

Duration (sec.)* 756 * 157 666 * 10.5 602 * 74 547 + 11.5 599 * 123
Max. HR (bpm)* 182 * 10 189 * 13 172 f 10 170 + 18 175 + 17
Change SBP 61 + 27 59 f. 26 66 * 23 52 f 27 57 * 26
(mm. Hg)*
Obs. irozmax 49.7 + 8.7 40.8 + 6.6 37.1 f 5.4 33.8 * 7.0 37.3 * 8.2
(ml./Kg.)*
Pred. iio?rnax 48.2 * 4.4 41.7 * 3.2 37.7 * 3.4 33.5 * 3.4 37.4 * 6.0
(ml./Kg.)*
Est. %‘o,max 47.8 * 9.9 40.5 * 5.7 38.1 * 4.6 33.9 * 6.3 37.2 * 7.5
(ml./Kg.)*
Functional aerobic -2 * 17 2 * 14 1 * 13 0 * 17 0 * 16
impairment (%)*

*Means rt standarddeviations.
Abbreviations:Max HR = maximalheartrate; ChangeSBP = maximalsystolic bloodpressureminusrestingsystolicpressure.

respiratory exchange ratio and VO, (see sex, age, and habitual physical activity
Appendix for formula). Each 60-second status (see equations under Results), desig-
sample of expired air was analyzed, and if nated “functional aerobic impairment”
exertion terminated during a final period (FAI) is defined as follows:
of more than 25 seconds it was extrapolated
to 60 seconds. The peak level of consecu- lio2maz predicted - 3ozrnoz observed
FAI= --x 100 (1)
tive %‘oz defined the Vozmax and usually 3 oImor predicted
occurred within the last minute; in the few
cases when it occurred in the minute before Stepwise multiple regressions and co-
termination, the final sample represented variance analyses were computed with
postmaximal Voz. Vos was corrected to BMD 02R programs (UCLA version of
kilograms of body weight, including light April 13, 1968) on a CDC 6400 computer.
clothing and shoes worn during the test. Nomograms for immediate assessment of
Relative aerobic requirements were defined FAI, with a straightedge intersecting
as per cent absolute value for any sub- “known age” and “observed duration,”
maximal \j02 relative to observed Vozmax were constructed for men, women, and
for that individual. cardiac men by geometric interpolation of
Reproducibility of Vonmax was deter- data computed from separate regression
mined in many persons by retesting from equations for predicting Vozmax (according
days to yeeks after the initial test. The to sex, age, and activity status) and esti-
value of Vozmax obtained by this protocol mation of Vo2max (according to observed
in several men was compared with that duration of this standardized multistage
observed by the research method of Tay- treadmill test of maximal exercise).
lor, Buskirk, and Henschell? which re-
quired 2 or more days to complete; re- Results
quired speed of running was reduced from Part one--Submaximal exercise
7 to 6 m.p.h. to accommodate older sub- 1. AEROBIC REQUIREMENTS.Means and
jects. standard deviations for oxygen require-
Per cent deviation in Vozmax observed ments per minute in ml. per kilogram of
relative to that predicted by regression on body weight, observed in healthy men and
 Maximal oxygen intake and functional aerobic impairment 551

Women
---___- ~----__---

Younger (< 4.5 years) Older (2 45 years )

_-- -- Total

Active Sedentary Ache Sedentary

I !

20 67 24 46 157
571 f 115 508 * 68 472 * 68 430 * 70 495 * 102
185 * 9 187 * 11 178 + 12 176 f 13 182 * 13
45 * 20 38 * 15 49 * 22 42 f 18 42 * 19

31.6 * 5.2 29.8 =t 5.6 26.7 * 3.6 25.2 * 3.4 28.7 * 6.7

31.6 =t 2.4 30.4* 2.8 26.7 * 1.4 24.2 =t 1.8 28.3 * 3.9

31.4 * 2.3 29.6 f 4.4 26.8* 3.2 25.5 * 3.7 28.6 * 5.0

1 * 12 3 * 12 0 * 1.5 3 * 13 -1 * 1.5

Table V. Variations in maximal exercise performance in cardiac men

Sample size 52 21 10 15
Duration (sec.)* 463 f 141 418 * 139 253 * 60 300 * 94
Max HR (bpm)’ 169 + 23 161 * 14 141 f 22 139 * 22
Change in BP (mm. Hg)* 61 * 28 41 * 26 31 * 42 30 * 19
Obs. Vo,max (ml./[Kg. min.])* l 27.7 * 6.5 26.5 * 6.8 19.8 * 4.4 20.2 * 3.6
Pred..Vo,max (ml./[Kg. min.l)“t l 36.1 * 2.8 35.6 * 2.1 34.3 f 2.4 34.4 f 2.1
Est. Vozmax (ml./[Kg. min.])* l 30.3 * 6.9 28.1 * 6.8 20.0 * 2.9 22.3 * 4.6
Functional aerobic impairment (‘%)* 23 +z 15 24 * 19 41 *14 41 * 12

*Means f standard deviations.

tUsed equation No. 4 for sedentary men.
IAbbreviations: HMI = healed myocardial infarction; AP = angina pectoris.

women during 12 successive minutes of the men and +0.926 for women). Intercepts
first 4 stages of the multistage treadmill for the regression equations for men and
test, are shown in Fig. 1 and Table III. women (Fig. 1) differed by 4 per cent
Repeated measurements at the same work- (P < 0.05) and the slopes by 7 per cent
load and minute of exercise in 26 persons (P < 0.05) when no adjustment was made
showed an insignificant mean paired differ- for age differences.
ence of -0.7 f 1.33 ml. per kilogram of 2. DIFFERENCES BETWEEN HEALTHY MEN
body weight per minute. At the lowest AND WOMEN. To correct for significant dif-
workloads (stages I and II), oxygen intake ferences in mean ages of healthy men and
approached a “plateau” for the last 2 min- women (49.3 and 38.3 years, respectively),
utes of each stage. After the first 5 minutes, 247 measurements of oxygen intake at
the increase in aerobic requirement was identical workloads and minutes of exercise
virtually linear. Overall correlation of iiOz were paired and were age-adjusted by co-
with elapsed time from the onset of sub- variance analysis. Mean f standard error
maximal exercise was high (r = +0.936 for for men of 27.0 f 0.4 ml./(Kg.*min.)

552 Bruce, Kusumi, and Hosmer
was 3.5 ml./(Kg.*rnin.) or 15 per cent
higher than that of 23.5 f 0.4 ml./(Kg..
min.) for women during the fifth to ninth
minute of exercise. Stepwise multiple re-
gression analysis, utilizing submaximal
oxygen intake as the dependent variable,
revealed the following:
~%ubmr = 16.62 + 2.74 (minutes
of exercise) - 2.584 (weighting
factor for sex) - 0.043 (years
of age) - 0.0281 (Kg.) (I* = 0.89)
where weighting factor for sex is 1 for men
and 2 for women. When duration of exercise
was measured with this standardized test-
ing procedure, neither speed nor grade of
walking contributed significantly to this
estimate.
3. CARDIAC MEN VERSUS HEALTHY
There were no significant differences in
weight-adjusted submaximal aerobic re-
quirements for cardiac men versus healthy
men for the first 4 minutes of this test (Fig.
1 and Table III). Thereafter requirements
averaged 2.0, 1.7, 3.2, 2.4, and 3.7 ml./(Kg.
*min.) lessin cardiacs than in healthy men
for the fifth through ninth minutes for
those patients who were able to continue
exertion that long before attaining maximal
capacity. Although correlation with dura-
tion in cardiacs was nearly as high (r =
+0.874), slope of regression was lower and
intercept higher than observed in healthy
men (P < 0.01) (Fig. 1). Thus a major
over-all difference was a 20 per cent lower
rate of change in oxygen intake in the
cardiac patients, which was compensated
for by an 18per cent higher intercept value.
Part two--Maximal exercise
1. DIFFERENCES IN <‘O,,,,
HEALTHY MEN. AND Mean Vozmax
WOMEN.
observed in 8 subgroups of healthy middle-
aged personasclassified according to sex,
age, and habitual physical activity status
are listed in Table IV. From physically
active younger men who averaged 35.1
years of age to sedentary older women who
averaged 50.7 years of age, there was a
cumulative 50 per cent decline in observed
\josmax from 49.7 to 25.2 ml./(Kg.*min.).
Overall Volmax of women approximated
77 per cent of that of men (Fig. 2). Similar
differences (46 per cent) were observed in
mean duration of exercise. Means of maxi-
Am. Heart J.
April. 1973
mal heart rate attained expected levels.
Correlation of Vozmax with duration of
exercise was quite high (r = +0.906), with
some differences in the coefficients for slope
and intercept of the regression equation for
44 physically active versus 94 sedentary
men (Fig. 3).
2. DIFFERENCES BETWEEN CARDIAC, HYPER-
TENSIVE, AND HEALTHY MEN IN Vozmax.
Measurements of Vozmax in 98 men, of
(2) whom 52 were hypertensive and 46 had
coronary heart disease, are presented in
Table V and Figs. 2 and 3. Means ranged
from 27.7 & 6.5 ml./(Kg.*min.) for hyper-
tensive men to 20.2 =t 3.6 ml./(Kg.*min.)
for 15 men with both healed myocardial
infarction and angina pectoris. Similarly,
duration of exercise fell from 463 f 141 to
MEN. 300 f 94 seconds, and maximal heart rate
from 169~0 139 beats per minute. Correla-
tion of Vozmax with duration was high
(r = +0.865), but coefficient for slope in
the regression equation was lower, and the
intercept higher than in healthy men (Fig.
3).
3.. REPRODUCIBILITY AND COMPARABILITY
OF Vozmax. Sixty-seven healthy men and
women, retested days to several weeks later,
showed excellent reproducibility (r = +
0.990) of Vozmax (Fig. 4). The standard
error of estimate (S y/x) of 1.9 ml./(Kg.*
min.) represented 3.2 per cent of the mean
Vo2max. Reproducibility of Vozmax in 12
cardiac patients who were clinically stable
was also excellent (r = +0.945).
Comparison of Vozmax by this contin-
uous, multistage testing procedure with
that observed by the discontinuous method
over 2 or more days showed excellent agree-
BETWEEN ment in 16 healthy men (r = +0.962)
(Fig. 5). The standard error of estimate was
1.9 ml./(Kg.*min.), or 3.8 per cent of the
mean Vozmax.
4. APPROACH TO VOZR~X. For each indi-
vidual, the highest measured oxygen in-
take was taken as 100 per cent of Vozmax,
and values observed for the 3 preceding
minutes were converted to per cent Vozmax
(Fig. 6-4). Absolute levels of Vozmax were
significantly different in healthy men,
women, and cardiac men (Tables IV and V
and Fig. 2). Nevertheless, at one minute
before peak oxygen intake, per cent Vozmax
averaged 92 per cent. In 21 women (13 per
 Maximal oxygen intake and functional aerobic impairment 553

End of Stage I Max (Mean)

Men

Women

Male
Cardiacs
1 I I I I

0 10 20 30 40
i/o2 ml,(kg 9 min)

Fig. 2. Divergent relationship of relative aerobic requirement (in relation to Vo2msx) and absolute values,
weight-adjusted, in healthy men and women and in male cardiac patients. Because of the marked differences
in VoZmsx or aerobic power, there are substantial differences in relative costs when individuals are performing
at the same workloads. Thus, cardiac patients and women work harder at the same levels of submaximal
exertion.

80 Observed -Active Men

Ranges Sedentary Men
Cardmc Men

70

60

X’
I -

l-

IC )-

I
0
Duration of Exercise, Min.
Fig. 3. Correlations and regression equations for relationship of Vo Zmsx to duration of exercise with this par-
ticular multistage treadmill protocol. Note differences in slopes and intercepts in relation to sex in healthy
persons and to cardiovascular disease in cardiac men. Note the differences in observed ranges of both variables.

cent) and 23 men (17 per cent) who con- approach to fro,max was remarkably iden-
tinued exertion beyond peak observed value tical, when mean oxygen intakes for 2 to 3
of ii02 or 302max, a 3 per cent fall in Vo, minutes prior to the peak values were
clearly documents that oxygen intake had expressed as per cent of $‘o,max (Fig. 6B).
reached its limit (Fig. 6A). A possible exception was observed in
Similarly, in most cardiac patients the patients with ischemic heart disease who
 Am. Heart J.
554 Bruce, Kusumi, and Hosmer April, 1973

70, /

.g
30. 0, . .
o” 90
-o” 2’ . Men N: 35
$0” 0 womenNz32
ZO- p’
,/ 2MTest
oy 20 30 40 50 60 70 0
VOpMaxmKkg.ml”)
VO,max m!/(kg.mln) DIscontlnuous Treadmfll
Fig. 4. Vo,,., reached days to weeks later in re-test
compared with Vo pmax of initial test. Note reason- Fig. 5. Values of ijozrnax for 16 healthy men, re-
ably close approximation to line of identity. corded during continuous multistage13 and discon-
tinuous” treadmill tests compared. Mean and stan-
dard deviation for multistage were 49.7 and b7.0;
for discontinuous they were 49.0 and h6.5, respec-
tively. Mean of paired differences was 0.15 * 1.9
were retested with nitroglycerin which in- (N.S.).
creased vozmax of patients with either
healed myocardial infarction or angina
pectorisz3 (Fig. 7), but the approach to Active men: ljoz = 69.7 -0.612 (years of
age) (r= -0.704) (3)
Vozmax was not modified (Fig. 6C and D).
Since the absolute values of i702max were Sedentary men: 30, = 57.8 - 0.445 (years of
age) (I= -0.659) (4)
lower in the hypertensives and cardiac
Active women: vj~* = 44.4 - 0.343 (years of
patients, this further documents the im-
age) (I= -0.631) (5)
portance of scaling aerobic metabolism of
Sedentary women: li,, = 41.2 - 0.343 (years of
submaximal exercise to vozmax.18
age) (I= -0.720) (6)
5. PREDICTION OF vO,max INDEPENDENTLY
OF EXERCISE TESTING VARIABLES IN HEALTHY An analysis of covariance to compare the
PERSONS. Stepwise multiple regression anal- slopes and adjusted means showed that
ysis (Sect@ I of Appendix Table A), with both were significantly different for the
observed Vozmax as a dependent variable, men, and the adjusted means were signifi-
indicates the feasibility of predicting cantly different for the women. The stan-
i’ozmax from physical characteristics. In dard error of estimate (S y/x) ranged from
decreasing order of importance, indepen- 3.7 ml./(Kg.*min.) for equation 6 to 6.6
dent variables were sex, age, physical ac- for equation 3.
tivity, body weight, height, and history of 6. ESTIMATION OF VOzmax FROM DURA-
cigarette smoking. With the first four TION OF MULTISTAGE TEST. Stepwise multi-
variables, 65 per cent of observed variation ple regression analysis, including variables
of \io,max (defined by r2 of 0.65) was ac- derived from multistage exercise testing,
counted for (Section I of Appendix Table using observed Vozmax as the dependent
A). Since the effect of sex on the intercept variable (Section I I of Appendix Table A),
was approximately 3.5 times that of physi- showed that duration of time from the start
cal activity status, predicted values for of Stage I of this standardized test was the
women were often underestimated. Bi- most important single determinant of ob-
variate regression equations in ml./(Kg. l served \io2max (r2 = 0.822). Addition of
min.) provided more realistic predictions sex as a second variable increased r2 to
of vo2max in ml./(Kg.*min.) for each 0.846, and including weight and age resulted
type of healthy person, as follows: in a negligible increment in r2 to 0.855.
Volume 85
Number 4 Maximal oxygen intake and functional aerobic ,impairment 555

A Normals 8. Cardiac Patients

601 I I I I I I 601
Max-3 Max-2 Max-l Max Max+1 Max-3 Max-2 Max-l Max Max+1
Minutes of Observation Minutes of Observation

C. Control D. PostnitroglycerIn
I---
IOO-

- Hypertensive
- HMI
- Angtna
e--r Anglna . HM

Norma I ( MeantSD I

60 I I 1 I 60 1 1 8 I
Max-3 Max-2 Max-l Max Max+1 Max-3 Max-2 Max-l Max Max+1
Minutes of Observation Minutes of Observation

Fig. 6, A through D. A, Mean oxygen intakes, expressed at per cent Vormsxr for the 3 minutes prior to
vormax, and for 25 to 60 seconds after Vormax (for the few persons who were able to continue). Despite highly
significant absolute differences in Vo, of men and women, relalive aerobic requirements for 1 to 3 minutes
prior to this peak value are virtually identical. B, Note parallel relationship in cardiac patients in per cent
Vowssx, even when value of Vormax is greatly reduced. C, Similarly, approach to VoZmax in four subgroups of
cardiovascular patients indicate a minor djfference in those with both healed myocardial infarction and
angina pectoris. D, When absolute value of Vormax is increased by treatment with nitroglycerin sublingually
(see Fig. 7), the approach to VolmSxr in terms of per cent VoZmax for the preceding 2 minutes, shows only
minor changes.

Because duration varied with habitual exercise in seconds as the independent

physical activity status, the latter made variable and \jozmax in ml./(Kg.*min.)
no additional contribution to estimated as the dependent variable, was
vo2max. Regression equation for estimated
10.5 + 0.035 (seconds) (I = 0.821) (8)
\jozmax, in ml./(Kg.*min.) for healthy
bersons became :
L
Thus the rate of change to attain \io,max
was distinctly lower -in cardiac patients
Estimated ~~,,,,, = 6.70 - 2.82 (weigh&g
factor for sex) + 0.056 (duration in than in healthy persons, but this was com-
seconds) (r = 0.920) (7) pensated for by a higher intercept value
(P < 0.01).
where weighting factor for sex is 1 for men
and 2 for women. Part three- Functional aerobic impairment
Bivariate regression equation, computed (FAI)
for cardiac men, with duration of maximal 1. VARIATIONS IN NORMAL VALUES. Uti-
 Am. Heart .I.
556 Bruce, Kusumi, and Homer .4jvil, 1973

NS
NG

PC.005
NG

P<.OOl
NG

1 t
0 5 10 15 20 25 30 35
mlnkg . mln)

Fig. 7. Acute effects of nitroglycerin sublingually (NG) on Qopmax of normals and cardiac patients. There was
no significant change (NS) in the normal subjects. (Reprinted with permission of the Publication Office,
American Heart Association, from Detry and Bruce, Circulation 43:155, 1971.)

Healthy

Cardiac

Hypertension FAI

HMI
Cardiac
Men
Anglna

AngIna + HMI

I # I 1 1
0 10 20 30 40 50
Co2 max mlikg-min)

Fig. 8. Variations in complimentary relationship of iioZmax and FAI in healthy men and men with cardio-
vascular disease expressed in absolute values of 02 intake, or deficit in 02 intake in ml./(Kg..min.). Note
greater functional impairment in coronary patients with angina than in those with either hypertension or
healed myocardiai infarction.

lizing regression equations 3 through 6 for
prediction of Vo?max and comparing values
with observed Vosmax, functional aerobic
impairment averaged 0 & 14 per cent, with
minor variations in the
healthy persons (Table IV). The 95 per
cent confidence interval was between -27
per cent and +26 per cent. Negative values
for FAI indicated that observed Vo,max
was >lOO per cent of predicted average
normaI.
2. VALUES OBSERVED IN CARDIAC
Similarly, using regression equation 4 for
predicting Vopmax according to age of
sedentary men, FAI in male cardiac pa-
tients was calculated from the observed
values of Vozmax. FAI ranged from 23 +
I5 per cent in 52 hypertensive men to
41 f 12 per cent in 15 coronary patients
with both healed myocardial infarction and
8 subgroups of angina pectoris (Fig. 8). Vo,max averaged
77 per cent in hypertensive patients and
59 per cent in coronary patients with angina
and prior infarction of values expected for
comparable age and activity status in
hea!thy men. In other words, relationship
of Vozmax and FAI observed in these car-
PATIENTS. diac patients is complementary.
3. NOMOGRAMS FOR APPROXIMATION OF
FAI. Individual nomograms for men,
women, and cardiac men using linear scales
for age and duration of maximal exercise to
Volume 85
Number 4 Maximal oxygen intake and junctional aerobic impairment 557

69 MEN

15-

20-v 15
T
25-- 20

30-- 25

a- 35-- 30
lo i
iq 40-

P,,.

i50-
B

k 55--

6C--
60
65.-
65
70-- t 0 -.13$j
14
70
75- 0 i 15 t t
14

751 115
Fig. 9A. Nomogram for finding per cent deviation
of individual’s estimated values from average pre- Fig. 9B. Nomogram for finding per cent deviation of
dicted values of VoZmax in healthy middle-aged men. individual’s estimated values from average pre-
Vozmax is estimated from equations 7, 8, or 9. FAI dicted values of Votmsx in healthy middle-aged
is obtained by projecting a line from “age” to women. For details see legend for Fig. 9A.
“duration of exercise” and reading the value at
which this line intersects the diagonal which is
appropriate for “habitual-activity status.” Note
that for any given age FAI varies markedly with vascular status, have quantitatively dif-
duration of exertion, but less with habitual-activity ferent values of FAI.
status. Conversely, for any given durationof exercise,
to the Same limits of maximal exertion, FAI varies Discussion
markedly with age, but less with habitual-activity
status. These nomograms apply only for the multi- The multistage, continuous test of up-
stage treadmill exercise test. right exercise described here is a clinical
method for measuring, predicting, and
evaluating maximal oxygen intake. With
derive estimated Vo,max from the appro- progressive increments in workload every
priate equation, 7 or 8, and separate diag- 3 minutes to individually determined limits
onals according to physical activity status of maximal possibleexertion during medical
for predicted Vo,max from equations 3 supervision and monitoring, it is an expe-
through 6 were constructed to facilitate ditious, safe, and reliable method to mea-
rapid clinical assessmentof exercise capac- sure Vozmax physiologically and to esti-
ity in terms of FAI by equation 1 (Fig. mate it clinically. A motor-driven, properly
9). (It must be emphasized that the scaling calibrated tread,mill has two important
of these nomograms does not apply to any advantages. Since the rate of energy expen-
other exercise testing procedure.) Project- diture is regulated involuntarily (unless the
ing a straight line between the values for subject or patient supports part of his body
age in years and observed duration in weight by leaning on the handrail), it is
minutes identifies FAI at the intersection a precision tool with remarkable repro-
of the appropriate diagonal for habitual ducibility. Higher values of Vopmax are
activity status of an individual. Since angles obtained with a treadmill than with a
and scaling of diagonals are slightly differ- bicycle ergometer or a step test,15and values
ent, any five individuaIs of identical age obtained within minutes by this continuous
and duration of maximal exercise, but of method are comparable to those obtained
differing sex, physical activity, and cardio- by discontinuous research method re-
 Am. Heavt .I.
5.58 Bruce, Kusumi, and Hosmer A@;(, 1973

the rate of change per kilogram of body

weight is higher for men than for women,
and higher in healthy men than in cardiac
15
men. Age-adjusted mean values, at identi-
cal workloads and minutes of observation,
20 -- 2 E are 3.5 ml. per kilogram of body weight or
15 per cent higher in these middle-aged men
25 -- 3 i than in women. Smaller differences of 12 to
-- 4 + 13 per cent in younger adults have been
$
-- 5 2 attributed to differences in bodily dimen-
r sions and composition,21 metabolism,22 and
-- 6 5 mechanical efficiency during rapid walking
and jogging upgrade.22
Since maximal oxygen intakes observed
in non-athletic women* are lower than in
men, per cent Vozmax at any given level of
submaximal exercise is higher in women
(Fig. 2). Similarly, with lower Vozmax in
@3+ older persons, per cent Vozmax for the same
65 workloads is higher in older than in younger
persons. Because of even lower Vo,max in
70 patients with symptomatic cardiovascular
4 5
disease, per cent Vosmax is still greater at
751
submaximal workloads than is observed in
Fig. 9C. Nomogram for finding per cent deviation of healthy persons. Thus the relative aerobic
individual‘s estimated values from average pre- requirement for any submaximal exertion
dicted values of VoZmax in middle-aged cardiac men.
For details see legend for Fig. 9A. varies inversely with Vo2max (Fig. 2).
As maximal oxygen intake is approached,
the linear relationship between oxygen in-
quiring 2 or more days.” Utilizing the take and duration of exertion becomes
experimental design of this particular multi- asymptotic; indeed, in about 15 per cent
stage test is advantageous. The oxygen of healthy persons it reaches a peak and
requirement for the first stage is only one falls slightly before exertion is stopped.
half to two thirds of that required for the Nevertheless, the peak values for observed
more commonly used 3-minute double oxygen intake per kilogram of body weight
Master two-step testI (for severely dis- are highly correlated with total duration
abled cardiac patients, it can be reduced of this multistage exercise test; weight-
further by lowering the grade to 0 per cent adjusted rates of change for Vozmax are
or 5 per cent). This low level permits appre- higher in healthy persons than in cardiac
hensive persons to become adjusted and men. Although these coefficients for slope
comfortable, before experiencing progres- and intercept for men and women and
sive workload increments with faster speeds cardiac men are different from those used
and higher grades every 3 minutes. After to estimate submaximal oxygen intake, the
the fourth minute, there is virtually a intercept for the submaximal regression
linear rise in oxygen intake (Table III and equation is greater.
Fig. 1). Thus, oxygen intake may be esti- Estimation of Vozmax from duration of
mated with adequate reliability for clinical exercise under these conditions of testing
purposes from the duration of time. This varies more with sex than with physical
also applies to Vo*max, provided that the activity status of healthy persons. For men
appropriate regression equation is used. there is a greater difference on the basis of
Indeed it is more reliable than estimating cardiovascular disease than with physical
Vozmax from submaximal exercise per-
formance.20 *Data for a few athletic women with large muscle masses are
omitted because of unusually high values for ire,,,,; in-
At time periods that represent only sub- clusion of these values would have narrowed the dkerence
maximal workloads for healthy persons, between means for men and women.
Volume 85
Number 4 Maximal oxygen intake and functional aerobic impairment 559

activity status. These differences are ap- Over 800 measurements of Vo2max were
parent in the observed ranges and com- also made during submaximal exercise to
puted slopes and intercepts of the relation- define the aerobic requirements under these
ship of Vozmax to duration illustrated in conditions of testing. This revealed different
Fig. 3. Accordingly, for a more reliable coefficients for slope and intercept of
appraisal of FAI in cardiac patients, a regression equation for relationship of
separate nomogram is available for cardiac Vozsubmax to duration of submaximal
men. As yet not enough women with cardio- exercise.
vascular disease have had direct measure- Functional aerobic impairment (FAI)
ments of Vo,max to derive a reliable regres- is the per cent difference between observed
sion equation for them. However, collection (or estimated) Vozmax and that predicted
of such data is in progress. from age, sex, and activity status by regres-
In conclusion, Vo,max characterizes the sion equations. Nomograms for rapid der-
functional limits of the cardiovascular sys- ivation of FAI from age in years and dura-
tem to deliver oxygen to satisfy aerobic tion of maximal exercise were constructed
requirements. Since in most patients with for healthy men, women, and cardiac men
cardiovascular disease limitationsof Vo,max to facilitate clinical usage of these methods.
are not due to significant arterial unsatura- Functional aerobic impairment was 23
tion! anemia, or polycythemia, restriction per cent in a group of symptomatic hyper-
of Vozmax closely reflects limitations in tensive men; it was 24 per cent in men with
maximal cardiac output, because of reduc- healed myocardial infarction, free from
tions in stroke volume as well as in heart angina on maximal exertion, but 41 per
rate.25 Assessment of Vo,max is readily and cent in men with angina of effort, with or
reliably attainable, but absolute values are without evidence of prior infarction. In men
insufficient for evaluation without normal with either angina or only healed myo-
standards in health, adjusted for sex, age, cardial infarction, impairment was reduced
and habitual physical activity status. For during treatment with nitroglycerin.
clinjcal purposes, the percentage difference
in Vozmax, or FAI, can be derived easily Addendum
and rapidly with the appropriate nomo- Since the preparation of this manuscript,
gram, once the duration in minutes is ascer- similar data have been obtained on another
tained, but this applies only when this 1,024 asymptomatic healthy men with a
standardized multistage treadmill exercise mean age of 45.6 f 7.4 years. These men
test is utilized. enrolled in the Seattle Heart Watch pro-
spective study were considered after maxi-
mal exercise testing as “unlikely” to be at
Summary risk for future cardiac manifestations of
Maximal oxygen intake (Vo,max) was coronary disease. The FAI, which was de-
measured, using an open circuit technique, rived from observed duration of exercise
during the last 2 to 4 minutes of a multi- and the nomogram for men, averaged 0.5
stage treadmill test of maximal exercise in f 11.4 per cent. As comparison of this
151 men. and 144 women of 29 to 73 years figure with that for the 138 men reported
of age. Vozmax was higher in men than in in the text where FAI equals 0 f 16 per
women (P < O.OOOl), lower in sedentary cent shows that the means are virtually
than in physically active persons (P < identical and that the standard deviation
0.001 in men, < 0.01 in women), and for the additional 1,024 men is nearly 30
diminished with age in cross-sectional com- per cent smaller, the validation of FAI on
parisons. It was highly correlated with another and larger sample of healthy per-
duration of exercise by this standardized sons is established.
protocol. Accordingly, by regression equa-
tions average normal values for healthy per- The authors are deeply indebted to the many
sons could be predicted from sex, activity subjects who willingly performed these tests, and to
colleagues who assisted, particularly to Dr. Loring
status, and age; values expected on testing B. Rowell for methods of gas analysis, Drs. J. R.
could be estimated from the duration of Blackman, J. A. Mazzarella, T. R. Hornsten, J. R.
exercise. McDonough, G. Profant, and J-M. Detry and the
 Am. Heart J.
560 Bruce, Kusumi, and Hosmer A#ril. 1973

numerous medical residents for supervising the tests; fatiguing static and dynamic exercise in man,
to Gladys Pettet, L.P.N., and Elma Kipper, L.P.N., Clin. Sci. 34:29, 1968.
for performing tests, to Karen Nilson, B.S., for 14. Lind, A. R.: Editorial-Cardiovascular responses
gas analysis, Verona Hofer, B.A., for computer to static exercise (Isometrics, anyone?), Circu-
data processing, and Alison Ross for editing and lation %:173, 1970.
Jacqueline Eddy for typing the manuscript. 15. Shephard, R. V., Aleen, C., Benade, A. V. S.,
Davies, C. T. M., di Prampero, P. E., Hedman,
REFERENCES R., Merriman, J. E., Myhre, K., and Simmons,
1. Mitchell, J. H., Sproule, B. J., and Chapman, R.: The maximum oxygen intake. An inter-
C. V.: The physiological meaning of the maxi- national reference standard of cardiorespiratory
mal oxygen intake tests, J. Clin. Invest. fitness, Bull. W.H.O. 33:757, 1968.
37538, 19.58. 16. Doan, A. E., Peterson, D. R., Blackman, J. R.,
2. Buskirk, E., and Taylor, H. L.: Maximal oxygen and Bruce, R. A.: Myocardial ischemia after
intake and its relation to body composition maximal exercise in healthy men, AM. HEART J.
with special reference to chronic physical ac- 69:11, 1965.
tivity and obesity, J. Appl. Physiol. 11:72, 1957. 17. Taylor, H. I.., Buskirk, E., and Henschel, A.:
3. Robinson, S.: Experimental studies of physical Maximal oxygen intake as an objective
fitness in relation to age, Arbeitsphysiol. measure of cardiorespiratory performance,
10:251, 1938. J. Appl. Physiol. 8:73, 1958.
4. Astrand, P. 0.: Experimental studies of physi- 18. Blackman, J. R., Rowell, L. B., Kennedy, J. W.,
cal working capacity in relation to sex and age, Twiss, R. D., and Conn, R. D.: The physio-
Copenhagen, 1952, Munksgaard. logical significance of maximal oxygen intake
5. Astrand, I.: Aerobic work capacity in men and in “pure” mitral stenosis, Circulation 36:497,
women with special reference to age, Acta 1967.
Physiol. Stand. 49(Suppl.):169, 1960. 19. Blackburn, H., Winckler, G., Vilandre, J.,
6. Hermansen, L., and Anderson, K. L.: Aerobic Hodgson, J., and Taylor, H. L.: in Brunner, D.,
work capacity in young Norwegian men and and Jokl, E., editors: Medicine and sport, vol. 4,
women. 1. ADDI. Phvsiol. 20:425. 1965. Physical activity and aging, Basel, 1970, S.
7. Saltin, B., and Astrand, P. 0.: Maximal oxygen Karger AG, p. 28.
uptake in athletes, J. Appl. Physiol. 23:353, 20. Rowell, L. B., Taylor, H. L., and Wang, Y.:
1967. Limitations to prediction of maximal oxygen
8. Astrand, P. 0.: Physical performance as a func- intake, J. Appl. Physiol. 19:919, 1969.
tion of age, J.A.M.A. 204:105, 1968. 21. Quenouille, M. D., Boyne, A. W., Fisher, W’. B.,
9. Cotes, J. E., Davies, C. T. M., Edhold, 0. G., and Leitch, I.: Statistical studies of recorded
Healy, M. H. R., and Tanner, J. M.: Factors energy expenditure in men I. Basal metabolism
relating to the aerobic capacity of 46 healthy related to sex, stature, age, climate and race,
British males and females, ages 18 to 28 years, Bucksburn, Scotland (Rowett Institute). I
Com-
I

Proc. R. Sot. Lond. Biol. 174:91, 1969. monwealth Bureau of Animal Nutrition, Tee.
10. McDonough, J. R., Kusumi, F., and Bruce, Commun. No. 17, 1951.
R. A.: Variations in maximal oxygen intake 22. Booyens, J., and Keatinge, W’. R.: The expendi-
with physical activity in middle-aged men, ture of energy by men and women walking, J.
Circulation 41:743, 1970. Physiol. 138:165, 1957.
11. Profant, G. R., Early, R., Nilson, K., Kusumi, 23. Detry, J-M. R., and Bruce, R. A.: Effects of
F., and Bruce, R. A.: Responses to maximal nitroglycerin on “maximal” oxygen intake and
exercise in healthy middle-aged women, J. exercise electrocardiogram in coronary heart
Appl. Physiol. 33595, 1972. disease, Circulation 43:155, 1971.
12. Saltin, B., Blomqvist, G., Mitchell, J. H., 24. Kasser, I. S., and Bruce, R. A.: Comparative
Johnson, R. L., W’ildenthal, K., and Chapman, effects of aging and coronary heart disease on
C. B.: Response to exercise after bed rest and submaximal and maximal exercise, Circulation
after training, Circulation 37 and 38(Suppl. 7):1, 39:759, 1969.
1968. 25. Consolazio, C. E., Johnson, R. E., and Pecora,
13. Bruce, R. A., Lind, A. R., Franklin, D., Muri, L.: Physiological measurement of metabolic
A. L., MacDonald, H. R., McNicol, G. W., functions in man, New York, 1963, McGraw-
and Donald, K. W.: The effects of digoxin on Hill, p. 8.

Appendix
I understand that I shall be questioned
INFORMED CONSENT and examined by a physician, and have
(by patient) an electrocardiogram recorded (to show
In order evaluate
to the functional whether or not testing should proceed),
performance and capacity of the heart, after which I shall run or wralk on a trend-
lungs, and blood vessels, I hereby consent, mill, with speed and gradient increasing
voluntarily, to perform an exercise test. every 3 minutes, until the limits of fatigue,
 Maximal oxygen intake and functional aerobic impairment 561

breathlessness, chest pain, and/or other measures, and that in the unlikely event
symptoms are of such severity that I that these precautions are insufficient,
should stop the effort. My blood pressure hospital treatment will be available to me.
and electrocardiogram will be monitored I have been given to understand that the
while I am exercising, and my oxygen benefits of testing include quantitative as-
intake will be determined. sessment of working capacity and critical
I understand that the risks of testing appraisal of the disorders or diseases that
include occasional changes in the rhythm impair capacity, and that this knowledge
of my heart beats and the possibility of facilitates better treatment and more ac-
excessive changes in blood pressure, so that curate prognosis for future cardiac events.
there is a remote chance of my fainting or I have been assured that I have the right
an even more remote chance of a heart to withdraw from the tests at any time,
attack, particularly if I take a hot shower with impunity, that confidential informa-
shortly after strenuous exercise testing. I tion about me will not be given to non-
have been assured that professional super- medical persons (such as employers and
vision will protect me against injury, insurance agents) without my consent, and
by providing appropriate precautionary that my welfare will be protected.

APPENDIX

Table A. Stepwise multiple regressionanalysis

1. Prediction of vmmaz, independent of testing, in ml./(Kg. *min.) (N = 235; M = 138; F = 157)

Coe@ients Stutiatical parameters

-

Physical
Sex status, Smoking F value Multiple increment
Step Constant M = 1 Age active = 1 Weight o-4 Height toe&r r r2 in r* SEE
F=.Z sedentary = 2

1 46.35 -9.1 130.97 0.557 0.310 0.310 6.79

2 69.13 -12.0 -0.407 210.72 0.774 0.600 0.290 5.18
3 74.99 -11.89 -0.413 -3.37 28.70 0.797 0.636 0.036 4.95
4 85.42 -13.73 -0.409 -3.24 -0.114 13.90 0.808 0.652 0.017 4.84
5 85.10 -13.62 -0.406 -3.23 -0.109 -0.499 3.88 0.811 0.657 0.005 4.82
6 69.74 -13.02 -0.395 -3.23 -0.145 -0.476 0.096 3.32 0.813 0.661 0.004 4.80

II. For estimation of vo2rnaz from ezercise testing, in ml./(Kg.. min.)

Coejkienls Statistical parameters

Physical
Sex SlatUS, F value Multiple Increment
Step Constanf M = 1 Age adive = 1 Weight Duration Height to enler J r* in 13 SEE
F=d sedentary = 2

1 -0.52 0.061 1350.93 0.907 0.822 0.822 3.45

2 6.70 -2.82 0.056 44.09 0.920 0.846 0.023 3 22
3 14.69 -3.95 -0.077 0.051 11.78 0.923 0.852 0.006 3.16
4 20.40 -4.91 -0.083 -0.050 0.050 6.21 0.925 0.855 0.003 3.13
5 11.15 -4.57 -0.077 -0.072 0.049 0.059 3.01 0.925 0.856 0.002 3.12
6 12.23 -4.66 -0.081 -0.297 -0.073 0.049 0.060 0.49 0.926 0.857 0.000 3.12
 .4in. Heart 1.
562 Bruce, Kusumi, and Hosmer April, 1973

In addition to participating in this exer- F1o2

cise test, I agree to register my name for k= constant for -FINZ = 0.2647
follow-up studies.
Date \j~ = minute volume of expired air (STPD)
a.m. vo2= ?E (kFEN, - FEO*)~~
Time -p.m. = VE ([kxz (1 - xl)/%] - x2)
Signed = i.lE (kx2 [1 - xl] - w2)/x1
Witness

Derivation of equation for oxygen

intake (Vo,) where:
x1= ~~~~ (in expired air without COZ)
xz = F~o2 with CO2 prior to CO2 absorption
FE N2 = x2 (1 - Xl)/~l