C a rdi o p u l m o n a r y E x e rc i s e

Tes t i n g in Pu l m o n a r y
Arterial Hypertension
Alexander E. Sherman, MDa,*, Rajan Saggar, MDa,b

KEYWORDS
 Pulmonary arterial hypertension  Pulmonary hypertension  Cardiopulmonary exercise test  CPET

KEY POINTS
 Cardiopulmonary exercise testing (CEPT) is a safe, noninvasive method of evaluating for pulmonary
arterial hypertension with roles in assessing treatment response and prognosis.
 Reduced oxygen uptake and ventilatory inefficiency are hallmarks of a pulmonary vascular limita-
tion and should prompt further evaluation.
 The greater diagnostic resolution of CPET allows for potential earlier detection of disease progres-
sion compared with resting studies.

INTRODUCTION subsequent therapies have targeted exercise ca-

Cardiopulmonary exercise testing (CPET) is a
noninvasive method of assessing functional ca-
pacity and characterizing exercise limitation.1,2
Precapillary pulmonary arterial hypertension
(PAH), defined by a mean pulmonary artery pres-
sure (mPAP) of greater than 20 mm Hg and pulmo-
nary vascular resistance (PVR) 3 or greater Wood
units, is a disease characterized by elevated pul-
monary artery pressures and PVR leading to
impaired right ventricular function and heart fail-
ure.3,4 PAH causes a multitude of downstream ef-
fects affecting cardiac function and pulmonary gas
exchange leading to exercise intolerance and
shortness of breath.5 CPET has been used to
investigate PAH at each stage of clinical progres-
sion including detection in high-risk populations,
diagnosis, treatment response, and prognosis.6,7
Early in disease development, symptoms of
PAH are nonspecific and include impaired exer-
cise tolerance. Since the first treatment of PAH,
epoprostenol, was shown to improve mortality,
pacity as an endpoint from regulatory agencies
for approval.8–12 Although submaximal exercise
testing such as the six-minute walk test (6MWT)
remain a central parameter in treatment response
and risk assessment, parameters derived from
CPET have been shown to aid in diagnosis, treat-
ment response, and have prognostic significance
in PAH and remains a critical and underutilized
test.13,14
This review summarizes developments and evi-
dence on the application of CPET in the field of
PAH. Changes in exercise physiology and gas ex-
change reflecting the pathophysiology of pulmo-
nary hypertension include reduction in oxygen
uptake (VO _ 2) at anaerobic threshold (AT) and at
peak exercise, ventilatory inefficiency, arterial hyp-
oxemia, and altered kinetics of VO _ 2.
Reduction in Oxygen Uptake
Reduced VO_ 2 is a key abnormality seen in multiple
cardiopulmonary processes with exercise
heartfailure.theclinics.com

a
Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School
of Medicine at UCLA, 650 Charles East Young Drive South 43-229 CHS, Los Angeles, CA 90095-1690, USA;
b
Pulmonary Hypertension Program, Pulmonary Vascular Disease Program, Lung & Heart-Lung Transplant
and Pulmonary Hypertension Programs, Pulmonary and Critical Care Division, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA
* Corresponding author. Division of Pulmonary, Critical Care, & Sleep Medicine, 650 Charles East Young Drive
South 43-229 CHS, Los Angeles, CA 90095-1690.
E-mail address: asherman@mednet.ucla.edu

Heart Failure Clin 19 (2023) 35–43

https://doi.org/10.1016/j.hfc.2022.08.015
1551-7136/23/Ó 2022 Elsevier Inc. All rights reserved.