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Vol. 76. Issue 3.
Pages 213 (March 2023)
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Vol. 76. Issue 3.
Pages 213 (March 2023)
Letter to the Editor
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Cardiopulmonary exercise testing in patients with severe aortic stenosis: lights and shadows. Response
Prueba de esfuerzo con consumo de oxígeno en pacientes con estenosis aórtica grave: luces y sombras. Respuesta
Néstor Báez-Ferrera, Pablo Avanzasb,c,d, Alberto Domínguez-Rodrígueza,e,f,
Corresponding author

Corresponding author.
a Departamento de Cardiología, Hospital Universitario de Canarias, Tenerife, Spain
b Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
c Instituto de Investigación del Principado de Asturias, Oviedo, Asturias, Spain
d Departamento de Medicina, Facultad de Medicina, Universidad de Oviedo, Oviedo, Asturias, Spain
e Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Tenerife, Spain
f Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Juan Lacalzada-Almeida, Belén Marí-López, Rebeca Muñoz-Rodríguez
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To the Editor,

We appreciate the critical analysis regarding our study provided by Lacalzada-Almeida et al., in which they highlight their experience in the use of cardiopulmonary exercise testing (CPET) in patients with aortic stenosis (AS).

In their study, Lacalzada-Almeida et al.1 found a higher percentage of abnormal CPET results—defined by symptoms and electrocardiographic and blood pressure changes—in patients with severe or paradoxical low-gradient AS than in patients with moderately severe AS. No differences were found in the peak oxygen consumption (pVO2) or the VE/VCO2 slope between these 3 groups. This may be explained by the limited population included and possible selection bias, as the authors point out, by excluding patients with inconclusive symptoms attributable to AS. In addition, a nonnegligible percentage of patients reached an RER <1.1, which could lead to erroneous analyses if submaximal CPET parameters were not taken into account.1

Currently, CPET is the only objective tool available to estimate myocardial oxygen consumption, ventilatory efficacy, and muscle performance on exertion, information of value to determine the cause of a patient's symptoms.2 Hence, we propose CPET use in patients with asymptomatic severe AS, as many of them are falsely asymptomatic because of several concurrent factors, such as advanced age, frailty, obesity, and others.2 pVO2 values <20mL/kg/min and VE/VCO2 slope values >30 are pathological and imply a higher risk of adverse events on follow-up, as described by Guazzi et al.3 in the first published report proposing an algorithm for the study of valve disease with CPET.

Thus, our group proposes an objective algorithm to identify these falsely asymptomatic patients using CPET. In the absence of randomized studies, we believe it could be a useful instrument for this purpose.


No funding was received for the present publication.


All authors have contributed to writing and critical review of the article.


P. Avanzas is an associate editor of Revista Española de Cardiología; the editorial procedure established by the journal has been followed to guarantee impartial management of the manuscript. The other authors declare that they have no conflicts of interest.


J. Lacalzada-Almeida, M.M. Izquierdo-Gómez, I. Laynez-Cerdeña, et al.
Role of Exercise Testing and Speckle Tracking Echocardiography in Paradoxical Severe Aortic Stenosis.
N. Báez-Ferrer, P. Avanzas, A. Domínguez-Rodríguez.
Papel de la prueba de esfuerzo con consumo de oxígeno en pacientes con estenosis aórtica grave.
M. Guazzi, R. Arena, M. Halle, M.F. Piepoli, J. Myers, C.J. Lavie.
2016 focused update: Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations.
Eur Heart J., 39 (2018), pp. 1144-1161
Copyright © 2022. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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