Exercise testing in COVID-19 era: Clinical profile, results and feasibility wearing a facemask

The Impact of Medical Face Masks and Rehabilitation Duration on the Performance Output and Outcomes of Cardiologic Rehabilitants

During the COVID-19 pandemic, wearing a medical face mask became mandatory in daily life and also in cardiological rehabilitation. In order to investigate whether the performance and outcomes of cardiological rehabilitation were affected by face masks, we compared data from patients who underwent rehabilitation with face masks with data from patients without face masks. In total, 114 patients from an ambulant rehabilitation center were included. Of them, 60 patients completed rehabilitation without a face mask (NFM). In contrast, 54 patients (with a face mask, WFM) completed their rehabilitation during the COVID-19 pandemic and had to wear medical face masks for the entire day and also during ergometer training or other interventions. Subgroups were formed with patients who accepted to extend rehabilitation for one week (4 WG); the other patients only completed 3-week rehabilitation (3 WG). We analyzed the performance and outcomes of all groups (NFM; WFM, 3 WG and 4 WG). At baseline, no group differences were detected. All groups significantly improved their power output and heart rate recovery, without any group differences. We conclude that face masks and also an additional rehabilitation week do not affect the exercise performance or outcomes of out-house cardiological rehabilitation.

Complications of exercise and pharmacologic stress echocardiography

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).

The physiological, perceptual, and thermoregulatory responses to facemask use during exercise

The use of masks in public settings and when around people has been recommended to limit the spread of Coronavirus disease 2019 (COVID-19) by major public health agencies. Several different types of masks classified as either medical- or non-medical grade are commonly used among the public. However, concerns with difficulty breathing, re-breathing exhaled carbon dioxide, a decrease in arterial oxygen saturation, and a decrease in exercise performance have been raised regarding the use of mask during exercise. We review the current knowledge related to the effect of different masks during exercise on cardiorespiratory, metabolic, thermoregulatory, and perceptual responses. As such, the current literature seems to suggest that there are minimal changes to cardiovascular, metabolic, and no changes to thermoregulatory parameters with facemask use. However, differences in ventilatory parameters have been reported with submaximal and maximal intensity exercise to volitional fatigue. Literature on perceptual responses to exercise indicate an impact on ratings of perceived exertion, dyspnea, and overall discomfort dependent on mask use as well as exercise intensity. In conclusion, data from the current literature suggests a minimal impact on physiological, perceptual, and thermoregulatory responses dependent on the type of mask used during exercise.

Effect of Face Masks on Physiological and Perceptual Responses during 30 Minutes of Self-Paced Exercise in Older Community Dwelling Adults

This study examined the effects of different types of masks (no mask, surgical mask (SM), and N95-mask) on physiological and perceptual responses during 30-min of self-paced cycle ergometer exercise. This study was a prospective randomly assigned experimental design. Outcomes included workload (Watts), oxygen saturation (SpO₂), end-tidal carbon dioxide (PetCO₂), heart rate (HR), respiratory rate (RR), rating of perceived exertion (RPE), and rating of perceived dyspnea (RPD). Volunteers (54-83 years (n = 19)) completed two familiarization sessions and three testing sessions on an air braked cycle ergometer. No significant difference was found for condition x time for any of the dependent variables. RPE, RPD, and PetCO₂ were significantly higher with an N95-mask vs. no mask (NM) ((p = 0.012), (p = 0.002), (p < 0.001)). HR was significantly higher with the SM compared to the NM condition (p = 0.027) (NM 107.18 ± 9.96) (SM 112.34 ± 10.28), but no significant difference was found when comparing the SM to the N95 condition or when comparing the N95condition to the NM condition. Watts increased across time in each condition (p = 0.003). Initially RR increased during the first 3 min of exercise (p < 0.001) with an overall gradual increase noted across time regardless of mask condition (p < 0.001). SpO₂ significantly decreased across time but remained within normal limits (>95%). No significant difference was found in Watts, RR, or SpO₂ regardless of mask condition. Overall, the N95mask was associated with increased RPE, RPD, and PetCO₂ levels. This suggests trapping of CO₂ inside the mask leading to increased RPE and RPD.

Cardiovascular disease and COVID-19, a deadly combination: A review about direct and indirect impact of a pandemic

Coronavirus disease 2019 (COVID-19) is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular manifestations. The cardiovascular manifestations reported comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. There is also an indirect impact of the pandemic on the management of cardiovascular care that has been shown clearly in multiple publications. In this review, we summarize the deadly relation of COVID-19 with cardiovascular events and the wider impact on several cardiovascular care areas by the pandemic situation.

The Physiological Effects of Face Masks During Exercise Worn Due to COVID-19: A Systematic Review

CONTEXT

Use of face masks in sport has been a particularly complex issue during the COVID-19 pandemic.

OBJECTIVES

A systematic review to examine the physiological effects the different types of masks have on healthy adults when doing physical exercise.

DATA SOURCES

PubMed, SPORTDiscus, Scopus, and Litcovid were searched up to March 20, 2021, following the PRISMA model. Articles published in the last 5 years with healthy adults.

STUDY SELECTION

A total of 633 studies related to the use of masks during physical exercise were found, of which 8 articles met the criteria to be included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

The search process and the review of the articles were carried out by independent expert researchers. The risk of bias and the methodological quality of the different studies included in the systematic review were calculated following the Cochrane criteria using an adaptation for random cross-studies. Once the information was properly structured, the results were extracted, and the findings of the study analyzed.

RESULTS

There were significant changes in the following physiological variables when engaging in physical exercise using masks: 25% in the heart rate and dyspnea, 37.5% in the rating of perceived exertion, 50% in the pulmonary variables, and 37.5% in discomfort. The oxygen saturation, blood pressure, systolic blood pressure, diastolic blood pressure, and the concentration of blood lactate did not present any significant effect in this study.

CONCLUSION

The usage of masks by a healthy adult population during the performance of physical exercise has shown minimal effects with regard to physiological, cardiorespiratory, and perceived responses. Some symptoms can be dyspnea, effort perceived, or discomfort, among others. These findings indicate that the use of masks is not harmful to individuals' health. It does not present any significant detrimental effect on physical performance or risk to their well-being. However, further experiments are required to corroborate the findings of this review.

Effects of Medical Face Masks on Physical Performance in Patients With Coronary Artery Disease or Hypertension

In this randomized, prospective monocentric study, 40 subjects with coronary artery disease or hypertension (cardiovascular disease [CVD] group) were assigned to either surgical mask (SM) or class 2 filtering facepiece mask (FFP2). They performed cycle ergometry exercise tests with progressive intensity until exhaustion with the assigned mask and another test with no mask (NM) in random order. A control group of 10 healthy subjects randomly performed 3 exercise tests with NM, SM, and FFP2, respectively. Blood pressure, heart rate, 12-lead electrocardiogram, exertion, shortness of breath, and capillary blood gases from the earlobe were documented. Across all groups, exercise testing with face masks resulted in a significantly reduced peak power output in watts compared with testing with NM (CVD group: SM vs NM: -5.0 ± 7.0%, p = 0.005; FFP2 vs NM: -4.7 ± 14%, p = 0.03; control group: SM vs NM: -6.8 ± 4.4%, p = 0.008; FFP2 vs NM: -8.9 ± 6.3%; p = 0.01) without differences in hemodynamic parameters, such as maximum heart rate and systolic blood pressure. Wearing an FFP2 compared with NM resulted in significant higher carbon dioxide partial pressure (CVD group: FFP2: 36.0 ± 3.2 mm Hg vs NM: 33.3 ± 4.4 mm Hg, p = 0.019; control group: FFP2: 32.6 ± 2.8 mm Hg vs NM: 28.1 ± 1.7 mm Hg, p <0.001) with corresponding differences in hydrogen carbonate and base excess, but not to a clinically critical extent. In conclusion, exercise testing with SM and FFP2 resulted in a significant reduction of peak power output without differences in hemodynamic parameters in subjects with preexisting CVD and in healthy subjects.

Feasibility, efficacy and safety of exercise stress echocardiography during the COVID-19 pandemic

OBJECTIVE

To assess the feasibility, efficacy and safety of performing exercise stress echocardiography (ESE) for the assessment of myocardial ischaemia during the COVID-19 pandemic.

METHODS AND RESULTS

Baseline data were collected prospectively on 740 consecutive patients (mean age 61.4 years, 56.8% males), referred for a stress echocardiogram (SE), who underwent ESE between July 2020 (immediate post lockdown) and January 2021 according to national safety guidelines, in addition to patients wearing masks during ESE. Retrospective analysis was performed on follow-up data for outcomes. Propensity score matching was used to compare workload achieved during ESE pre-COVID-19, in 768 consecutive patients who underwent ESE between May 2014 and May 2015. Of the 725 (97.9%) diagnostic tests obtained, 69 (9.3%) demonstrated significant inducible ischaemia (≥3 segments) with no serious adverse events. Of the 61 patients who underwent coronary angiography, 51 (83%) demonstrated flow-limiting coronary artery disease. During a mean follow-up period of 4.6 months, one first-cardiac event was recorded.Compliance with mask-wearing throughout ESE was seen in 98.7% of patients. Of the 17 healthcare professionals performing ESE, none contracted COVID-19 during this period. SE service performance increased to 96.8% of prepandemic levels (100%) from 26.6% at the start of July 2020 to the end of December 2020.Propensity-matched data showed no significant difference in exercise workload between patients undergoing ESE during and prepandemic.

CONCLUSION

Performing ESE during the COVID-19 pandemic, with safety measures in place, is feasible, efficacious and safe. It impacted on the time patients were waiting to undergo a diagnostic test and yielded appropriate outcomes.Service evaluation authorisation of research capability numberSE20/059.

The effect of the protective face mask on cardiorespiratory response during aerobic exercise

Protective face mask (PFM) has been widely used for safety purposes and, after the advent of the COVID-19 pandemic, its use is growing steadily, not only among healthcare personnel but also the general population. While PFM is important to preserve the wearer from contaminating agents present in the airflow, they are well known to increase the subjective perception of breathing difficulty. Although some studies demonstrated that PFM use worsens exercise tolerance, there are several studies stating that there is no such limitation with the use of PFM. Moreover, no serious adverse effects during physical exercise have been found in the literature. Physical exercise represents a significant challenge to the human body through a series of integrated changes in function that involve most of its physiologic systems. In this respect, cardiovascular and respiratory systems provide the capacity to sustain physical tasks over extended periods. Within this scenario, both convective oxygen (O₂ ) transport (product of arterial O₂ content x blood flow) to the working locomotor muscles and O₂ diffusive transport from muscle capillaries to mitochondria are of paramount importance to endurance performance. Interestingly, the effects of PFM on cardiorespiratory response during aerobic exercise depends on the type of mask and exercise (i.e., walking, running, or cycling), including decrease in ventilatory demands, arterial oxygen levels, maximal oxygen consumption, and endurance performance. The purpose of this review was to elucidate the effect of protective face mask-wearing on 1) cardiorespiratory responses during aerobic exercise and 2) endurance performance.

Safety of surgical masks during phisical activity evaluated with graded cycle ergometry test

AIMS

At the time of the coronavirus disease 2019 (COVID-19) pandemic wearing surgical mask (SM) is recommended for the prevention of contracting or exposing others to airborne transmission of COVID-19. It is somewhat controversial whether wearing SM during exercise affects performance and health status and/or may influence the results. In order to give an answer we planned a prospective, randomized, crossover study to evaluate the effects of wearing a SM or no-SM in 33 (17 male) physically active helthy subjects during a graded exercise cycle ergometry test.

METHODS

The two tests were performed in random order in the same subjects. The participants were all tested the same day, after a recovery time of at least of one hour, in order to avoid interferences on physical performances. Arterial oxygen saturation, heart rate and arterial blood pressure were assessed throughout the exercise tests every step of two minutes, at the end of exercise, performed at the same time with and without mask.

RESULTS AND CONCLUSIONS

Wearing SM had no effect on performance, since the duration of cycle ergometry test with SM and without SM median, respectively, was 14.2, [lower-upper quartile 13.9-14.8] versus 14.3 [13.9-15.5] minutes, p=0.094, and median peak power was 150 W [150-180] versus 150 W [120-180] p=0.754. When expressed relative to peak exercise performance, no differences were found between wearing or not wearing SM regarding arterial oxygen saturation, or heart rate at any time during the exercise tests. Wearing SM during vigorous exercise had no detrimental effect on cardiovascular parameters, as well as on exercise metrics in all participants. No ventricular repolarization abnormalities and no arrhythmias were reported on the electrocardiograms.

Lifting dyspnoea invisibility: COVID-19 face masks, the experience of breathing discomfort, and improved lung health perception - a French nationwide survey

QUESTION ADDRESSED

In contrast with pain, dyspnoea is not visible to the general public who lack the corresponding experiential baggage. We tested the hypotheses that the generalised use of face masks to fight SARS-CoV2 dissemination could change this and sensitise people to respiratory health.

METHODS

General population polling (1012-person panel demographically representative of the adult French population -quota sampling method-; 517 women, 51%). 860 (85%) answered "no" to "treated for a chronic respiratory disease" ("respiratory healthy", RH) and 152 "yes" ("respiratory disease", RD). 14% of RH respondents reported having a close family member treated for a chronic respiratory disease (RH-family+ and RH-family-). Respondents described mask-related attitudes, beliefs, inconveniencies, dyspnoea, and changes in their respiratory health vision . RESULTS: Compliance with masks was high (94.7%). Dyspnoea ranked first among mask inconveniencies (RD 79.3%, RH 67.3%, p=0.013). "Air hunger" was the main sensory dyspnoea descriptor. Mask-related dyspnoea was independently associated with belonging to RH-family+ (Odds Ratio [OR] [95% confidence interval (CI)]: 1.85 [1.16-2.98]) and removing masks to improve breathing (OR 5.21 [3.73-7.28]). It was negatively associated with considering masks effective to protect others (OR]: 0.42 [0.25-0.75]). Half the respondents were more concerned with their respiratory health since wearing masks; 41% reported better understanding patients' experiences.

ANSWER TO THE QUESTION

Wearing protective face masks leads to the mass discovery of breathing discomfort. It raises the public's awareness of what respiratory diseases involve and sensitises to the importance of breathing. These data should be used as the fulcrum of respiratory-health-oriented communication actions.

The impact of face masks on performance and physiological outcomes during exercise: a systematic review and meta-analysis

Face masks are promoted for preventing spread of viruses; however, wearing a mask during exercise might increase CO₂ rebreathing, decrease arterial oxygenation, and decrease exercise performance. A systematic review and meta-analysis was conducted on the impact of wearing a mask during exercise. Data sources included SPORTDiscus, PubMed, and Medline. Eligibility criteria included all study designs comparing surgical, N95, or cloth masks to a no mask condition during any type of exercise where exercise performance and/or physiological parameters were evaluated. Healthy and clinical participants were included. Mean differences (MD) or standardized mean differences (SMD) with 95% confidence intervals were calculated and pooled effects assessed. Twenty-two studies involving 1573 participants (620 females, 953 males) were included. Surgical, or N95 masks did not impact exercise performance (SMD -0.05 [-0.16, 0.07] and -0.16 [-0.54, 0.22], respectively) but increased ratings of perceived exertion (SMD 0.33 [0.09, 0.58] and 0.61 [0.23, 0.99]) and dyspnea (SMD 0.6 [0.3, 0.9] for all masks). End-tidal CO₂ (MD 3.3 [1.0, 5.6] and 3.7 [3.0, 4.4] mm Hg), and heart rate (MD 2 [0,4] beats/min with N95 masks) slightly increased. Face masks can be worn during exercise with no influences on performance and minimal impacts on physiological variables. PROSPERO registration: CRD42020224988. Novelty: Face masks can be worn during exercise with no impacts on performance and minimal impacts on physiological variables.

Exercise testing in COVID-19 era: Clinical profile, results and feasibility wearing a facemask

BACKGROUND

No data are available about whether Coronavirus disease 2019 (COVID-19) pandemic have led to changes in clinical profiles or results of exercise testing once the usual activity was reassumed, as well as if wearing a facemask has any impact on the tests. The aim of this study is to evaluate differences in the patients referred to exercise stress testing in the context of COVID-19 pandemic and analyse the feasibility and results of these tests wearing a facemask.

METHODS

We included all patients referred for an exercise test from 1 June to 30 September 2020 and compared them with the patients attended within the same period in 2019 before and after propensity score matching. All patients referred in 2020 wore a facemask.

RESULTS

A total of 854 patients were included: 398 in the 2020 group and 456 in 2019. No significant differences in baseline characteristics of the patients were observed, with the exception of dyspnoea, which was nearly twice as high in 2020 as compared with 2019. Regarding the results of the tests, no differences were observed, with almost 80% of maximal tests, similar functional capacity and over a 20% of positive exercise tests in both groups. These results remained after propensity score matching.

CONCLUSION

COVID-19 pandemic has not changed the clinical profile of patients referred to exercise testing. In addition, performing exercise testing wearing a facemask is feasible, with no influence in functional capacity and clinical results.