67-year-old man for consultation. Referred by CPET team due to, sub-optimal test.
- NIDDM – normal HbA1c. single agent. No complications
- Hypertension and hypercholesterolaemia
- Muscle-invasive bladder cancer – for NAC then surgery
- CPET – impaired cardio-respiratory function (pre-NAC)
- Max Test – HRmax – 92%, RER 1.22
- Peak vo2 15.2ml/kg/min AT 9.7ml/kg/min, nadir VE/VCO2 44.1
- HRR – 3bpm
- O2 pulse and HR rose appropriately until workload of 45 watts then plateaued; indicating a limitation in stroke volume
- Limited by leg pain/fatigue.
- No chest pain, desaturation, or ischaemic ECG changes.
- DASI 6.7 METs
- Deconditioned, rarely exercises. Previously been walking regularly with NDIS worker but ceased due to covid.
- Schizo-affective disorder
- stable on current therapy for 20 years
- Patient concerned that being in hospital could precipitate a relapse.
- Expressing concerns regarding ileal conduit
- CPET results place patient in high-risk category for major surgery.
- Raised nadir VE/Vco2 indicates impairment in ventilatory efficiency – normal spirometry therefore possible cardiac cause?
- HRR less than 12 is also an indicator of higher risk for perioperative m&m
- RCRI = 1
- NSQIP – above average risk for cardiac, respiratory, and renal complications.
- Patient discussion – understands risks. Motivated to exercise. Remains uncertain if wants to proceed with surgery, will revisit issues with surgeon and urology CNC.
- Echocardiogram considered – no clinical indication. Should we perform based on CPET?
- CPET results are significant in this patient but form one aspect of the perioperative assessment. Not in keeping with clinical picture, therefore further consideration required.
- For further discussion at CPET MDT
- Prehabilitation – funding is possible via NDIS pathway
- Likely re-test post NAC and prehab