67-year-old man for consultation. Referred by CPET team due to, sub-optimal test.

Background

• NIDDM – normal HbA1c. single agent. No complications
• Hypertension and hypercholesterolaemia

Issues

• 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

Discussion

• 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.

Plan

• For further discussion at CPET MDT
• Prehabilitation – funding is possible via NDIS pathway
• Likely re-test post NAC and prehab