Progress in Cardiovascular Diseases 83 (2024) 55–61

Contents lists available at ScienceDirect

Progress in Cardiovascular Diseases

journal homepage: www.onlinepcd.com

Using cardiorespiratory fitness assessment to identify pathophysiology in

long COVID – Best practice approaches
Mark A. Faghy a, b, c, *, Caroline Dalton d, Rae Duncan e, Ross Arena a, b, c, Ruth E.M. Ashton a, c
a
Biomedical and Clinical Exercise Science Research Theme, University of Derby, Derby, UK
b
Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
c
Healthy Living for Pandemic Event Protection Network, Chicago, IL, USA
d
Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
e
Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Cardio-respiratory fitness (CRF) is well-established in the clinical domains as an integrative measure of the
Long COVID body’s physiological capability and capacity to transport and utilise oxygen during controlled bouts of physical
Cardiopulmonary exercise testing exertion. Long COVID is associated with >200 different symptoms and is estimated to affect ~150 million people
Exertional symptoms
worldwide. The most widely reported impact is reduced quality of life and functional status due to highly
sensitive and cyclical symptoms that manifest and are augmented following exposure to physical, emotional,
orthostatic, and cognitive stimuli, more commonly known as post-exertional symptom exacerbation (PESE)
which prevents millions from engaging in routine daily activities. The use of cardiopulmonary exercise testing
(CPET) is commonplace in the assessment of integrated physiology; CPET will undoubtedly play an integral role
in furthering the pathophysiology and mechanistic knowledge that will inform bespoke Long COVID treatment
and management strategies. An inherent risk of previous attempts to utilise CPET protocols in patients with
chronic disease is that these are compounded by PESE and have induced a worsening of symptoms for patients
that can last for days or weeks. To do this effectively and to meet the global need, the complex multi-system
pathophysiology of Long COVID must be considered to ensure the design and implementation of research that
is both safe for participants and capable of advancing mechanistic understanding.

Introduction genetic potential, health status, and physical activity/exercise training

routines.5 The plasticity of CRF is heavily reliant on regular activities
Overview of Cardiorespiratory Fitness (CRF) and Methods of Assessment that provide a frequent and appropriate stress/overload stimulus to the
body’s physiologic systems, which with repetition and time leads to
The protective benefits of increased CRF have been well-established adaptations that reduce the physiologic load associated with completing
over decades of research that has demonstrated vast benefits to health exercise or functional tasks. Determining and measuring CRF can be
and wellbeing and include reducing the risk of noncommunicable dis­ achieved via several subjective and objective methodologies, with the
eases1,2 and mortality.3 CRF is well-established in the clinical domain as gold standard involving online gas analysis during an incremental car­
an integrative measure of the body’s physiological capability and ca­ diopulmonary exercise testing (CPET) to exhaustion.6 However, the
pacity to transport and utilise oxygen during a controlled bout of requirement for specialist equipment and highly trained staff are often
physical exertion,4 which is determined by multiple factors, including considered a barrier to accessing CPET, and as a result more subjective

Abbreviation list: ACE2, angiotensin-converting enzyme 2; a-vO2 diff, arteriovenous oxygen difference; CNS, Central Nervous System; COVID-19, Coronavirus
disease 2019; CPET, Cardiopulmonary exercise testing; CTPA, CT pulmonary angiogram; CRF, Cardiorespiratory Fitness; CT, Computerised Tomography; CVD,
cardiovascular disease; DECT, Dual-energy computed tomography; ECG, electrocardiogram; eCRF, Estimated Cardiorespiratory Fitness; eCRF, Estimated CRF; FMD,
Flow mediated dilation.; HR, Heart rate; IL, Interleukin; ME/CFS, Myalgic encephalomyelitis/chronic fatigue syndrome; MRI, Magnetic Resonance Imaging; O2,
Oxygen; OH, orthostatic hypotension.; PA, Physical activity; PESE, Post Exertional Symptom Exacerbation; POTs, postural orthostatic tachycardia syndrome; QoL,
quality of life; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TNF-α, tumor necrosis factor alpha; V/Q, Ventilation / Perfusion.
* Corresponding author at: Biomedical and Clinical Exercise Science Research Theme, University of Derby, Derby, UK.
E-mail address: [email protected] (M.A. Faghy).

https://doi.org/10.1016/j.pcad.2024.02.005

Available online 27 February 2024

0033-0620/© 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M.A. Faghy et al. Progress in Cardiovascular Diseases 83 (2024) 55–61

methods to estimate CRF are adopted.7 Despite well-documented limi­ extensive insight are recommended to review the work by Davis et al17
tations and a high degree of variability within published data sets that and Altman et al.18 Whilst a plethora of research exists and demonstrates
could be considered problematic when making clinical judgments and a need for integrative assessments using CPET, careful consideration is
decisions, estimated CRF (eCRF) approaches are common practice and needed to prevent the use of excessive exertion that could result in
the suitability and application of eCRF approaches are outside the scope perpetuating patient symptoms and can in some cases carry a significant
of this article and have been discussed previously.8 The use of 2-day risk to participants, which will be discussed later in the article. Here we
CPET approaches has also gained popularity in the assessment of provide an overview of the most important pathophysiological consid­
chronic disease, this is primarily due to their role in identifying aerobic erations that may impair exercise performance and provide a summary
and physiological deficits and impairments, whereas one-time assess­ of the current understanding that could be furthered by detailed in­
ments are better suited to identifying abnormalities with patients often vestigations and assessments of CRF.
returning a ‘normal result’.9 However, the appropriateness and methods
of determining CRF in the context of chronic disease areas remain a
Pulmonary abnormalities and perfusion
pertinent discussion in the context of Long COVID, where a dearth of
understanding of the pathophysiology continues to impact the quality of
Long COVID patients often present with unexplained persistent chest
life and functional status of millions of people worldwide and is an ur­
pain, breathlessness, exercise limitation, and fatigue, in the weeks after
gent threat to global health.10
hospitalisation or the onset of symptoms. Whilst the cause of these
symptoms has yet to be understood in its entirety there is evidence that
Pathophysiology of long COVID
various interrelating factors might be responsible. From a pulmonary
perspective, these include impaired lung function and gas exchange,
Defined as a persistent and episodic symptom profile that presents
which could also be caused by haemodynamic derangements in the
after a suspected or confirmed infection with severe acute respiratory
pulmonary and circulatory vascular beds. Imaging studies have
syndrome coronavirus 2 (SARS-CoV-211;), Long COVID is associated
demonstrated significant lung abnormalities which include pulmonary
with >200 different symptoms12 and is currently estimated to affect
thrombosis, fibrosis, thromboembolism, and small airways diseases
~150 million people worldwide.13 The most widely reported impact is
following infection with COVID-1919 and ventilation defects and
reduced quality of life (QoL) and functional status14 due to highly sen­
regional reductions in pulmonary perfusion have been demonstrated
sitive and cyclical symptoms that manifest and are augmented following
utilizing hyperpolarised xenon magnetic resonance imaging (MRI).20
exposure to physical, emotional, orthostatic, and cognitive stimuli,
Paired expiratory axial computerised tomography (CT) images also
preventing millions from engaging in routine daily activities, including
demonstrate widespread lobular and regional low attenuation21 and are
employment, social activities and even family roles.15 Research to test
indicative of air trapping in people with Long COVID, which is irre­
developed hypothesis and mechanistic understanding is ongoing, the
spective of acute infection severity22 and persists for longer than 12
emergent theories point to persistent issues with the transport, delivery,
months.23 Whilst common in other chronic respiratory conditions such
and function of vital systems within the body that broadly impacts
as Chronic Obstructive Pulmonary Disease and viral pneumonia, the
functional status and QoL.16 These will be discussed briefly here in the
cause in Long COVID patients has yet to be established but it has been
context of Long COVID pathophysiology (Fig. 1) to inform the impor­
suggested to occur because of chronic airway inflammation, pulmonary
tance of diagnostic assessment using CPET and readers wishing to seek
endotheliitis, and/or fibrosis.24 Reduced lung volumes indicate likely

Fig. 1. A schematic to represent the complex/dynamic and interrelated pathophysiology of Long COVID.

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M.A. Faghy et al. Progress in Cardiovascular Diseases 83 (2024) 55–61

restrictive parenchymal physiology25 and air trapping has been acute COVID-19 and Long COVID cases which is significantly elevated
demonstrated by reduced end-expiratory volume and hyperinflation and when compared to healthy controls.30 Importantly here is the associa­
a presentation of breathing difficulties, chest tightness, and dyspnoea.24 tion between arterial stiffness and endothelial damage where the
Air trapping prompts a ventilation/perfusion (V/Q) mismatch contrib­ integrity of vascular endothelium is compromised by increased systemic
uting to reduced physical performance and hypoxaemia downstream as hyperinflammation and cytokine release.37 Insight derived from CPET
oxygen transfer is impeded. Dual energy computed tomography (DECT) by assessing changes in the blood pressure response and electrocardio­
and V/Q have been shown to be more sensitive at detecting micro­ gram (ECG) in responses to controlled stimuli can play an integral role in
perfusion defects in the lungs of Long COVID patients when compared determining the integrative cause and response to cardiovascular re­
with CT pulmonary angiogram (CTPA).26 Dhawan et al27 used lung V/Q sponses which when paired with knowledge up and downstream can
scintigraphy, with single-photon emission computed tomography, to lead to increased awareness about the extent to which endothelial
assess for residual clots and small pulmonary vessel disease for patients dysfunction impairs physiologic function.
who have recovered from COVID-19 but continue to demonstrate
persistent respiratory symptoms. Imaging to determine V/Q mismatch is Clotting abnormalities
important as it could play a leading role in the evaluation of pulmonary
small vessel disease, which is not optimally demonstrated via CT pul­ Fibrin amyloid microclots have been demonstrated in Long COVID38
monary angiography. Whilst there is still a need for more detailed and and articulately described outside of this article.38,39 Importantly in the
investigative approaches, initial data shows patterns of small vessel context of this paper is the role that fibrin amyloid microclots may play
disease and lung parenchymal disease, and therefore V/Q scanning in increasing levels of tissue hypoxia and impairing oxygen exchange.
could play a crucial role in elucidating the evolution of vascular disease These clots are resistant to fibrinolysis and are large enough to tempo­
and long-term pulmonary vascular sequela of COVID-19 and Long rarily block capillaries, which if restored rapidly may lead to tissue
COVID.27 damage known as ischemic reperfusion injury40 both of which can
significantly impact the ability of the body’s system to match the
Endothelial dysfunction external demands with an ‘appropriate’ physiological response thus
impairing functional status and QoL. Furthermore, ischemic reperfusion
Cardiovascular complications following COVID-19 are relatively injury results in the production of reactive oxygen species, which in turn
common and include arrhythmia, pericarditis, myocarditis, microvas­ increases oxidative stress and is known to increase inflammatory cyto­
cular angina, myocardial infarction, stroke and heart failure. SARS-CoV- kines and tissue hypoxia which may persist and present in a multitude
2 has been shown to cause endothelial dysfunction. Endothelial and complex symptom profiles.38 SARS-CoV-2 has also been demon­
dysfunction is the precursor to the development of atherosclerosis.28,29 strated to interact with platelets and fibrinogen to induce changes in
Atherosclerosis is the disease process that causes angina, myocardial hypercoagulability which are suggestive of a direct pathological effect
infarction, stroke, transient ischemic attack, stroke, vascular dementia upon cellular function without being directly taken up by cells.39 Whilst
and peripheral vascular disease. Endothelial dysfunction has also been not directly assessed by CPET, indirect assessments of ECG and blood
implicated in platelet activation, hypercoagulopathy and thrombotic pressure alongside gas transfer variables will indicate how well the
disease. Evidence shows that SARS-CoV-2 can damage the vascular cardio-pulmonary interface is working at baseline and in response to an
endothelium which could be a trigger for vascular disease and impact exercise stimulus. Biochemical insight from blood gas analysis and blood
physiological function.30 The vascular endothelium is the innermost lactate assessments conducted before and after 2-day CPET approaches
layer of blood vessels and provides a dynamic interface between circu­ can be used to indicate changes in aerobic/anaerobic metabolism that is
lating blood and tissues/organs of the body. The endothelium is widely known to be a response to impaired gas transfer which has been shown
recognised as playing an integral part in regulating tissue homeostasis in Long COVID.
via the production of vasoactive molecules that tightly control vaso­
dilatory and vasoconstrictory, pro-proliferative and anti-proliferative, Chronic inflammation and immune dysregulation
pro-thrombotic and anti-thrombotic, pro-oxidant and antioxidant,
fibrinolytic and anti-fibrinolytic, and pro-inflammatory and anti- Acute COVID-19 is associated with an immune system response that
inflammatory responses.31 Subsequently, the endothelium plays an stimulates polyclonal T-cell activation which releases an array of in­
important physiological role in maintaining barrier integrity, regulating flammatory molecules, such as cytokines, interleukins, and chemokines.
vascular tone, maintaining anti-inflammatory, anti-oxidant, and anti- Whilst a ‘typical’ response to a virus is indeed helpful in fighting
thrombotic interface, anti-proliferative properties, and the regulation infection, overproduction of these inflammatory molecules is often
of cellular metabolism of ATP, glucose, and amino acids.32 Due to their referred to as a ‘cytokine storm’ which has a very distinct immuno­
superficial nature, endothelial cells are a preferential target for SARS- pathological feature that is associated with COVID-19. The term cyto­
CoV-2 which attacks these cells once it binds to the angiotensin- kine storm refers to a broad systemic inflammatory response, which
converting enzyme 2 (ACE2) receptor33 and transmembrane serine involves elevated circulating cytokine profiles that occur following
protease 2 facilitates the disassociation of the viral spike protein.34 The systemic infection. As the production and release of cytokines increase
subsequent occurrence of endocytosis of the complex of ACE2 receptor in magnitude, inflammatory molecules, such as serum amyloid A, von
in the presence of the virus reduces the number of ACE2 receptors that Willebrand factor, interleukin (IL)-6, IL-8, IL-10, and tumor necrosis
are available on the cell surface, leading to a dysregulation of ACE2 factor-alpha (TNF-α) increase drastically.38 It is established that coro­
receptor expression and causing endothelial dysfunction and activation naviruses are neurotropic and may invade the blood-brain barrier and
of prothrombotic state commonly seen in COVID-19.35 Flow mediated access the central nervous system (CNS) through periphery or olfactory
dilation (FMD) techniques have been regularly used to determine neurons and the hippocampus is particularly vulnerable to infection,
endothelial dysfunction and Nandadeva et al.36 demonstrated reduced which could contribute to post-infection reductions in cognitive func­
FMD values in COVID-19 patients that were symptomatic and recovered tion41 and whole body activities. Ortelli et al.42 demonstrated a hyper-
when compared to asymptomatic controls. Importantly dyspnoea, inflammatory response in Long COVID patients with a presentation of
cough, and chest pain, which are among the most common symptoms fatigue and cognitive deficit. The authors found evidence for central
were demonstrated to be associated with impaired endothelial function. abnormal neuromuscular fatigue, impaired cognitive control, reduced
To date, there remains a need to determine whether endothelial function global cognition, apathy, and executive dysfunction in the post-COVID
plays a causative role in the presentation of these symptoms or if indeed period which was confirmed against healthy controls. The authors
they co-exist together. Arterial stiffness has also been demonstrated in concluded that altered neuronal function in the context of the profound

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increase of circulating cytokines (particularly IL-6), appears to lungs, heart, liver, kidneys, and brain.51 Mitochondrial dysfunction
contribute to CNS complications and may have broad implications following viral infection is not a new phenomenon with previous data
downstream in the regulation and delivery of physical activity and ex­ highlighting increased tissue damage during infection and recovery
ercise. Plasma IL-4 is also involved in brain function, such as memory, phases which is attenuated with time.52 Nasopharyngeal samples from
and has been demonstrated to be increased in COVID-19 patients which SARs-COV-2 patients demonstrate impaired transcription of nuclear
can be linked to ongoing neuroinflammation following a COVID-19 DNA, and mitochondrial OXPHOS genes and triggered an antiviral im­
infection.43 Koumpa et al studied protein markers of neuronal mune response that impairs mitochondrial function51 and remains
dysfunction including amyloid-beta, neurofilament light chain, neuro­ impaired despite viral resolution and could contribute to severe Long
granin, total tau, and pT181-tau which they demonstrated to be COVID pathology. In essence, these mechanisms will affect the uptake
increased in the neuronal-enriched extra-cellular protein of those and utilisation of oxygen within skeletal muscles, thus affecting aerobic
recovering from COVID when compared to pro-COVID-19 historical and anaerobic contributions to the provision of energy at a cellular level.
controls. Hyperactivation and/or dysregulation of immune cell activa­ It has been postulated that anaerobic thresholds are reduced in athletic
tion can occur and cause clinically significant and irreversible multi- populations with Long COVID which the authors attribute to virally
organ damage, failure, and even death.37 Severe COVID-19 infections mediated mitochondrial dysfunction that extends beyond expected post-
have also been demonstrated to induce B cell and T cell lymphocyte viral infection deconditioning and could be associated with impaired
deficiencies which in turn can cause hyperinflammation as lymphocytes tissue oxygenation and substrate oxidation.53 In context, structural and
are actively involved in the resolution of inflammation after infection. mechanistic impairments result in reduced total aerobic contribution
Depleted T cell and B cell numbers are strongly associated with persis­ and increase the reliance on anaerobic provisions which is time limited.
tent SARS-CoV-2 shedding and may contribute to chronic immune It is plausible that patients with myalgic encephalomyelitis/chronic fa­
activation in Long COVID44. Mast cell activation has also been described tigue syndrome (ME/CFS) and Long COVID could breach aerobic
as part of the body’s hyperinflammatory responses in both acute COVID- thresholds and work in an anaerobic state at markedly lower intensities
19 infection and Long COVID. Mast cell activation is responsible for compared to healthy controls and as a result mitochondrial dysfunction
repeated and severe allergic symptoms that broadly affect bodily sys­ could play an integral role in the clinical presentation of post-exertional
tems and consequently, a multitude of symptoms which include symptom exacerbation (PESE), which is triggered by physical, cognitive,
gastrointestinal upset and shortness of breath45 which is linked to orthostatic and emotional stimuli and remains one the biggest chal­
impaired exercise performance. lenges to Long COVID. Physical and biochemical responses to physical
exercise tasks can be determined with 2-day CPET designs that include
Autonomic dysfunction pre and post-test assessments via venepuncture/blood gas analysis to
quantify aerobic/anaerobic thresholds which can be used to support the
Whilst widely reported as a symptom that affects the quality of life development of bespoke, person-centred rehabilitative and management
and functional status, symptoms of autonomic dysfunction that are pathways.54 The addition and monitoring of near-infrared spectroscopy
consistent with dysautonomia are common, but the index of a formal (NIRS) techniques that quantifies tissue oxygenation and tissues satu­
diagnosis is varied. Common presentations of dysautonomia include ration could also provide novel insights into an abnormal exercise
orthostatic intolerance, fatigue, palpitations, cognitive impairment, response and between day impaired physiologic function and dysfunc­
nausea, and temperature dysregulation which has also been observed tion55 but have yet to be tested in the context of PESE and Long COVID.
with reports demonstrating that Long COVID patients have lower heart
rate variability when compared with matched controls.46 Whilst the Role of 2-day CPETs to examine long covid pathophysiology
mechanisms of these symptoms have yet to be understood in their en­
tirety, multiple suggestions have been discussed. These include relative CPET remains highly relevant and indicated to evaluate individuals
hypovolemia caused by failed peripheral vasoconstriction which is living with chronic conditions such as ME/CFS and Long COVID. Whilst
consistent with both postural orthostatic tachycardia syndrome (POTS) caution is advised to prevent PESE, measurements obtained from
and orthostatic hypotension (OH).47,48 The impact here is an increase in cardiorespiratory responses to physiological stress could provide insight
cardiac stress via a reduction in both stroke volume and cardiac output regarding the integrity of the pulmonary-vascular interface and char­
which impacts tissue oxygenation, and metabolic function and can result acterisation of any impairment or abnormal cardio-respiratory func­
in tachycardia and compensatory overdrive in sympathetic activity. tion.56 To date, there is clear evidence that CRF is compromised
Assessing arteriovenous oxygen difference (a-vO2) during CPET might following acute infection with COVID-1957 and in patients diagnosed
shed light on potential autonomic dysfunction as a-vO2 difference con­ with Long COVID58. This is not surprising as the virus and the resulting
tinues to increase in line with increased physical exertion, producing a impact upon the body’s pathophysiology (outlined above) adversely
linear or curvilinear rise in the O2 pulse. If there is a plateau in O2 pulse affects the cardiac, pulmonary, and skeletal muscular systems, which are
with increasing work this may be indicative of low stroke volume and an well documented to influence a person’s CRF.59 A recent meta-analysis
indicator of autonomic dysfunction.49 This data can be coupled along­ by Lim et al60 that reviewed the use of CPETs in PESE identified that
side measures of cardiovascular parasympathetic function by analysing overall mean values of all parameters are reduced on day two when
heart rate variability and blood pressure response to exercise. Whilst compared with healthy controls, especially when analysed that the
more interrogative methods such as transcranial Doppler and neuro­ ventilatory threshold (overall mean: − 10.8 at Test 1 vs. − 33.0 at Test 2,
logical assessment are required for clinical diagnosis, CPET methods p < 0.05). The authors conclude that two-day CPET serves as an
offer an opportunity to assess the during and post-exercise response of objective assessment of PESE in ME/CFS patients but there is great
multiple systems in response to the same stimuli, which might provide a consideration required for future clinical trials to determine the feasi­
more useful interpretation of understanding of impairment. bility of working with patients from fatigue-inducing disorders and to
prevent excessive and unnecessary exertion that could result in a relapse
Mitochondrial dysfunction in symptoms. In the context of chronic disease, Long COVID, the
assessment of CRF via CPET provides an opportunity to utilise expertise
Recent developments have demonstrated mitochondrial dysfunction from clinical exercise domains to: 1) provide mechanistic knowledge of
and as a consequence impaired exercise tolerance in Long COVID pa­ Long Covid; 2) quantify functional status and inform the development,
tients.50 As the body’s powerhouse for aerobic metabolism, impaired implementation, and monitoring of safe interventions to support reha­
mitochondrial activity has a widespread impact on bodily systems and bilitation; and 3) monitor the aerobic/anaerobic response to drug
functions which has been demonstrated in major organs such as the therapies.61,62 In the context of COVID-19, CPET provides an ideal

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M.A. Faghy et al. Progress in Cardiovascular Diseases 83 (2024) 55–61

approach to assess the intersection between pathophysiologic and clin­ position of power, and trust and retain a duty of care for participants and
ical manifestations, allowing for a refined account of the impact the viral whilst participants will want to help and will comply with instructions,
infection has both cross-sectionally and longitudinally, most impor­ this needs to be considered from a risk/benefit perspective that priori­
tantly during a bout, or repeated bouts of physical exertion in a highly tises patient safety. Therefore, phrases like ‘I want you to stay
controlled environment. However, the use and implementation of CPET comfortably within your capacity, I don’t want you to push yourself, it is
in Long COVID must consider the use of novel/adapted protocols to very important that you don’t overdo it’ should be used to replace more
mitigate against a potential and excessive exacerbation of symptoms traditional phrases. Ensuring that participants have their accessibility
that may result following the completion of maximal protocols. requirements considered and are given plenty of time to complete all
study protocols and not rushed is important and the provision of a place
Consideration for Using 2-Day CPET in Long COVID to rest following participation is also key to participant safety. This
might include completing additional surveys/questionnaires that are
Without question, CPET will play an integral role in furthering the important to the study design in advance of CPET which could also be
pathophysiology and it remains the gold standard assessment, providing made available digitally, to reduce the physical and cognitive load
for the most non-invasive, comprehensive, and accurate assessment of imposed during testing.
CRF. Typical CPET approaches are conducted to exhaustion and require
maximal effort, as governed by established test termination criteria.63 Inclusion/exclusion criteria
However, its application in Long COVID has been criticised by patient
groups for not considering and even prioritising patient safety. The The risk of causing inadvertent harm can also be mitigated by
ability of Long COVID patients to produce maximal efforts will likely implementing strict inclusion/exclusion criteria which include identi­
induce PESE over a course of days and even weeks which will drastically fying and screening individuals who are at risk of a severe PESE reaction.
reduce QoL. Therefore, care must be taken to ensure protocols are Pre and post-test screening measures should also include objective
suitably adapted and cognisant of the challenges associated with the determination of symptoms and details of any relapses that might also
nuances of chronic disease settings. In a recent meta-analysis, Lim et al pose additional risks to patients. These methods should also consider the
demonstrated significant reductions in all parameters from a review of use of digital apps that can profile symptoms systematically. COVID-19
studies using 2-day CPET approaches,60 however, they determined that mitigations: COVID-19 is being allowed to circulate worldwide with
all variables were reduced at the ventilatory threshold and this could variants of concern contributing to sustained levels of transmission with
serve as an objective endpoint rather than completing protocols to persistent symptoms reported in every one in ten infections.17 For those
volitional tolerance. This is pertinent in the context of ME/CFS and Long with Long COVID, the threat of further infection and therefore a wors­
COVID where PESE and a worsening of symptoms can be exacerbated ening of symptoms is a very real consideration, and all laboratories
with minimal physical, emotional, cognitive, and/or orthostatic stimuli. should still implement strict COVID-19 mitigation strategies which
This should include giving thought to the wrap-around services that include regular testing, use of masks, ensuring adequate ventilation,
mitigate risks to patients during and following testing that might impact thorough and regular cleaning processes to reduce the risk to all
patients. We, therefore, encourage engraining all research design pro­ involved.
cesses with the lived experience to inform the investigation of infor­
mative research questions that adopt innovative protocol designs and
produce accessible and meaningful insight that can be used to advance Communication
clinical practice and inform effective management and restorative
pathways that are underpinned with interdisciplinary64 and whole sys­ The art of communication between clinical professionals and pa­
tem thinking65. To assist, we outline some important steps and consid­ tients has been the center of much discussion and even debate previ­
erations that we have developed with a national patient and public ously. Qualitative research in Long COVID highlights that patients do
involvement and engagement representatives that can be used to not feel heard and are even gaslit by some healthcare practitioners,15,66
address previously documented challenges in this area to help establish creating a disconnect between two key stakeholders. Demonstrating
research in this area to progress. knowledge, awareness, understanding, and being proactive for partici­
pants is crucial not only to make participants feel comfortable and at
Adapting approaches ease with the study, which for some will represent a big decision.

Conventional CPET to volitional exhaustion are supported by de­ Conclusion

cades of research demonstrating immense clinical value, however, the
confounders of PESE provide a challenge to the design and imple­ Without question, CPET will play an integral role in furthering the
mentation of research in COVID-19/Long COVID. Therefore, it is knowledge of the pathophysiology of Long COVID and it remains the
appropriate to establish protocols that acknowledge the previously re­ gold-standard method for most non-invasive, comprehensive, and ac­
ported impairment and explore the physical determinants in a way that curate assessments of CRF. However, the nuances and multi-system
captures the relevant and important data (i.e., ventilatory and anaerobic pathophysiology of Long COVID creates additional considerations that
thresholds) without exercising to maximal levels that might induce PESE must be considered to ensure the design and implementation of research
that will affect patients in the aftermath of testing for days or even that is both safe for participants and capable of advancing mechanistic
weeks. Suitable adaptations to the protocols are well established in other understanding.
clinical areas and consideration should be given to the starting intensity,
within test increments, and the test termination criteria monitored Disclosures
continuously to prevent excessive workloads and risk to some patients.
Consideration should also be given to the use and choice of terminology None.
that is used during tests. Phrases like ‘just keep going as long as you can’
or ‘let us know if you want to stop’ should be avoided and there needs to CRediT authorship contribution statement
be a recognition of the following: 1) that some patients will not have
knowledge of PESE and/or its consequences and will therefore have no Mark A. Faghy: Supervision. Caroline Dalton: Supervision. Rae
concept that they should be limiting their exertion to prevent a wors­ Duncan: Supervision. Ross Arena: Supervision. Ruth E.M. Ashton:
ening of symptoms; and 2) Researchers/health practitioners are in a Supervision.

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M.A. Faghy et al. Progress in Cardiovascular Diseases 83 (2024) 55–61

Declaration of competing interest 27. Dhawan RT, Gopalan D, Howard L, et al. Beyond the clot: perfusion imaging of the
pulmonary vasculature after COVID-19. Lancet Respir Med. 2021;9(1):107–116.
https://doi.org/10.1016/S2213-2600(20)30407-0.
None. 28. Liu Y, Zhang HG. Vigilance on new-onset atherosclerosis following SARS-CoV-2
infection. Front Med. 2021;7, 629413.
References 29. Guzik TJ, Mohiddin SA, Dimarco A, et al. COVID-19 and the cardiovascular system:
implications for risk assessment, diagnosis, and treatment options. Cardiovasc Res.
2020;116(10):1666–1687. https://doi.org/10.1093/cvr/cvaa106.
1. Ozemek C, Laddu DR, Lavie CJ, et al. An update on the role of cardiorespiratory 30. Schnaubelt S, Oppenauer J, Tihanyi D, et al. Arterial stiffness in acute COVID-19 and
fitness, structured exercise and lifestyle physical activity in preventing potential associations with clinical outcome. J Intern Med. 2021;290(2):437–443.
cardiovascular disease and health risk. Prog Cardiovasc Dis. 2018;61(5–6):484–490. https://doi.org/10.1111/joim.13275.
2. Ross R, Blair SN, Arena R, et al. Importance of assessing cardiorespiratory fitness in 31. Xu S, Ilyas I, Ping Weng J. Endothelial dysfunction in COVID-19: an overview of
clinical practice: a case for fitness as a clinical vital sign: a scientific statement from evidence, biomarkers, mechanisms and potential therapies. Acta Pharmacol Sin.
the American Heart Association. Circulation. 2016;134(24):e653–e699. 2023;44(4):695–709.
3. Ezzati M, Obermeyer Z, Tzoulaki I, Mayosi BM, Elliott P, Leon DA. Contributions of 32. Fodor A, Tiperciuc B, Login C, et al. Endothelial dysfunction, inflammation, and
risk factors and medical care to cardiovascular mortality trends. Nat Rev Cardiol. oxidative stress in COVID-19—mechanisms and therapeutic targets. Oxid Med Cell
2015;12(9):508–530. https://doi.org/10.1038/nrcardio.2015.82. Longev. 2021;2021:8671713. https://doi.org/10.1155/2021/8671713.
4. Albouaini K, Egred M, Alahmar A. Cardiopulmonary exercise testing and its 33. Mavraganis G, Dimopoulou MA, Delialis D, et al. Clinical implications of vascular
application. Postgrad Med J. 2007;83(985):675–682. https://doi.org/10.1136/ dysfunction in acute and convalescent COVID-19: a systematic review. Eur J Clin
hrt.2007.121558. Invest. 2022;52(11), e13859.
5. Christle JW, Arena R. Cardiopulmonary exercise testing and prescription of exercise. 34. Peacock TP, Goldhill DH, Zhou J, et al. The furin cleavage site in the SARS-CoV-2
In: Pressler A, Niebauer J, eds. Textbook of Sports and Exercise Cardiology. Springer spike protein is required for transmission in ferrets. Nat Microbiol. 2021;6(7):
International Publishing; 2020:897–912. https://doi.org/10.1007/978-3-030- 899–909. https://doi.org/10.1038/s41564-021-00908-w.
35374-2_43. 35. Del Turco S, Vianello A, Ragusa R, Caselli C, Basta G. COVID-19 and cardiovascular
6. American Thoracic Society/American College of Chest Physicians. ATS/ACCP consequences: is the endothelial dysfunction the hardest challenge? Thromb Res.
statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003;167 2020;196:143–151. https://doi.org/10.1016/j.thromres.2020.08.039.
(2):211. 36. Nandadeva D, Young BE, Stephens BY, et al. Blunted peripheral but not cerebral
7. Harber MP, Peterman JE, Imboden M, et al. Cardiorespiratory fitness as a vital sign vasodilator function in young otherwise healthy adults with persistent symptoms
of CVD risk in the COVID-19 era. Prog Cardiovasc Dis. 2023;76:44–48. https://doi. following COVID-19. Am J Physiol Heart Circ Physiol. 2021;321(3):H479–H484.
org/10.1016/j.pcad.2022.12.001. https://doi.org/10.1152/ajpheart.00368.2021.
8. Lee J, Song RJ, Yola IM, et al. Association of estimated cardiorespiratory fitness in 37. Arena R, Bond S, Calvo IR, et al. Shelter from the Cytokine Storm: Healthy Living Is a
midlife with cardiometabolic outcomes and mortality. JAMA Netw Open. 2021;4 Vital Preventative Strategy in the COVID-19 Era. Prog Cardiovasc Dis. July–August
(10):e2131284. 2022;73:56–60.
9. van Campen CM, Rowe PC, Visser FC. Two-day cardiopulmonary exercise testing in 38. Pretorius E, Vlok M, Venter C, et al. Persistent clotting protein pathology in long
females with a severe grade of Myalgic Encephalomyelitis/Chronic Fatigue COVID/post-acute sequelae of COVID-19 (PASC) is accompanied by increased levels
Syndrome: Comparison with patients with mild and moderate disease. In: of antiplasmin. Cardiovasc Diabetol. 2021;20(1):172. https://doi.org/10.1186/
HealthcareVol 8. s12933-021-01359-7.
10. Faghy MA, Owen R, Thomas C, et al. Is long COVID the next global health crisis? 39. Grobbelaar LM, Venter C, Vlok M, et al. SARS-CoV-2 spike protein S1 induces fibrin
J Glob Health.. 2022:12. (ogen) resistant to fibrinolysis: implications for microclot formation in COVID-19.
11.. World Health Organisation. Coronavirus disease (COVID-19): Post COVID-19 Biosci Rep. 2021;41(8). https://doi.org/10.1042/BSR20210611. BSR20210611.
condition. Accessed April 13; 2022. https://www.who.int/news-room/questions- 40. Kell DB, Pretorius E. The potential role of ischaemia–reperfusion injury in chronic,
and-answers/item/coronavirus-disease-(covid-19)-post-covid-19-condition. relapsing diseases such as rheumatoid arthritis, long COVID, and ME/CFS: evidence,
12. Hayes LD, Ingram J, Sculthorpe NF. More than 100 persistent symptoms of SARS- mechanisms, and therapeutic implications. Biochem J. 2022;479(16):1653–1708.
CoV-2 (long COVID): a scoping review. Front Med. 2021;8:2028. https://doi.org/ 41. Maltezou HC, Pavli A, Tsakris A. Post-COVID syndrome: an insight on its
10.3389/fmed.2021.750378. pathogenesis. Vaccines. 2021;9(5):497.
13. Hanson SW, Abbafati C, Aerts JG, et al. A global systematic analysis of the 42. Ortelli P, Ferrazzoli D, Sebastianelli L, et al. Neuropsychological and
occurrence, severity, and recovery pattern of long COVID in 2020 and 2021. neurophysiological correlates of fatigue in post-acute patients with neurological
medRxiv. 2022. Published online. manifestations of COVID-19: insights into a challenging symptom. J Neurol Sci.
14. Faghy MA, Maden-Wilkinson T, Arena R, et al. COVID-19 patients require multi- 2021;420, 117271.
disciplinary rehabilitation approaches to address persisting symptom profiles and 43. Koumpa FS, Forde CT, Manjaly JG. Sudden irreversible hearing loss post COVID-19.
restore pre-COVID quality of life. Expert Rev Respir Med. 2022;16(5):595–600. BMJ Case Rep CP. 2020;13(11), e238419.
https://doi.org/10.1080/17476348.2022.2063843. 44. Hu F, Chen F, Ou Z, et al. A compromised specific humoral immune response against
15. Thomas C, Faghy MA, Owen R, et al. Lived experience of patients with long COVID: the SARS-CoV-2 receptor-binding domain is related to viral persistence and periodic
a qualitative study in the UK. BMJ Open. 2023;13(4), e068481. shedding in the gastrointestinal tract. Cell Mol Immunol. 2020;17(11):1119–1125.
16. Ashton R, Ansdell P, Hume E, et al. COVID-19 and the long-term cardio-respiratory https://doi.org/10.1038/s41423-020-00550-2.
and metabolic health complications. Rev Cardiovasc Med. 2022;23(2). 45. Sumantri S, Rengganis I. Immunological dysfunction and mast cell activation
17. Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: major findings, syndrome in long COVID. Asia Pac Allergy. 2023;13(1):50–53.
mechanisms and recommendations. Nat Rev Microbiol. 2023;21(3):133–146. 46. Jason LA, Islam MF, Conroy K, et al. COVID-19 symptoms over time: comparing
https://doi.org/10.1038/s41579-022-00846-2. long-haulers to ME/CFS. Fatigue Biomed Health Behav. 2021;9(2):59–68.
18. Altmann DM, Whettlock EM, Liu S, Arachchillage DJ, Boyton RJ. The immunology 47. Tran VT, Porcher R, Pane I, Ravaud P. Course of post COVID-19 disease symptoms
of long COVID. Nat Rev Immunol. 2023:1–17. Published online. over time in the ComPaRe long COVID prospective e-cohort. Nat Commun. 2022;13
19. Singh SJ, Baldwin MM, Daynes E, et al. Respiratory Sequelae of COVID-19: Pulmonary (1):1812.
and Extrapulmonary Origins, and Approaches to Clinical Care and Rehabilitation. Lancet 48. Walker A, Kelly C, Pottinger G, Hopkins C. Parosmia—a common consequence of
Respir Med; 2023. Published online. covid-19. BMJ. 2022:377.
20. Wild JM, Gleeson FV, Svenningsen S, et al. Review of hyperpolarized pulmonary 49. Vignati C, Cattadori G. Measuring cardiac output during cardiopulmonary exercise
functional 129Xe MR for long-COVID. J Magn Reson Imaging. 2024. https://doi.org/ testing. Ann Am Thorac Soc. 2017;14(Supplement 1):S48–S52.
10.1002/jmri.28940. 50. Wang P, Ma J, Kim YC, et al. WASF3 disrupts mitochondrial respiration and may
21. Tanaka N, Matsumoto T, Miura G, et al. Air trapping at CT: high prevalence in mediate exercise intolerance in myalgic encephalomyelitis/chronic fatigue
asymptomatic subjects with normal pulmonary function. Radiology. 2003;227(3): syndrome. Proc Natl Acad Sci. 2023;120(34), e2302738120. https://doi.org/
776–785. 10.1073/pnas.2302738120.
22. Whiteson JH. Pulmonary Sequelae of Coronavirus Disease 2019. Phys Med Rehabil 51. Guarnieri JW, Dybas JM, Fazelinia H, et al. Core mitochondrial genes are down-
Clin. 2023;34(3):573–584. regulated during SARS-CoV-2 infection of rodent and human hosts. Sci Transl Med.
23. Kanne JP, Little BP, Schulte JJ, Haramati A, Haramati LB. Long-term lung 2023;15(708):eabq1533.
abnormalities associated with COVID-19 pneumonia. Radiology. 2022;306(2), 52. Filler K, Lyon D, Bennett J, et al. Association of mitochondrial dysfunction and
e221806. fatigue: a review of the literature. BBA Clin. 2014;1:12–23.
24. Cho JL, Villacreses R, Nagpal P, et al. Quantitative chest CT assessment of small 53. Barker-Davies RM, Ladlow P, Chamley R, Nicol E, Holdsworth DA. Reduced athletic
airways disease in post-acute SARS-CoV-2 infection. Radiology. 2022;304(1): performance post-COVID-19 is associated with reduced anaerobic threshold. BMJ
185–192. Case Rep CP. 2023;16(2), e250191.
25. Guler SA, Ebner L, Aubry-Beigelman C, et al. Pulmonary function and radiological 54. Owen R, Ashton RE, Ferraro FV, et al. Forming a consensus opinion to inform long
features 4 months after COVID-19: first results from the national prospective COVID support mechanisms and interventions: a modified Delphi approach.
observational Swiss COVID-19 lung study. Eur Respir J. 2021;57(4). EClinicalMedicine; 2023:62. Accessed October 10, 2023 https://www.thelancet.
26. Afat S, Othman AE, Nikolaou K, Gassenmaier S. Dual-energy computed tomography com/journals/eclinm/article/PIIS2589-5370(23)00322-X/fulltext.
of the lung in COVID-19 patients: mismatch of perfusion defects and pulmonary 55. Jones S, D’Silva A, Bhuva A, et al. Improved exercise-related skeletal muscle oxygen
opacities. Diagnostics. 2020;10(11):870. consumption following uptake of endurance training measured using near-infrared
spectroscopy. Front Physiol. 2017;8:1018.

60
M.A. Faghy et al. Progress in Cardiovascular Diseases 83 (2024) 55–61

56. Faghy MA, Sylvester KP, Cooper BG, Hull JH. Cardiopulmonary exercise testing in network. Prog Cardiovasc Dis. 2021;67:2–10. https://doi.org/10.1016/j.
the COVID-19 endemic phase. Br J Anaesth. 2020;125(4):447–449. https://doi.org/ pcad.2021.01.004.
10.1016/j.bja.2020.06.006. 62. Faghy MA, Ashton RE, Maden-Wilkinson TM, et al. Integrated sports and respiratory
57. Cassar MP, Tunnicliffe EM, Petousi N, et al. Symptom persistence despite medicine in the aftermath of COVID-19. Lancet Respir Med. 2020;8(9):852. https://
improvement in cardiopulmonary health–insights from longitudinal CMR, CPET and doi.org/10.1016/S2213-2600(20)30307-6.
lung function testing post-COVID-19. EClinicalMedicine. 2021:41. 63. Pollock ML, Gaesser GA, Butcher JD, et al. ACSM position stand: the recommended
58. Baratto C, Caravita S, Faini A, et al. Impact of COVID-19 on exercise quantity and quality of exercise for developing and maintaining cardiorespiratory
pathophysiology: a combined cardiopulmonary and echocardiographic exercise and muscular fitness, and flexibility in healthy adults. J AZ. Med Sci. 1998;30(6).
study. J Appl Physiol. 2021;130(5):1470–1478. 64. Faghy MA, Ashton RE, Skipper L, Kane B. Long COVID–integrated approaches to
59. Arena R, Faghy MA. Cardiopulmonary exercise testing as a vital sign in patients chronic disease management? Am J Med.. 2023 https://doi.org/10.1016/j.
recovering from COVID-19. Expert Rev Cardiovasc Ther. 2021;19(10):877–880. amjmed.2023.04.037. Published online.
60. Lim EJ, Kang EB, Jang ES, Son CG. The prospects of the two-day cardiopulmonary 65. Pronk NP, Faghy MA. Causal systems mapping to promote healthy living for
exercise test (CPET) in ME/CFS patients: a Meta-analysis. J Clin Med. 2020;9(12): pandemic preparedness: a call to action for global public health. Int J Behav Nutr
4040. https://doi.org/10.3390/jcm9124040. Phys Act. 2022;19(1):13. https://doi.org/10.1186/s12966-022-01255-7.
61. Faghy MA, Arena R, Stoner L, et al. The need for exercise sciences and an integrated 66. Owen R, Ashton RE, Skipper L, et al. Long COVID quality of life and healthcare
response to COVID-19: a position statement from the international HL-PIVOT experiences in the UK: a mixed method online survey. Qual Life Res. 2023;22.
https://doi.org/10.1007/s11136-023-03513-y. Published online September.

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