Cardiodynamic variables measured by impedance cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults.

Accurate prediction of aerobic capacity is necessary to guide appropriate exercise prescription. It is common to use 6-minute walk distance (6MWD) to predict peak oxygen uptake (VO2peak) in the clinical environment. The aim of this study was to determine whether prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT. A total of 62 healthy university students aged 21±1 years completed in separate days, a cardiopulmonary exercise test (CPET) and two 6MWTs (30 min apart), during which heart rate (HR), stroke volume (SV) and cardiac output (CO) were measured by ICG (PhysioFlow® PF07 EnduroTM). The CPET was conducted with the Ergoselect 200 Ergoline and oxygen consumption measured by a MasterScreenTM CPX breath-by-breath metabolic cart. Multiple regression analyses were conducted to generate VO2peak prediction equations using 6MWD with, or without the cardiovascular indices recorded at the end of the best performed 6MWT as predictor variables. The mean peak HR (bpm), SV (ml) and CO (L/min) recorded during 6MWT were 156±18, 95.6±9, 15±2.8 and during CPET were 176±16, 91.3±8, 16.2±2.7, respectively. Analyses revealed the following VO2peak prediction equation: VO2peak = 100.297+(0.019x6MWD)+(-0.598xHR6MWT)+(-1.236xSV6MWT) + (8.671 x CO6MWT). This equation has a squared multiple correlation (R2) of 0.866, standard error of the estimate (SEE) of 2.28 mL/kg/min and SEE:VO2peak (SEE%) of 7.2%. Cross-validation of equation stability using predicted residual sum of squares (PRESS) statistics showed a R2 (Rp2), SEE (SEEp) and SEEp% of 0.842, 2.38 mL/kg/min and 7.6% respectively. The minimal shrinkage of R2 implied regression model stability. Correlation between measured and predicted VO2peak using this equation was strong (r = 0.931, p<0.001). When 6MWD alone was used as the predictor for VO2peak, the generated equation had a lower R2 (0.549), and a higher SEE (4.08 mL/kg/min) and SEE% (12.9%). This is the first study which included cardiac indices during a 6MWT as variables for VO2peak prediction. Our results suggest that inclusion of cardiac indices measured during the 6MWT more accurately predicts VO2peak than using 6MWD data alone.

Introduction

Cardiorespiratory fitness is an essential component of health. The gold standard for evaluation of aerobic capacity is through a graded cardiopulmonary exercise test (CPET) [1]. However, a CPET requires expensive equipment and trained-personnel to administer the test [2]. A 6-minute walk test (6MWT) is a field test commonly used to assess functional capacity in people with chronic cardiopulmonary diseases [3-5]. The 6-minute walk distance (6MWD) is reportedly an accurate predictor of peak oxygen consumption (VO2peak) in both paediatric [6] and older adult populations [7, 8]. One determinant of maximal oxygen consumption is cardiac output, which in turn is influenced by stroke volume and heart rate. While heart rate can easily be measured during a 6MWT, non-invasive measurements of CO and SV during a 6MWT have not been regularly considered. Impedance cardiography (ICG) is a non-invasive technique which provides essential indices of cardiovascular function, including HR, SV and CO. Our previous work showed that in a post-stroke population, ICG provides reliable, detailed, non-invasive cardiodynamic data during a 6MWT [9]. We hypothesise that inclusion of ICG measured data during a 6MWT will produce a stronger predictor of VO2peak, compared to 6MWD alone. The aim of this study was to investigate whether the inclusion of cardiovascular indices recorded during a 6MWT improved the accuracy and stability of a regression model predicting VO2peak, compared to a predictive equation using 6MWD alone.

Materials and methods

This was a cross-section observational study approved by the Institutional Review Board of Shenzhen Second People’s Hospital (Ethics approval number: 20191211001). The study protocol (Register number: ChiCTR2000028771) is available at the Chinese Clinical Trial Register Center website: http://www.chictr.org.cn/index.aspx. Protocol of this study is also available at Protocol.io, dx.doi.org/10.17504/protocols.io.bupdnvi6.

Participants

University students with normal health were recruited to participate in this study. Invitation emails were sent via the student portal of all students registered at the School of Rehabilitation of a local university affiliated with the hospital where this project was conducted. Exclusion criteria were: (1) students with known cardiovascular, pulmonary or musculoskeletal disorders that might limit their participation in maximal ergometric exercise test; (2) pregnancy; and (3) any anxiety/depression psychiatric disorder.

Procedures

Students who responded to the invitation email were invited to the involved hospital. The cardiopulmonary exercise test (CPET) and 6-minute walk test (6MWT) processes were explained, and signed informed consent was obtained. Testing was determined randomly by drawing lots from an envelope, whereby each participant on separate days completed, either the CPET, or, two consecutive 6MWT spaced 30 minutes apart, as the first test. Participants were invited to attend the cardiopulmonary laboratory of the hospital at a time >2 hours after a light meal. All participants were requested to avoid caffeine-containing products, nicotine, and alcohol at least 12 hours before attending the laboratory.

Cardiodynamic parameters including HR, SV, CO were recorded at one-second intervals by means of ICG (PhysioFlow® PF07 EnduroTM Paris, France) during 6MWT and CPET. Oxygen saturation (SpO2) was recorded with the Heal Force pulse oximeter (POD-3, China). Systolic and diastolic blood pressure (SBP and DBP) was measured with the OMRON electronic blood pressure monitor (U30, China). Rate of perceived exertion (RPE) at the end of each test was recorded with the modified 0–10 Borg Scale [10].

6MWT

The 6MWT was performed in a 30-meter hospital hallway, following the standard protocol recommended by the American Thoracic Society (ATS) [11]. This study design required comparison of cardiodynamic variables during a 6MWT and a CPET, thus two trials of 6MWT, with a rest period of at least 30 minutes between tests, were recorded to minimise the risk of possible learning effect and to ensure maximal effort. During data collection, participants were also asked to rest in a sitting position for 10 minutes before and after the 6MWT. The cardiodynamic parameters (HR, SV and CO) were measured using the ICG at one-second intervals during both tests. The SpO2 was recorded before and after each 6MWT. The SBP and DBP were measured at two-minute intervals during the 10-minute rest period, before and after each 6MWT. The RPE was recorded immediately at the end of each 6MWT.

CPET

Each participant also performed a progressive CPET in the hospital cardiopulmonary laboratory using a cycle ergometer (Ergoselect 200, Ergoline GmbH, Germany). Throughout the test, 12-lead electrocardiography was continuously recorded, and the participant was required to wear a mask and breathe through a calibrated volume sensor. Oxygen consumption, carbon dioxide consumption and respiratory exchange ratio (RER) were measured by the MasterScreenTM CPX, breath-by-breath metabolic cart (CareFusion, Germany).

The gas analysis system was fully calibrated immediately before each test in accordance with the manufacturer’s instructions. The HR, SV, and CO were also measured with ICG at one-second intervals during the CPET.

The Garatachea 3-stage exercise protocol was adopted [12]. The first stage commenced with participants resting for three minutes in an upright position on the cycle ergometer with hands rested on the handlebars. Stage 2 required pedalling with free load for three minutes at a speed of 60 revolutions per minute. During Stage 3 the participant continued pedalling at the same speed but with a load of 25W, increased incrementally by 25W per minute, until the subject, despite encouragement, could no longer maintain the required speed, or, the participant’s respiratory exchange quotient (REQ) exceeded 1.1 [12]. Participants were asked to rate their sensation of fatigue using the modified Borg scale. The cool down work rate was 15W at 60 revolutions per min for 3 minutes, followed by resting in a seated position.

Impedance cardiography ICG

The PhysioFlow® PF07 is a portable, non-invasive device that adopts real-time wireless monitoring of morphology-based impedance cardiography signals via a blue tooth USB adapter to measure HR, SV and CO at one-second intervals. Electrodes were applied as described by Tonelli and colleagues [13]. The HR was derived directly from the ECG [14], SV was calculated from the cardiac ejection waveform and the CO was obtained by the multiplication of the SV and HR [15]. ICG data during the last 10 seconds of the 6MWT and CPET were averaged as the peak cardiodynamic variables. This ICG measurement method was previously reported as reliable [9].

Statistical analysis

All statistical analyses were performed using the IBM SPSS for Windows, version 25 (Armonk, NY: IBM Corp). Demographic data and clinical variables of all participants were summarized using descriptive statistics. Variables of interval-ratio data meeting normality assumption were compared using independent t test for gender difference. Chi-square test was used for analysis of categorical data of different gender. The results from the 6MWT that produced a higher 6MWD were used for statistical analyses. A total of five multiple linear regression analyses were conducted. The first set of two analyses were performed to examine the unique contribution of HR or SV changes to the outcome variable ‘change in CO’, during the 6MWT and CPET. Forced entry regression method with HR change and SV change as predictor variables was used. The second set, which included three multiple linear regression analyses was conducted with VO2peak recorded during the CPET as the outcome variable to generate regression equations. In this set, the first regression equation was generated using age, gender, BMI, and HRpeak, SVpeak and COpeak measured during CPET as predictor variables. The second regression equation was developed with variables of 6MWD, age, gender, BMI, plus ICG recorded HR, SV and CO at the end of the better performed 6MWT as predictors for VO2peak. The third regression equation was created using 6MWD as the sole variable predicting VO2peak. A stepwise backward regression method was then adopted to determine the statistically significant predictor variables retained in the regression equations. The appropriateness and precision of the regression parameters were evaluated with the squared multiple correlation (R2), the standard error of estimate (SEE), and partial SEE (SEE%), which was ‘SEE:meanVO2peak’ ratio expressed as a percentage. The predicted residual sum of squares (PRESS) statistic [16] was computed to estimate the degree of R2 shrinkage when the VO2peak regression equation was used for cross-validation across similar but independent samples. PRESS-derived Rp2, SEEp and SEEp% were compared with those of the final regression models.

Sample size estimation

A sample size of at least 51 subjects was required for the multiple regression analyses using the PASS 15.0.5 (Kaysville, Utah: NCSS) for an estimated Cohen’s effect size of 0.35 with 7 predictor variables, a level of significance of 0.05 and statistical power of 0.8 [17].

Results

A total of 62 participants (25 males) with normal health aged 21.3±1.2 years old participated in this study between 20th December 2019 and 30th November 2020. All participants achieved a REQ of 1.1 within 12 minutes of commencing the CPET. The mean age, BMI, lean body mass, exercise habits and clinical characteristics are shown in Table 1.

Table 1

Demographic data of the 62 participants.

Data in mean±SD unless annotated otherwise.

	Total cohort (n = 62)	Males (n = 25)	Females (n = 37)	P value#
Age (years)	21.3±1.2	22.0±1.4	20.8±0.7	<0.001
BMI (kg/m2)	21.4±3.0	22.9±3.3	20.4±2.3	0.001
Lean body mass (kg)	43.5±8.7	52.2±5.9	37.7±4.4	<0.001
Exercise habits
<3 times/week (%)	50 (80.6%)	16 (25.8%)	34 (54.8%)
3–5 times/week (%)	11 (17.7%)	8 (12.9%)	3 (4.8%)	<0.05
>5 times/week (%)	1 (1.6%)	1 (1.6%)	0 (0%)
Age predicted HRmax	199±1	198±1	199±1	>0.05
6MWD–test 1	610±64	646±54	586±60	<0.001
6MWD–test 2	630±75	670±64	603±70	<0.001
Borg score at the end of the test with greater 6MWD	7±1	7±1	7±1	>0.05
Peak work rate achieved during CPET (W)	136±41	177±29	108±19	<0.001
Borg score at the end of the CPET	8±1	8±1	8±1	>0.05

#Variables between gender were compared with independent t-test except “exercise habits”, which were compared with Chi-square test.

HRmax = maximal heart rate; 6MWD = distance covered in the 6-minute walk test; CPET = cardiopulmonary exercise test.

The male participants were slightly older, had a higher BMI, lean body mass, 6MWD and achieved a higher peak work rate during CPET compared with the female participants. There were more female participants who exercised less than three times per week, but more male participants who exercised three to five times per week. Descriptive statistics of ICG measured HR, SV and CO for genders are displayed in Table 2.

Table 2

Cardiodynamic data (mean±SD) measured using ICG during 6MWT and CPET.

	6MWT							CPET
	6MWD (m)	Heart rate		Stroke volume		Cardiac output		Peak VO2 (ml/min/kg)	Heart rate		Stroke volume		Cardiac output
		RHR6MWT (bpm)	PHR6MWT (bpm)	RSV6MWT (ml)	PSV6MWT (ml)	RCO6MWT (L/min)	PCO6MWT (L/min)		RHRCPET (bpm)	PHRCPET (bpm)	RSVCPET (ml)	PSVCPET (ml)	RCOCPET (L/min)	PCOCPET (L/min)
Male	688±44	87±13	161±15	70.7±7.9	96.6±9.7	6.1±1.1	15.6±2.7	33.2±6.2	87±13	181±16	74.3±10.3	94.4±8.6	6.4±1.1	17.2±2.9
Female	660±65	85±10	152±19	66.5±7.7	95±8.5	5.6±0.9	14.6±2.8	30.4±5.7	86±11	173±15	67±8.1	89.1±7	5.8±1.1	15.5±2.3
Total	671±59	86±11	156±18	68.2±8	95.6±9	5.8±1	15±2.8	31.5±6	86±12	176±16	69.9±9.7	91.3±8	6±1.1	16.2±2.7

ICG = impedance cardiography; 6MWT = 6 minute walk test; CPET = cardiopulmonary exercise test; VO2 = oxygen consumption; RHR6MWT = resting heart rate in 6MWT; PHR6MWT = peak heart rate in 6MWT; RSV6MWT = resting stroke volume in 6MWT; PSV6MWT = peak stroke volume in 6MWT; RCO6MWT = resting cardiac output in 6MWT; PCO6MWT = peak cardiac output in 6MWT test; RHRCPET = resting heart rate in CPET; PHRCPET = peak heart rate in CPET; RSVCPET = resting stroke volume in CPET; PSVCPET = peak stroke volume in CPET; RCOCPET = resting cardiac output in CPET; PCOCPET = peak cardiac output in CPET.

The VO2peak achieved during CPET correlated strongly with peak ICG HR, SV and CO data measured during CPET and 6MWT (Table 3). However, the correlation between VO2 recorded at anaerobic threshold (AT) during CPET and ICG cardiodynamic data recorded at the end of 6MWT were much lower (Table 3). Recorded SpO2 and blood pressure responses were uneventful. (S1 Table).

Table 3

Correlations of VO2peak with peak HR, SV and CO measured by ICG during 6MWT and CPET and correlations of VO2AT with peak HR, SV and CO measured at the end of 6MWT.

Variable	Correlation with VO2peak	P value
	Pearson r
HRPeak (bpm)	0.93	<0.001
SVPeak (ml)	0.70	<0.001
COPeak (L/min)	0.89	<0.001
HR6MWT (bpm)	0.88	<0.001
SV6MWT (ml)	0.75	<0.001
CO6MWT (L/min)	0.90	<0.001
	Correlation with VO2AT
	Pearson r
HR6MWT (bpm)	0.49	<0.001
SV6MWT (ml)	0.35	<0.05
CO6MWT (L/min)	0.46	<0.001

6MWT = 6-minute walk test; CPET = cardiopulmonary exercise testing; VO2peak = peak oxygen consumption; HRPeak = peak heart rate at CPET; SVPeak = peak stroke volume at CPET; COPeak = peak cardiac output at CPET; HR6MWT = heart rate at the end of 6MWT; SV6MWT = stroke volume at the end of 6MWT; CO6MWT = cardiac output at the end of 6MWT, AT = anaerobic threshold.

Regression analyses 1 and 2

Multiple linear regression analyses revealed that the changes in HR or SV contributed equally to the change of CO during the 6MWT. However, the contribution of HR changes was more than double the contribution of SV, to the change in CO during CPET (Table 4).

Table 4

Contributions of unique changes in HR and SV to changes in CO (multiple linear regression analyses using change in CO as an outcome variable).

	At the end of 6MWT			CPET
				At anaerobic threshold			At the end of CPET
	male	female	all	male	female	all	male	female	all
HR change standardized beta coefficient	0.59	0.59	0.61	0.82	0.64	0.71	0.75	0.64	0.72
SV change standardized beta coefficient	0.58	0.50	0.51	0.48	0.45	0.44	0.55	0.45	0.45
HR change semipartial correlation	0.56	0.46	0.53	0.82	0.50	0.64	0.75	0.54	0.68
SV change semipartial correlation	0.55	0.39	0.44	0.48	0.35	0.40	0.55	0.38	0.43
HR change unique contribution to CO change (%)	31	21	28	68	25	40	57	29	46
SV change unique contribution to CO change (%)	30	15	20	23	12	16	30	14	18

6MWT = 6-minute walk test; CPET = cardiopulmonary exercise testing; HR = heart rate; SV = stroke volume; CO = cardiac output.

Regression analysis 3

Regression analysis also revealed that SVpeak and COpeak recorded at CPET were the final significant predictor variables for VO2peak. This regression model: VO2peak(mL/kg/min) = 29.335 + (-0.648 x SVpeak (mL)) + (3.795 x COpeak (L/min)) was associated with a R2 of 0.886, SEE of 2.07 mL/kg/min and SEE% of 6.6% (Model 1 in Table 5).

Table 5

Multiple regression analyses for prediction of VO2peak.

Prediction Models	Coefficients	β	SEE (mL/kg/min)	SEE%	R2	SEEp (mL/kg/min)	SEEp%	Rp2
Model 1#			2.07	6.6%	0.886	2.14	6.8%	0.871
constant	29.335
SVpeak	-0.648	-0.864*
COpeak	3.795	1.688*
Model 2A#			2.28	7.2%	0.866	2.38	7.6%	0.842
constant	100.297	0.182*
6MWD	0.019	1.788*
HR6MWT	-0.598	1.840*
SV6MWT	-1.236	4.077*
CO6MWT	8.671	0.182*
Model 2B#			4.08	12.9%	0.549	4.12	13.1%	0.523
constant	-19.248
6MWD	0.076	0.741*

#Model 1- 6MWD, SVpeak and COpeak during CPET as predictor variables.

#Model 2A- 6MWD, HR6MWT, SV6MWT, CO6MWT, as predictor variables.

#Model 2B- 6MWD alone as the predictor variable.

R2 = squared multiple correlation; Rp2 = predicted residual sum of squares (PRESS) derived squared multiple correlation; SEE% = partial SEE (SEE/mean of VO2peak × 100%); SEEp = PRESS derived standard error of estimate; SEEp% = PRESS derived partial SEE (SEEp/mean of VO2peak × 100%); β = standardized regression weights.

*P < .005.

Regression analysis 4

Applying multiple linear regression analyses using cardiodynamic data collected during the 6MWT as predictor variables and VO2peak recorded at CPET as the outcome variable derived the equation:

VO2peak(mL/kg/min) = 100.297 + (0.019 x 6MWD(m)) + (-0.598 x HR6MWT) + (-1.236 x SV6MWT)+(8.671 x CO6MWT).

The R2 of this equation was 0.866, with SEE of 2.28 mL/kg/min, and SEE% of 7.2%. (Model 2A, Table 5). The PRESS derived regression model illustrated a Rp2 of 0.842, SEEp of 2.38mL/kg/min and SEEp% of 7.6%. The shrinkage of R2 was only 2.4%.

In our subject cohort, correlation analysis between predicted VO2peak derived from equation Model 2A and the actual measured VO2peak during CPET showed that there was a strong correlation between the measured and predicted VO2peak (r = 0.931, p<0.001).

Regression analysis 5

When 6MWD was used as the only predictor for VO2peak, the equation generated was VO2peak = -19.248 + (0.076 x 6MWD(m)) (Model 2B, Table 5).

This equation had a lower R2 of 0.549, and a higher SEE of 4.08 mL/kg/min and SEE% of 12.9%.

Discussion

The 6MWD has been reported as a reliable predictor of VO2peak in both the paediatric [6] and older adult populations [7, 8], but this is the first study to show that the addition of cardiodynamic variables recorded by ICG provides a more accurate prediction of VO2peak in a young healthy adult population. Although the maximal exertion level (RPE) differed between CPET (8/10) and 6MWT (7/10), measured VO2peak correlated strongly with the cardiodynamic variables recorded during both the 6MWT and the CPET (Table 3).

HR, SV and CO data measured non-invasively during an exercise test allows a comprehensive investigation of the cardiac responses to exercise. These cardiac parameters are relatively easily obtained by ICG technology, and recent advances in clinical applications of this technique are well described [18]. The current study showed that an increase in cardiac output during a 6MWT in healthy adults was contributed almost equally by changes in HR (28%) or SV (20%); however, the increase in CO during CPET appeared to be dominated by an increase in HR (46%) more than SV (18%) (Table 4). This is not surprising. As reflected by a higher RPE, CPET demanded a higher workload than the 6MWT; at a high workload, increases in heart rate limit diastolic filling time, leading to a decrease in end-diastolic volume, which subsequently limits the increase in SV [19]. This accords with the higher maximal HR recorded at the end of a CPET compared to that recorded at the end of a 6MWT, while the maximal SV achieved was similar (Table 2). Interestingly, Table 4 also shows that the increased contribution to CO by HR, rather than SV, as a response to exercise, began at AT. Be that as it may, although the peak HR, SV and CO achieved at the end of 6MWT were not as high as the data measured at the end of a CPET, the correlation between oxygen consumption and cardiodynamic parameters measured at the end of 6MWT was strongest with VO2 peak and not with oxygen consumption at AT (Table 3). This finding suggests that although submaximal, 6MWT induced exercise responses beyond AT and closer to peak CPET levels.

The gold standard for evaluation of aerobic capacity uses CPET to measure VO2peak (maximal oxygen consumption) [1]. Various predictors for VO2peak during a CPET have been reported and include work rate, body weight, age and gender [20-22]. Our data suggested that the significant predictors for VO2peak in our subject cohort were ICG-derived SVpeak and COpeak during the CPET (R2 0.89). Clinically, CPET is not always practical, and submaximal field tests such as 6MWT are therefore relied upon to provide a convenient indication of aerobic capacity. Cardiodynamic parameters induced by a 6MWT were strongly correlated to similar cardiac parameter responses induced by a CPET, as seen in Table 3. Our study showed that the inclusion of cardiodynamic data recorded by ICG during the 6MWT accurately predict the VO2peak in our subject cohort. The R2 value for this regression model was 0.87, which is comparable to the CPET regression model (0.89). Furthermore, PRESS analysis shows a R2 shrinkage of only 2.4%, suggesting that inclusion of the cardiac predictor variables further stabilised the prediction equation.

When 6MWD alone was used as the predictor variable for VO2peak, the R2 was only 0.55, and SEE% almost doubled (13%). The use of 6MWD as a predictor variable for VO2peak has been reported in the literature [6-8] (Table 6). The R2 and SEE values generated in different regression equations varied. Direct comparison between our regression models and others is not deemed appropriate, because the predictor variables reported were different. Age, gender and BMI have been used by others [6-8]; however, these variables were not significant predictors in our final regression equation. Exclusion of these variables in the VO2peak prediction equation was also reported in Sperandio et al study [8]. Furthermore, apart from different predictor variables entered for regression analysis, variation in age range and ethnicity of the sample population may also limit a meaningful comparison between regression equations [6].

Table 6

VO2peak prediction equations using 6-minute walk distance (6MWD) as predictor variable.

Studies	Age (year)	Gender (n)	6MWD (m)	VO2peak (mL/kg/min)	Equation	R2	SEE (mL/kg/min)	SEE%
Current study	21.3 ± 1.2 (19–26)	Males (25)	Males: 688 ± 44	Males: 33.2 ± 6.2	#Model 2A:	0.866	2.28	7.2%
		Females (37)			#Model 2B:	0.549	4.08	12.9%
			Females: 660 ± 65	Females: 30.4 ± 5.7
			Total: 671 ± 59	Total: 31.5 ± 6.0
Sperandio et al 2015 [8]	54 ± 10 (40–74)	Males (40)	608 ± 97	35 ± 11	#Sperandio equation	0.76	-	-
		Females (46)
Jalili et al 2018 [6]	12.49±2.72 (8–17)	Boys (349)	716 ± 60	41.24 ± 6.00	#Jalili equation	0.79	2.91	6.9%
Mänttäri et al 2018 [7]	50±13 (19–75)	Males (39)	Males: 660 ± 84	Males: 35.2 ±7.8	#Mänttäri @Males:	0.82	3.6	9.5%
		Females (36)
			Females: 624±62	Females: 33.6 ±7.3	#Mänttäri @Females:	0.89	3.5	9.3%
			Total: 652 ±74	Total: 34.4 ±7.6

6MWD = 6-minute walk distance; BMI = body mass index; VO2peak/VO2max = peak oxygen consumption.

Equations

# Model 2A: VO2peak (mL/kg/min) = 100.297 + (0.019 x 6MWD(m)) + (-0.598x HR6MWT (bpm)) + (-1.236x SV6MWT (mL)) + (8.671 x CO6MWT(L/min)) VO2peak (mL/kg/min) = -2.863 + (0.0563 x 6MWD(m)).

# Model 2B: VO2peak (mL/kg/min) = -19.248 + (0.076 x 6MWD(m)).

# Sperandio et al [8]: VO2peak (mL/kg/min) = -2.863 + (0.0563 x 6MWD(m)).

# Jalili et al [6]: VO2max (mL/kg/min) = 12.701 + (0.06 × 6MWD (m))–(0.732 × BMI (kg/m2)).

# Mänttäri et al [7]

@ Males: VO2max (mL/kg/min) = 110.546 + 0.063 x 6MWD(m) - 0.250 x age—0.486 x BMI(kg/m2) -0.420 x height(cm) - 0.109 x HR.

@ Females: VO2max (mL/kg/min) = 22.506–0.271 x weight(kg) + 0.051x 6MWD(m) - 0.065 x age.

Implications of the study

ICG is a technique which is non-invasive and simple to employ. It also provides appropriate data for meaningful analysis of the cardiac responses to activity or exercise. Exercise programs are often prescribed by heath-professionals in community health centres. Prediction of exercise capacity should be used to guide appropriate exercise prescription. The findings of this study show a need for further investigation of appropriate VO2peak prediction equations in different disease population, using cardiodynamic parameters recorded by ICG during a 6MWT. Further, the potential benefit of using ICG to investigate the cardiodynamic response to exercise and specific intervention, before and after operation in various patients, warrants further investigation.

Limitations of the study

The implications of our study are restricted to healthy young adults. In consequence the prediction equation cannot be generalised to population of older adults nor people with chronic illness. However, this study affirmed the hypothesis that cardiodynamic parameters recorded during the 6MWT are better predictors of aerobic capacity compared to the 6MWD alone. Application of portable telemetric measurement of oxygen consumption during the 6MWT would allow direct comparison of oxygen consumption recorded during 6MWT and CPET, however, telemetric equipment was not available in our laboratory. Such comparisons but without cardiodynamic data have been reported previously [7]. Further studies in populations with various disease backgrounds are necessary for meaningful application in prediction of aerobic capacity in different disease populations.

Conclusions

The findings of this study suggest that a regression model in healthy young adults which includes as predictor variables HR, SV and CO measured by ICG, together with the 6MWD, is a better predictor of aerobic capacity than a regression model using 6MWD alone. Further studies are required to test this regression model in various patient cohorts.

Oxygen saturation and blood pressures at baseline, immediately post and 10 min post-CPET and post-6MWT.

Data are mean±SD. 6MWT = 6 minute walk test; CPET = cardiopulmonary exercise test; SpO2 = oxygen saturation measured by oximeter; SBP = systolic blood pressure; DBP = diastolic blood pressure.

(DOCX)

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27 Apr 2021

PONE-D-21-09792

Cardiodynamic variables measured by Impedance Cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript "Cardiodynamic variables measured by Impedance Cardiography during a 6-minute

walk test are reliable predictors of peak oxygen consumption in young healthy adults" is very interesting and of high clinical utility. The design of the study is correct and thoughful, the aim is clear, the results support the conclusions. The disucussion is consisent and balanced. The proposed 6MWT/ICG and elaborated equation for calculation of VO2peak could be used in practice, i.e. for screening exams in young subjects. At first glance simply study effected in really valuable conclusions.

I have only minor comments to be cosidered:

1. Introduction, verse 38 "....measured data during a 6MWT will be a stronger predictor of...." - maybe better "....measured data during a 6MWT will produce a stronger predictor of...."

2. Methods, verse 68-70 - the sentence about MasterScreen CPX - please delete here and insert in sentence verse 85-86 in CPET description.

Reviewer #2: The present study investigates the use of impedance cardiography during a 6MWT for better predictability of VO2max. In general, the study seems well conducted and the manuscript is clear and easy to read. The authors should be complemented for addressing an important issue in the assessment of physical fitness in the clinical setting. I have only few comments for consideration.

Abstract:

- Line 10-21: A presentation of the peak values HR, SV, CO in CEPT and 6MWT would contribute to a better understanding of the study in the abstract. The description of the regression analyses could be more concise.

Introduction:

- Line 32-34: A little more detail is needed regarding the prediction of oxygen consumption due to the 6MWT.

Methods:

- Line 73: Why were two consecutive 6MWT conducted?

Discussion:

- Line 318: Measuring VO2 with a portable spirometry during the 6MWT would also be useful.

- Also, the feasibility nature of the study should be addressed.

The authors have demonstrated the benefits of impedance cardiography in simple clinical examinations. Further investigations (e.g. before and after operations) in various patient cohorts would be useful in the sequel. I recommend considering the manuscript for publication.

Reviewer #3: In the manuscript "Cardiodynamic variables measured by Impedance Cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults" authors determine whether prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT.

This manuscript is correctly written, with the connection between aim, results, discussion and conclusions preserved. In my opinion, it is of significant clinical importance, although it is very limited to the studied age group, without chronic diseases, according to the authors' opinion.

Minor comments:

1. While planning training or rehabilitation, it is important to determine the anaerobic threshold. Do you have any data on the level of effort achieved during the 6MWT (line 273-submaximal)? At the end of 6MWT, does the patient get VO2 corresponding to peak VO2 or VO2 at anaerobic threshold (AT) during CPET? Hence, there may be a difference in the strength of the correlation between hemodynamic parameters and VO2 between CPET and 6MWT. The incresases in SV and HR from their values at rest to those at the AT (AT–rest) are similar, but the increase in SV is significantly lower than HR after AT. Moreover, the increase in SV after AT is sensitive to lack of training and chronic diseases. Please complete the discussion on line 260-269.

2. How did you choose values for hemodynamic parameters suitable for analysis? How did you deal with measurement errors? Please complete the methodology - line 103.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Małgorzata Kurpaska, MD, PhD

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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2 May 2021

We are grateful for all our reviewers’ valuable and insightful comments and have modified our manuscript following their suggestions.

Reviewer #1:

The manuscript "Cardiodynamic variables measured by Impedance Cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults" is very interesting and of high clinical utility. The design of the s

tudy is correct and thoughtful, the aim is clear, the results support the conclusions. The discussion is consistent and balanced. The proposed 6MWT/ICG and elaborated equation for calculation of VO2peak could be used in practice, i.e. for screening exams in young subjects. At first glance simply study effected in really valuable conclusions.

I have only minor comments to be considered:

1. Introduction, verse 38 "....measured data during a 6MWT will be a stronger predictor of...." - maybe better "....measured data during a 6MWT will produce a stronger predictor of...."

2. Methods, verse 68-70 - the sentence about MasterScreen CPX - please delete here and insert in sentence verse 85-86 in CPET description.

Authors responses:

We are grateful for Reviewer 1’s supportive comments. We have replaced ‘be’ with ‘produce’ in the sentence as advised. Please see line 43 under Introduction.

We have now moved the description of MasterScreen CPX to the section under CPET, please see line 93.

Reviewer #2:

The present study investigates the use of impedance cardiography during a 6MWT for better predictability of VO2max. In general, the study seems well conducted and the manuscript is clear and easy to read. The authors should be complemented for addressing an important issue in the assessment of physical fitness in the clinical setting. I have only few comments for consideration.

Authors response: We are grateful for Reviewer 2’s encouraging comments

Abstract:

- Line 10-21: A presentation of the peak values HR, SV, CO in CEPT and 6MWT would contribute to a better understanding of the study in the abstract. The description of the regression analyses could be more concise.

Authors response: The peak values of HR, SV, CO in CPET and 6MWT are now included in the Abstract. Units in the equation were removed so the equation now appears more concise.

Introduction:

- Lines 32-34: A little more detail is needed regarding the prediction of oxygen consumption due to the 6MWT.

Authors response: An extra sentence is now included in the Introduction to highlight the relationship between oxygen consumption and ICG cardiodynamic data during 6MWT. Please see lines 36-39.

Methods:

- Line 73: Why were two consecutive 6MWT conducted?

Authors response: the reason for conducting two 6MWTs is now included, please refer to lines 78-81.

Discussion:

- Line 318: Measuring VO2 with a portable spirometry during the 6MWT would also be useful.

Authors response: This is an excellent point. We were aware of the advantage of using a portable telemetric device to measure oxygen consumption during 6MWT. Unfortunately, we did not have the resources to acquire this equipment. This has now been addressed as a limitation. Please see lines 328-331.

Also, the feasibility nature of the study should be addressed. The authors have demonstrated the benefits of impedance cardiography in simple clinical examinations. Further investigations (e.g. before and after operations) in various patient cohorts would be useful in the sequel. I recommend considering the manuscript for publication.

Authors response: we have now included the feasibility point in the section “Implications of our study’, please refer to lines 319-321.

Reviewer #3:

In the manuscript "Cardiodynamic variables measured by Impedance Cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults" authors determine whether prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT.

This manuscript is correctly written, with the connection between aim, results, discussion and conclusions preserved. In my opinion, it is of significant clinical importance, although it is very limited to the studied age group, without chronic diseases, according to the authors' opinion.

Authors response: We are thankful for Reviewer 3’s positive comments. We are currently extending our study to include subjects after stroke.

Minor comments:

1. While planning training or rehabilitation, it is important to determine the anaerobic threshold. Do you have any data on the level of effort achieved during the 6MWT (line 273-submaximal)? At the end of 6MWT, does the patient get VO2 corresponding to peak VO2 or VO2 at anaerobic threshold (AT) during CPET? Hence, there may be a difference in the strength of the correlation between hemodynamic parameters and VO2 between CPET and 6MWT. The incresases in SV and HR from their values at rest to those at the AT (AT–rest) are similar, but the increase in SV is significantly lower than HR after AT. Moreover, the increase in SV after AT is sensitive to lack of training and chronic diseases. Please complete the discussion on line 260-269.

Authors response: Thank you for this excellent comment. Indeed we have collected data on VO2 at anaerobic threshold during CPET. We have reported that the RPE level achieved at the end of CPET was 8/10 and that for 6MWT was 7/10 (line 250) but we did not report our AT data because the correlation between cardiodynamic and VO2peak data was much stronger than correlation with VO2 at AT. As suggested by the reviewer, we now consider that this information would be a nice addition to our report. We have therefore included data recorded at AT in Tables 3 and 4, and in the Results section: lines 182-184, and the Discussion at lines 263-269 and lines 276-277.

2. How did you choose values for hemodynamic parameters suitable for analysis? How did you deal with measurement errors? Please complete the methodology - line 103.

Authors response: Thank you for pointing this out. We averaged the final 10 seconds of the ICG data recorded to provide the peak cardiodynamic variables of the 6MWT, and data for CPET were computed similarly. This measurement method was considered reliable as previously reported [9]. We have now included this in the Methodology section, lines 112-114.

Submitted filename: Responses to reviewers comments.docx

Click here for additional data file.

12 May 2021

Cardiodynamic variables measured by Impedance Cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults

PONE-D-21-09792R1

Dear Dr. Jones,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Shane Patman, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The authors have made the adjustments requested and I am happy that these changes have improved the article.

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

17 May 2021

PONE-D-21-09792R1

Cardiodynamic variables measured by Impedance Cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults

Dear Dr. Jones:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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