The Role of Cardiopulmonary Exercise Testing in People With Heart Failure With Preserved Ejection Fraction
Conditions: Heart Failure With Preserved Ejection Fraction (HFPEF)
Sponsor: University of Ulster

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Dated 
10th January 2026 
Title 
The Role of Cardiopulmonary Exercise Testing in people with Heart Failure with 
Preserved Ejection Fraction 
 
Investigators 
Dr. Saqib Javaid 
Prof. George Kernohan 
Prof. Chris Bleakley 
Dr. Rachel Savage 
Dr. Peter McKavanagh 
Dr. Stephen McMeekin 
 
 

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Study Protocol 
Ethical approvals from Ulster Research Governance, REC NI and SEHSCT were obtained. The data 
collection for this cross-sectional study was conducted at the Cardiology department of Ulster 
hospital between July 2024 to July 2025.   
Study population and recruitment process: 
Medical records of patients with suspicion for heart failure with preserved ejection fraction were 
screened by the Staff Grade Cardiology Registrar (direct healthcare team) under the supervision of 
the Principal Investigator, Dr. Peter McKavanagh (Cardiologist) at the participating site (Ulster 
Hospital, Dundonald). This screening was based on the following inclusion and exclusion criteria.  
Inclusion Criteria 
• 
Males and females 
• 
Age ranged between 18 – 80 years. 
• 
Clinical suspicion of heart failure with preserved ejection fraction 
• 
Ejection Fraction of ≥50% on the most recent Echocardiogram 
• 
Ability to undertake leg exercise without any impediment 
Exclusion Criteria 
• 
Ejection fraction <50% on echocardiogram  
• 
Hospital admission in the past 6 months 
• 
Female subjects that are knowingly pregnant or believe they may be pregnant 
• 
Contra-indication of CPET: myocardial infarction, unstable angina, uncontrolled 
arrhythmias, moderate to severe valvular stenosis, acute infection, acute endocarditis and 
history of syncope. 
 
Recruitment and informed consent - 
The screened patients were contacted via phone call by the member of the direct healthcare 
team, informing them about the research project, seeking their verbal consent to receive patient 
information sheet (PIS). The participant information sheet (PIS) (Annex-1) was posted out to these 
patients containing information related to the investigation, the conduct of the test, potential risks 
and benefits, and potential of identifying new undiagnosed condition.  

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The contact details and past medical history of the patients were shared with the external 
research team (PhD researcher, Ulster University). The transfer of data took place using secured, 
password protected organizational email ID.  
These patients were given a period of 5 days (cooling off period) to read through the PIS and 
decide whether they would like to volunteer for the study or not. After 5 days, these patients were 
contacted via phone call by the PhD researcher and those agreeing to participate in the study were 
scheduled for an appointment to the hospital. The pre-requisites of the exercise test are re-stated 
verbally, that includes avoiding strenuous exercise, tea, coffee, smoking and alcohol on the day. 
The participants are advised to take regular medications for the day and wear appropriate clothing 
(i.e loose fitted clothes and running shoes). 

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Recruitment Process. 
 

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Cardiopulmonary Exercise Testing (CPET) Protocol : 
 
CPET Team: 
Member 
Name 
Designation 
Role 
1 
Saqib Javaid 
Medical 
Doctor 
& 
PhD 
Researcher 
Overall CPET Lead 
2 
David Moorehead 
 
Cardiac Physiologist 
ECG Monitoring 
3 
Gemma Moss 
Respiratory Physiologist 
Spirometry, 
Patient 
interaction during CPET 
 
CPET Testing Protocol 
The testing protocol was divided into 5 phases: spirometry, CPET preparation, resting baseline, 
warm-up, increasing the workload, and recovery. 
i- 
Spirometry: 
The assessment involved measurements of forced expiratory volume in the first second (FEV1), 
forced vital capacity (FVC) and their ratio (FEV1/FVC). These measures help identify any pre-
existing respiratory limitations that could influence CPET results. The CPET software system 
automatically calculates the maximum voluntary ventilation (MVV) using the FEV1 value from the 
spirometry using the formula MVV = FEV1 x 40. The MVV calculated is used as a reference for 
respiratory reserve during CPET. 
ii- 
Preparation phase: 
Gas and volume calibration was carried out. Patient details including age, biological sex, weight, 
height was entered in the CPET software. Calculation of Incremental workload protocol is done 
using the Wasserman’s formula: 
W = PredVO2max – VO2unloaded  
                 103 

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The participant was asked to mount the cycle ergometer, and a facemask is attached covering the 
mouth and nose. The participant was instructed not to speak during the test and communicate 
only using hand movements to avoid artifacts. The disposable chest and limb electrodes was 
attached to the participant for ECG recording and a ear lobe pulse oximeter was attached. 
Resting baseline 
The participant rested on the cycle ergometer without movement to record the baseline readings 
and minimize alterations caused by anxiety. 
Unloaded cycling (warm-up) 
The participant was asked to pedal along for 3 minutes with the cycle ergometer unloaded. The 
participant was advised to keep the cadence (RPM) between 60 to 65 at all times of the test. 
Increasing workload 
Lasting 10 ± 2 minutes, this phase involved a gradual (ramped) increase in exercise intensity. The 
workload (resistance required to turn the flywheel) increased at a pre-defined/calculated rate for 
the duration that the patient was able to continue cycling. The patients were motivated to keep 
cycling while keeping the cadence above 55 rpm at all times. Blood pressure recordings at 2 
minutes interval at the initial segment of the phase followed 1 minute interval once the respiratory 
exchange ratio was seen to cross 1.0 mark. The perceived exertion assessed via the Borg-10 scale 
was recorded at 4 minutes into the test and as close to maximal exhaustion as possible. The test 
was switched to recovery phase at the point where the patients raised their hand signaling, they 
were maximally exhausted. 
Recovery 
The recovery phase lasted for 3-5 minutes during which the load on the bike was reduced to zero 
watts while patients continued to cycle at the same cadence. Serial BP readings were taken at 
every 2-minute intervals. The test was terminated once VO2 had returned to 50% of the peak 
values or the heart rate and systolic BP return to within the 20 beats/min and 20mm Hg of the 
pretest resting values respectively. 
 

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Post-CPET workflow analysis 
After the CPET is concluded and the patient has left, the CPET software is switched to workflow 
mode. In the workflow mode, the preliminary basic analysis is done as the software guides through 
different stages of the workflow mode. The peak values, ventilatory thresholds and the slopes are 
confirmed manually by adjusting the areas on the curved out of which the software identifies and 
reports those values. Once in place, the software generated a preliminary report that can be saved 
into the system. 
Statistical Plan 
Data was analyzed using SPSSv29. Continuous variables were assessed for normality using the 
Shapiro-Wilk test and visual inspection of histograms and Q-Q plots. Normally distributed 
continuous variables are presented as mean ± standard deviation (SD), while non-normally 
distributed variables are presented as median (interquartile range). Categorical variables are 
presented as frequencies and percentages. 
For normally distributed continuous variables, independent samples t-tests were used to compare 
differences between two groups. For non-normally distributed continuous variables, the Mann-
Whitney U test was applied. Categorical variables were analyzed using chi-square tests.  
Relationships between continuous variables were examined using Pearson's correlation coefficient 
for normally distributed variables and Spearman's rank correlation for non-normally distributed 
variables. Statistical significance was set at p<0.05 for all tests.  
 

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Appendices 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 10: Diagnostic algorithm proposed by HF and ESC. 
 
 

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Figure 11: Scoring system for diagnosis of HFpEF . 
 
 

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Figure 12: Flyer shared to facilitate patient & public involvement. 

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Annex- 1 
 
Participant Information Sheet 
 
Hi, 
Please read the information below and answer questions at the end. 
 
Invitation 
You are being invited to take part in a research project being conducted in the Cardiology Lab 
at Ulster Hospital. Before you decide whether or not to participate, please read the following 
information and do not hesitate to ask any questions about anything that is unclear to you. 
 
What is the purpose of the study? 
To find out how people with certain heart related problems respond during an exercise test. This 
will help our understanding of your condition, its causes and potential treatments in the future. 
 
Who has been invited to participate? 
All patients ranging from 18 to 80 years registered with the South-eastern Health and Social 
Care Trust in Northern Ireland with a clinical suspicion of heart related problems are invited 
to participate. 
 
What the participation will involve? 
If you are interested in taking part in this study, you will be asked to complete a consent 
form and provide contact details prior to participation. 
 
• You will be invited to visit the Cardiology Lab at the Ulster Hospital. The day and time of 
will be mutually agreed beforehand. Directions to the lab and things to carry along will 
also be conveyed at the time of booking the visit. You will be provided with a pre- 
validated parking ticket. 
• You will be asked to read the consent form before signing it. Any related queries will be 
welcomed. 
• A familiarization session will be delivered in which you will be demonstrated how the 
exercise test will be performed. This will take approximately 30 minutes. 
• If you require further time to make up your mind, a second visit will be booked. If you are 

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happy to proceed with the testing preparation will be made accordingly. You will be asked 
to perform the test on an exercise bike for about 8 to 12 minutes. During the test, you will 
be breathing in a mask covering your nose and mouth. An elastic belt will be worn around 
the chest with a heart sensor at the front. Four other sensors will be attached to the front 
of the chest to monitor your heart. There will be qualified clinical staff with you at all 
times. 
• You will be guided about the pre-requites of the exercise test well before the testing day. 
These include avoiding strenuous exercise, smoking, tea and coffee 24 hours before the 
test. On the day of the exercise test, you should arrive wearing appropriate clothing and 
footwear (T-shirt and Joggers). 
• The exercise test will be postponed if you have fever, cold, cough or any sign of infection. 
 
Who has sponsored and reviewed this study? 
This research project is sponsored by Ulster University. The study has received ethical 
approval from filter committee and research governance of Ulster University as well as 
approved from the Research Ethic Committee Northern Ireland (REC NI). 
Benefits: 
 
Taking part in the research will give you information of your condition and your symptoms. 
We will give you feedback on your current level of fitness and working towards a healthier 
lifestyle. Your participation will also help us to understand certain heart conditions which 
could inform future treatments. There is also a possibility of identifying any other potential 
health related findings related to lungs and muscles. 
Risks and/or disadvantages of taking part? 
There is very little risk associated with taking part in this study. It is normal to feel out of 
breath during the test and muscles may be sore after the exercise test or the day after. 
Some participants may feel chest discomfort, faint, abnormal rise in blood pressure and 
abnormal heart rhythm. In extremely rare cases there is a risk of sudden cardiac arrest. 
The accompanying hospital staf f and research team are fully trained and equipped to 
promptly respond and tackle any events. 
Do I have to take part? 
It is completely up to you to decide whether or not you take part. If you decide to 
participate, you will be given this information sheet to keep, and you will be asked to provide 
contact details and sign a consent form. 
 

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Will my taking part in this study be kept confidential? 
All information collected for the study will be kept strictly confidential, in accordance with 
General Data Protection Regulations (GDPR) rules and will be kept for 10 years. The research 
data will be coded so that you cannot be identified, and the data will be held on password 
protected computers. Your name, address and personal details will not be made available to 
any organization beyond the study team. It is intended that the findings from this study willbe 
published in scientific or medical journals and presented at conferences. You will not be 
identified in any report or publication. 
 
Where can you find out more about how your information is used? 
You can find out more about how we use your information. 
 
• at www.hra.nhs.uk/information-about-patients/ 
• by asking one of the research team 
• by sending email to our data protection officer, Eoin Coyle, at e.coyle2@ulster.ac.uk 
or ringing at 02871675525 
 
What happens when the study end? 
You will be contacted by a member of your direct care team (doctor or staff nurse) from the 
hospital informing you about the study results. This might also include any other potential 
health related findings/issues identified. 
 
Right to withdraw: 
You can stop being part of a research study at any time, without giving a reason. You can do 
so by informing the principal investigator, Dr. McKavanagh through his secretary via the 
phone (028 9048 4511 ext 21762) or by email (Wendy.Wratten@setrust.hscni.net). A 
decision to withdraw, or a decision not to participate, will not have any implications. 
on the healthcare services being provided to you. If you withdraw from the research team will 
keep the research data about you that they already have. You can find out what would happen 
with your data before you agree to take part in a study. 
 
Who can I contact if I have a complaint? 
If you want to complain about how researchers have handled your information, you should 
contact the research team. If you are not happy after that, you can contact the Data 
Protection Officer Eoin Coyle, at e.coyle2@ulster.ac.uk or ringing at 02871675525. 
Furthermore, related information for submitting a complain through the Trust can be 
accessed at https://setrust.hscni.net/wp-content/uploads/2020/08/How-to-Make-a- 

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Complaint-English-V10.1-Aug-2020.pdf. 
Contact details of local Principal Investigator 
Dr Peter McKavanagh 
Secretary: Wendy.Wratten@setrust.hscni.net Tel: 028 9048 4511 ext 21762 
 
Thank you for taking the time to read this information. Please read the following questions and 
answer accordingly. 
 
Q.1 Are there any aspects that needs further clarification? Is there anything else you would 
like to know about? 
 
Q.2 Is there anything you want us to omit or change? 
 
Q.3 After going through the contents above, would you be encouraged to participate in this 
study? 

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Instructions for Testing Day 
 
Please abide by the following instructions when you visit the hospital for the testing: 
• Arrive at the hospital 5 min before the appointment time. 
• Avoid strenuous exercise, tea, coffee, smoking and alcohol on the test day. 
• Continue taking your usual medications. 
• Wear appropriate clothing (i.e. loose fitted clothes and jogging shoes). 
 
 
Consider postponing the test in case you have any one of the following: 
• Fever 
• Cold 
• Cough 
• or any sign of infection 
 
 
In case of any appointment related query or changes, please inform Dr. Javaid as soon as 
possible using the contact details stated below. 
 
Contact details:  
Dr. Saqib Javaid 
07869195234 
javaid-s2@ulster.ac.uk 
 
 

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