{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T16:45:01Z","timestamp":1785775501402,"version":"3.56.0"},"reference-count":31,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T00:00:00Z","timestamp":1784764800000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>To evaluate the applicability of the RoMa classification in patients with transthyretin cardiac amyloidosis (ATTR-CM) and to assess its association with functional capacity and key cardiopulmonary exercise testing (CPET) parameters.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>Consecutive adults (\u226518 years) with confirmed ATTR-CM from two tertiary centres who completed symptom-limited maximal CPET were included. RoMa classes were defined using predefined cut-offs for per cent-predicted peak heart rate (HRpp \u226580%) and per cent-predicted peak O2-pulse (O2pp \u2265100%): RoMa I (high HRpp\/high O2pp), RoMa II (high HRpp\/low O2pp), RoMa III (low HRpp\/high O2pp), and RoMa IV (low HRpp\/low O2pp). We evaluated 165 patients (90% male; 77% wild-type ATTR, 20% variant ATTR). RoMa distribution was as follows: RoMa I, n = 33; RoMa II, n = 73; RoMa III, n = 30; and RoMa IV, n = 29. Age did not differ across classes (P = 0.36). Functional capacity declined across the RoMa strata: median 6-min walk distance (6MWD) decreased from 420 (RoMa I) to 313\u2005m (RoMa IV) (overall P = 0.009; P-trend = 0.005), and NYHA class worsened (overall P = 0.003; P-trend = 0.005). Peak VO2 (% predicted) differed between groups (RoMa I: 93.0; II: 70.8; III: 75.2; IV: 51.9; overall P &amp;lt; 0.001; P-trend &amp;lt; 0.001), and ventilatory inefficiency increased (VE\/VCO2 slope: 34; 39; 37; 47, respectively; overall P &amp;lt; 0.001; P-trend &amp;lt; 0.001; peak PetCO2: 30; 27; 29; 25, respectively; overall P &amp;lt; 0.001; P-trend = 0.003). 6MWD correlated with peak VO2 (r = 0.626; P &amp;lt; 0.001; n = 131) and inversely with VE\/VCO2 slope (\u03c1 = \u22120.484; P &amp;lt; 0.001; n = 130).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In ATTR-CM, application of the RoMa classification was feasible and identified distinct CPET-derived exercise-response profiles associated with functional impairment. These findings support RoMa as a promising exploratory framework for functional phenotyping in ATTR-CM.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/eurjpc\/zwag379","type":"journal-article","created":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T11:31:05Z","timestamp":1784633465000},"source":"Crossref","is-referenced-by-count":0,"title":["A novel method to classify exercise response in patients with cardiac amyloidosis\u2014the RoMa classification"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-5837-5708","authenticated-orcid":false,"given":"Antonio","family":"K\u00f6sters","sequence":"first","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna , Spitalgasse 23, Vienna 1090 ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikita","family":"Ermolaev","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna , Spitalgasse 23, Vienna 1090 ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elisabetta","family":"Salvioni","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahshid","family":"Eslami","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna , Spitalgasse 23, Vienna 1090 ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lisa","family":"Seilinger","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna , Spitalgasse 23, Vienna 1090 ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mauro","family":"Contini","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8235-9353","authenticated-orcid":false,"given":"Carlo","family":"Vignati","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2276-9630","authenticated-orcid":false,"given":"Jeness","family":"Campodonico","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irene","family":"Mattavelli","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fiorella","family":"Puttini","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2680-3867","authenticated-orcid":false,"given":"Piergiuseppe","family":"Agostoni","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0360-2360","authenticated-orcid":false,"given":"Roza","family":"Badr Eslam","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna , Spitalgasse 23, Vienna 1090 ,","place":["Austria"]},{"name":"Medical University of Vienna Department of Clinical Pharmacology, , Vienna 1090 ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robin","family":"Willixhofer","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern , Bern 3010 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Massimo","family":"Mapelli","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino, IRCCS , Milan ,","place":["Italy"]},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan , Milan 20122 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,7,23]]},"reference":[{"key":"2026080311514415400_zwag379-B1","doi-asserted-by":"crossref","first-page":"549","DOI":"10.1161\/CIRCHEARTFAILURE.109.881326","article-title":"Six-minute walk test and cardiopulmonary exercise testing in patients with chronic heart failure: a comparative analysis on clinical and prognostic insights","volume":"2","author":"Guazzi","year":"2009","journal-title":"Circ Heart Fail"},{"key":"2026080311514415400_zwag379-B2","doi-asserted-by":"crossref","first-page":"e7","DOI":"10.1161\/CIR.0000000000000792","article-title":"Cardiac amyloidosis: evolving diagnosis and management: a scientific statement from the American Heart Association","volume":"142","author":"Kittleson","year":"2020","journal-title":"Circulation"},{"key":"2026080311514415400_zwag379-B3","doi-asserted-by":"crossref","first-page":"1958","DOI":"10.3390\/jcm15051958","article-title":"Hereditary transthyretin amyloidosis in Austria: clinical, genetic, and demographic insights from a nationwide cohort","volume":"15","author":"Ermolaev","year":"2026","journal-title":"J Clin Med"},{"key":"2026080311514415400_zwag379-B4","doi-asserted-by":"crossref","first-page":"2740","DOI":"10.1002\/ehf2.14406","article-title":"Cardiopulmonary exercise testing predicts prognosis in amyloid cardiomyopathy: a systematic review and meta-analysis","volume":"10","author":"Cantone","year":"2023","journal-title":"ESC Heart Fail"},{"key":"2026080311514415400_zwag379-B5","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1001\/jamacardio.2024.0022","article-title":"Cardiopulmonary exercise testing in evaluating transthyretin amyloidosis","volume":"9","author":"Patel","year":"2024","journal-title":"JAMA Cardiol"},{"key":"2026080311514415400_zwag379-B6","doi-asserted-by":"crossref","DOI":"10.3389\/fcvm.2022.898033","article-title":"Diagnostic and prognostic values of cardiopulmonary exercise testing in cardiac amyloidosis","volume":"9","author":"Banydeen","year":"2022","journal-title":"Front Cardiovasc Med"},{"key":"2026080311514415400_zwag379-B7","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCHEARTFAILURE.121.008381","article-title":"Impact of tafamidis and optimal background treatment on physical performance in patients with transthyretin amyloid cardiomyopathy","volume":"15","author":"Badr Eslam","year":"2022","journal-title":"Circ Heart Fail"},{"key":"2026080311514415400_zwag379-B8","doi-asserted-by":"crossref","first-page":"1285","DOI":"10.1016\/j.cardfail.2021.06.022","article-title":"Prognostic role of cardiopulmonary exercise testing in wild-type transthyretin amyloid cardiomyopathy patients treated with tafamidis","volume":"27","author":"Dalia","year":"2021","journal-title":"J Card Fail"},{"key":"2026080311514415400_zwag379-B9","doi-asserted-by":"crossref","first-page":"704","DOI":"10.2459\/JCM.0000000000001636","article-title":"Cardiopulmonary exercise testing in transthyretin amyloid cardiomyopathy patients: a long-term follow-up study","volume":"25","author":"Willixhofer","year":"2024","journal-title":"J Cardiovasc Med (Hagerstown)"},{"key":"2026080311514415400_zwag379-B10","doi-asserted-by":"crossref","first-page":"7111","DOI":"10.3390\/jcm14197111","article-title":"Functional capacity evaluation and rehabilitation strategies in cardiac amyloidosis: a comprehensive review","volume":"14","author":"Plevritaki","year":"2025","journal-title":"J Clin Med"},{"key":"2026080311514415400_zwag379-B11","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.amjcard.2019.03.035","article-title":"Use of ventilatory efficiency slope as a marker for increased mortality in wild-type transthyretin cardiac amyloidosis","volume":"124","author":"Yunis","year":"2019","journal-title":"Am J Cardiol"},{"key":"2026080311514415400_zwag379-B12","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1002\/ejhf.2016","article-title":"Prognostic value of cardiopulmonary exercise testing in cardiac amyloidosis","volume":"23","author":"Nicol","year":"2021","journal-title":"Eur J Heart Fail"},{"key":"2026080311514415400_zwag379-B13","doi-asserted-by":"crossref","first-page":"1618","DOI":"10.1016\/j.jacc.2017.08.012","article-title":"Cardiopulmonary exercise testing: what is its value?","volume":"70","author":"Guazzi","year":"2017","journal-title":"J Am Coll Cardiol"},{"key":"2026080311514415400_zwag379-B14","doi-asserted-by":"publisher","DOI":"10.1093\/eurjpc\/zwaf402","article-title":"Cardiopulmonary exercise testing in hypertrophic cardiomyopathy: the role of reduced O2 pulse and chronotropic incompetence in myocardial adaptation","author":"Willixhofer","year":"2025","journal-title":"Eur J Prev Cardiol"},{"key":"2026080311514415400_zwag379-B15","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.125.046438","article-title":"Roma: a cardiopulmonary exercise testing based risk tool in hypertrophic cardiomyopathy","volume":"15","author":"Willixhofer","year":"2026","journal-title":"J Am Heart Assoc"},{"key":"2026080311514415400_zwag379-B16","doi-asserted-by":"crossref","first-page":"1554","DOI":"10.1093\/eurheartj\/ehab072","article-title":"Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC Working Group on Myocardial and Pericardial Diseases","volume":"42","author":"Garcia-Pavia","year":"2021","journal-title":"Eur Heart J"},{"key":"2026080311514415400_zwag379-B17","doi-asserted-by":"crossref","first-page":"2404","DOI":"10.1161\/CIRCULATIONAHA.116.021612","article-title":"Nonbiopsy diagnosis of cardiac transthyretin amyloidosis","volume":"133","author":"Gillmore","year":"2016","journal-title":"Circulation"},{"key":"2026080311514415400_zwag379-B18","doi-asserted-by":"crossref","first-page":"1076","DOI":"10.1016\/j.jacc.2005.05.073","article-title":"Noninvasive etiologic diagnosis of cardiac amyloidosis using 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy","volume":"46","author":"Perugini","year":"2005","journal-title":"J Am Coll Cardiol"},{"key":"2026080311514415400_zwag379-B19","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1161\/CIR.0b013e3181e52e69","article-title":"Clinician\u2019s guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association","volume":"122","author":"Balady","year":"2010","journal-title":"Circulation"},{"key":"2026080311514415400_zwag379-B20","doi-asserted-by":"crossref","first-page":"2020","DOI":"10.1152\/jappl.1986.60.6.2020","article-title":"A new method for detecting anaerobic threshold by gas exchange","volume":"60","author":"Beaver","year":"1986","journal-title":"J Appl Physiol (1985)"},{"key":"2026080311514415400_zwag379-B21","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1016\/j.ijcard.2019.04.053","article-title":"How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure","volume":"288","author":"Agostoni","year":"2019","journal-title":"Int J Cardiol"},{"key":"2026080311514415400_zwag379-B22","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1016\/j.ijcard.2019.11.106","article-title":"Peak oxygen pulse responses during maximal cardiopulmonary exercise testing: reference standards from FRIEND (Fitness Registry and the Importance of Exercise: an International Database)","volume":"301","author":"Arena","year":"2020","journal-title":"Int J Cardiol"},{"key":"2026080311514415400_zwag379-B23","doi-asserted-by":"crossref","first-page":"S49","DOI":"10.1164\/arrd.1984.129.2P2.S49","article-title":"Predicted values for clinical exercise testing","volume":"129","author":"Hansen","year":"1984","journal-title":"Am Rev Respir Dis"},{"key":"2026080311514415400_zwag379-B24","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1136\/heartjnl-2024-324607","article-title":"Prevalence and functional impact of chronotropic incompetence in amyloid cardiomyopathy: a multicentre analysis","volume":"111","author":"Magr\u00ec","year":"2025","journal-title":"Heart"},{"key":"2026080311514415400_zwag379-B25","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jjcc.2024.03.008","article-title":"Atrial fibrillation in the setting of cardiac amyloidosis\u2014a review of the literature","volume":"84","author":"Bazoukis","year":"2024","journal-title":"J Cardiol"},{"key":"2026080311514415400_zwag379-B26","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCHEARTFAILURE.120.007503","article-title":"How patients with heart failure perform daily life activities: an innate energy-saving strategy","volume":"13","author":"Mapelli","year":"2020","journal-title":"Circ Heart Fail"},{"key":"2026080311514415400_zwag379-B27","doi-asserted-by":"crossref","first-page":"ii47","DOI":"10.1093\/eurjpc\/zwad155","article-title":"Activities of daily living in heart failure patients and healthy subjects: when the cardiopulmonary assessment goes beyond traditional exercise test protocols","volume":"30","author":"Mapelli","year":"2023","journal-title":"Eur J Prev Cardiol"},{"key":"2026080311514415400_zwag379-B28","doi-asserted-by":"crossref","first-page":"812","DOI":"10.1002\/ehf2.13781","article-title":"Brisk walking can be a maximal effort in heart failure patients: a comparison of cardiopulmonary exercise and 6 min walking test cardiorespiratory data","volume":"9","author":"Mapelli","year":"2022","journal-title":"ESC Heart Fail"},{"key":"2026080311514415400_zwag379-B29","doi-asserted-by":"crossref","first-page":"1269","DOI":"10.1002\/ehf2.14618","article-title":"Taking a walk on the heart failure side: comparison of metabolic variables during walking and maximal exertion","volume":"11","author":"Mapelli","year":"2024","journal-title":"ESC Heart Fail"},{"key":"2026080311514415400_zwag379-B30","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.jacc.2024.04.011","article-title":"Prognostic value of a 6-minute walk test in patients with transthyretin cardiac amyloidosis","volume":"84","author":"Ioannou","year":"2024","journal-title":"J Am Coll Cardiol"},{"key":"2026080311514415400_zwag379-B31","doi-asserted-by":"crossref","DOI":"10.14814\/phy2.70308","article-title":"Ventilatory efficiency in cardiac amyloidosis\u2014A systematic review and meta-analysis","volume":"13","author":"Willixhofer","year":"2025","journal-title":"Physiol Rep"}],"container-title":["European Journal of Preventive Cardiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/eurjpc\/advance-article-pdf\/doi\/10.1093\/eurjpc\/zwag379\/69884702\/zwag379.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/eurjpc\/advance-article-pdf\/doi\/10.1093\/eurjpc\/zwag379\/69884702\/zwag379.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T15:51:50Z","timestamp":1785772310000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/eurjpc\/advance-article\/doi\/10.1093\/eurjpc\/zwag379\/8740716"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,23]]},"references-count":31,"URL":"https:\/\/doi.org\/10.1093\/eurjpc\/zwag379","relation":{},"ISSN":["2047-4873","2047-4881"],"issn-type":[{"value":"2047-4873","type":"print"},{"value":"2047-4881","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,23]]},"article-number":"zwag379"}}