{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T12:03:52Z","timestamp":1790165032026,"version":"4.1.0"},"reference-count":71,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T00:00:00Z","timestamp":1790121600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Permanent cardiac pacing abolishes symptomatic bradycardia, yet a substantial proportion of recipients remain limited on exertion. Chronotropic incompetence is present in about half of pacemaker-wearing patients when assessed by the Wilkoff index, and the rate-responsive function intended to correct it is frequently left at the settings applied at implantation. Read across the whole cardiopulmonary exercise test rather than at peak effort, the relationship between heart rate and oxygen consumption distinguishes an inadequate sensor slope, an activity threshold set too high, a reaction time out of step with the onset of exercise, and an upper rate limit reached prematurely, each with a distinct correction. Reprogramming alters the result of the test within 24 h, so the settings should be corrected before rehabilitation begins. The objective is not the highest achievable rate but the individual ceiling above which the ventricle no longer converts frequency into output. Because heart rate is partly device-determined, training intensity should be anchored to the ventilatory threshold, to the corresponding workload and to perceived exertion, with heart rate being monitored for safety rather than used to set intensity. The aim of this review is to describe how cardiopulmonary exercise testing guides device reprogramming and training prescription in the pacemaker-wearing patient.<\/jats:p>","DOI":"10.3390\/jcm15197394","type":"journal-article","created":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T11:09:08Z","timestamp":1790161748000},"page":"7394","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cardiopulmonary Exercise Testing in Patients with Cardiac Pacemakers: From Device Optimization to Individualized Cardiac Rehabilitation"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4562-7221","authenticated-orcid":false,"given":"Bogdan","family":"Caloian","sequence":"first","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmen Silvia","family":"Caloian","sequence":"additional","affiliation":[{"name":"Department of Periodontology, Faculty of Dental Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1944-4088","authenticated-orcid":false,"given":"Raluca","family":"Tomoaia","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diana Andrada","family":"Irimie","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Florina Iulia","family":"Fringu","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dan Horatiu","family":"Comsa","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7352-9584","authenticated-orcid":false,"given":"Gabriel Laurentiu","family":"Cismaru","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3796-6522","authenticated-orcid":false,"given":"Gabriel Nicolae","family":"Gusetu","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Radu Ovidiu","family":"Rosu","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1744-7952","authenticated-orcid":false,"given":"Dana","family":"Pop","sequence":"additional","affiliation":[{"name":"Department of Cardiology-Rehabilitation, Faculty of Medicine, University of Medicine and Pharmacy \u201cIuliu Hatieganu\u201d, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3427","DOI":"10.1093\/eurheartj\/ehab364","article-title":"2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1016\/S0735-1097(03)00757-5","article-title":"A randomized comparison of atrial and dual-chamber pacing in 177 consecutive patients with sick sinus syndrome: Echocardiographic and clinical outcome","volume":"42","author":"Nielsen","year":"2003","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1046\/j.1540-8167.2004.03537.x","article-title":"Accuracy of mode switch algorithms for detection of atrial tachyarrhythmias","volume":"15","author":"Passman","year":"2004","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"568","DOI":"10.1111\/j.1540-8159.1998.tb00100.x","article-title":"Cardiac rehabilitation in patients with rate responsive pacemakers","volume":"21","author":"Greco","year":"1998","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1301","DOI":"10.1053\/euhj.2001.3078","article-title":"Defining the optimum upper heart rate limit during exercise: A study in pacemaker patients with heart failure","volume":"23","author":"Kindermann","year":"2002","journal-title":"Eur. Heart J."},{"key":"ref_6","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":"ref_7","first-page":"705","article-title":"Exercise testing for chronotropic assessment","volume":"10","author":"Wilkoff","year":"1992","journal-title":"Cardiol. Clin."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1093\/europace\/euj017","article-title":"Predictors of chronotropic incompetence in the pacemaker patient population","volume":"8","author":"Melzer","year":"2006","journal-title":"Europace"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"133022","DOI":"10.1016\/j.ijcard.2025.133022","article-title":"Effectiveness of rate-adaptive pacing on patients with chronotropic incompetence: Systematic review and meta-analysis of randomized controlled trials","volume":"423","author":"Kuroda","year":"2025","journal-title":"Int. J. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"euaf050","DOI":"10.1093\/europace\/euaf050","article-title":"European Society of Cardiology (ESC) clinical consensus statement on indications for conduction system pacing","volume":"27","author":"Glikson","year":"2025","journal-title":"Europace"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"524","DOI":"10.1001\/jama.281.6.524","article-title":"Impaired chronotropic response to exercise stress testing as a predictor of mortality","volume":"281","author":"Lauer","year":"1999","journal-title":"JAMA"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"3227","DOI":"10.1093\/eurheartj\/ehab484","article-title":"2021 ESC Guidelines on cardiovascular disease prevention in clinical practice","volume":"42","author":"Visseren","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_13","first-page":"419","article-title":"The influence of cardiac pacemaker programming modes on exercise capacity","volume":"32","author":"Caloian","year":"2018","journal-title":"In Vivo"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"577","DOI":"10.12680\/10.12680\/balneo.2023.577","article-title":"Optimizing cardiac rehabilitation by pacemaker reprogramming. Can we immediately improve the exercise capacity?","volume":"14","author":"Caloian","year":"2023","journal-title":"Balneo PRM Res. J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1736","DOI":"10.1093\/eurjpc\/zwaa121","article-title":"Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: A consensus document from the European Association of Preventive Cardiology (EAPC) and European Heart Rhythm Association (EHRA)","volume":"28","author":"Pedretti","year":"2021","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Caloian, B., Caloian, C.S., Tomoaia, R., Irimie, D.A., Fringu, F.I., Comsa, D.H., Cismaru, G.L., Gusetu, G.N., Rosu, R.O., and Pop, D. (2026). Cardiopulmonary exercise testing in the differential diagnosis between athlete\u2019s heart and cardiac pathology: Current evidence and diagnostic challenges. Diagnostics, 16.","DOI":"10.3390\/diagnostics16162573"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1010","DOI":"10.1161\/CIRCULATIONAHA.110.940577","article-title":"Chronotropic incompetence: Causes, consequences, and management","volume":"123","author":"Brubaker","year":"2011","journal-title":"Circulation"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1520","DOI":"10.1161\/01.CIR.93.8.1520","article-title":"Impaired heart rate response to graded exercise: Prognostic implications of chronotropic incompetence in the Framingham Heart Study","volume":"93","author":"Lauer","year":"1996","journal-title":"Circulation"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1457","DOI":"10.1046\/j.1460-9592.2000.01457.x","article-title":"Assessment of the chronotropic response at the anaerobic threshold: An objective measure of chronotropic function","volume":"23","author":"Meine","year":"2000","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"764","DOI":"10.1016\/j.jacc.2009.06.006","article-title":"The effects of right ventricular apical pacing on ventricular function and dyssynchrony: Implications for therapy","volume":"54","author":"Tops","year":"2009","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2932","DOI":"10.1161\/01.CIR.0000072769.17295.B1","article-title":"Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction","volume":"107","author":"Sweeney","year":"2003","journal-title":"Circulation"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3115","DOI":"10.1001\/jama.288.24.3115","article-title":"Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial","volume":"288","author":"Wilkoff","year":"2002","journal-title":"JAMA"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1016\/j.hrthm.2022.09.019","article-title":"Pacing-induced cardiomyopathy: A systematic review and meta-analysis of definition, prevalence, risk factors, and management","volume":"20","author":"Somma","year":"2023","journal-title":"Heart Rhythm"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2272","DOI":"10.1016\/j.hrthm.2016.09.027","article-title":"Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function","volume":"13","author":"Kiehl","year":"2016","journal-title":"Heart Rhythm"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.jchf.2017.09.018","article-title":"Rate-response programming tailored to the force-frequency relationship improves exercise tolerance in chronic heart failure","volume":"6","author":"Gierula","year":"2018","journal-title":"JACC Heart Fail."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1885","DOI":"10.1016\/j.jacc.2016.02.042","article-title":"Chronotropic incompetence does not limit exercise capacity in chronic heart failure","volume":"67","author":"Jamil","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"American Thoracic Society, and American College of Chest Physicians (2003). ATS\/ACCP statement on cardiopulmonary exercise testing. Am. J. Respir. Crit. Care Med., 167, 211\u2013277.","DOI":"10.1164\/rccm.167.2.211"},{"key":"ref_28","first-page":"300","article-title":"Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: Recommendations for performance and interpretation. Part II: How to perform cardiopulmonary exercise testing in chronic heart failure","volume":"13","author":"Piepoli","year":"2006","journal-title":"Eur. J. Cardiovasc. Prev. Rehabil."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2261","DOI":"10.1161\/CIR.0b013e31826fb946","article-title":"EACPR\/AHA scientific statement. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations","volume":"126","author":"Guazzi","year":"2012","journal-title":"Circulation"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e694","DOI":"10.1161\/CIR.0000000000000406","article-title":"2016 focused update: Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations","volume":"133","author":"Guazzi","year":"2016","journal-title":"Circulation"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1920","DOI":"10.1111\/j.1540-8159.1994.tb03774.x","article-title":"Quantitative comparison of rate response and oxygen uptake kinetics between different sensor modes in multisensor rate adaptive pacing","volume":"17","author":"Leung","year":"1994","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1046\/j.1460-9592.2003.00024.x","article-title":"Comparison of the cardiopulmonary response to exercise in recipients of dual sensor DDDR pacemakers versus a healthy control group","volume":"26","author":"Page","year":"2003","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2020","DOI":"10.1152\/jappl.1986.60.6.2020","article-title":"A new method for detecting the anaerobic threshold by gas exchange","volume":"60","author":"Beaver","year":"1986","journal-title":"J. Appl. Physiol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"\u015awier\u017cy\u0144ska, E., Or\u0119ziak, A., G\u0142\u00f3wczy\u0144ska, R., Rossillo, A., Grabowski, M., Szumowski, \u0141., Caprioglio, F., and Sterli\u0144ski, M. (2023). Rate-responsive cardiac pacing: Technological solutions and their applications. Sensors, 23.","DOI":"10.3390\/s23031427"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1016\/j.jacep.2016.06.008","article-title":"Safety and efficacy of exercise training in patients with an implantable cardioverter-defibrillator: A meta-analysis","volume":"3","author":"Pandey","year":"2017","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Nielsen, K.M., Zwisler, A.D., Taylor, R.S., Svendsen, J.H., Lindschou, J., Anderson, L., Jakobsen, J.C., and Berg, S.K. (2019). Exercise-based cardiac rehabilitation for adult patients with an implantable cardioverter defibrillator. Cochrane Database Syst. Rev., CD011828.","DOI":"10.1002\/14651858.CD011828.pub2"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"3097","DOI":"10.1093\/eurheartj\/ehu130","article-title":"Exercise and competitive sports in patients with an implantable cardioverter-defibrillator","volume":"35","author":"Heidbuchel","year":"2014","journal-title":"Eur. Heart J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"756","DOI":"10.4081\/monaldi.2016.756","article-title":"Cardiac rehabilitation in patients with pacemakers and implantable cardioverter defibrillators","volume":"86","author":"Iliou","year":"2016","journal-title":"Monaldi Arch. Chest Dis."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1357","DOI":"10.1016\/j.jacc.2007.09.073","article-title":"Inappropriate implantable cardioverter-defibrillator shocks in MADIT II: Frequency, mechanisms, predictors, and survival impact","volume":"51","author":"Daubert","year":"2008","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1161\/01.CIR.83.3.778","article-title":"Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure","volume":"83","author":"Mancini","year":"1991","journal-title":"Circulation"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"977","DOI":"10.1161\/CIRCHEARTFAILURE.113.000471","article-title":"Prognostic value of indeterminable anaerobic threshold in heart failure","volume":"6","author":"Agostoni","year":"2013","journal-title":"Circ. Heart Fail."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1016\/j.ahj.2003.07.014","article-title":"Peak VO2 and VE\/VCO2 slope in patients with heart failure: A prognostic comparison","volume":"147","author":"Arena","year":"2004","journal-title":"Am. Heart J."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1053\/euhj.1999.1863","article-title":"Cardiopulmonary exercise testing for prognosis in chronic heart failure: Continuous and independent prognostic value from VE\/VCO2 slope and peak VO2","volume":"21","author":"Francis","year":"2000","journal-title":"Eur. Heart J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1002\/ejhf.156","article-title":"Cardiopulmonary exercise testing in systolic heart failure in 2014: The evolving prognostic role","volume":"16","author":"Piepoli","year":"2014","journal-title":"Eur. J. Heart Fail."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1567","DOI":"10.1016\/S0735-1097(96)00412-3","article-title":"Oxygen uptake efficiency slope: A new index of cardiorespiratory functional reserve derived from the relation between oxygen uptake and minute ventilation during incremental exercise","volume":"28","author":"Baba","year":"1996","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1016\/S0735-1097(00)00691-4","article-title":"Oxygen uptake efficiency slope: An index of exercise performance and cardiopulmonary reserve requiring only submaximal exercise","volume":"36","author":"Hollenberg","year":"2000","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Kasiak, P., Kowalski, T., R\u0119bi\u015b, K., Klusiewicz, A., Starczewski, M., \u0141adyga, M., Wiecha, S., Barylski, M., Poliwczak, A.R., and Wierzbi\u0144ski, P. (2024). Below or all the way to the peak? Oxygen uptake efficiency slope as the index of cardiorespiratory response to exercise\u2014The NOODLE study. Front. Physiol., 15.","DOI":"10.3389\/fphys.2024.1348307"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Kasiak, P., Kowalski, T., R\u0119bi\u015b, K., Klusiewicz, A., Sadowska, D., Wilk, A., Wiecha, S., Barylski, M., Poliwczak, A.R., and Wierzbi\u0144ski, P. (2024). Oxygen uptake efficiency plateau is unaffected by fitness level\u2014The NOODLE study. BMC Sports Sci. Med. Rehabil., 16.","DOI":"10.1186\/s13102-024-00939-w"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1853","DOI":"10.1111\/j.1540-8159.1995.tb03832.x","article-title":"Relationship between heart rate and oxygen kinetics during constant workload exercise","volume":"18","author":"Kay","year":"1995","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1693","DOI":"10.1161\/CIRCULATIONAHA.119.045066","article-title":"Personalized rate-response programming improves exercise tolerance after 6 months in people with cardiac implantable electronic devices and heart failure: A phase II study","volume":"141","author":"Gierula","year":"2020","journal-title":"Circulation"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"e317","DOI":"10.1161\/CIRCULATIONAHA.120.048807","article-title":"Letter by Lau and Tse regarding article, \u201cPersonalized rate-response programming improves exercise tolerance after 6 months in people with cardiac implantable electronic devices and heart failure: A phase II study\u201d","volume":"142","author":"Lau","year":"2020","journal-title":"Circulation"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e319","DOI":"10.1161\/CIRCULATIONAHA.120.050610","article-title":"Response by Gierula et al. to letter regarding article, \u201cPersonalized rate-response programming improves exercise tolerance after 6 months in people with cardiac implantable electronic devices and heart failure: A phase II study\u201d","volume":"142","author":"Gierula","year":"2020","journal-title":"Circulation"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1777","DOI":"10.1093\/europace\/euab110","article-title":"Impact of closed loop stimulation on prognostic cardiopulmonary variables in patients with chronic heart failure and severe chronotropic incompetence: A pilot, randomized, crossover study","volume":"23","author":"Proff","year":"2021","journal-title":"Europace"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1001\/jama.2023.0675","article-title":"Rate-adaptive atrial pacing for heart failure with preserved ejection fraction: The RAPID-HF randomized clinical trial","volume":"329","author":"Reddy","year":"2023","journal-title":"JAMA"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"105278","DOI":"10.1016\/j.jaccas.2025.105278","article-title":"Cardiopulmonary exercise testing\u2013guided optimization of pacemaker rate-response in an endurance athlete with sinus node dysfunction","volume":"30","author":"Hsieh","year":"2025","journal-title":"JACC Case Rep."},{"key":"ref_56","first-page":"414","article-title":"Effect of fixed-rate vs. rate-responsive pacing on exercise capacity in patients with permanent, refractory atrial fibrillation and left ventricular dysfunction treated with atrioventricular junction ablation and biventricular pacing (RESPONSIBLE)","volume":"19","author":"Palmisano","year":"2017","journal-title":"Europace"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1093\/europace\/eus425","article-title":"Effect of rate-adaptive pacing on performance and physiological parameters during activities of daily living in the elderly: Results from the CLEAR (Cylos Responds with Physiologic Rate Changes during Daily Activities) study","volume":"15","author":"Singh","year":"2013","journal-title":"Europace"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1111\/pace.13857","article-title":"A new algorithm for optimization of rate-adaptive pacing improves exercise tolerance in patients with HFpEF","volume":"43","author":"Serova","year":"2020","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Squeo, M.R., Di Giacinto, B., Perrone, M.A., Santini, M., Sette, M.L., Fabrizi, E., Vaquer, A., Parisi, A., Spataro, A., and Biffi, A. (2022). Efficacy and safety of a combined aerobic, strength and flexibility exercise training program in patients with implantable cardiac devices. J. Cardiovasc. Dev. Dis., 9.","DOI":"10.3390\/jcdd9060182"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1177\/2047487312460484","article-title":"Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: A joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation","volume":"20","author":"Mezzani","year":"2013","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1093\/eurjpc\/zwab007","article-title":"Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: Why and how. A position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology","volume":"29","author":"Hansen","year":"2022","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1097\/HJR.0b013e32832914c8","article-title":"Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: A report from the Exercise Physiology Section of the European Association for Cardiovascular Prevention and Rehabilitation","volume":"16","author":"Mezzani","year":"2009","journal-title":"Eur. J. Cardiovasc. Prev. Rehabil."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"873","DOI":"10.1161\/CIR.0b013e31829b5b44","article-title":"Exercise standards for testing and training: A scientific statement from the American Heart Association","volume":"128","author":"Fletcher","year":"2013","journal-title":"Circulation"},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Di, R., Huang, Z., Huang, H., Li, S., Gao, X., and Bai, J. (2024). Summary of the best evidence for risk stratification of exercise rehabilitation in patients with a cardiac implantable electronic device. Front. Cardiovasc. Med., 11.","DOI":"10.3389\/fcvm.2024.1455486"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"1845","DOI":"10.1056\/NEJMoa013168","article-title":"Cardiac resynchronization in chronic heart failure","volume":"346","author":"Abraham","year":"2002","journal-title":"N. Engl. J. Med."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"791","DOI":"10.4081\/monaldi.2017.791","article-title":"Exercise-based cardiac rehabilitation in cardiac resynchronization therapy recipients: A primer for practicing clinicians","volume":"87","author":"Ambrosetti","year":"2017","journal-title":"Monaldi Arch. Chest Dis."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1097\/01.hjr.0000230104.93771.7d","article-title":"Moderate exercise training improves functional capacity, quality of life, and endothelium-dependent vasodilation in chronic heart failure patients with implantable cardioverter defibrillators and cardiac resynchronization therapy","volume":"13","author":"Belardinelli","year":"2006","journal-title":"Eur. J. Cardiovasc. Prev. Rehabil."},{"key":"ref_68","doi-asserted-by":"crossref","unstructured":"Niebauer, J. (2017). The rehabilitation in cardiac resynchronisation therapy. Cardiac Rehabilitation Manual, Springer International Publishing.","DOI":"10.1007\/978-3-319-47738-1"},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"2292","DOI":"10.1016\/j.jacc.2005.02.097","article-title":"The incremental benefit of rate-adaptive pacing on exercise performance during cardiac resynchronization therapy","volume":"46","author":"Tse","year":"2005","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"486","DOI":"10.23736\/S2724-5683.25.06885-1","article-title":"Cardiac rehabilitation in patients with atrial fibrillation","volume":"74","author":"Cersosimo","year":"2026","journal-title":"Minerva Cardiol. Angiol."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"euaf181","DOI":"10.1093\/europace\/euaf181","article-title":"Two-year outcomes of left bundle branch area pacing versus traditional right ventricular pacing in middle-aged adults: A registry-based trial","volume":"27","author":"Bertini","year":"2025","journal-title":"Europace"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7394\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T11:29:35Z","timestamp":1790162975000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7394"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,23]]},"references-count":71,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197394"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197394","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,23]]}}}