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©The European Society of Cardiology 2020. Article reuse guidelines : sagepub.com/journals-permissions, Secondary prevention through comprehensive cardiac rehabilitation has been recognized as the most cost-effective intervention to ensure favourable outcomes across a wide spectrum of cardiovascular disease, reducing cardiovascular mortality, morbidity and disability, and to increase quality of life. The delivery of a comprehensive and ‘modern’ cardiac rehabilitation programme is mandatory both in the residential and the out-patient setting to ensure expected outcomes. The present position paper aims to update the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions, in order to assist the whole cardiac rehabilitation staff in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and patients in the recognition of the positive nature of cardiac rehabilitation. Starting from the previous position paper published in 2010, this updated document maintains a disease-oriented approach, presenting both well-established and more controversial aspects. Particularly for implementation of the exercise programme, advances in different training modalities were added and new challenging populations were considered. A general table applicable to all cardiovascular conditions and specific tables for each clinical condition have been created for routine practice.

(1) Background: There is much debate about the use of salt-restricted diet for managing heart failure (HF). Dietary guidelines are inconsistent and lack evidence. (2) Method: The OFICSel observatory collected data about adults hospitalised for HF. The data, collected using study-specific surveys, were used to describe HF management, including diets, from the cardiologists’ and patients’ perspectives. Cardiologists provided the patients’ clinical, biological, echocardiography, and treatment data, while the patients provided dietary, medical history, sociodemographic, morphometric, quality of life, and burden data (burden scale in restricted diets (BIRD) questionnaire). The differences between the diet recommended by the cardiologist, understood by the patient, and the estimated salt intake (by the patient) and diet burden were assessed. (3) Results: Between March and June 2017, 300 cardiologists enrolled 2822 patients. Most patients (90%) were recommended diets with

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited., Preventive cardiology encompasses the whole spectrum of cardiovascular disease (CVD) prevention, at individual and population level, through all stages of life. This includes promotion of cardiovascular (CV) health, management of individuals at risk of developing CVD, and management of patients with established CVD, through interdisciplinary care in different settings. Preventive cardiology addresses all aspects of CV health in the context of the social determinants of health, including physical activity, exercise, sports, nutrition, weight management, smoking cessation, psychosocial factors and behavioural change, environmental, genetic and biological risk factors, and CV protective medications. This is the first European Core Curriculum for Preventive Cardiology, which will help to standardize, structure, deliver, and evaluate training in preventive cardiology across Europe. It will be the basis for dedicated fellowship programmes and a European Society of Preventive Cardiology (EAPC) subspecialty certification for cardiologists, with the intention to improve quality and outcome in CVD prevention.

Introduction Studies on effectiveness of cardiac rehabilitation (CR) in elderly cardiovascular disease patients are rare, and it is unknown, which patients benefit most. We aimed to identify predictors for 1-year outcomes of cardiorespiratory fitness and CV risk factor (CVRF) control in patients after completing CR programs offered across seven European countries. Methods Cardiovascular disease patients with minimal age 65 years who participated in comprehensive CR were included in this observational study. Peak oxygen uptake (VO2), body mass index (BMI), resting systolic blood pressure (BPsys), and low-density lipoprotein-cholesterol (LDL-C) were assessed before CR (T0), at termination of CR (T1), and 12 months after start of CR (T2). Predictors for changes were identified by multivariate regression models. Results Data was available from 1241 out of 1633 EU-CaRE patients. The strongest predictor for improvement in peak VO2 was open chest surgery, with a nearly four-fold increase in surgery compared to non-surgery patients. In patients after surgery, age, female sex, physical inactivity and time from index event to T0 were negative predictors for improvement in peak VO2. In patients without surgery, previous acute coronary syndrome and higher exercise capacity at T0 were the only negative predictors. Neither number of attended training sessions nor duration of CR were significantly associated with change in peak VO2. Non-surgery patients were more likely to achieve risk factor targets (BPsys, LDL-C, BMI) than surgery patients. Conclusions In a previously understudied population of elderly CR patients, time between index event and start of CR in surgery and disease severity in non-surgery patients were the most important predictors for long-term improvement of peak VO2. Non-surgery patients had better CVRF control.

Background Due to the progressive deconditioning, comorbidities and higher complication rates, elderly patients are in particular need of cardiac rehabilitation. We compared elderly patients (65+ years old) participating in cardiac rehabilitation, focusing on baseline characteristics, risk factor control and functional assessment. Methods The EU-CaRE study is a prospective study comparing cardiac rehabilitation in eight centres across Western Europe. Consecutive patients with acute coronary syndrome, stable coronary artery disease and heart valve replacement undergoing cardiac rehabilitation were included. Results Of 1633 patients (median age 72 years) participating, 54% had acute coronary syndrome, 33% had stable coronary artery disease and 13% followed valve replacement. Fifty-five per cent had undergone percutaneous coronary intervention and 29% coronary artery bypass grafting. Characteristics varied across centres: 23% (17–27%) were women, 4% (0–12%) were of non-European origin and 16% (4–32%) were living alone. Median time from index event to start of cardiac rehabilitation varied from 11 to 49 days ( p 2peak was relatively low (16 mL/kg per min) and varied significantly between the participating centres, largely unaffected by multivariable adjustment. Overall patients received guideline recommended treatment: 93% (87–97%) were on a statin and 70% (55–85%) an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. However, risk factor control was inadequate: 58% had three or more risk factors not controlled. Conclusion EU-CaRE provides a snapshot of the elderly population with heart disease participating in cardiac rehabilitation across countries in Western Europe. Risk factors and exercise capacity indicate the continued need for cardiac rehabilitation in these patients. Of concern, the lag-time to start of cardiac rehabilitation needs improvement in many centres.

Importance: Although nonparticipation in cardiac rehabilitation is known to increase cardiovascular mortality and hospital readmissions, more than half of patients with coronary artery disease in Europe are not participating in cardiac rehabilitation. Objective: To assess whether a 6-month guided mobile cardiac rehabilitation (MCR) program is an effective therapy for elderly patients who decline participation in cardiac rehabilitation. Design, Setting, and Participants: Patients were enrolled in this parallel multicenter randomized clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. Researchers assessing primary outcome were masked for group assignment. A total of 4236 patients were identified with a recent diagnosis of acute coronary syndrome, coronary revascularization, or surgical or percutaneous treatment for valvular disease, or documented coronary artery disease, of whom 996 declined to start cardiac rehabilitation. Subsequently, 179 patients who met the inclusion and exclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programmes in the Elderly trial. Data were analyzed from January 21 to October 11, 2019. Interventions: Six months of home-based cardiac rehabilitation with telemonitoring and coaching based on motivational interviewing was used to stimulate patients to reach exercise goals. Control patients did not receive any form of cardiac rehabilitation throughout the study period. Main Outcomes and Measures: The primary outcome parameter was peak oxygen uptake (Vo2peak) after 6 months. Results: Among 179 patients randomized (145 male [81%]; median age, 72 [range, 65-87] years), 159 (89%) were eligible for primary end point analysis. Follow-up at 1 year was completed for 151 patients (84%). Peak oxygen uptake improved in the MCR group (n = 89) at 6 and 12 months (1.6 [95% CI, 0.9-2.4] mL/kg-1/min-1and 1.2 [95% CI, 0.4-2.0] mL/kg-1/min-1, respectively), whereas there was no improvement in the control group (n = 90) (+0.2 [95% CI, -0.4 to 0.8] mL/kg-1/min-1and +0.1 [95% CI, -0.5 to 0.7] mL/kg-1/min-1, respectively). Changes in Vo2peak were greater in the MCR vs control groups at 6 months (+1.2 [95% CI, 0.2 to 2.1] mL/kg-1/min-1) and 12 months (+0.9 [95% CI, 0.05 to 1.8] mL/kg-1/min-1). The incidence of adverse events was low and did not differ between the MCR and control groups. Conclusions and Relevance: These results suggest that a 6-month home-based MCR program for patients 65 years or older with coronary artery disease or a valvular intervention was safe and beneficial in improving Vo2peak when compared with no cardiac rehabilitation. Trial Registration: trialregister.nl Identifier: NL5168.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com, A proper determination of the exercise intensity is important for the rehabilitation of patients with cardiovascular disease (CVD) since it affects the effectiveness and medical safety of exercise training. In 2013, the European Association of Preventive Cardiology (EAPC), together with the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation, published a position statement on aerobic exercise intensity assessment and prescription in cardiovascular rehabilitation (CR). Since this publication, many subsequent papers were published concerning the determination of the exercise intensity in CR, in which some controversies were revealed and some of the commonly applied concepts were further refined. Moreover, how to determine the exercise intensity during resistance training was not covered in this position paper. In light of these new findings, an update on how to determine the exercise intensity for patients with CVD is mandatory, both for aerobic and resistance exercises. In this EAPC position paper, it will be explained in detail which objective and subjective methods for CR exercise intensity determination exist for aerobic and resistance training, together with their (dis)advantages and practical applications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com., This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

International audience; The exercise test is still a key examination in cardiology, used for the diagnosis of myocardial ischemia, as well as for the clinical evaluation of other heart diseases. The cardiopulmonary exercise test can further define functional capacity and prognosis for any given cardiac pathology. These new guidelines focus on methods, interpretation and indications for an exercise test or cardiopulmonary exercise test, as summarized below. The safety rules associated with the exercise test must be strictly observed. Interpretation of exercise tests and cardiopulmonary exercise tests must be multivariable. Functional capacity is a strong predictor of all-cause mortality and cardiovascular events. Chest pain, ST-segment changes and an abnormal ST/heart rate index constitute the first findings in favor of myocardial ischemia, mostly related to significant coronary artery disease. Chronotropic incompetence, abnormal heart rate recovery, QRS changes (such as enlargement or axial deviations) and the use of scores (based on the presence of various risk factors) must also be considered in exercise test interpretation for a coronary artery disease diagnosis. Arrhythmias or conduction disorders arising during the exercise test must be considered in the assessment of prognosis, in addition to a decrease or low increase in blood pressure during the exercise phase. When performing a cardiopulmonary exercise test, peak oxygen uptake and the volume of expired gas/carbon dioxide output slope are the two main variables used to evaluate prognosis.

IF 2.271; International audience; Background. - Clinical studies have shown a beneficial effect of cardiac rehabilitation (CR) on mortality.Objective. - To study the effect of CR prescription at discharge on 5-year mortality in patients with acute myocardial infarction (AMI).Methods. - Participants, from the 2005 French FAST-MI hospital registry, were 2894 survivors at discharge, divided according to AMI type: ST-segment elevation myocardial infarction (STEMI; n=1523) and non-STEMI (NSTEMI; n=1371). The effect of CR prescription on mortality was analysed using a Cox proportional hazards model.Results. - At discharge, 22.1% of patients had a CR prescription. Patients referred to CR were younger (62.4 vs. 67.5 years), were more frequently men and more had presented with STEMI (67.8% vs. 48.3%) than non-referred patients. Ninety-four (14.7%) deaths occurred among patients referred to CR and 585 (25.9%) among non-referred patients (P= 60 years) and AMI type showed that the inverse association was stronger in men (HR 0.64, 95% CI 0.48-0.87) than in women (HR 0.95, 95% CI 0.64-1.39), in younger (HR 0.34, 95% CI 0.15-0.77) than in older patients (HR 0.84, 95% CI 0.65-1.07) and in NSTEMI (HR 0.63, 95% CI 0.46-0.88) than in STEMI (HR 0.99, 95% CI 0.69-1.40).Conclusion. - After hospitalization for AMI, referral to CR remains a significant predictor of improved patient survival; some subgroups seem to gain greater benefit. (C) 2015 Elsevier Masson SAS. All rights reserved.

International audience; Progress in the medical treatment of patients with heart failure with systolic dysfunction, cardiac resynchronization therapy, internal cardiac defibrillators and multidisciplinary management programmes has resulted in dramatic improvements in survival and quality of life; however, this progress has led to an increase in the prevalence of advanced heart failure. In the context of organ shortage for cardiac transplantation, the technological developments in left ventricular assist devices, shown in recent positive clinical studies, provide real hope for patients with advanced heart failure. This article summarizes the most recent clinical studies concerning left ventricular assist devices and discusses for whom and when a left ventricular assist device should be proposed.

SummaryBackgroundAssessment of health-related quality of life is widely recommended by European health agencies in relevant research studies as well as in clinical care.AimsTo validate the French version of the MacNew heart disease health-related quality of life questionnaire.MethodsAs part of the International HeartQoL Project, 323 French-speaking patients with ischaemic heart disease (angina, n=76; myocardial infarction [MI], n=155; heart failure, n=91; mean age 58.6±11.3 years) were recruited at seven cardiac rehabilitation centres. All patients completed the French versions of the MacNew questionnaire, the Short Form-36 Health Survey (SF-36) and the Hospital Anxiety and Depression Scale, to evaluate the psychometric properties of the French version of the MacNew instrument.ResultsThe mean MacNew global scale scores were 4.6±0.8, 5.0±1.0 and 4.8±0.9 in patients with angina, MI and heart failure, respectively (P

Background Female heart diseases are underdiagnosed and undertreated. They are also probably under referred to cardiac rehabilitation (CR). The aim of our study is to compare CR benefits between men and women. Methods A total of 442 patients suffering from heart failure were referred to our center for CR between 2010 and 2014. Only 67 were women (15%). All patients had physical examination, electrocardiogram, echocardiography and a cardio-pulmonary exercise test (CPET) before and at the end of CR. Results Age was similar between men and women with 56.8±12.4 versus 56.2±14.5 years (p: NS). Ischemic heart disease was the main etiology for men (57.6%), but not for women (30%, p Patient’s CR characteristics are summarized in table. Abstract 0525 – Table: Patient’s clinical, echocardiographic and CPET’s characteristics Men (n=375) Women (n=67) p Before CR Heart Rate (bpm)80.3±15.7 80.3±15.7 77.3±16.4 NS Systolic blood pressure (mmHg) 109.8±19 102.8±19 Left ventricle Ejection Fraction (%) 28.8±8.7 29.3±8.9 NS CPET workload (watts) 76±27 58.1±20 Peak oxygen uptake: 15.6±5.2 14.7±4.9 NS – VO2 max (ml/kg/mn) – % of the normal value 56.2±17.8 63.9±22 First ventilatory threshold (VT1) (ml/kg/mn) 10.9±3.4 10.5±4 NS After CR Heart Rate (bpm) 76.8±14.6 75.4±14.3 NS Systolic blood pressure (mmHg) 110.4±20.8 98.5±19.2 NS CPET workload (watts) 92.5±32 67.8±20 Peak oxygen uptake: 18.2±5.7 16.1±4.8 NS – VO2 max (ml/kg/mn) – % of the normal value 65.5±19.3 68.5±18 First ventilatory threshold (VT1) (ml/kg/mn) 12.4±3.9 11.9±3.7 NS The benefit on CPET strength was similar (24.8±33 W for men and 22.1±35.4 W for women, p: NS), and also for the VO2 max. There were no differences in treatments at discharge. Conclusion: Women have the same benefits after CR for heart failure. Efforts must be provided to increase their referral to CR.

Introduction The gain of peak VO2 after exercise training has prognostic value in CHF patients. The predictive factors influencing this response remain debated. As oxygen pulse is correlated with the stroke volume, it could reflect cardiac adaptation during exercise. The aim of this study is to evaluate the cardiac participation in benefits of exercise training (ET). Methods We included prospectively 53 CHF patients (mean age: 57± 12 years, LVEF 29 ± 6%) who underwent two cardiopulmonary exercises (CPX): before and after 20 endurance exercise training sessions. We analysed for the two CPX heart rate, workload, VO2, oxygen pulse and calculated stroke volume and cardiac output at rest, anaerobic threshold (AT) and peak exercise. We measured BNP levels before and after the exercise training program. Patients were considered as responders if the gain of peak VO2 was >10%. Results Mean change in peak VO2 after exercise training is 17% for global population, 36% for responders (n=27) and – 4% for non responders (n=26). At baseline, responder patients have a lower worload at AT and at peak exercise (52.6 ± 19 vs 62.2 ± 17 watts p: 0.035 and 68.9 ± 28 vs 86.6 ± 27 watts p:0.035); a lower oxygen uptake (14.8 ± 4.8 vs 17.5 ± 4,6ml/kg/min p: 0.04), a chronotropic incompetence (max heart rate 99.8 ± 19.8 vs 116 ± 25 b/min p:0.01), a lower maximal cardiac output (6.6 ± 2.5 vs 8.0 ± 2,3l/min p:0.019) and a higher BNP serum level (median 506 vs 279 pg/l p:0.019). However oxygen pulse trends or left ventricular function do not influence changes in peak VO2 at any time and regardless of the training type (continuous vs interval training). Conclusion Cardiac adaptations in CHF patients do not seem to play major role in the response to exercise. Benefits of exercise training on exercise tolerance in CHF patients are mainly due to peripheral improvements.

Background Cardiac rehabilitation (CR) is recommended after acute coronary syndrome (ACS), as it reduces morbidity and improves quality of life. In France, about 20 to 30% of patients are referred to CR after ACS. The aim of our study is to evaluate if early referral ( Methods From April 2014 to April 2015, thirty nine patients were referred to CR after their discharge from cardiac care unit (one center). The early referral group (ERG) included 16 patients, all of them had their first medical contact in CR within 7 days after ACS. The late referral group (LRG) included 23 patients. All patients had physical examination, electrocardiogram, echocardiography and exercise test (ExT) before and at the end of CR. Results 21% of patients hospitalized for ACS were referred to CR. Mean age was 55.5±9.8 years with only 3 females (7.6%). The characteristics of each group are summarized in table. Abstract 0487 – Table: Characteristics of each group ERG (n=16) LRG (n=23) p Age (Years) 58.8±10.8 53.5±9.7 P=0.04 BMI (Kg/m 2 ) 25.6±2.7 25.08±2.6 NS Hypertension (%) 37.5 34.7 NS Diabetes (%) 18 17.3 NS Smoking (%) 81.2 69.56 P ACS complications 12.5 21.7 P Delay ACS-First medical CR contact (days) 5.8±1 13.7±8.6 P Delay ACS-CR starting (days) 18.4±15 25.4±14 P LV EF (%) 54.2±6.6 60.8 8.7 NS ExT before CR 7±1.1 6.9±1.6 NS METS 128.7 ±27.3 126.5±34.7 NS Workload (watts) 11.1 ±2.2 11.4±2.4 NS Number of CR sessions 0 8% NS Complications during CR (%) 8.4±2.7 8±1.9 NS Ext after CR 152.8±32 151.3±43.3 NS METS Workload (watts) No complications occurred during CR in ERG, for the LRG 2 patients had chest angina due to an incomplete initial revascularization procedure. Conclusion Referral rate to CR after ACS is in the range of French national rates. Benefits of CR are similar independently from referral delay. CR is also safe even when started early after ACS.