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Exercise and Sports in the Therapy of Chronic Diseases - Coronary Heart Disease Abstract. Despite increasingly advanced diagnostic and therapeutic methods, coronary heart disease and myocardial infarction continue to be by far the leading cause of death worldwide. This makes it all the more important in this context to make full use of known but far from optimally used therapeutic measures. Adequate physical activity in everyday life and additional targeted training lead to an evidence-based improvement in quality of life, a reduction in morbidity and above all to a significant reduction in cardiac and overall mortality. However, an accurate risk assessment of the individual patient with consistent training recommendations and monitoring is crucial in medical training advice. Today's sports recommendations for coronary heart disease have become much more liberal than before and allow patients with a relatively low risk of sudden cardiac death to do virtually any kind of exercise. This progressive posture, according to optimal risk assessment, is important, as newer data also show a dose-dependent increase in the preventive effect in coronary heart disesase patients with an increase in the extent of weekly training.

Regarding the effectiveness of disease management programs (DMPs) in Germany, several studies have been published on the DMP for type 2 diabetes. This pilot study provides methodological insights into evaluating the DMP for coronary heart disease (CHD), which currently includes 1.7 million participants, and reveals trends in healthcare outcomes for mortality, guideline adherent prescribing and costs. Major methodological challenges that need to be considered for the development of an appropriate matching method for this indication have been identified. The results show positive trends in favor of the DMP regarding mortality, costs and medication according to guidelines. A matching design is applicable to the CHD indication; the knowledge gained regarding the quality of care can be used for a targeted development of the program., (Copyright © 2015. Published by Elsevier GmbH.)

The risk for cardiovascular events, congestive heart failure and cardiac arrhythmia is significantly increased in patients with diabetes. Although poor glycaemic control has been associated with an increased cardiovascular event rate, aggressive glucose-lowering strategies have failed to improve cardiovascular endpoints or mortality. Therefore, treatment-associated adverse effects, especially hypoglycaemia and weight gain, must be carefully outbalanced against the potential benefits of better glycaemic control. Furthermore, certain drug-specific aspects must be considered: Pioglitazone is contraindicated in patients with heart failure, and DPP-4 inhibitors have recently been associated with an increased heart failure rate. Heart rate may increase during treatment with GLP-1 analogues. Only with metformin a reduction in cardiovascular endpoint has been demonstrated in patients with diabetes. Insulin and sulphonylureas have yielded neutral results in the available endpoint trials. Endpoint studies with GLP-1 analogues or SGLT-2 inhibitors have not yet been completed. These various drug-specific actions in the cardiovascular system need to be born in mind for the choice of the optimal glucose-lowering strategy in patients with cardiac comorbidities., (© Georg Thieme Verlag KG Stuttgart · New York.)

The prevalence of a major depressive disorder in patients after myocardial infarction is 20%. Depression is a risk factor for incident coronary heart disease and poor prognosis after myocardial infarction. Poor lifestyle habits and adherence to cardiac therapy as well as metabolic and pathophysiologic changes may partially explain this link. The threatening experience of an acute coronary event and immune and inflammatory changes may be unique features contributing to incident depression after myocardial infarction. While psychotherapy, antidepressants, and physical exercise may alleviate depressive symptoms in patients with coronary heart disease, cardiac rehabilitation additionally reduces mortality risk. Attempts are being undertaken to identify the cardiotoxic characteristics of depression to develop even more effective therapies in the future.

Background: Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates., Methods: The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year., Results: 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days., Conclusion: This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services., (© Georg Thieme Verlag KG Stuttgart · New York.)

Over the past 20 years the German Pension Insurance has rehabilitated nearly 800,000 patients with coronary heart disease. In particular, phase-II rehabilitation has been established as an integral part of cardiac patient care. However, the decreasing number of participants in phase-III must be seen critically. Today's cardiac rehabilitation is characterised by evidence-based treatment modules and a sophisticated quality assurance system that ensures quality orientation in all aspects, from access to rehabilitation through to aftercare. Future developments such as vocationally-oriented medical rehabilitation and the use of new technologies will further improve cardiac rehabilitation. Positive patient feedback and scientific evidence of the effectiveness of cardiac rehabilitation are further incentives to maintain this forward-looking approach.

Cardiac monitoring with ECG and blood pressure recording is routinely performed during a stress test and blood pressure response is an important part of its interpretation. Unfortunately, the latter is not straightforward, partly because of the inconsistent definition of a pathologic blood pressure response, the different populations included in the studies and divergent test modalities. An exaggerated blood pressure response in normotensive subjects without coronary heart disease is associated with an increased risk of future arterial hypertension, whereas in patients with known or suspected coronary heart disease, prognosis is not worse than in patients with normal blood pressure response. By contrast, exercise induced hypotension, particularly in patients with coronary artery disease indicates an increased risk for cardiac events and should be investigated further, usually by performing coronary angiography.

Depression is considered an independent risk factor for coronary artery disease (CAD) and other vascular conditions. Moreover, comorbid depressive disorder in CAD patients carries an increased risk of cardiac events and mortality. Among survivors of acute myocardial infarction, up to 20% meet diagnostic criteria for major depression, the presence of which carries a fivefold increased risk of cardiac death within 6 months. Heart patients with depressive comorbidity require particular care for both adequate treatment of their affective disorder and reduction of their cardiac risk. Antidepressant treatment must follow established guidelines; special care is needed to avoid cardiac side effects. In this review, we discuss the pathophysiological and prognostic significance of comorbid depression in CAD and weigh risks and benefits of available treatment options - particularly different drug classes and psychotherapy - in light of recent study results.

The aim of this article is to provide an overview on depression as a risk factor for the onset and follow-up of cardiovascular disease (CVD). In brief, the current state of psychobiological mechanisms bridging the gap between affective states and somatic consequences are presented. Four meta-analyses dealing with depression as a CVD risk factor in apparently healthy populations with >100,000 participants included, extracted an adjusted effect estimator of 1.60-1.90. Depressed subjects present with an unhealthier lifestyle (nutrition, smoking, physical activity). Three major psychobiological pathways directly acting on the circulatory system are under discussion: (1) hyperregulation of the autonomic nervous system (e.g., increased mean heart rate, increased heart rate responses, impaired heart rate variability), (2) overshooting stress responses of the endocrine system with impaired feedback mechanisms (e.g., for cortisol release), and (3) the immune system with dysregulated release of acute phase proteins and proinflammatory cytokines, all involved in a bidirectional crosstalk with the patient's affective state and leading to platelet activation and flow mediated endothelial (dys-)function. Nonadherence and adverse side effects of medications also contribute to the lethal properties of depression in CVD.

β-Blockers are an essential component of medical therapy in patients with ischemic heart disease or cardiac dysfunction of any genesis. They have an effect at the level of the sinus and the atrioventricular node, as well as on the atrial and ventricular refractory period of the myocardium. Overall, there are complicated antifibrillatory effects which are involved in the reduction of morbidity and mortality of this the therapy. According to the guidelines, it is important to uptitrate to highest tolerated dose. In patients with atrial fibrillation, antiadrenergic therapy should be the first line treatment; if well tolerated, then β-blockers alone or as a combination with an antiarrhythmic drug is preferable. Future prospective studies on the antiarrhythmic effects in this therapeutic area should include comparisons of different α - and β-selective active substances. Increasing knowledge of the differential therapy with the available active substances including intravenously applicable short-acting β-blockers, e.g., in intensive care therapy - should distinguish the different therapeutic effects.

Cardiovascular rehabilitation encompasses the optimization of secondary prevention to reduce morbidity and mortality, the improvement of physical fitness and quality of life as well as the reintegration into social life and employment. This requires a multifactorial intervention on the physical, psychological, educative and social level by a multidisciplinary team. In Germany, cardiac rehabilitation started early after an index event, could demonstrate a significant reduction of total mortality, myocardial infarction and hospitalization during a follow-up of 1-2 years in 4 cohort studies including 10,758 patients with myocardial infarction and bypass surgery. This reduction of clinical events was obtained in addition to rapid revascularization therapy during the acute coronary event and on top of an evidence based secondary preventive medication. By national and international medical societies, cardiac rehabilitation is recommended as well in patients with congestive heart failure, after valve replacement or valve repair, after heart transplantation and cardioverter/defibrillator implantation. In the future, cardiac rehabilitation in Germany should be evaluated by a randomized controlled trial and multifactorial interventions should be tailored individually to specific patient subgroups and medical conditions.

Coronary heart disease (CHD) poses a special challenge for risk assessments. Various kinds of diagnostic or therapeutic procedures, concomitant diseases, risk factors and symptoms need to be connected logically in order to assess the risk of each individual applicant. "Reinsurance manuals" are available to risk assessors in life insurance for this purpose. Using these manuals, the risk assessor can calculate the risk loadings for applicants with specific pre-existing conditions, e.g., CHD. Various tasks thus fall to the reinsurer, which must be able to give grounds for the increased risk loadings, provide the manuals with a process-oriented structure and simultaneously support the primary insurer's business objectives via an intelligent risk assessment. Taking CHD as an example, the following article explains how these tasks can be solved with the aid of medical and mathematical approaches, and how the insurability of applicants with CHD can be extended via the re-evaluation of risks.

Background: Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers., Patients and Methods: The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude., Results: An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved., Conclusion: The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Women and men differ in drug needs and drug metabolism. Usually women are smaller and lighter and have a higher body fat percentage and lower kidney function. Primary drug-metabolizing enzymes in the intestinal wall and liver, which are part of the cytochrome P450 family, have different activities in men and women. Their substrates (beta-blockers, blockers of calcium channels such as nifedipine and verapamil, cyclosporine, and many others) are metabolized differently. Sex differences were observed after administration of digitalis, which is often overdosed in women. Furthermore, beta-blockers are found at higher plasma levels in women and ACE inhibitors cause more side effects in women than in men. In women, acetylsalicylic acid provides effective primary prophylaxis against stroke but not myocardial infarction. In men, these drugs have opposite effects. Anticoagulants and thrombolytics often lead to bleeding complications in women, QT prolonging drugs produce more frequently arrhythmia. It is therefore very important to control drugs following approval and to look out for these differences between men and women.

Patients' compliance or adherence to medical therapy recommendations has been identified to be a pivotal element in achievement of treatment success. Nonadherence is a commonly-found phenomenon among patients suffering chronic pain. Its negative impact on the individual health status and on health systems has put forth strategies to improve adherence in the therapy of chronicpain. These include the use of medications with reliable and high efficacy combined with low rate and severity of side effects, limited need of medication to manage breakthrough pain as well as the reduction of application frequency.

A steady increase in the numbers of diabetic patients in coronary surgery has been recorded over the last years. The causes for these rises are seen mainly in the general demographic development in the western industrialized nations, the epidemic progress and wide spread of diabetes mellitus, and changes in assignment behavior. In the following, the specific risk profile of diabetic coronary patients in heart surgery and tried and tested treatment concepts for this particularly challenging group of patients with reference to most recent study results will be presented. Particularly the peculiarities of coronary heart disease in diabetic patients, the choice of the revascularization method, different operative strategies for diabetic patients with coronary heart disease, and challenges faced at the cardiac surgery intensive care unit are discussed in detail.

Depending on the reduction in glomerular filtration rate (GFR) as a measure of renal insufficiency and depending on their age, patients with chronic kidney disease have a 1.5 to 1,000-fold higher cardiovascular risk. Renal insufficiency is inherently an independent risk factor for cardiovascular events, which is likewise the case for patients also presenting with hypertension or diabetes mellitus. When cardiac insufficiency or coronary heart disease is already manifest, the GFR is the most important predictive factor for the patients' further survival. Proteinuria or albuminuria as signs of kidney disease are also important markers and correlate with the cardiovascular risk in the range of both macro- and microalbuminuria. Endothelial dysfunction, oxidative stress, dyslipidemia, and increased atherosclerosis are being discussed as pathophysiological mechanisms of elevated cardiovascular risk.

Gender related issues in manifestation, diagnosis and treatment of coronary artery disease are important but still not well recognized. Women are more likely to present late after first symptoms of myocardial infarction. Myocardial infarction is more often unrecognized. In regard to complications after myocardial infarctions ventricular tachycardia and cardiac arrest are more frequent and women are also more likely to develop heart failure or cardiogenic shock. The reason for this is most probably the fact that women presenting with myocardial infarction are of older age and have a higher incidence of co-morbidities. Thrombolysis and coronary angioplasty are less often performed in women in the setting of myocardial infarction. However there is a clear trend toward improvement of this situation during the last years. The reopening rate of occluded coronary arteries with thrombolysis and with coronary angioplasty is similar in women compared to men. Perioperative risk with aorto-coronary bypass surgery is higher in women, which can not be fully explained by higher age and co-morbidities. However 10 years survival rate after aorto-coronary bypass-surgery is similar for men and women, although occlusion of venous grafts is seen more often in women. The benefit of structured cardiac rehabilitation after an acute event is similar for younger and older women and as good as in men. Positive effects of cardiac rehabilitation include increased physical performance, reduction of body fat, improvement of lipid-profiles and an improvement of the psychosocial situation and quality of life.

Patients with hypertensive heart disease have frequently ventricular arrhythmias in the 24-h-holter-EKG. Those patients with severe forms of arterial hypertension have more high grade ventricular tachycardia than those with less severe hypertension. Sudden cardiac death in arterial hypertensive seems to be linked with the prevalence of coronary artery disease, whereas LV hypertrophy is only a co-factor.

Elevated heart rate is associated with increased cardiovascular mortality. Heart rate reduction optimises myocardial oxygen consumption and decreases angina pectoris symptoms. Thus, heart rate control is an important therapeutic strategy in coronary artery disease and, for example, chronic heart failure. The pacemaker current I(f) plays a central role in determining spontaneous activity of the sinus node. Ivabradine, a selective inhibitor of the I(f) channel, reduces heart rate without any effect on cardiac contractility and without lowering blood pressure. While beta-blockers remain the first choice for heart rate reduction, in cases of adverse effects ivabradine may be used to treat stable angina pectoris. Studies evaluating possible further uses, for example in heart failure or after acute myocardial infarction, are still warranted.

Myocardial ischemia induces redistribution of different ions (H(+), K(+), Na(+), Ca(++)) across the cardiomyocyte membrane, as well as the loss of intracellular ATP content. This results in changes in the electrical properties including shortening of the action potential, appearance of delayed afterpotentials, and a modified refractoriness of the cardiomyocyte. These changes may induce or support malignant cardiac arrhythmias. Supersensitivity of sympathetic denervated myocardium may further support the electrical instability of ischemic myocardium.Virtues of studies indicate that patients with coronary artery disease who develop complex arrhythmias during or after exercise bear a substantially increased risk for sudden cardiac death. Other studies report about arrhythmic stabilization and reduced mortality if patients with reversible myocardial ischemia receive complete revascularization. However, none of these studies is without methodological flaws. Due to the lack of methodologically sound studies in sufficiently large patient cohorts, the question whether complete coronary revascularisation improves the prognosis of patients with coronary artery disease and which strategy (medical, interventional, or surgical) warrants the best outcomes remains open.

Guidelines for primary prevention of cardiovascular disease recommend a management based on global cardiovascular risk calculated with prediction rules. While cardiovascular prediction rules are applied as a tool to estimate risk, Guidelines describe which consequences to be drawn based on this risk information. We performed a workshop to discuss open questions for application of prediction rules in primary care. Technical aspects may not be a problem, however, additional barriers for application in daily routine exist. First, accuracy of risk estimation is unclear for some of the prediction rules. Second, risk factors, which are intuitively relevant (like obesity), are lacking in most of the prediction rules. Third, differences between guidelines and prediction rules are sometimes not clear for the general physician. In this article we want to answer the most important questions, which have been discussed during the workshop.

Adverse clinical consequences associated with conventional coronary artery bypass surgery (CCAB) have largely been attributed to cardiopulmonary bypass circuit (CPB), hypothermic cardiac arrest, aortic cannulation, and cross-clamping. Consequently, there has been a growing interest in safer alternatives to CCAB including off-pump beating-heart bypass surgery (OPCAB). Initial concerns regarding completeness of revascularization at the lateral wall were addressed by using modern stabilizers and heart positioning devices. First studies tended to be nonrandomized clinical reports rather than controlled clinical trials with the potential risk of unbalanced baseline characteristics leading to biases in favor of OPCAB. Since these early reports, several randomized trials including mixed-risk patient populations have been completed. Most of them failed to reveal superiority of OPCAB concerning mortality and major perioperative morbidity due to statistically underpowered design to detect clinically important but infrequent adverse outcome events. Likewise, in most of the recently published meta-analyses of randomized trials no difference in early mortality, myocardial infarction or stroke rate was found, but OPCAB was superior regarding blood loss, transfusion requirement, rethoracotomy, ventilation time, ICU (intensive care unit) and hospital stay and resource utilization as illustrated in Table 1. Most of the large observational studies comparing OPCAB and CCAB strategies demonstrated a benefit of OPCAB concerning early mortality, myocardial infarction and stroke rate as summarized in Table 2. However, in few published follow-up studies no significant differences concerning recurrence of angina, reintervention rate und late mortality were found. The decision between OPCAB and CCAB has to weigh several factors, including the likely risks and benefits of the two approaches for the particular patient, the experience of the surgeon, the complexity of the coronary disease, and the required coronary revascularization.