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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., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: We aimed 1) to test the applicability of the previously suggested prognostic value of CPET to elderly cardiac rehabilitation patients and 2) to explore the underlying mechanism of the greater improvement in exercise capacity (peak oxygen consumption, VO2) after CR in surgical compared to non-surgical cardiac patients., Methods: Elderly patients (≥65 years) commencing CR after coronary artery bypass grafting, surgical valve replacement (surgery-group), percutaneous coronary intervention, percutaneous valve replacement or without revascularisation (non-surgery group) were included in the prospective multi-center EU-CaRE study. CPETs were performed at start of CR, end of CR and 1-year-follow-up. Logistic models and receiver operating characteristics were used to determine prognostic values of CPET parameters for major adverse cardiac events (MACE). Linear models were performed for change in peak VO2 (start to follow-up) and parameters accounting for the difference between surgery and non-surgery patients were sought., Results: 1421 out of 1633 EU-CaRE patients performed a valid CPET at start of CR (age 73±5.4, 81% male). No CPET parameter further improved the receiver operation characteristics significantly beyond the model with only clinical parameters. The higher improvement in peak VO2 (25% vs. 7%) in the surgical group disappeared when adjusted for changes in peak tidal volume and haemoglobin., Conclusion: CPET did not improve the prediction of MACE in elderly CR patients. The higher improvement of exercise capacity in surgery patients was mainly driven by restoration of haemoglobin levels and improvement in respiratory function after sternotomy., Trial Registration: Netherlands Trial Register, Trial NL5166., Competing Interests: AWJVH reports grants from Medtronic, grants and personal fees from Astra Zeneca, outside the submitted work, UZ reports grants and personal fees from Astra Zeneca, grants and personal fees from Bayer, per-sonal fees from Boehringer Ingelheim, grants and personal fees from BMS, personal fees from Daiichi Sankyo, personal fees from Eli Lilly, grants and personal fees from Novartis, grants and personal fees from MSD, personal fees from Trommsdorf, personal fees from Amgen, outside the submitted work. LP and EK work for Diagram B.V., a contract research organization. These commercial affiliations do not alter our adherence to all PLOS ONE policies on sharing data and materials. All other authors have no conflict of interest to declare.

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., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

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., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background Although disease-specific exercise guidelines for cardiovascular disease (CVD) are widely available, it remains uncertain whether these different exercise guidelines are integrated properly for patients with different CVDs. The aim of this study was to assess the inter-clinician variance in exercise prescription for patients with various CVDs and to compare these prescriptions with recommendations from the EXercise Prescription in Everyday practice and Rehabilitative Training (EXPERT) tool, a digital decision support system for integrated state-of-the-art exercise prescription in CVD. Design The study was a prospective observational survey. Methods Fifty-three CV rehabilitation clinicians from nine European countries were asked to prescribe exercise intensity (based on percentage of peak heart rate (HR peak )), frequency, session duration, programme duration and exercise type (endurance or strength training) for the same five patients. Exercise prescriptions were compared between clinicians, and relationships with clinician characteristics were studied. In addition, these exercise prescriptions were compared with recommendations from the EXPERT tool. Results A large inter-clinician variance was found for prescribed exercise intensity (median (interquartile range (IQR)): 83 (13) % of HR peak ), frequency (median (IQR): 4 (2) days/week), session duration (median (IQR): 45 (18) min/session), programme duration (median (IQR): 12 (18) weeks), total exercise volume (median (IQR): 1215 (1961) peak-effort training hours) and prescription of strength training exercises (prescribed in 78% of all cases). Moreover, clinicians' exercise prescriptions were significantly different from those of the EXPERT tool ( p < 0.001). Conclusions This study reveals significant inter-clinician variance in exercise prescription for patients with different CVDs and disagreement with an integrated state-of-the-art system for exercise prescription, justifying the need for standardization efforts regarding integrated exercise prescription in CV rehabilitation.

The latest in cardiac rehabilitation has been impacted by: The East German PET publication which showed fewer ischaemic events and progression of the atheromatous disease in symptomatic and stable coronary patients who carry out regular physical exercise in comparison with patients who underwent angioplasty with stenting. Two meta-analyses updated the data showing the benefits of physical training: a 20% reduction in global mortality in coronary disease and 35% in cardiac failure. Two French studies reporting reassuring data for our daily practice: the serious complications of cardiac rehabilitation are exceptionally rare: the register for 2003 with data from 65 French centres, over 25,000 patients and 743,000 patient/exercise hours. Physical training two weeks after mitral valvuloplasty is not harmful for the valve repair and is beneficial in terms of exercise capacity for the patient. Epidemiological studies showing that women and elderly patients are, unfortunately, often excluded from programmes of cardiac rehabilitation.

The plasma concentrations of S-nitrosothiols, which are circulating nitric oxide metabolites with potential biologic activity, are increased among patients undergoing chronic hemodialysis (HD). However, the ability of S-nitrosothiols to release nitric oxide at physiologically relevant sites may be reduced among HD patients, because of impaired availability and/or activity of factors involved in S-nitrosothiol breakdown. The resultant lack of S-nitrosothiol bioavailability could contribute to the high cardiovascular risk for such patients. A possible relationship between plasma S-nitrosothiol levels and cardiac outcomes, as well as all-cause mortality rates, was investigated in a cohort of 250 chronic HD patients and who were undergoing regular dialysis three times per week were monitored for 1 yr. During that follow-up period, major cardiac events and all-cause deaths were prospectively recorded. At baseline, high plasma S-nitrosothiol levels (>2 micro M, corresponding to the top quartile of all measured values) were independently associated with pulse pressure in an adjusted multivariate analysis (odds ratio, 1.03; 95% confidence interval, 1.01 to 1.05; P = 0.007). During the follow-up period, 36 patients died (16 as a result of cardiac causes) and 33 patients experienced major adverse cardiac events. In an adjusted Cox proportional-hazards model, high plasma S-nitrosothiol concentrations (i.e., the top quartile versus the three other quartiles) were an independent predictor of cardiac events (hazard ratio, 3.30; 95% confidence interval, 1.61 to 6.76; P = 0.001) but not of all-cause death. Therefore, among chronic HD patients, markedly elevated plasma S-nitrosothiol levels are associated with pulse pressure and predict cardiovascular outcomes. These findings support the hypothesis that impaired S-nitrosothiol bioavailability in uremia is an important factor for the excessive cardiovascular risk among HD patients.

Background: Cardiac disease is the main cause of mortality in long-term hemodialysis patients. Cardiac troponins (cTn) have been proposed to be markers of cardiac damage, but their value is still debated in hemodialysis patients. The aim of this prospective study is to assess the prognostic value of biochemical cardiac markers in long-term hemodialysis patients., Methods: We measured serum levels of cTn I (cTnI), cTn T (cTnT), and creatine kinase-MB (CK-MB) in 258 asymptomatic patients (mean age, 60 +/- 15 years; 150 men) before the dialysis treatment. All causes of death and major adverse cardiac events (MACEs: cardiac death, myocardial infarction, or unstable angina) were recorded at 1 and 2 years of follow-up. A Cox proportional hazard regression model was used to identify factors predictive of mortality., Results: On inclusion, 48 patients (18.6%) had cTnT levels greater than 0.1 ng/mL, 46 patients (17.8%) had cTnI levels greater than 0.15 ng/mL, and 18 patients (7.0%) had CK-MB levels greater than 3 ng/mL. Of 246 patients followed up at 2 years, 64 patients (26%) had died, including 29 patients (11.8%) of cardiac disease, and 49 patients (19.9%) experienced at least 1 MACE. MACEs were significantly greater for patients with elevated predialysis serum cTnT and CK-MB levels (>0.1 ng/mL and 3 ng/mL, respectively) than for patients with normal levels of these cardiac markers (31.9% versus 17.1%; P = 0.01; 38.9% versus 18.4%; P = 0.02, respectively). No differences were found for cTnI levels. In multivariate analysis, age (relative risk [RR], 1.04; P = 0.002), previous ischemic heart disease (RR, 2.5; P = 0.0001), and serum cTnT levels greater than 0.1 ng/mL (RR, 1.9; P = 0.04) were independent significant factors for MACEs., Conclusion: Increased predialysis serum levels of cTnT and CK-MB, but not cTnI, were predictive of a high risk for overall mortality and MACEs at 2 years in asymptomatic hemodialysis patients.