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BACKGROUND: With 900′000 coronary angiographies (CA) per year, Germany has the highest annual per capita volume in Europe. Until now there are no prospective clinical data on the degree of guideline-adherence in the use of CA in patients with suspected chronic coronary syndrome (CCS) in Germany. METHODS: Between January 2019 and August 2021, 458 patients with suspected CCS were recruited in nine German centres. Guideline-adherence was evaluated according to the current European Society of Cardiology and German guidelines. Pre-test probability (PTP) for CAD was determined using age, gender, and a standardized patient questionnaire to identify symptoms. Data on the diagnostic work-up were obtained from health records. RESULTS: Patients were in mean 66.6 years old, male in 57.3 %, had known CAD in 48.4 % and presented with typical, atypical, non-anginal chest pain or dyspnoea in 35.7 %, 41.3 %, 23.0 % and 25.4 %, respectively. PTP according to the European guidelines was in mean 24.2 % (11.9 %-36.5 % 95 % CI). 20.9 % of the patients received guideline-recommended preceding non-invasive image guided testing. The use of CA was adherent to the European and German guideline recommendations in 20.4 % and 25.4 %, respectively. In multivariate-analysis, arterial hypertension and prior revascularization were predictors of guideline non-adherence. CONCLUSION: These are the first prospective clinical data which demonstrated an overall low degree of guideline-adherence in the use of CA in patients with suspected CCS in the German health care setting. To improve adherence rates, the availability of and access to non-invasive image guided testing needs to be strengthened. (German Clinical Trials Registry DRKS00015638 – Registration Date: 19.02.2019)

Supplementary Material 3

Aims The concept of disproportionate mitral regurgitation (MR) was recently from the analysis of the results of two large randomized trials that compared edge-to-edge repair with the MitraClip system and optimal medical treatment alone in a cohort of patients with functional MR and reduced left ventricular (LV) function. Patients with disproportionate MR were defined as having higher degrees of MR, measured with the effective regurgitant orifice area (EROA), than expected with respect to the amount of LV enlargement, as measured using the enddiastolic volume (EDV). Interestingly, disproportionate MR patients were found to benefit more pronounced from an interventional mitral valve repair than those with proportionate MR with respect to the risk of death and hospitalization for heart failure, and these benefits were paralleled by a relevant decrease in LVEDV. In our study we tested this concept, that was derived from the very controlled setting of a randomized trial, in a “real world” retrospective analysis. Methods and results 137 patients (mean age 78.4±7, log. EuroScore 24.5±13.8%) with symptomatic functional mitral regurgitation (MR) undergoing MitraClip procedure were included and followed for 6±2 months. All patients were highly symptomatic (NYHA functional class 3 or 4: 94.9%, NT-proBNP 6645.5±7517.8 pg/ml). At baseline left ventricular ejection fraction (LVEF) was 34.4±10% with an EDV of 155.8±66.5 ml. When dividing groups following the proposed concept, we found 46.7% of patients having disproportionate MR with larger EDV (167.2±61.4 ml, 137.6±70.8 ml, p=0.026) and not different EROA values (0.45±0.13 cm2, 0.44±0.21 cm2, p=0.59) compared to patients with proportionate MR. When analyzing clinical outcomes after 6 months, we found no difference in mortality (p=0.5) and rehospitalizations for heart failure (p=0.7). Patients in both groups significantly improved in functional NYHA class at discharge (p Conclusions We found no difference in mortality or rehospitalizations for heart failure when retrospectively analyzing our patient cohort divided in patients with proportionate and disproportionate MR. Both groups improved directly after MitraClip with respect to functional NYHA class, but only in patients with disproportionate MR this effect was sustained over the period of 6 months follow up. Patients with proportionate MR significantly worsened with respect to functional NYHA class 6 months after MitraClip and this effect is surely prone to lead to a higher rehospitalization rate when expanding follow up time to 12 months or more. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Elisabeth Krankenhaus Essen

The aim of this study was to investigate whether recovery from eccentric squat exercise varies depending on age and to assess whether the use of a mixed-method recovery (MMR) consisting of cold water immersion and compression tights benefits recovery. Sixteen healthy and resistance-trained young (age, 22.1\(\pm\)2.1years; \(\it N\)=8) and master male athletes (age, 52.4\(\pm\)3.5years; \(\it N\)=8), who had a similar half squat 1-repetition maximum relative to body weight, completed two identical squat exercise training sessions, separated by a 2-week washout period. Training sessions were followed by either MMR or passive recovery (PR). Internal training loads [heart rate and blood lactate concentration (BLa)] were recorded during and after squat sessions. Furthermore, maximal voluntary isometric contraction (MVIC) force, countermovement jump (CMJ) height, resting twitch force of the knee extensors, serum concentration of creatine kinase (CK), muscle soreness (MS), and perceived physical performance capability (PPC) were determined before and after training as well as after 24, 48, and 72h of recovery. A three-way mixed ANOVA revealed a significant time effect of the squat protocol on markers of fatigue and recovery (p

Additional file 1: Table S1. Correlation matrix for correlation coefficients (r) of common CMR and strain parameters including LV torsion. LVEF: left ventricular ejection fraction; GLS: global longitudinal strain; GCS: global circumferential strain; GRS: global radial strain; LV torsion: left ventricular torsion; LVEDV: left ventricular end-diastolic volume. Table S2. Univariate survival analysis of the secondary endpoint (Cox proportional-hazards regression). HR: hazard ratio; CI: confidence interval; LVEF: left ventricular ejection fraction; LVEDV: left ventricular end-diastolic volume; NT-pro BNP: N-terminal pro-hormone brain natriuretic peptide; LGE: late gadolinium enhancement; GLS: global longitudinal strain; GCS: global circumferential strain; GRS: global radial strain. Table S3. Multivariate survival analysis of the secondary endpoint (Cox proportional-hazards regression). HR: hazard ratio; CI: confidence interval; LVEF: left ventricular ejection fraction; LVEDV: left ventricular end-diastolic volume; LGE: late gadolinium enhancement; GLS: global longitudinal strain; GCS: global circumferential strain; GRS: global radial strain. Table S4a. Intra- and Interobserver variability of the strain parameters in healthy individuals. ICC: intra-class correlation coefficient; CI: confidence interval; GLS: global longitudinal strain; GCS: global circumferential strain; GRS: global radial strain; LV: left ventricular. Table S4b. Intra- and Interobserver variability of the strain parameters in DCM patients. ICC: intra-class correlation coefficient; CI: confidence interval; GLS: global longitudinal strain; GCS: global circumferential strain; GRS: global radial strain; LV: left ventricular.

Additional file 2: Figure S1. Kaplan���Meier analysis of a CMR risk score for the prediction of the secondary endpoint. CMR risk score is based on different CMR (LVEF, LGE) and strain parameters for the prediction of the secondary endpoint in DCM patients. Cut-off values as mentioned in Fig. 4: low risk (0-1p), intermediate risk (2-5p) and high risk (6p). CMR: cardiac magnetic resonance imaging; DCM: dilated cardiomyopathy; GLS: global longitudinal strain; GCS: global circumferential strain; GRS: global radial strain; LVEF: left ventricular ejection fraction; LGE: late gadolinium enhancement. Figure S2. Kaplan���Meier analysis of a simplified CMR risk score in DCM patients. The simplified CMR risk score is based on LVEF, LGE and GLS as the single strain parameter for the prediction of the primary endpoint (cut-off values as mentioned in Fig. 4 of the manuscript): low risk (0-2p) and high risk (3p). CMR: cardiac magnetic resonance imaging; DCM: dilated cardiomyopathy; LGE: late gadolinium enhancement; LVEF: left ventricular ejection fraction; GLS: global longitudinal strain.