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AimsDespite general awareness that screening for atrial fibrillation (AF) could reduce health hazards, large-scale implementation is lagging behind technological developments. As the successful implementation of a screening programme remains challenging, this study aims to identify facilitating and inhibiting factors from healthcare providers’ perspectives.Methods and resultsA mixed-methods approach was used to gather data among practice nurses in primary care in the southern region of the Netherlands to evaluate the implementation of an ongoing single-lead electrocardiogram (ECG)-based AF screening programme. Potential facilitating and inhibiting factors were evaluated using online questionnaires (N = 74/75%) and 14 (of 24) semi-structured in-depth interviews (58.3%). All analyses were performed using SPSS 26.0. In total, 16 682 screenings were performed on an eligible population of 64 000, and 100 new AF cases were detected. Facilitating factors included ‘receiving clear instructions’ (mean ± SD; 4.12 ± 1.05), ‘easy use of the ECG-based device’ (4.58 ± 0.68), and ‘patient satisfaction’ (4.22 ± 0.65). Inhibiting factors were ‘time availability’ (3.20 ± 1.10), ‘insufficient feedback to the practice nurse’ (2.15 ± 0.89), ‘absence of coordination’ (54%), and the ‘lack of fitting policy’ (32%).ConclusionLarge-scale regional implementation of an AF screening programme in primary care resulted in a low participation of all eligible patients. Based on the perceived barriers by healthcare providers, future AF screening programmes should create preconditions to fit the intervention into daily routines, appointing an overall project lead and a General Practitioner (GP) as a coordinator within every GP practice.

Aims Accumulating evidence questions the clinical value of percutaneous coronary intervention (PCI) for patients with chronic coronary syndrome (CCS). We therefore compare the impact of exercise-based cardiac rehabilitation (CR) vs. PCI in patients with CCS on 18-month mortality and morbidity, and evaluate the effects of combining PCI with exercise-based CR. Methods and results A retrospective cohort study was conducted in March 2021. An online, real-world dataset of CCS patients was acquired, utilizing TriNetX, a global federated health research network. Patients with CCS who received PCI were first compared with patients who were prescribed exercise-based CR. Second, we compared patients who received both CR + PCI vs. CR alone. For both comparisons, patients were propensity-score matched by age, sex, race, comorbidities, medications, and procedures. We ascertained 18-month incidence of all-cause mortality, rehospitalization, and cardiovascular comorbidity [stroke, acute myocardial infarction (AMI), and new-onset heart failure]. The initial cohort consisted of 18 383 CCS patients. Following propensity score matching, exercise-based CR was associated with significantly lower odds of all-cause mortality [0.37 (95% confidence interval (CI): 0.29–0.47)], rehospitalization [0.29 (95% CI: 0.27–0.32)], and cardiovascular morbidities, compared to PCI. Subsequently, patients that received both CR + PCI did not have significantly different odds for all-cause mortality [1.00 (95% CI: 0.63–1.60)], rehospitalization [1.00 (95% CI: 0.82–1.23)], AMI [1.11 (95% CI: 0.68–1.81)], and stroke [0.71 (95% CI: 0.39–1.31)], compared to CR only. Conclusions Compared to PCI, exercise-based CR associated with significantly lower odds of 18-month all-cause mortality, rehospitalization, and cardiovascular morbidity in patients with CCS, whilst combining PCI and exercise-based CR associated with lower incident heart failure only.

Background: Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract. Objective: This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames. Methods: Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a €10 (at the time of writing: €1=US $0.98) deposit up front (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome. Results: Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ηp2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P, Journal of Medical Internet Research, 24 (10), ISSN:1438-8871

©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.

Introduction eHealth interventions have the potential to improve the quality of healthcare and reduce costs. However, to implement eHealth interventions successfully instruments are needed to facilitate this process. This study aims to develop an eHealth implementation guideline for implementation of eHealth interventions in daily practice. Methods In June and July 2019 a literature research was conducted and, subsequently, a two-round Delphi study including 13 international eHealth experts in the field of healthcare, ICT & technology, and research was performed. Within the Delphi study, experts scored specific determinants using an online survey. Based on mean scores and interquartile ranges (IQRs) in the online survey, consensus between the experts was assessed. Results A total of five domains (i.e., Technology, Acceptance, Financing, Organizational, and Legislation & Policy) with 24 corresponding determinants were assessed by the experts. After the second Delphi round, consensus was achieved on the five domains and 23 determinants (mean scores ≥ 8; IQR ≤ 2). Only for the determinant ‘Evidence-Based Medicine’ was no consensus reached (mean score Conclusion The eHealth implementation guideline developed in this study may help healthcare providers/researchers assess the determinants of successful eHealth intervention prior to the implementation of the eHealth program

BACKGROUND Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (a type of incentive in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research often operationalized deposit contracts through framing a financial reward as a loss (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract. OBJECTIVE This study aims to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated (1) whether incentive conditions are more effective than a no-incentive control condition, (2) whether deposit contracts have lower uptake than financial rewards, (3) whether deposit contracts are more effective than financial rewards, and (4) whether loss frames are more effective than gain frames. METHODS Healthy participants (N = 126) with an average age of 22.7 years participated in a 20-day physical activity intervention. They downloaded a smartphone application that provided them with a personalised physical activity goal and either required a €10 deposit upfront (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or a gain. We employed a 2 (incentive type: deposit vs reward) x 2 (feedback frame: gain vs loss) between-subjects factorial design with a no incentive control condition. Our primary outcome was the number of days participants achieved their goal. Uptake of the intervention was a secondary outcome. RESULTS Overall, financial incentive conditions (M = 13.10 days) had higher effectiveness than the control condition (M = 8.00 days), p = .002, ηp2 = .147. Deposit contracts had lower uptake (61.7%) than rewards (100%), p = CONCLUSIONS We found that financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle for large scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge for more research on their boundary conditions before using loss framed incentives in practice. CLINICALTRIAL OSF Registries, https://osf.io/34ygt

Aims Recent studies showed that exercise-based cardiac rehabilitation (ECR) programmes are often not personalized to individual patient characteristics according to latest recommendations. This study investigates whether a computerized decision support (CDS) system based on latest recommendations and guidelines can improve personalization of ECR prescriptions. Pseudo-randomized intervention study. Methods and results Among participating Dutch cardiac rehabilitation centres, ECR programme characteristics of consecutive patients were recorded during 1 year. CDS was used during a randomly assigned 4-month period within this year. Primary outcome was concordance to latest recommendations in three phases (before, during, and after CDS) for 12 ECR programme characteristics. Secondary outcome was variation in training characteristics. We recruited ten Dutch CR centres and enrolled 2258 patients to the study. Overall concordance of ECR prescriptions was 59.9% in Phase 1, 62.1% in Phase 2 (P = 0.82), and 59.9% in Phase 3 (P = 0.56). Concordance varied from 0.0% to 99.9% for the 12 ECR characteristics. There was significant between-centre variation for most training characteristics in Phases 1 and 2. In Phase 3, there was only a significant variation for aerobic and resistance training intensity (P = 0.01), aerobic training volume (P Conclusion CDS did not substantially improve concordance with ECR prescriptions. As aerobic training volume was often lower than recommended and reduced during the study, a lack of institutional resources might be an important barrier in personalizing ECR prescriptions.

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

The role of comprehensive cardiac rehabilitation is well established in the secondary prevention of cardiovascular diseases such as coronary artery disease and heart failure. Numerous trials have demonstrated both the effectiveness as well as the cost-effectiveness of comprehensive cardiac rehabilitation in improving exercise capacity and quality of life, and in reducing cardiovascular mortality and morbidity. However, the current COVID-19 pandemic has led to closure of many cardiac rehabilitation centres in Europe resulting in many eligible patients unable to participate in the optimisation of secondary prevention and physical performance. This elicits an even louder call for alternatives such as cardiac telerehabilitation to maintain the delivery of the core components of cardiac rehabilitation to cardiovascular disease patients. The present call for action paper gives an update of recent cardiac telerehabilitation studies and provides a practical guide for the setup of a comprehensive cardiac telerehabilitation intervention during the COVID-19 pandemic. This set up could also be relevant to any cardiovascular disease patient not able to visit cardiac rehabilitation centres regularly after the COVID-19 pandemic ceases. ispartof: EUROPEAN JOURNAL OF PREVENTIVE CARDIOLOGY vol:28 issue:5 pages:524-540 ispartof: location:England status: published

Establishment of the maturational patterns of the fetal left and right ventricle strain and strain rate by two-dimensional speckle tracking echocardiography is a prerequisite for its routine clinical adaptation in pregnancy. The aim of this study is to review systematically current literature on the development of left and right ventricle strain and strain rate derived by speckle tracking during gestation. EMBASE, Medline and Central were searched, from inception to October 2019, for observational studies of singletons in uncomplicated, non-anomalous pregnancies, measuring global longitudinal strain and strain rate with 2D speckle tracking echocardiography in the fetal heart during gestation. 23 Studies met the inclusion criteria. The gestational age of the included fetuses varied from 12 to 42 weeks. Four studies used a longitudinal study design, with few consecutive measurements at varying gestational ages. 19 Studies performed either cross sectional or both longitudinal and cross sectional measurements. The ultrasound devices and speckle tracking algorithm software used, varied. Strain and strain rate during gestation increased, decreased or remained stable in the left and right fetal ventricle with increasing gestation. Due to considerable variation in the included gestational ages measured and inconsistency in the direction of strain and strain rate development, a meta-analysis could not be performed. Contradictory results concerning the development of strain and strain rate during gestation were shown, probably due to suboptimal study designs and varying algorithms and ultrasound devices used. A large longitudinal cohort study is needed to obtain reference values for fetal cardiac deformation in the uncomplicated, singleton pregnancy.

Background A promising new approach to support lifestyle changes in patients with cardiovascular disease (CVD) is the use of financial incentives. Although financial incentives have proven to be effective, their implementation remains controversial, and ethical objections have been raised. It is unknown whether health care professionals (HCPs) involved in CVD care find it acceptable to provide financial incentives to patients with CVD as support for lifestyle change. Objective This study aims to investigate HCPs’ perspectives on using financial incentives to support healthy living for patients with CVD. More specifically, we aim to provide insight into attitudes toward using financial incentives as well as obstacles and facilitators of implementing financial incentives in current CVD care. Methods A total of 16 semistructured, in-depth, face-to-face interviews were conducted with Dutch HCPs involved in supporting patients with CVD with lifestyle changes. The topics discussed were attitudes toward an incentive system, obstacles to using an incentive system, and possible solutions to facilitate the use of an incentive system. Results HCPs perceived an incentive system for healthy living for patients with CVD as possibly effective and showed generally high acceptance. However, there were concerns related to focusing too much on the extrinsic aspects of lifestyle change, disengagement when rewards are insignificant, paternalization and threatening autonomy, and low digital literacy in the target group. According to HCPs, solutions to mitigate these concerns included emphasizing intrinsic aspects of healthy living while giving extrinsic rewards, integrating social aspects to increase engagement, supporting autonomy by allowing freedom of choice in rewards, and aiming for a target group that can work with the necessary technology. Conclusions This study mapped perspectives of Dutch HCPs and showed that attitudes are predominantly positive, provided that contextual factors, design, and target groups are accurately considered. Concerns about digital literacy in the target group are novel findings that warrant further investigation. Follow-up research is needed to validate these insights among patients with CVD.

Publisher's version (útgefin grein), Background: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. Methods: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. Findings: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ± 1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). Interpretation: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes., This project was supported by a research grant from York University 's Faculty of Health. The funder had no role in study design, data collection, data analysis, interpretation or writing of the report.

PURPOSE: The clinical relevance of abnormal exercise testing (ET) results (at least 0.1 mV ST segment depression measured during exercise or recovery in three consecutive beats) in athletes without obstructive coronary artery disease (CAD) is not well understood. It is unknown whether this phenomenon reflects a physiological adaptation to sport or a truly ischemic response and a concomitant attenuated stroke volume (SV) response. The aim of this study was to investigate if athletes with abnormal ET results without obstructive CAD showed signs of an attenuated SV response using cardiopulmonary ET parameters.METHODS: A total of 78 male master athletes with abnormal ET results without obstructive CAD underwent cardiopulmonary ET. ΔO2 pulse/Δwork rate (WR), ΔV˙O2/ΔWR, and Δheart rate (HR)/ΔWR were assessed and compared with data from 78 male master athletes with normal ET results, matched for age, sports characteristics, and exercise capacity.RESULTS: The ΔO2 pulse/ΔWR ratio beyond anaerobic threshold in athletes with abnormal ET results was lower than that in athletes with normal ET results (0.73 ± 0.41 vs 1.12 ± 0.54, respectively, P < 0.001). The ΔV˙O2/ΔWR ratio was also lower in athletes with abnormal ET results (0.9 ± 0.2 vs 1.0 ± 0.3, respectively, P = 0.041). Furthermore, these athletes showed a greater increase in HR in the last 2 min of exercise (ΔHR/ΔWR ratio: 1.19 ± 0.5 vs 0.80 ± 0.6, P < 0.001).CONCLUSION: Athletes with abnormal ET results without obstructive CAD showed an attenuated O2 pulse slope, decreased ΔV˙O2/ΔWR ratio, and increased ΔHR/ΔWR ratio beyond anaerobic threshold when compared with athletes with a normal ET result. These results support the hypothesis that at least a part of the athletes with an abnormal ET in absence of obstructive CAD have an attenuated SV response at high-intensity exercise.

Background Despite proven clinical benefits, only a minority of patients complete outpatient cardiac rehabilitation (CR) after acute myocardial infarction (AMI). The main purpose of this study was to evaluate to what extent and at which time patients drop out of CR, and to assess which patient-related characteristics can predict dropout. Methods In a retrospective cohort study, we selected patients who had been hospitalised with an AMI in our centre in 2015 or 2016. Patients were selected pseudonymously based on reimbursement codes in the electronic health record. We extracted baseline characteristics and data on CR referral, enrolment and completion for each patient. Multivariable logistic regression was used to assess which characteristics predicted referral and dropout. Results The 666 patients included were predominantly male (66%), with a mean age of 69.0 years. Of the 640 eligible patients, 201 (31%) were not referred for CR. Enrolment after referral was 94%. Nonreferral was independently associated with older age, female sex, traveling distance, non-ST-elevation myocardial infarction (NSTEMI; as compared with STEMI), no coronary revascularisation and prior manifestations of coronary artery disease. Of the 414 enrolled patients, 24% did not complete their CR programmes (i.e. dropped out). Older age and worse exercise capacity at baseline were independently associated with dropout. The ability of the multiple regression models to predict nonreferral and noncompletion was good to fair, with an area under the receiver operating characteristic curves of 0.86 and 0.71, respectively. Conclusion The main reason for not participating in or not completing CR after AMI was nonreferral. To optimise CR utilisation, improvement of referral rates should be prioritised.

BACKGROUND: Healthy living is key in the prevention and rehabilitation of cardiovascular disease (CVD). Yet, supporting and maintaining a healthy lifestyle is exceptionally difficult and people differ in their needs regarding optimal support for healthy lifestyle interventions.OBJECTIVE: The goals of this study were threefold: to uncover stakeholders' needs and preferences, to translate these to core values, and develop eHealth technology based on these core values. Our primary research question is: What type of eHealth application to support healthy living among people with (a high risk of) CVD would provide the greatest benefit for all stakeholders?METHODS: User-centered design principles from the CeHRes roadmap for eHealth development were followed to guide the uncovering of important stakeholder values. Data were synthesized from various qualitative studies (i.e., literature studies, interviews, think-aloud sessions, focus groups) and usability tests (i.e., heuristic evaluation, cognitive walkthrough, think aloud study). We also developed an innovative application evaluation tool to perform a competitor analysis on 33 eHealth applications. Finally, to make sure to take into account all end-users needs and preferences in eHealth technology development, we created personas and a customer journey.RESULTS: We uncovered 10 universal values to which eHealth-based initiatives to support healthy living in the context of CVD prevention and rehabilitation should adhere to (e.g., providing social support, stimulating intrinsic motivation, offering continuity of care). These values were translated to 14 desired core attributes and then prototype designs. Interestingly, we found that the primary attribute of good eHealth technology was not a single intervention principle, but rather that the technology should be in the form of a digital platform disseminating various interventions, i.e., a 'one-stop-shop'.CONCLUSION: Various stakeholders in the field of cardiovascular prevention and rehabilitation may benefit most from utilizing one personalized eHealth platform that integrates a variety of evidence-based interventions, rather than a new tool. Instead of a one-size-fits-all approach, this digital platform should aid the matchmaking between patients and specific interventions based on personal characteristics and preferences.

Commercially available health technologies such as smartphones and smartwatches, activity trackers and eHealth applications, commonly referred to as wearables, are increasingly available and used both in the leisure and healthcare sector for pulse and fitness/activity tracking. The aim of the Position Paper is to identify specific barriers and knowledge gaps for the use of wearables, in particular for heart rate (HR) and activity tracking, in clinical cardiovascular healthcare to support their implementation into clinical care. The widespread use of HR and fitness tracking technologies provides unparalleled opportunities for capturing physiological information from large populations in the community, which has previously only been available in patient populations in the setting of healthcare provision. The availability of low-cost and high-volume physiological data from the community also provides unique challenges. While the number of patients meeting healthcare providers with data from wearables is rapidly growing, there are at present no clinical guidelines on how and when to use data from wearables in primary and secondary prevention. Technical aspects of HR tracking especially during activity need to be further validated. How to analyse, translate, and interpret large datasets of information into clinically applicable recommendations needs further consideration. While the current users of wearable technologies tend to be young, healthy and in the higher sociodemographic strata, wearables could potentially have a greater utility in the elderly and higher-risk population. Wearables may also provide a benefit through increased health awareness, democratization of health data and patient engagement. Use of continuous monitoring may provide opportunities for detection of risk factors and disease development earlier in the causal pathway, which may provide novel applications in both prevention and clinical research. However, wearables may also have potential adverse consequences due to unintended modification of behaviour, uncertain use and interpretation of large physiological data, a possible increase in social inequality due to differential access and technological literacy, challenges with regulatory bodies and privacy issues. In the present position paper, current applications as well as specific barriers and gaps in knowledge are identified and discussed in order to support the implementation of wearable technologies from gadget-ology into clinical cardiology.

Key Points Question Is cardiac telerehabilitation with relapse prevention cost-effective compared with center-based cardiac rehabilitation for the treatment of patients with coronary artery disease? Findings In this economic evaluation of data from 300 participants with coronary artery disease enrolled in the SmartCare-CAD randomized clinical trial, patients who received cardiac telerehabilitation with relapse prevention vs traditional center-based cardiac rehabilitation experienced comparable quality of life and nonsignificantly lower cardiac-associated health care costs and non–health care costs. Meaning This study found that cardiac telerehabilitation with relapse prevention was likely to be cost-effective compared with center-based cardiac rehabilitation and may be used as an alternative to center-based cardiac rehabilitation among patients with coronary artery disease., Importance Cardiac telerehabilitation (CTR) has been found to be a safe and beneficial alternative to traditional center-based cardiac rehabilitation (CR) and might be associated with higher participation rates by reducing barriers to CR use. However, implementation of CTR interventions remains low, which may be owing to a lack of cost-effectiveness analyses of data from large-scale randomized clinical trials. Objective To assess the cost-effectiveness of CTR with relapse prevention compared with center-based CR among patients with coronary artery disease. Design, Setting, and Participants This economic evaluation performed a cost-utility analysis of data from the SmartCare-CAD (Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform) randomized clinical trial. The cost-effectiveness and utility of 3 months of cardiac telerehabilitation followed by 9 months of relapse prevention were compared with the cost-effectiveness of traditional center-based cardiac rehabilitation. The analysis included 300 patients with stable coronary artery disease who received care at a CR center serving 2 general hospitals in the Netherlands between May 23, 2016, and July 26, 2018. All patients were entering phase 2 of outpatient CR and were followed up for 1 year (until August 14, 2019). Data were analyzed from September 21, 2020, to September 24, 2021. Intervention After baseline measurements were obtained, participants were randomly assigned on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group) using computerized block randomization. After 6 supervised center-based training sessions, patients in the intervention group continued training at home using a heart rate monitor and accelerometer. Patients uploaded heart rate and physical activity data and discussed their progress during a weekly video consultation with their physical therapist. After 3 months, weekly coaching was concluded, and on-demand coaching was initiated for relapse prevention; patients were instructed to continue using their wearable sensors and were contacted in cases of nonadherence to the intervention or reduced exercise or physical activity volumes. Main Outcomes and Measures Quality-adjusted life-years were assessed using the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS), and cardiac-associated health care costs and non–health care costs were measured by health care consumption, productivity, and informal care questionnaires (the Medical Consumption Questionnaire, the Productivity Cost Questionnaire, and the Valuation of Informal Care Questionnaire) designed by the Institute for Medical Technology Assessment. Costs were converted to 2020 price levels (in euros) using the Dutch consumer price index (to convert to US dollars, euro values were multiplied by 1.142, which was the mean exchange rate in 2020). Results Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life among patients receiving CTR vs center-based CR was comparable during the study according to the results of both utility measures (mean difference on EQ-5D-5L: −0.004; P = .82; mean difference on EQ-VAS: −0.001; P = .92). Intervention costs were significantly higher for CTR (mean [SE], €224 [€4] [$256 ($4)]) compared with center-based CR (mean [SE], €156 [€5] [$178 ($6)]; P, This economic evaluation assesses the cost-effectiveness of a cardiac telerehabilitation intervention incorporating relapse prevention compared with a traditional center-based cardiac rehabilitation program among patients with coronary artery disease in the Netherlands.

PURPOSE: The cardiac output (CO) response to exercise is a useful marker to grade the prognosis and severity of chronic heart failure (CHF). The recovery of the oxygen pulse (OP) is a non-invasive parameter, which is related to exercise capacity in cardiac patients. However, the relation between OP recovery and the central haemodynamic response to exercise remains to be determined. We hypothesized that an impaired OP recovery is associated with a reduced CO response to exercise in CHF patients.METHODS: Sixty one CHF patients performed cardiopulmonary exercise test with simultaneous measurement of CO. Impaired OP recovery was defined as an overshoot during the first minute of recovery or OP at 1-min recovery as a percentage of peak OP (OPRR ).RESULTS: An OP overshoot was observed in 9% (n = 5) of patients. In these patients, peak CO and VO2 were significantly lower (peak CO 7.9 ± 0.8 versus 11.2 ± 4.3 L/min and peak VO2 14.1 ± 4.7 versus 19.6 ± 5.8 ml min-1 kg-1 ). Mean relative recovery of OP was 78 ± 20%. Slow OP recovery (negative OPRR ) was seen in 13% (n = 8). Peak CO and VO2 were significantly lower in the negative OPRR group (11 ± 4 versus 8 ± 0.7 L/min and 19.7 ± 5.9 versus 14.6 ± 3.7 ml kg min-1 ). There was a significant relation between OPRR and stroke volume (SV) RR (r = .57), as well as between OPRR and a-v O2 diff RR (rs = .4).CONCLUSION: An impaired OP recovery is associated with a reduced CO response to exercise and worse functional status. Therefore, the OP recovery can be used to grade the severity of CHF.

Importance Hypertensive pregnancy disorders (HPDs) are associated with an increased risk of long-term cardiovascular disease. Speckle tracking echocardiography (STE) might be useful in the early detection of preclinical cardiac changes in women with HPDs. Objective The aim of this study was to study whether STE is a suitable method to detect differences in cardiac function in pregnant women with HPD compared with normotensive pregnant women or between women with a history of a pregnancy complicated by HPD compared with women with a history of an uncomplicated pregnancy. Evidence acquisition The databases Medline, EMBASE, and Central were systematically searched for studies comparing cardiac function measured with STE in pregnant women with HPD or women with a history of HPD and women with a history of normotensive pregnancies. Results The search identified 16 studies, including 870 women with a history of HPD and 693 normotensive controls. Most studies during pregnancy (n = 12/13) found a decreased LV-GLS (left ventricular global longitudinal strain) in HPD compared with normotensive pregnant controls. LV-GRS (left ventricular global radial strain) and LV-GLCS (left ventricular global circumferential strain) are decreased in women with early-onset and severe preeclampsia. Women with a history of early-onset preeclampsia show lasting myocardial changes, with significantly decreased LV-GLS, LV-GLCS, and LV-GRS. Conclusions and relevance LV-GLS is significantly decreased in pregnant women with HPD compared with normotensive pregnant women. Other deformation values show a significant decrease in women with severe or early-onset preeclampsia, with lasting myocardial changes after early-onset preeclampsia.

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.

The benefit of regular physical activity and exercise training for the prevention of cardiovascular and metabolic diseases is undisputed. Many molecular mechanisms mediating exercise effects have been deciphered. Personalised exercise prescription can help patients in achieving their individual greatest benefit from an exercise-based cardiovascular rehabilitation programme. Yet, we still struggle to provide truly personalised exercise prescriptions to our patients. In this position paper, we address novel basic and translational research concepts that can help us understand the principles underlying the inter-individual differences in the response to exercise, and identify early on who would most likely benefit from which exercise intervention. This includes hereditary, non-hereditary and sex-specific concepts. Recent insights have helped us to take on a more holistic view, integrating exercise-mediated molecular mechanisms with those influenced by metabolism and immunity. Unfortunately, while the outline is recognisable, many details are still lacking to turn the understanding of a concept into a roadmap ready to be used in clinical routine. This position paper therefore also investigates perspectives on how the advent of 'big data' and the use of animal models could help unravel inter-individual responses to exercise parameters and thus influence hypothesis-building for translational research in exercise-based cardiovascular rehabilitation. The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: TSB is supported by a Medical Research Council UK New Investigator award (MR/S025472/1). EMVC is supported by Fund for Scientific Research Flanders (Senior Clinical Investigator fellowship) and Koning Boudewijnstichting (Fund Joseph Oscar Waldmann-Berteau 2015). NK receives project-specific funding from the German Centre for Cardiovascular Research (DZHK; 81X2100238 and 81X2100243), the German Foundation of Heart Research (F/39/17) and the German Diabetes Foundation (FP-0421-2018). ABG, VA, MB, VC, MD, DH, HMCK and PL do not receive funding pertinent to this work.

Metabolic syndrome (MetS) – a clustering of pathological conditions, including abdominal obesity, hypertension, dyslipidemia and hyperglycaemia – is closely associated with the development of type 2 diabetes mellitus (T2DM) and a high risk of cardiovascular disease. A combination of multigenetic predisposition and lifestyle choices accounts for the varying inter-individual risk to develop MetS and T2DM, as well as for the individual amount of the increase in cardiovascular risk in those patients. A physically active lifestyle can offset about half of the genetically mediated cardiovascular risk. Yet, the extent to which standardized exercise programmes can reduce cardiovascular risk differs between patients. Exercise parameters, such as frequency, intensity, type and duration or number of repetitions, differentially target metabolic function, vascular health and physical fitness. In addition, exercise-induced molecular mechanisms are modulated by other patient-specific variables, such as age, diet and medication. This review discusses the molecular and cellular mechanisms underlying the effects of exercise training on cardiovascular risk specifically in patients with MetS and T2DM.

Aims In asymptomatic athletes, abnormal exercise test (ET) results have a poor positive predictive value. It is unknown whether abnormal ET results in the absence of obstructive coronary artery disease (CAD) are related to coronary microvascular dysfunction. It is also unknown whether they should be considered false-positive ET results or a consequence of physiological adaptation to sport. In our study, we evaluated whether athletes with abnormal ET results and documented myocardial ischaemia in the absence of obstructive CAD have an attenuated microvascular function and whether coronary microvascular dysfunction is related to endothelial dysfunction. Methods and results Nine athletes with concordant abnormal ET and myocardial perfusion scintigraphy (MPS) results without obstructive CAD were compared with age- and gender-matched individuals with a low-to-intermediate a priori risk of CAD. Coronary flow reserve was assessed by Rubidium-82 positron emission tomography (PET) imaging. Endothelin‑1 concentrations were measured to evaluate endothelial function. Coronary flow reserve was significantly lower in athletes (3.3 ± 0.8 versus 4.2 ± 0.6, p = 0.014 respectively). Endothelin‑1 levels were significantly higher in athletes (1.3 ± 0.2 pg/ml versus 1.0 ± 0.2 pg/ml, p = 0.012 respectively). There was no correlation between endothelin‑1 concentrations and mean global coronary flow reserve (r = 0.12). Conclusion Athletes with abnormal ET and MPS outcomes indicative for myocardial ischaemia and no obstructive CAD have a lower coronary flow reserve compared with non-athletes with low-to-intermediate a priori risk of CAD, suggesting an attenuated coronary microvascular function. Higher endothelin‑1 concentrations in athletes suggest that endothelial-dependent dysfunction is an important determinant of the attenuated microvascular function.

Objective. Near-infrared spectroscopy (NIRS) measurements of tissue oxygen saturation (StO2) are useful for the assessment of skeletal muscle perfusion and function during exercise, however, they are influenced by overlying skin and adipose tissue. This study explored the extent and nature of the influence of adipose tissue thickness (ATT) on StO2. Approach. NIR spatially resolved spectroscopy (SRS) derived oxygenation was measured on vastus lateralis in 56 patients with chronic heart failure (CHF) and 20 healthy control (HC) subjects during rest and moderate intensity exercise with simultaneous assessment of oxygen uptake kinetics (τ ). In vitro measurements were performed on a flow cell with a blood mixture with full oxygen saturation (100%), which was gradually decreased to 0% by adding sodium metabisulfite. Experiments were repeated with 2 mm increments of porcine fat layer between the NIRS device and flow cell up to 14 mm. Main results. Lower ATT, higher τ , and CHF were independently associated with lower in vivo StO2 in multiple regression analysis, whereas age and gender showed no independent relationship. With greater ATT, in vitro StO2 was reduced from 100% to 74% for fully oxygenated blood and increased from 0% to 68% for deoxygenated blood. Significance. This study shows that ATT independently confounds NIR-SRS derived StO2 by overestimating actual skeletal muscle oxygenation and by decreasing its sensitivity for deoxygenation. Because physiological properties (e.g. presence of disease and slowing of τ ) also influence NIR-SRS, a correction based on optical properties is needed to interpret calculated values as absolute StO2.

The extent and speed of transient skeletal muscle deoxygenation during exercise onset in patients with chronic heart failure (CHF) are related to impairments of local O2 delivery and utilization. This study examined the physiological background of submaximal exercise performance in 19 moderately impaired patients with CHF (Weber class A, B, and C) compared with 19 matched healthy control (HC) subjects by measuring skeletal muscle oxygenation (SmO2) changes during cycling exercise. All subjects performed two subsequent moderate-intensity 6-min exercise tests (bouts 1 and 2) with measurements of pulmonary oxygen uptake kinetics and SmO2 using near-infrared spatially resolved spectroscopy at the vastus lateralis for determination of absolute oxygenation values, amplitudes, kinetics (mean response time for onset), and deoxygenation overshoot characteristics. In CHF, deoxygenation kinetics were slower compared with HC (21.3 ± 5.3 s vs. 16.7 ± 4.4 s, P < 0.05, respectively). After priming exercise (i.e., during bout 2), deoxygenation kinetics were accelerated in CHF to values no longer different from HC (16.9 ± 4.6 s vs. 15.4 ± 4.2 s, P = 0.35). However, priming did not speed deoxygenation kinetics in CHF subjects with a deoxygenation overshoot, whereas it did reduce the incidence of the overshoot in this specific group ( P < 0.05). These results provide evidence for heterogeneity with respect to limitations of O2 delivery and utilization during moderate-intensity exercise in patients with CHF, with slowed deoxygenation kinetics indicating a predominant O2 utilization impairment and the presence of a deoxygenation overshoot, with a reduction after priming in a subgroup, indicating an initial O2 delivery to utilization mismatch.

Background High-intensity interval training (HIT) improves exercise capacity in patients with chronic heart failure (CHF). Moreover, HIT was associated with improved resting cardiac function. However, the extent to which these improvements actually contribute to training-induced changes in exercise capacity remains to be elucidated. Therefore, we evaluated the effects of HIT on exercising central haemodynamics and skeletal muscle oxygenation. Methods Twenty-six CHF patients were randomised to a 12-week 4 × 4 minute HIT program at 85-95% of peak VO2 or usual care. Patients performed maximal and submaximal cardiopulmonary exercise testing with simultaneous assessment of cardiac output and skeletal muscle oxygenation by near infrared spectroscopy, using the amplitude of the tissue saturation index (TSIamp). Results Peak workload increased by 11% after HIT (p between group = 0.01) with a non-significant increase in peak VO2 (+7%, p between group = 0.19). Cardiac reserve increased by 37% after HIT (p within group = 0.03, p between group = 0.08); this increase was not related to improvements in peak workload. Oxygen uptake recovery kinetics after submaximal exercise were accelerated by 20% (p between group = 0.02); this improvement was related to a decrease in TSIamp (r = 0.71, p = 0.03), but not to changes in cardiac output kinetics. Conclusion HIT induced improvements in maximal exercise capacity and exercising haemodynamics at peak exercise. Improvements in recovery after submaximal exercise were associated with attenuated skeletal muscle deoxygenation during submaximal exercise, but not with changes in cardiac output kinetics, suggesting that the effect of HIT on submaximal exercise capacity is mediated by improved microvascular oxygen delivery-to-utilisation matching.

The clinical benefits of rehabilitation in cardiovascular disease are well established. Among cardiovascular disease patients, however, patients with type 2 diabetes mellitus require a distinct approach. Specific challenges to clinicians and healthcare professionals in patients with type 2 diabetes include the prevalence of peripheral and autonomic neuropathy, retinopathy, nephropathy, but also the intake of glucose-lowering medication. In addition, the psychosocial wellbeing, driving ability and/or occupational status can be affected by type 2 diabetes. As a result, the target parameters of cardiovascular rehabilitation and the characteristics of the cardiovascular rehabilitation programme in patients with type 2 diabetes often require significant reconsideration and a multidisciplinary approach. This review explains how to deal with diabetes-associated comorbidities in the intake screening of patients with type 2 diabetes entering a cardiovascular rehabilitation programme. Furthermore, we discuss diabetes-specific target parameters and characteristics of cardiovascular rehabilitation programmes for patients with type 2 diabetes in a multidisciplinary context, including the implementation of guideline-directed medical therapy. ispartof: EUROPEAN JOURNAL OF PREVENTIVE CARDIOLOGY vol:26 issue:2_SUPPL pages:133-144 ispartof: location:England status: published

The aims of this study were to establish cardiac rehabilitation availability and density, as well as the nature of programmes, and to compare these by European region (geoscheme) and with other high-income countries. A survey was administered to cardiac rehabilitation programmes globally. Cardiac associations were engaged to facilitate programme identification. Density was computed using global burden of disease study ischaemic heart disease incidence estimates. Four high-income countries were selected for comparison ( N = 790 programmes) to European data, and multilevel analyses were performed. Cardiac rehabilitation was available in 40/44 (90.9%) European countries. Data were collected in 37 (94.8% country response rate). A total of 455/1538 (29.6% response rate) programme respondents initiated the survey. Programme volumes (median 300) were greatest in western European countries, but overall were higher than in other high-income countries ( P

Background: CRT leads to improvement in exercise capacity, cardiac function and mortality in selected CHF patients. Exercise capacity improves even greater when combining CRT with moderate-intensity exercise training (ET). However, high-intensity interval training (HIT) as additional therapy to CRT has not yet been established. Given the complementary physiological effects of HIT, we hypothesized that HIT after CRT may have additional effects on exercise capacity. Methods: 24 CHF patients, NYHA class II/III and accepted for CRT underwent an echocardiogram, QoL questionnaire and CPET with cardiac output (CO) measurements before implantation, at 3 and 6 months. After 3 months, patients were randomized to usual care (UC) or HIT, consisting of 36 sessions at 85–95% of peak V̇O 2. Results: Peak V̇O 2 increased after CRT (17±5.3 to 18.7±6.2 ml/kg/min, p < 0.05); after HIT there was a non-significant increase of 1.4 ml/kg/min (p = 0.12). Peak workload increased after CRT (109±45 to 118±44 W, p = 0.001). An additional significant within- and between group increase after HIT was found in the intervention group (128±42 to 148±48 W, versus 110±50 to 110±50, respectively, p = 0.03). Peak CO did not change significantly after CRT or HIT. V̇O 2 recovery kinetics speeded by 27% after CRT (p = 0.04), no further improvement after HIT was observed. LVEF increased 25% after CRT (p = 0.0001), no additional increase was seen after HIT. Conclusion: This study demonstrates that HIT provides additional improvement of exercise capacity without a concomitant change in peak V̇O 2 or CO suggesting that the additional effect of HIT is mainly mediated by an improvement of anaerobic performance.

Publisher's version (útgefin grein), Background: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. Methods: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. Findings: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = .92, 95%CI = .91–.93) or public (OR = .83, 95%CI = .82–84) funding compared to hybrid sources. Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. Interpretation: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation., This research was supported by a grant from York University 's Faculty of Health. The funder had no role in study design, data collection, data analysis, interpretation or writing of the report.

Patients with type 2 diabetes mellitus suffer from dysregulation of a plethora of cardiovascular and metabolic functions, including dysglycaemia, dyslipidaemia, arterial hypertension, obesity and a reduced cardiorespiratory fitness. Exercise training has the potential to improve many of these functions, such as insulin sensitivity, lipid profile, vascular reactivity and cardiorespiratory fitness, particularly in type 2 diabetes mellitus patients with cardiovascular comorbidities, such as patients that suffered from an acute myocardial infarction, or after a coronary intervention such as percutaneous coronary intervention or coronary artery bypass grafting. The present position paper aims to provide recommendations for prescription of exercise training in patients with both type 2 diabetes mellitus and cardiovascular disease. The first part discusses the relevance and practical applicability of treatment targets that may be pursued, and failure to respond to these targets. The second part provides recommendations on the contents and methods to prescribe exercise training tailored to these treatment targets as well as to an optimal preparation and dealing with barriers and risks specific to type 2 diabetes mellitus and cardiac comorbidity.

Oxygen uptake (V̇o2) kinetics are prolonged in patients with chronic heart failure (CHF). This may be caused by impaired oxygen delivery or skeletal muscle derangements. We investigated whether impaired cardiac output (Q̇) kinetics limit skeletal muscle oxygen delivery relative to the metabolic demands at submaximal exercise in CHF patients by evaluating the relation between Q̇ kinetics and skeletal muscle deoxygenation. Forty-three CHF patients, NYHA II-III, performed a constant-load exercise test at 80% of the ventilatory aerobic threshold (VAT) to assess V̇o2 kinetics (τV̇o2). Q̇ kinetics (τQ̇) were assessed by a radial artery pulse contour analysis method. Skeletal muscle deoxygenation was assessed by near infrared spectroscopy at the m. vastus lateralis, using the minimal value of the tissue saturation index during onset of exercise (TSImin). Patients were categorized in slow and normal Q̇ responders relative to metabolic demands (τQ̇/V̇o2 ≥1 and τQ̇/V̇o2

Although test characteristics of exercise electrocardiography are well established in symptomatic patients, data on healthy athletes are scarce. This systematic review focuses on the diagnostic utility of exercise electrocardiography for the detection of coronary heart disease in athletes during pre-participation screening. This systematic review evaluated the prevalence of an abnormal exercise test result and the positive predictive value of exercise electrocardiography in asymptomatic athletes. In addition, the long-term prognosis of a false-positive test result was evaluated. An electronic search was performed using the Cochrane Library, PubMed, and MEDLINE. Only studies using exercise electrocardiography in an unselected population of asymptomatic athletes were included. Data on population characteristics, cardiovascular risk factors, exercise test parameters, left ventricular hypertrophy, and morbidity/mortality were extracted and analyzed. The mean prevalence of an abnormal exercise test result was 0.6 % (range 0–29 %), with a positive predictive value of 9 % (range 0–55 %). Left ventricular hypertrophy was observed in 57 % of the athletes with an abnormal exercise test result, in 50 % of the athletes with a false-positive exercise test result, and in 24 % of the athletes with a normal exercise test. Among athletes with a false-positive test, only one athlete (3 %) experienced a possible cardiac event. This systematic review revealed a relatively low prevalence of positive exercise test results in asymptomatic athletes, but a very poor positive predictive value. There were insufficient data available to determine the prognostic implications of false-positive test results in asymptomatic athletes.

Skeletal muscle function in patients with heart failure and reduced ejection fraction (HFrEF) greatly determines exercise capacity. However, reports on skeletal muscle fiber dimensions, fiber capillarization, and their physiological importance are inconsistent. Twenty-five moderately impaired patients with HFrEF and 25 healthy control (HC) subjects underwent muscle biopsy sampling. Type I and type II muscle fiber characteristics were determined by immunohistochemistry. In patients with HFrEF, enzymatic oxidative capacity was assessed, and pulmonary oxygen uptake (V̇o2) and skeletal muscle oxygenation during maximal and moderate-intensity exercise were measured using near-infrared spectroscopy. While muscle fiber cross-sectional area (CSA) was not different between patients with HFrEF and HC, the percentage of type I fibers was higher in HC (46 ± 15 vs. 37 ± 12%, respectively, P = 0.041). Fiber type distribution and CSA were not different between patients in New York Heart Association (NYHA) class II and III. Type I muscle fiber capillarization was higher in HFrEF compared with HC[capillary-to-fiber perimeter exchange (CFPE) index: 5.70 ± 0.92 vs. 5.05 ± 0.82, respectively, P = 0.027]. Patients in NYHA class III had slower V̇o2 and muscle deoxygenation kinetics during onset of exercise and lower muscle oxidative capacity than those in class II ( P < 0.05). Also, fiber capillarization was lower but not compared with HC. Higher CFPE index was related to faster deoxygenation ( rspearman = −0.682, P = 0.001), however, not to muscle oxidative capacity ( r = −0.282, P = 0.216). Type I muscle fiber capillarization is higher in HFrEF compared with HC but not in patients with greater exercise impairment. Greater capillarization may positively affect V̇o2 kinetics by enhancing muscle oxygen diffusion. NEW & NOTEWORTHY The skeletal myopathy of chronic heart failure (HF) includes a greater percentage of fatigable type II fibers and, for less impaired patients, greater skeletal muscle fiber capillarization. Near-infrared spectroscopy measurements of skeletal muscle oxygenation indicate that greater capillarization may compensate for reduced blood flow in mild HF by enhancing the diffusive capacity of skeletal muscle. This thereby augments and speeds oxygen extraction during contractions, which is translated into faster pulmonary oxygen uptake kinetics.

Background A recent survey among Dutch cardiac rehabilitation centers demonstrated considerable between-center variations in the contents of exercise training programs. For patients entering cardiac rehabilitation, current guidelines recommend tailored exercise training programs based on patient characteristics and rehabilitation goals. Objective This study was to analyze to what extent these patient characteristics are determinants of variations in training programs. Design This was a prospective, observational study with cross-sectional measurements among 10 cardiac rehabilitation centers. Methods The following data were obtained about patients entering cardiac rehabilitation: referral diagnosis, rehabilitation goals, and exercise training variables. Primary outcomes were variations in total aerobic training time, intensity, and volume before and after case-mix correction for population differences between centers. Secondary outcomes were variations in other training characteristics and the role of exercise testing in the determination of training intensity. Also, the roles of diagnosis and training goals in determining aerobic training time and intensity were studied. Results Data from 700 participants were analyzed. There were significant variations between centers in all aerobic and most resistance training characteristics. For aerobic training intensity, time, and volume, great variations remained after case-mix correction. An exercise test was performed for 656 participants (93.7%) but was used to determine training intensity in only 344 (52.4%) of these participants. In most centers, referral diagnosis and rehabilitation goals were unrelated to aerobic training time or intensity. Limitations Some form of selection bias cannot be excluded because the competing centers represented a minority of Dutch exercise-based cardiac rehabilitation centers. Conclusions This study showed that the contents of training programs varied considerably between cardiac rehabilitation centers, independent of population differences. Furthermore, aerobic training time and intensity were mostly unrelated to rehabilitation goals and referral diagnosis.

Purpose: Assessment of limitations in the perfusion dynamics of skeletal muscle may provide insight in the pathophysiology of exercise intolerance in, e.g., heart failure patients. Power doppler ultrasound (PDUS) has been recognized as a sensitive tool for the detection of muscle blood flow. In this volunteer study (N = 30), a method is demonstrated for perfusion measurements in the vastus lateralis muscle, with PDUS, during standardized cycling exercise protocols, and the test–retest reliability has been investigated. Methods: Fixation of the ultrasound probe on the upper leg allowed for continuous PDUS measurements. Cycling exercise protocols included a submaximal and an incremental exercise to maximal power. The relative perfused area (RPA) was determined as a measure of perfusion. Absolute and relative reliability of RPA amplitude and kinetic parameters during exercise (onset, slope, maximum value) and recovery (overshoot, decay time constants) were investigated. Results: A RPA increase during exercise followed by a signal recovery was measured in all volunteers. Amplitudes and kinetic parameters during exercise and recovery showed poor to good relative reliability (ICC ranging from 0.2–0.8), and poor to moderate absolute reliability (coefficient of variation (CV) range 18–60%). Conclusions: A method has been demonstrated which allows for continuous (Power Doppler) ultrasonography and assessment of perfusion dynamics in skeletal muscle during exercise. The reliability of the RPA amplitudes and kinetics ranges from poor to good, while the reliability of the RPA increase in submaximal cycling (ICC = 0.8, CV = 18%) is promising for non-invasive clinical assessment of the muscle perfusion response to daily exercise.

The goals of this study were to determine the prevalence and determinants of false-positive exercise tests in athletes. Data from all athletes who visited the Department of Sport Medicine for assessment of sports eligibility during a 1.5-year period were reviewed retrospectively. Potential determinants of (false) positive test results that were evaluated included demographics, cardiovascular risk factors, sports characteristics, resting electrocardiogram (ECG) abnormalities, and exercise capacity. Data from 1298 athletes were included. In 53 athletes (4.1%), the exercise ECG was classified as positive. Among 38 athletes who were referred to a sports cardiologist for further diagnostic evaluation, 36 (95%) were classified as having a false-positive test result and 2 athletes (5%) required coronary revascularization. Athletes with a false-positive test were older than athletes with a negative test (53 ± 8 vs 45 ± 13 years, P = 0.03). In conclusion, exercise electrocardiography has a low positive predictive value in asymptomatic recreational and competitive athletes, with a false-positive test result being associated with higher age. Given the relatively high prevalence of false-positive test results in this population, efforts should be made to develop strategies aimed at identifying false-positive test results in a simple noninvasive manner.

Contains fulltext : 155228.pdf (Publisher’s version ) (Open Access) RATIONALE: To improve the quality of exercise-based cardiac rehabilitation (CR) in patients with chronic heart failure (CHF) a practice guideline from the Dutch Royal Society for Physiotherapy (KNGF) has been developed. GUIDELINE DEVELOPMENT: A systematic literature search was performed to formulate conclusions on the efficacy of exercise-based intervention during all CR phases in patients with CHF. Evidence was graded (1-4) according the Dutch evidence-based guideline development criteria. CLINICAL AND RESEARCH RECOMMENDATIONS: Recommendations for exercise-based CR were formulated covering the following topics: mobilisation and treatment of pulmonary symptoms (if necessary) during the clinical phase, aerobic exercise, strength training (inspiratory muscle training and peripheral muscle training) and relaxation therapy during the outpatient CR phase, and adoption and monitoring training after outpatient CR. APPLICABILITY AND IMPLEMENTATION ISSUES: This guideline provides the physiotherapist with an evidence-based instrument to assist in clinical decision-making regarding patients with CHF. The implementation of the guideline in clinical practice needs further evaluation. CONCLUSION: This guideline outlines best practice standards for physiotherapists concerning exercise-based CR in CHF patients. Research is needed on strategies to improve monitoring and follow-up of the maintenance of a physical active lifestyle after supervised CR.

Background: Although exercise-based cardiac rehabilitation improves exercise capacity of coronary artery disease patients, it is unclear which training characteristic determines this improvement. Total energy expenditure and its constituent training characteristics (training intensity, session frequency, session duration and programme length) vary considerably among clinical trials, making it hard to compare studies directly. Therefore, we performed a systematic review and meta-regression analysis to assess the effect of total energy expenditure and its constituent training characteristics on exercise capacity. Methods: We identified randomised controlled trials comparing continuous aerobic exercise training with usual care for patients with coronary artery disease. Studies were included when training intensity, session frequency, session duration and programme length was described, and exercise capacity was reported in peakVO(2). Energy expenditure was calculated from the four training characteristics. The effect of training characteristics on exercise capacity was determined using mixed effects linear regression analyses. The analyses were performed with and without total energy expenditure as covariate. Results: Twenty studies were included in the analyses. The mean difference in peakVO(2) between the intervention group and control group was 3.97 ml.min(-1).kg(-1) (p

Aim: Although cardiac rehabilitation improves physical fitness after a cardiac event, many eligible patients do not participate in cardiac rehabilitation and the beneficial effects of cardiac rehabilitation are often not maintained over time. Home-based training with telemonitoring guidance could improve participation rates and enhance long-term effectiveness. Methods and results: We randomised 90 low-to-moderate cardiac risk patients entering cardiac rehabilitation to three months of either home-based training with telemonitoring guidance or centre-based training. Although training adherence was similar between groups, satisfaction was higher in the home-based group (p = 0.02). Physical fitness improved at discharge (p

Background Previous studies revealed a relatively high prevalence of electrocardiographic findings indicative for myocardial ischemia in asymptomatic athletes undergoing pre-participation screening. Myocardial perfusion scintigraphy is generally considered a valuable diagnostic and prognostic modality and often used for further diagnostic evaluation in these subjects. However, data on the diagnostic accuracy of myocardial perfusion scintigraphy in athletes are scarce. Objectives The main purpose of this study was to investigate the positive predictive value of myocardial perfusion scintigraphy for detection of coronary artery disease in asymptomatic athletes with abnormal exercise testing results during pre-participation screening. The secondary aim was to evaluate the prognostic value of myocardial perfusion scintigraphy. Methods Electronic charts of asymptomatic athletes who underwent myocardial perfusion scintigraphy following an abnormal exercise testing were retrospectively reviewed. Myocardial perfusion scintigraphy and exercise testing studies were revised. Athlete characteristics and cardiovascular risk factors were evaluated. Results One hundred and forty-three athletes were included. 29 athletes (20%) showed concordant abnormal exercise testing and myocardial perfusion scintigraphy results. Coronary imaging was performed in 20 of these 29 athletes. Four athletes showed significant coronary artery disease (positive predictive value = 20%). The positive predictive value increased to 33% when athletes were selected who should have undergone exercise testing according to the guideline recommendations. During a mean follow-up interval of 4.7 ± 2.2 years, eight cardiac events occurred. Athletes with an abnormal myocardial perfusion scintigraphy result had a fourfold increased risk at a future cardiac event (2.9%/year versus 0.75%/year, p = 0.031). Conclusions The positive predictive value of myocardial perfusion scintigraphy for the detection of significant coronary artery disease in asymptomatic athletes with a positive exercise testing result is low, even in a selection of athletes with a relatively high cardiovascular risk. Although an abnormal myocardial perfusion scintigraphy result was associated with a fourfold higher annual event rate, the absolute annual event rate in this group was still low. Efforts should be made to develop better diagnostic strategies to evaluate asymptomatic athletes with abnormal exercise testing results during pre-participation screening.