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BACKGROUND: The incidence of asymptomatic pericardial effusion is high after cardiac surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in this setting, but no study has assessed their efficacy. OBJECTIVE: To assess whether the NSAID diclofenac is effective in reducing postoperative pericardial effusion volume. DESIGN: Multicenter randomized, double-blind, placebo-controlled study. (Clinical trials.gov registration number: NCT00247052) SETTING: 5 postoperative cardiac rehabilitation centers. PATIENTS: 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. INTERVENTION: Random assignment at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. MEASUREMENTS: The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS: The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P = 0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P = 0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. LIMITATION: The sample was not large enough to find small beneficial effects of diclofenac or assess the cardiovascular tolerance of diclofenac. CONCLUSION: In patients with pericardial effusion after cardiac surgery, diclofenac neither reduced the size of the effusions nor prevented late cardiac tamponade. PRIMARY FUNDING SOURCE: French Society of Cardiology. [ABSTRACT FROM AUTHOR]

Aims: The ability to be physically active is pivotal to the quality of life in elderly patients. This study aims to describe the association between exercise capacity and health-related quality of life (HRQoL), anxiety, and depression following an exercise-based cardiac rehabilitation (CR) programme in elderly cardiac patients., Methods and Results: Patients aged ≥65 years with acute and chronic coronary syndrome or heart valve surgery were consecutively included from eight CR centres in seven European countries. Exercise capacity [VO2peak(mL/kg/min)] was assessed with a cardiopulmonary exercise test (97%) or a 6-min walk test. Outcome variables included HRQoL [36-item Short-Form Health Survey physical and mental component scores (PCS and MCS)], anxiety (Generalized Anxiety Disorder-7), and depression (Patient Health Questionnaire-9). Mixed models were used to address the association between baseline and the development in VO2peak, and outcome variables stratified on sex, and adjusted for baseline values, age, and CR centre. A total of 1633 patients were included (T0), 1523 (93%) completed end-of-CR assessment (T1), and 1457 (89%) were available for 1-year follow-up (T2). Women had higher percentage of predicted VO2peak but poorer scores in HRQoL, anxiety, and depression at all time points. All scores improved in both sexes at follow-up. We found significant associations between VO2peak at baseline as well as development in VO2peak and all outcome variables at T1 and T2 in men (all P < 0.001). In women, VO2peak was only associated with PCSs (P < 0.001)., Conclusion: Improvements in exercise capacity were strongly associated with improvements in HRQoL and mental health, however, with stronger associations in men. The results highlight the importance of physical fitness for HRQol and mental health. The findings from this study might be useful to better target individual CR programmes., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Aims: To evaluate the impact of cardiac rehabilitation (CR) on optimization of secondary prevention treatments for acute coronary syndrome (ACS), medication persistence, medical follow-up, rehospitalization, and all-cause mortality., Methods and Results: The National Health Insurance database was used to identify all patients hospitalized for ACS in France in 2019 and those among them who received CR. Patients' characteristics and outcomes were described and compared between CR and non-CR patients. Poisson regression models were used to identify the impact of CR after adjusting for confounders. A Cox model was fitted to identify the variables related to mortality after adjustment for medication persistence and cardiologic follow-up. In 2019, 22% of 134 846 patients hospitalized for ACS in France received CR within 6 months of their discharge. After 1 year, only 60% of patients who did not receive CR were still taking BASI (combination of beta-blockers, antiplatelet agents, statins, and renin-angiotensin-aldosterone system inhibitors) drugs. This rate and the medical follow-up rate were higher in patients who received CR. Two years after the ACS event, patients who received CR had better medical follow-up and lower mortality risk, after adjusting for cofounding variables [adjusted hazard ratio all-cause mortality = 0.65 (0.61-0.69)]. After adjustment for the dispensing of cardiovascular drugs and cardiologic follow-up, the independent effect of CR was not as strong but remained significant [hazard ratio = 0.90 (95% confidence interval: 0.84-0.95)]., Conclusion: Patients who received CR after hospitalization for ACS had a better prognosis. Optimization of efficient secondary prevention strategies, improved medication persistence, and enhanced cardiologic follow-up seemed to play a major role., Competing Interests: Conflict of interest: J.B. reports, outside the submitted work, personal fees and/or non-financial support from AstraZeneca, Bayer, Gedeon Richter, Elkendi, Hikma, Leurquin, Omron, Organon, Sanofi, ViiV, Vivactis, and Vivoptim. M.-C.I. reports, outside the submitted work, personal fees from AstraZeneca, Novartis, Sanofi, and Servier. A.C. reports, outside the submitted work, non-financial support from Amgen SAS. C.G., A.G., P.T., and V.O. have nothing to report., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Coronary heart disease remains one of the leading causes of morbidity and mortality, and is responsible for significant social costs. Resumption of work is an essential objective when this pathology concerns working patients. French data remain patchy and relatively old. The French Society of Cardiology's Exercise, Rehabilitation, Sport and Prevention Group has proposed a multicentre study to update these data., Methods: Following an acute coronary syndrome (ACS), the cardiology team asked the patient, who was currently working, to complete a questionnaire on his or her pathology, occupation and plans to return to work. An interview after 6 months enabled the clinical and professional situation of the patient to be analyzed, in order to study the factors predictive of a return to work., Results: 364 patients were included in 6 interventional and 17 cardiac rehabilitation centres between 2018 and 2019. The resumption rate was 81% (n = 295), 93% of them in the same position, with a mean delay of 106 ± 56 days. The cardiologic independent factors for non-return were left ventricular ejection fraction, the presence of an anticoagulant, angina or heart failure, and occupational factors, shift work, exposure to cold, and imposed work rates. Factors that lengthened the time taken to return to work included delayed access to rehabilitation, the carrying of heavy loads, difficult postures and imposed work rates, as well as the patient's lack of a project, the absence of a cardiologist's opinion and the request for a modified workstation., Conclusion: The rate of return to work remains fairly stable despite the evolution of disease management, and the time to return to work relatively high. One way of improving the situation is to enhance access to cardiac rehabilitation programs, for example by offering alternatives such as tele-rehabilitation for a proportion of patients. This will free up more time for more severe patients, to better prepare them physically and psychologically for a return to work, which will also have a beneficial economic effect., Competing Interests: Déclaration de liens d'intérêt Les auteurs déclarent ne pas avoir de lien d'intérêt avec cet article, (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life., Aims: To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities., Methods: All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified., Results: In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic., Conclusions: Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Supervised exercise training decreases total and cardiac mortality and increases quality of life of heart failure with reduced ejection fraction (HFrEF) patients. However, response to training is variable from one patient to another and factors responsible for a positive response to training remain unclear. The aims of the study were to compare cardiac hemodynamic changes after an exercise training program in responders (R) versus non-responders (NR) HFrEF patients, and to compare different discriminators used to assess response to training., Methods: Seventy-six HFrEF patients (86% males, 57 ± 12 years) completed an exercise training program for 4 weeks. Patients underwent cardiopulmonary exercise testing (CPET) on a cycle ergometer before and after training. Cardiac hemodynamics were measured by impedance cardiography during CPET. The R and NR groups were classified using the median change in peak oxygen uptake (V̇O 2peak )., Results: There were statistically significant differences in V̇O 2peak (+35% vs. -1%, P < 0.0001) and in peaks of ventilation (+30% vs. +2%, P < 0.0001), cardiac output (CO peak ) (+25% vs. +4%, P < 0.01), systolic blood pressure (+12% vs. +2%, P < 0.05), diastolic blood pressure (+9% vs. +4%, P < 0.05) and heart rate (+8% vs. +1%, P < 0.01) between R and NR after the training program. V̇O 2peak was the best discriminator between R and NR (receiver operating characteristic (ROC) area under the curve (AUC) = 0.83, P < 0.0001), followed by CO peak (ROC AUC = 0.77, P < 0.0001)., Conclusion: V̇O 2peak is the best discriminator between HFrEF R and NR patients after the training program. Responders showed improvements in peak hemodynamic parameters. These results pave the way for other studies to determine how the individualization of exercise training programs and peak hemodynamic parameters potentially linked to a better positive response status., Competing Interests: None to declare., (Copyright 2024, Kirsch et al.)

Recent international guidelines recommend rapid initiation and titration of basic treatments of heart failure but do not explain how to achieve this goal. Despite these recommendations, implementation of treatment in daily practice is poor. This may be partly explained by the profile of the patients (frailty, comorbidities), safety considerations and tolerability issues related to kydney function, low blood pressure or heart rate and hyperkalaemia. In this special article, we intended to help the physician, through an algorithmic approach, to quickly and safely introduce guideline-directed medical therapy in the field of heart failure with ejection fraction under 50%., Competing Interests: Déclaration de liens d'intérêts Le Pr M KOMAJDA déclare des activités de consultant, orateur ou membre de comités d'essais cliniques pour Bayer AstraZeneca, Boehringer Ingelheim, Servier. Les autres auteurs ne déclarent aucun lien d'intérêt en lien avec cet article., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Purpose: Chronic kidney disease (CKD) is common in heart failure (HF). Chronic kidney disease often worsens the prognosis and impairs the management of patients with HF. Chronic kidney disease is frequently accompanied by sarcopenia, which limits the benefits of cardiac rehabilitation (CR). The aim of this study was to evaluate the impact of CR on cardiorespiratory fitness in HF patients with reduced ejection fraction (HFrEF) according to the CKD stage., Methods: We conducted a retrospective study including 567 consecutive patients with HFrEF, who underwent a 4-wk CR program, and who were evaluated by cardiorespiratory exercise test before and after the program. Patients were stratified according to their estimated glomerular filtration rate (eGFR). We performed multivariate analysis looking for factors associated with an improvement of 10% in peak oxygen uptake (V˙ o2peak )., Results: Thirty-eight percent of patients had eGFR <60 mL/min/1.73m². With decreasing eGFR, we observed deterioration in V˙ o2peak , first ventilatory threshold (VT1) and workload and an increase in brain natriuretic peptide levels at baseline. After CR, there was an improvement in V˙ O2peak (15.3 vs 17.8 mL/kg/min, P < .001), VT1 (10.5 vs 12.4 mL/kg/min, P < .001), workload (77 vs 94 W, P < .001), and brain natriuretic peptide (688 vs 488 pg/mL, P < .001). These improvements were statistically significant for all stages of CKD. In a multivariate analysis predicting factors associated with V˙ o2peak improvement, renal function did not interfere with results., Conclusions: Cardiac rehabilitation is beneficial in patients with HFrEF with CKD regardless of CKD stage. The presence of CKD should not prevent the prescription of CR in patients with HFrEF., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Inefficient ventilation is an established prognostic marker in patients with heart failure. It is not known whether inefficient ventilation is also linked to poor prognosis in patients with left ventricular dysfunction (LVD) but without overt heart failure., Objectives: To investigate whether inefficient ventilation in elderly patients with LVD is more common than in patients without LVD, whether it improves with exercise-based cardiac rehabilitation (exCR), and whether it is associated with major adverse cardiovascular events (MACE)., Methods: In this large multicentre observational longitudinal study, patients aged ≥65 years with acute or chronic coronary syndromes (ACS, CCS) without cardiac surgery who participated in a study on the effectiveness of exCR in seven European countries were included. Cardiopulmonary exercise testing (CPET) was performed before, at the termination of exCR, and at 12 months follow-up. Ventilation (VE), breathing frequency (BF), tidal volume (VT), and end-expiratory carbon dioxide pressure (P ET CO 2 ) were measured at rest, at the first ventilatory threshold, and at peak exercise. Ventilatory parameters were compared between patients with and without LVD (based on cardio-echography) and related to MACE at 12 month follow-up., Results: In 818 patients, age was 72.5 ± 5.4 years, 21.9% were women, 79.8% had ACS, and 151 (18%) had LVD. Compared to noLVD, in LVD resting VE was increased by 8%, resting BF by 6%, peak VE , peak VT, and peak P ET CO 2 reduced by 6%, 8%, and 5%, respectively, and VE/VCO 2 slope increased by 11%. From before to after exCR, resting VE decreased and peak P ET CO 2 increased significantly more in patients with compared to without LVD. In LVD, higher resting BF, higher nadir VE/VCO 2 , and lower peak P ET CO 2 at baseline were associated with MACE., Conclusions: Similarly to patients with HF, in elderly patients with ischemic LVD, inefficient resting and exercise ventilation was associated with worse outcomes, and ExCR alleviated abnormal breathing patterns and gas exchange parameters., Competing Interests: AV reports grants from Medtronic, grants and personal fees from Astra Zeneca, outside the submitted work, UZ reports grants and personal fees from Astra Zeneca, Bayer, BMS, Novartis, and MSD, and personal fees from Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Trommsdorf, and Amgen, all outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Eser, Marcin, Prescott, Prins, Kolkman, Bruins, van der Velde, Gil, Iliou, Ardissino, Zeymer, Meindersma, Van't Hof, de Kluiver and Wilhelm.)

Purpose: Data are scarce concerning the sustainable effects of cardiac rehabilitation (CR), on cardiorespiratory fitness (CRF) of patients with coronary artery disease (CAD). This study, carried out using data from a French multicenter study, aimed to clarify the evolution of the CRF of patients with CAD 1 yr after the end of a CR stay., Methods: Patients were included after an acute coronary syndrome (77%) and/or coronary revascularization, occurring <3 mo beforehand. All underwent a CR program with CRF evaluation by exercise testing (ET) on a cycle ergometer at the beginning of CR (ET1), at its end (ET2), and 1 yr later (ET3)-all ETs were performed with medication., Results: Two hundred fifty-nine patients were included (age 60 ± 10 yr, 89% male) in 16 French CR centers. Left ventricular ejection fraction was 55.3 ± 9%. Revascularization was complete (82%). Maximal workloads were 110 ± 37 (ET1), 139 ± 43 (ET2), and 144 ± 46 W (ET3) ( P < .001). The estimated metabolic equivalents of the task (METs) were respectively 5.3 ± 1.4, 6.4 ± 1.6 ( P < .001), and 6.6 ± 1.7 ( P < .002). One year later, 163 patients (63%) improved or maintained their CRF (ET3 ≥ ET2), 73 (28%) decreased (ET1 < ET3 < ET2), and 23 (9%) lost the benefit of CR (ET3 ≤ ET1)., Conclusion: Among completers who agreed to enroll in this study, most patients with CAD seem to maintain their CRF 1 yr after CR., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

(1) Background: Exercise is recommended to improve physical fitness in patients recovering from acute type A aortic dissection (ATAAD). However, surgery corrects the diseased blood vessels and reduces the risk of ATAAD, but it does not redefine a safe exercise blood pressure (BP) threshold. This review aimed to discuss whether the safe threshold of exercise BP can be upregulated after ATAAD surgery to increase exercise intensity with additional benefits. (2) Data sources: The PubMed databases were searched with the keywords "type A acute aortic dissection surgery", "exercise", "BP", "stress", and variations of these terms. (3) Study selection: Data from clinical trials, guidelines, and recent reviews were selected for review. (4) Results: Regular exercise can be considered a cardioprotective intervention for aortic dissection patients by attenuating hemodynamic responses at rest and during exercise. Previous studies have mainly focused on moderate-intensity aerobic exercise. In practice, the exercise systolic BP of some patients was higher than 160 mm Hg without adverse events, which indicates that the training intensity may be underestimated for patients after ATAAD surgery. Limited studies suggest a light-to-moderate resistance training for selected patients because it may cause a greater increase in BP. (5) Conclusions: Moderate-intensity continuous aerobic exercise supplemented by low-intensity resistance training is appropriate for cardiac rehabilitation after ATAAD surgery. The BP increase based on the normal exercise BP response, corresponding to the moderate-intensity is relatively safe. For high-risk post-ATAAD patients, considering the overall volume of training, personalizing the exercise regimen to remain within "safe" BP limits, and avoiding excessive fluctuations in BP should be the primary considerations for exercise training.

Introduction: Surgically treated acute type A aortic dissection (ATAAD) patients are often restricted from physical exercise due to a lack of knowledge about safe blood pressure (BP) ranges. The aim of this study was to describe the evolution of early postoperative cardiac rehabilitation (CR) for patients with ATAAD., Methods: This is a retrospective study of 73 patients with ATAAD who were referred to the CR department after surgery. An incremental symptom-limited exercise stress test (ExT) on a cyclo-ergometer was performed before and after CR, which included continuous training and segmental muscle strengthening (five sessions/week). Systolic and diastolic blood pressure (SBP and DBP) were monitored before and after all exercise sessions., Results: The patients (78.1% male; 62.2 ± 12.7 years old; 54.8% hypertensive) started CR 26.2 ± 17.3 days after surgery. During 30.4 ±11.6 days, they underwent 14.5 ± 4.7 sessions of endurance cycling training, and 11.8 ± 4.3 sessions of segmental muscle strengthening. At the end of CR, the gain of workload during endurance training and functional capacity during ExT were 19.6 ± 10.2 watts and 1.2 ± 0.6 METs, respectively. The maximal BP reached during endurance training was 143 ± 14/88 ± 14 mmHg. The heart rate (HR) reserve improved from 20.2 ± 13.9 bpm to 33.2 ± 16.8 bpm while the resting HR decreased from 86.1 ± 17.4 bpm to 76.4 ± 13.3 bpm., Conclusion: Early post-operative exercise-based CR is feasible and safe in patients with surgically treated ATAAD. The CR effect is remarkable, but it requires a close BP monitoring and supervision by a cardiologist and physical therapist during training.

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

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.)

(1) Background: There is much debate about the use of salt-restricted diet for managing heart failure (HF). Dietary guidelines are inconsistent and lack evidence. (2) Method: The OFICSel observatory collected data about adults hospitalised for HF. The data, collected using study-specific surveys, were used to describe HF management, including diets, from the cardiologists' and patients' perspectives. Cardiologists provided the patients' clinical, biological, echocardiography, and treatment data, while the patients provided dietary, medical history, sociodemographic, morphometric, quality of life, and burden data (burden scale in restricted diets (BIRD) questionnaire). The differences between the diet recommended by the cardiologist, understood by the patient, and the estimated salt intake (by the patient) and diet burden were assessed. (3) Results: Between March and June 2017, 300 cardiologists enrolled 2822 patients. Most patients (90%) were recommended diets with <6 g of salt/day. Mean daily salt consumption was 4.7 g (standard deviation (SD): 2.4). Only 33% of patients complied with their recommended diet, 34% over-complied, and 19% under-complied (14% unknown). Dietary restrictions in HF patients were associated with increased burden (mean BIRD score of 8.1/48 [SD: 8.8]). (4) Conclusion: Healthcare professionals do not always follow dietary recommendations, and their patients do not always understand and comply with diets recommended. Restrictive diets in HF patients are associated with increased burden. An evidence-based approach to developing and recommending HF-specific diets is required.

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Cardiac rehabilitation (CR) is the right place to optimize the medical treatment in coronary artery disease (CAD) patients., Aims: To report the medical management in CAD patients during CR and evaluate the consequences., Methods: CAD patients who attended a CR program within less than three months of an acute coronary syndrome (ACS), a percutaneous coronary intervention (PCI), or a coronary artery bypass graft (CABG) were included in a prospective multicenter study. Medical treatments were analyzed at the beginning and at discharge of the CR stay. Results of exercise tests were compared between 4 groups. G1: unchanged medication, n=443, G2: beta-blockers or bradycardic agents adaptation n=199, G3: renin-angiotensin system (RAS) inhibitors adaptation, n=194, G4: both medications adaptation, n=164., Results: One thousand consecutive patients were included in 23 French CR centers (85.3% males; mean age 59.9 ± 11 years). The index event was ACS (68.5%), PCI (62.6%) and CABG (36.3%). During CR, we noted an adaptation for beta-blockers in 32.1%, in other bradycardic agents (ivabradine, verapamil, diltiazem, amiodarone) in 9.5%, and in RAS inhibitors in 36.3%. Patients of group 1 had an initial resting heart rate lower than in group 2 and 4, but at the final exercise testing, the range of the decrease was more important in group 2 and 4. The combination of physical training and therapeutic modifications resulted in similar exercise capacities in the four groups, from 5.2, 5.3, 5.4 and 5.2 MET (p=0.68), to 6.3, 6.5, 6.5 and 6.1 MET (p=0.44), respectively., Conclusion: The METRO study showed that significant alteration in medical treatment during cardiac rehabilitation programs could take part in improving physical capacity., Competing Interests: Conflict of interest None, (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO 2 peak when compared with no CR., Objective: To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR., Methods: Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis. The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio., Results: The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO 2 peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO 2 peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO 2 peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants., Conclusion: From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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

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.

Aims: Socioeconomic status is a strong predictor of cardiovascular health. The aim of this study was to describe the immediate and long-term effects of cardiac rehabilitation (CR) across socioeconomic strata in elderly cardiac patients in Europe., Methods and Results: The observational EU-CaRE study is a prospective study with eight CR sites in seven European countries. Patients ≥65 years with coronary heart disease or heart valve surgery participating in CR were consecutively included. Data were obtained at baseline, end of CR and at one-year follow up. Educational level as a marker for socioeconomic status was divided into basic, intermediate and high. The primary endpoint was exercise capacity (peak oxygen consumption (VO2peak)). Secondary endpoints were cardiovascular risk factors, medical treatment and scores for depression, anxiety and quality of life (QoL). A total of 1626 patients were included; 28% had basic, 48% intermediate and 24% high education. A total of 1515 and 1448 patients were available for follow-up analyses at end of CR and one-year, respectively. Patients with basic education were older and more often female. At baseline we found a socioeconomic gradient in VO2peak, lifestyle-related cardiovascular risk factors, anxiety, depression and QoL. The socioeconomic gap in VO2peak increased following CR (p for interaction <0.001). The socioeconomic gap in secondary outcomes was unaffected by CR. The use of evidence-based medication was good in all socioeconomic groups., Conclusions: We found a strong socioeconomic gradient in VO2peak and cardiovascular risk factors that was unaffected or worsened after CR. To address inequity in cardiovascular health, the individual adaption of CR according to socioeconomic needs should be considered., (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., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

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

Aims: Cardiac rehabilitation (CR) is strongly recommended but participation of elderly patients has not been well characterized. This study aims to analyse current rates and determinants of CR referral, participation, adherence, and compliance in a contemporary European cohort of elderly patients., Methods and Results: The EU-CaRE observational study included data from consecutive patients aged ≥ 65 with acute coronary syndrome, revascularization, stable coronary artery disease, or heart valve replacement, recruited in eight European centres. Rates and factors determining offering, participation, and adherence to CR programmes and compliance with training sessions were studied across centres, under consideration of extensive-outpatient vs. intensive-inpatient programmes. Three thousand, four hundred, and seventy-one patients were included in the offering and participation analysis. Cardiac rehabilitation was offered to 80.8% of eligible patients, formal contraindications being the main reason for not offering CR. Mean participation was 68.0%, with perceived lack of usefulness and transport issues being principal barriers. Mean adherence to CR programmes of participants in the EU-CaRE study (n = 1663) was 90.3%, with hospitalization/physical impairment as principal causes of dropout. Mean compliance with training sessions was 86.1%. Older age was related to lower offering and participation, and comorbidity was associated with lower offering, participation, adherence, and compliance. Intensive-inpatient programmes displayed higher adherence (97.1% vs. 85.9%, P < 0.001) and compliance (full compliance: 66.0% vs. 38.8%, P < 0.001) than extensive-outpatient programmes., Conclusion: In this European cohort of elderly patients, older age and comorbidity tackled patients' referral and uptake of CR programmes. Intensive-inpatient CR programmes showed higher completion than extensive-outpatient CR programmes, suggesting this formula could suit some elderly patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Exercise training (ET) increases exercise tolerance, improves quality of life and likely the prognosis in heart failure patients with reduced ejection fraction (HFrEF). However, some patients do not improve, whereas exercise training response is still poorly understood. Measurement of cardiac output during cardiopulmonary exercise test might allow ET response assessment according to the different steps of oxygen transport., Methods: Fifty-three patients with HFrEF (24 with ischemic cardiomyopathy (ICM) and 29 with dilated cardiomyopathy (DCM) had an aerobic ET. Before and after ET program, peak oxygen consumption (VO 2peak ) and cardiac output using thoracic impedancemetry were measured. Oxygen convection (QO 2peak ) and diffusion (DO 2 ) were calculated using Fick's principle and Fick's simplified law. Patients were considered as responders if the gain was superior to 10%., Results: We found 55% VO 2peak responders, 62% QO 2peak responders and 56% DO 2 responders. Four patients did not have any response. None baseline predictive factor for VO 2peak response was found. QO 2peak response was related to exercise stroke volume (r = 0.84), cardiac power (r = 0.83) and systemic vascular resistance (SVR peak ) (r = -0.42) responses. Cardiac power response was higher in patients with ICM than in those with DCM (p < 0.05). Predictors of QO2 peak response were low baseline exercise stroke volume and ICM etiology. Predictors of DO 2 response were higher baseline blood creatinine and prolonged training., Conclusion: The analysis of the response to training in patients with HFrEF according to the different steps of oxygen transport revealed different phenotypes on VO 2peak responses, namely responses in either oxygen convection and/or diffusion., Competing Interests: Declaration of Competing Interest None, (Copyright © 2021 Elsevier B.V. All rights reserved.)

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

Background: The effectiveness of transitional care services for patients discharged from hospital after acute heart failure is challenging, especially in terms of reducing subsequent heart failure hospitalizations. The increased adoption of smartphone applications in society offers a new opportunity to interact with patients to avoid rehospitalization. Thus, electronic health (e-health) can enhance the impact of existing therapeutic education programmes., Aims: To determine the prevalence of smartphone use among patients with chronic heart failure, and to assess the epidemiological characteristics and therapeutic management of these patients, with a broader aim of developing smartphone-based therapeutic education programmes for patients., Methods: The French Observatoire français de l'insuffisance cardiaque et du sel (OFICSel) registry was conducted in 2017 by 300 cardiologists, and included both inpatients and outpatients who had been hospitalized for heart failure at least once in the previous 5 years. Data collection included demographic and heart failure-related variables, which were provided by the cardiologist and by the patient via a questionnaire., Results: Among the 2822 patients included, 2517 completed the questionnaire. Of this total, 907 patients (36%) were smartphone users. Compared with non-users, smartphone users were younger, were more frequently men, more frequently lived in cities, had a higher educational level and were more frequently professionally active. Smartphone users less frequently had diabetes, hypertension, atrial fibrillation or ischaemic cardiopathy. Only 22% of patients were actively participating in a therapeutic education programme., Conclusion: Smartphones were used by more than one-third of patients with heart failure in France in 2017, underscoring the feasibility of developing a smartphone application to deliver therapeutic education to the population with chronic heart failure., (Copyright © 2020. Published by Elsevier Masson SAS.)

Objectives: Guidelines for exercise intensity prescription in Cardiac Rehabilitation (CR) are inconsistent and have recently been discussed controversially. We aimed (1) to compare training intensities between European CR centres and (2) to assess associations between training intensity and improvement in peak oxygen consumption ([Formula: see text]O2) in elderly CR patients., Methods: Peak [Formula: see text]O2, heart rate and work rate (WR) at the first and second ventilatory thresholds were measured at start of CR. Training heart rate was measured during three sessions spread over the CR. Multivariate models were used to compare training characteristics between centres and to assess the effect of training intensity on change in peak [Formula: see text]O2., Results: Training intensity was measured in 1011 out of 1633 EU-CaRE patients in 7 of 8 centers and the first and secondary ventilatory threshold were identified in 1166 and 817 patients, respectively. The first and second ventilatory threshold were found at 44% (SD 16%) and 78% (SD 9%) of peak WR and 78% (SD 9%) and 89% (SD 5%) of peak heart rate, respectively. Training intensity and session duration varied significantly between centres but change in peak [Formula: see text]O2 over CR did not. Training above the first individual threshold (β 0.62, 95% confidence interval [0.25-1.02]) and increase in training volume per hour (β 0.06, 95%CI [0.01-0.12]) were associated with a higher change in peak [Formula: see text]O2., Conclusion: While training intensity and volume varied greatly amongst current European CR programs, changes in peak [Formula: see text]O2 were similar and the effect of training characteristics on these changes were small., Competing Interests: The authors have read the journal's policy and the authors of this manuscript have the following 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, personal 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 are paid employees of Diagram B.V. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare. All other authors have no Conflict of Interest to declare.

Aims: The European Cardiac Rehabilitation in the Elderly (EU-CaRE) HORIZON 2020 project compares the sustainable effects of cardiac rehabilitation (CR) in elderly patients., Methods and Results: A total of 1633 patients with coronary artery disease (CAD) or heart valve replacement (HVR), with or without revascularization, aged 65 or above, who participated in CR were included. Peak oxygen uptake (VO 2peak ), smoking, body mass index, diet, physical activity, serum lipids, psychological distress and medication were assessed before and after CR (T0 and T1) and after 12 months (T2). Patients undergoing coronary artery bypass surgery or surgical HVR had lower VO 2peak at T0 and a greater increase to T1 and T2 (2.8 and 4.4 ml/kg/min, respectively) than CAD patients undergoing percutaneous or no revascularization (1.6 and 1.4 ml/kg/min, respectively). After multivariable adjustment, earlier CR uptake was associated with greater improvements in VO 2peak . The proportion of CAD patients with three or more uncontrolled risk factors declined from 58.4% at T0 to 40.1% at T2 ( p  < 0.0001). Psychological distress scores all improved and adherence to medication was overall good at all sites. There were significant differences in risk factor burden across sites, but no CR program was superior to others., Conclusions: The outcomes of VO 2peak in CR programs across Europe seemed mainly determined by timing of uptake and were maintained or even further improved at 1-year follow-up. Despite significant improvements, 40.1% of CAD patients still had three or more risk factors not at target after 1 year. Differences across sites could not be ascribed to characteristics of the CR programs offered.

Aims: Functional capacity is an important endpoint for therapies oriented to older adults with cardiovascular diseases. The literature on predictors of exercise capacity is sparse in the elderly population. In a longitudinal European study on effectiveness of cardiac rehabilitation of seven European countries in elderly (>65 years) coronary artery disease or valvular heart disease patients, predictors for baseline exercise capacity were determined, and reference ranges for elderly cardiac patients provided., Methods: Mixed models were performed in 1282 patients (mean age 72.9 ± 5.4 years, 79% male) for peak oxygen consumption relative to weight (peak VO 2 ; ml/kg per min) with centre as random factor and patient anthropometric, demographic, social, psychological and nutritional parameters, as well as disease aetiology, procedure, comorbidities and cardiovascular risk factors as fixed factors., Results: The most important predictors for low peak VO 2 were coronary artery bypass grafting or valve surgery, low resting forced expiratory volume, reduced left ventricular ejection fraction, nephropathy and peripheral arterial disease. Each cumulative comorbidity or cardiovascular risk factors reduced exercise capacity by 1.7 ml/kg per min and 1.1 ml/kg per min, respectively. Males had a higher peak VO 2 per body mass but not per lean mass. Haemoglobin was significantly linked to peak VO 2 in both surgery and non-surgery patients., Conclusions: Surgical procedures, cumulative comorbidities and cardiovascular risk factors were the factors with the strongest relation to reduced exercise capacity in the elderly. Expression of peak VO 2 per lean mass rather than body mass allows a more appropriate comparison between sexes. Haemoglobin is strongly related to peak VO 2 and should be considered in studies assessing exercise capacity, especially in studies on patients after cardiac surgery.

Background: The prevalence of patients with concomitant cardiovascular disease and diabetes mellitus (DM) is increasing rapidly. We aimed to compare the effectiveness of current cardiac rehabilitation (CR) programs across seven European countries between elderly cardiac patients with and without DM., Methods: 1633 acute and chronic coronary artery disease (CAD) patients and patients after valve intervention with an age 65 or above who participated in comprehensive CR (3 weeks to 3 months, depending on centre) were included. Peak oxygen uptake (VO 2 peak), body mass index, resting systolic blood pressure, low-density lipoprotein-cholesterol (LDL-C), and glycated haemoglobin (HbA1c) were assessed before start of CR, at termination of CR (variable time point), and 12 months after start of CR, with no intervention after CR. Baseline values and changes from baseline to 12-month follow-up were compared between patients with and without DM using mixed models, and mortality and hospitalisation rates using logistic regression., Results: 430 (26.3%) patients had DM. Patients with DM had more body fat, lower educational level, more comorbidities, cardiovascular risk factors, and more advanced CAD. Both groups increased their VO 2 peak over the study period but with a significantly lower improvement from baseline to follow-up in patients with DM. In the DM group, change in HbA1c was associated with weight change but not with change in absolute VO 2 peak. 12-month cardiac mortality was higher in patients with DM., Conclusions: While immediate improvements in VO 2 peak after CR in elderly patients with and without DM were similar, 12-month maintenance of this improvement was inferior in patients with DM, possibly related to disease progression. Glycemic control was less favourable in diabetic patients needing insulin in the short- and long-term. Since glycemic control was only related to weight loss but not to increase in exercise capacity, this highlights the importance of weight loss in obese DM patients during CR. Trial registration NTR5306 at trialregister.nl; trial registered 07/16/2015; https://www.trialregister.nl/trial/5166.

Physical activity is important in heart failure to improve functional capacity, quality of life and prognosis, and is a class IA recommendation in the European Society of Cardiology guidelines (Ponikowski et al., 2016). The benefits of exercise training are widely recognized. Cardiac rehabilitation centres offer tailored exercise training to patients with heart failure, as part of specialized multidisciplinary care, alongside pharmacological treatment optimization and patient education. After cardiac rehabilitation, maintenance of regular physical activity long term is essential, as the benefits of exercise training vanish within a few weeks. Unfortunately, only 10% of patients benefit from a cardiac rehabilitation programme after hospitalization for acute heart failure, and the majority of patients do not pursue long-term physical activity. In this paper, two Working Groups of the French Society of Cardiology (the heart failure group [Groupe Insuffisance Cardiaque et Cardiomyopathies; GICC] and the cardiac rehabilitation group [Groupe Exercice Réadaptation Sport et Prévention; GERS-P]) discuss the obstacles to broader access to cardiac rehabilitation centres, and propose ways to improve the diffusion of cardiac rehabilitation programmes and encourage long-term adherence to physical activity., (Copyright © 2019 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background: Cardiac rehabilitation is strongly recommended in patients after acute myocardial infarction., Aims: To assess cardiac rehabilitation prescription after acute myocardial infarction according to predicted risk, and its association with 1-year mortality, using the FAST-MI registries., Methods: We used data from three 1-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 13130 patients with acute myocardial infarction admitted to coronary or intensive care units. Atherothrombotic risk stratification was performed using the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P). Patients were classified into three categories: Group 1 (low risk; no or one risk indicator; score of 0 or 1); Group 2 (intermediate risk; two risk indicators; score of 2); and Group 3 (high risk; at least three risk indicators; score of≥3)., Results: Among the 12291 patients, cardiac rehabilitation prescription was 43.6% (49.9% in Group 1; 43.0% in Group 2; 35.2% in Group 3). Using Cox multivariable analysis, cardiac rehabilitation prescription was associated with lower mortality at 1 year in the overall population (3.8% vs. 8.2%; hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.61-0.85; P<0.001). Cardiac rehabilitation was associated with improved 1-year mortality, with homogeneous relative risk reductions in low- and intermediate-risk categories (HR 0.70, 95% CI 0.51-0.94) compared with high-risk patients (HR 0.72, 95% CI 0.59-0.88). In absolute terms, however, mortality decrease associated with cardiac rehabilitation was positively correlated with risk level (Group 1, 0.9% vs. 2.4%; Group 2, 3.0% vs. 4.2%; Group 3, 10.5% vs. 17.3%)., Conclusion: Cardiac rehabilitation prescription was inversely correlated with patient risk. A positive association between cardiac rehabilitation and 1-year survival after acute myocardial infarction was present whatever the risk level, but the greatest mortality reduction was observed in high-risk patients., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: Due to the progressive deconditioning, comorbidities and higher complication rates, elderly patients are in particular need of cardiac rehabilitation. We compared elderly patients (65+ years old) participating in cardiac rehabilitation, focusing on baseline characteristics, risk factor control and functional assessment., Methods: The EU-CaRE study is a prospective study comparing cardiac rehabilitation in eight centres across Western Europe. Consecutive patients with acute coronary syndrome, stable coronary artery disease and heart valve replacement undergoing cardiac rehabilitation were included., Results: Of 1 633 patients (median age 72 years) participating, 54% had acute coronary syndrome, 33% had stable coronary artery disease and 13% followed valve replacement. Fifty-five per cent had undergone percutaneous coronary intervention and 29% coronary artery bypass grafting. Characteristics varied across centres: 23% (17-27%) were women, 4% (0-12%) were of non-European origin and 16% (4-32%) were living alone. Median time from index event to start of cardiac rehabilitation varied from 11 to 49 days ( p  < 0.001). Mean VO 2peak was relatively low (16 mL/kg per min) and varied significantly between the participating centres, largely unaffected by multivariable adjustment. Overall patients received guideline recommended treatment: 93% (87-97%) were on a statin and 70% (55-85%) an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. However, risk factor control was inadequate: 58% had three or more risk factors not controlled., Conclusion: EU-CaRE provides a snapshot of the elderly population with heart disease participating in cardiac rehabilitation across countries in Western Europe. Risk factors and exercise capacity indicate the continued need for cardiac rehabilitation in these patients. Of concern, the lag-time to start of cardiac rehabilitation needs improvement in many centres.

Background: Full secondary prevention medication regimen is often under-prescribed after acute myocardial infarction., Design: The purpose of this study was to analyse the relationship between prescription of appropriate secondary prevention treatment at discharge and long-term clinical outcomes according to risk level defined by the Thrombolysis In Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS-2P) after acute myocardial infarction., Methods: We used data from the 2010 French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI) registry, including 4169 consecutive acute myocardial infarction patients admitted to cardiac intensive care units in France. Level of risk was stratified in three groups using the TRS-2P score: group 1 (low-risk; TRS-2P=0/1); group 2 (intermediate-risk; TRS-2P=2); and group 3 (high-risk; TRS-2P≥3). Appropriate secondary prevention treatment was defined according to the latest guidelines (dual antiplatelet therapy and moderate/high dose statins for all; new-P2Y12 inhibitors, angiotensin-converting-enzyme inhibitor/angiotensin-receptor-blockers and beta-blockers as indicated)., Results: Prevalence of groups 1, 2 and 3 was 46%, 25% and 29% respectively. Appropriate secondary prevention treatment at discharge was used in 39.5%, 37% and 28% of each group, respectively. After multivariate adjustment, evidence-based treatments at discharge were associated with lower rates of major adverse cardiovascular events (death, re-myocardial infarction or stroke) at five years especially in high-risk patients: hazard ratio = 0.82 (95% confidence interval: 0.59-1.12, p = 0.21) in group 1, 0.74 (0.54-1.01; p = 0.06) in group 2, and 0.64 (0.52-0.79, p < 0.001) in group 3., Conclusions: Use of appropriate secondary prevention treatment at discharge was inversely correlated with patient risk. The increased hazard related to lack of prescription of recommended medications was much larger in high-risk patients. Specific efforts should be directed at better prescription of recommended treatment, particularly in high-risk patients.

The exercise test is performed routinely in cardiology; its main indication is the diagnosis of myocardial ischemia, evaluated along with the subject's pretest probability and cardiovascular risk level. Other criteria, such as analysis of repolarization, must be taken into consideration during the interpretation of an exercise test, to improve its predictive value. An exercise test is also indicated for many other cardiac diseases (e.g. rhythm and conduction disorders, severe asymptomatic aortic stenosis, hypertrophic cardiomyopathy, peripheral artery disease, hypertension). Moreover, an exercise test may be indicated for specific populations (women, the elderly, patients with diabetes mellitus, patients in a preoperative context, asymptomatic patients and patients with congenital heart defects). Some cardiac diseases (such as chronic heart failure or arterial pulmonary hypertension) require a cardiopulmonary exercise test. Finally, an exercise test or a cardiopulmonary exercise test is indicated to prescribe a cardiac rehabilitation programme, adapted to the patient., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

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: Follow-up care and rehabilitation services [soins de suite et réadaptation (SSR)], especially cardiac rehabilitation (CR), constitute a key stage for patients who have had an acute myocardial infarction (AMI)., Aims: To study admission to SSR, especially for CR, among patients hospitalized for AMI in France in 2014, and its temporal trend between 2010 and 2014., Methods: We used the French National Hospital Database to select patients hospitalized with a main diagnosis of AMI (identified by ICD-10 codes I21 to I23) in the first semester of each year from 2010 to 2014. We then searched for rehabilitation admission in the 6 months after the index hospitalization. We calculated age-standardized rates of admission for CR and for other rehabilitation purposes. The average annual percentage change in admission rates was analysed by Poisson regression., Results: In 2014, among the 29,424 patients hospitalized for an AMI in the first 6 months of the year, 10,873 (36.9%) were subsequently admitted to SSR units. More specifically, the age-standardized rate of patients hospitalized in CR units reached 28.4% (n=8380), and was greater among men (29.6%, n=6707) than among women (24.9%, n=1673). Between 2010 and 2014, rates of admission for CR increased by 5.0% per year in men and 6.6% per year in women. We found a great increase in ambulatory CR management, which accounted for half of the admissions for CR in 2014., Conclusions: Favourable trends in rates of admission for CR were reported in both sexes and at all ages, except the oldest. The increase in ambulatory management contributed to these changes. Despite these trends, rates of admission for CR after AMI remain low., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Sleep-related disordered breathing is common in patients with chronic heart failure., Aim: To assess the efficacy of short-term nocturnal ventilatory therapy combined with exercise training (V+ET) compared with exercise training alone (ET) in patients with chronic heart failure with sleep-disordered breathing., Methods: Patients in New York Heart Association functional class II-IIIb, with an apnoea-hypopnoea index (AHI)>15/h, and enrolled in a cardiac rehabilitation programme, were centrally randomized to V+ET or ET. Subjects were classified as having obstructive sleep apnoea (OSA) (n=49) or central sleep apnoea (CSA)/mixed (n=69). The primary outcome was the change in the 10-second average oxygen consumption at maximum exercise (VO 2peak ) at the end of the cardiac rehabilitation programme., Results: Fifty-eight patients were randomized to V+ET and 60 patients to ET. The median increase in VO 2peak was 15% [interquartile range 6-36%] in the V+ET group and 16% [0-31%] in the ET group (P=0.34). AHI decreased in both groups, but significantly more in the V+ET group (P=0.006). The decrease in the ventilatory efficiency (VE/VCO 2 ) slope was not statistically different between the two-randomization groups (P=0.10). In subjects with CSA, the VE/VCO 2 slope decreased significantly more in the V+ET group (P=0.03), while there was no difference between the two-randomization groups in subjects with OSA (P=0.75). Six cardiovascular events occurred in patients with OSA (all randomized to the ET group); in subjects with CSA, two events occurred in the V+ET group and three in the ET group., Conclusions: Short-term nocturnal ventilation combined with exercise training does not increase the exercise capacity of patients with chronic heart failure., (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.

Background Exercise training as part of a comprehensive cardiac rehabilitation is recommended for patients with cardiac heart failure. It is a valuable method for the improvement of exercise tolerance. Some studies reported a similar improvement with quadricipital electrical myostimulation, but the effect of combined exercise training and electrical myostimulation in cardiac heart failure has not been yet evaluated in a large prospective multicentre study. Purpose The aim of this study was to determine whether the addition of low frequency electrical myostimulation to exercise training may improve exercise capacity and/or muscular strength in cardiac heart failure patients. Methods Ninety-one patients were included (mean age: 58 ± 9 years; New York Heart Association II/III: 52/48%, left ventricular ejection fraction: 30 ± 7%) in a prospective French study. The patients were randomised into two groups: 41 patients in exercise training and 50 in exercise training + electrical myostimulation. All patients underwent 20 exercise training sessions. In addition, in the exercise training + electrical myostimulation group, patients underwent 20 low frequency (10 Hz) quadricipital electrical myostimulation sessions. Each patient underwent a cardiopulmonary exercise test, a six-minute walk test, a muscular function evaluation and a quality of life questionnaire, before and at the end of the study. Results A significant improvement of exercise capacity (Δ peak oxygen uptake+15% in exercise training group and +14% in exercise training + electrical myostimulation group) and of quality of life was observed in both groups without statistically significant differences between the two groups. Mean creatine kinase level increased in the exercise training group whereas it remained stable in the combined group. Conclusions This prospective multicentre study shows that electrical myostimulation on top of exercise training does not demonstrate any significant additional improvement in exercise capacity in cardiac heart failure patients.

Frailty is a geriatric syndrome characterised by a vulnerability status associated with declining function of multiple physiological systems and loss of physiological reserves. Two main models of frailty have been advanced: the phenotypic model (primary frailty) or deficits accumulation model (secondary frailty), and different instruments have been proposed and validated to measure frailty. However measured, frailty correlates to medical outcomes in the elderly, and has been shown to have prognostic value for patients in different clinical settings, such as in patients with coronary artery disease, after cardiac surgery or transvalvular aortic valve replacement, in patients with chronic heart failure or after left ventricular assist device implantation. The prevalence, clinical and prognostic relevance of frailty in a cardiac rehabilitation setting has not yet been well characterised, despite the increasing frequency of elderly patients in cardiac rehabilitation, where frailty is likely to influence the onset, type and intensity of the exercise training programme and the design of tailored rehabilitative interventions for these patients. Therefore, we need to start looking for frailty in elderly patients entering cardiac rehabilitation programmes and become more familiar with some of the tools to recognise and evaluate the severity of this condition. Furthermore, we need to better understand whether exercise-based cardiac rehabilitation may change the course and the prognosis of frailty in cardiovascular patients.

Background: Return to work (RTW) after acute coronary syndrome (ACS) is an important issue for the patient's future., Aims: The study aim was to determine whether RTW practice complies with guidelines or is delayed by failure in patient management. We analysed the factors influencing RTW beyond the 90-day period recommended by guidelines., Methods: We conducted a survey of 216 self-employed workers admitted to the hospital for ACS using self-report questionnaires and medical examination. Factors influencing RTW, occupational and cardiac features, and recall and source of medical information were investigated., Results: Ninety-three of 216 patients did not return to work by 90 days, despite good cardiac performance in 30 cases (32 %). The mean sick leave duration was 93.3±103.7 days. Advice concerning return to work was completely missing for 44 % of patients. Cardiac performance was independent of sick leave duration, but was correlated with the likelihood of RTW (P<0.001). Patients assimilated about 70 % of the medical information they were provided, but only 53 % of work-related information. Recall of work-related information was better among patients admitted to a rehabilitation facility (65 %) compared to those who did not receive rehabilitation (P<0.05)., Conclusion: Cardiologists should assess the patient's cardiac performance within 2 months after ACS. Patient management should also include cardiac rehabilitation or therapeutic education toward improving information recall., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Large subsets of patients admitted in cardiac rehabilitation centers are having a pacemaker, cardiac resynchronization (CRT) or implantable cardiac defibrillator (ICD). Cardiac rehabilitation for patients, mostly with heart failure, with implanted electronic devices as pacemakers or ICD is a unique opportunity not only to optimize the medical treatment, to increase their exercise capacity and improves their clinical condition but also to supervise the correct functioning of the device. CRT reduces clinical symptoms and increases slightly the exercise capacity. But in these patients, the clinical improvements are likely to be explained by both the enhancement of cardiac function induced by the device and by the improved peripheral (muscular and vascular) and cardiac effects of exercise. The additional expected gain by exercise in this population is between 14 to 25%. In patients implanted with an ICD, exercise training is safe, without increasing shocks or anti-tachycardia pacing therapy. The comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves exercise capacity, quality of life, general and mental health. Nevertheless, further large scale studies was needed to evaluate the most appropriate management and demonstrate definitively the role of cardiac rehabilitation in this particular group of patients.