Ana Abreu

Challenges in secondary prevention of cardiovascular diseases: A review of the current practice

With the changing demography of populations and increasing prevalence of co-morbidity, frail patients and more complex cardiac conditions, the modern medicine is facing novel challenges leading to rapid innovation where evidence and experiences are lacking. This scenario is also evident in cardiovascular disease prevention, which continuously needs to accommodate its ever changing strategies, settings, and goals. The present paper summarises actual challenges of secondary prevention, and discusses how this intervention should not only be effective but also efficient. By this way the paper tries to bridge the gaps between research and real-world findings and thereby may find ways to improve standard care.

Frailty and cardiac rehabilitation: A call to action from the EAPC Cardiac Rehabilitation Section

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.

European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS)

EHRA Scientific Committee Task Force: Bulent Gorenek (chair)*, Antonio Pelliccia (co-chair), Emelia J. Benjamin, Giuseppe Boriani, Harry J. Crijns, Richard I. Fogel, Isabelle C. Van Gelder, Martin Halle, Gulmira Kudaiberdieva, Deirdre A. Lane, Torben Bjerregaard Larsen, Gregory Y. H. Lip, Maja-Lisa Løchen, Francisco Marin, Josef Niebauer, Prashanthan Sanders, Lale Tokgozoglu, Marc A. Vos and David R. Van Wagoner Document reviewers: Laurent Fauchier, Irina Savelieva, Andreas Goette, Stefan Agewall, Chern-En Chiang, Márcio Figueiredo, Martin Stiles, Timm Dickfeld, Kristen Patton, Massimo Piepoli, Ugo Corra, Pedro Manuel Marques-Vidal, Pompilio Faggiano, Jean-Paul Schmid and Ana Abreu Eskisehir Osmangazi University, Eskisehir, Turkey; Institute of Sport Medicine and Science, Rome, Italy; Framingham, MA, USA; University of Modena and Reggio Emilia, Modena Italy; Maastricht University Medical Centre, Maastricht, The Netherlands; St Vincent Medical Group, Indiana, USA; University Medical Center Groningen, Groningen, The Netherlands; Prevention and Sports Medicine, Technical University Munich, München, Germany; Adana, Turkey; University of Birmingham, Birmingham, UK; Aalborg University Hospital, Aalborg, Denmark; UiT The Arctic University of Norway, Tromso, Norway; Mary MacKillop Institute for Health Research, Centre for Research Excellence to Reduce Inequality in Heart Disease, Australian Catholic University, Melbourne, Australia; Hospital Universitario Virgen De La Arrixaca, Murcia, Spain; Paracelsus Medical University Salzburg, Salzburg, Austria; Royal Adelaide Hospital, Adelaide, South Australia;Hacettepe University, Ankara, Turkey; UMC Utrecht, Utrecht, The Netherlands; Cleveland Clinc Foundation, Cleveland, OH, USA; Centre Hospitalier Universitaire Trousseau, Tours, France; St George’s University of London, London, UK; St. Vincenz-Krankenhaus Gmbh Paderborn, Germany; Oslo University Hospital Ulleval, Ullevål, Norway; Taipei Veterans General Hospital, Taipei, Taiwan; State University of Campinas, San Paolo, Brazil; Waikato Hospital, Hamilton, New Zealand; Baltimore, MD, USA; University of Washington, Seattle, USA; Polichirurgico Hospital G. Da Saliceto, Romagna, Italy; Irccs Rehabilitation Medical Center, Veruno, Italy; University Hospital of Lausanne, Lausanne, Switzerland; Unita’ Operativa di Policardiografia, Brescia, Italy; Spital Tiefenau, Bern, Switzerland; and Hospital de Santa Marta, Lisboa, Portugal

The European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool: A digital training and decision support system for optimized exercise prescription in cardiovascular disease. Concept, definitions and construction methodology

Background Exercise rehabilitation is highly recommended by current guidelines on prevention of cardiovascular disease, but its implementation is still poor. Many clinicians experience difficulties in prescribing exercise in the presence of different concomitant cardiovascular diseases and risk factors within the same patient. It was aimed to develop a digital training and decision support system for exercise prescription in cardiovascular disease patients in clinical practice: the European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool. Methods EXPERT working group members were requested to define (a) diagnostic criteria for specific cardiovascular diseases, cardiovascular disease risk factors, and other chronic non-cardiovascular conditions, (b) primary goals of exercise intervention, (c) disease-specific prescription of exercise training (intensity, frequency, volume, type, session and programme duration), and (d) exercise training safety advices. The impact of exercise tolerance, common cardiovascular medications and adverse events during exercise testing were further taken into account for optimized exercise prescription. Results Exercise training recommendations and safety advices were formulated for 10 cardiovascular diseases, five cardiovascular disease risk factors (type 1 and 2 diabetes, obesity, hypertension, hypercholesterolaemia), and three common chronic non-cardiovascular conditions (lung and renal failure and sarcopaenia), but also accounted for baseline exercise tolerance, common cardiovascular medications and occurrence of adverse events during exercise testing. An algorithm, supported by an interactive tool, was constructed based on these data. This training and decision support system automatically provides an exercise prescription according to the variables provided. Conclusion This digital training and decision support system may contribute in overcoming barriers in exercise implementation in common cardiovascular diseases.

Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry

AIM Results from EuroCaReD study should serve as a benchmark to improve guideline adherence and treatment quality of cardiac rehabilitation (CR) in Europe. METHODS AND RESULTS Data from 2.054 CR patients in 12 European countries were derived from 69 centres. 76% were male. Indication for CR differed between countries being predominantly ACS in Switzerland (79%), Portugal (62%) and Germany (61%), elective PCI in Greece (37%), Austria (36%) and Spain (32%), and CABG in Croatia and Russia (36%). A minority of patients presented with chronic heart failure (4%). At CR start, most patients already were under medication according to current guidelines for the treatment of CV risk factors. A wide range of CR programme designs was found (duration 3 to 24weeks; total number of sessions 30 to 196). Patient programme adherence after admission was high (85%). With reservations that eCRF follow-up data exchange remained incomplete, patient CV risk profiles experienced only small improvements. CR success as defined by an increase of exercise capacity >25W was significantly higher in young patients and those who were employed. Results differed by countries. After CR only 9% of patients were admitted to a structured post-CR programme. CONCLUSIONS Clinical characteristics of CR patients, indications and programmes in Europe are different. Guideline adherence is poor. Thus, patient selection and CR programme designs should become more evidence-based. Routine eCRF documentation of CR results throughout European countries was not sufficient in its first application because of incomplete data exchange. Therefore better adherence of CR centres to minimal routine clinical standards is requested.

Exercise Prescription in Patients with Different Combinations of Cardiovascular Disease Risk Factors: A Consensus Statement from the EXPERT Working Group

Whereas exercise training is key in the management of patients with cardiovascular disease (CVD) risk (obesity, diabetes, dyslipidaemia, hypertension), clinicians experience difficulties in how to optimally prescribe exercise in patients with different CVD risk factors. Therefore, a consensus statement for state-of-the-art exercise prescription in patients with combinations of CVD risk factors as integrated into a digital training and decision support system (the EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool) needed to be established. EXPERT working group members systematically reviewed the literature for meta-analyses, systematic reviews and/or clinical studies addressing exercise prescriptions in specific CVD risk factors and formulated exercise recommendations (exercise training intensity, frequency, volume and type, session and programme duration) and exercise safety precautions, for obesity, arterial hypertension, type 1 and 2 diabetes, and dyslipidaemia. The impact of physical fitness, CVD risk altering medications and adverse events during exercise testing was further taken into account to fine-tune this exercise prescription. An algorithm, supported by the interactive EXPERT tool, was developed by Hasselt University based on these data. Specific exercise recommendations were formulated with the aim to decrease adipose tissue mass, improve glycaemic control and blood lipid profile, and lower blood pressure. The impact of medications to improve CVD risk, adverse events during exercise testing and physical fitness was also taken into account. Simulations were made of how the EXPERT tool provides exercise prescriptions according to the variables provided. In this paper, state-of-the-art exercise prescription to patients with combinations of CVD risk factors is formulated, and it is shown how the EXPERT tool may assist clinicians. This contributes to an appropriately tailored exercise regimen for every CVD risk patient.

Do clinicians prescribe exercise similarly in patients with different cardiovascular diseases? Findings from the EAPC EXPERT working group survey

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 (HRpeak)), 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 HRpeak), 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.

Cardiac Rehabilitation in Cardiac Valve Surgery Patients: Beyond Cost-Effectiveness

Life expectancy growth and progressively complex therapeutic technique development are increasing health costs, which reminds us that financial resources are not unlimited. The numbers of surgical and percutaneous procedures for valve replacement and repair have been sharply rising, demanding an emergent economic analysis of the preventive and therapeutic interventions involved. Nowadays, economic analysis of health-related interventions is considered an important tool for optimisation of resources and frequently requested as essential to prove the real impact of interventions. Cardiac rehabilitation (CR) programmes, in several studies and different realities, have been demonstrated to be cost-effective in myocardial infarction and heart failure, but this benefit is not transferable to heart valve surgery. Despite the European Society of Cardiology (ESC) and European Association of Preventive Cardiology (EAPC) recommendations, CR in cardiovascular disease and particularly in heart failure and valve disease, is markedly underused due to several barriers. Data regarding CR in valve disease are scarce, even though CR has long been recommended for all patients after heart valve surgery, especially for those with a post-operative course complicated by heart failure. Recently, a Cochrane systematic review demonstrated that exercise-based rehabilitation compared with no exercise for adults after heart valve surgery, with or without other interventions, may improve exercise capacity. The authors considered that, due to the lack of scientific evidence, further high quality randomised clinical trials are needed in order to assess the impact of exercise-based rehabilitation on patient-relevant outcomes, including mortality, quality of life and cost-effectiveness analysis. This last outcome, costeffectiveness, may be an important part of decision making, a reason why CR programme directors need to recognise and document the efficiency of their own programmes. Keeping in mind that economic health analyses are always complex and very dependent on the target patients, countries and considered costs, the results obtained might be different according to the evaluated specific settings, always needing critical evaluation. The present study approaches this very interesting and important topic, since the cost-effectiveness and cost-utility analysis of CR in myocardial infarction and in heart failure, as previously remarked, cannot be extrapolated to valve surgery patients. This is the first CR cost-utility analysis in patients undergoing heart valve surgery and followed for six months, from the CopenHeartVR trial. It has the strength to include patient randomisation instead of gathering a CR cohort without a control group and to provide rather complete information on multiple costs, namely those which are patient-borne (transportation expenses and time spent on transportation and CR).

Cardiac rehabilitation after acute myocardial infarction: Still insufficient referral!…

Article history: Received 20 February 2018 Accepted 9 March 2018 and PCI. They also had more in-hospital complications, NYHA class III or IV, depressed left ventricular systolic function (LVEF b30–35%) and smoking habit. Age N65 years and presence of comorbidities, like peripheral artery disease, cerebrovascular disease and previous myocardial infarction, were negative determinants for CR [7].

Obituary: Romualdo Belardinelli

Romy, a good friend to all of us, was a board member of the cardiac rehabilitation section of the European Association of Preventive Cardiology (EAPC) for many years and was a founding member of the Metabolic Exercise Cardiac Kidney Indexes (MECKI) score research initiative. His career was brilliant. Romy had a worldwide working experience and had many partnerships in Italy and abroad. He was a cardiopulmonary exercise testing (CPET) expert and his works on cardiac rehabilitation and exercise-induced cardiac ischaemia are still milestones. He was a research fellow at UCLA – Harbor Medical Center, Division of Cardiopulmonary Physiology and Critical Care Medicine, Torrance, CA, USA (Director Prof. K Wasserman) from 1991