Klaus-Peter Mellwig

Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular risk factors: recommendations from the EACPR (Part II)

In a previous paper, as the first of a series of three on the importance of characteristics and modalities of physical activity (PA) and exercise in the management of cardiovascular health within the general population, we concluded that, in the population at large, PA and aerobic exercise capacity clearly are inversely associated with increased cardiovascular disease risk and all-cause and cardiovascular mortality and that a dose–response curve on cardiovascular outcome has been demonstrated in most studies. More and more evidence is accumulated that engaging in regular PA and exercise interventions are essential components for reducing the severity of cardiovascular risk factors, such as obesity and abdominal fat, high BP, metabolic risk factors, and systemic inflammation. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit for each separate risk factor. The present paper, therefore, will review and make recommendations for PA and exercise training in the management of cardiovascular health in individuals with cardiovascular risk factors. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and individual members of the public. Based on previous and the current literature overviews, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and regarding appropriate risk evaluation during exercise in individuals with cardiovascular risk factors.

Sudden cardiac arrest in sports - need for uniform registration: A Position Paper from the Sport Cardiology Section of the European Association for Cardiovascular Prevention and Rehabilitation

There are large variations in the incidence, registration methods and reported causes of sudden cardiac arrest/sudden cardiac death (SCA/SCD) in competitive and recreational athletes. A crucial question is to which degree these variations are genuine or partly due to methodological incongruities. This paper discusses the uncertainties about available data and provides comprehensive suggestions for standard definitions and a guide for uniform registration parameters of SCA/SCD. The parameters include a definition of what constitutes an ‘athlete’, incidence calculations, enrolment of cases, the importance of gender, ethnicity and age of the athlete, as well as the type and level of sporting activity. A precise instruction for autopsy practice in the case of a SCD of athletes is given, including the role of molecular samples and evaluation of possible doping. Rational decisions about cardiac preparticipation screening and cardiac safety at sport facilities requires increased data quality concerning incidence, aetiology and management of SCA/SCD in sports. Uniform standard registration of SCA/SCD in athletes and leisure sportsmen would be a first step towards this goal.

Time for action regarding cardiovascular emergency care at sports arenas: a lesson from the arena study

Sudden cardiac arrest (SCA) is a common cause of death worldwide, most often triggered by ventricular fibrillation or asystole.1 The estimated prevalence in adult individuals (>35 years) is about 1 in 1000 per year in the USA.2 The major determinant for survival in such instances is the time to defibrillation,1 with the critical interval from the onset of a lethal arrhythmia to subsequent shock, to restore sinus rhythm, being 3–5 min.2 The efficacy of automated external defibrillators (AEDs) to prevent SCAs has been demonstrated in large public settings, such as airports and casinos3,4 and their implementation in other crowded venues has also been advocated.5 Large sports arenas typically gather several thousands of spectators, including adult and senior individuals with risk factor for cardiac events, repeatedly exposed to intense emotion.6 Although much attention is put on the athletes on the field, most cases of SCA in this setting will occur among spectators, and simply watching (emotional) sports events has been demonstrated to trigger cardiac events.7 The National Association of Emergency Medical Services Physicians (NAEMSP) recommends a medical action plan (MAP), including AEDs, as a blue-print for delivering emergency medical care at mass gathering events (e.g. more than 1000 persons).8 In the USA, moreover, AEDs are recommended in large sports facilities and gyms, and also in the school setting when the time to defibrillation exceeds the critical threshold of 5 min.9,10 On the contrary, no recommendations regarding acute cardiovascular care at sports arenas exist at present in Europe, and the current implementation of medical action plans (including AEDs) in major continental sports arenas is largely unknown. We sought to investigate the existing cardiovascular safety procedures of major sports arenas in Europe, with special attention to the availability of …

Position paper: proposal for a core curriculum for a European Sports Cardiology qualification.

Sports cardiology is a new and rapidly evolving subspecialty. It aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk. The European Society of Cardiology (ESC) advocates systematic preparticipation cardiovascular screening in an effort to identify competitive athletes at risk of exercise-related cardiovascular events and sudden cardiac death. However, the implementation of preparticipation screening is hindered because of lack of structured training and as a result lack of sufficient expertise in the field of sports cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which sports cardiology was incorporated within the topic ‘Rehabilitation and Exercise Physiology’. However, the exponential rise in knowledge and the growing demand for expertise in the field of sports cardiology dictates the need to systematically structure the knowledge base of sports cardiology into a detailed curriculum. We envisage that the curriculum would facilitate more uniform training and guideline implementation throughout Europe, and safeguard that evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities is performed by physicians with expertise in the field. The current manuscript provides a comprehensive curriculum for sports cardiology, which may serve as a framework upon which universities and national and international health authorities will develop the training, evaluation and accreditation in sports cardiology.

Heparin-induced extracorporeal low-density lipoprotein precipitation.

Abstract: Heparin‐induced extracorporeal low‐density lipoprotein (LDL) precipitation (HELP) is a selective and careful apheresis procedure. Through the application of heparin and lowering the pH value, lipoproteins and fibrinogen are reduced by 50–60%. In addition, adhesion molecules (ICAM‐1, VCAM‐1, p‐selectin) which play a key role in the development and progression of atherosclerosis, are also markedly reduced. A PET scan performed 20 h after LDL apheresis shows the improvement of coronary vasodilation capacity. This is supposed to be mainly due to the marked reduction of LDL cholesterol and fibrinogen with consecutive improvement of endothelial dysfunction and rheology.

Elektromyostimulation (EMS) bei kardiologischen Patienten

ZusammenfassungHintergrund:Die Vorstellung, dass moderates Ausdauertraining im Rahmen der Sekundärprävention die Prognose der chronischen Herzinsuffizienz (CHI) verbessert, wurde inzwischen hinreichend validiert. In der klinischen Routine bleiben jedoch erfahrungsgemäß nur wenige, gut geführte, hoch motivierte und zumeist jüngere Patienten einer dauerhaften sportlichen Begleittherapie zugänglich. Die eigenen Erfahrungen mit Ganzkörper-Elektromyostimulation (EMS-Training) an herzinsuffizienten Patienten zeigen ein bislang nicht erahntes Potential bei der Regeneration neurohumoraler, inflammatorischer und skelettmuskulärer Krankheitssymptome im Rahmen der Systemerkrankung CHI.Die mittels Spiroergometrie dosierte, möglichst tägliche dynamische Belastung ist adjuvanter Bestandteil der leitliniengerechten Therapie von Patienten mit chronischer Herzinsuffizienz. Die positive Beeinflussung klinischer Symptome und der Prognose ist durch Ergebnisse prospektiver, randomisierter Studien evidenzbasiert belegt. In der klinischen Praxis zeigt sich jedoch, dass die Erfolge nur bei intensiver Betreuung und Führung dieser Patienten erreicht werden. Einmal in das häusliche Umfeld gänzlich entlassen, hält die Mehrzahl der Patienten die tägliche Herausforderung einer selbstständigen, aktiven Form der körperlichen Belastung aus mentalen, physischen oder sozialen Gründen nicht aufrecht, und der Circulus vitiosus Systemerkrankung CHI manifestiert sich erneut.Patienten und Methodik:Vor diesem Hintergrund haben die Autoren in einer prospektiven Pilotstudie die Wirkung und die Akzeptanz der Ganzkörper-EMS, einer Art passiven, von der mentalen Einstellung und dem physischen Leistungsvermögen weitgehend unabhängigen Trainingsform, bei herzinsuffizienten Patienten untersucht.Ergebnisse:Eine bis zu 96%ige Steigerung der Sauerstoffaufnahme an der anaeroben Schwelle konnte nachgewiesen werden (VO2at 19,39 [± 5,3] ml/kg Körpergewicht [KG] vor Trainingsbeginn; VO2at 24,25 [±6,34] ml/kg KG am Ende der Trainingsphase; p < 0,05). Der diastolische Blutdruck sank signifikant (psyst < 0,05; pdiast < 0,001), der Muskelzuwachs betrug bis 14% bei Gewichtskonstanz. Die Trainingsmethode wurde zu 100% akzeptiert (keine Abbrecher), die Patienten gaben eine deutlich gesteigerte subjektive Leistungsfähigkeit an.Schlussfolgerung:Die Ergebnisse lassen ein erhebliches Potential in der kardiologischen Primär- und Sekundärrehabilitation erahnen, wobei gerade schwer eingeschränkte Patienten mit CHI überproportional profitierten.AbstractBackground:Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease.Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50–70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%.It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers.Patients and Methods:The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude.Results:An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO2at 19.39 [± 5.3] ml/kg vs. 24.25 [± 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved.Conclusion:The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.BACKGROUND Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers. PATIENTS AND METHODS The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude. RESULTS An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved. CONCLUSION The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Elektromyostimulation: Verbesserung von Lebensqualität, Sauerstoffaufnahme und linksventrikulärer Funktion bei chronischer Herzinsuffizienz

AIM OF THE STUDY Regular physical activity has found to be a strategy to increase exercise capacity in patients with chronic heart failure (CHF). Next to endurance training also electromyostimulation (EMS) of thigh and gluteal muscles results in an increased capacity in CHF patients. EMS therapy was either done by stimulating 8 major muscle groups involving also trunk and arm muscles (extended electromyostimulation (exEMS)) in comparison to EMS therapy limited to gluteal and leg muscles (limEMS). METHODS 31 individuals completed the EMS training program. Stable CHF patients (NYHA class II-III) received either exEMS (18 patients, 11 males, mean age 59.8±13.8 years) or limEMS (13 patients, 10 males, 63.6±9.4 years). Training was performed for 10 weeks twice weekly for 20 min, the level of daily activity remained unchanged. Effects on exercise capacity, left ventricular function (EF - ejection fraction) and QoL (quality of life) were evaluated. RESULTS QoL was found to be improved in all domains of the SF-36 questionnaire. In the exEMS group there was a significant improvement in the domain physical functioning (54.09±29.9 to 75.45±15.6, p=0.48) and emotional role (63.63±45.8 to 93.93±20.1 p=0.048). LimEMS group showed significant improvement in the domain vitality (37.5±6.9 to 52.8±12.5, p=0.02).There was a significant increase of oxygen uptake at aerobic threshold in all groups (exEMS: +29.6%, p<0.001; limEMS +17.5%, p<0.001). EF -increased from 36.94±8.6 to 42.36±9.1% (+14.7%, p=0.003) in the exEMS group (limEMS 37.7±3.6 to 40.3±5.9% [+6.9%, p=0.18]). CONCLUSION EMS contributes to an improved quality of life and can improve oxygen uptake and EF in CHF. It may be an alternative therapy in CHF patients who are otherwise unable to undertake conventional forms of exercise training.

Lipoprotein (a) and coronary heart disease - is there an efficient secondary prevention?

Lipoprotein (a) (Lp (a)) is one risk factor for the development of cardiovascular diseases. Several studies have shown that Lp (a) hyperlipoproteinaemia has a particular influence on the development of coronary heart disease (CHD). A retrospective single-centre observation study was performed to evaluate the effectiveness of lipid apheresis on the basis of consecutively performed percutaneous coronary interventions (PCI) in patients with high Lp (a) values and angiographically documented CHD. In 23 pts (male 18, age 60.04 ± 0.58 years) with angiographically documented CHD (first manifestation 48.00 ± 9.41 years), elevated LDL cholesterol (144.39 ± 92.01 mg/dl) and Lp (a) (133.04 ± 39.68 mg/dl), 49 PCI and 3 coronary artery bypass grafting (CABG) procedures had been performed prior to the initiation of lipid apheresis. Following the initiation of weekly lipid apheresis, LDL cholesterol was 99.43 ± 36.53 mg/dl and Lp (a) 91.13 ± 33.02 mg/dl. In a time interval of 59.87 ± 49.49 months (median 51.00, range 1–153 months) 15 pts did not require an additional PCI. In 8 pts (7 pts 3‑vessel disease, 1 pt 2‑vessel disease) 14 PCI – no CABG – were performed after 69.38 ± 71.67 months (median: 32.50, range 17–232 months). The incidence of PCI could thus be reduced by 71.43%.

Electromyostimulation (EMS) in cardiac patients. Will EMS training be helpful in secondary prevention

ZusammenfassungHintergrund:Die Vorstellung, dass moderates Ausdauertraining im Rahmen der Sekundärprävention die Prognose der chronischen Herzinsuffizienz (CHI) verbessert, wurde inzwischen hinreichend validiert. In der klinischen Routine bleiben jedoch erfahrungsgemäß nur wenige, gut geführte, hoch motivierte und zumeist jüngere Patienten einer dauerhaften sportlichen Begleittherapie zugänglich. Die eigenen Erfahrungen mit Ganzkörper-Elektromyostimulation (EMS-Training) an herzinsuffizienten Patienten zeigen ein bislang nicht erahntes Potential bei der Regeneration neurohumoraler, inflammatorischer und skelettmuskulärer Krankheitssymptome im Rahmen der Systemerkrankung CHI.Die mittels Spiroergometrie dosierte, möglichst tägliche dynamische Belastung ist adjuvanter Bestandteil der leitliniengerechten Therapie von Patienten mit chronischer Herzinsuffizienz. Die positive Beeinflussung klinischer Symptome und der Prognose ist durch Ergebnisse prospektiver, randomisierter Studien evidenzbasiert belegt. In der klinischen Praxis zeigt sich jedoch, dass die Erfolge nur bei intensiver Betreuung und Führung dieser Patienten erreicht werden. Einmal in das häusliche Umfeld gänzlich entlassen, hält die Mehrzahl der Patienten die tägliche Herausforderung einer selbstständigen, aktiven Form der körperlichen Belastung aus mentalen, physischen oder sozialen Gründen nicht aufrecht, und der Circulus vitiosus Systemerkrankung CHI manifestiert sich erneut.Patienten und Methodik:Vor diesem Hintergrund haben die Autoren in einer prospektiven Pilotstudie die Wirkung und die Akzeptanz der Ganzkörper-EMS, einer Art passiven, von der mentalen Einstellung und dem physischen Leistungsvermögen weitgehend unabhängigen Trainingsform, bei herzinsuffizienten Patienten untersucht.Ergebnisse:Eine bis zu 96%ige Steigerung der Sauerstoffaufnahme an der anaeroben Schwelle konnte nachgewiesen werden (VO2at 19,39 [± 5,3] ml/kg Körpergewicht [KG] vor Trainingsbeginn; VO2at 24,25 [±6,34] ml/kg KG am Ende der Trainingsphase; p < 0,05). Der diastolische Blutdruck sank signifikant (psyst < 0,05; pdiast < 0,001), der Muskelzuwachs betrug bis 14% bei Gewichtskonstanz. Die Trainingsmethode wurde zu 100% akzeptiert (keine Abbrecher), die Patienten gaben eine deutlich gesteigerte subjektive Leistungsfähigkeit an.Schlussfolgerung:Die Ergebnisse lassen ein erhebliches Potential in der kardiologischen Primär- und Sekundärrehabilitation erahnen, wobei gerade schwer eingeschränkte Patienten mit CHI überproportional profitierten.AbstractBackground:Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease.Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50–70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%.It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers.Patients and Methods:The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude.Results:An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO2at 19.39 [± 5.3] ml/kg vs. 24.25 [± 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved.Conclusion:The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.BACKGROUND Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers. PATIENTS AND METHODS The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude. RESULTS An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved. CONCLUSION The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Stratification for noninvasive coronary angiography: patient preselection considering atypical angina pectoris, conventional cardiovascular risk assessment, and calcium scoring

Background Noninvasive coronary angiography (NCA) is recommended to be applied as a filter before invasive coronary angiography in patients with intermediate cardiovascular risk. Design In this prospective single-center study, we validated multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)-based NCA by primarily selecting patients with atypical angina pectoris (AAP). Methods In 68 patients (63.6 ± 11.4 years) with AAP, the Prospective Cardiovascular Muenster Study score and the Agatston score equivalent (ASE; calcium score) were initially determined for cardiovascular risk assessment. Subsequently, MSCT and MRI-based NCA were performed followed by quantitative invasive coronary angiography for validation. All tests were finally analyzed. Results CAD (prevalence 38.2%) was diagnosed in 67.7% of patients at high, 61.5% at intermediate, and 37.8% at low cardiovascular risk according to the Prospective Cardiovascular Muenster Study. CAD was diagnosed in 88.2% of patients with an ASE ≥ 75th percentile and in 90.9% with an ASE ≥ 90th percentile. With regard to NCA, patient-based analysis resulted in a sensitivity of 96.2% for MSCT versus 69.2% for MRI, in a specificity of 95.2 versus 64.3%, in a positive predictive value of 97.6 versus 77.1%, in a negative predictive value of 92.6 versus 54.5%, and a diagnostic accuracy of 95.6 versus 66.2% (P < 0.05). Conclusion In a patient group with a heterogeneous cardiovascular risk, primarily considering AAP allows for effective patient preselection for NCA. This may be optimized by precluding patients with an ASE ≥ 75th percentile. MSCT rather than MRI may then effectively be involved. Eur J Cardiovasc Prev Rehabil 16:201-209