Standardised Exercise Prescription for Patients with Chronic Coronary Syndrome and/or Heart Failure: A Consensus Statement from the EXPERT Working Group.

Whereas exercise training, as part of multidisciplinary rehabilitation, is a key component in the management of patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), physicians and exercise professionals disagree among themselves on the type and characteristics of the exercise to be prescribed to these patients, and the exercise prescriptions are not consistent with the international guidelines. This impacts the efficacy and quality of the intervention of rehabilitation. To overcome these barriers, a digital training and decision support system [i.e. EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool], i.e. a stepwise aid to exercise prescription in patients with CCS and/or CHF, affected by concomitant risk factors and comorbidities, in the setting of multidisciplinary rehabilitation, was developed. The EXPERT working group members reviewed the literature and formulated exercise recommendations (exercise training intensity, frequency, volume, type, session and programme duration) and safety precautions for CCS and/or CHF (including heart transplantation). Also, highly prevalent comorbidities (e.g. peripheral arterial disease) or cardiac devices (e.g. pacemaker, implanted cardioverter defibrillator, left-ventricular assist device) were considered, as well as indications for the in-hospital phase (e.g. after coronary revascularisation or hospitalisation for CHF). The contributions of physical fitness, medications and adverse events during exercise testing were also considered. The EXPERT tool was developed on the basis of this evidence. In this paper, the exercise prescriptions for patients with CCS and/or CHF formulated for the EXPERT tool are presented. Finally, to demonstrate how the EXPERT tool proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented.

[Cardiopulmonary exercise testing for exercise prescription in cardiac rehabilitation]. / Spiroergometrie zur Trainingssteuerung in der kardiologischen Rehabilitation.

Aerobic endurance training is a core component of exercise training (ET) during cardiac rehabilitation (CR). Improvements of cardiopulmonary performance and symptom-free exercise capacity that can be achieved by ET during CR are essential for patient's prognosis and quality of life. Before initiating exercise training in CR, a detailed risk stratification including incremental exercise testing is required in order to ensure safe and effective exercise training conditions. Cardiopulmonary exercise testing (CPX) with measurement of respiratory gases is considered the gold standard of cardiopulmonary performance diagnostics. The oxygen uptake measured at the highest exercise intensity achieved (peakVO2) has strong prognostic implications in primary and secondary prevention of cardiovascular diseases, respectively. The use of CPX with measurement of peakVO2 and determination of ventilatory thresholds (VT) enables a reliable determination of the individual cardiopulmonary performance (peakVO2) and also the aerobic exercise capacity. In addition, CPX is a valuable tool to detect increments in exercise capacity that were achieved by ET during CR. The measurement of peakVO2 and the determination of ventilatory thresholds are basic parameters for an individually tailored exercise prescription. In addition, the targeted control of aerobic endurance training on the basis of CPX parameters increases the effectiveness and safety of the exercise program during CR. In this article, recommendations for an individual exercise prescription, based on the results of CPX, are given for patients with coronary heart disease (CHD), heart failure, as well as for patients with CHD and concomitant type 2 diabetes mellitus.

[Cardiac Rehabilitation]. / Kardiologische Rehabilitation.

A scientific guideline has been developed to update and harmonize exercise based cardiac rehabilitation (CR) in German speaking countries of Europe. It addresses all aspects of CR including indications, contents and delivery. Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. Other indications for CR were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process. CR is associated with a significant reduction in all-cause mortality in patients after ACS and CABG, whereas HFrEF-patients benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases such as heart valve surgery or intervention, adults with congenital heart disease and peripheral arterial disease also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, modulation of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions (PI) should be performed on the basis of individual needs. There was a trend towards reduction of depressive symptoms for "distress management" and "lifestyle changes" for PI. Patient education is able to increase patients` knowledge and motivation as well as behavior changes regarding physical activity, dietary habits and smoking cessation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. This guideline reinforces the substantial benefit of CR in specific cardiac indications, and it points out the minimal therapeutic needs in CR-delivery.

Resistance Training in Patients With Coronary Artery Disease, Heart Failure, and Valvular Heart Disease: A REVIEW WITH SPECIAL EMPHASIS ON OLD AGE, FRAILTY, AND PHYSICAL LIMITATIONS.

PURPOSE: Current guidelines recommend individually adapted resistance training (RT) as a part of the exercise regime in patients with cardiovascular diseases. The aim of this review was to provide insights into current knowledge and understanding of how useful, feasible, safe, and effective RT is in patients with coronary artery disease (CAD), heart failure (HF), and valvular heart disease (VHD), with particular emphasis on the role of RT in elderly and/or frail patients. REVIEW METHODS: A review based on an intensive literature search: systematic reviews and meta-analyses published in 2010 or later; recent studies not integrated into meta-analyses or systematic reviews; additional manual searches. SUMMARY: The results highlight the evaluation of effects and safety of RT in patients with CAD and HF with reduced ejection fraction (HFrEF) in numerous meta-analyses. In contrast, few studies have focused on RT in patients with HF with preserved ejection fraction (HFpEF) or VHD. Furthermore, few studies have addressed the feasibility and impact of RT in elderly cardiac patients, and data on the efficacy and safety of RT in frail elderly patients are limited. The review results underscore the high prevalence of age-related sarcopenia, disease-related skeletal muscle deconditioning, physical limitations, and frailty in older patients with cardiovascular diseases (CVD). They underline the need for individually tailored exercise concepts, including RT, aimed at improving functional status, mobility, physical performance and muscle strength in older patients. Furthermore, the importance of the use of assessment tools to diagnose frailty, mobility/functional capacity, and physical performance in the elderly admitted to cardiac rehabilitation is emphasized.

[Impact of COVID-19 on cardiac rehabilitation during the first year of the pandemic: A comparison of the performance numbers in Germany from 2019 and 2020]. / Wie stark hat die COVID-19-Pandemie die kardiologische Rehabilitation im ersten Jahr der Pandemie beeinflusst? Ein Vergleich der Leistungszahlen aus 2019 mit 2020 in Deutschland.

INTRODUCTION: In Germany, the COVID-19 pandemic led to substantial changes in outpatient and acute clinical cardiac care and rehabilitation. To estimate the influence of the COVID-19 pandemic on cardiac rehabilitation in 2020, institutional performance was compared to the pre-pandemic year 2019. METHODS: The performance numbers from rehabilitation institutions were compared. These data were provided in 2019 and 2020 as part of an online survey that the German Society for the Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) performs annually. RESULTS: Complete data for 2019 and 2020 were available from 60 institutions. The overall number of patients treated was reduced by 14.3%, with substantial differences between institutions. Women were more affected (-16.4%) than men (-13.4%) and retirees (-14.5%) significantly more than people still in the workforce (-7.5%). In 25 institutions (42.4%) there was a COVID-19 outbreak resulting in a partial or complete shutdown in 15.7%. In total, 34.5% of the institutions treated patients with COVID-19 infection, 30.5% after such an infection. A large majority of these institutions (72.1%) had to bear the costs for testing suspected cases of SARS-CoV-2-infection alone. CONCLUSION: The economic and logistic burden of the COVID-19 pandemic has posed a threat to cardiac rehabilitation in Germany.

Efficacy of Lipid-Lowering Therapy during Cardiac Rehabilitation in Patients with Diabetes Mellitus and Coronary Heart Disease.

BACKGROUND: Cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) increases adherence to a healthy lifestyle and to secondary preventive medication. A notable example of such medication is lipid-lowering therapy (LLT). LLT during CR improves quality of life and prognosis, and thus is particularly relevant for patients with diabetes mellitus, which is a major risk factor for CHD. DESIGN: A prospective, multicenter registry study with patients from six rehabilitation centers in Germany. METHODS: During CR, 1100 patients with a minimum age of 18 years and CHD documented by coronary angiography were included in a LLT registry. RESULTS: In 369 patients (33.9%), diabetes mellitus was diagnosed. Diabetic patients were older (65.5 ± 9.0 vs. 62.2 ± 10.9 years, p < 0.001) than nondiabetic patients and were more likely to be obese (BMI: 30.2 ± 5.2 kg/m2 vs. 27.8 ± 4.2 kg/m2, p < 0.001). Analysis indicated that diabetic patients were more likely to show LDL cholesterol levels below 55 mg/dL than patients without diabetes at the start of CR (Odds Ratio (OR) 1.9; 95% CI 1.3 to 2.9) until 3 months of follow-up (OR 1.9; 95% CI 1.2 to 2.9). During 12 months of follow-up, overall and LDL cholesterol levels decreased within the first 3 months and remained at the lower level thereafter (p < 0.001), irrespective of prevalent diabetes. At the end of the follow-up period, LDL cholesterol did not differ significantly between patients with or without diabetes mellitus (p = 0.413). CONCLUSION: Within 3 months after CR, total and LDL cholesterol were significantly reduced, irrespective of prevalent diabetes mellitus. In addition, CHD patients with diabetes responded faster to LTT than nondiabetic patients, suggesting that diabetic patients benefit more from LLT treatment during CR.

[Cardiac rehabilitation during the COVID-19 pandemic in Germany - a quick poll of the German Society of rehabilitation and Prevention of Heart and Circulation Diseases (DGPR)]. / Situation der kardiologischen Rehabilitation im Rahmen der COVID-19-Pandemie in Deutschland ­ eine Blitzumfrage der Deutschen Gesellschaft für Rehabilitation und Prävention von Herz-Kreislauferkrankungen (DGPR) zur aktuellen Situation (August 2020).

BACKGROUND: In Germany, the COVID-19 pandemic has significantly changed cardiological care in both the outpatient and inpatient setting, including the cancellation of elective interventions. The investigation presented here was carried out in order to obtain information on the extent to which this also applies to cardiac rehabilitation facilities. METHODS: In August 2020, all 107 member institutions of the DGPR were contacted and asked to take part in an online survey containing 12 sets of questions on the topic. RESULTS: At the end of August, data were available from 45 institutions. 31.1 % of the institutions provided rehabilitation services for patients with cardiac complications/manifestations of COVID-19 disease, mainly after acute coronary syndrome (29.6 %) and pulmonary artery embolism (25.9 %). More than 40 % of the facilities were required to close down partially or completely, and 14 % feared a partial or complete closure by the end of 2020. The costs for testing, if SARS-CoV-2 infection was suspected (72.1 %), were mainly borne by the rehabilitation facilities. CONCLUSIONS: Despite the limitations of a short-term data collection and a response rate of approx. 45 %, the present study gives indications of the challenging situation of the COVID-19 pandemic for cardiological rehabilitation facilities in Germany.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2.

BACKGROUND: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients' groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. METHODS: Generation of evidence and search of literature have been described in part 1. RESULTS: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for "distress management" and "lifestyle changes". PE is able to increase patients' knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients' groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. CONCLUSIONS: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1.

BACKGROUND: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. METHODS: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. RESULTS: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. CONCLUSIONS: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

[Evidence based guideline for cardiac rehabilitation in German speaking countries of Europe]. / S3-Leitlinie zur kardiologischen Rehabilitation im deutschsprachigen Raum Europas.

An evidence based clinical guideline for cardiac rehabilitation (CR) has been published in collaboration between the German Association of Cardiac Rehabilitation and Prevention of Cardiovascular Diseases (DGPR) and the working groups of prevention and rehabilitation of the cardiac societies of Austria (ÖKG) and Switzerland (CPRS). This guideline has been consented by relevant medical societies in Germany (cardiologists, cardiac surgeans, sports medicine, psychosomatic medicine, rehabilitation scientists). In addition, patients suffering from cardiovascular diseases were involved to emphasize shared decision making in the recommendations. As return to work is a major goal of CR, German pension insurance (DRV-Bund) was associated in the development of this guideline as well. Evidence of CR was evaluated by systematic review of the literature and new meta-analysis performed and published by the guideline committee for patients with coronary artery disease and systolic heart failure. In addition, psychosocial intervention during CR was evaluated by new meta-analysis as well. Other indications for CR and interventions during CR were evaluated by literature review and were consented between collaborating medical societies. This guideline published on 7th of January 2020 in German language (www.awmf.org).

Evaluation of Aerobic Exercise Intensity in Patients with Coronary Artery Disease and Type 2 Diabetes Mellitus.

(1) Background: Physical activity is recommended in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) to reduce hyperglycemia and cardiovascular risk. Effective aerobic exercise intensity, however, is not well defined. (2) Methods: 60 consecutive patients performed cardiopulmonary exercise testing (CPX) of 30 min duration targeting a respiratory exchange ratio (RER) between 0.85 and 0.95, being strictly aerobic. Plasma glucose (PG) was measured before and after CPX as well as one and two h after exercise. Maximum exercise intensity was evaluated using a standard bicycle exercise test. (3) Results: 50 patients completed the protocol (62 ± 10 years, BMI (body mass index) 30.5 ± 4.9 kg/m2, HbA1c (glycated haemoglobin) 6.9 ± 0.8%, left ventricular ejection fraction 55 ± 8%). Aerobic exercise capacity averaged at 32 ± 21 Watt (range 4-76 Watt) representing 29.8% of the maximum exercise intensity reached. PG before and after CPX was 9.3 ± 2.2 and 7.6 ± 1.7 mmol/L, respectively (p < 0.0001). PG was further decreased significantly at one and two h after exercise to 7.5 ± 1.6 mmol/L and 6.0 ± 1.0 mmol/L, respectively (p < 0.0001 for both as compared to PG before CPX). (4) Conclusions: Aerobic exercise capacity is very low in patients with CAD and T2DM. Exercise at aerobic intensity allowed for significant reduction of plasma glucose. Individual and effective aerobic exercise prescription is possible by CPX.