The role of cardiac rehabilitation in vocational reintegration Belgian working group of cardiovascular prevention and rehabilitation position paper.

Cardiovascular disease is one of the main causes of morbidity and sick leave in Belgium, imposing a great socio-economic burden on the contemporary healthcare system and society. Cardiac rehabilitation is an evidence-based treatment strategy that not only improves the cardiac patients' health state but also holds promise so as to facilitate vocational reintegration in the society. This position paper was developed and endorsed by the Belgian Working Group of Cardiovascular Prevention and Rehabilitation. It provides an overview of the currently available Belgian data with regard to the role of cardiac rehabilitation in return to work after an initial cardiac event. It identifies the relevant barriers and facilitators of vocational integration of cardiac patients and summarises the contemporary Belgian legal and medical framework in this regard. Cardiac rehabilitation remains a primordial component of the post-acute event management of the cardiac patient, facilitating vocational reintegrating and thereby decreasing the pressure on social security. Despite the availability of a relevant legislative framework, there is a need for well-defined algorithms to assess readiness for return to work that can be used in daily clinical practice.

Accuracy of Apple Watch Measurements for Heart Rate and Energy Expenditure in Patients With Cardiovascular Disease: Cross-Sectional Study.

BACKGROUND: Wrist-worn tracking devices such as the Apple Watch are becoming more integrated in health care. However, validation studies of these consumer devices remain scarce. OBJECTIVES: This study aimed to assess if mobile health technology can be used for monitoring home-based exercise in future cardiac rehabilitation programs. The purpose was to determine the accuracy of the Apple Watch in measuring heart rate (HR) and estimating energy expenditure (EE) during a cardiopulmonary exercise test (CPET) in patients with cardiovascular disease. METHODS: Forty patients (mean age 61.9 [SD 15.2] yrs, 80% male) with cardiovascular disease (70% ischemic, 22.5% valvular, 7.5% other) completed a graded maximal CPET on a cycle ergometer while wearing an Apple Watch. A 12-lead electrocardiogram (ECG) was used to measure HR; indirect calorimetry was used for EE. HR was analyzed at three levels of intensity (seated rest, HR1; moderate intensity, HR2; maximal performance, HR3) for 30 seconds. The EE of the entire test was used. Bias or mean difference (MD), standard deviation of difference (SDD), limits of agreement (LoA), mean absolute error (MAE), mean absolute percentage error (MAPE), and intraclass correlation coefficients (ICCs) were calculated. Bland-Altman plots and scatterplots were constructed. RESULTS: SDD for HR1, HR2, and HR3 was 12.4, 16.2, and 12.0 bpm, respectively. Bias and LoA (lower, upper LoA) were 3.61 (-20.74, 27.96) for HR1, 0.91 (-30.82, 32.63) for HR2, and -1.82 (-25.27, 21.63) for HR3. MAE was 6.34 for HR1, 7.55 for HR2, and 6.90 for HR3. MAPE was 10.69% for HR1, 9.20% for HR2, and 6.33% for HR3. ICC was 0.729 (P<.001) for HR1, 0.828 (P<.001) for HR2, and 0.958 (P<.001) for HR3. Bland-Altman plots and scatterplots showed good correlation without systematic error when comparing Apple Watch with ECG measurements. SDD for EE was 17.5 kcal. Bias and LoA were 30.47 (-3.80, 64.74). MAE was 30.77; MAPE was 114.72%. ICC for EE was 0.797 (P<.001). The Bland-Altman plot and a scatterplot directly comparing Apple Watch and indirect calorimetry showed systematic bias with an overestimation of EE by the Apple Watch. CONCLUSIONS: In patients with cardiovascular disease, the Apple Watch measures HR with clinically acceptable accuracy during exercise. If confirmed, it might be considered safe to incorporate the Apple Watch in HR-guided training programs in the setting of cardiac rehabilitation. At this moment, however, it is too early to recommend the Apple Watch for cardiac rehabilitation. Also, the Apple Watch systematically overestimates EE in this group of patients. Caution might therefore be warranted when using the Apple Watch for measuring EE.

Serial pulmonary vascular resistance assessment in patients late after ventricular septal defect repair.

BACKGROUND: The long-term evolution of pulmonary vascular resistance (PVR) after ventricular septal defect (VSD) repair is unknown. This study serially evaluated resting and exercise PVR after VSD repair in childhood. METHODS: Patients were enrolled from the outpatient Adult Congenital Heart Disease clinic of the University Hospitals Leuven and compared to age- and gender-matched controls. Participants underwent resting and exercise echocardiography and cardiopulmonary exercise testing at baseline and follow-up. Total PVR was calculated as the ratio of mean pulmonary artery pressure (mPAP) to cardiac output (CO). The slope of the mPAP-CO curve (exercise PVR) was obtained using linear regression analysis. RESULTS: Twenty-seven patients (mean age 31 ±â€¯7 years, 70% male) and 18 controls were included. At baseline, patients had larger right ventricular (RV) end-diastolic areas (10 ±â€¯2 vs 9 ±â€¯1 cm2/m2, p = 0.001) and lower tricuspid annular plane systolic excursion (TAPSE) (17 (17-19) vs 26 (22-28) mm, p < 0.001). After 1.1 (1.0-1.5) years follow-up, similar differences in RV areas and TAPSE were found. Patients reached lower peak workload and cardiac index compared to controls at each time point. Peak total PVR was higher (Baseline: 2.7 ±â€¯0.8 vs 2.2 ±â€¯0.3 mm Hg/L/min, p = 0.005; Follow-up: 2.9 ±â€¯0.9 vs 2.1 ±â€¯0.3 mm Hg/L/min, p < 0.001) and the mPAP-CO slope was steeper (Baseline: 2.2 ±â€¯0.8 vs 1.7 ±â€¯0.3 mm Hg/L/min, p = 0.008; Follow-up: 2.5 ±â€¯0.9 vs 1.6 ±â€¯0.3 mm Hg/L/min, p < 0.001) in patients. The mPAP-CO slope in patients correlated inversely with peak oxygen uptake (R = -0.41 and - 0.45, p = 0.036 and 0.022, baseline and follow-up, respectively). CONCLUSION: Despite repair, VSD patients seem to show altered pulmonary hemodynamics and RV impairment at rest and exercise, supporting life-long follow-up.

The development and codesign of the PATHway intervention: a theory-driven eHealth platform for the self-management of cardiovascular disease.

Cardiovascular diseases (CVDs) are a leading cause of premature death worldwide. International guidelines recommend routine delivery of all phases of cardiac rehabilitation (CR). Uptake of traditional CR remains suboptimal, as attendance at formal hospital-based CR programs is low, with community-based CR rates and individual long-term exercise maintenance even lower. Home-based CR programs have been shown to be equally effective in clinical and health-related quality of life outcomes and yet are not readily available. The aim of the current study was to develop the PATHway intervention (physical activity toward health) for the self-management of CVD. Increasing physical activity in individuals with CVD was the primary behavior. The PATHway intervention was theoretically informed by the behavior change wheel and social cognitive theory. All relevant intervention functions, behavior change techniques, and policy categories were identified and translated into intervention content. Furthermore, a person-centered approach was adopted involving an iterative codesign process and extensive user testing. Education, enablement, modeling, persuasion, training, and social restructuring were selected as appropriate intervention functions. Twenty-two behavior change techniques, linked to the six intervention functions and three policy categories, were identified for inclusion and translated into PATHway intervention content. This paper details the use of the behavior change wheel and social cognitive theory to develop an eHealth intervention for the self-management of CVD. The systematic and transparent development of the PATHway intervention will facilitate the evaluation of intervention effectiveness and future replication.

PATHway I: design and rationale for the investigation of the feasibility, clinical effectiveness and cost-effectiveness of a technology-enabled cardiac rehabilitation platform.

INTRODUCTION: Exercise-based cardiac rehabilitation (CR) independently alters the clinical course of cardiovascular diseases resulting in a significant reduction in all-cause and cardiac mortality. However, only 15%-30% of all eligible patients participate in a phase 2 ambulatory programme. The uptake rate of community-based programmes following phase 2 CR and adherence to long-term exercise is extremely poor. Newer care models, involving telerehabilitation programmes that are delivered remotely, show considerable promise for increasing adherence. In this view, the PATHway (Physical Activity Towards Health) platform was developed and now needs to be evaluated in terms of its feasibility and clinical efficacy. METHODS AND ANALYSIS: In a multicentre randomised controlled pilot trial, 120 participants (m/f, age 40-80 years) completing a phase 2 ambulatory CR programme will be randomised on a 1:1 basis to PATHway or usual care. PATHway involves a comprehensive, internet-enabled, sensor-based home CR platform and provides individualised heart rate monitored exercise programmes (exerclasses and exergames) as the basis on which to provide a personalised lifestyle intervention programme. The control group will receive usual care. Study outcomes will be assessed at baseline, 3 months and 6 months after completion of phase 2 of the CR programme. The primary outcome is the change in active energy expenditure. Secondary outcomes include cardiopulmonary endurance capacity, muscle strength, body composition, cardiovascular risk factors, peripheral endothelial vascular function, patient satisfaction, health-related quality of life (HRQoL), well-being, mediators of behaviour change and safety. HRQoL and healthcare costs will be taken into account in cost-effectiveness evaluation. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the director and clinical director of the PATHway study and by the ethical committee of each participating site. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses and events. TRIAL REGISTRATION NUMBER: NCT02717806. This trial is currently in the pre-results stage.

Functional and haemodynamic assessment of mild-to-moderate pulmonary valve stenosis at rest and during exercise.

OBJECTIVE: In adult patients with mild-to-moderate pulmonary valve (PV) stenosis, exercise capacity and haemodynamics have not been extensively studied, although regular exercise is recommended. Therefore, we aimed to assess exercise capacity to study the increase in PV gradient during exercise and to evaluate the impact of this increased pressure load on the RV. METHODS: Nineteen patients (8 female; 29±6.4 years) with isolated mild-to-moderate PV stenosis and no prior cardiac interventions were consecutively enrolled from the outpatient clinic of adult congenital heart disease. All patients underwent cardiopulmonary exercise testing, transthoracic echocardiography and bicycle stress echocardiography. Results for exercise testing were compared with age-matched and gender-matched control patients. RESULTS: In the studied population, resting heart rate (89±11 vs 75±14 bpm; p=0.001), peak power (199±66 vs 263±68 W; p=0.006); peak VO2 (31.2±9.9 vs 39±7.4 mL/kg/min; p=0.011); oxygen uptake efficiency slope (2430±913 vs 3292±943(mL/min)/(L/min); p=0.007) and VE/VCO2 slope (26.8±5.2 vs 22.6±4.3; p=0.01) differed significantly from controls. A linear increase of peak PV gradient with increasing flow was observed in the pooled dataset (Pearson's R=0.947; p<0.0001) and slopes identical as for control patients were obtained for the oxygen pulse-workload relationship. Right heart morphology and function were preserved in the studied patients. CONCLUSIONS: Patients with mild-to-moderate PV stenosis have decreased exercise capacity. A linear increase in PV gradient with flow suggests a fixed valve area throughout the exercise. Although systolic RV pressure load increases during exercise, good ventricular performance was observed without signs of functional or morphological changes of the right heart. CLINICAL TRIAL NUMBER: NCT01444222.