A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement.

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Do we need to rethink the determination of exercise-related energy expenditure in cardiac telerehabilitation interventions?

The American College of Sports Medicine determined the energy consumption of daily activities and sports. Cardiac telerehabilitation (CTR) requires knowing how much energy people consume in daily life outside of cardiac rehabilitation activities. Therefore, we have investigated if the estimated values are valid in CTR. Data from two studies were incorporated. The first study measured ventilatory threshold (VT)1, VT2, and peak exercise on cardiopulmonary exercise testing (CPET) collected from 272 cardiac (risk) patients and compared them to the estimated oxygen consumption (VO2) at low-to-moderate-intense exercise (3-6 metabolic equivalents [METs]). Next, a patient-tailored application was developed to support CTR using these estimated values, and the intervention (the second study) was conducted with 24 coronary artery disease patients using this application during a CTR intervention. In the first study, VO2 at VT1, VT2 and peak exercise corresponded to 3.2 [2.8, 3.8], 4.3 [3.8, 5.3], and 5.4 [4.5, 6.2] METs, which are significantly different from the estimated VO2 at low-to-moderate-intense exercise, especially lower in older, obese, female, and post-myocardial infarction/heart failure patients. These VO2 varied considerably between patients. The telerehabilitation study did not show significant progress in peak VO2, but using the application's estimated target, 97.2% of the patients achieved their weekly target, which is a significant overestimate. The estimated and observed exercise-related energy expenditures by CPET were significantly different, resulting in an overestimation of the exercise done by the patients at home. The results can have a significant impact on the quantification of exercise dose during (tele)rehabilitation programs.

Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology.

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.

Fully automated muscle quality assessment by Gabor filtering of second harmonic generation images.

Although structural changes on the sarcomere level of skeletal muscle are known to occur due to various pathologies, rigorous studies of the reduced sarcomere quality remain scarce. This can possibly be explained by the lack of an objective tool for analyzing and comparing sarcomere images across biological conditions. Recent developments in second harmonic generation (SHG) microscopy and increasing insight into the interpretation of sarcomere SHG intensity profiles have made SHG microscopy a valuable tool to study microstructural properties of sarcomeres. Typically, sarcomere integrity is analyzed by fitting a set of manually selected, one-dimensional SHG intensity profiles with a supramolecular SHG model. To circumvent this tedious manual selection step, we developed a fully automated image analysis procedure to map the sarcomere disorder for the entire image at once. The algorithm relies on a single-frequency wavelet-based Gabor approach and includes a newly developed normalization procedure allowing for unambiguous data interpretation. The method was validated by showing the correlation between the sarcomere disorder, quantified by the M-band size obtained from manually selected profiles, and the normalized Gabor value ranging from 0 to 1 for decreasing disorder. Finally, to elucidate the applicability of our newly developed protocol, Gabor analysis was used to study the effect of experimental autoimmune encephalomyelitis on the sarcomere regularity. We believe that the technique developed in this work holds great promise for high-throughput, unbiased, and automated image analysis to study sarcomere integrity by SHG microscopy.

Effect of comprehensive cardiac telerehabilitation on one-year cardiovascular rehospitalization rate, medical costs and quality of life: A cost-effectiveness analysis.

BACKGROUND: Notwithstanding the cardiovascular disease epidemic, current budgetary constraints do not allow for budget expansion of conventional cardiac rehabilitation programmes. Consequently, there is an increasing need for cost-effectiveness studies of alternative strategies such as telerehabilitation. The present study evaluated the cost-effectiveness of a comprehensive cardiac telerehabilitation programme. DESIGN AND METHODS: This multi-centre randomized controlled trial comprised 140 cardiac rehabilitation patients, randomized (1:1) to a 24-week telerehabilitation programme in addition to conventional cardiac rehabilitation (intervention group) or to conventional cardiac rehabilitation alone (control group). The incremental cost-effectiveness ratio was calculated based on intervention and health care costs (incremental cost), and the differential incremental quality adjusted life years (QALYs) gained. RESULTS: The total average cost per patient was significantly lower in the intervention group (€2156 ± €126) than in the control group (€2720 ± €276) (p = 0.01) with an overall incremental cost of €-564.40. Dividing this incremental cost by the baseline adjusted differential incremental QALYs (0.026 QALYs) yielded an incremental cost-effectiveness ratio of €-21,707/QALY. The number of days lost due to cardiovascular rehospitalizations in the intervention group (0.33 ± 0.15) was significantly lower than in the control group (0.79 ± 0.20) (p = 0.037). CONCLUSIONS: This paper shows the addition of cardiac telerehabilitation to conventional centre-based cardiac rehabilitation to be more effective and efficient than centre-based cardiac rehabilitation alone. These results are useful for policy makers charged with deciding how limited health care resources should best be allocated in the era of exploding need.

Chronotropic Incompetence During Exercise in Type 2 Diabetes: Aetiology, Assessment Methodology, Prognostic Impact and Therapy.

During incremental exercise tests, chronotropic incompetence (CI), which is the inability of the heart rate (HR) to rise in proportion to an increase in metabolic demand, is often observed in patients with type 2 diabetes mellitus (T2DM). Despite the fact that CI is associated with exercise intolerance and elevated risks of development of cardiovascular disease and premature death, this clinical anomaly is often ignored or overlooked by clinicians and physiologists. CI is, however, a significant clinical abnormality that deserves further attention, examination and treatment. The aetiology of CI in T2DM remains poorly understood and is complex. Certain T2DM-related co-morbidities or physiological anomalies may contribute to development of CI, such as altered blood catecholamine and/or potassium levels during exercise, structural myocardial abnormalities, ventricular and/or arterial stiffness, impaired baroreflex sensitivity and cardiovascular autonomic neuropathy. Clinicians should thus be aware of the potential presence of yet undetected anomalies or diseases in T2DM patients who experience CI during exercise testing. However, an effective treatment for CI in T2DM is yet to be developed. Exercise training programmes seem to be the only potentially effective and feasible interventions for partial restoration of the chronotropic response in T2DM, but it remains poorly understood how these interventions lead to restoration of the chronotropic response. Studies are thus warranted to elucidate the aetiology of CI and develop an effective treatment for CI in T2DM. In particular, the impact of (different) exercise interventions on CI in T2DM deserves greater attention in future studies.

Comparison of two motion sensors for use in cardiac telerehabilitation.

We compared the activity estimated by a pedometer and an accelerometer in coronary artery disease patients included in a phase III cardiac rehabilitation programme. Nine patients were divided into two groups and wore the pedometer for four weeks, and then subsequently the accelerometer for four weeks, or vice versa. The recorded daily exercise level (total daily steps and calories burned) was measured for each patient and compared with oxygen uptake and ventilatory threshold measured by ergospirometry at the end of the study. There was a significant correlation between the calories measured by the accelerometer and the ventilatory threshold (i.e. the sub-maximal capacity), r = 0.75 (P = 0.05). There was a significant correlation between the measured steps on the accelerometer and the ventilatory threshold, r = 0.72 (P = 0.07). There were no significant correlations for the pedometer. A questionnaire concerning ease of use of the sensors indicated that the cardiac patients favoured the pedometer.

Long-term cost-benefit ratio of cardiac rehabilitation after percutaneous coronary intervention.

OBJECTIVE: Cardiac rehabilitation (CR) has been shown to reduce short-term mortality and morbidity after percutaneous coronary intervention (PCI). Nonetheless, the long-term effects of CR after PCI and its cost-benefit ratio are not well studied. This study analyses the effect of multidisciplinary, hospital-based, ambulatory CR on long-term health-related costs after PCI. METHODS AND RESULTS: 213 patients were studied after PCI: 133 patients referred to cardiac rehabilitation were compared with 80 patients who were referred for PCI from another hospital, where no rehabilitation was available. The hospital files of these patients were studied and the patient and/or his/her general practitioner were contacted by telephone after a follow-up of approximately 4.5 years. All cardiovascular events (recurrent angina, coronary revascularization, acute myocardial infarction, and death) were noted and their cost to the community was calculated. Compared to no CR, CR resulted in a significant reduction of hospitalizations for angina (75% vs. 45%), and coronary revascularizations (17% vs. 7%). There was a significant increase in the incidence of myocardial infarction (2.5% vs. 7.5%). The intervention group experienced a total of 0.93 events/patient, as compared to 1.52 events/patient in the control group. The total health care cost (including the cost of CR) at 4.5 years of follow-up was lower in the rehabilitation group compared to the control group (4,862 Euro/patient vs. 5,498 Euro/patient). CONCLUSION: Cardiac rehabilitation after PCI not only significantly reduces the number of cardiac events, but, despite the additional cost due to CR, results in cost savings from the Belgian health care payer's perspective.