[General measures and management of pulmonary arterial hypertension]. / Allgemeine Maßnahmen und Management der pulmonalarteriellen Hypertonie.

Care of patients with pulmonary arterial hypertension (PAH) needs a multi-facetet concept and measures, including management of adverse reactions, right heart insufficiency as well as information on pregnancy, travels by air, psychosocial support, physical exercise training and prophylaxis by vaccination.Positive study results led to an higher recommendation of specialized exercise training in pulmonary hypertension. Also, the recommendation on iron substitution was amended according to the current evidence.In the current guidelines, special focus was given to the elaboration of recommendations regarding pregnancy, including patient information, contraception and patient management in case of pregnancy.This article aims to provide an overview on the recommendations of general measuremes, special circumstances and patient management according to the ESC/ERS guidelines. Amendments to the guideline recommendations are given as comments from the authors of this article.

Standardized exercise training is feasible, safe, and effective in pulmonary arterial and chronic thromboembolic pulmonary hypertension: results from a large European multicentre randomized controlled trial.

AIMS: This prospective, randomized, controlled, multicentre study aimed to evaluate efficacy and safety of exercise training in patients with pulmonary arterial (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS AND RESULTS: For the first time a specialized PAH/CTEPH rehabilitation programme was implemented in 11 centres across 10 European countries. Out of 129 enrolled patients, 116 patients (58 vs. 58 randomized into a training or usual care control group) on disease-targeted medication completed the study [85 female; mean age 53.6 ± 12.5 years; mean pulmonary arterial pressure 46.6 ± 15.1 mmHg; World Health Organization (WHO) functional class II 53%, III 46%; PAH n = 98; CTEPH n = 18]. Patients of the training group performed a standardized in-hospital rehabilitation with mean duration of 25 days [95% confidence interval (CI) 17-33 days], which was continued at home. The primary endpoint, change of 6-min walking distance, significantly improved by 34.1 ± 8.3 m in the training compared with the control group (95% CI, 18-51 m; P < 0.0001). Exercise training was feasible, safe, and well-tolerated. Secondary endpoints showed improvements in quality of life (short-form health survey 36 mental health 7.3 ± 2.5, P = 0.004), WHO-functional class (training vs. control: improvement 9:1, worsening 4:3; χ2P = 0.027) and peak oxygen consumption (0.9 ± 0.5 mL/min/kg, P = 0.048) compared with the control group. CONCLUSION: This is the first multicentre and so far the largest randomized, controlled study on feasibility, safety, and efficacy of exercise training as add-on to medical therapy in PAH and CTEPH. Within this study, a standardized specialized training programme with in-hospital start was successfully established in 10 European countries.

[Postacute care after transcatheter aortic valve implantation (TAVI)]. / Nachsorge nach kathetergestütztem perkutanen Aortenklappenersatz (TAVI).

With increasing age valvular heart disease is among the most frequent diseases of the heart. Relevant valvular disease impairs not only the long-term prognosis but also physical resilience, activities of daily living and the quality of life. In cases of middle to high-grade symptomatic cardiac defects, valve replacement or valve reconstruction is still the surgical procedure of choice; however, in recent years the transcatheter percutaneous aortic valve replacement (TAVI) procedure has become more prominent for the most frequent defect, aortic valve stenosis. This article provides an overview of the aftercare and rehabilitation of patients following a TAVI intervention.

Exercise training improves peak oxygen consumption and haemodynamics in patients with severe pulmonary arterial hypertension and inoperable chronic thrombo-embolic pulmonary hypertension: a prospective, randomized, controlled trial.

AIMS: The impact of exercise training on the right heart and pulmonary circulation has not yet been invasively assessed in patients with pulmonary hypertension (PH) and right heart failure. This prospective randomized controlled study investigates the effects of exercise training on peak VO2/kg, haemodynamics, and further clinically relevant parameters in PH patients. METHODS AND RESULTS: Eighty-seven patients with pulmonary arterial hypertension and inoperable chronic thrombo-embolic PH (54% female, 56 ± 15 years, 84% World Health Organization functional class III/IV, 53% combination therapy) on stable disease-targeted medication were randomly assigned to a control and training group. Medication remained unchanged during the study period. Non-invasive assessments and right heart catheterization at rest and during exercise were performed at baseline and after 15 weeks. Primary endpoint was the change in peak VO2/kg. Secondary endpoints included changes in haemodynamics. For missing data, multiple imputation and responder analyses were performed. The study results showed a significant improvement of peak VO2/kg in the training group (difference from baseline to 15 weeks: training +3.1 ± 2.7 mL/min/kg equals +24.3% vs. control -0.2 ± 2.3 mL/min/kg equals +0.9%, P < 0.001). Cardiac index (CI) at rest and during exercise, mean pulmonary arterial pressure, pulmonary vascular resistance, 6 min walking distance, quality of life, and exercise capacity significantly improved by exercise training. CONCLUSION: Low-dose exercise training at 4-7 days/week significantly improved peak VO2/kg, haemodynamics, and further clinically relevant parameters. The improvements of CI at rest and during exercise indicate that exercise training may improve the right ventricular function. Further, large multicentre trials are necessary to confirm these results.

Economic evaluation of exercise training in patients with pulmonary hypertension.

PURPOSE: Exercise training as an add-on to medical therapy has been shown to improve exercise capacity, quality of life, and possibly prognosis in patients with pulmonary hypertension (PH). The purpose of this study was to analyze the impact of exercise training on healthcare costs in PH. METHODS: Estimated healthcare costs have been compared between patients with severe PH under optimized medical therapy only (control group) versus patients who received exercise training as an add-on to medical therapy (training group). Cost-analysis included a cost-estimation model of costs for baseline and follow-up visits and all PH-related healthcare events that occurred within the follow-up period. Time to clinical worsening and survival were assessed by clinical records, phone, and/or control visits. RESULTS: At baseline, the training (n = 58) and control group (n = 48) did not differ in age, gender, WHO-functional class, 6-min walking distance, hemodynamic parameters, or PH-targeted medication. During a follow-up of 24 ± 12 months, the training group had significantly better survival rates at 1 and 3 years and less worsening events (death, lung transplantation, hospitalization due to PH, new PAH-targeted medication) than the control group (15 vs. 25 events, p < 0.05), which also led to lower estimated healthcare costs of 657 within a period of 2 years. CONCLUSIONS: This is the first study to investigate the cost-effectiveness of exercise training in PH. Due to less worsening events within 2 years, healthcare costs were lower in patients performing exercise training as add-on to medical therapy than in patients with medical treatment only. Further prospective, randomized studies are needed to confirm these findings.

[What do rehabilitation patients expect from a telemedicine cardiac rehab aftercare? Results from interviews with rehabilitation patients]. / Welche Erwartungen haben Rehabilitanden an eine telemedizinische kardiologische Reha-Nachsorge? Ergebnisse aus Interviews mit Rehabilitanden.

BACKGROUND: Rehabilitation aftercare programs can enable patients with cardiovascular disease to sustain and improve achievements made during their rehabilitation. However, not every patient is able to attend outpatient aftercare programs, especially if they interfere with professional or social responsibilities. Telemedical alternatives could provide those patients with longer durations or varying degrees of aftercare, regardless of location or time restriction. The present study aimed to investigate what cardiovascular rehabilitation patients expect from a telemedical aftercare program. METHODS: Data was collected in individual semi-structured interviews with cardiovascular rehabilitation patients, where subjects were asked about their expectations towards a telemedical aftercare program. To identify groups of associated topics, the results obtained were analyzed using qualitative content analysis. RESULTS: Nine cardiovascular rehabilitation patients were interviewed (8 male, 1 female). None of the respondents had ever taken part in a telemedical aftercare program; however, eight out of the nine patients indicated their willingness to participate in such a program. Patients preferred telephone-based aftercare programs where they could speak with a member of staff familiar with the patient's clinical picture, circumstances and goals. Some respondents wanted additional web-based services or services via text message. CONCLUSIONS: Overall, the option of telemedical aftercare was viewed favorably by rehabilitation patients as long as the program included personal contact with a healthcare provider. Respondents preferred interaction via familiar media, especially by phone. Low-threshold experiences with new technologies may help overcome reservations and facilitate acceptance of innovative telemedical services in rehabilitation patients. Personal interaction with an attending member of staff should occur throughout aftercare programs, at least occasionally or during initial the stage.