The Prevention and Cardiac Rehabilitation Group of the Saudi Heart Association Recommendations Regarding Establishing a Cardiac Rehabilitation Service.

Cardiac rehabilitation (CR) is a cornerstone in the secondary prevention of cardiovascular disease (CVD). Comprehensive cardiac rehabilitation has obtained the highest class of recommendation and the level of evidence for the treatment of patients with ST-segment elevation myocardial infarction, after myocardial revascularization, with chronic coronary syndromes, and in patients with heart failure (HF). Comprehensive cardiac rehabilitation should be implemented as soon as possible, be multi-phasic, and adjusted to the individual needs of the patient. CR is still suboptimally used, and many cardiac centers do not have such services (2). The provision of CR services should be based on standards and key performance indicators, and guidelines containing a minimum standard of cardiac rehabilitation utilization should be published to improve the quality of the CR program. This document presents an expert opinion that summarizes the current medical knowledge concerning the goals, target population, organization, clinical indications, and implementation methods of the CR program in the Kingdom of Saudi Arabia.

Comprehensive cardiac rehabilitation as the keystone in the secondary prevention of cardiovascular disease.

Comprehensive cardiac rehabilitation (CR) is a mainstay of the secondary prevention of cardiovascular disease. In the European Society of Cardiology guidelines, comprehensive cardiovascular rehabilitation has the highest class of recommendation and level of evidence as an effective method for the treatment of patients with ST-segment elevation myocardial infarction, after myocardial revascularization, with chronic coronary syndrome, for CVD prevention in clinical practice, and in patients with heart failure (HF). This document presents an expert opinion of the Cardiac Rehabilitation and Exercise Physiology Section of the Polish Cardiac Society concerning the definition, goals, target population, organization of rehabilitation services, standard clinical indications and methods of implementation. Moreover, it describes psychosocial risk factors influencing the course of CR and secondary prevention of cardiovascular disease in patients undergoing CR. Comprehensive CR is as a process that should be implemented as soon as possible, continued without interruption, and consist of multiple stages. Moreover, it should be tailored to the individual clinical situation and should be accepted by the patient and their family, friends, and caregivers.

Cardiopulmonary exercise testing in adult cardiology: expert opinion of the Working Group of Cardiac Rehabilitation and Exercise Physiology of the Polish Cardiac Society.

Cardiopulmonary exercise testing (CPET) is an important diagnostic tool in contemporary clinical practice. This document presents an expert opinion from the Working Group on Cardiac Rehabilitation and Exercise Physiology of the Polish Cardiac Society concerning the indications, performance technique, and interpretation of results for CPET in adult cardiology. CPET is an electrocardiographic exercise test expanded with exercise evaluation of ventilatory and gas exchange parameters. It allows for a global assessment of the exercise performance including the pulmonary, cardiovascular, hematopoietic, neuropsychological, and musculoskeletal systems. It provides a noninvasive dynamic evaluation during exercise and is a reference modality for exercise capacity assessment. Moreover, it allows the measurement of numerous prognostic parameters. It is useful in cardiology, pulmonology, oncology, perioperative assessment, rehabilitation as well as in sports medicine and in the evaluation of healthy people. This test not only helps to diagnose the causes of exercise intolerance but also supports the evaluation of the treatment. New opportunities are offered by combining CPET with imaging such as exercise stress echocardiography. These tests are complementary and synergistic in their diagnostic and prognostic strength.

Electrocardiographic exercise testing in adults: performance and interpretation. An expert opinion of the Polish Cardiac Society Working Group on Cardiac Rehabilitation and Exercise Physiology.

Electrocardiographic (ECG) exercise stress test has been a major diagnostic test in cardiology for several decades. Ongoing technological advances that have led to a wide use of imaging techniques and development of new guidelines have called for a revised and updated approach to the technique and interpretation of the ECG exercise testing. The present document outlines an expert opinion of the Polish Cardiac Society Working Group on Cardiac Rehabilitation and Exercise Physiology regarding the performance and interpretation of ECG exercise testing in adults. We discussed technical requirements and necessary equipment for the exercise testing laboratory as well as healthcare personnel competencies necessary to supervise ECG exercise testing and fully interpret test findings. Broad indications for ECG exercise testing include diagnostic assessment of coronary artery disease (CAD), including pre-test probability of CAD, evaluation of functional disease severity and risk strati- fication in patients with established CAD, assessment of response to treatment, evaluation of exercise-related symptoms and exercise capacity, patient evaluation before exercise training/cardiac rehabilitation, and risk stratification prior to non-cardiac surgery. ECG exercise testing is safe if indications and contraindications are observed, testing is appropriately monitored, and indications for test termination are clearly established. The exercise protocol should be adjusted to the expected exercise capacity of a patient so as to limit the duration of exercise to 8-12 min. Clinical, haemodynamic, and ECG response to exercise is evaluated during the test. The test report should include information about the exercise protocol used, reason for test termination, perceived exertion, presence/severity of anginal symptoms, peak exercise capacity or tolerated workload in relation to the predicted exercise capacity, heart rate response, and the presence or absence of ST-T changes. The test report should conclude with a summary including clinical and ECG assessment.

Impact of exercise-based cardiac rehabilitation on attitude to the therapy, aims in life and professional work in patients after myocardial infarction.

BACKGROUND: Comprehensive cardiac rehabilitation aims to restore pathophysiological and psychosocial consequences of myocardial infarction (MI). The aim of the study was to assess how exercise-only-based cardiac rehabilitation (ECR) influences the attitude to the therapy (ATT), to the aims in life and professional work (AAL) amongst men and women after MI. MATERIAL AND METHODS: The study comprised 44 post-MI patients: 28 men and 16 women, mean age 58±10 years old, referred to ECR. Patients underwent 24 interval cycle ergometer trainings 3 times a week. At the beginning and after the training program (TP) each patient underwent exercise stress test (EST) and was scored to ATT and ALL based on the Psychological Effects of Rehabilitation Score Scale (PERSS) according to Tylka and Makowska. The analysis covered: 1) EST findings: maximal workload and test duration (min), 2) ATT and AAL based on PERSS, 3) resuming professional work. RESULTS: Exercise capacity improved significantly after TP. Attitude to the aims in life and professional work significantly increased in the whole group (4.4±2.8 vs. 5.1±2.4, p < 0.01) and separately in men (4.5±2.9 vs. 5.1±2.5, p < 0.05) and women (4.3±2.6 vs. 5.0±2.0, p < 0.05). Attitude to the therapy did not change significantly in the whole group (5.6±2.8 vs. 6.0±2.8) and in men (5.9±2.9 vs. 6.0±2.9), but increased significantly in women (5.0±2.5 vs. 6.1±2.7, p < 0.05). Professional work was resumed, averagely by 86.4% of all patients (85.7% men and 87.5% women). CONCLUSIONS: Physical training beneficially influenced post-MI men's and women's attitude to the aims in life, professional work and attitude to the therapy in women. Med Pr. 2019;70(1):1-7.

Myocardial Expression of PPARγ and Exercise Capacity in Patients after Coronary Artery Bypass Surgery.

Activation of PPARs may be involved in the development of heart failure (HF). We evaluated the relationship between expression of PPARγ in the myocardium during coronary artery bypass grafting (CABG) and exercise tolerance initially and during follow-up. 6-minute walking test was performed before CABG, after 1, 12, 24 months. Patients were divided into two groups (HF and non-HF) based on left ventricular ejection fraction and plasma proBNP level. After CABG, 67% of patients developed HF. The mean distance 1 month after CABG in HF was 397 ± 85 m versus 420 ± 93 m in non-HF. PPARγ mRNA expression was similar in both HF and non-HF groups. 6MWT distance 1 month after CABG was inversely correlated with PPARγ level only in HF group. Higher PPARγ expression was related to smaller LVEF change between 1 month and 1 year (R = 0.18, p < 0.05), especially in patients with HF. Higher initial levels of IL-6 in HF patients were correlated with longer distance in 6MWT one month after surgery and lower PPARγ expression. PPARγ expression is not related to LVEF before CABG and higher PPARγ expression in the myocardium of patients who are developing HF following CABG may have some protecting effect.

A novel model of exercise walking training in patients after coronary artery bypass grafting.

BACKGROUND: Exercise training is an established, guideline-recommended treatment approach in cardiovascular disease. Designing novel methods of exercise training that would be accepted by the patients seems to be a way to increase patient attendance at cardiac rehabilitation (CR). The 6-min walking test (6-MWT) is a simple, safe and objective method to assess exercise capacity. In patients without heart failure, oxygen consumption after 6 min of walking reaches the ventilatory threshold (VT) level. Training up to the VT level is recommended in CR. Theoretical grounds exist for designing a novel model of CR based on diagnostic 6-MWT. AIM: Pilot implementation and evaluation of the effectiveness of a new form of walking training based on 6-MWT in low-risk patients after coronary artery bypass grafting (CABG). METHODS: The study included 119 men after CABG undergoing phase II CR. Depending on whether patients granted a consent to undergo home-based electrocardiography (ECG) telemonitored CR or not, they were divided into two groups: group A (60 patients) - standard CR combined with the new model (walking 6 times for 6 min with 3-min intervals) for 5 days a week; and group B (59 controls) - standard CR. At baseline and after 3 and 12 months, the patients underwent the following tests: 6-MWT, 24-h Holter ECG monitoring (including evaluation of heart rate variability), and biochemical laboratory tests. RESULTS: No significant differences in 6-MWT distance were found between the groups at baseline and at 3 and 12 months. At 3 months, 6-MWT distance increased significantly in both groups (group A: 419 ± 73 vs. 515 ± 70 m, p < 0.02; group B: 422 ± 86 vs. 519 ± 73 m, p < 0.02). At 3 and 12 months, body mass was higher in group B controls (p < 0.05). At 3 months, glycaemia and high-sensitivity C-reactive protein (hsCRP) levels were significantly lower in group A patients (p < 0.05). At 12 months, triglyceride levels were higher in group B (p < 0.05). At 3 months, SDNN was higher in group A. After 12 months, LF was lower in group A. At baseline, the LF/HF ratio was significantly higher in group A (p < 0.05) but during further follow-up, favourable changes in the LF/HF ratio were noted only in group A. CONCLUSIONS: The novel model of exercise walking training had a favourable effect on body mass, glycaemia and hsCRP level reduction, and induced favourable changes of the sympathovagal balance.

Feasibility of home-based cardiac telerehabilitation: Results of TeleInterMed study.

BACKGROUND: Cardiac rehabilitation (CR) is recommended as an important component of a comprehensive approach to cardiovascular disease (CVD) patients. Data have shown that a small percentage of eligible patients participate in CR despite their well established benefits. Applying telerehabilitation provides an opportunity to improve the implementation of and adherence to CR. The purpose of the study was to evaluate a wide implementation and feasibility of home-based cardiac telerehabilitation (HTCR) in patients suffering from CVD and to assessits safety, patients' acceptance of and adherence to HTCR. METHODS: The study included 365 patients (left ventricular ejection fraction 56 ± 8%; aged 58 ± 10 years). They participated in 4-week HTCR based on walking, nordic walking or cycloergometer training. HTCR was telemonitored with a device adjusted to register electrocardiogram (ECG) recording and to transmit data via mobile phone to the monitoring center. The moments of automatic ECG registration were pre-set and coordinated with CR. The influence on physical capacity was assessed by comparing changes - in time of exercise test, functional capacity, 6-min walking test distance from the beginning and the end of HTCR. At the end of the study, patients filled in a questionnaire in order to assess their acceptance of HTCR. RESULTS: HTCR resulted in a significant improvement in all parameters. There were neither deaths nor adverse events during HTCR. Patients accepted HTCR, including the need for interactive everyday collaboration with the monitoring center. There were only 0.8% non-adherent patients. CONCLUSIONS: HTCR is a feasible, safe form of rehabilitation, well accepted by patients. The adherence to HTCR was high and promising.

Influence of warm­up ischemia on the effects of exercise training in patients with stable angina.

INTRODUCTION:  It is still unknown whether ischemia­inducing training in patients with stable angina is superior to the training conducted below the ischemic threshold (IT) according to the current guidelines. OBJECTIVES:  The aim of the study was to assess the influence of warm­up ischemia prior to training on the effects of training conducted either at or below the IT in patients with stable angina. PATIENTS AND METHODS:  Thirty male patients aged 56 ±8 years, after myocardial infarction, with stable angina and positive exercise test (ET1) were divided into 2 groups: group A included 18 patients with the warm­up effect, group B - 12 patients without this effect. All patients followed an 8­week interval training program (TP). The intensity of training was planned to reach the heart rate at the IT. Successive ETs were performed immediately after the TP (ET2), at day 3 (ET3), day 10 (ET4), and at 1 month (ET5).   RESULTS:  After the TP, there was a statistically significant improvement in group A in all analyzed variables except maximum ST depression (max STD). Maximal workload increased by 28%, walking distance by 24%, duration by 20%, and time to 1­mm STD by 28%. Max STD reduction amounted to 14% (P =0.13). The beneficial effect of training on exercise­induced ischemia was maintained for up to 10 days (ET4) and on physical capacity for up to 1 month (ET5). In group B, the TP did not affect time to 1­mm STD, but physical capacity improved significantly and was maintained for up to 1 month (ET5). CONCLUSIONS:  The warm­up effect appears to be necessary to attenuate myocardial ischemia after training. 

Antioxidative activity of sulodexide, a glycosaminoglycan, in patients with stable coronary artery disease: a pilot study.

BACKGROUND: Oxidative stress may promote chronic inflammation and contribute to accelerated atherogenesis in patients with coronary artery disease (CAD). Sulodexide, a glycosaminoglycan consisting primarily of heparin, has been shown to affect oxidative stress in experimental settings. The purpose of this pilot study was to determine the effect of sulodexide administration on oxidative stress, inflammation and plasma lipids in patients with proven stable CAD. MATERIAL/METHODS: Fifty-six optimally treated male CAD patients (pts), mean age 57+/-6 yrs, were randomized to either 8 weeks of sulodexide treatment (SUL, n=28), or to a control group (n=28). At baseline and at the end of the study, all pts underwent full clinical and standard laboratory plasma level assessment of lipids, markers of inflammation, and 8-isoprostane, as a sensitive index of oxidative stress. RESULTS: At entry the 2 groups did not differ significantly in terms of age, coronary risk factors, clinical status and concomitant medication. SUL treatment appeared to be safe and caused a significant decrease in the level of plasma 8-isoprostane (77.4 vs 44.5 pg/ml, p<0.0001) compared with controls (75.7 vs 68.3 pg/ml, p=NS). In contrast, neither LDL cholesterol (2.71 vs 2.72 mmol/l) and triglycerides (1.38 vs 1.43 mmol/l), nor markers of inflammation - fibrinogen (3.7 vs 3.6 g/l), C-reactive protein (0.14 vs 0.13 mg/l), leukocyte count (6.33 vs 6.32x10(9)/l) - were affected by SUL treatment. CONCLUSIONS: Sulodexide administration resulted in significant reduction in oxidative stress in stable CAD patients, and neither the changes in cholesterol metabolism nor in systemic inflammation underlay this effect.

Cardiac rehabilitation following myocardial infarction.

This article provides an overview of current recommendations regarding cardiac rehabilitation (CR) after myocardial infarction and its clinical application. Evidence shows that exercise- based CR after cardiac events positively affects the extent of disability and level of quality of life, and has also important beneficial role in modifying morbidity and mortality. Cardiac rehabilitation is an integral component of the care for patients who have undergone acute myocardial infarction, after invasive coronary procedures and those with chronic stable angina. Although in the last four decades physical training has assumed a major role in health care of coronary artery disease patients, cardiac rehabilitation does not consist exclusively of regular exercising. Comprehensive cardiac rehabilitation should include the following components: clinical evaluation, optimization of pharmacotherapy, physical training, psychological rehabilitation, evaluation and reduction of coronary disease risk factors, life style modification, and patient education. Comprehensive cardiac rehabilitation should be addressed by the designated team (physician, physiotherapist, nurse, psychologist, dietician, social worker) immediately after acute phase of myocardial infarction and should contain individualized programs designed to optimize physical, psychological, social and emotional status. Modern model of comprehensive cardiac rehabilitation should be initiated as early as possible, continued for required time, properly staged, and individualized depending on clinical status of the patients.

[Transplant coronary artery disease--treatment with statins]. / Transplantacyjna choroba wiencowa--leczenie statynami.

Hypercholesterolemia is a common disorder after heart transplantation and my be associated with the development of transplant coronary artery disease. 3-hydroxy 3-methylglutaryl coenzyme A reductase inhibitors (HMG CoA) are the most effective drugs to lower cholesterol level in transplant patients. However, interaction of immunosuppressants with HMG CoA inhibitors, which are metabolized by cytochrome P 450, increase incidence of skeletal muscle myopathy and rhabdomyolysis.

[Skeletal myopathy associated with concomitant use of statin and cyclosporin in a heart transplant patient - case report]. / Miopatia zwiazana ze stosowaniem statyny wraz z cyklosporyna po transplantacji serca.

62-year-old woman after heart transplantation due to congestive heart failure of ischemic origin with history of hyperlipidemia was treated with cyclosporin and statin. Concomitant use of these agents caused clinical and biochemical symptoms of skeletal myopathy. After statin withdrawal the symptoms of myopathy disappeared.