Antithrombotic therapy in patients with acute coronary syndrome: similarities and differences between a European expert consensus document and the 2023 European Society of Cardiology guidelines.

Antithrombotic therapy represents the cornerstone of the pharmacological treatment in patients with acute coronary syndrome (ACS). The optimal combination and duration of antithrombotic therapy is still matter of debate requiring a critical assessment of patient comorbidities, clinical presentation, revascularization modality, and/or optimization of medical treatment. The 2023 European Society of Cardiology (ESC) guidelines for the management of patients with ACS encompassing both patients with and without ST segment elevation ACS have been recently published. Shortly before, a European expert consensus task force produced guidance for clinicians on the management of antithrombotic therapy in patients with ACS as well as chronic coronary syndrome. The scope of this manuscript is to provide a critical appraisal of differences and similarities between the European consensus paper and the latest ESC recommendations on oral antithrombotic regimens in ACS patients.

Adherence to drug therapy in patients with heart failure associated with reduced ejection fractions (HFrEF) during cardiac rehabilitation and after 3 and 6 months.

INTRODUCTION: Heart failure represents a major challenge for healthcare systems worldwide. Rehabilitation is recommended as an important pillar of therapy for these patients, especially for those with reduced left ventricular ejection fraction (HFrEF: heart failure with reduced ejection fraction). METHODS: The data collected in this multi-center project provide information on the rates of patients with HFrEF who were treated in five German rehabilitation facilities and whether the patients adhered to drug therapy at 3-/6-month follow-up. The project was supported by an unrestricted grant from Novartis-Pharma-GmbH. RESULTS: The mean age of the 234 patients included was 63.4 ± 10.6 years and 78% were male. The mean LVEF was 31 ± 8% at admission and 36 ± 10% at discharge. Only 20.6% of the patients were assigned to rehabilitation with the main indication HF. The most frequent main indication was acute coronary syndrome (46.6%). A high proportion of patients was already on the recommended drug therapy upon admission (94% beta blockers, 100% angiotensin-effective drugs, 70% mineralocorticoid receptor antagonists, etc.). This was optimized, in particular by a higher proportion of patients treated with sodium-glucose cotransporter-2 inhibitors (35% admission vs. 45% discharge) and sacubitril/valsartan (49% admission vs. 64% discharge), which was further optimized during the 6-month follow-up (e.g., 50% SGLT2 inhibitors, 67% sacubitril/valsartan). DISCUSSION: These data illustrate the effect of rehabilitation in terms of optimizing drug therapy, which stabilized over the course of 6 months. Furthermore, only a few patients with the main diagnosis HFrEF are referred for cardiac rehabilitation, although it is an essential part of guideline-based therapy.

[Work Participation after Multimodal Rehabilitation due to Cardiovascular Diseases - Representative Analyses using Routine Data of the German Pension Insurance]. / Berufliche Teilhabe nach einer medizinischen Rehabilitation aufgrund von kardiovaskulären Erkrankungen ­ Repräsentative Analysen auf Basis der Routinedaten der Deutschen Rentenversicherung.

PURPOSE: Cardiovascular diseases represent a large proportion of the disease burden of the adult population in Germany. Their importance in rehabilitation has increased continuously in recent years. Several studies have investigated return to work of cardiac patients after rehabilitation, which is relevant from the perspective of pension insurance. However, there is a lack of representative findings for the German region on employment trajectories and their influencing factors. METHODS: The rehabilitation statistics database of the German Pension Insurance (GPI) was used for this study. Subjects were patients with cardiovascular diseases undergoing rehabilitation in 2017. Analyses were performed for the total group and differentiated by relevant diagnosis groups. Occupational participation was operationalized via a monthly state variable up to 24 months after rehabilitation and the rate of all persons who were employed at the 12- and 24- month follow-up and in the 3 months before, respectively. Multiple logistic regression models were calculated to analyze the influencing factors. RESULTS: The total sample comprised 59,667 patients. The average age in all groups was between 53 and 56 years. Men were disproportionately represented; 70% of the services were provided as follow-up rehabilitations and 88% in the inpatient setting. Stable employment rates were 66% after one year and 63% after two years in the overall group (disease groups: 49% to 71%). The strongest influencing factors were the amount of pay and the number of sickness absence days before rehabilitation, active employment before rehabilitation, and age. CONCLUSION: For the first time, representative data on occupational participation following rehabilitation on behalf of the GPI are available for the disease groups considered. The analyses underline the need to focus on occupational perspectives already in medical rehabilitation or directly thereafter.

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.

Effect of multicomponent rehabilitation on independence and functioning in elderly patients with common age-associated diseases: protocol for a scoping review (REHOLD).

INTRODUCTION: Elderly patients after hospitalisation for acute events on account of age-related diseases (eg, joint or heart valve replacement surgery) are often characterised by a remarkably reduced functional health. Multicomponent rehabilitation (MR) is considered an appropriate approach to restore the functioning of these patients. However, its efficacy in improving functioning-related outcomes such as care dependency, activities of daily living (ADL), physical function and health-related quality of life (HRQL) remains unclarified. We outline the research framework of a scoping review designed to map the available evidence of the effects of MR on the independence and functional capacity of elderly patients hospitalised for age-related diseases in four main medical specialties beyond geriatrics. METHODS AND ANALYSIS: The biomedical databases (PubMed, Cochrane Library, ICTRP Search Platform, ClinicalTrials) and additionally Google Scholar will be systematically searched for studies comparing centre-based MR with usual care in patients ≥75 years of age, hospitalised for common acute events due to age-related diseases (eg, joint replacement, stroke) in one of the specialties of orthopaedics, oncology, cardiology or neurology. MR is defined as exercise training and at least one additional component (eg, nutritional counselling), starting within 3 months after hospital discharge. Randomised controlled trials as well as prospective and retrospective controlled cohort studies will be included from inception and without language restriction. Studies investigating patients <75 years, other specialties (eg, geriatrics), rehabilitation definition or differently designed will be excluded. Care dependency after at least a 6-month follow-up is set as the primary outcome. Physical function, HRQL, ADL, rehospitalisation and mortality will be additionally considered. Data for each outcome will be summarised, stratified by specialty, study design and type of assessment. Furthermore, quality assessment of the included studies will be performed. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at national and/or international congresses. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/GFK5C.

Update on the risk assessment of a rehabilitation stay for patients after allogeneic stem cell transplantation.

OBJECTIVE: High-dose chemotherapy with allogeneic stem cell transplantation is the only chance of cure for many haemato-oncological patients. After such therapy, the immune system is weakened, and the contact with other people should therefore be limited as much as possible. The question arises whether a rehabilitation stay can be recommended to these patients, which risk factors for complications during the rehabilitation stay can be identified, and whether physicians and patients can be provided with decision-making aids as to when the optimal time is to start rehabilitation. METHODS: We report about 161 rehabilitation stays of patients after high-dose chemotherapy with allogeneic stem cell transplantation. Premature discontinuation of the rehabilitation was selected as the criterion for a serious complication during the rehabilitation and the underlying reasons were analysed. RESULTS: The rate of prematurely terminated rehabilitation stays (13.6%) corresponds to our previous result from 2020. The analysis of the reasons for early termination comes to the conclusion that the rehabilitation stay is only considered as a reason for termination in very few cases, if at all. The risk factors identified for premature termination of the rehabilitation stay were male sex, the period (days) between transplantation and the beginning of the rehabilitation stay, haemoglobin value, platelets and presence of immunosuppressing agent. The most significant risk factor is a decreased platelet count at the time rehabilitation begins. The platelet count, the likelihood that it will improve in the further course and the urgency of the rehabilitation stay can be used to help decide when the optimal time for rehabilitation is given. CONCLUSION: Rehabilitation can be recommended to patients after allogeneic stem cell transplantation. Based on various factors, recommendations can be made for the right time for rehabilitation.

Antithrombotic treatment strategies in patients with established coronary atherosclerotic disease.

Multiple guidelines and consensus papers have addressed the role of antithrombotic strategies in patients with established coronary artery disease (CAD). Since evidence and terminology continue to evolve, the authors undertook a consensus initiative to guide clinicians to select the optimal antithrombotic regimen for each patient. The aim of this document is to provide an update for clinicians on best antithrombotic strategies in patients with established CAD, classifying each treatment option in relation to the number of antithrombotic drugs irrespective of whether the traditional mechanism of action is expected to mainly inhibit platelets or coagulation cascade. With the aim to reach comprehensiveness of available evidence, we systematically reviewed and performed meta-analyses by means of both direct and indirect comparisons to inform the present consensus document.

Within and beyond 12-month efficacy and safety of antithrombotic strategies in patients with established coronary artery disease: two companion network meta-analyses of the 2022 joint clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association for Acute CardioVascular Care (ACVC), and European Association of Preventive Cardiology (EAPC).

AIMS: To appraise all available antithrombotic treatments within or after 12 months following coronary revascularization and/or acute coronary syndrome in two network meta-analyses. METHODS AND RESULTS: Forty-three (N = 189 261 patients) trials within 12 months and 19 (N = 139 086 patients) trials beyond 12 months were included for efficacy/safety endpoints appraisal. Within 12 months, ticagrelor 90 mg bis in die (b.i.d.) [hazard ratio (HR), 0.66; 95% confidence interval (CI), 0.49-0.88], aspirin and ticagrelor 90 mg (HR, 0.85; 95% CI, 0.76-0.95), or aspirin, clopidogrel and rivaroxaban 2.5 mg b.i.d. (HR, 0.66; 95% CI, 0.51-0.86) were the only treatments associated with lower cardiovascular mortality, compared with aspirin and clopidogrel, without or with greater bleeding risk for the first and the other treatment options, respectively. Beyond 12 months, no strategy lowered mortality; compared with aspirin; the greatest reductions of myocardial infarction (MI) were found with aspirin and clopidogrel (HR, 0.68; 95% CI, 0.55-0.85) or P2Y12 inhibitor monotherapy (HR, 0.76; 95% CI: 0.61-0.95), especially ticagrelor 90 mg (HR, 0.54; 95% CI, 0.32-0.92), and of stroke with VKA (HR, 0.56; 95% CI, 0.44-0.76) or aspirin and rivaroxaban 2.5 mg (HR, 0.58; 95% CI, 0.44-0.76). All treatments increased bleeding except P2Y12 monotherapy, compared with aspirin. CONCLUSION: Within 12 months, ticagrelor 90 mg monotherapy was the only treatment associated with lower mortality, without bleeding risk trade-off compared with aspirin and clopidogrel. Beyond 12 months, P2Y12 monotherapy, especially ticagrelor 90 mg, was associated with lower MI without bleeding trade-off; aspirin and rivaroxaban 2.5 mg most effectively reduced stroke, with a more acceptable bleeding risk than VKA, compared with aspirin.Registration URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifiers: CRD42021243985 and CRD42021252398.

[The ECG in cardiac rehabilitation]. / Das EKG in der Rehabilitation.

The concept and the benefits of cardiac rehabilitation are well established and scientifically proven. In the context of shortened in-hospital stays and older patients receiving more complex interventions, complications of those procedures might occur during cardiac rehabilitation. This article discusses guideline-directed diagnosis and treatment of complications after transcatheter aortic valve replacement, especially delayed-onset heart block, post-operative atrial fibrillation, and acute coronary ischemia in the setting of pre-existent bundle branch block.

Impact of SARS-CoV-2 pandemic on rehabilitation of patients after high-dose chemotherapy with allogeneic hematopoietic stem cell transplantation: results of a monocentric, retrospective analysis.

OBJECTIVE: Because immunocompromised patients are particularly vulnerable during the SARS-CoV-2 pandemic, patients undergoing high-dose chemotherapy with allogeneic hematopoietic stem cell transplantation (HDC/alloSCT) face the question of whether they should enter a rehabilitation stay. We therefore asked to what extent the pandemic has changed the acceptance of a rehabilitation stay and whether and how high the risk of infection for these patients should be assessed. METHODS: We analyzed all patients after HDC/alloSCT admitted to our rehabilitation facility during the period, since the first SARS-CoV-2 wave occurred in Germany (03/15/2020) and compared them with patients admitted to our rehabilitation facility before. RESULTS: Analysis of our data showed a significant reduction in rehabilitation stays of patients after HDC/alloSCT during the SARS-CoV-2 pandemic. Patients arrived for rehabilitation significantly later after HDC/alloSCT and were less likely to take immunosuppressive medications. The anxiety score in the HADS was lower and the platelet count was higher. In contrast, parameters such as age, sex, or leukocyte value did not play a role. None of the patients became infected with SARS-CoV-2 during rehabilitation. CONCLUSIONS: The acceptance of a rehabilitation stay during the SARS-CoV-2 pandemic has changed, but there does not seem to be an increased risk for the patients.

Rehabilitation of patients after CAR T-cell therapy. Experiences on 5 patients.

OBJECTIVE: CAR T-cell therapy is an effective treatment for various relapsed or refractory haemato-oncological diseases. However, this therapy results in significant immunosuppression that lasts for months. Whether these patients are at risk during a rehabilitation stay, e.g., due to infections, has not yet been answered. METHODS: We describe the rehabilitation stay under special hygienic conditions of the five patients rehabilitated in our clinic after CAR T-cell therapy. Complications that occurred during rehabilitation are reported, as well as the positive effects of rehabilitation on physical performance, polyneuropathic complaints, anxiety and depression, and individual limitations. RESULTS: One patient reported signs of infection already at the beginning of rehabilitation. This was treated with antibiotics, and rehabilitation could be continued. No complications occurred in any of the other patients. All patients reported having benefited physically and psychologically from the rehabilitation, and two expressed the intention to return to work. CONCLUSIONS: As far as we know, this is the first report on several patients after CAR T-cell therapy. Based on the limited data, there is no reason to withhold a rehabilitation stay from patients after CAR T-cell therapy.

The First Year of Noninvasive Remote Telemonitoring in Chronic Heart Failure Is not Cost Saving but Improves Quality of Life: The Randomized Controlled CardioBBEAT Trial.

Introduction: Remote telemonitoring (RTM) for patients with chronic heart failure (HF) holds promise to improve prognosis and well-being beyond the standard of care (SoC). The CardioBBEAT trial assessed the health economic and clinical impact of an interactive bidirectional RTM system (Motiva®) versus SoC for patients with HF and a reduced ejection fraction (HFrEF), in Germany. Methods: This multicenter, randomized controlled trial enrolled 621 patients with HFrEF (mean age 63.0 ± 11.5 years, 88% men). The primary endpoint was the integrated effect of the intervention on total costs and nonhospitalized days alive after 12 months, reported as incremental cost-effectiveness ratio (ICER). Costs (in k€) were based on actual charges of patients' statutory health insurance. Among secondary outcome measures were mortality and disease-specific quality of life. Results: We found a neutral effect on nonhospitalized days alive (RTM mean 341 ± 59 days, SoC 346 ± 45 days; p = 0.298) associated with increased total costs (RTM 18.5 ± 39.5 k€, SoC 12.8 ± 22.0 k€; p = 0.046). This yielded an ICER of -1.15 k€/day. RTM did not impact mortality risk. All quality of life scales were consistently and meaningfully improved in the RTM group at 12 months compared to SoC (all p < 0.01). Conclusions: The first 12 months of RTM were not cost-effective compared to SoC in patients with HFrEF, but associated with a relevant improvement in disease-specific quality of life. The balanced assessment of the potential benefit of RTM requires integration of both the societal and patient perspective. ClinTrials.gov (NCT02293252).

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.

Test-retest reliability of center of pressure measures for postural control assessment in older cardiac patients.

BACKGROUND: Elderly patients are a growing population in cardiac rehabilitation (CR). As postural control declines with age, assessment of impaired balance is important in older CR patients in order to predict fall risk and to initiate counteracting steps. Functional balance tests are subjective and lack adequate sensitivity to small differences, and are further subject to ceiling effects. A quantitative approach to measure postural control on a continuous scale is therefore desirable. Force plates are already used for this purpose in other clinical contexts, therefore could be a promising tool also for older CR patients. However, in this population the reliability of the assessment is not fully known. RESEARCH QUESTION: Analysis of test-retest reliability of center of pressure (CoP) measures for the assessment of postural control using a force plate in older CR patients. METHODS: 156 CR patients (≥75 years) were enrolled. CoP measures (path length (PL), mean velocity (MV), and 95% confidence ellipse area (95CEA)) were analyzed twice with an interval of two days in between (bipedal narrow stance, eyes open (EO) and closed (EC), three trials for each condition, 30 s per trial), using a force plate. For test-retest reliability estimation absolute differences (Δ: T0-T1), intraclass correlation coefficients (ICC) with 95% confidence intervals, standard error of measurement and minimal detectable change were calculated. RESULTS: Under EO condition ICC were excellent for PL and MV (0.95) and good for 95CEA (0.88) with Δ of 10.1 cm (PL), 0.3 cm/sec (MV) and 1.5 cm2 (95CEA) respectively. Under EC condition ICC were excellent (≥ 0.95) for all variables with larger Δ (PL: 21.7 cm; MV: 0.7 cm/sec; 95CEA: 2.4 cm2). SIGNIFICANCE: In older CR patients, the assessment of CoP measures using a force plate shows good to excellent test-retest reliability.

Whole-Body EMS Superimposed Walking and Nordic Walking on a Treadmill-Determination of Exercise Intensity to Conventional Exercise.

Electrical muscle stimulation (EMS) is an increasingly popular training method and has become the focus of research in recent years. New EMS devices offer a wide range of mobile applications for whole-body EMS (WB-EMS) training, e.g., the intensification of dynamic low-intensity endurance exercises through WB-EMS. The present study aimed to determine the differences in exercise intensity between WB-EMS-superimposed and conventional walking (EMS-CW), and CON and WB-EMS-superimposed Nordic walking (WB-EMS-NW) during a treadmill test. Eleven participants (52.0 ± years; 85.9 ± 7.4 kg, 182 ± 6 cm, BMI 25.9 ± 2.2 kg/m2) performed a 10 min treadmill test at a given velocity (6.5 km/h) in four different test situations, walking (W) and Nordic walking (NW) in both conventional and WB-EMS superimposed. Oxygen uptake in absolute (VO2) and relative to body weight (rel. VO2), lactate, and the rate of perceived exertion (RPE) were measured before and after the test. WB-EMS intensity was adjusted individually according to the feedback of the participant. The descriptive statistics were given in mean ± SD. For the statistical analyses, one-factorial ANOVA for repeated measures and two-factorial ANOVA [factors include EMS, W/NW, and factor combination (EMS*W/NW)] were performed (α = 0.05). Significant effects were found for EMS and W/NW factors for the outcome variables VO2 (EMS: p = 0.006, r = 0.736; W/NW: p < 0.001, r = 0.870), relative VO2 (EMS: p < 0.001, r = 0.850; W/NW: p < 0.001, r = 0.937), and lactate (EMS: p = 0.003, r = 0.771; w/NW: p = 0.003, r = 0.764) and both the factors produced higher results. However, the difference in VO2 and relative VO2 is within the range of biological variability of ± 12%. The factor combination EMS*W/NW is statistically non-significant for all three variables. WB-EMS resulted in the higher RPE values (p = 0.035, r = 0.613), RPE differences for W/NW and EMS*W/NW were not significant. The current study results indicate that WB-EMS influences the parameters of exercise intensity. The impact on exercise intensity and the clinical relevance of WB-EMS-superimposed walking (WB-EMS-W) exercise is questionable because of the marginal differences in the outcome variables.