Recommendations on how to provide cardiac rehabilitation services during the COVID-19 pandemic.

The ongoing coronavirus disease 2019 (COVID-19) crisis is having a large impact on acute and chronic cardiac care. Due to public health measures and the reorganisation of outpatient cardiac care, traditional centre-based cardiac rehabilitation is currently almost impossible. In addition, public health measures are having a potentially negative impact on lifestyle behaviour and general well-being. Therefore, the Working Group of Cardiovascular Prevention and Rehabilitation of the Dutch Society of Cardiology has formulated practical recommendations for the provision of cardiac rehabilitation during the COVID-19 pandemic, by using telerehabilitation programmes without face-to-face contact based on current guidelines supplemented with new insights and experiences.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation.

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Lyme carditis: clinical characteristics of 105 cases.

105 North American and European cases of Lyme carditis, being documented and in part published in the period 1977-1990, are reviewed and compared. The male: female ratio was 3:1, as well in Europe as in the USA. Transient atrioventricular block is the most frequent manifestation of Lyme carditis, with a remarkable similarity in the frequency of complete AV block and attending neurological illness in Europe and the USA. The distribution of (maximal observed) atrioventricular block in all patients existed of 49% third degree, 16% second degree and 12% first degree. Data of electrophysiological studies show that affection of the cardiac conduction system can be local or very diffuse. Other manifestations like rhythm disturbances, (myo)pericarditis and heart failure were less striking and have a less similar frequency in the European and American cases. Medicational therapy seems not to be an unconditional requirement for recovery of Lyme carditis itself, but cannot be withheld because of the proven beneficial effects of antibiotic therapy in other manifestations of Lyme borreliosis. Temporary pacemakers are frequently inserted, but pacemaker implantation is rarely needed. The overall prognosis of Lyme carditis seems to be good, although delayed recovery has been described and possible late manifestations have been suggested.

Range of atrioventricular conduction disturbances in Lyme borreliosis: a report of four cases and review of other published reports.

Four patients with Lyme borreliosis had atrioventricular conduction disturbances. All four were positive for specific antibodies against Borrelia burgdorferi measured by indirect immunofluorescence tests. Biopsy specimens, which were obtained in three patients, showed band-like infiltrates of plasma cells and lymphocytes in the endocardium. There was diffuse infiltration of the interstitium of the myocardium by lymphocytes, plasma cells, and macrophages. In two patients single fibre necrosis was seen in the myocardium. Biopsy specimens of the heart showed spirochetes in all three patients and serial sections stained by the Bosma-Steiner technique showed that they resembled Borrelia burgdorferi. At follow up one patient had persistent complete atrioventricular block, despite treatment with antibiotics and corticosteroid, and a permanent pacemaker was implanted.

Demonstration of spirochetes in cardiac biopsies of patients with Lyme disease.

Cardiac involvement occurring early in Borrelia burgdorferi infection is a clinical manifestation of human Lyme disease. Therefore, two patients with acute complete atrioventricular heart blocks and unexplained recurrent dizziness were studied. Both patients had significantly elevated serum titers of IgM and IgG antibodies to B. burgdorferi. Right ventricular subendocardial biopsies showed dense infiltrates consisting of lymphocytes and plasma cells. Silver staining revealed spirochetes characteristic of B. burgdorferi near and in the infiltrates, between the muscle fibers, and in the endocardium. One patient responded to penicillin; the other did not, necessitating installation of a pacemaker. Thus, permanent heart damage may result from cardiac involvement in Lyme disease.

Transient complete AV block in Lyme disease. Electrophysiologic observations.

The findings in a patient with complete AV block and intra-atrial conduction disturbances due to Lyme disease are presented. The electrocardiographic follow-up and serial EP findings suggest that complete AV block in Lyme disease may signify a more extensive affection of the AV conduction system (with eventually attendant intra-atrial conduction disturbances) than described in earlier reports. An almost complete resolution of the considerable damage to the conduction system occurred within two weeks.