Do clinicians prescribe exercise similarly in patients with different cardiovascular diseases? Findings from the EAPC EXPERT working group survey

Background: Although disease-specific exercise guidelines for cardiovascular disease (CVD) are widely available, it remains uncertain whether these different exercise guidelines are integrated properly for patients with different CVDs. The aim of this study was to assess the inter-clinician variance in exercise prescription for patients with various CVDs and to compare these prescriptions with recommendations from the EXercise Prescription in Everyday practice and Rehabilitative Training (EXPERT) tool, a digital decision support system for integrated state-of-the-art exercise prescription in CVD. Design: The study was a prospective observational survey. Methods: Fifty-three CV rehabilitation clinicians from nine European countries were asked to prescribe exercise intensity (based on percentage of peak heart rate (HRpeak)), frequency, session duration, programme duration and exercise type (endurance or strength training) for the same five patients. Exercise prescriptions were compared between clinicians, and relationships with clinician characteristics were studied. In addition, these exercise prescriptions were compared with recommendations from the EXPERT tool. Results: A large inter-clinician variance was found for prescribed exercise intensity (median (interquartile range (IQR)): 83 (13) % of HRpeak), frequency (median (IQR): 4 (2) days/week), session duration (median (IQR): 45 (18) min/session), programme duration (median (IQR): 12 (18) weeks), total exercise volume (median (IQR): 1215 (1961) peak-effort training hours) and prescription of strength training exercises (prescribed in 78% of all cases). Moreover, clinicians’ exercise prescriptions were significantly different from those of the EXPERT tool (p < 0.001). Conclusions: This study reveals significant inter-clinician variance in exercise prescription for patients with different CVDs and disagreement with an integrated state-of-the-art system for exercise prescription, justifying the need for standardization efforts regarding integrated exercise prescription in CV rehabilitation

Can level of education, accreditation and use of databases in cardiac rehabilitation be improved? Results from the European Cardiac Rehabilitation Inventory Survey

Introduction: Professional skills, education and accreditation, along with clinical outcome assessment, are considered important factors to achieve comprehensive delivery and quality of cardiac rehabilitation (CR). This study assessed professional educational programmes, accreditation and use of databases in CR across the European countries. Materials and methods: Questions on professional education, accreditation and clinical databases from the European Cardiac Rehabilitation Inventory Survey, which is a postal questionnaire survey, conducted from November 2007 to January 2009 among national CR-related organizations in Europe; 28 countries responded (72%) to this survey. Results: Among the participating countries, 32% had guidelines on professional CR skills, 61% had formal educational programmes and 29% had accreditation systems for professional CR skills. One hundred and seventy-four ad-hoc educational and scientific activities were registered during 2005–2007. Forty-three percent of the countries had established CR programme accreditation systems, primarily aimed at phase 2. One in three (35%) countries had established clinical CR databases with a further 25% planning to do so. Conclusion: More than half of the European countries had developed formal CR educational programmes. Furthermore, many ad-hoc CR-related meetings and conference activities take place across Europe. Although only a quarter of countries had developed accreditation systems aimed at professionals, programme accreditation was somewhat more widespread with over a third having programme accreditation systems. Clinical databases were underdeveloped. A greater focus on education, accreditation and database implementation is needed to promote CR availability and the quality of CR services for the benefit of cardiac patients across Europe

The European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool : A digital training and decision support system for optimized exercise prescription in cardiovascular disease. Concept, definitions and construction methodology

Background Exercise rehabilitation is highly recommended by current guidelines on prevention of cardiovascular disease, but its implementation is still poor. Many clinicians experience difficulties in prescribing exercise in the presence of different concomitant cardiovascular diseases and risk factors within the same patient. It was aimed to develop a digital training and decision support system for exercise prescription in cardiovascular disease patients in clinical practice: the European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool. Methods EXPERT working group members were requested to define (a) diagnostic criteria for specific cardiovascular diseases, cardiovascular disease risk factors, and other chronic non-cardiovascular conditions, (b) primary goals of exercise intervention, (c) disease-specific prescription of exercise training (intensity, frequency, volume, type, session and programme duration), and (d) exercise training safety advices. The impact of exercise tolerance, common cardiovascular medications and adverse events during exercise testing were further taken into account for optimized exercise prescription. Results Exercise training recommendations and safety advices were formulated for 10 cardiovascular diseases, five cardiovascular disease risk factors (type 1 and 2 diabetes, obesity, hypertension, hypercholesterolaemia), and three common chronic non-cardiovascular conditions (lung and renal failure and sarcopaenia), but also accounted for baseline exercise tolerance, common cardiovascular medications and occurrence of adverse events during exercise testing. An algorithm, supported by an interactive tool, was constructed based on these data. This training and decision support system automatically provides an exercise prescription according to the variables provided. Conclusion This digital training and decision support system may contribute in overcoming barriers in exercise implementation in common cardiovascular diseases

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

Prevalence of colonization by methicillin-resistant Staphylococcus aureus ST398 in pigs and pig farm workers in an area of Catalonia, Spain

Background: A livestock-associated clonal lineage (ST398) of methicillin-resistant Staphylococcus aureus (MRSA) has been identified causing colonization or infection in farm workers. The aim of the study was to analyze the prevalence of MRSA-ST398 colonization in pigs and in pig farmers in an area with a high pig population (Osona, Barcelona province, Catalonia, Spain). Methods: We performed a cross-sectional prevalence study in Osona (Catalonia, Spain), from June 2014 to June 2015. All pig farm workers from 83 farms were studied. Twenty of these farms were randomly selected for the study of both pigs and farmers: 9 fattening and 11 farrow-to-finish farms. All workers over the age of 18 who agreed to participate were included. Samples were analyzed to identify MRSA-ST398 and their spa type. Results: Eighty-one of the 140 pig farm workers analyzed (57.9% (95% IC: 50.0-66.4%)) were MRSA-positive, all of them ST398. The mean number of years worked on farms was 17.5 ± 12.6 (range:1-50), without significant differences between positive and negative MRSA results (p = 0.763). Over 75% of MRSA-ST398 carriers worked on farms with more than 1250 pigs (p < 0.001). At least one worker tested positive for MRSA-ST398 on all 20 selected pig farms. Ninety-two (46.0% (95% IC: 39.0-53.0%)) of the nasal swabs from 200 pigs from these 20 farms were MRSA-positive, with 50.5% of sows and 41.4% of fattening pigs (p = 0.198) giving MRSA-positive results. All the isolates were tetracycline-resistant, and were identified as MRSA-ST398. The spa type identified most frequently was t011 (62%). Similar spa types and phenotypes of antibiotic resistance were identified in pigs and farmers of 19/20 tested farms. Conclusions: The prevalence of MRSA-ST398 among pig farm workers and pigs on farms in the studied region is very high, and the size of the farm seems to correlate with the frequency of colonization of farmers. The similar spa-types and phenotypes of resistance detected in pigs and workers in most of the farms studied suggest animal-to-human transmission. © 2016 The Author(s)

Exercise Prescription in Patients with Different Combinations of Cardiovascular Disease Risk Factors : A Consensus Statement from the EXPERT Working Group

Whereas exercise training is key in the management of patients with cardiovascular disease (CVD) risk (obesity, diabetes, dyslipidaemia, hypertension), clinicians experience difficulties in how to optimally prescribe exercise in patients with different CVD risk factors. Therefore, a consensus statement for state-of-the-art exercise prescription in patients with combinations of CVD risk factors as integrated into a digital training and decision support system (the EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool) needed to be established. EXPERT working group members systematically reviewed the literature for meta-analyses, systematic reviews and/or clinical studies addressing exercise prescriptions in specific CVD risk factors and formulated exercise recommendations (exercise training intensity, frequency, volume and type, session and programme duration) and exercise safety precautions, for obesity, arterial hypertension, type 1 and 2 diabetes, and dyslipidaemia. The impact of physical fitness, CVD risk altering medications and adverse events during exercise testing was further taken into account to fine-tune this exercise prescription. An algorithm, supported by the interactive EXPERT tool, was developed by Hasselt University based on these data. Specific exercise recommendations were formulated with the aim to decrease adipose tissue mass, improve glycaemic control and blood lipid profile, and lower blood pressure. The impact of medications to improve CVD risk, adverse events during exercise testing and physical fitness was also taken into account. Simulations were made of how the EXPERT tool provides exercise prescriptions according to the variables provided. In this paper, state-of-the-art exercise prescription to patients with combinations of CVD risk factors is formulated, and it is shown how the EXPERT tool may assist clinicians. This contributes to an appropriately tailored exercise regimen for every CVD risk patient