Impact of a comprehensive cardiac rehabilitation programme versus coronary revascularisation in patients with stable angina pectoris:study protocol for the PRO-FIT randomised controlled trial

Background: Currently, in the majority of patients with stable angina pectoris (SAP) treatment consists of optimal medical treatment, potentially followed by coronary angiography and subsequent coronary revascularisation if necessary”. Recent work questioned the effectiveness of these invasive procedures in reducing re-events and improving prognosis. The potential of exercise-based cardiac rehabilitation on clinical outcomes in patients with coronary artery disease is well-known. However, in the modern era, no studies compared the effects of cardiac rehabilitation versus coronary revascularisation in patients with SAP. Methods: In this multicentre randomised controlled trial, 216 patients with stable angina pectoris and residual anginal complaints under optimal medical treatment will be randomised to: 1) usual care (i.e., coronary revascularisation), or 2) a 12-month cardiac rehabilitation (CR) programme. CR consists of a multidisciplinary intervention, including education, exercise training, lifestyle coaching and a dietary intervention with a stepped decline in supervision. The primary outcome will be anginal complaints (Seattle Angina Questionnaire-7) following the 12-month intervention. Secondary outcomes include cost-effectiveness, ischemic threshold during exercise, cardiovascular events, exercise capacity, quality of life and psychosocial wellbeing. Discussion: In this study, we will examine the hypothesis that multidisciplinary CR is at least equally effective in reducing anginal complaints as the contemporary invasive approach at 12-months follow-up for patients with SAP. If proven successful, this study will have significant impact on the treatment of patients with SAP as multidisciplinary CR is a less invasive and potentially less costly and better sustainable treatment than coronary revascularisations. Trial registration: Netherlands Trial Register, NL9537. Registered 14 June 2021.</p

Exercise-related major adverse cardiovascular events in asymptomatic recreational master athletes:A case series

BACKGROUND: In master athletes, atherosclerotic coronary artery disease (CAD) is the primary condition leading to major adverse cardiovascular events during sports. We report two cases of asymptomatic recreational athletes who suffered from an exercise-induced cardiovascular event. CASE SUMMARY: The first athlete is a 70-year-old male speed skater without known history of cardiovascular disease. He has no typical risk factors for CAD and denied preceding symptoms. During training at the speed skating rink, he suddenly experienced severe chest pain. Electrocardiogram (ECG) showed ST-segment elevation in the precordial leads. In the ambulance, an episode of ventricular fibrillation was converted to atrial fibrillation. Coronary angiography showed a thrombus in the left anterior descending (LAD) coronary artery, treated with a glycoprotein IIb/IIIa inhibitor intravenously. The second athlete is a 59-year-old male endurance athlete who presented with chest pain during cycling. He had a history of cavotricuspid isthmus ablation and pulmonary vein isolation for paroxysmal atrial fibrillation and flutter but experienced no symptoms in the weeks prior to the event. He also had no risk factors for CAD. ECG showed ST-segment elevation in the inferior leads and reciprocal depression in V2–V4. Successful primary percutaneous intervention of the circumflex artery was performed. DISCUSSION: Limited data are available to guide recommendations for cardiovascular screening in master athletes. Since master athletes with CAD are often asymptomatic, more knowledge on the optimal pre-participation screening algorithm for identifying individuals at risk of adverse cardiac events is required

Does recovery from submaximal exercise predict response to cardiac resynchronisation therapy?

BACKGROUND: Exercise parameters are not routinely incorporated in decision making for cardiac resynchronisation therapy (CRT). Submaximal exercise parameters better reflect daily functional capacity of heart failure patients than parameters measured at maximal exertion, and may therefore better predict response to CRT. We compared various exercise parameters, and sought to establish which best predict CRT response. METHODS: In 31 patients with chronic heart failure (61% male; age 68±7 years), submaximal and maximal cycling testing was performed before and 3 months after CRT. Submaximal oxygen onset (τVO(2) onset) and recovery kinetics (τVO(2) recovery), peak oxygen uptake (VO(2) peak) and oxygen uptake efficiency slope (OUES) where measured. Response was defined as ≥15% relative reduction in end-systolic volume. RESULTS: After controlling for age, New York Heart Association and VO(2) peak, fast submaximal VO(2) kinetics were significantly associated with response to CRT, measured either during onset or recovery of submaximal exercise (area under the curve, AUC=0.719 for both; p<0.05). By contrast, VO(2) peak (AUC=0.632; p=0.199) and OUES (AUC=0.577; p=0.469) were not associated with response. Among patients with fast onset and recovery kinetics, below 60 s, a significantly higher percentage of responders was observed (91% and 92% vs 43% and 40%, respectively). CONCLUSIONS: Impaired VO(2) kinetics may serve as an objective marker of submaximal exercise capacity that is age-independently associated with non-response following CRT, whereas maximal exercise parameters are not. Assessment of VO(2) kinetics is feasible and easy to perform, but larger studies should confirm their clinical utility

Cardiac telerehabilitation:current status and future perspectives

Multidisciplinary cardiac rehabilitation (CR) improves the prognosis and quality of life of patients with cardiovascular disease and has therefore received strong recommendations in international guidelines for the treatment of patients with chronic coronary syndromes and chronic heart failure. Aiming to both resolve several barriers that impede participation in CR and to improve the effectiveness of CR, cardiac telerehabilitation (CTR) has emerged as a cost-effective alternative to traditional, centre-based CR. Although the body of evidence for the feasibility and effectiveness of CTR is large and still growing, real-life implementations are scarce, which may be due to insufficient knowledge about CTR interventions and due to the challenges its implementation comes with. Up to now, mainly exercise-related core components of CR and e‑coaching have been investigated in the setting of CTR. Translation of research findings to clinical practice may be hampered by methodological limitations present in most CTR studies, being selection bias of participants, lack of long-term follow-up, heterogeneity of studied interventions and the lack of robust outcome measures. Besides conducting highly needed implementation studies for CTR interventions, their implementation could be facilitated by the development of guideline-based, multidisciplinary and personalised CTR programmes and widespread reimbursement for CTR.</p

Effects and costs of home-based training with telemonitoring guidance in low to moderate risk patients entering cardiac rehabilitation: The FIT@Home study

BACKGROUND: Physical training has beneficial effects on exercise capacity, quality of life and mortality in patients after a cardiac event or intervention and is therefore a core component of cardiac rehabilitation. However, cardiac rehabilitation uptake is low and effects tend to decrease after the initial rehabilitation period. Home-based training has the potential to increase cardiac rehabilitation uptake, and was shown to be safe and effective in improving short-term exercise capacity. Long-term effects on physical fitness and activity, however, are disappointing. Therefore, we propose a novel strategy using telemonitoring guidance based on objective training data acquired during exercise at home. In this way, we aim to improve self-management skills like self-efficacy and action planning for independent exercise and, consequently, improve long-term effectiveness with respect to physical fitness and physical activity. In addition, we aim to compare costs of this strategy with centre-based cardiac rehabilitation. METHODS/DESIGN: This randomized controlled trial compares a 12-week telemonitoring guided home-based training program with a regular, 12-week centre-based training program of equal duration and training intensity in low to moderate risk patients entering cardiac rehabilitation after an acute coronary syndrome or cardiac intervention. The home-based group receives three supervised training sessions before they commence training with a heart rate monitor in their home environment. Participants are instructed to train at 70-85% of their maximal heart rate for 45–60 minutes, twice a week. Patients receive individual coaching by telephone once a week, based on measured heart rate data that are shared through the internet. Primary endpoints are physical fitness and physical activity, assessed at baseline, after 12 weeks and after one year. Physical fitness is expressed as peak oxygen uptake, assessed by symptom limited exercise testing with gas exchange analysis; physical activity is expressed as physical activity energy expenditure, assessed by tri-axial accelerometry and heart rate measurements. Secondary endpoints are training adherence, quality of life, patient satisfaction and cost-effectiveness. DISCUSSION: This study will increase insight in long-term effectiveness and costs of home-based cardiac rehabilitation with telemonitoring guidance. This strategy is in line with the trend to shift non-complex healthcare services towards patients’ home environments. TRIAL REGISTRATION: Dutch Trial Register: NTR3780. Clinicaltrials.gov register: NCT0173241

Corrigendum to ‘Put your money where your feet are:The real-world effects of StepBet gamified deposit contracts for physical activity’ [Internet Interv., volume 31, March 2023, 100610] (Internet Interventions (2023) 31, (S2214782923000106), (10.1016/j.invent.2023.100610))

The authors regret that the Standard Deviation (SD) for those who failed their challenge (n = 19,693) was erroneously reported in the Abstract (page 1) and Table 2 of the Results section (page 6) as 3013 steps. The correct Standard Deviation that should have been reported there is 2993 steps. Furthermore, in the Results section under header 3.3 Exploratory Analyses (page 6) we erroneously state that exploratory analyses were performed on a subsample of 29,001 participants. The correct number that should have been reported there is 29,002 participants. The authors would like to apologise for any inconvenience caused.corrigendum voor DOI 10.1016/j.invent.2023.100610Design AestheticsApplied Ergonomics and Desig