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Background: Home-based interventions might facilitate the lifelong uptake of a physically active lifestyle following completion of a supervised phase II exercise-based cardiac rehabilitation. Yet, data on the long-term effectiveness of home-based exercise training on physical activity and exercise capacity are scarce., Objective: The purpose of the TeleRehabilitation in Coronary Heart disease (TRiCH) study was to compare the long-term effects of a short home-based phase III exercise programme with telemonitoring guidance to a prolonged centre-based phase III programme in coronary artery disease patients. The primary outcome was exercise capacity. Secondary outcomes included physical activity behaviour, cardiovascular risk profile and health-related quality of life., Methods: Ninety coronary artery disease patients (80 men) were randomly assigned to 3 months of home-based (30), centre-based (30) or a control group (30) on a 1:1:1 basis after completion of their phase II ambulatory cardiac rehabilitation programme. Outcome measures were assessed at discharge of the phase II programme and after one year., Results: Eighty patients (72 (91%) men; mean age 62.6 years) completed the one-year follow-up measurements. Exercise capacity and secondary outcomes were preserved in all three groups ( P time  > 0.05 for all), irrespective of the intervention ( P interaction  > 0.05 for all). Eighty-five per cent of patients met the international guidelines for physical activity ( P time  < 0.05). No interaction effect was found for physical activity., Conclusion: Overall, exercise capacity remained stable during one year following phase II cardiac rehabilitation. Our home-based exercise intervention was as effective as centre-based and did not result in higher levels of exercise capacity and physical activity compared to the other two interventions., Trial Registration: ClinicalTrials.gov NCT02047942. https://clinicaltrials.gov/ct2/show/NCT02047942.

Exercise training improves peak oxygen uptake, an important predictor of mortality in coronary artery disease patients. The influence of clinical and disease characteristics on training response is not well established in coronary artery disease. Therefore, we aimed to evaluate whether baseline cardiovascular disease variables and training intensity can predict the maximal aerobic response to exercise training. The Study on Aerobic INTerval EXercise training in coronary artery disease patients (SAINTEX-CAD) previously showed that 12 weeks of aerobic interval training and continuous training equally improved peak oxygen uptake in coronary artery disease patients. We identified 24 exercise non-responders (change peak oxygen uptake <1 ml/kg/min) among 167 participants in SAINTEX-CAD. In a between-group comparison, exercise non-responders were older, their baseline peak oxygen uptake and oxygen uptake efficiency slope were higher, and exercise non-responders were more frequently included after elective percutaneous coronary intervention (all p  < 0.05). In multiple logistic regression analysis, age (odds ratio = 1.11 (1.04-1.18), p  = 0.001), history of elective percutaneous coronary intervention (odds ratio = 3.31 (1.12-9.76), p  = 0.030) and higher baseline peak oxygen uptake (odds ratio = 1.16 (1.06-1.27), p  = 0.001) were independent predictors of exercise non-response. In multiple linear regression analysis, age (ß = -0.605, p  = 0.001), history of elective percutaneous coronary intervention (ß = -15.401, p  = 0.010), training intensity (ß=0.447, p  = 0.008), baseline physical activity (ß=0.014, p  = 0.003) and oxygen uptake efficiency slope (ß = -0.014, p  < 0.001) predicted percentage change in peak oxygen uptake and explained 41% of the variability in percentage change in peak oxygen uptake. To summarize, 14% of coronary artery disease patients were exercise non-responders. Higher baseline peak oxygen uptake and oxygen uptake efficiency slope, history of elective percutaneous coronary intervention, older age, lower training intensity and lower baseline physical activity were predictors of training non-response. Identification of patients with a large likelihood of non-response is a first step towards patient tailored exercise programmes.

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.

Background: Peak oxygen uptake is an independent predictor of mortality in patients with coronary artery disease (CAD). However, patients with CAD are not always capable of reaching peak effort, and therefore submaximal gas exchange variables such as the oxygen uptake efficiency slope (OUES) have been introduced. Baseline exercise capacity as expressed by OUES provides prognostic information and this parameter responds to training. Therefore, we aimed to assess the prognostic value of post-training OUES in patients with CAD., Methods: We included 960 patients with CAD (age 60.6 ± 9.5 years; 853 males) who completed a cardiac rehabilitation program between 2000 and 2011. The OUES was calculated before and after cardiac rehabilitation and information on mortality was obtained. The relationships of post-training OUES with all-cause and cardiovascular (CV) mortality was assessed by Cox proportional hazards regression analyses. Receiver operator characteristic curve analysis was performed in order to obtain the optimal cut-off value., Results: During 7.37 ± 3.20 years of follow-up (range: 0.45-13.75 years), 108 patients died, among whom 47 died due to CV reasons. The post-training OUES was related to all-cause (hazard ratio: 0.50, p < 0.001) and CV (hazard ratio: 0.40, p < 0.001) mortality. When significant covariates, including baseline OUES, were entered into the Cox regression analysis, post-training OUES remained related to all-cause and CV mortality (hazard ratio: 0.40, p < 0.01 and 0.26, p < 0.01, respectively). In addition, the change in OUES due to exercise training was positively related to mortality (hazard ratio: 0.49, p < 0.01)., Conclusion: Post-training OUES has stronger prognostic value compared to baseline OUES. The lack of improvement in exercise capacity expressed by OUES after an exercise training program relates to a worse prognosis and can help distinguish patients with favorable and unfavorable prognoses., (© The European Society of Cardiology 2016.)

Background: Aerobic interval training (IT) seems to be superior to continuous training (CT) in improving exercise capacity (peak oxygen uptake (VO2)) in coronary artery disease (CAD) patients in some, but not in all studies. Based on theoretical calculations, these comparative studies stated that the energy expenditure (EE) of both programmes is similar. To date, the caloricity of both programmes has never been objectively measured. Therefore, our aim was to objectively measure the EE of the IT and CT programmes described in the protocol of the SAINTEX-CAD study (based on Wisloff et al.; ITw and CTw), and the actually performed training intensities in the SAINTEX-CAD study by Conraads et al. (ITc and CTc)., Methods: Following a two-week run-in period with three IT and three CT training sessions, 18 male CAD patients (mean age 62.4 ± 6.1 years) performed four training sessions in random order on the cycle ergometer: an ITw, CTw, ITc and CTc test session. The EE was assessed by indirect calorimetry using gas exchange measurements obtained with the Oxycon mobile., Results: We found a higher EE for CTc compared to ITc (352 ± 90.8 kcal versus 269 ± 70.7 kcal; p = 0.026), while CTw and ITw seemed to be isocaloric (317 ± 85.2 kcal versus 273 ± 65.3 kcal; p = 0.42). Higher lactate levels were reached after IT sessions (ITw 5.42 ± 1.42 mmol/l, ITc 5.05 ± 1.38 mmol/l) compared to CT sessions (CTw 2.45 ± 1.04 mmol/l, CTc 3.41 ± 1.44 mmol/l) (p < 0.01). Lactate levels increased above baseline levels (1.91 ± 0.34 mmol/l) except for the CTw session., Conclusion: CTc expended significantly more energy compared to ITc, showing that the programmes used in the SAINTEX-CAD study were not isocaloric. In contrast, isocaloricity was met for CTw and ITw., (© The European Society of Cardiology 2016.)

Background: Aerobic interval training (AIT) and aerobic continuous training (ACT) both improve physical fitness (peak VO2) in coronary artery disease patients. However, little is known about the long-term effects of AIT and ACT on peak VO2 and exercise adherence., Design: This study is a randomized clinical multicenter trial., Methods: In total, 163 patients were assessed after 12 weeks of AIT or ACT and 12 months after their enrollment. Physical fitness and physical activity measures served as the primary outcomes, and peripheral endothelial function, cardiovascular risk factors and quality of life (QoL) served as the secondary outcomes., Results: Twenty-six patients dropped out during the intervention; 11 were lost during the follow-up period. Dropouts (n = 37) consisted of more women (p = 0.001) compared to completers (n = 163). Physical fitness (VO2, heart rate and workload at peak and at thresholds) and physical activity (steps, active energy expenditure [kcal], physical activity duration [minutes]) were preserved at the 1-year follow-up (p-time > 0.05) after both AIT and ACT (p-interaction > 0.05). Forty percent of patients showed increased peak VO2, 52% showed increased active energy expenditure and 91.2% met the recommended levels of 150 minutes/week of moderate physical activity (p-group > 0.05). Further, peripheral endothelial function, QoL and cardiovascular risk factors, except systolic blood pressure (p-time < 0.05), remained stable (p-time > 0.05) after both AIT and ACT (p-interaction > 0.05)., Conclusion: The short-term improvements of center-based AIT and ACT on physical fitness, physical activity, peripheral endothelial function, cardiovascular risk factors and QoL are sustained after a 1-year follow-up period. The majority of patients (>90%) met the recommended physical activity levels of 150 minutes/week., (© The European Society of Cardiology 2016.)

Background: Peak exercise capacity is an independent predictor for mortality in patients with coronary artery disease. However, sometimes cardiopulmonary exercise tests are stopped prematurely. Therefore, submaximal exercise measures such as the oxygen uptake efficiency slope have been introduced. The aim of this study was to assess the prognostic value of the oxygen uptake efficiency slope and other exercise parameters, in patients with coronary artery disease., Methods: Between 2000 and 2011, 1409 patients with coronary artery disease (age 60.7 ± 9.9 years; 1205 males) underwent cardiopulmonary exercise tests. A maximal effort was not reached in 161 (11.5%) patients. The oxygen uptake efficiency slope was calculated and information on mortality was obtained. Cox proportional hazards regression analyses were used to assess the relation of oxygen uptake efficiency slope and other gas exchange variables with all-cause and cardiovascular mortality. Receiver operating characteristic curve analyses was performed to define optimal cut-off values., Results: During an average follow-up of 7.45 ± 3.20 years (range 0.16-13.95 years), 158 patients died, among which 68 patients for cardiovascular reasons. The oxygen uptake efficiency slope was related to all-cause (hazard ratio: 0.568, p < 0.001) and cardiovascular (hazard ratio: 0.461, p < 0.001) mortality. When significant covariates were entered in the analysis, oxygen uptake efficiency slope remained related to mortality (p < 0.05). When other submaximal exercise parameters were added to the model, oxygen uptake efficiency slope and minute ventilation/carbon dioxide production slope also remained significantly related to mortality., Conclusion: The oxygen uptake efficiency slope is an independent predictor for all-cause and cardiovascular mortality in patients with coronary artery disease, irrespective of a truly maximal effort during cardiopulmonary exercise tests. Furthermore, the oxygen uptake efficiency slope provides prognostic information, complementary to the minute ventilation/carbon dioxide production slope and peak exercise capacity., (© The European Society of Cardiology 2015.)

Background: The oxygen uptake efficiency slope (OUES) has been proposed as an independent, reproducible and objective measure of cardiorespiratory function that does not require maximal exercise testing. Existing reference values have been published for healthy paediatric populations and healthy elderly. However, reference ranges and equations for healthy adults of working age are insufficiently documented. The aim of the present study was to establish prediction equations and to describe reference values for healthy men and women aged 20-60 years., Design: Cross-sectional study., Methods: One thousand four hundred and eleven (877 men) healthy individuals (mean age 38.6 years; range 20-60) completed a maximal graded cycle exercise test until volitional exhaustion. Subsequently, oxygen uptake was plotted against the logarithm of total ventilation and the OUES was calculated by means of linear regression analysis., Results: Multivariate regression analyses revealed age, sex and body surface area as statistically significant determinants of the OUES. Following this, sex-specific prediction equations for the OUES were established and cross-validated. Finally, the distribution of the OUES with age was described and reference values were established for men and women separately., Conclusions: This study established a comprehensive set of reference values and reference equations for the OUES for a healthy population of men and women aged between 20 and 60 years., (© The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

We aimed to investigate the effect of exercise on endothelium-dependent vasodilator function assessed simultaneously in the brachial artery and in the distal arterial bed by flow-mediated dilation and the pulse amplitude tonometry method, respectively, in coronary artery disease patients. The study included 146 patients with stable coronary artery disease (123 men, mean age 62 ± 9 years) who participated in the Cardiac Rehabilitation and Genetics of Exercise performance study. All patients completed a 12-week supervised cardiac rehabilitation programme (three sessions per week at an intensity of 80% of the heart rate reserve). At baseline and upon completion of the training, we measured brachial artery diameters by means of ultrasound scanning (linear array transducer of 12 MHz) and simultaneously assessed pulse amplitudes in the fingertip using a pulse amplitude tonometry device both at rest and after reactive hyperaemia induced by a 5-min forearm cuff occlusion. Peak oxygen uptake significantly increased (+22%; p < 0.0001) and flow-mediated dilation improved from 10.0% to 13.1% (+37%; p < 0.0001), whereas the reactive hyperaemia index of the pulse amplitude tonometry method remained unchanged (p = 0.47) following exercise-based cardiac rehabilitation. However, the basal digital pulse amplitude (+58%; p < 0.001) increased as a result of training, as did the digital pulse amplitude after reactive hyperaemia (+22%; p < 0.05). Exercise-based cardiac rehabilitation is associated with an improvement in endothelial function, as can be measured by flow-mediated dilation but not by the reactive hyperaemia index of the pulse amplitude tonometry method.

Purpose: This study aimed at evaluating (1) right ventricular (RV) mean power during exercise, (2) the contribution of flow and pressure to RV mean power, and (3) the impact of pulmonary artery pressure on RV function during exercise., Methods: Fifty patients with atrial septal defect (ASD) type secundum (20 open, 30 closed) were enrolled. All underwent standard echocardiography, a bicycle stress echocardiography, and symptom-limited cardiopulmonary exercise testing. RV mean power was calculated as the product of RV cardiac output and mean pulmonary artery pressure (mPAP). RV function was assessed using RV fractional area change (FAC) at rest and at peak exercise., Results: RV mean power was linearly related with oxygen uptake (VO₂) in patients with open (R (2)= 0.88; p < 0.0001) and closed ASD (R(2)= 0.90; p < 0.0001). The increase in RV mean power was steeper in open than in closed ASD patients (p < 0.0001). The change in RV cardiac output (7.1 ± 3.4 vs. 5.7 ± 2.4 l/min; p = 0.132) was not statistically different, but the change in mPAP (21.7 ± 9.6 vs. 12.8 ± 4.6 mmHg; p < 0.0001) and RV mean power (0.97 ± 0.56 vs. 0.53 ± 0.22 W; p = 0.009) were higher in patients with an open ASD. The change in RV FAC from rest to peak exercise was related to peak mPAP in open (R = -0.589; p =  0.010) and closed (R = -0.450; p = 0.021) ASD patients., Conclusion: RV mean power during exercise is higher in patients with an open than in patients with a closed ASD. The workload of the RV in patients with an open ASD is higher at rest due to a left-to-right shunt, at peak exercise due to an additional increase in mPAP. A higher increase in afterload may affect RV function during exercise.