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Objectives Micro ribonucleic acids (miRNAs) are small non-coding RNA molecules that control gene expression by translational inhibition. Exercise has been shown to affect several miRNAs’ expression in healthy subjects, but this has not yet been studied in patients with coronary artery disease (CAD). Since exercise training confers beneficial long-term effects and may also trigger acute coronary events, it is of utmost interest to be able to identify those who are risk for untoward effects. Therefore, we set out to assess miRNA expression in response to maximal ergospirometry in patients with CAD. Methods Total RNA was extracted from blood drawn immediately before and 5 min after maximal cycle-ergospirometry (10 male and 10 female CAD patients). A qRT-PCR was performed for 187 target miRNAs associated with endothelial function/dysfunction, cardiovascular disease, myocardial infarction, and sudden cardiac death. Results In response to a maximal ergospirometry, 33 miRNAs significantly changed their expression levels. Of these miRNAs 16 were significantly differently expressed between gender. Using multi-variance analysis, nine miRNAs (let-7e-5p; miR-1; miR-19b-1-5p; miR-103a-3p; miR-148b-3p; miR-181b-5p; miR-188-5p; miR-423-5p; miR-874-3p) showed significantly different responses to maximal ergospirometry between genders. Conclusions We report for the first time that in patients with CAD, miRNA expression is amenable to maximal ergospirometry and that the extent of changes differs between genders. Affected by exercise and gender were miRNAs that are associated, among others, with pathways for glucose metabolism, oxidative stress, and angiogenesis. Future studies should assess whether disease-specific miRNA expression in response to maximal exercise might serve as a marker for patient outcome.

©The European Society of Cardiology 2020. Article reuse guidelines : sagepub.com/journals-permissions, Secondary prevention through comprehensive cardiac rehabilitation has been recognized as the most cost-effective intervention to ensure favourable outcomes across a wide spectrum of cardiovascular disease, reducing cardiovascular mortality, morbidity and disability, and to increase quality of life. The delivery of a comprehensive and ‘modern’ cardiac rehabilitation programme is mandatory both in the residential and the out-patient setting to ensure expected outcomes. The present position paper aims to update the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions, in order to assist the whole cardiac rehabilitation staff in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and patients in the recognition of the positive nature of cardiac rehabilitation. Starting from the previous position paper published in 2010, this updated document maintains a disease-oriented approach, presenting both well-established and more controversial aspects. Particularly for implementation of the exercise programme, advances in different training modalities were added and new challenging populations were considered. A general table applicable to all cardiovascular conditions and specific tables for each clinical condition have been created for routine practice.

Purpose Ascent to high altitude increases right ventricular (RV) afterload and decreases myocardial energy supply. This study evaluates physiologic variables and comprehensive echocardiographic indices of RV and right atrial (RA) function following rapid ascent to high altitude. Methods Fifty healthy volunteers actively ascended from 1130 to 4559 m in Results sPAP increased from baseline (24 ± 4 mmHg) to the first altitude examination (39 ± 8 mmHg, p p = 0.07) secondary to a significant increase of RA contraction strain (19.2 ± 6.4 vs. 25.4 ± 9.6%, p Conclusion Active and rapid ascent of healthy individuals to 4559 m is associated with an increased contractile performance of the RA that compensates for the increased workload of the RV.

Micro ribonucleic acids (miRNAs) are small non-coding RNA molecules that control gene expression by translational inhibition. They have been identified to play a role in a multitude of physiological and pathophysiological cellular processes amongst others in the heart. Due to their ability to be released into the blood as well as their stability in body fluids, they appear suitable as biomarkers. This review discusses the role of selected miRNA that currently emerge as biomarkers for coronary artery disease, their potential to discriminate between different diseases, as well as how they might be used as predictive tools for cardiac events or disease outcome. Furthermore, we propose procedural steps of miRNA analysis, to allow better comparison between studies in the future.

The purpose of this study was to investigate echocardiographic changes in left ventricular (LV) diastolic filling and left atrial (LA) strain mechanics following prolonged exercise. Ten male triathletes completed a 60-min swim, 180-min bike exercise, and a 60-min all-out run in a laboratory environment. Special attention was paid to prevent dehydration and energy deficit during the exercise protocol. All participants underwent comprehensive echocardiographic analyses of Doppler- and volumetric-derived LV diastolic filling indices and novel speckle-tracking echocardiography (STE)-derived LA strain indices. LV stroke volume (pre: 108.0±15.9 vs. post: 88.8±19.0 mL; p=0.03) and LA passive emptying volume (pre: 31.2±7.5 vs. post: 22.4±9.8 mL; p=0.05) were significantly reduced following the exercise protocol. Of the STE-derived indices of LA function, reservoir and conduit strain did not change significantly, while there was a trend towards enhanced contraction strain (pre: 15.1±3.8 vs. post: 19.4±4.8%; p=0.07). Resting heart rate was significantly higher post-exercise (53.1±5.0 vs. 81.9±16.9 bpm; p

This article provides an overview of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology on sports participation in individuals with valvular heart disease (VHD). The aim of these recommendations is to encourage regular physical activity including sports participation, with reasonable precaution to ensure a high level of safety for all affected individuals. Valvular heart disease is usually an age-related degenerative process, predominantly affecting individuals in their fifth decade and onwards. However, there is an increasing group of younger individuals with valvular defects. The diagnosis of cardiac disorders during routine cardiac examination often raises questions about on-going participation in competitive sport with a high dynamic or static component and the level of permissible physical effort during recreational exercise. Although the natural history of several valvular diseases has been reported in the general population, little is known about the potential influence of chronic intensive physical activity on valve function, left ventricular remodelling pulmonary artery pressure, and risk of arrhythmia. Due to the sparsity of data on the effects of exercise on VHD, the present document is largely based on clinical experience and expert opinion.

SARS‐CoV‐2 infection has emerged as not only a pulmonary but also potentially multi‐organ disease, which may cause long‐term structural damage of different organ systems including the lung, heart, vasculature, brain, liver, kidney, or intestine. As a result, the current SARS‐CoV‐2/COVID‐19 pandemic will eventually yield substantially increased numbers of chronically diseased patients worldwide, particularly suffering from pulmonary fibrosis, post‐myocarditis, chronic heart failure, or chronic kidney disease. Exercise recommendations for rehabilitation are complex in these patients and should follow current guidelines including standards for pre‐exercise medical examinations and individually tailored exercise prescription. It is of utmost importance to start exercise training at an early stage after COVID‐19 infection, but at the same time paying attention to the physical barriers to ensure safe return to exercise. For exercise recommendations beyond rehabilitation programs particularly for leisure time and elite athletes, more precise advice is required including assessment of sports eligibility and specific return‐to‐sports exercise programs. Because of the current uncertainty of long‐term course of SARS‐CoV‐2 infection or COVID disease, long‐term follow‐up seems to be necessary., publishedVersion

Functional impairment caused by chronic obstructive pulmonary disease (COPD) impacts on activities of daily living and quality of life. Indeed, patients’ submaximal exercise capacity is of crucial importance. It was the aim of this study to investigate the effects of an exercise training intervention with and without supplemental oxygen on submaximal exercise performance. This is a secondary analysis of a randomized, controlled, double‐blind, crossover trial. 29 COPD patients (63.5 ± 5.9 years; FEV1 46.4 ± 8.6%) completed two consecutive 6‐week periods of high‐intensity interval cycling and strength training, which was performed three times/week with either supplemental oxygen or medical air (10 L/min). Submaximal exercise capacity as well as the cardiocirculatory, ventilatory, and metabolic response were evaluated at isotime (point of termination in the shortest cardiopulmonary exercise test), at physical work capacity at 110 bpm of heart rate (PWC 110), at the anaerobic threshold (AT), and at the lactate‐2 mmol/L threshold. After 12 weeks of exercise training, patients improved in exercise tolerance, shown by decreased cardiocirculatory (heart rate, blood pressure) and metabolic (respiratory exchange ratio, lactate) effort at isotime; ventilatory response was not affected. Submaximal exercise capacity was improved at PWC 110, AT and the lactate‐2 mmol/L threshold, respectively. Although supplemental oxygen seems to affect patients’ work rate at AT and the lactate‐2 mmol/L threshold, no other significant effects were found. The improved submaximal exercise capacity and tolerance might counteract patients’ functional impairment. Although cardiovascular and metabolic training adaptations were shown, ventilatory efficiency remained essentially unchanged. The impact of supplemental oxygen seems less important on submaximal training effects.

While cardiac and pulmonary rehabilitation programs traditionally involve exercise therapy and risk management following an event (eg, myocardial infarction and stroke), or an intervention (eg, coronary artery bypass surgery and percutaneous coronary intervention), prehabilitation involves enhancing functional capacity and optimizing risk profile prior to a scheduled intervention. The concept of prehabilitation is based on the principle that patients with higher functional capabilities will better tolerate an intervention, and will have better pre- and post-surgical outcomes. In addition to improving fitness, prehabilitation has been extended to include multifactorial risk intervention prior to surgery, including psychosocial counseling, smoking cessation, diabetes control, nutrition counseling, and alcohol abstinence. A growing number of studies have shown that patients enrolled in prehabilitation programs have reduced post-operative complications and demonstrate better functional, psychosocial, and surgery-related outcomes. These studies have included interventions such as hepatic transplantation, lung cancer resection, and abdominal aortic aneurysm (repair, upper gastrointestinal surgery, bariatric surgery, and coronary artery bypass grafting). Studies have also suggested that incorporation of prehabilitation before an intervention in addition to traditional rehabilitation following an intervention further enhances physical function, lowers risk for adverse events, and better prepares a patient to resume normal activities, including return to work. In this overview, we discuss prehabilitation coming of age, including key elements related to optimizing pre-surgical fitness, factors to consider in developing a prehabilitation program, and exercise training strategies to improve pre-surgical fitness.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model), Treatment of hypertension and its complications remains a major ongoing health care challenge. Around 25% of heart attacks in Europe are already attributed to hypertension and by 2025 up to 60% of the population will have hypertension. Physical inactivity has contributed to the rising prevalence of hypertension, but patients who exercise or engage in physical activity reduce their risk of stroke, myocardial infarction, and cardiovascular mortality. Hence, current international guidelines on cardiovascular disease prevention provide generic advice to increase aerobic activity, but physiological responses differ with blood pressure (BP) level, and greater reductions in BP across a population may be achievable with more personalized advice. We performed a systematic review of meta-analyses to determine whether there was sufficient evidence for a scientific Consensus Document reporting how exercise prescription could be personalized for BP control. The document discusses the findings of 34 meta-analyses on BP-lowering effects of aerobic endurance training, dynamic resistance training as well as isometric resistance training in patients with hypertension, high-normal, and individuals with normal BP. As a main finding, there was sufficient evidence from the meta-review, based on the estimated range of exercise-induced BP reduction, the number of randomized controlled trials, and the quality score, to propose that type of exercise can be prescribed according to initial BP level, although considerable research gaps remain. Therefore, this evidence-based Consensus Document proposes further work to encourage and develop more frequent use of personalized exercise prescription to optimize lifestyle interventions for the prevention and treatment of hypertension.

Aims Pre-participation evaluation (PPE) is recommended to prevent sudden cardiac death in athletes. Although imaging is not advocated as a first-line screening tool, there is a growing interest in the use of echocardiography in PPE of athletes. This survey aimed to map the use of imaging in the setting of PPE and explore physician beliefs and potential barriers that may influence individual practices. Methods An international survey of healthcare professionals was performed across ESC Member Countries. Percentages were reported based on the number of respondents per question. Results In total, 603 individuals from 97 countries participated in the survey. Two-thirds (65%) of respondents use echocardiography always or often as part of PPE of competitive athletes and this practice is not influenced by the professional or amateur status of the athlete. The majority (81%) of respondents who use echocardiography as a first-line screening tool perform the first echocardiogram during adolescence or at the first clinical evaluation, and 72% repeat it at least once in the athletes’ career, at 1–5 yearly intervals. In contrast, cardiac magnetic resonance is reserved as a second-line investigation of symptomatic athletes. The majority of the respondents did not report any barriers to echocardiography, while several barriers were identified for cardiac magnetic resonance. Conclusions Echocardiography is frequently used as a first-line screening tool of athletes. In the absence of scientific evidence, before such practice is recommended, large studies using echocardiography in the PPE setting are necessary.

Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the “Association of the Scientific Medical Societies in Germany” (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction

Spinal cord injury (SCI) is associated with a reduced level of physical activity, deterioration of patient body composition, metabolic profile, quality of life, and psychological functioning. As a result, risk of cardiovascular disease (CVD) increases and CVD-related death occurs at an earlier age than in individuals without SCI. Regular participation in exercise has been shown to exert beneficial effects also in patients with SCI. In this review, we analyze and discuss the effects of regular exercise training in SCI on cardiovascular function, autonomic function of the cardiovascular system, arterial stiffness, metabolism, inflammation, and gene expression.

Currently, no medical therapy is effective in limiting progression of small abdominal aortic aneurysms (AAA; ≤5.5 cm). Previously, we have demonstrated safety and efficacy of exercise training in patients with AAA. However, the impact of exercise training on vascular markers of AAA progression, such as lipid accumulation product and matrix metalloproteinase 9 (MMP-9, linked to destruction of aortic matrix), is unknown. The aim of this study was to assess the impact of exercise training on AAA diameter, lipid accumulation product, MMP-9, and other risk markers of vascular disease.In this randomized trial, complete data of 96 patients (male: n = 87, female: n = 9; exercise training (exercise) n = 42, usual care n = 54) were studied. Changes in AAA diameter, exercise capacity, lipid accumulation product (men = [waist circumference 65] × fasting triglycerides; women = [waist circumference -58] × triglycerides) and MMP-9 were performed.The exercise group demonstrated a significant increase in maximal exercise time and estimated metabolic equivalent of tasks. Lipid accumulation product decreased in exercise and increased in usual care (P.001 between groups); MMP-9 remained statistically unchanged in exercise, but increased significantly in usual care (P = .005; between groups P = .094). In both groups, there was a significant increase in transverse diameter, but no difference between groups; neither group assignment nor level of fitness correlated with AAA enlargement. No adverse clinical events occurred.This is the first study to demonstrate that in AAA, exercise beneficially modifies lipid accumulation product and MMP-9, both markers of vascular disease, without inducing aneurysmal growth beyond what is otherwise observed during usual care.

Background Exercise training is a cornerstone of the treatment of chronic obstructive pulmonary disease (COPD) in all disease stages. Data about the training effects with supplemental oxygen in nonhypoxemic patients remains inconclusive. In this study we set out to investigate the training and oxygen effects on inflammatory markers, vascular function, and endothelial progenitor cells in this population of increased cardiovascular risk. Methods In this prospective, randomized, double-blind, crossover study, 29 patients with nonhypoxemic COPD performed combined endurance and strength training 3 times a week while breathing medical air or supplemental oxygen for the first 6-week period, and were then reallocated to the opposite gas for the following 6 weeks. Exercise capacity, inflammatory biomarkers, endothelial function (peripheral arterial tone analysis), and endothelial progenitor cells were assessed. Data were also analyzed for a subgroup with endothelial dysfunction (reactive hyperemia index Results Following 12 weeks of exercise training, patients demonstrated a significant improvement of peak work rate and an associated decrease of blood fibrinogen and leptin. Eosinophils were found significantly reduced after exercise training in patients with endothelial dysfunction. In this subgroup, peripheral arterial tone analysis revealed a significant improvement of reactive hyperemia index. Generally, late endothelial progenitor cells were found significantly reduced after the exercise training intervention. Supplemental oxygen during training positively influenced the effect on exercise capacity without impact on inflammation and endothelial function. Conclusions This is the first randomized controlled trial in patients with COPD to show beneficial effects of exercise training not only on exercise capacity, but also on systemic/eosinophilic inflammation and endothelial dysfunction.

Introduction: Chemotherapy-induced peripheral neuropathy (CIPN) is a worldwide concern in patients receiving neurotoxic agents for cancer therapy. High tone external muscle stimulation is a promising therapeutic approach to alleviate symptoms of CIPN. Methods: This pilot study aims to investigate whether the application of home-based high-tone external muscle stimulation therapy (HTEMS) improves symptoms of CIPN. The trial is planned as a therapist- and assessor-blinded, 1:1 randomized controlled study. A total of 50 patients with chemotherapy-induced peripheral polyneuropathy will be included. All patients will perform therapy at home. Study participants will be allocated randomly to the HTEMS therapy (intervention group) or to the transcutaneous electrical nerve stimulation (TENS, control group), respectively, following a standardized therapy schedule. Compliance of participants can be verified by reading out the tool box. Outcomes will be evaluated at baseline and after 8 weeks of home-based therapy. The primary outcome includes improvement of CIPN according to the patient-reported EORTC QLQ-CIPN 20 questionnaire. Secondary outcomes are the patient-reported change in health-related quality of life and clinician-reported changes of vibration sensibility, tendon reflexes, temperature sensibility, perception of touch, and strength of the lower leg muscles. Further a safety- and process evaluation will be performed. Discussion: This pilot RCT aims to evaluate the impact of home-based HTEMS as compared to TENS in CIPN. There is a need for an effective treatment for CIPN and the results of this study are expected to possibly identify a novel and effective treatment strategy in the future.

Aim Cardiac rehabilitation (CR) is a key component of the treatment of cardiac diseases. The Austrian outpatient CR model is unique, as it provides patients with an extended professionally supervised, multidisciplinary program of 4–6 weeks of phase II (OUT-II) and 6–12 months of phase III (OUT-III) CR. The aim of this analysis was to assess the efficacy of the Austrian outpatient CR model using a nationwide registry. Methods Data of all consecutive patients ( N = 7560) who completed OUT-II and/or OUT-III between 1 January 2005 and 31 December 2015 were entered prospectively into a registry. OUT-III patients were analyzed separately according to whether the preceding phase II was performed as outpatient (OUT-II/OUT-III, N = 2403) or in-patient (IN-II/OUT-III, N = 2789). All patients underwent assessment of anthropometry, resting blood pressure, lipid profile, fasting blood glucose, exercise capacity, quality of life, anxiety and depression. Results During OUT-II, patients significantly improved their metabolic risk factor profile and increased exercise capacity by 14.3%. OUT-II/OUT-III patients achieved an additional increase in exercise capacity by 10%, further improvement in high-density lipoprotein (HDL) and stabilization of the remaining risk factors. IN-II/OUT-III patients increased their maximal exercise capacity by 18.4% and there was improvement in blood pressure, HDL, low-density lipoprotein and glucose levels. Conclusion Extended, professionally supervised, multidisciplinary outpatient CR in a large nationwide registry of consecutive patients consistently improved maximal exercise capacity and relevant modifiable cardiovascular risk factors beyond effects seen after IN- or OUT-II alone.

Coronary artery disease (CAD) is a progressive disease, typically starting early in life. CAD is strongly associated with cardiovascular morbidity and mortality. Regular physical activity (PA) has positive effects on multiple risk factors for CAD, while high-intensity PA may act as a trigger for sudden cardiac death, especially in susceptible individuals with an underlying cardiovascular abnormality. Therefore, recommendations for cardiovascular evaluation of older individuals aiming to participate in leisure-time or competitive sports, as well as for those with risk factors for or with established CAD, has been established. If athletes with an increased risk profile for CAD show a normal, truly maximal exercise test, they are not restricted from any competitive sport. Patient-athletes with clinically proven CAD and considered to be at low-risk for cardiac events may be selectively advised to participate in competitive sports but restrictions may apply on an individual basis for certain sports with the highest CV demand (such as extreme power and endurance disciplines) and in older athletes, having a higher risk. Patient-athletes with clinically proven CAD, defined as high risk, should receive appropriate management and be restricted from competitive sport. In patient-athletes with CAD and significant ischemia during exercise, as in all patients, anti-ischemic therapy needs to be optimized. In case of inducible ischemia, revascularization is strongly suggested. Athletes considered as “low-risk” for cardiac events post-MI and/or post-PCI are recommended a minimum of 3 months structured and progressive rehabilitation before assuming/resuming participation in competitive sports. Periodical, at least annual follow-ups of athletes with CAD are recommended, including risk factor management by lifestyle and medications, according to guidelines. Any symptoms should be evaluated, and repeated exercise-testing could be used, for risk stratification and/or modified exercise prescription.

Improved clinical care has led to an increase in the number of adults with congenital heart disease (CHD) engaging in leisure time and competitive sports activities. Although the benefits of exercise in patients with CHD are well established, there is a low but appreciable risk of exercise-related complications. Published exercise recommendations for individuals with CHD are predominantly centred on anatomic lesions, hampering an individualized approach to exercise advice in this heterogeneous population. This document presents an update of the recommendations for competitive sports participation in athletes with cardiovascular disease published by the Sports Cardiology & Exercise section of the European Association of Preventive Cardiology (EAPC) in 2005. It introduces an approach which is based on the assessment of haemodynamic, electrophysiological and functional parameters, rather than anatomic lesions. The recommendations provide a comprehensive assessment algorithm which allows for patient-specific assessment and risk stratification of athletes with CHD who wish to participate in competitive sports.

Current guidelines of all leading international professional societies, e.g. the European Society of Cardiology, advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease including arterial hypertension. Despite its undisputed multitude of beneficial effects, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. In athletes, both the definition of arterial hypertension and target values for treatment do not differ from the general population. Sport participation should not per se be regarded as a risky undertaking, but all athletes with a diagnosis of hypertension should undergo a complete cardiovascular evaluation with a particular focus on signs of subclinical target organ damage such as left ventricular hypertrophy. If blood pressure is well controlled, usually no restrictions for competitive sport participation apply, but in the presence of target organ damage or associated clinical conditions, particularly power sports may be discouraged, and a close clinical follow-up is recommended. For medical treatment, angiotensin converting enzyme inhibitors or angiotensin II receptor blockers are preferred over beta blockers or diuretics since these agents are likely to affect exercise performance and are also at least partly listed as prohibited drugs. This chapter focuses on the updated recommendations of the Sports Cardiology Section of the European Association of Preventive Cardiology, an association of the European Society of Cardiology. Here, we will give guidance to physicians who have to decide on the risk of an athlete suffering from arterial hypertension during sport participation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com., This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

An abdominal aortic aneurysm (AAA) is a localized dilation caused by weakening of the vessel wall, most often in the infrarenal area. With the ageing of the population and better detection and screening methods, the prevalence of AAAs has increased markedly in recent years. Today, AAAs account for an increasing burden on health care costs in the Western world. AAA is the 13th leading cause of death in the US and is the third leading cause of sudden death in men >60 years of age, accounting for roughly 4–5% of sudden deaths. AAAs are usually asymptomatic and are often not discovered until they rupture or cause symptoms due to localized pressure on adjacent tissues. Until recently, these patients were generally discouraged from participating in rehabilitation programs because of a lack of data on the impact of exercise on the aneurysm, and whether exercise could be performed safely. However, recent randomized trials have documented that patients with AAA who participate in rehabilitation programs achieve functional benefits that are similar to post-MI patients, and that moderate exercise is not associated with higher safety risks. In fact, given the evolution of cardiac rehabilitation from traditional exercise-based programs to comprehensive secondary prevention and chronic disease management, AAA patients would be ideal candidates for intervention since AAA is a disease strongly associated with cardiometabolic risk. This chapter reviews the available evidence on exercise testing and training in AAA, along with the potential for exercise therapy to reduce AAA risk and limit AAA progression.

Background There is a well‐known correlation between obesity, sedentary lifestyle, and breast cancer incidence and outcome. The Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT) exercise study was a multicenter, randomized clinical trial and assessed the feasibility and efficacy of physical training in 50 breast cancer patients undergoing aromatase inhibitor treatment. Methods Postmenopausal, estrogen receptor‐positive breast cancer patients under aromatase inhibitor treatment were randomized 1:1 to counseling and unsupervised training for 48 weeks (unsupervised arm) or counseling and a sequential training (supervised arm) with a supervised phase (24 weeks) followed by unsupervised physical training (further 24 weeks). Primary endpoint was the individual maximum power output on a cycle ergometer after 24 weeks of exercise. A key secondary endpoint was the feasibility of achieving 12 METh/week (metabolic equivalent of task hours per week). Results Twenty‐three patients (92%) in the unsupervised arm and 19 patients (76%) in the supervised arm with early‐stage breast cancer completed the study. After 24 weeks, the supervised arm achieved a significantly higher maximum output in watt (mean 132 ± standard deviation [SD] 34; 95% confidence interval [CI] 117‐147) compared to baseline (107 ± 25; 95%CI 97‐117; P = 0.012) with a numerically higher output than the unsupervised arm (week 24 115 ± 25; 95%CI 105‐125; P = 0.059). Significantly higher METh/week was reported in the supervised arm compared to the unsupervised arm during the whole study period (week 1‐24 unsupervised: 18.3 (7.6‐58.3); supervised: 28.5 (6.7‐40.1); P = 0.043; week 25‐48; P = 0.041)). Conclusion This trial indicates that patients in an exercise program achieve higher fitness levels during supervised than unsupervised training.

Hypoxia challenges left ventricular (LV) function due to reduced energy supply. Conflicting results exist whether high‐altitude exposure impairs LV diastolic function and thus contributes to the high altitude‐induced increase in systolic pulmonary artery pressure (sPAP) and reduction in stroke volume (SV). This study aimed to assess LV diastolic function, LV end‐diastolic pressure (LVEDP), and LA mechanics using comprehensive echocardiographic imaging in healthy volunteers at 4559 m. Fifty subjects performed rapid (

Aims Exercise is a trigger for acute coronary events especially in the untrained. Identifying subjects at risk remains a challenge. We set out to assess whether a distinct pattern of micro ribonucleic acids (miRNAs) expressed in response to an acute bout of all-out exercise might exist that would allow discrimination between health and disease. Methods Twenty healthy subjects and 20 patients with coronary artery disease (CAD) performed an all-out cycle ergometry. Total RNA was extracted from blood drawn before and after exercise. Each blood sample was analysed for 187 target miRNAs by quantitative reverse transcription polymerase chain reaction. Results At baseline, 18 miRNAs allowed discrimination between healthy subjects and CAD patients. In response to an acute all-out exercise in healthy subjects 51 miRNAs and in CAD patients 60 miRNAs were significantly modulated (all p Conclusion In this most comprehensive analysis of exercise effects on circulating miRNAs to date we demonstrate for the first time that a distinct combination of miRNAs together with variables of exercise capacity allow robust discrimination between healthy subjects and CAD patients. We postulate that miRNAs may eventually serve as biomarkers to identify patients with CAD and possibly even those at risk of exercise-induced cardiac events.

Decreased oxygen saturation (SO2) at high altitude is associated with potentially life-threatening diseases, e.g., high-altitude pulmonary edema. Wearable devices that allow continuous monitoring of peripheral oxygen saturation (SpO2), such as the Garmin Fēnix® 5X Plus (GAR), might provide early detection to prevent hypoxia-induced diseases. We therefore aimed to validate GAR-derived SpO2 readings at 4559 m. SpO2 was measured with GAR and the medically certified Covidien Nellcor SpO2 monitor (COV) at six time points in 13 healthy lowlanders after a rapid ascent from 1130 m to 4559 m. Arterial blood gas (ABG) analysis served as the criterion measure and was conducted at four of the six time points with the Radiometer ABL 90 Flex. Validity was assessed by intraclass correlation coefficients (ICCs), mean absolute percentage error (MAPE), and Bland–Altman plots. Mean (±SD) SO2, including all time points at 4559 m, was 85.2 ± 6.2% with GAR, 81.0 ± 9.4% with COV, and 75.0 ± 9.5% with ABG. Validity of GAR was low, as indicated by the ICC (0.549), the MAPE (9.77%), the mean SO2 difference (7.0%), and the wide limits of agreement (−6.5; 20.5%) vs. ABG. Validity of COV was good, as indicated by the ICC (0.883), the MAPE (6.15%), and the mean SO2 difference (0.1%) vs. ABG. The GAR device demonstrated poor validity and cannot be recommended for monitoring SpO2 at high altitude.

This paper presents a brief summary of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) on sports-participation in patients with coronary artery disease, coronary artery anomalies or spontaneous dissection of the coronary arteries, all entities being associated with myocardial ischaemia.1 Given the wealth of evidence supporting the benefits of exercise for primary and secondary prevention of coronary artery disease, individuals should be restricted from competitive sport only when a substantial risk of adverse event or disease progression is present. These recommendations aim to encourage regular physical activity including participation in sports and, with reasonable precaution, ensure a high level of safety for all individuals with coronary artery disease. The present document is based on available current evidence, but in most instances because of lack of evidence, also on clinical experience and expert opinion.

The rising incidence and prevalence of type 2 diabetes mellitus (T2DM) call for effective control of cardiovascular risk factors in order to prevent or at least delay deleterious effects of non-communicable diseases. In concert with dietary and pharmacological interventions, exercise training is a cornerstone of disease management in diabetic patients. Since approximately 75% of the insulin-stimulated glucose uptake occurs in skeletal muscles, increasing muscle mass through resistance training appears as a logical therapeutic approach...

Contains fulltext : 209356.pdf (Publisher’s version ) (Closed access) Myocardial diseases are associated with an increased risk of potentially fatal cardiac arrhythmias and sudden cardiac death/cardiac arrest during exercise, including hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, arrhythmogenic cardiomyopathy, and myo-pericarditis. Practicing cardiologists and sport physicians are required to identify high-risk individuals harbouring these cardiac diseases in a timely fashion in the setting of preparticipation screening or medical consultation and provide appropriate advice regarding the participation in competitive sport activities and/or regular exercise programmes. Many asymptomatic (or mildly symptomatic) patients with cardiomyopathies aspire to participate in leisure-time and amateur sport activities to take advantage of the multiple benefits of a physically active lifestyle. In 2005, The European Society of Cardiology (ESC) published recommendations for participation in competitive sport in athletes with cardiomyopathies and myo-pericarditis. One decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of cardiomyopathies and myo-pericarditis. The present document, therefore, aims to offer a comprehensive overview of the most updated recommendations for practicing cardiologists and sport physicians managing athletes with cardiomyopathies and myo-pericarditis and provides pragmatic advice for safe participation in competitive sport at professional and amateur level, as well as in a variety of recreational physical activities.

BACKGROUND: Recent findings revealed negative effects of deregulated molecular circadian rhythm in coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM). Physical exercise training (ET) has been shown to promote anti-diabetic and anti-atherogenic responses in skeletal muscle of these patients, but the role of the circadian clock-machinery remains unknown. This study investigated whether mRNA expression of clock genes in skeletal muscle of CAD and T2DM patients is influenced by physical ET intervention. METHODS: Nineteen patients with CAD and T2DM (age 64 ± 5 years) were randomised to either six months of ET (four weeks of in-hospital ET followed by a five-month ambulatory programme) or usual care. At the beginning of the study, after fourweeks and after six months parameters of metabolic and cardiovascular risk factors, and physical exercise capacity were assessed. Gene expression was measured in skeletal muscle biopsies by quantitative real-time polymerase chain reaction (PCR). RESULTS: A selection of clock genes and associated components (circadian locomoter output cycle kaput protein (CLOCK), period (PER) 1, cryptochrome (CRY) 2 and aminolevulinate-deltA-synthase-1 (ALAS1)) was reliably measured and used for further analysis. A time-dependent effect in gene expression was observed in CLOCK (p = 0.013) and a significant interaction between time and intervention was observed for ALAS1 (p = 0.032; p = 0.014) as a result of ET. CONCLUSION: This is the first study to analyse clock gene expression in skeletal muscles of patients with CAD and T2DM participating in a long-lasting exercise intervention. ET, as one of the cornerstones in prevention and rehabilitation of CAD and T2DM, exerts no effects on CLOCK genes but meaningful effects on the clock-associated gene ALAS1.

Lifestyle in general (nutrition, exercise, smoking habits), besides the genetic predisposition, is known to be a strong predictor for the development of diabetes. Exercise in particular is not only useful in improving glycaemia by lowering insulin resistance and positively affect insulin secretion, but to reduce cardiovascular risk.To gain substantial health benefits a minimum of 150 min of moderate or vigorous intense aerobic physical activity and muscle strengthening activities per week are needed. The positive effect of training correlates directly with the amount of fitness gained and lasts only as long as the fitness level is sustained. The effect of exercise is independent of age and gender. It is reversible and reproducible.Based on the large evidence of exercise referral and prescription the Austrian Diabetes Associations aims to implement the position of a "physical activity adviser" in multi-professional diabetes care.

Objectives: Night shift workers are at cardiometabolic risk due to circadian misalignment. We investigated whether infrequent exercise before each night shift that intentionally would not improve physical performance improves glucose tolerance and 24-h blood pressure profiles and synchronizes circadian rhythms of melatonin and cortisol in rotating night shift workers. Methods: A total of 24 rotating night shift workers (mean age, 35.7 ± 11.8 years) were randomized to exercise or no intervention. Workers in the exercise group performed 15.2 ± 4.5 exercise sessions within 2 h before each night shift. Before and after 12 weeks of exercise intervention and 12 weeks after the intervention, spiroergometry, oral glucose tolerance testing and 24-h blood pressure profiles were performed. Plasma melatonin and cortisol levels were measured in 3-hourly intervals during one 24-h period on each study day. Results: Exercise did not significantly change serum glucose nor insulin levels during oral glucose tolerance testing. Timed physical exercise had no effect on physical performance, nor did it change the circadian rhythms of melatonin and cortisol or influence 24-h blood pressure profiles. Conclusion: Physical exercise before each night shift at a low intensity level that does not improve physical performance does not affect circadian timing, glucose tolerance or 24-h blood pressure profiles in rotating night shift workers.

© 2015 Mayo Foundation for Medical Education and Research, and the European Society of Cardiology. This article is being published concurrently in Mayo Clinic Proceedings [1]. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article. [1] Arena R, Guazzi M, Lianov L, Whitsel L, Berra K, Lavie CJ, Kaminsky L, Williams M, Hivert M-F, Franklin NC, Myers J, Dengel D, Lloyd-Jones DM, Pinto FJ, Cosentino F, Halle M, Gielen S, Dendale P, Niebauer J, Pelliccia A, Giannuzzi P, Corra U, Piepoli MF, Guthrie G, Shurney D. Healthy Lifestyle Interventions to Combat Noncommunicable Diseased - A Novel Nonhierarchical Connectivity Model for Key Stakeholders: A Policy Statement From the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine. Mayo Clinic Proceedings 2015; DOI: 10.1016/j.mayocp.2015.05.001 [In Press], Noncommunicable diseases (NCDs) have become the primary health concern for most countries around the world. Currently, more than 36 million people worldwide die from NCDs each year, accounting for 63% of annual global deaths; most are preventable. The global financial burden of NCDs is staggering, with an estimated 2010 global cost of $6.3 trillion (US dollars) that is projected to increase to $13 trillion by 2030. A number of NCDs share one or more common predisposing risk factors, all related to lifestyle to some degree: (1) cigarette smoking, (2) hypertension, (3) hyperglycemia, (4) dyslipidemia, (5) obesity, (6) physical inactivity, and (7) poor nutrition. In large part, prevention, control, or even reversal of the aforementioned modifiable risk factors are realized through leading a healthy lifestyle (HL). The challenge is how to initiate the global change, not toward increasing documentation of the scope of the problem but toward true action-creating, implementing, and sustaining HL initiatives that will result in positive, measurable changes in the previously defined poor health metrics. To achieve this task, a paradigm shift in how we approach NCD prevention and treatment is required. The goal of this American Heart Association/European Society of Cardiology/European Association for Cardiovascular Prevention and Rehabilitation/American College of Preventive Medicine policy statement is to define key stakeholders and highlight their connectivity with respect to HL initiatives. This policy encourages integrated action by all stakeholders to create the needed paradigm shift and achieve broad adoption of HL behaviors on a global scale.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD. The 2nd Summit on Electrocardiographic Interpretation in Athletes was sponsored by the American Medical Society for Sports Medicine, the FIFA Medical Assessment and Research Center (F-MARC), and the National Collegiate Athletic Association (NCAA). Participating medical societies included the American College of Cardiology (ACC) Sports & Exercise Council, and the Section on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), a registered branch of the European Society of Cardiology (ESC).

A 54-year-old man presents at the Institute of Sports Medicine, Prevention and Rehabilitation for an assessment of his physical fitness. His wife gave him a voucher for a physical fitness check as a birthday present since he has never had an assessment of his physical fitness before. He is a carpenter and reports to be healthy and free of symptoms. Two years ago, he had a non-ST-elevation myocardial infarction of the anterior wall. The left descending artery had been treated with a drug-eluting stent in the local cardiology department. On presentation, he reports no angina or other cardiac disorders. The patient smokes one pack of cigarettes per day (30 pack years). Both of his parents are still alive, his father is 76 years old and suffers from type 2 diabetes and chronic obstructive pulmonary disease, whereas his 75-year-old mother has no known disorders. Neither his two brothers nor his sister has any cardiovascular diseases, and his two sons who are 27 and 30 years old are also healthy. He reports 30–45 min of jogging once a week, and his present medication includes 100 mg of acetylsalicylic acid, a beta-blocker (metoprolol 50 mg 1/2-0-0), an angiotensin-converting enzyme (ACE) inhibitor (ramipril 2.5 mg 1-0-0), and a statin (simvastatin 40 mg 0-0-1). How is this patient best advised to improve his cardiovascular risk profile?

Atrial fibrillation (AF) is an important and highly prevalent arrhythmia, which is associated with significantly increased morbidity and mortality, including a four- to five-fold increased risk for stroke,1,2 a two-fold increased risk for dementia,3,4 a three-fold risk for heart failure,2 a two-fold increased risk for myocardial infarction,5,6 and a 40–90% increased risk for overall mortality.2,7 The constantly increasing number of AF patients and recognition of increased morbidity, mortality, impaired quality of life, safety issues, and side effects of rhythm control strategies with antiarrhythmic drugs, and high healthcare costs associated with AF have spurred numerous investigations to develop more effective treatments for AF and its complications.8 Although AF treatment has been studied extensively, AF prevention has received relatively little attention, while it has paramount importance in the prevention of morbidity and mortality, and complications associated with arrhythmia and its treatment. Current evidence shows a clear association between the presence of modifiable risk factors and the risk of developing AF. By implementing AF risk reduction strategies aiming at risk factors such as obesity, hypertension, diabetes, and obstructive sleep ap-noea (OSA), which are interrelated, we impact upon the escalating incidence of AF in the population and ultimately decrease the healthcare burden of associated co-morbidities of AF. To address this issue, a Task Force was convened by the European Heart Rhythm Association and the European Association of Cardiovascular Prevention and Rehabilitation, endorsed by the Heart Rhythm Society and Asia-Pacific Heart Rhythm Society, with the remit to comprehensively review the published evidence available, to publish a joint consensus document on the prevention of AF, and to provide up-to-date consensus recommendations for use in clinical practice. In this document, our aim is to summarize the current evidence on the association of each modifiable risk factor with AF and the available data on the impact of possible interventions directed at these factors in preventing or reducing the burden of AF. While the evidence on AF prevention is still emerging, the topic is not fully covered in current guidelines and some aspects are still controversial. Therefore, there is a need to provide expert recommendations for professionals participating in the care of at-risk patients and populations, with respect to addressing risk factors and lifestyle modifications. Health economic considerations Atrial fibrillation is a costly disease, both in terms of direct, and indirect costs, the former being reported by cost of illness studies as per-patient annual costs in the range of US $2000–14200 in North America and of €450–3000 in Europe.9 In individuals with AF or at risk of developing AF, any effective preventive measure, intervention on modifiable risk factors or comorbidities, as well as any effective pharmacological or non-pharmacological treatment has the aim to reduce AF occurrence, thromboembolic events and stroke, morbidity and, possibly, mortality related to this arrhythmia. Apart from the clinical endpoints, achievement of these goals has economic significance, in terms of positive impact on direct and indirect costs and favourable cost–effectiveness at mid- or long-term, in the perspective of healthcare systems.10–12 In view of the epidemiological profile of AF and progressive aging of the population,13 an impressive increase of patients at risk of AF or affected by AF,14 also in an asymptomatic stage, is expected in the next decades, inducing a growing financial burden on healthcare systems, not only in Europe and North America, but also worldwide.15,16 In consideration of this emerging epidemiological threat due to AF, it is worth considering a paradigm shift, going beyond the conventional approach of primary prevention based on treatment of AF risk factors, but, instead, considering the potential for ‘primordial’ prevention, defined as prevention of the development of risk factors predisposing to AF in the first place.17 This approach, aimed at avoiding the emergence and penetration of risk factors into the population, has been proposed in general terms for the prevention of cardiovascular diseases17 and should imply combined efforts of policymakers, regulatory and social service agencies, providers, physicians, community leaders, and consumers, in an attempt to improve social and environmental conditions, as well as individual behaviours, in the pursuit of adopting healthy lifestyle choices.16 Since a substantial proportion of incident AF events can be attributable to elevated or borderline levels of risk factors for AF,18 this approach could be an effective way to reduce the financial burden linked to AF epidemiology. In terms of individual behaviour and adoption of a ‘healthy lifestyle’, it is worth considering that availability of full healthcare coverage (through health insurance or the healthcare system) may in some cases facilitate the unwanted risk of reducing, at an individual level, the motivation to adopt all the preventive measures that are advisable, in line with the complex concept of ‘moral hazard effect’.19 Patient education and patient empowerment are the correct strategies for avoiding this undesirable effect.

Evidence-based medicine urges physicians to translate results from clinical trials to their patients. This, however, can only work, if real world patients are represented in clinical trials.We searched the literature on chronic heart failure (1950-2/2011) for studies designed to detect effects on mortality (mortality studies, MS) and exercise training studies (ETS) as the leading non-pharmaceutical/non-surgical treatment option in order to compare their characteristics with European (Euro Heart Survey on Heart Failure, EHSHF) and North American (Framingham Heart Study, FHS) epidemiological studies.After an extensive literature search, we identified 207 ETS and 59 MS. Subjects enrolled in ETS were younger (ETS: 62.5 ± 6.6; MS: 63.9 ± 4.6; EHSHF: 71.0 ± 3.5; FHS: 78.0 years), more often male (ETS: 80.9%; MS: 77.3%; EHSHF: 53.0%; FHS: 49.6%; p0.001), and had substantially less comorbidities such as diabetes mellitus (ETS: 13.6%; MS: 22.5%; EHSHF: 27.0%; FHS: 25.3%; p0.001), or hypertension (ETS: 26.3%; MS: 39.1%; EHSHF: 53.0%; FHS: 46.9%; p0.001). Angiotensin converting enzyme-inhibitors, beta-blockers, and angiotensin-receptor-blockers were more commonly used in ETS than in EHSHF (all p0.001). Only 16 (10.6%) ETS and 20 (62.5%) MS reported ethnic background.Heart failure patients in exercise training studies and mortality studies do not represent real world patients. In order to extrapolate data to the general population future exercise training studies as well as mortality studies need to include representative patients. Otherwise, knowledge gained can only be translated to a minority of our patients.

Context Modern lifestyle, with its lack of everyday physical activity and exercise training, predisposes people to chronic diseases such as diabetes mellitus, obesity, hypertension, and coronary artery diseases. Brisk walking as a simple and safe form of exercise is undisputedly an effective measure to counteract sedentary lifestyle risks even in the most unfit and could lead to a reduction of the prevalence of chronic diseases in all populations. The purpose of this review is to systematically summarize, analyze, and interpret the health benefits of Nordic walking (walking with poles), and to compare it to brisk walking and jogging. Evidence acquisition A systematic and comprehensive literature search was performed between November 2010 and May 2012. Data were analyzed between April 2011 and May 2012. Evidence synthesis Sixteen RCTs with a total of 1062 patients and 11 observational studies with 831 patients were identified. The current analysis revealed that with regard to short- and long-term effects on heart rate, oxygen consumption, quality of life, and other measures, Nordic walking is superior to brisk walking without poles and in some endpoints to jogging. Conclusions Nordic walking exerts beneficial effects on resting heart rate, blood pressure, exercise capacity, maximal oxygen consumption, and quality of life in patients with various diseases and can thus be recommended to a wide range of people as primary and secondary prevention.

AMI : acute myocardial infarction ARVC : arrhythmogenic right ventricular cardiomyopathy BrS : Brugada syndrome CACS : coronary artery calcium score CAD : coronary artery disease ChD : Chagas heart disease CMR : cardiac magnetic resonance CPVT : catecholaminergic polymorphic ventricular tachycardia CTCA : computed tomography coronary angiography CV : cardiovascular DCM : dilated cardiomyopathy EAPCR : European Association for Cardiovascular Prevention and Rehabilitation HCM : hypertrophic cardiomyopathy LGE : late gadolinium enhancement LQTS : long QT syndrome LV/RV : left/right ventricle LVH : left ventricle hypertrophy NSVT : non-sustained ventricular tachycardia PPE : preparticipation evaluation PVC : premature ventricular contractions SCA/SCD : sudden cardiac arrest/death TTE : transthoracic echocardiography VF : ventricular fibrillation VT : ventricular tachycardia Sudden cardiac death (SCD) associated with athletic activity is a rare but devastating event. Victims are usually young and apparently healthy, and while many of these deaths remain unexplained, a substantial number of victims harbour an underlying and potentially detectable cardiovascular (CV) disease.1–4 The vast majority of these events are due to malignant tachyarrhythmias, usually ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into ventricular fibrillation (VF), occurring in individuals with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, channelopathies). Intensive exercise training and competitive sport participation is a trigger that may favour insurgence of ominous ventricular tachyarrhythmias in predisposed individuals.5 Consequently, there is a great interest in early identification of at-risk individuals for whom appropriate treatment, followed or not by physical activity adjustment, may be implemented to minimize the risk of SCD. However, the role of pre-participation evaluation (PPE) in athletes as a feasible and efficient strategy to identify individuals at risk has remained controversial. …

Endothelial dysfunction occurs early during atherogenesis and it can be normalized by exercise training. Unfortunately, patients' compliance with exercise prescription remains low, often because the given choices do not appeal to them. In Alpine regions, skiing is a popular mode of exercise, and therefore we set out to assess whether it can induce antiatherogenic effects.We randomized 42 subjects into a group of 12weeks of guided skiing (intervention group, IG, n=22; 12 males/10 females; age: 66.6±2.1years) or a control group (CG, n=20; 10 males/10 females; age: 67.3±4.4years). Early (CD3-CD34+CD45+) and late endothelial progenitor cells (EPCs; CD45dimCD34+KDR+ peripheral blood mononuclear cells, PBMCs), peripheral arterial tonometry and endothelial biomarkers were assessed at the beginning and end of the study.In the IG, participants completed 28.5±2.6 skiing days at an average heart rate of 72.7±8.5% of their maximum heart rate. Changes in early (IG: +0.001±0.001% PBMC; CG: -0.001±0.001% PBMC; IG vs. CG: p0.001) but not late EPCs differed significantly. Changes in peripheral arterial tone differed significantly between IG (Reactive Hyperemia Index: +0.18±0.76) and CG (-0.39±0.85; p=0.045), as did homocysteine (IG: -1.3±1.3μmol/l; CG: -0.4±1.4μmol/l; p=0.037) while other endothelial biomarkers remained essentially unchanged.This study shows that skiing induces several beneficial effects on markers of atherogenesis including EPCs, peripheral arterial tone and homocysteine. Our findings suggest that recreational alpine skiing may serve as a further mode of preventive exercise training, which might result in improved compliance with current recommendations.

In Europe, between 1985 to 1989 and 2000 to 2004, a decline of >30% in cardiovascular disease (CVD) and coronary heart disease mortality was observed.1,2 However, according to the latest figures of the European Heart Network, the annual mortality of CVD still exceeds 4 million (ie, 47% of all deaths) in Europe and 1.9 million (ie, 40% of all deaths) in the European Union.2 Furthermore, despite a falling trend in most European countries, CVD remains the most common cause of death in women and men. The financial burden for the European Union economy is estimated to be almost €196 billion a year, of which 54% is attributable to healthcare costs, 24% to productivity losses, and 22% to the informal care of people with CVD. Response by Mendes on p 2537 In the United States, an even greater decrease in cardiovascular mortality of 67% was achieved between 1969 and 2013. In addition, during this time period, age-standardized years of potential life lost per 1000 decreased by 68%.3 Despite this meaningful improvement, >50 years after the first coronary artery bypass grafting (CABG) in 19644 and almost 40 years after the first percutaneous coronary intervention in 1977,5 the incidence and prevalence of CVD remain high. So does the annual rate of CABG, even though it continues to drop, for example, to 1081 CABGs per 1 million adults in 2007 to 2008 in the United States.6 Obviously, coronary revascularization is widely appreciated for alleviating symptoms and improving prognosis. However, as a structural intervention, it does not address disease progression, which is why revascularization must be paired with measures of secondary prevention to maximize benefit. Given the social and economic burden of coronary artery disease, optimization of evidence-based treatment is paramount. According to current guidelines, treatment of …

Small intestinal function may be altered in decompensated chronic heart failure (CHF) and translocating LPS may contribute to systemic inflammation observed in CHF.We measured intestinal permeability (melibiose and rhamnose), active (3-O-methyl-d-glucose (3-OMG)) and passive (d-xylose) carrier-mediated absorption in 20 CHF patients (12 edematous and 8 non-edematous) and 8 controls by saccharide absorption technique assessing urinary recovery of orally administered sugars. We additionally measured LPS concentrations in 42 patients with decompensated heart failure and after recompensation.CHF patients had a 54% reduction of active carrier-mediated intestinal transport compared to controls (p0.0001). This reduction was strongest in edematous compared to non-edematous patients and controls (recovery in urine: 13.2±2.0% vs. 20.8±2.4% vs. 36.0 ± 3.7%, all p ≤ 0.05). Patients showed a 34% reduction of passive carrier-mediated transport, strongest in edematous patients (p=0.006). A greater impairment of active carrier-mediated transport remained significant after adjustment for non-mucosal factors in CHF (p=0.0004). Non carrier-mediated intestinal permeability was not altered. Data from 42 decompensated patients showed a decrease in LPS after recompensation (p=0.004). Edematous patients had highest blood concentrations of LPS, TNF and sTNF-R1 (p0.04). CHF patients with abnormal LPS concentrations0.50EU/mL (n=7) had the highest concentrations of TNF (7.0 ± 1.6 vs. 3.1 ± 0.3pg/mL, p0.02), and sTNF-R1 (3499 ± 52 vs. 1599±219 pg/mL, p=0.02).Active carrier-mediated intestinal transport is reduced in decompensated CHF indicating epithelial dysfunction possibly as a consequence of intestinal ischemia. Higher LPS concentrations in edematous CHF relate to inflammation. LPS decreased after recompensation. This suggests a cause/effect relationship between edematous gut wall, epithelial dysfunction and translocating LPS.

In a previous paper, as the first of a series of three on the importance of characteristics and modalities of physical activity (PA) and exercise in the management of cardiovascular health within the general population, we concluded that, in the population at large, PA and aerobic exercise capacity clearly are inversely associated with increased cardiovascular disease risk and all-cause and cardiovascular mortality and that a dose–response curve on cardiovascular outcome has been demonstrated in most studies. More and more evidence is accumulated that engaging in regular PA and exercise interventions are essential components for reducing the severity of cardiovascular risk factors, such as obesity and abdominal fat, high BP, metabolic risk factors, and systemic inflammation. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit for each separate risk factor. The present paper, therefore, will review and make recommendations for PA and exercise training in the management of cardiovascular health in individuals with cardiovascular risk factors. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and individual members of the public. Based on previous and the current literature overviews, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and regarding appropriate risk evaluation during exercise in individuals with cardiovascular risk factors. ispartof: European Journal of Preventive Cardiology vol:19 issue:5 pages:1005-1033 ispartof: location:England status: published

Alpine skiing and ski training involves elements of static and dynamic training, and may therefore improve insulin sensitivity. Healthy men and women who where beginners/intermediate level of alpine skiing, were studied before (Pre) and immediately after (Post) 12 weeks of alpine ski training. After an additional 8 weeks a third test (retention study, Ret) was performed. The subjects were randomized into an intervention group (IG, n=22, age=66.6 ± 0.4 years) or a control group (CG, n=20, age=67.0 ± 1.0 years). Plasma glucose decreased (P

This study investigated whether regular alpine skiing could reverse sarcopenia and muscle weakness in older individuals. Twenty-two older men and women (67 ± 2 years) underwent 12 weeks of recreational skiing, two to three times a week, each session lasting ∼ 3.5 h. An age-matched, inactive group (n=20, 67 ± 4 years) served as a control (CTRL). Before and after the training period, knee extensors muscle thickness (T(m) ), pennation angle (θ) and fascicle length (L(f) ) of the vastus lateralis muscle were measured by ultrasound. Maximum isokinetic knee extensor torque (MIT) at an angular velocity of 60°/s was measured by dynamometry. After the training, T(m) increased by 7.1% (P