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Objective To determine immediate performance measures for short-term, multicomponent cardiac rehabilitation (CR) in clinical routine in patients of working age, taking into account cardiovascular risk factors, physical performance, social medicine, and subjective health parameters and to explore the underlying dimensionality. Design Prospective observational multicenter register study in 12 rehabilitation centers throughout Germany. Setting Comprehensive 3-week CR. Participants Patients (N=1586) ≤65 years of age (mean 53.8±7.3y, 77.1% men) in CR (May 2017-May 2018). Interventions Not applicable. Main Outcome Measures Feasibility, defined by data availability for ≥85% of patients (CR admission and discharge), and modifiability based on pre-post comparison (statistical significance, with P value

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

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Heart failure patients (HF-rEF, HF-pEF or in combination) represent a relevant proportion of patients in cardiological rehabilitation facilities. They require a multimodal therapy concept due to the impaired systolic and/or diastolic ventricular function, the risk of malignant arrhythmias and the cardiac implantable electrical devices (CIED). In addition to guideline-based pharmacotherapy, individualized training therapy and psychosocial support play a key role in the rehabilitation of heart failure patients. Professional reintegration is determined by hemodynamic stability, cognitive performance, job requirements and job security, especially for CIED carriers. The suitability for driving is mainly determined in individual decisions and depends, among other things, on the left ventricular ejection fraction, the hemodynamic stability and the arrhythmia-free interval.

Hintergrund Herzinsuffizienz in einem terminalen Stadium kann haufig nur mit einer Herztransplantation oder mit einem ventricular assist Device (VAD) behandelt werden. Die immer haufiger durchgefuhrte Implantation eines VAD wird wegen des bestehenden Organmangels zunehmend auch als dauerhafte Therapie gewahlt. Problem Die zunehmende Therapie mit einem VAD fuhrt zu einem erhohten Bedarf an Rehabilitationsangeboten. Die Entwicklung entsprechender Standards fur diese Patientengruppe ist daher notwendig. Bisher sind nur Erfahrungen einzelner Zentren mit kleinen Patientenzahlen veroffentlicht. Leitlinien zu diesem Thema liegen nicht vor. Ergebnisse Eine Arbeitsgruppe der Deutschen Gesellschaft fur Pravention und Rehabilitation von Herz-Kreislauf-Erkrankungen (DGPR) hat ein Konsensuspapier 1 entwickelt, um Stellung zu Hintergrunden und Ablaufen der Rehabilitation mit einem VAD zu beziehen. Dabei wurden indikationsspezifische Probleme analysiert und Strategien erarbeitet. Die wichtigsten Aspekte der Rehabilitation mit dem Ziel einer moglichst sicheren Teilhabe am Alltagsleben sind hier zusammenfassend dargestellt.

Purpose Following MCS implantation adequate functional performance is crucial for participation in self-determined social life. Exercise-based cardiac rehabilitation (CR) is intended to make an important contribution to recovery before patients can be discharged home. It was our aim to evaluate functional performance measured with the six-minute walking distance (6MWD) at the end of inpatient CR and possible influencing factors. Methods Retrospective analysis of monocentric quality assurance data: we included patients (≥18 years old) who underwent MCS implantation between 2006 and 2016 and subsequently completed exercise-based inpatient CR. 6MWD was measured routinely at begin and end of CR. In total the results of 435 patients (54±12 yrs old, 16% female, 42%DCM, 43% ICM, 9% myocarditis) with MCS support (413 LVAD, 17 BVAD, 2 RVAD, 3 TAH) could be analyzed. Results CR began 54±42 days after implantation and lasted 24±6 days. Overall the 6MWD improved significantly from 292±109 to a total of 375±109 m (p Conclusion In patients with MCS systems 6MWD improved significantly during exercise-based inpatient CR regardless from different support types. The reached distance of about 375 m reflects adequate functional performance as prerequisite for the activities of daily living. In the future, randomized and controlled studies should be sought to verify and confirm the effects of exercise-based CR in patients with MCS.

Herzinsuffizienz ist eine der haufigsten und kostenintensivsten chronischen Erkrankungen. Patientenschulung ist ein wichtiger Bestandteil der Herzinsuffizienz-Therapie. Rehabilitation soll die Selbstmanagement-Fahigkeiten der Patienten und den Krankheitsverlauf verbessern. Ein strukturiertes Schulungsprogramm fur Herzinsuffizienz zur Vermittlung von Wissen uber die Erkrankung und Erlernen von krankheitsgerechtem Verhalten wurde erstellt und dessen Wirksamkeit in einem Kontrollgruppendesign getestet. Patienten mit Herzinsuffizienz wurden am Beginn einer Rehabilitation cluster-randomisiert einer Interventionsgruppe oder einer Kontrollgruppe zugewiesen. Beide Gruppen erhielten eine speziell auf Herzinsuffizienz-Patienten ausgerichtete Rehabilitation. Die Interven­tionsgruppe erhielt zusatzlich das Schulungsprogramm, die Kontrollgruppe einen einzelnen Vortrag zur Wissensvermittlung. Am Ende der Rehabilitation und nach 6 Monaten wurden das Wissen und die Vollstandigkeit der empfohlenen Selbstkontrollen uberpruft. Zusatzlich wurden die Krankheitsschwere und die Pharmakotherapie ­ermittelt. Beide Gruppen zeigten eine Verbesserung des Krankheitsstatus. Teilnehmer der Patientenschulung hatten nachhaltig hoheres Wissen, erreichten nach 6 Monaten eine hohere Zieldosis ihrer Medikation und dokumentierten ihre Selbstkontrollen haufiger. Unabhangig von der Schulungsintervention kommt es wahrend der kardiologischen Rehabilitation zu einer Verbesserung des Krankheitsstatus. Die wirksamen Einzelkomponenten sind dabei noch unklar. Das untersuchte Schulungsprogramm vermittelt ein besseres Krankheitswissen und bessere Selbstmanagement-Fahigkeiten. Aufgrund der dargestellten Ergebnisse erscheint es sinnvoll, kardiologische Rehabilitation in Versorgungsprogramme fur Herzinsuffizienz einzubinden – ein spezielles Herzinsuffizienz-Schulungsprogramm sollte dabei integriert werden.

Angste bei Patienten mit chronischen oder lebensbedrohenden Erkrankungen sind haufig zu beobachtende Anpassungsreaktionen, die sich unbehandelt zu ernsthaften Storungen entwickeln konnen und den Krankheitsverlauf sowie die Prognose allgemein verschlechtern. Schwierigkeiten im Rahmen der Standarddiagnostik ergeben sich vor allem aus den Fragen, ob die beschriebene Angstsymptomatik ein Ausdruck der korperlichen Erkrankung ist oder aber eine eigenstandige Angststorung mit Krankheitswert wiederspiegelt? Das Konzept der Pathologischen Realangst knupft an diesen Fragen an und beschreibt die Angst vor einer realen Bedrohung, die vor allem bei Patienten mit chronischen Erkrankungen, insbesondere bei denen mit lebensbedrohlichem Charakter, zum Ausdruck kommt. Verzerrte Wahrnehmungen der zugrunde liegenden Krankheit, hervorgerufen durch subjektive Krankheitsvorstellungen, fuhren haufig zu fehlgeleiteten Kausalannahmen und bedingen eine verzerrte Interpretation von korperlichen Krankheitssymptomen. Daraus resultierend kommt es zu einer angstlichen Aufmerksamkeitsfokussierung und letztendlich zu einer Entwicklung der Pathologischen Realangst. Im Folgenden wird ein erster Versuch unternommen, Pathologische Realangst naher zu erklaren und in ihrer klinischen Relevanz zu beschreiben. Das Konzept soll vor allem zur Prazisierung der Angstdiagnostik beitragen und dazu anregen eine facherubergreifende medizinische Versorgung anzustreben.

Background Self management of oral anticoagulation (OAC) decreases complication rates and improves quality of life. Manual and cognitive abilities of patients and patient training in a structured format are a precondition for this concept. Up to now, there is no evidence about knowledge increase from teaching programs. Methods Seventy-six patients (mean age, 57.4 years, 71% male) who started long-term OAC were included in the prospective multi-center study at three teaching centers representing different populations of anticoagulation patients: a department of cardiovascular surgery, an inpatient rehabilitation center and an anticoagulation clinic. The patients were trained in a structured education program for two days. For the evaluation, the patients performed standardized tests including 16 questions prior to start (T0), after each training unit (T1/T2) and 6 weeks later (T3). The primary endpoint was the percentage of > or =75% of patients who could answer > or =50% of questions correctly at T3. Secondary endpoints were the overall and item-specific percentages of correct answers at the end of each training unit (T1, T2) and at T3. In addition, the teaching program was rated by the patients on a six-point rating scale. Results Seventy-four out of 76 patients gave at least 50% correct answers at T3 (97.4%; 95% confidence interval, 90.8-99.7%). The average rates of correct answers developed from 40% (T0), 86% (T1), 94% (T2) to 96% (T3). The greatest increase of knowledge was observed with blood components, interpretation of International Normalized Ratio (INR) value, and the interaction of anticoagulation with other variables (e.g. drugs or infection). Patients rated the teaching program between 1 (best rating) and 2 at all time points. At T3, the patients reported less fear of complications and less limitations in their daily life than in earlier evaluations. Conclusion The structured training program INRatio appears to be an appropriate instrument for instruction of INR self management. In comparison with baseline knowledge, the percentage of correctly answered questions was twice as high directly after the end of training and remained at a high level of >90% for at least 6 weeks.

Heart failure is one of the most common und costly chronic diseases. Patient education is an important part of heart failure therapy. Rehabilitation aims to improve self-management abilities and the course of the disease. A structured heart failure education program was established to create knowledge about the disease and to implement a disease friendly behavior. The effectiveness was tested in a randomized controlled design.Patients were cluster randomized -assigned to an intervention group or a control group at the beginning of a rehabilitation. Both received a rehabilitation specifically geared to heart-failure-patients. The intervention group received additionally the education program, the control group a single lecture on the disease. At the end of rehabilitation and 6 months later the knowledge and integrity of the recommended self-tests have been checked. In addition the disease severity and pharmacotherapy were determined.Both groups showed improvements in disease status. Participants of the education program had a sustained higher knowledge, were better adjusted to medication after 6 months and documented their self-tests more frequently.Regardless to the education intervention an improvement of the disease status occurs during cardiac rehabilitation. The effective single components are still unclear. The evaluated education program leads specifically to an improved disease-related knowledge and improved self-management skills. Due to these results it seems useful to include cardiac rehabilitation in heart failure disease-management programs - a specific heart failure education program should be integrated.

Background Chronic heart failure requires a complex treatment regimen on a life-long basis. Therefore, self-care/self-management is an essential part of successful treatment and comprehensive patient education is warranted. However, specific information on program features and educational strategies enhancing treatment success is lacking. This trial aims to evaluate a patient-oriented and theory-based self-management educational group program as compared to usual care education during inpatient cardiac rehabilitation in Germany. Methods/Design The study is a multicenter cluster randomized controlled trial in four cardiac rehabilitation clinics. Clusters are patient education groups that comprise HF patients recruited within 2 weeks after commencement of inpatient cardiac rehabilitation. Cluster randomization was chosen for pragmatic reasons, i.e. to ensure a sufficient number of eligible patients to build large-enough educational groups and to prevent contamination by interaction of patients from different treatment allocations during rehabilitation. Rehabilitants with chronic systolic heart failure (n = 540) will be consecutively recruited for the study at the beginning of inpatient rehabilitation. Data will be assessed at admission, at discharge and after 6 and 12 months using patient questionnaires. In the intervention condition, patients receive the new patient-oriented self-management educational program, whereas in the control condition, patients receive a short lecture-based educational program (usual care). The primary outcome is patients’ self-reported self-management competence. Secondary outcomes include behavioral determinants and self-management health behavior (symptom monitoring, physical activity, medication adherence), health-related quality of life, and treatment satisfaction. Treatment effects will be evaluated separately for each follow-up time point using multilevel regression analysis, and adjusting for baseline values. Discussion This study evaluates the effectiveness of a comprehensive self-management educational program by a cluster randomized trial within inpatient cardiac rehabilitation in Germany. Furthermore, subgroup-related treatment effects will be explored. Study results will contribute to a better understanding of both the effectiveness and mechanisms of a self-management group program as part of cardiac rehabilitation. Trial registration German Clinical Trials Register: DRKS00004841; WHO International Clinical Trials: = DRKS00004841

Absence of an adequate reason for anxiety is a criterion for pathological anxiety. However, the presence of danger or fear-provoking stimuli may even be a risk factor for anxiety and does not exclude that there is additionally pathological anxiety too. The question is, to what degree can heart-related anxiety be explained by the severity of illness or trait anxiety? Two hundred and nine patients (37.8% women) from a cardiology inpatient unit completed the Heart-Anxiety-Questionnaire, Progression-Anxiety-Questionnaire, Job-Anxiety-Scale and the State-Trait-Anxiety-Inventory. The severity of cardiac illness was rated by the treating cardiologists using the Multidimensional Severity of Morbidity Rating. Time absent from work due to sickness was assessed as an indicator for illness-related impairment. Heart anxiety was significantly related to progression anxiety and, to a lesser extent, trait anxiety and indicators of subjective symptoms of somatic illness. No association was found with medical ratings for prognosis, multimorbidity, or reduction in life expectancy. Heart-related anxiety is a symptom of an anxiety disorder. Although partially dependent on subjective suffering, it cannot be explained by the severity of medical illness. Treatment of health-related anxieties should focus on how to cope with subjective symptoms of illness.

Information of patients about their illness is necessary for patient empowerment and coping with illness. This can be done by written material, i.e. bibliotherapy [1-6]. Scientific data suggest that bibliotherapy can help patients to better understand their illness, improve their health behaviour, and reduce anxiety [2, 3, 7]. The objective of the present study is to investigate in a randomized controlled trial the effects of bibliotherapy on illness-related knowledge, i.e. health literacy, and on heart-related anxiety in cardiology patients.

Hintergrund und Fragestellung: Herzinsuffizienz ist ein haufiges klinisches Syndrom mit wachsender Bedeutung und schlechter Prognose. Patientenschulung ist ein zentraler Bestandteil der medizinischen Rehabilitation mit dem Ziel die Folgen chronischer Krankheiten durch gezielte Forderung von Krankheitskompetenz und Selbstmanagement zu verringern und die Lebensqualitat von Patienten zu verbessern. Im Rahmen der vorliegenden explorativen Untersuchung wird ein neu entwickeltes Patientenschulungsprogramm fur Herzinsuffizienz vorgestellt und die direkte Bewertung des Programms durch Patienten, die Veranderungen des krankheitsbezogenen Wissens, die gesundheits- und krankheitsbezogene Lebensqualitat, sowie die psychische Symptombelastung im Verlauf erfasst. Methode: 64 Patienten (79,7% Manner) nahmen im Rahmen einer kardiologischen Rehabilitation an einer kompetenz-fokussierenden Schulung fur Herzinsuffizienzpatienten teil. Die Patienten fullten zu Beginn, am Ende sowie sechs Monate nach der Rehabilitation Selbstbeurteilungsfragebogen zum psychischen Wohlbefinden und zur Lebenszufriedenheit, einen auf die Schulungsinhalte bezogenen Wissenstest und einen Evaluationsfragebogen aus. Ergebnisse: Die Bewertung des Schulungsprogramms durch die Teilnehmer war sehr gut. Wissen und Lebensqualitat waren am Ende und sechs Monate nach der Rehabilitation signifikant gestiegen, die psychische Symptombelastung (Angstlichkeit und Depressivitat) reduziert. Schlussfolgerung: Wahrend einer kardiologischen Rehabilitation erfahrt ein strukturiertes Schulungsprogramm fur Patienten mit Herzinsuffizienz eine hohe Akzeptanz seitens der Patienten. Die Patienten erfahren eine Verbesserung ihres Wissens uber die Erkrankung, eine Reduktion von Angst- und Depressivitatserleben und eine Verbesserung ihrer Lebensqualitat. Die Indikation fur eine Schulung muss insbesondere bei Patienten mit Angstneigung sorgfaltig abgeklart werden.

The increasing use of ventricular assist devices (VADs) in terminal heart failure patients provides new challenges to cardiac rehabilitation physicians. Structured cardiac rehabilitation strategies are still poorly implemented for this special patient group. Clear guidance and more evidence for optimal modalities are needed. Thereby, attention has to be paid to specific aspects, such as psychological and social support and education (e.g., device management, INR self-management, drive-line care, and medication).In Germany, the post-implant treatment and rehabilitation of VAD Patients working group was founded in 2012. This working group has developed clear recommendations for the rehabilitation of VAD patients according to the available literature. All facets of VAD patients' rehabilitation are covered. The present paper is unique in Europe and represents a milestone to overcome the heterogeneity of VAD patient rehabilitation.