Training and attitudes concerning cardiac rehabilitation in Portugal: A national survey of physician members of the Portuguese Society of Cardiology.

INTRODUCTION AND OBJECTIVES: Cardiac rehabilitation (CR) is a central component in the management of cardiovascular disease. While its potential benefits have been extensively explored and confirmed, its implementation is still suboptimal, due to various possible barriers. This study aimed to assess training and attitudes concerning CR among physicians in a Portuguese setting. METHODS: An online questionnaire structured in three parts (participant characteristics, training and attitudes concerning CR, and a brief general knowledge assessment) was developed and sent to members of the Portuguese Society of Cardiology. The study population encompassed physicians with a medical specialty or residents from the third year onward of a specialty program. RESULTS: A total of 97 individuals (57.7% male, 61.9% aged ≤50 years) presented valid answers. CR was available at the workplace of 54.6% of participants. Most of them considered that the time allocated to CR training during residency was inadequate, and thought that more time was needed for this purpose. Most had not dedicated (or intended to dedicate) time for CR training, with lack of time being the most frequently attributed reason. In terms of referral, a substantial proportion of subjects did not refer patients, with lack of CR centers and human resources being the most frequent reasons. CONCLUSIONS: This survey provides contemporary data on CR training and attitudes, highlighting areas of potential improvement, such as time allocated to training in this area. These results could provide a useful pragmatic framework for optimization of training and awareness in this pivotal field of cardiovascular medicine.

Sixty years of the Bruce protocol: reappraising the contemporary role of exercise stress testing with electrocardiographic monitoring.

The cardiovascular response to exercise has long been a focus of interest. Over a century ago, the first descriptions of electrocardiographic changes occurring during exercise highlighted the possible relevance of this dynamic assessment. In this background, the inception of the Bruce protocol circa 60 years ago allowed for a major leap in this field by providing a standardized framework with which to address this issue, by means of an integrated and structured methodology. Since then, exercise stress testing with electrocardiographic monitoring (ExECG) has become one of the most widely appraised tests in cardiovascular medicine. Notably, past few decades have been profoundly marked by substantial advances in the approach to cardiovascular disease, challenging prior notions concerning both its physiopathology and overall management. Among these, the ever-evolving presentations of cardiovascular disease coupled with the development and implementation of several novel diagnostic modalities (both invasive and noninvasive) has led to a shifting paradigm in the application of ExECG. This technique, however, has continuously shown to be of added value across various momentums of the cardiovascular continuum, as depicted in several contemporary guidelines. This review provides a pragmatical reflexion on the development of ExECG, presenting a comprehensive overview concerning the current role of this modality, its challenges, and its future perspectives.

Inflammation and ischemic heart disease: The next therapeutic target?

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest.

Current state of cardiac rehabilitation in Portugal: Results of the 2019 national survey.

INTRODUCTION: Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal. OBJECTIVES: This study reports the results of the 2019 survey on CR. METHODS: In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention. RESULTS: In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates <25%. CONCLUSION: The present survey shows an increase in the number of centers and patients undergoing phase II CR, and an increase in the estimated CR coverage after ACS. Despite this, the level of increase means that overall patient representation remained below the optimal range, while the data also showed a decrease in the number of patients in phase III programs. These findings reinforce the importance of optimization of CR entry and maintenance, in order to improve the uptake of this pivotal intervention.

Inflammation and ischemic heart disease: The next therapeutic target?

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest.

Suppression of tumorigenicity 2 after exercise: a systematic review.

Exercise is a pivotal physiological activity, associated with benefits. Whilst the importance of physical activity is consensual along different steps of the cardiovascular (CV) continuum, there has been interest in assessing the CV adaptations to vigorous exercise. Indeed, exercise can be associated with increases in cardiac biomarkers, though the scope of this observation remains elusive. Interleukin 1 receptor related protein, Suppression of tumorigenicity 2 (ST2) is a biomarker related to the pathophysiology of fibrosis, having shown promise in the study of heart failure. Knowledge of ST2 kinetics could improve understanding of the mechanistic pathways related to CV adaptations to exercise. To assess the current state-of-the-art concerning ST2 levels after exercise in healthy individuals. A systematic review was carried out on three databases (Pubmed, ISI Web of Science and Scopus), up to October 2020, using the queries "ST2" or "ST-2" + "exercise" or "running". A total of six studies were included in the review, encompassing 349 subjects (73% male gender) in which ST2 was assessed. Most studies reported increases in ST2 levels after exercise. Three studies, encompassing a total of 219 individuals, described a cut-off level of 35 ng/dL for ST2. In these, 92.7% of subjects had ST2 levels above this cut-off after exercise (running in all studies). Most studies report increased levels of ST2 after exercise, with an important number of individuals exceeding the 35 ng/dL threshold. Given the small number of individuals represented and the lack of imaging data and long-term follow-up, further prospective larger studies should target this.

Current role and future perspectives of cardiac rehabilitation in coronary heart disease.

Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

Complete atrioventricular block during exercise: New insights from an old test.

Exercise stress testing can have a central role in the assessment of cardiovascular disease. Contemporary data, however, has highlighted the added value of imaging modalities over the exercise electrocardiogram in the investigation of coronary artery disease. Given the physiological changes associated with exercise and the possibility to address other parameters such as rhythm changes and the chronotropic response, exercise stress testing with continuous electrocardiographic monitoring can still have an important place in contemporary clinical practice. We report the case of a complete atrioventricular block associated with exercise and discuss the current role of exercise stress testing with continuous electrocardiographic monitoring in this entity.

Myocardial deformation measures by cardiac magnetic resonance tissue tracking in myocarditis: Relationship with systolic function and myocardial damage.

INTRODUCTION AND OBJECTIVES: Cardiac magnetic resonance (CMR)-based tissue tracking (TT) enables quantification of myocardial deformation and may be used as an objective measure of myocardial involvement in myocarditis. The aims of this study were to characterize myocardial deformation alterations in myocarditis and to determine their relationship with the extent of late gadolinium enhancement (LGE), regional wall motion abnormalities (WMA) and left ventricular ejection fraction (LVEF). METHODS: A single-center, retrospective study was conducted by identifying patients with clinically suspected myocarditis who underwent CMR between 2012 and 2016. The myocardial deformation parameters were derived by TT and correlated with LVEF, LGE and WMA, through Spearman's coefficient. RESULTS: A cohort of 78 patients with myocarditis (aged 42.7±17.2 years) were included. CMR characteristics including morphologic parameters (LVEF 52.1±12.8%), extent of WMA (29.3±41.0%) and of LGE (30.5±21.8%) were assessed. Significant correlations were found between all deformation parameters (strain, strain rate, velocity and displacement) and both LVEF and extent of WMA. LGE was significantly correlated with systolic radial strain (r: -0.32, p=0.004), strain rate (r: -0.27, p=0.017) and displacement (r: -0.32, p=0.004) as well as systolic circumferential strain (r: 0.28, p=0.013). CONCLUSION: Deformation parameters are an objective method for quantification of myocardial function in myocarditis. They correlate with LVEF, extent of WMA and degree of myocardial damage. Further studies are needed to assess their incremental beneficial value for the diagnosis and risk stratification of myocarditis.

La función diastólica se altera en pacientes con prehipertensión: datos del estudio EPIPorto / Diastolic function is impaired in patients with prehypertension: data from the EPIPorto study

Introducción y objetivos: La hipertensión causa cambios subclínicos en la estructura y la función del ventrículo izquierdo, es decir, disfunción diastólica. La disfunción diastólica es un predictor de insuficiencia cardiaca, pues participa en la asociación entre hipertensión e insuficiencia cardiaca con fracción de eyección conservada. El objetivo es evaluar en una gran cohorte poblacional de adultos asintomáticos si los pacientes con prehipertensión tienen cambios precoces en la función diastólica. Métodos: Se evaluó de manera transversal una cohorte poblacional consistente en 925 adultos de 45 años o más sin enfermedad cardiovascular conocida. Todos los participantes se sometieron a un examen clínico y ecocardiográfico detallado. Se clasificó a los participantes, según las guías europeas para la clasificación de la presión arterial (PA) en la consulta, como óptima, prehipertensión (normal y normal-alta) e hipertensión. La función diastólica se evaluó mediante ecocardiografía usando las velocidades de e' y la razón E/e'. La disfunción diastólica se definió utilizando las recomendaciones conjuntas de ASE/EACVI de 2016 y un algoritmo de orientación clínica de 2017. Resultados: En esta cohorte (61,5 ± 10,5 años; el 37% varones), tenía prehipertensión el 30,4% e hipertensión el 51,0%. Se utilizó la PA óptima como referencia, y se observó una disminución progresiva de la velocidad e' en los individuos prehipertensos e hipertensos (12,2 ± 3,5 frente a 11,3 ± 3,1 frente a 9,6 ± 2,9 cm/s respectivamente; p de tendencia < 0,001). Después del ajuste multivariable, ambas categorías de PA fueron predictoras independientes de una menor velocidad e' (prehipertensión, ß = -0,56; p = 0,035; hipertensión, ß = -1,08; p < 0,001). Conclusiones: En esta cohorte poblacional, los adultos con prehipertensión mostraron una relajación cardiaca alterada antes del inicio de la hipertensión

Introduction and objectives: Hypertension causes subclinical changes in left ventricular structure and function, namely diastolic dysfunction. Diastolic dysfunction is a predictor of heart failure, being involved in the association between hypertension and heart failure with preserved ejection fraction. We aimed to determine whether patients with prehypertension have early changes in diastolic function in a large community-based cohort of asymptomatic adults. Methods: A cross-sectional evaluation was performed of a community-based cohort consisting of 925 adults, aged 45 years or older, without known cardiovascular disease. All participants underwent detailed clinical and echocardiographic examination. The participants were categorized according to the European guidelines for the classification of office blood pressure (BP) levels as optimal, prehypertensive (normal and high-normal categories), and hypertensive. Diastolic function was evaluated by echocardiography using e' velocities and E/e' ratio. Diastolic dysfunction was defined using the 2016 ASE/EACVI Joint Recommendations and a 2017 clinically-oriented algorithm. Results: In this cohort (61.5 ± 10.5 years; 37% men), prehypertension was present in 30.4% and hypertension in 51.0%. Using optimal BP as the reference, there was a progressive decrease of e' velocity in prehypertensive and hypertensive individuals (12.2 ± 3.5 vs 11.3 ± 3.1 vs 9.6 ± 2.9 cm/s, respectively; P for trend < .001). After multivariable adjustment, both BP categories were independent predictors of a lower e' velocity (ß = -0.56, P = .035 for prehypertension and ß = -1.08, P < .001 for hypertension). Conclusions: In this large community-based cohort, adults with prehypertension already showed impaired cardiac relaxation before the onset of hypertension

Prevalence of auto-antibodies associated to pulmonary arterial hypertension in scleroderma - A review.

The prevalence of auto-antibodies associated to pulmonary arterial hypertension in scleroderma patients was reviewed, based on reports cited in two major scientific databases. Data were collected on the following types of antibodies: antinuclear, anti-double-stranded DNA, anticentromere, anti-CENP-A, anti-CENP-B, anti-bicaudal D2, anti-nucleolar, anti-Scl-70 (anti-topoisomerase I), anti-topoisomerase II α, anti-RNP, anti-U1RNP, anti-U3RNP, anti-RNA polymerase III, anti-Th/To, anti-histone, antiphospholipid, anti-PmScl, anti-Sm, anti SSA (anti-Ro),anti SSB (La), anti-Ro52 (TRIM 21), anti-Ku, anti-B23, anti-RuvBL1, anti-RuvBL2, anti-fibrin bound tissue plasminogen activator, anti-endothelial cell, anti-phosphatidylserine-prothrombin complex, anti-endothelin-1 type A receptor, anti-angiotensin II type 1 receptor, anti­carbonic anhydrase II, anti-fibroblast, anti-cyclic citrullinated peptide, anti-4-sulfated N-Acetyl-lactosamine, class I and II anti-human leukocyte antigen. Auto-antibodies were shown by different authors to be associated to this condition, with different prevalence values for each type of auto-antibody. Antinuclear antibodies, anti-centromere antibodies, antiphospholipid antibodies, anti-U3 RNP antibodies and anti-Th/To antibodies would appear to show a particularly important prevalence in scleroderma patients with pulmonary hypertension, appearing in about 8/10 (antinuclear), 1/ 2 (anti-centromere, anti-phospholipid), and 1/4 (anti-U3RNP, anti-Th/To) of patients. The available evidence points in the direction of a strong association between auto-immune mechanisms and pulmonary hypertension in the setting of scleroderma.