Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

[ESC guidelines 2019 on diagnostics and management of acute pulmonary embolism]. / ESC-Leitlinien 2019 zu Diagnostik und Management der akuten Lungenembolie.

This article on the new European Society of Cardiology (ESC) guidelines for diagnostics and management of acute pulmonary embolism (PE) focusses on new or changed recommendations compared to the previous version of the guidelines from 2014. The current risk-adjusted management algorithm for acute PE includes the clinical severity, aggravating comorbid conditions and right ventricular dysfunction. For low-risk patients early discharge and outpatient treatment are possible, whereas for high-risk patients reperfusion treatment and hemodynamic support have to be considered, depending on the hemodynamic situation and contraindications in the individual patient. Effective therapeutic anticoagulation for at least 3 months is recommended for all patients with PE. Potential indicators for extended anticoagulation are given in the guidelines (class I or class IIa recommendations). New oral anticoagulants (NOAC) are the first choice for anticoagulation in preference to vitamin K antagonists (VKA); however, they are not recommended in patients with severe renal dysfunction, during pregnancy or lactation and in patients with antiphospholipid antibody syndrome. Furthermore, a new algorithm for the follow-up after acute PE is proposed in the guidelines. In cases of symptomatic persistent pulmonary hypertension (PH) the transfer to a specialized center is recommended.

Socially disadvantaged city districts show a higher incidence of acute ST-elevation myocardial infarctions with elevated cardiovascular risk factors and worse prognosis.

BACKGROUND: The importance of socioeconomic status (SES) for coronary heart disease (CHD)-morbidity is subject of ongoing scientific investigations. This study was to explore the association between SES in different city-districts of Bremen/Germany and incidence, severity, treatment modalities and prognosis for patients with ST-elevation myocardial infarctions (STEMI). METHODS: Since 2006 all STEMI-patients from the metropolitan area of Bremen are documented in the Bremen STEMI-registry. Utilizing postal codes of their home address they were assigned to four groups in accordance to the Bremen social deprivation-index (G1: high, G2: intermediate high, G3: intermediate low, G4: low socioeconomic status). RESULTS: Three thousand four hundred sixty-two consecutive patients with STEMI admitted between 2006 and 2015 entered analysis. City areas with low SES showed higher adjusted STEMI-incidence-rates (IR-ratio 1.56, G4 vs. G1). This elevation could be observed in both sexes (women IRR 1.63, men IRR 1.54) and was most prominent in inhabitants <50 yrs. of age (women IRR 2.18, men IRR 2.17). Smoking (OR 1.7, 95%CI 1.3-2.4) and obesity (1.6, 95%CI 1.1-2.2) was more prevalent in pts. from low SES city-areas. While treatment-modalities did not differ, low SES was associated with more extensive STEMIs (creatine kinase > 3000 U/l, OR 1.95, 95% CI 1.4-2.8) and severe impairment of LV-function post-STEMI (OR 2.0, 95% CI 1.2-3.4). Long term follow-up revealed that lower SES was associated with higher major adverse cardiac or cerebrovascular event (MACCE)-rates after 5 years: G1 30.8%, G2 35.7%, G3 36.0%, G4 41.1%, p (for trend) = 0.02. This worse prognosis could especially be shown for young STEMI-patients (<50 yrs. of age) 5-yr. mortality-rates(G4 vs. G1) 18.4 vs. 3.1%, p = 0.03 and 5-year-MACCE-rates (G4 vs. G1) 32 vs. 6.3%, p = 0.02. CONCLUSIONS: This registry-data confirms the negative association of low socioeconomic status and STEMI-incidence, with higher rates of smoking and obesity, more extensive infarctions and worse prognosis for the socio-economically deprived.

Sex-based differences in outcomes with bivalirudin or unfractionated heparin for transcatheter aortic valve replacement: Results from the BRAVO-3 randomized trial.

BACKGROUND: Women comprise almost 50% of patients undergoing transcatheter aortic valve replacement (TAVR) and previous studies have indicated higher rates of procedural complications and bleeding in women compared to men. It is unknown whether men and women demonstrate a differential response to bivalirudin versus unfractionated heparin (UFH) in TAVR. We sought to evaluate outcomes by sex and type of anticoagulant from the Bivalirudin Versus Heparin Anticoagulation in Transcatheter Aortic Valve Replacement (BRAVO-3) trial of transfemoral TAVR. METHODS: BRAVO-3 was a randomized multicenter trial comparing transfemoral TAVR with bivalirudin versus UFH (31 centers, n = 802). The primary endpoint was 48 h major bleeding defined as Bleeding Academic Research Consortium (BARC) type ≥3b. Major adverse cardiovascular events (MACE) were a composite of 30-day death, myocardial infarction, or stroke. Net adverse cardiovascular events (NACE) were a composite of BARC ≥3b bleeding or 30-day MACE. We examined the outcomes in men and women. RESULTS: The total cohort included 49% women (n = 391, 195 received bivalirudin and 196 UFH) and 51% men (n = 411, 209 received bivalirudin and 202 UFH). Women were older than men with fewer comorbidities including coronary artery disease, atrial fibrillation, diabetes but similar EuroSCORE I. Women received smaller sheath and device sizes compared with men without differences in the use of vascular closure devices. At 48-hr post-TAVR there was no difference in bleeding or vascular complications in women compared to men. The use of bivalirudin did not result in significantly lower bleeding at 48 hr or 30-days compared to UFH. CONCLUSIONS: There was no difference in early outcomes with bivalirudin versus UFH in men or women undergoing contemporary TAVR. © 2016 Wiley Periodicals, Inc.

Characteristics, management modalities and outcome in chronic systolic heart failure patients treated in tertiary care centers: results from the EVIdence based TreAtment in Heart Failure (EVITA-HF) registry.

BACKGROUND: Limited data exist regarding baseline characteristics and management of heart failure with reduced ejection fraction (EF) in tertiary care facilities. METHODS: EVITA-HF comprises web-based case report data on demography, comorbidities, diagnostic and therapy measures, quality of life, adverse events and 1-year follow-up of patients hospitalized for chronic heart failure and an ejection fraction of less than 40%. RESULTS: Between February 2009 and June 2011, a total of 1,853 consecutive, hospitalized patients (pts) were included in 16 centers in Germany. Mean age was 70 years, 76% were male. Median EF was 30%, and 63% were in NYHA III/IV. Ischemic cardiomyopathy was present in 56%, history of hypertension in 76%, diabetes in 39%, impaired renal function in 33%, thyroid dysfunction in 12%, and malignoma in 7%. Sixty-eight percent of pts had a non-elective admission. Rhythm was sinus/atrial fibrillation or flutter/pacemaker in 64, 28 and 11%, respectively. Median heart rate amounted to 80 bpm, median blood pressure to 122/74 mmHg. LBBB was present in 26% of non-pacemaker pts. Eighteen percent had an ICD or CRT-D. Medication (admission vs. discharge) consisted of ACEI or ARB in 73 vs. 88%, ß-blocker in 71 vs. 89%, mineral corticosteroid receptor antagonist (MRA) in 32 vs. 57%, diuretics in 68 vs. 83% (p < 0.001 for each). Forty-two percent of pts received a specific treatment procedure beyond pharmacotherapy, of these 48% revascularization, 39% device therapy, 14% electrical cardioversion, 5% ablation procedures, 9 % valvular procedures, 6% iv inotropes, 1.8% IABP or LVAD implantation. At discharge, 33% of survivors had ICD- or CRT-D implants. One-year mortality amounted to 16.8%, and death or rehospitalization to 56%. NYHA class III/IV was found in 30% (p < 0.001 vs. index admission), general health status was improved in 45% and unchanged in 36% of patients. Eighty-five percent of pts took ACEI or ARB, 86% ß-blockers, 47% MRA, and 78% diuretics (p < 0.001 vs. index discharge for all). CONCLUSION: Patients with chronic heart failure and low ejection fraction represent an elderly and multimorbid population. While hospitalized, they experience a significant optimization of prognosis-relevant medication, revascularization and device therapy. After 1 year, mortality is moderate; drug adherence is high and NYHA status favourable. The EVITA-HF registry is able to reflect coherently the real-world management, efforts and follow-up in heart failure pts managed in tertiary care facilities.

[Differential therapy in coronary heart disease]. / Differenzialtherapie der koronaren Herzkrankheit.

The various contemporary therapeutic options for coronary artery disease (CAD) require differentiated, individualized treatment strategies. The foundations of CAD therapy are lifestyle modifications targeted on the individual risk profile of the patients. Pharmacological therapy of CAD should prevent secondary coronary events (e.g. platelet aggregation inhibitors and statins) and reduce angina in symptomatic patients (e.g. short-acting nitrates, beta blockers, calcium channel blockers and if necessary ivabradine and ranolazine). Revascularization therapy has to be performed promptly in patients with acute coronary syndromes; however, in patients with stable CAD the decision to perform revascularization therapy has to consider symptoms, detection of ischemia and if appropriate intracoronary assessment of hemodynamic relevance of an intermediate stenosis (fractional flow reserve). The differential indications of percutaneous coronary intervention compared to coronary artery bypass grafting depend on the severity of coronary artery disease and the morphology (SYNTAX score), comorbidities and the will of the individual patient. The international guidelines emphasize the value of an interdisciplinary treatment decision in a "heart team". In summary, differential therapy of CAD has become challenging in the current clinical practice; future developments will probably further improve individualized strategies to treat patients with CAD.

Smoking ban in public areas is associated with a reduced incidence of hospital admissions due to ST-elevation myocardial infarctions in non-smokers. Results from the Bremen STEMI Registry.

INTRODUCTION: Laws banning tobacco smoking from public areas have been passed in several countries, including the region of Bremen, Germany at the end of 2007. The present study analyses the incidence of hospital admissions due to ST-elevation myocardial infarctions (STEMIs) before and after such a smoking ban was implemented, focusing on differences between smokers and non-smokers. In this respect, data of the Bremen STEMI Registry (BSR) give a complete epidemiological overview of a region in northwest Germany with approximately 800,000 inhabitants since all STEMIs are admitted to one central heart centre. METHODS AND RESULTS: Between January 2006 and December 2010, data from the BSR was analysed focusing on date of admission, age, gender, and prior nicotine consumption. A total of 3545 patients with STEMI were admitted in the Bremen Heart Centre during this time period. Comparing 2006-2007 vs. 2008-2010, hence before and after the smoking ban, a 16% decrease of the number of STEMIs was observed: from a mean of 65 STEMI/month in 2006-2007 to 55/month in 2008-2010 (p < 0.01). The group of smokers showed a constant number of STEMIs: 25/month in 2006-2007 to 26/month in 2008-2010 (+4%, p = 0.8). However, in non-smokers, a significant reduction of STEMIs over time was found: 39/month in 2006-2007 to 29/month in 2008-2010 (-26%, p < 0.01). The decline of STEMIs in non-smokers was consistently observed in all age groups and both sexes. Adjusting for potentially confounding factors like hypertension, obesity, and diabetes mellitus did not explain the observed decline. CONCLUSIONS: In the BSR, a significant decline of hospital admissions due to STEMIs in non-smokers was observed after the smoking ban in public areas came into force. No reduction of STEMI-related admissions was found in smokers. These results may be explained by the protection of non-smokers from passive smoking and the absence of such an effect in smokers by the dominant effect of active smoking.

[Treatment of ST-segment elevation acute myocardial infarction in hospitals with and without cardiac catheterization laboratory]. / Therapie des akuten ST-Streckenhebungs-Myokardinfarkts in Krankenhäusern mit und ohne Herzkatheterlabor.

BACKGROUND AND OBJECTIVE: The goal of treatment of patients with ST-segment elevation acute myocardial infarction (STEMI) is to restore perfusion as soon as possible, preferably by primary percutaneous coronary intervention (PCI). The aim of this study of the German Myocardial Infarction Registry (DHR) was to document acute care and in-hospital course of STEMI patients in Germany. METHODS: Over three months patients with STEMI were consecutively included and their basic data, treatments and in-hospital complications were centrally recorded using an internet-based standardized questionnaire. RESULTS: Included were 6,330 patients from 243 hospitals, in group 1 (primary admission in 136 hospitals with cath lab) 4,656 patients (74%) and in group 2 (primary admission in 107 hospitals without cath lab) 1,674 (26%). Reperfusion therapy was performed more frequently in patients of group 1 (91.1% PCI, 2.7% fibrinolysis) than in group 2 (80.7% PCI after transfer, 6.4% fibrinolysis). In-hospital mortality was 7.3% in all patients, 7.0% in group 1 and 8.3% in group 2. CONCLUSION: The DHR data show that about three quarters of patients with STEMI are primarily admitted to hospitals with cath labs. Primary PCI is the preferred treatment option both in hospitals with and without cath labs (in the latter after transfer); it is performed in about 85% of STEMI patients. In-hospital mortality is with over 7% higher in real-life than in randomized studies.

Impact of coronary artery disease on in-hospital mortality in patients with aortic valve disease. Results from the German ALKK registry.

OBJECTIVE: Although aortic valve disease (AVD) is frequently associated with coronary artery disease (CAD), little is known about the impact of significant coronary artery disease on mortality after diagnostic cardiac catheterization in patients with AVD. METHODS: We analyzed data of the coronary angiography registry of the "Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte" (ALKK) in Germany. The primary endpoint was in-hospital mortality. RESULTS: A total of 1427 consecutive patients with AVD (438 patients with CAD versus 989 patients without CAD) underwent diagnostic catheterization in 2006 in 42 hospitals. All cause in-hospital mortality was more than threefold higher in patients with CAD (16/438; 3.7%) as compared to patients without CAD (12/989; 1.2%; p < 0.01; OR 3.09, 95% CI 1.45-6.58). Even after adjustment for age, sex, presence of diabetes mellitus and renal insufficiency, in-hospital all cause mortality remained statistically significant different between the two groups (OR 2.4; 95% CI 1.09-5.28; p < 0.01). Several factors, such as transient ischemic attack/stroke, volume of contrast agent, and left heart catheter-associated complications could not be identified as possible causes for the increase in mortality. CONCLUSION: This analysis in patients with the leading diagnosis of AVD shows a significantly higher in-hospital mortality after diagnostic cardiac catheterization in case of an accompanying CAD. However, further studies are necessary to identify the driving force for the increase in mortality.

[Physical exercise training for cardiovascular diseases]. / Trainingstherapie bei kardiologischen Patienten (Sportkardiologie).

Clinical application of physical exercise has developed into an evidence-based therapeutic option for cardiovascular diseases, especially coronary artery disease (CAD) and chronic heart failure (CHF). In CAD regular physical exercise training partially corrects endothelial dysfunction and leads to an economization of left ventricular function. Meta-analyses have shown a reduction of angina pectoris symptoms and a decrease of total and cardiovascular mortality by regular aerobic exercise training. Endurance training for CHF reduces cardiac afterload by correcting peripheral endothelial dysfunction und leads to a better left ventricular function. In addition exercise training reduces the adrenergic tone and the stimulation of the renin-angiotensin-aldosterone system in CHF. Exercise training provides positive effects on the metabolism and function of skeletal muscle (e.g. reduced inflammation and oxidative stress). Supervised regular physical exercise training in CHF is safe and has improved the morbidity in clinical studies. Thus aerobic exercise training is an important component of therapeutic management of stable CAD and CHF with a class 1a recommendation in the current guidelines.

Exercise training restores the endothelial response to vascular growth factors in patients with stable coronary artery disease.

OBJECTIVE: Exercise training partially corrects endothelial dysfunction in patients with coronary artery disease (CAD). Growth factors like vascular endothelial growth factor (VEGF) as well as erythropoietin (EPO) are known to modulate the bioavailability of nitric oxide and, thereby, contribute to the maintenance of a normal vascular tone. The aim of the present study was to determine the impact of 4 weeks of exercise training on circulating growth factors and to elucidate their involvement in the training-induced changes in vasomotion in patients with CAD. METHODS AND RESULTS: A total of 39 patients were enrolled (training group: n = 20; control group: n = 19). At start of study and after 4 weeks, average peak flow velocity (APV) of the left internal mammary artery (LIMA) in response to acetylcholine was measured invasively in the treatment and control groups. Serum concentrations of VEGF and EPO were determined by enzyme-linked immunosorbent assay. After exercise training, LIMA APV in response to acetylcholine was increased by 93% (from 69 ± 17% at start of study to 133 ± 16% at 4 weeks, p < 0.01 vs. start of study and control). At start of study, there was no association between any of the vascular growth factors and endothelial function. However, after exercise training a close correlation was apparent between the acetylcholine-induced change in APV and EPO (r = 0.69, p < 0.01) and VEGF (r = 0.76, p < 0.01) serum concentrations. In the control group, these correlations were not evident and there was no change in endothelial function either. CONCLUSION: Exercise training improves agonist-mediated endothelium-dependent vasodilatation in CAD, partially through a restoration of the endothelial response to EPO and VEGF.

[Effects of physical training of chronic cardiac insuffciency]. / Grundlegender Wandel in der Therapie der chronischen Herzinsuffizienz: Vom Sessel auf das Laufband!

During the last ten years,the traditional dogma "physical rest" for patients with chronic cardiac insufficiency (CCI) has been increasingly abandoned. Studies on the effects of low intensity physical endurance training for patients with stable CCI showed the following effects after 12 months: Decrease in the heart size and a slight improvement in the EF, reduction of the systemic vascular resistance during rest and during stress through improvement of the endothelial function, increase in the physical performance by 12 to 26%, reduction of local inflammation and improvement of the oxidative metabolism in skeletal muscles, an end to muscle atrophy and reduction of the total mortality. Training programs for patients with chronic cardiac insufficiency today represent an established auxiliary therapy for CCI with prognostic relevance.

[Physical exercise in older patients with chronic heart failure]. / Körperliche Aktivität bei älteren Patienten mit chronischer Herzinsuffizienz.

Maximal exercise capacity undergoes a steady decline after the age of 30 by approximately 10 % per decade. As a consequence of this development older people > 65 years of age suffer from the exercise limitation caused by age-associated cardiac, vascular and skeletal muscle changes. These physiologic alterations make older people especially vulnerable for the cardiovascular and peripheral alterations associated with chronic heart failure (CHF). These changes are not phenomenologically different from age-associated changes. Physical activity plays an important role for regaining a considerable part of vasomotor function, skeletal muscle contractility, and cardiac reserve. Up to now there are no prospective trials comparing the effects of physical training between older and younger patients with CHF. However, smaller observational studies indicate that elderly patients benefit equally well from training interventions with regard to functional improvements in proportion to their lower baseline values. In an aging population training aims at maintaining skeletal muscle force and muscle mass as well as locomotor coordination. Ultimately, the goal is to reduce the substantial morbidity among elderly CHF patients which constitute 79 % of all hospital admissions for heart failure.

Recommendations for resistance exercise in cardiac rehabilitation. Recommendations of the German Federation for Cardiovascular Prevention and Rehabilitation.

Aerobic endurance training has been an integral component of the international recommendations for cardiac rehabilitation for more than 30 years. Notwithstanding, only in recent years have recommendations for a dynamic resistance-training program been cautiously put forward. The perceived increased risk of cardiovascular complications related to blood pressure elevations are the primary concern with resistance training in cardiac patients; recent studies however have demonstrated that this need not be a contraindication in all cardiac patients. While blood pressure certainly may rise excessively during resistance training, the actual rise depends on a variety of controllable factors including magnitude of the isometric component, the load intensity, the amount of muscle mass involved as well as the number of repetitions and/or the load duration. Intra-arterial blood pressure measurements in cardiac patients have demonstrated that that during low-intensity resistance training [40-60% maximum voluntary contraction (MVC)] with 15-20 repetitions, only modest elevations in blood pressure are revealed, similar to those seen during moderate endurance training. When properly implemented by an experienced exercise therapist, in specific patient groups an individually tailored, medically supervised dynamic resistance training program carries no inherent higher risk for the patient than aerobic endurance training. As an adjunct to endurance training, in selected patients, resistance training can increase muscle strength and endurance, as well as positively influence cardiovascular risk factors, metabolism, cardiovascular function, psychosocial well-being and quality of life. According to present data, resistance training is however not recommended for all patient groups. The appropriate training method and correct performance are highly dependent on each patient's clinical status, cardiac stress tolerance and possible comorbidities. Most studies have used middle-aged men of average normal aerobic performance capacity and with good left-ventricular (LV) function. Data are lacking for high-risk groups, women and older patients. With the current knowledge it is reasonable to include resistance training without any restraints as part of cardiac rehabilitation programs for coronary artery disease (CAD) patients with good cardiac performance capacity (i.e., revascularised and with good myocardial function). As patients with myocardial ischaemia and/or poor left ventricular function may develop wall motion disturbances and/or severe ventricular arrhythmias during resistance exercise, the following criteria are suggested for resistance training: moderate-to-good LV function, good cardiac performance capacity [>5-6 metabolic equivalents of oxygen consumption (METS)=1.4 watt/kg body weight], no symptoms of angina pectoris or ST segment depression under continued maintenance of the medical therapy. Based on available data, this article presents recommendations for risk stratification in cardiac rehabilitation programs with respect to the implementation of dynamic resistance training. Additional recommendations for specific patient groups and detailed directions showing how to structure and implement such therapy programs are presented as well.

[The stakes of force perseverance training and muscle structure training in rehabilitation. Recommendations of the German Federation for Prevention and Rehabilitation of Heart-Circulatory Diseases e.v]. / Einsatz von Kraftausdauertraining und Muskelaufbautraining in der kardiologischen Rehabilitation. Empfehlungen der Deutschen Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen e. V.

While aerobic endurance training has been a substantial part of international recommendations for cardiac rehabilitation during the last 30 years, there is still a rather reserved attitude of the medical community to resistance exercise in this field. Careful recommendations for resistance exercise in cardiac patients was only published a few years ago. It has been taken for granted that strength exercise elicits a substantial increase in blood pressure and thus imposes, especially in cardiac patients, a risk of potentially fatal cardiovascular complications. Results of the latest studies show that the existing recommended overcaution is not justified. Strength exercise can indeed result in extreme increases of blood pressure, but this is not the case for all loads of this kind. The actual blood pressure response to strength exercise depends on the isometric component, the exercise intensity (load or resistance used), muscle mass activated, the number of repetitions in the set and/or the duration of the contraction as well as involvement of Valsalva maneuver. Intra arterially performed blood pressure measurements during resistance exercise in patients with heart disease showed that strength training carried out at low intensities (40-60% of MVC) and with high numbers of repetitions (15-20) only evokes a moderate increase of blood pressure comparable with blood pressure measures induced by moderate endurance training. If used properly and performed accurately, individually dosed, medically supervised and controlled through experienced sport therapists, a dynamic resistance exercise is-at least for a certain group of patients-not associated with higher risks than an aerobic endurance training and can in addition to endurance training improve muscle force and endurance, have a positive influence on cardiovascular function, metabolism, cardiovascular risk factors as well as psychosocial well-being and overall quality of life. However, with respect to currently available data, resistance exercise cannot be generally recommended for all groups of patients. The appropriate kind and execution of training is highly dependent on current clinical status, cardiac capacity as well as possible accompanying diseases of the patient. Most of the studies carried out up to date included small samples of middle-aged male patients with almost normal levels of aerobic endurance performance and good left ventricular function. Data is missing for risk groups, older patients and women. Therefore, an integration of dynamic resistance exercises in cardiac rehabilitation can only be recommended without hesitation for CHD patients with high physical capacity (good myocardial function, revascularized). Since patients with myocardial ischemia and/or low left ventricular functioning might develop wall motion disturbances and/or dangerous ventricular arrhythmia when performing resistance exercises, prevalence of the following conditions is recommend: moderate to high LV-function, high physical performance (>5-6 metabolic equivalents= >1.4 watts/kg body weight) in absence of angina pectoris symptoms or ST-depression, by maintained current medication. In the proposed recommendations, a classification of risks for resistance training in cardiac rehabilitation is being made based on current data and is complemented by specific recommendations for particular groups of patients and detailed guidelines for setup and completion of the therapy program.

Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.