Novel advances in cardiac rehabilitation : Position paper from the Working Group on Preventive Cardiology and Cardiac Rehabilitation of the Netherlands Society of Cardiology.

Cardiac rehabilitation (CR) has evolved as an important part of the treatment of patients with cardiovascular disease. However, to date, its full potential is fairly underutilised. This review discusses new developments in CR aimed at improving participation rates and long-term effectiveness in the general cardiac population. It consecutively highlights new or challenging target groups, new delivery modes and new care pathways for CR programmes. These new or challenging target groups include patients with atrial fibrillation, obesity and cardiovascular disease, chronic coronary syndromes, (advanced) chronic heart failure with or without intracardiac devices, women and frail elderly patients. Also, the current evidence regarding cardiac telerehabilitation and loyalty programmes is discussed as new delivery modes for CR. Finally, this paper discusses novel care pathways with the integration of CR in residual risk management and transmural care pathways. These new developments can help to make optimal use of the benefits of CR. Therefore we should seize the opportunities to reshape current CR programmes, broaden their applicability and incorporate them into or combine them with other cardiovascular care programmes/pathways.

Recommendations on how to provide cardiac rehabilitation services during the COVID-19 pandemic.

The ongoing coronavirus disease 2019 (COVID-19) crisis is having a large impact on acute and chronic cardiac care. Due to public health measures and the reorganisation of outpatient cardiac care, traditional centre-based cardiac rehabilitation is currently almost impossible. In addition, public health measures are having a potentially negative impact on lifestyle behaviour and general well-being. Therefore, the Working Group of Cardiovascular Prevention and Rehabilitation of the Dutch Society of Cardiology has formulated practical recommendations for the provision of cardiac rehabilitation during the COVID-19 pandemic, by using telerehabilitation programmes without face-to-face contact based on current guidelines supplemented with new insights and experiences.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation.

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

[Cardiologists should take this to heart: doctors often do not recognise stress as a risk factor for cardiovascular disease]. / De schrik zou de cardioloog om het hart moeten slaan.

The strong association between distress and heart disease is frequently in the news, for example when a celebrity dies after terrible news such as death of a child. Researchers in the Netherlands found that high scores on the Cardiac Anxiety Questionnaire after a myocardial infarction lead to an increased risk of new cardiac events, regardless of underlying cardiac disease severity. Although the brain-heart axis is well known in literature, it is hardly a common subject in daily clinical cardiac practice. Signs and symptoms frequently lead to an 'oculostenotic reflex' instead of proper mental diagnosis. Despite the fact that patients are familiar with stress as a major risk factor, guidelines concerning this relationship are lacking. What can we do to bring about change? By emphasising the integral aspect of patient care in medical education, and by training medical specialists, on the premise that 'you cannot recognise what you do not know'. Recent research confirmed the relationship between stress and atherosclerosis by visual means. Could this be the solution for hesitant doctors: a picture?

Depressive effect of an antidepressant: therapeutic failure of venlafaxine in a case lacking CYP2D6 activity.

Understanding the mechanisms of drug metabolism and interactions can help to prevent side-effects. Not only drug interactions, environmental factors, disease processes and ageing are factors in the inter-individual metabolic capacity variance but also genetic factors probably play an important role, as is illustrated in the case presented. Besides therapeutic drug monitoring, genotyping some important cytochrome P450 (CYP450) enzymes was of additional value in explaining why the patient developed severe adverse effects and, moreover, did not experience any therapeutical effect of venlafaxine. Results indicated that the patient was a poor metabolizer for CYP2D6, the most important phase I enzyme to metabolize venlafaxine. This corroborates that polymorphisms in the CYP450 gene influence the metabolic activity of the corresponding enzymes, thus affecting the subsequent serum drug levels and their metabolites. This case highlights the potential benefit of both clinical and genetic risk stratification (pharmacogenetics) prior to treatment, either for setting the individual dose or for making a decision about using a particular drug.

The effects of guideline implementation for proton pump inhibitor prescription on two pulmonary medicine wards.

BACKGROUND: It has been demonstrated that 40% of patients admitted to pulmonary medicine wards use proton pump inhibitors (PPIs) without a registered indication. AIM: To assess whether implementation of a guideline for proton pump inhibitor (PPI) prescription on pulmonary medicine wards could lead to a decrease in use and improved appropriateness of prescription. METHODS: This prospective study comprised two periods, i.e. the situation before and after guideline implementation. In each period, 300 consecutive patients were included. We registered patient characteristics, medications and occurrence of upper gastrointestinal-related disorders. RESULTS: After implementation, fewer patients were started on PPIs [21% vs. 13%; odds ratio (OR): 0.56; 95% confidence interval (CI): 0.33-0.97] and more users discontinued their use; however, the latter was not significant (3% vs. 6%; OR for continuation: 0.56; 95% CI: 0.14-2.23). Multivariable logistic regression analysis confirmed that PPI use during hospitalization decreased after implementation (adjusted pooled OR: 0.54; 95% CI: 0.32-0.90). Implementation did not result in a change in reported reasons for PPI prescription. There was no significant difference in the occurrence of upper GI-related disorders in the first 3 months after discharge. CONCLUSIONS: Guideline implementation for PPI prescription on two pulmonary medicine wards resulted in a reduction in the number of patients starting PPIs during hospitalization, but appropriateness of prescribing PPIs was not affected. Further studies are needed to determine how appropriateness of PPI prescription on pulmonary medicine wards can be further improved.

[Chest pain due to a panic disorder: the significance of a multidisciplinary approach]. / Pijn op de borst door een angststoornis: het belang van een multidisciplinaire benadering.

A 50-year-old man and a 76-year-old woman were presented with noncardiac chest pain at a medical-psychiatric unit, which is a dual medical and psychiatric inpatient unit in the University Hospital Maastricht, Tthe Netherlands. Since more than one year both patients had had complaints without a medical explanation for their symptoms. Somatic and psychiatric investigations were performed by a multidisciplinary team. Both patients were diagnosed with a panic disorder which has been shown to be highly treatable. Panic disorder induced noncardiac chest pain is a common problem that often remains unrecognized, due to the fact that patients primarily report somatic symptoms. The consequences are a high medical consumption and economic costs due to loss of working days. Moreover, anxiety may even increase cardiac morbidity and mortality directly. This stresses the importance of effective screening for psychopathology in this large group of patients. A multidisciplinary approach is advisable to motivate such patients for treatment, as they accept the presence of a psychiatrist in a combined clinic more readily.

Review article: The prevalence and clinical relevance of cytochrome P450 polymorphisms.

BACKGROUND: Most drugs currently used in clinical practice are effective in only 25% to 60% of patients, while adverse drug reactions (ADRs) as a consequence of treatment are estimated to cost billions of US dollars and tens of thousands of deaths. AIM: To review the prevalence and clinical significance of cytochrome P450 polymorphisms. RESULTS: The cytochrome P450 enzyme families 1-3 are responsible for 70 to 80% of all phase I dependent drug metabolisms. In 90% metabolic activity dependents on six enzymes: CYP1A2, CYP3A, CYP2C9, CYP2C19, CYP2D6 and CYP2E1. Polymorphisms in the CYP450 gene can influence metabolic activity of the subsequent enzymes. A poor metabolizer (PM) has no or very poor enzyme activity. A consequence of PM is drug toxicity if no other metabolic route is available, or when multiple drugs are metabolized by the same cytochrome. In that case dose reduction is an option to prevent toxic effects. CONCLUSIONS: In the future genotyping should be considered to identify patients who might be at risk of severe toxic responses, in order to guide appropriate individual dosage. Medical therapy should be a close cooperation between clinicians, pharmacologists and laboratory specialists, leading to reduced therapeutic errors, ADRs and health care costs.

Cardiological risk factors for depressive symptoms after a first myocardial infarction.

OBJECTIVE: To detect possible cardiological risk factors in the acute phase of MI for developing depressive symptoms after first MI. DESIGN: Retrospective analysis of cardiac and psychiatric data of 111 consecutive patients admitted with a first MI. METHODS: During one year, all consecutive patients with a first MI, less than 12 hours chest pain and a maximal aspartate aminotransferase (ASAT) value of at least 80 U/l, admitted to the University Hospital of Maastricht, were screened for the presence of depressive symptoms using the 90-item 'Symptom checklist' (SCL-90) questionnaire at one month post-MI. Inclusion criteria were fulfilled by 111 patients; 28 patients refused to participate in the study. RESULTS: No correlation was found between LVEF, peak ASAT, peak CK value and characteristics, location or mode of treatment of the MI and depressive symptoms post-MI. A statistically significant negative correlation was found between SCL-90 depression score and cardiac tissue loss as defined by cumulative ASAT release at 24, 48 and 72 hours after the acute event (p values 0.029, 0.028 and <0.009, respectively) at the one month post-MI screening. CONCLUSIONS: No cardiological parameters were correlated to depressive symptoms post-MI. If there was a connection at all, this appeared to be a negative correlation between infarct size as measured by ASAT release and the occurrence of depressive symptoms at one month post-MI.

Effect of treatment of panic disorder in patients with frequent ICD discharges: a pilot study.

Anxiety and depression are common in patients receiving an implantable cardioverter defibrillator (ICD). An association between the number of ICD discharges and mood disturbances has been found. We performed a pilot study in ICD patients with frequent ICD shocks having a comorbid diagnosis of panic disorder with agoraphobia and depression, in which we treated them with a combination of a selective serotonin reuptake inhibitor (SSRI) and a behavior program. We hypothesized that this intervention would result in a decrease of ventricular premature beats or arrhythmias and possibly in a reduction of number of shocks. Four of 5 patients treated with such a combination therapy experienced no discharge of the ICD during a 6 month follow-up. The total number of ventricular premature beats decreased significantly after treatment. There was also clear psychiatric improvement. These results warrant larger scale studies on the pathophysiological mechanisms as well as treatment issues.

[Panic disorder in patients with chest pain and palpitations: an often unrecognized relationship]. / Paniekstoornis bij patiënten met pijn op de borst en palpitaties: een onvoldoende onderkend verband.

The prevalence of panic disorder in patients who present with chest pain or palpitations to a First Heart Aid setting varies in the literature between 0%-59%. In a high percentage of cases, panic disorder is not recognized by the cardiologist in patients who present initially with chest pain or palpitations. Patients with panic disorder have a large and ongoing medical consumption. A selective serotonin reuptake inhibitor and/or cognitive therapy appear to be good treatment of panic disorder in patients who present initially with chest pain or palpitations. A CO2 challenge test elicits the symptoms in patients with panic disorder with high sensitivity and specificity but this test has not been validated in patients who present initially with chest pain or palpitations and in whom the diagnosis 'panic disorder' is not yet established.

[Panic disorder, chest pain and palpitations: a pilot study of a Dutch First Heart Aid]. / Paniekstoornissen, pijn op de borst en palpitaties: een pilotonderzoek op een Nederlandse Eerste Harthulp.

OBJECTIVE: To determine how many patients, presenting to a First Heart Aid (FHA) with chest pain or palpitations without a cardiac origin for their complaints, have a panic disorder and/or depression. DESIGN: Prospective and questionnaire investigation. METHOD: In 3 months (November 1st 1998-January 31st 1999) all patients presenting to the FHA of the University Hospital Maastricht, the Netherlands, and who were not admitted, were screened for the presence of psychopathology by means of a questionnaire, the 'Hospital anxiety and depression scale' (HADS). Patients scoring above 8 on the HADS with no cardiac cause for their initial complaint were interviewed using the 'Mini international neuropsychiatric interview' (MINI) to determine whether there was a panic disorder and/or a depressive episode. RESULTS: Of a total of 621 patients 251 met the inclusion criteria; 134 (53%) gave informed consent (72 (54%) men and 62 (46%) women, with a mean age of 55.9 (SD: 13.2; range: 23-84)). Of the 134, 77 had a HADS score > or = 8; in 59 (30 men; 29 women) the MINI was carried out; in 49 (83%) panic disorder (n = 45) or depression (n = 4) was diagnosed. In 7/45 the cardiologist had diagnosed a psychiatric disorder ('Hyperventilation'). CONCLUSION: In 83% of the patients who visited the Maastricht FHA with cardiac complaints but without a cardiac origin and who had a HADS score > or = 8, panic disorder and/or depression was diagnosed.

Efficacy and safety of fluoxetine in the treatment of patients with major depression after first myocardial infarction: findings from a double-blind, placebo-controlled trial.

OBJECTIVE: Depression and hostility are significant risk factors for mortality and morbidity after myocardial infarction (MI). Much research is still needed to identify effective ways to reduce emotional distress in patients with cardiovascular disease. This double-blind, placebo-controlled study investigated the efficacy and safety of the antidepressant fluoxetine in patients with depression after their first MI. METHODS: Fifty-four patients with major depression after MI were randomly assigned to receive a flexible-dose regimen of fluoxetine or placebo for the first 9 weeks of a double-blind, placebo-controlled trial. Patients without serious adverse effects who wished to continue participating in the study were given fluoxetine or placebo for an additional 16 weeks. To evaluate the efficacy of fluoxetine, the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Hostility Scale of the 90-item Symptom Check List (SCL-90) were used as primary measures of outcome. To evaluate the safety of fluoxetine, cardiac function was measured before and after treatment with echocardiography and electrocardiography. RESULTS: The a priori difference in antidepressive efficacy (4-point difference in HAMD-17 scores between the fluoxetine and placebo groups) was not met. However, the response rate among patients receiving fluoxetine was significantly greater than that among patients receiving placebo at week 25 (48 vs. 26%, p = .05). Among patients with mild depression (HAMD-17 score < or =21), HAMD-17 scores were significantly different (p < .05) between the fluoxetine and placebo groups at weeks 9 (by 5.4 points) and 25 (by 5.8 points). Also, hostility scores at week 25 were significantly reduced among patients receiving fluoxetine (p = .02). Analysis of electrocardiographic and echocardiographic parameters revealed no decrease in cardiac function as a result of treatment with fluoxetine. CONCLUSIONS: Although the overall difference between the fluoxetine and placebo groups was not significant, there was a trend favoring fluoxetine in this relatively small sample. The response rate in the group receiving fluoxetine was comparable with that observed in other studies of patients with cardiovascular disease. In addition, fluoxetine seemed to be particularly effective in patients with mild depression and was associated with a statistically significant reduction in hostility. The results of this study suggest that fluoxetine can be safely used to treat patients with post-MI depression beginning 3 months after the event.

Med Psych Units: Proceedings and abstracts of the Triptych Workshop 9 december 1999 Maastricht.

Med Psych Units (MPU) are neither clear-cut medical nor psychiatric units. This makes it difficult to acquire funding for these often expensive units. Despite this, there are many reasons why MPU's should be a necessary part of any larger scale inpatient service of a general and teaching hospital. It is therefore even more remarkable that such units hardly exist in Europe and that only about twenty exist in the USA. Five main reasons why such units should be opened are: The increasing average age of the population of the Western World, with high co-morbidity and polypharmacy in the elderly and elderly elderly. An increase in the number of chronic physical diseases resulting in co-morbid psychiatric disorders. This increase in chronicity is the consequence of increasingly successful treatment of acute and potentially lethal diseases; for example, acute myocardial infarction and the subsequent development of chronic heart disease. The decreasing duration of hospital admission. On average the duration of stay in a general hospital in The Netherlands is now nine days. The number of day-treatments has doubled in the last decade. This situation means that it is not possible to observe the behavior of patients on a general medical ward or to carry out a psychiatric consultation. Inadequate medical evaluation of psychiatric patients. According to a recent survey by the Dutch Ministry of Health, the care given for physical disease to psychiatric patients in mental hospitals in The Netherlands needs much to be desired for. The psychiatric co-morbidity of somatic diseases is accompanied by a high consumption of medical facilities and high economic losses, unless adequately recognized and treated.