Atrial remodelling associated with sporting discipline, sex and duration in elite sports: a cross-sectional echocardiographic study among Danish elite athletes.

Background: Elite endurance training is characterised by a high-volume load of the heart and has been associated with atrial fibrillation (AF) in middle-aged men. We compared left atrial (LA) remodelling among elite athletes engaged in sports, categorised as having low, intermediate, and high cardiac demands. Methods: This cross-sectional echocardiographic study of healthy elite athletes evaluated LA size and function measured as LA maximum volume (maxLAVi) and contraction strain. Athletes were grouped according to the cardiac demands of their sport (low, intermediate, high). Morphological measures were indexed to body surface area and reported as least square means; differences between groups were reported with 95% CIs. Results: We included 482 elite athletes (age 21±5 years (mean±SD), 39% women). MaxLAVi was larger in the high group (28.4 mL/m2) compared with the low group (20.2 mL/m2; difference: 8.2, CI 5.3 to 11.1 mL/m2; p<0.001), where measurements in men exceed those in women (26.4 mL/m2 vs 24.7 mL/m2; difference 1.6 mL/m2; CI 0.3 to 2.9 mL/m2; p=0.0175). In the high group, LA contraction strain was lower compared with the low group (-10.1% vs -12.9%; difference: 2.8%; CI 1.3 to 4.3%; p<0.001), and men had less LA contraction strain compared with women (-10.3% vs -11.0%; difference 0.7%; CI 0.0 to 1.4%; p=0.049). Years in training did not affect maxLAVi or LA contraction strain. Conclusion: MaxLAVi was higher while LA contraction strain was lower with increased cardiac demands. MaxLAVi was larger, and LA contraction was lower in men compared with women. Whether these sex-based differences in LA remodelling are a precursor to pathological remodelling in male athletes is unknown.

Prolonged Endurance Exercise Increases Macrophage Content and Mitochondrial Respiration in Adipose Tissue in Trained Men.

BACKGROUND: The aim of this study was to investigate the effect of prolonged endurance exercise on adipose tissue inflammation markers and mitochondrial respiration in younger and older men. METHODS: "Young" (aged 30 years, n = 7) and "old" (aged 65 years, n = 7) trained men were exposed to an exercise intervention of 15 consecutive days biking 7 to 9 hours/day at 63% and 65% of maximal heart rate (young and old, respectively), going from Copenhagen, Denmark to Palermo, Italy. Adipose tissue was sampled from both the gluteal and abdominal depot before and after the intervention. Mitochondrial respiration was measured by high-resolution respirometry, and adipose inflammation was assessed by immunohistochemical staining of paraffin embedded sections. RESULTS: An increased number of CD163+ macrophages was observed in both the gluteal and abdominal depot (P < .01). In addition, an increased mitochondrial respiration was observed in the abdominal adipose tissue from men in the young group with complex I (CIp) stimulated respiration, complex I + II (CI+IIp) stimulated respiration and the capacity of the electron transport system (ETS) (P < .05), and in the older group an increase in CIp and CI+IIp stimulated respiration (P < .05) was found. CONCLUSION: Overall, we found a positive effect of prolonged endurance exercise on adipose tissue inflammation markers and mitochondrial respiration in both young and old trained men, and no sign of attenuated function in adipose tissue with age.

Are statins making older persons weaker? A discontinuation study of muscular side effects.

Thirteen percent of the Danish population are treated with a statin-half of these are in primary prevention, and most are > 65 years old. Statins have known muscular side effects (i.e., myalgia) correlated to reduced muscle performance. This study examines if years of statin treatment in older people introduce subclinical muscle discomfort and loss of muscle mass and strength. In total, 98 participants (71.1 ± 3.6 years (mean ± SD)), who were in primary prevention treatment for elevated plasma cholesterol with a statin, were included in this study. Statin treatment was discontinued for 2 months and then re-introduced for 2 months. Primary outcomes included muscle performance and myalgia. Secondary outcomes included lean mass and plasma cholesterol. Functional muscle capacity measured as a 6-min walk test increased after discontinuation (from 542 ± 88 to 555 ± 91 m, P < 0.05) and remained increased after re-introduction (557 ± 94 m). Similar significant results were found with a chair stand test (15.7 ± 4.3 to 16.3 ± 4.9 repetitions/30 s) and a quadriceps muscle test. Muscle discomfort during rest did not change significantly with discontinuation (visual analog scale from 0.9 ± 1.7 to 0.6 ± 1.4) but increased (P < 0.05) with the re-introduction (to 1.2 ± 2.0) and muscle discomfort during activity decreased (P < 0.05) with discontinuation (from 2.5 ± 2.6 to 1.9 ± 2.3). After 2 weeks of discontinuation, low-density lipoprotein cholesterol increased from 2.2 ± 0.5 to 3.9 ± 0.8 mM and remained elevated until the re-introduction of statins (P < 0.05). Significant and lasting improvements in muscle performance and myalgia were found at the discontinuation and re-introduction of statins. The results indicate a possible statin-related loss of muscle performance in older persons that needs further examination.

The effect of aerobic exercise training on asthma control in postmenopausal women (ATOM): a randomized controlled pilot study.

Objective: To evaluate if high-intensity interval training three times weekly for 12 weeks improves asthma control in overweight, postmenopausal women with uncontrolled, late-onset asthma. Methods: The reported study is a randomized clinical pilot study (www.clinicaltrials.gov; NCT03747211) that compared 12 weeks of high-intensity interval training (spinning) with usual care. The five-question Asthma Control Questionnaire (ACQ-5) was used as primary outcome. Secondary measures included systemic inflammation and inflammation of the airways, body composition, and cardiac function during exercise. Results: We included 12 women with asthma (mean age 65 years (SD 6); mean body mass index 30 kg/m2 (SD 2)) from whom eight were randomized to exercise and four to control. Baseline ACQ-5 was 1.95 (SD 0.53) in the control group and 2.03 (0.54) in the exercise group. Patients had a mean blood eosinophil level of 0.16 × 109cells/L (SD 0.07) and a mean fraction of exhaled nitric oxide of 23 ppb (SD 25). Mixed models showed that participants in the exercise group reduced their ACQ-5 by 0.55 points (95%CI -1.10 to -0.00; P = 0.08) compared with the control group. The exercise group significantly reduced their mean body fat percentage (-2.7%; 95%CI -4.5 to -0.8; P = 0.02), fat mass (-2.8 kg; 95%CI -5.1 to -0.4; P = 0.044) and android fat mass (-0.33 kg; 95%CI -0.60- -0.06; P = 0.038). In analyses of cardiac measures, we saw no significant effects on right ventricular function (fractional area change), diastolic function or left ventricular function. Conclusions: Although changes in ACQ-5 were slightly insignificant, these preliminary findings indicate that aerobic exercise training can be used as a means to improve asthma control in overweight, postmenopausal women with asthma.

Cognitive-behavioural therapy reduces psychological distress in younger patients with cardiac disease: a randomized trial.

AIMS: To test whether usual outpatient cardiac rehabilitation (CR) supplemented by a cognitive-behavioural therapy (CBT) intervention may reduce anxiety and depression compared with usual CR. METHODS AND RESULTS: In this multicentre randomized controlled trial, 147 cardiac patients (67% men, mean age 54 years, 92% with coronary artery disease) with psychological distress defined as a hospital anxiety and depression scale (HADS) anxiety or depression score ≥8 were randomized to five sessions of group CBT plus usual CR (intervention, n = 74) or CR alone (control, n = 73). Patients with severe distress or a psychiatric diagnosis were excluded. The intervention was delivered by cardiac nurses with CBT training and supervised by a psychologist. A reference, non-randomized group (background, n = 41) of consecutive patients without psychological distress receiving usual CR was included to explore the effect of time on HADS score. The primary outcome, total HADS score after 3 months, improved more in the intervention than in the control group [the mean total HADS score improved by 8.0 (standard deviation 5.6) vs. 4.1 (standard deviation 7.8), P < 0.001]. Significant between-group differences were maintained after 6 months. Compared with the control group, the intervention group also had greater adherence to CR (P = 0.003), more improvement in the heart-related quality of life (HeartQoL) at 6 months (P < 0.01), and a significant reduction in cardiac readmissions at 12 months (P < 0.01). The background group had no significant change in HADS score over time. CONCLUSION: Brief CBT provided by cardiac nurses in relation to CR reduced anxiety and depression scores, improved HeartQoL and adherence to CR, and reduced cardiovascular readmissions. The programme is simple and may be implemented by CR nurses.

The COVID-19 in athletes (COVA) study: a national study on cardio-pulmonary involvement of SARS-CoV-2 infection among elite athletes.

Background: COVID-19 can cause cardiopulmonary involvement. Physical activity and cardiac complications can worsen prognosis, while pulmonary complications can reduce performance. Aims: To determine the prevalence and clinical implications of SARS-CoV-2 cardiopulmonary involvement in elite athletes. Methods: An observational study between 1 July 2020 and 30 June 2021 with the assessment of coronary biomarkers, electrocardiogram, echocardiography, Holter-monitoring, spirometry, and chest X-ray in Danish elite athletes showed that PCR-tested positive for SARS-CoV-2. The cohort consisted of male football players screened weekly (cohort I) and elite athletes on an international level only tested if they had symptoms, were near-contact, or participated in international competitions (cohort II). All athletes were categorized into two groups based on symptoms and duration of COVID-19: Group 1 had no cardiopulmonary symptoms and duration ≤7 days, and; Group 2 had cardiopulmonary symptoms or disease duration >7 days. Results: In total 121 athletes who tested positive for SARS-CoV-2 were investigated. Cardiac involvement was identified in 2/121 (2%) and pulmonary involvement in 15/121 (12%) participants. In group 1, 87 (72%), no athletes presented with signs of cardiac involvement, and 8 (7%) were diagnosed with radiological COVID-19-related findings or obstructive lung function. In group 2, 34 (28%), two had myocarditis (6%), and 8 (24%) were diagnosed with radiological COVID-19-related findings or obstructive lung function. Conclusions: These clinically-driven data show no signs of cardiac involvement among athletes who tested positive for SARS-CoV-2 infection without cardiopulmonary symptoms and duration <7 days. Athletes with cardiopulmonary symptoms or prolonged duration of COVID-19 display, exercise-limiting cardiopulmonary involvement.

Hemodynamic Response in Ascending Aorta Surgery Patients during Moderate Intensity Resistance Training.

Background: In patients undergoing ascending aortic surgery (AAS), postsurgical physical exercise with a safe and effective exercise prescription is recommended. Resistance training is associated with blood pressure (BP) elevations that may increase the risk of new aortic dissection or rupture. However, the acute hemodynamic response to resistance training for this patient group is unknown. Aim: The aim of this study was to investigate peak systolic BP (SBP) increases in AAS patients during moderate intensity resistance training. Methods: SBP was measured continuously beat-to-beat with a noninvasive method during three sets of leg presses at moderate intensity. A 15-repetition maximum strength test was performed to estimate the maximal amount of resistance a participant could manage 15 times consecutively (equivalent to approximately 60-65% of their maximum strength). Results: The study had 48 participants in total, i.e., 24 cases and 24 controls. Both groups consisted of 10 females (42%) and 14 males (58%). The case group had a mean age of 60.0 (SD ± 11.9) years and a mean of 16.3 months since surgery (minimum 4.4 and maximum 39.6 months). 22 of the 24 cases received antihypertensive medication. The median baseline BP was 119/74 mmHg among cases and 120/73 mmHg among controls. During the first set of leg presses, the median peak SBP was 152 mmHg, in the second set 154 mmHg, and in the third set 165 mmHg. Corresponding values in controls were 170 mmHg, 181 mmHg, and 179 mmHg. The highest peak SBP registered in an AAS patient was 190 mmHg and in any healthy control was 287 mmHg. Conclusion: The findings indicate that AAS patients in control of their BP have the endurance to perform 3 sets of resistance training at moderate intensity as their SBP increases with a maximum of 39% from the baseline compared to the 51% increase in the control group.

The motivation for physical activity is a predictor of VO2peak and is a useful parameter when determining the need for cardiac rehabilitation in an elderly cardiac population.

BACKGROUND: Exercise-based cardiac rehabilitation (CR) is an essential contributor to a successful recovery for elderly cardiac patients. The motivation for physical activity is a psychological parameter seldom described in secondary prevention, and it is plausible that motivation contributes to the differential effect of CR. PURPOSE: To investigate if motivation, measured using the behavioural regulation in an exercise questionnaire (BREQ-2), predicts VO2peak in elderly cardiac patients before and after CR. METHODS: A prospective cohort study of elderly ischemic cardiac patients and patients with valvular disease participating in cardiac rehabilitation was used. Motivation was measured using BREQ-2, which measures five constructs of motivation and a summed score-the relative autonomy index (RAI). VO2peak was measured before and after CR using a cardiopulmonary exercise test (CPET). RESULTS: Two hundred and three patients performed the baseline tests and initiated CR. One hundred and eighty-two completed CR and comprised the follow-up group. The mean VO2peak was 18 ml/kg/min (SD±5.1). VO2peak increased significantly with increasing motivation, 1.02 (.41-1.62) ml/kg/min pr. SD. Mean improvement from CR was 2.3 ml/kg/min (SD±4.3), the equivalent of a 12% increase. A change in VO2peak after CR was likewise positively associated with increased motivation, .74 (.31-1.17) pr. SD. CONCLUSION: The level of motivation predicts VO2peak before CR, and is also able to predict changes in VO2peak following CR. Motivation measured with the BREQ-2 questionnaire can be applied as a screening tool for elderly cardiac patients before they initiate CR to identify patients with need of specific attention.

Extreme duration exercise affects old and younger men differently.

AIM & METHODS: Extreme endurance exercise provides a valuable research model for understanding the adaptive metabolic response of older and younger individuals to intense physical activity. Here, we compare a wide range of metabolic and physiologic parameters in two cohorts of seven trained men, age 30 ± 5 years or age 65 ± 6 years, before and after the participants travelled ≈3000 km by bicycle over 15 days. RESULTS: Over the 15-day exercise intervention, participants lost 2-3 kg fat mass with no significant change in body weight. V̇O2 max did not change in younger cyclists, but decreased (p = 0.06) in the older cohort. The resting plasma FFA concentration decreased markedly in both groups, and plasma glucose increased in the younger group. In the older cohort, plasma LDL-cholesterol and plasma triglyceride decreased. In skeletal muscle, fat transporters CD36 and FABPm remained unchanged. The glucose handling proteins GLUT4 and SNAP23 increased in both groups. Mitochondrial ROS production decreased in both groups, and ADP sensitivity increased in skeletal muscle in the older but not in the younger cohort. CONCLUSION: In summary, these data suggest that older but not younger individuals experience a negative adaptive response affecting cardiovascular function in response to extreme endurance exercise, while a positive response to the same exercise intervention is observed in peripheral tissues in younger and older men. The results also suggest that the adaptive thresholds differ in younger and old men, and this difference primarily affects central cardiovascular functions in older men after extreme endurance exercise.

Are Prolonged Ventricular Pauses in Atrial Fibrillation a Marker of Poor Prognosis?

BACKGROUND: In patients with atrial fibrillation (AF), the long-term prognosis of long electrocardiographic pauses in the ventricular action is not well studied. METHODS: Consecutive Holter recordings in patients with AF (n = 200) between 2009 and 2011 were evaluated, focusing on pauses of at least 2.5 s. Outcomes of interest were all-cause mortality and pacemaker implantation. RESULTS: Forty-three patients (21.5%) had pauses with a mean of 3.2 s and an SD of 0.9 s. After a median follow-up of 99 months (ranging 89-111), 47% (20/43) of the patients with and 45% (70/157) without pauses were deceased. Pauses of ≥2.5 s did not constitute a risk of increased mortality: HR = 0.75 (95% CI: 0.34-1.66); p = 0.48, neither did pauses of ≥3.0 s: HR = 0.43 (95% CI: 0.06-3.20); p = 0.41. Sixteen percent of patients with pauses underwent pacemaker implantation during follow-up. Only pauses in patients referred to Holter due to syncope and/or dizzy spells were associated with an increased risk of pacemaker treatment: HR = 4.7 (95% CI: 1.4-15.9), p = 0.014, adjusted for age, sex, and rate-limiting medication. CONCLUSION: In patients with AF, prolonged electrocardiographic pauses of ≥2.5 s or ≥3.0 s are not a marker for increased mortality in this real-life clinical study.

Excessive supraventricular ectopic activity and risk of incident atrial fibrillation in a consecutive population referred to ambulatory cardiac monitoring.

BACKGROUND: Excessive supraventricular ectopic activity (ESVEA), defined as ≥720 premature atrial contractions (PAC) per day or any runs of ≥20 PACs, has been proposed as a surrogate marker for paroxysmal atrial fibrillation (PAF). OBJECTIVE: We aimed to estimate the prognostic impact of ESVEA on the future development of PAF in consecutive patients referred to ambulatory cardiac monitoring. METHODS: The cohort consists of a population with comorbidities referred to 48-hour ambulatory electrocardiogram aged 30-98 (n = 1316) between 2009 and 2011. After exclusion of known or current atrial fibrillation (AF) (n = 527) and patients with pacemakers (n = 7), 782 patients were included, with a median follow-up of 8.1 years. Events of incident AF and death were retrieved from patient records. RESULTS: Mean age was 58.6 ± 15.5 years and 56.5% were women. A total of 101 patients had ESVEA at baseline (12.9%). During follow-up, 69 (8.9%) developed incidental AF. Twenty-three patients with ESVEA developed AF (23%). Incidence rate of AF in patients with and without ESVEA was 37.1/1000 person-years and 9.1 per 1000 person-years, respectively (P < .001). ESVEA was associated with incident AF after adjustment for potential confounders in Cox regression analysis (hazard ratio [HR]: 2.39; 95% confidence interval [CI]: 1.40-4.09) and in competing risk analysis with death as competing risk (subdistribution HR: 2.35; 95% CI: 1.30-4.17). CONCLUSION: ESVEA increases the risk of incident AF substantially in a population referred to ambulatory cardiac monitoring.

Intensive group-based cognitive therapy in patients with cardiac disease and psychological distress-a randomized controlled trial protocol.

BACKGROUND: Many patients with coronary artery disease (CAD) and valvular heart disease (VHD) suffer from psychological distress. Such stress is associated with increased morbidity, reduced quality of life and delayed return to work. European guidelines emphasize recognition and intervention, but evidence-based treatment options are limited and perceived as costly. The present study will test the effect of brief, group-based cognitive therapy as an adjunct to usual cardiac rehabilitation in a randomized design. METHODS: A total of 148 patients with CAD and/or VHD after surgical intervention and concomitant psychological distress (defined as HADS anxiety (A) or depression (D) score ≥8) will be randomized to either usual out-patient cardiac rehabilitation (CR) comprising an 8-week multidisciplinary programme or usual care supplemented by five group-based cognitive therapy sessions performed by trained CR nurses. A structured, standardized treatment manual will be used. Patients will be randomized 1:1 at three different sites. Additionally, a non-randomized sub-group of 40 matched patients without signs of psychological distress will be followed to investigate spontaneous variation in HADS. The primary outcome is Hospital Anxiety and Depression Score (HADS). Secondary outcomes are adherence to cardiac rehabilitation (CR), health-related quality of life measured by HeartQoL, time to return to work, adherence to lifestyle interventions and cardiovascular readmissions. Patients are followed up for 12 months. DISCUSSION: To our knowledge, this is the first randomized controlled trial (RCT) on patients with cardiac disease with an intensive group-based programme of cognitive therapy performed by CR nurses, which makes it affordable and widely implementable. The outcome will elucidate the feasibility and effect of cognitive therapy as an adjunct to CR in patients with post-surgery CAD and/or VHD and psychological distress and could possibly benefit patients with other heart conditions as well. The clinical trial complies with the Declaration of Helsinki. The trial has been approved by The Regional Research Ethics Committee (file number H-16042832) and The Danish Data Protection Agency. The results will be disseminated as original research in peer-reviewed manuscripts. TRIAL REGISTRATION: www.clinicaltrials.gov NCT04254315 . Retrospectively registered on 30 January 2020.

Effect of aerobic exercise training on asthma control in postmenopausal women (the ATOM-study): protocol for an outcome assessor, randomised controlled trial.

INTRODUCTION: Late-onset asthma in postmenopausal women is characterised by poor disease control with daily symptoms and reduced quality of life despite treatment with inhaled antiasthma therapies. These patients represent a phenotype that is characterised by low eosinophilic airway inflammation, severe symptoms, moderate obesity and poor response to inhaled antiasthma therapies, which highlights the need of identification of alternative treatment strategies. Thus, this study aims to evaluate if regular high-intensity aerobic exercise improves symptom control in postmenopausal women with asthma. METHODS AND ANALYSIS: This is an ongoing randomised controlled trial planning to enrol 40 postmenopausal women with late-onset asthma. Participants are randomised 1:1 either to supervised exercise training (spinning) three times per week for 12 weeks or to usual care. The primary outcome is change from baseline to follow-up in the Asthma Control Questionnaire. Secondary outcomes are changes in markers of systemic inflammation, airway inflammation, body composition and right ventricular function of the heart. ETHICS AND DISSEMINATION: The study is approved by the Ethics Committee in the Capital Region of Denmark nr. H-18028966 and the Danish Data Protection Agency nr. VD-2019-59. The methods used in the study are well known and have a low risk with a chance of substantial improvement in disease control in this patient group. Results are planned to be published in an international peer-reviewed medical journal regardless of outcome. TRIAL REGISTRATION NUMBER: NCT03747211.

Reopening elite sport during the COVID-19 pandemic: Experiences from a controlled return to elite football in Denmark.

As the SARS-CoV-2 infection rate decreased in spring 2020, phased reopening of Danish society began, including a reopening of elite football (soccer), adhering to a strict protocol. In this study, we report the consequences of resumption of competitive play in the two best football (soccer) leagues for men in Denmark measured by number of SARS-CoV-2 positive players. The players were tested weekly for SARS-CoV-2 for 11 consecutive weeks. The test protocol comprised 26 teams with 748 players. In total, 6511 tests were done with a positivity rate of 0.06%. The incidence rate of players testing positive for SARS-CoV-2 was 0.53% (4/748). There were no signs of a chain of infection. We found a low incidence rate of SARS-CoV-2, and based on this, a controlled reopening of professional football strictly following a detailed protocol appears safe for the players.

Effect of aerobic exercise training on asthma in adults: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of aerobic exercise training on asthma control, lung function and airway inflammation in adults with asthma. DESIGN: Systematic review and meta-analysis. METHODS: Randomised controlled trials investigating the effect of ≥8 weeks of aerobic exercise training on outcomes for asthma control, lung function and airway inflammation in adults with asthma were eligible for study. MEDLINE, Embase, CINAHL, PEDro and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to April 3, 2019. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS: We included 11 studies with a total of 543 adults with asthma. Participants' mean (range) age was 36.5 (22-54) years; 74.8% of participants were female and the mean (range) body mass index was 27.6 (23.2-38.1) kg·m-2. Interventions had a median (range) duration of 12 (8-12) weeks and included walking, jogging, spinning, treadmill running and other unspecified exercise training programmes. Exercise training improved asthma control with a standard mean difference (SMD) of -0.48 (-0.81--0.16). Lung function slightly increased with an SMD of -0.36 (-0.72-0.00) in favour of exercise training. Exercise training had no apparent effect on markers of airway inflammation (SMD -0.03 (-0.41-0.36)). CONCLUSIONS: In adults with asthma, aerobic exercise training has potential to improve asthma control and lung function, but not airway inflammation.

Brief recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

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

Improvement in VO2peak predicts readmissions for cardiovascular disease and mortality in patients undergoing cardiac rehabilitation.

BACKGROUND: Improvement in exercise capacity is a main goal of cardiac rehabilitation but the effects are often lost at long-term follow-up and thus also the benefits on prognosis. We assessed whether improvement in VO2peak during a cardiac rehabilitation programme predicts long-term prognosis. METHODS AND RESULTS: We performed a retrospective analysis of 1561 cardiac patients completing cardiac rehabilitation in 2011-2017 in Copenhagen. Mean age was 63.6 (11) years, 74% were male and 84% had coronary artery disease, 6% chronic heart failure and 10% heart valve replacement. The association between baseline VO2peak and improvement after cardiac rehabilitation and being readmitted for cardiovascular disease and/or all-cause mortality was assessed with three different analyses: Cox regression for the combined outcome, for all-cause mortality and a multi-state model. During a median follow-up of 2.3 years, 167 readmissions for cardiovascular disease and 77 deaths occurred. In adjusted Cox regression there was a non-linear decreasing risk of the combined outcome with higher baseline VO2peak and with improvement of VO2peak after cardiac rehabilitation. A similar linear association was seen for all-cause mortality. Applying the multi-state model, baseline VO2peak and change in VO2peak were associated with risk of a cardiovascular disease readmission and with all-cause mortality but not with mortality in those having an intermediate readmission for cardiovascular disease. CONCLUSION: VO2peak as well as change in VO2peak were highly predictive of future risk of readmissions for cardiovascular disease and all-cause mortality. The predictive value did not extend beyond the next admission for a cardiovascular event.

Brief recommendations for participation in competitive sports of athletes with arterial hypertension: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.

Depression, Socioeconomic Factors, and Ethnicity as Predictors of Cardiorespiratory Fitness Before and After Cardiac Rehabilitation.

PURPOSE: To determine whether cardiac patients with psychosocial or socioeconomic problems have lower peak oxygen uptake ((Equation is included in full-text article.)O2peak) and whether these factors modify the effect of cardiac rehabilitation (CR). METHODS: A retrospective cohort study of patients with ischemic heart disease, valvular heart disease, or heart failure referred for CR. (Equation is included in full-text article.)O2peak was assessed by a maximal cardiopulmonary exercise test. Pre-existing depression was defined by use of antidepressants and new-onset depression by a modified Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire at CR intake. Socioeconomic status was defined by educational attainment and working status; ethnicity as Western European or non-Western European. Full data from baseline assessment were available on 1217 patients and follow-up on 861 patients. RESULTS: Mean ± SD (Equation is included in full-text article.)O2peak before CR was 21.8 ± 6.8 mL/kg/min. After multivariable adjustment, lower (Equation is included in full-text article.)O2peak was associated with lower educational attainment, not working, and non-Western ethnicity but not with depression. Mean improvement of (Equation is included in full-text article.)O2peak following CR was 2.4 ± 4.3 mL/kg/min. After multivariable adjustment educational attainment, employment status and ethnicity were significant predictors of improvement of (Equation is included in full-text article.)O2peak while depression was not. CONCLUSION: Education, attachment to the workforce, and ethnicity were all associated with lower (Equation is included in full-text article.)O2peak before CR, and the disparity was increased following CR. Having pre-existing depression and new-onset depression did not influence (Equation is included in full-text article.)O2peak either before or after CR. These results point to important subgroups in need of specially-tailored rehabilitation programs.