Issue 30.09. Focus on cardiac rehabilitation, exercise, and sport cardiology

Cardiovascular disease (CVD) continues to be a primary cause of mortality and morbidity in Europe, and it must be treated with strategies that go beyond drugs, but also focused on physical activity, changes in lifestyle, risk factor management, improved well-being, and social and vocational participation. Cardiac rehabilitation (CR) is a comprehensive, individualized, patient-tailored, multidisciplinary programme aimed at achieving the above-mentioned goals. Despite its clinical benefits, cost, and effectiveness, the adoption of CR in Europe remains suboptimal, and there is a lack of current state-specific information. This centralized pan-European study [Overview of Cardiac Rehabilitation (OCRE)] aimed to characterize and advance the knowledge in the setting of the European Society of Cardiology (ESC) affiliated nations.1 This cross-sectional investigation was conducted using an online questionnaire sent to 51 ESC member countries. It covered pertinent demographic, structural, and quality control topics, such as adopted CVD prevention and rehabilitation guidelines, as well as the main obstacles to their implementation. Although the level of CR provision in Europe is encouraging, it is frequently of suboptimal quality, indicating that the allocation of human and financial resources must be improved. Positive aspects included low dropout rates, a brief average start time following acute myocardial infarction (AMI), and the standardization of public funding. Whereas, suboptimal aspects include low uptake rates and short average duration, absence of mandatory CR rotation in cardiology training, lack of guidance documents, absence of national accreditation, and electronic database registries. Cardiac rehabilitation promotes clinical and functional recovery in older patients following acute cardiac syndromes, the success of which is impacted not only by the severity of the cardiac disease but also by comorbidities and frailty. Frailty is a dynamic age-related vulnerability marked by diminishing function, a loss of physiological reserves in numerous organs or systems, and an increased risk of unfavourable consequences such as institutionalization and mortality. Here, Quach et al.2 explored the relationship between admission frailty and long-term results, as well as the relationship between frailty changes during CR and long-term outcomes. Data from 3371 patients admitted to a 12-week CR programme in Halifax, Nova Scotia, from May 2005 to April 2015 were analysed. A 25-item frailty index (FI) estimated frailty levels at CR admission and completion. The FI improvements were determined by calculating the difference between admission and discharge FI. Higher frailty levels at the time of CR admission were associated with a shorter time to death, re-hospitalization, and Emergency Department visit, whereas frailty improvements during CR were associated with delayed all-cause hospitalization. Genotype positive–phenotype negative (GEN + PHEN) individuals carry a pathogenic or suspected pathogenic variant without manifesting the disease phenotypically. In recent years, the pervasive use of genetic testing in probands and relatives has led to an increase in the identification of these individuals, creating new clinical management challenges. In this review, the authors discuss the current state of knowledge on GEN + PHEN individuals and the dilemmas surrounding the impact of exercise and prognosis, with a particular focus on cardiomyopathies and channelopathies, which are the most common causes of sudden cardiac death (SCD) in the young and in young athletes.3 In this context, it is important to note that international guidelines, which have historically been restrictive in terms of sports participation and focused on disqualification, have recently adopted a more lenient stance promoting a shared decision-making approach in the absence of clinical markers of increased risk. This is the case, for instance, with hypertrophic cardiomyopathy, where the paucity of robust evidence on the effect of exercise on the risk of SCD and on phenotypic expression has led to a more permissive approach towards sport participation for GEN + PHEN individuals. In certain conditions, such as arrhythmogenic cardiomyopathy, however, guidelines do not differentiate between GEN + PHEN individuals and patients with overt disease and recommend avoiding high-intensity recreational exercise and competitive sports. Significant epidemiological, clinical, and basic science evidence indicates that regular physical activity and exercise training delay the development of atherosclerosis and reduce the incidence of coronary heart disease (CHD) events. Nevertheless, in susceptible individuals, vigorous physical activity can also temporarily and acutely increase the risk of AMI and SCD. Maintaining physical fitness through regular physical activity may aid in the prevention of events, as a disproportionate number of AMI and SCD occur in the least physically active individuals engaging in unaccustomed physical activity. In this issue of the journal, Čulić and colleagues sought to estimate the number of AMIs that can be attributed to physical exertion and to investigate possible modifiers of this association. This meta-analysis comprised 12 case-crossover studies with a total of 19 891 individuals. Physical activity may be responsible for 10.6% of all AMIs, however, the impact was greater in younger people or those who exercised one to three times per week. Exertion causes almost every sixth infarction among the latter. Beta-blockers may protect against the triggering impact of physical exertion.4 Endurance training (ET) improves cardiorespiratory fitness inducing cardiac morphological and functional adaptations. The extent of these changes and the differences related to gender, age, or type of training have been a debated topic. In this issue of the journal, Morrison et al.5 present a systematic review and meta-analysis gathering 82 studies. They showed that left ventricle remodelling is more pronounced in young males, especially those already trained, with respect to middle-age or older (where no changes were observed). Furthermore, only males showed a significant increase in wall thickness when compared to females. The study adds another piece in the understanding of ET-induced cardiac remodelling, pinpointing the gender and age-related differences. Exercise training is a cornerstone of secondary cardiovascular disease prevention. High-intensity interval training (HIIT) is becoming widely used to improve cardiorespiratory fitness, based on a more efficient model of physical training.6,7 Nonetheless, its use in secondary prevention has been questioned after equivocal results. In this issue of the journal, McGregor et al.8 present a multi-centre randomized control trial where 187 patients with CHD were randomized to HITT and 195 to moderate-intensity steady-state (MISS). After 8 weeks, functional capacity (measured with VO2 peak) improved more in HIIT (2.37 mL/kg/min; SD, 3.11) than in MISS group (1.32 mL/kg/min; SD, 2.66), even after adjusting age, sex, and study site. The paper is notable for the study design and for the new evidence supporting HIIT in secondary prevention where the targets are frequently unmet. The role of screening for CVD in masters (>35 years) athletes (MAs) is still debated, being variously used in different countries. The impact of a such screening has never been extensively evaluated in this specific population. Morrison et al.9 present an interesting study on 798 MAs who underwent to CVD screening [with anthropometrics, blood pressure and resting electrocardiogram assessment, questionnaires, and Framingham risk score (FRS) calculation]. Subjects positive at screening received further assessment with eventual stress tests. The most common diagnosis was CHD, predicted by age, FRS, and LDL levels. Major adverse cardiac events (MACEs) occurred only in subjects with abnormal screening test (90% of those with FRS higher than 10%) but the second-line assessment with stress tests failed to identify the underlying cardiac disease in most cases. As suggested by the authors, the study confirmed the importance of CVD screening but also revealed the limits of an approach based on ischaemia-detection in MAs. The use of an evaluation based on coronary anatomy assessment might be more effective in MACEs prevention, at least in subjects with high risk. The role of exercise stress echocardiography test in heart failure with preserved ejection fraction (HFpEF) is well defined by current European and American consensus. It represents the most impactful step, after careful clinical assessment, in diagnostic progression. Less is known about the prognostic significance of this approach. Saito et al.10 assessed the outcome (all-cause mortality and worsening HF) of 368 subjects who underwent to exercise stress echocardiography with the diagnostic suspect of HFpEF. Of those, 182 patients were diagnosed of HFpEF (according with HFA-PEFF algorithm) and showed a seven-fold increased risk of composite events than controls [hazard ratio (HR) 7.52; 95% confidential interval (CI), 2.24–25.2; P = 0.001]. Guideline-recommended therapies were initiated in 90 patients, showing a reduction of composite endpoint (HR 0.33; 95% CI, 0.12–0.91; P = 0.03) with respect to HFpEF subjects who did not received therapy. The study adds new evidence for the use of HFpEF diagnostic algorithms with the additional purpose of early prognosis improvement. Although it is widely acknowledged that physical activity reduces the risk of chronic non-communicable disease and mortality, accumulating evidence suggests that occupational physical activity (OPA) may not confer the same health benefits as leisure time physical activity (LTPA). This so-called physical activity health paradox may be explained by fundamental differences between LTPA and OPA, such as disparities in intensity, quantity of static vs. dynamic movements, duration, and recovery time. In addition, this association appears to be less prevalent among women, where fewer studies have shown or indicated that elevated OPA is associated with an increased risk of CVD, while other studies have shown a protective effect or found no association. To further investigate this topic, the present study sought to examine the association between OPA and risk for ischaemic heart disease (IHD), as well as any potential gender differences in this association, using data from the Danish Monica I (Monitoring Trends and Determinants of Cardiovascular Disease) study.11 The authors confirmed that the association between occupational physical activity and IHD was gender-specific. In fact, a high level of physical activity at work was associated with a risk of IHD that was ∼45% higher in men and ∼65% lower in women. The increase in breast cancer longevity has resulted in a growing survivor population that appears to develop multiple comorbidities, particularly treatment-induced CVD, especially among patients treated with anthracyclines. In fact, it is known that these compounds act by inducing supraphysiological production of reactive oxygen species, which appear to be central mediators of numerous direct and indirect adverse cardiac effects. Physical exercise (PA) practiced before, during, or after breast cancer treatments may represent a viable non-pharmacological strategy to increases cardiac tolerance against numerous cardiotoxic agents, thereby enhancing several functional, subclinical, and clinical parameters. In this randomized controlled trial, the authors investigated the effects of a supervised exercise training programme (SETP) on cardiac toxicity markers in women with breast cancer receiving anthracycline-containing chemotherapy.12 Ninety-three women with early-stage breast cancer were randomly allocated to a SETP plus usual care group (n = 47) or usual care alone group (n = 46). The SETP consisted of three sessions per week, combining aerobic and resistance training, conducted concurrently across the anthracycline-containing chemotherapy length. The authors demonstrated that, despite the fact that ET does not prevent the early decline in left ventricular ejection fraction and global longitudinal strain, it is a safe supportive strategy during chemotherapy and significantly improves cardiorespiratory fitness. Sufficient exercise and adequate sleep both contribute to a longer life expectancy. However, it is unknown how PA and sleep duration interact to enhance health. Previous research key drawback was the use of self-reported PA and sleep, which is subjective and may be erroneous. An accelerometer device, on the other hand, captures movement, providing objective and more trustworthy estimations of activity and sleep time. This study recruited 92 221 participants in the UK Biobank cohort aged 40 to 73 years who wore an accelerometer wristband for 1 week between 2013 and 2015.13 Short (<6 h), regular (6–8 h), and long (>8 h) sleep durations were assigned to each night. The total amount of PA was classified into tertiles (low, moderate, and high). During a 7-year median follow-up period, 3080 participants died, with 1074 dying from CVD and 1871 dying from cancer. Both short and lengthy sleep times evaluated by accelerometer were linked to an increased risk of all-cause and CVD death. A higher volume of PA or moderate-to-vigorous PA at the WHO-recommended level, as evaluated with an accelerometer, reduced the increased mortality risks associated with short or lengthy sleep duration. For a widespread adoption of cardiopulmonary exercise test (CPET) in paediatrics, a set of valid paediatric VO2max reference values needs to be established, which may then be used to define the higher and lower limits of the norm. Moreover, the linear equations now in use may be unsuited for the modern paediatric population, particularly for the extreme weights. To address this important issue, here, a study aimed to establish VO2max reference Z-score values from a large cohort of children representative of the contemporary paediatric population, including those with extreme weights. Following the guidelines for high-quality CPET assessment, 909 children aged 5 to 18 from the general French population (development cohort) and 232 children from the general German and American populations (validation cohort) underwent a CPET. Utilizing linear, quadratic, and polynomial mathematical regression equations, the optimal VO2max Z-score model was determined.14 This study is of the utmost importance because providing Z-scores to assess aerobic fitness in the paediatric population will be beneficial in the follow-up of children with a variety of chronic diseases.

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